Workforce Composition and Distribution: Recommendations and Action Steps

1. Define national goals for redesign of the U.S. maternity care workforce based on a primary care model with access to collaborative specialty care, consistent with the health care reform priority of primary preventive services and care coordination.

  • Seek broad, multi-stakeholder support for a primary maternity care system that positions caregivers with expertise in physiologic childbearing as the standard for the majority of healthy women and their babies and gives all providers training in the skills and knowledge to support physiologic childbirth.
    • Align financial incentives with goals for a primary maternity care system and workforce diversity. (See the Blueprint Section on Payment Reform to Align Incentives with Quality.)
    • Communicate available comparative effectiveness data to the key stakeholders at the federal level to support expanding the primary maternity care workforce and access to freestanding birth centers.
    • Foster enabling legislation to strengthen the primary maternity care workforce at the state level by soliciting support of medical leaders, communicating support to state legislators, and writing letters to editors (including use of comparative effectiveness data).
    • Support universal educational and training standards in physiologic childbearing for physicians, midwives, and nurses and tie these to certification and licensure. (See the Blueprint Section on Scope, Content, and Availability of Health Professions Education.)

2. Carry out an independent capacity assessment to determine projected workforce needs, and identify strategies for achieving the optimal maternity care workforce.

  • Engage an independent entity (such as the Center for Health Professions, University of California at San Francisco, or a leading health-related foundation) to oversee an in-depth maternity provider workforce analysis.
    • Project the maternity care provider workforce capacity for the coming decade and beyond and the optimal workforce needs of childbearing women and newborns, with respect to size, composition, and geographic distribution. Identify policy strategies for creating an optimal workforce.
    • Cover in the analysis: family physicians who provide maternity services, general obstetricians, maternal-fetal medicine specialists, neonatologists, midwives with nationally recognized credentials (CNM, CM, CPM), maternity nurses, and mental health professionals who can provide appropriate care for child-bearing women and families.
    • Address the mismatch between the demographic composition of the current maternity care workforce and the rapidly changing racial/ethnic, linguistic, geographic, and socio-economic composition of the childbearing population.
    • Develop and disseminate a credible, comprehensive report of the workforce analysis.
    • Identify an objective oversight group with suit-able power and authority to provide leader-ship and guidance to make the needed transition.

3. Support the appropriate volume, geographic distribution, and density of providers in each discipline through health care policy and reimbursement realignment.

  • Ensure payment for primary maternity care services at a rate of not less than 100% of fees for specialists reimbursed for providing similar services.
  • Ensure payment for birth centers at a rate of not less than 100% of reimbursement levels for equivalent codes in hospitals.
  • Support legislative initiatives to increase access to regulated and licensed Certified Professional Midwives.
  • Develop and implement strategies specific to each of the maternity professions to increase recruitment of students.
    • Explore and replicate innovative midwifery education models to increase student enrollment in programs for nationally credentialed midwives.
    • Reduce entry barriers for prospective maternity nursing students, and create efficient education options such as accelerated second degree programs (e.g., BA to BSN, AD to BS) and undergraduate to graduate programs.
    • Improve obstetrician retention and new provider numbers by developing and implementing innovative career tracking options within maternity care (such as hospitalist, outpatient only, and gynecology only).
    • Ensure that family medicine residents have adequate opportunities to experience maternity care rotations in effective learning environments.
  • Increase the diversity of the maternity care workforce. Develop career ladders (e.g., for nursing aides, nurses, doulas, midwives), through training and mentoring subsidies in safety net settings. Implement outreach programs to educate primary and especially secondary students about these career opportunities and to mentor them. Link level of federal funding for graduate health professions education and clinical training to improved outreach and diversity.
  • Within health plans and Medicaid programs, foster transparency and access to a choice of caregivers with diverse disciplinary and racial, ethnic, and linguistic backgrounds, to allow consumer demand to influence optimal workforce composition and distribution.
  • Improve maternity care workforce distribution in geographically and socioeconomically under-served areas. Expand the number of NHSC sites, and extend eligibility for NHSC scholarships to all nationally credentialed maternity care providers. Increase funding for health care provider education and debt forgiveness for practice in underserved areas. Employ new technologies to increase access to education and continuing competency (e.g., distance learning programs, webinars) and to specialty consultation by primary maternity caregivers in remote under-served areas (e.g., telemedicine, locum tenens).
  • Continue to develop interstate models of licensure for maternity caregivers.
  • Establish regional, interdisciplinary maternity care hubs to improve maternity care workforce distribution in geographically and socioeconomically underserved areas.

4. Develop, test, and implement interventions to improve collaborative practice among primary maternity caregivers and other members of the maternity team.

  • Implement institutional support and incentives for collaborative practice models at the health care system level. Evaluate impact of policies and procedures, work schedules, job descriptions, performance evaluations, and client and staff satisfaction measures. Reduce health care system barriers to midwifery practice through collaboration and privileging.
  • Identify exemplary U.S.- and non-U.S.-based models of collaborative practice and investigate strategies for shared financial and practice resources and replication.
  • Engage expert consultation from other industries to adapt and apply to maternity care systems-level solutions for improving multidisciplinary collaboration.
  • Carry out studies to assess the impact on the workforce of ‘‘laborists’’ (health professionals who provide hospital-based maternity care only) in comparison with usual care.
  • Within health care reform, identify opportunities to foster multidisciplinary collaboration among maternity professionals through payment reform and care coordination.

Lead Responsibilities

Key stakeholders include clinicians and their professional organizations, consumers and advocates, payors and purchasers, and federal and state agencies.


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