Rebirth of the Midwife

Tisha Holloway was exhausted. She had been laboring in a North Carolina hospital for almost 26 hours to give birth to her first child, but the baby just wouldn’t come.

“I tried to do everything right during my pregnancy,” the 27-year-old woman says. “I ate right, exercised, kept my weight down. Just before I went into the hospital, my obstetrician said everything was fine.”

But something began to go wrong. Worried about the baby’s size, Holloway’s obstetrician decided to induce labor before her due date. The long labor began to stress both Holloway and her baby. Eventually, baby Jeda had to be delivered by Caesarean section.

Four days later Holloway left the hospital with a healthy 7-pound baby girl, postoperative pain, and a bill of $9,000.

“I was very upset,” she says. “I shouldn’t have been induced. If I had waited three or four days, Jeda might have come naturally. I decided I would never have another child.”

But when Jeda was 1 year old, Holloway changed her mind. This time she searched the Internet for a way to have a vaginal birth after Caesarean section (VBAC). Her search led to the Vanderbilt nurse-midwifery faculty practice and to certified nurse-midwife Linda Hughlett, MSN’04.

Hughlett reviewed Holloway’s records and explained that she had an 85 percent chance of delivering her second child vaginally. She monitored Holloway throughout her pregnancy, explaining the process each step along the way and involving Holloway in planning the baby’s birth. Last August, after 17 hours of labor, Holloway safely delivered another daughter, Jxia, vaginally at Vanderbilt University Hospital.

Vanderbilt nurse-midwives do not offer home births; all of their patients deliver in Vanderbilt Hospital’s labor and delivery suite. Women can labor in any position that feels comfortable. They can get out of the labor bed to walk around and even use hydrotherapy (immersion in a warm tub of water) to relieve labor pains. Their husbands and families can be with them throughout labor and delivery. They can choose to have their babies by “natural childbirth” or to receive analgesics and epidurals.

“It was amazing,” says Holloway of the nurse-midwife–assisted delivery. “I felt great and went home two days later. I recommend it 100 percent.”

Holloway had the kind of low-intervention birth she always wanted, supported by her husband and midwife. No surgery, no scarring, at half the cost of her first child’s birth.

Midwives Deliver

More than 4 million babies are born each year in the United States. Nurse-midwives assist in slightly more than 7 percent of those births. In 2005 the average hospital charge ranged from $7,000 for an uncomplicated vaginal birth to $16,000 for a complicated Caesarean section, according to a study funded by the Milbank Foundation.

Those figures have implications for the current national discussion about health-care reform.

Are nurse-midwife–assisted births safe? The ACNM says yes, and that midwife-assisted births result in lower rates of intervention. Certified nurse-midwives (CNM) follow the standard of care developed by the American College of Nurse-Midwives. The American College of Obstetrics and Gynecology recommends against using midwives who have not been certified by the ACNM or have not passed the American Midwifery Certification Board exam.

“The word ‘midwife’ means ‘with woman,’” Conway-Welch says. “Nurse-midwives have a special philosophy: They are very patient. They take their cues for medication needs from the woman. The midwife role is to be supportive to the woman as she has her baby.”

Every year nearly 3,000 babies are born at Vanderbilt University Hospital. Today about one-fourth are delivered by certified nurse-midwives, who have delivered about 4,500 babies since the program began in 1995. Only about 135 babies were delivered by CNMs the first year, says founding director Barbara A. Petersen, associate professor of nursing.

Last year CNMs delivered 799 babies at Vanderbilt Hospital. Of those, 4.1 percent were premature. Ten percent of the mothers were referred to obstetricians for Caesarean sections. About 30 to 35 infants were transferred to the neonatal intensive care unit. One fetal death and no maternal deaths occurred.

By contrast, 14.8 percent of all babies born in Tennessee in 2006 were premature, according to the Tennessee Chapter of the March of Dimes, and the state’s overall infant mortality rate was 8.8 per 1,000 births.

Vanderbilt has two nurse-midwifery programs: one based in the School of Nursing and another in the School of Medicine.

The School of Nursing offers the only master’s-level nurse-midwifery program in the state of Tennessee. Its clinical practice is the only one in Nashville where certified nurse-midwives deliver full-scope care to low-risk mothers.

Vanderbilt School of Nursing offers one of only 38 fully accredited nurse-midwifery programs in the United States, says Francie Likis, BS’93, MSN’94, associate director of graduate studies for Vanderbilt’s Institute for Medicine and Public Health and editor-in-chief of the Journal of Midwifery & Women’s Health.

Since 1996, 168 master’s-level nurse-midwives have graduated from the VUSN program; 44 nurse-midwifery students are currently enrolled. Vanderbilt nurse-midwifery alumni practice all around the United States and internationally. They have won numerous awards, including the ACNM’s prestigious Kitty Ernst Award, which has been presented to both Likis and Julia Phillippi, MSN’99, instructor in the School of Nursing.

Role Reversal

Nurse-midwives at Vanderbilt play a major role not only in labor and delivery but also in educating Vanderbilt University School of Medicine residents. In the Division of Midwifery and Advanced Practice (MWAP), experienced nurse-midwives serve on the faculty, teaching obstetrics residents how to manage and deliver babies to low-risk mothers. MWAP is the first School of Medicine division completely staffed by non-physicians. It includes six certified nurse-midwives and seven women’s health nurse practitioners, according to director Deborah Wage, MSN’91, CNM, assistant professor of obstetrics and gynecology. Wage developed the division in 2006 along with Dr. Nancy Chescheir, then chair of the ob/gyn department.

Wage and her colleagues are integrating the midwifery model of care into the School of Medicine’s academic program—an approach that has proven successful at many of the top schools of medicine, including Brown, Duke and Tufts universities.

(For more about the important role that certified nurse-midwives play in the education of medical residents, view the July–August 2009 issue of the Journal of Midwifery & Women’s Health, including a paper by Wage co-authored with Assistant Professor Angela Wilson-Liveryman, CNM, and Joan Slager.)

“When we are in labor and delivery, we function as the ‘gatekeeper’ and have constant interaction as sort of a team leader among patients, residents, nursing staff and our M.D. colleagues,” explains Wage. “It is a very busy and robust role.

“Our goal is to give the residents more hands-on experience with normal obstetrics. In cases of high-risk patients, midwives team with perinatalogists, with the nurse-midwife providing for collaboration.”

“It’s a win-win situation,” observes Dr. Frank Boehm, MD’65, professor and vice chair of the Vanderbilt Department of Obstetrics and Gynecology. “Nurse-midwifery is a wonderful addition to our department and hospital. They deliver low-risk pregnant patients and, in the event that low-risk status turns into a high-risk situation, the many resources of Vanderbilt staff and technology are there to help.”

Dr. Howard Jones III, the Betty and Lonnie S. Burnett Chairman of Obstetrics and Gynecology, concurs. “At Vanderbilt our nurse-midwives are a very valuable group of faculty members. They have a special ability to connect with and educate patients.”

Jones also points to one of the challenges posed by nurse-midwives. “At some point certain patients will need Caesareans or other interventions. It is very important for nurse-midwives to have a good relationship with obstetrician consultants. By and large we meet that challenge very well.”

Wage has received a $1 million grant from the state of Tennessee to institute a new prenatal care and educational program called Centering Pregnancy. A model that provides care to patients of similar gestational ages in a group setting, Centering Pregnancy is used at the ob/gyn department’s satellite clinic at Nashville’s 100 Oaks shopping center. The Tennessee Chapter of the March of Dimes is also funding a similar program at the Vine Hill/Franklin Road Community Clinic in Nashville’s Melrose area.

While new to Vanderbilt, Centering Pregnancy has been used at other medical centers for about 10 years. “It has a track record of improving perinatal outcomes,” Wage says. “We believe residents will take this model with them when they leave Vanderbilt.”

Care Across the Lifespan

Vanderbilt School of Nursing’s nurse-midwifery specialty prepares students to manage the obstetric and primary health-care needs of women across the lifespan, as well as care for the typical newborn. Students who opt for the dual midwife/family nurse practitioner program are qualified to care for both the woman and her family. VUSN graduates also are eligible to take the national board certification exam.

VUSN supports clinics at two sites: the West End Women’s Health Center and the Vine Hill/Franklin Road Community Clinic. The university owns the West End site, where the mostly Caucasian patients have an average age of 30, are often college educated, and are generally covered by commercial health insurance.

Vine Hill/Franklin Road is a federally qualified health center owned by University Community Health Services Inc. The company contracts with VUSN nurse-midwives to provide care for their patients, many of whom are African Americans or immigrants with an average age of 26. Most are underserved and either uninsured or covered by TennCare, the state’s Medicaid program.

Patients at both sites range from teenagers to women in their 40s. The nurse-midwives also provide primary gynecological care, including pap smears, breast examinations, and referrals for mammograms and bone-density tests for osteoporosis.

Professional fees are based on a sliding scale. The maximum charge for an uncomplicated labor and delivery by a certified nurse-midwife is $1,200, while the average insurance reimbursement for comprehensive obstetrical care is $3,000, says Tonia Moore-Davis, clinical practice manager of VUSN’s nurse-midwifery faculty practice. Hospital fees are extra.

“Patients can also save money by choosing nonmedicated deliveries; having fewer unnecessary tests, inductions and surgeries; and shortened hospital stays,” Moore-Davis says.

When a woman like Tisha Holloway chooses to see a nurse-midwife, she is followed closely, just as she would be by a physician. Her weight, blood pressure and baby’s size are checked with each office visit. However, she only receives and pays for laboratory tests that are necessary for her individual situation. Repeated ultrasounds and unnecessary blood tests are rarely ordered, but women may choose genetic counseling and amniocentesis if desired.

“We believe that pregnancy and birth are typically normal, healthy events,” says Mavis Schorn, associate professor of nursing and director of nurse-midwifery at the School of Nursing. “We include the woman in decisions about her pregnancy and birth. We strive to prevent complications through prenatal education about such issues as appropriate weight gain to decrease the incidence of pregnancy-related diabetes and high blood pressure.”

Nurse-Midwives and Health-Care Reform

Studies show that childbirth in the United States routinely involves relatively low nurse-midwifery rates, high Caesarean-section rates, and high neonatal death rates. According to the Milbank Foundation, childbirth is the leading cause of hospitalization in the U.S., and Caesarean sections are the most common operating-room procedures. Pregnancy and delivery are the most costly hospital conditions for both Medicaid and private insurers, followed by care for newborns.

“The United States spends a substantial portion of its health-care dollars on maternity care with no improvement in perinatal outcomes,” wrote Francie Likis in a 2009 Journal of Midwifery & Women’s Health editorial. “In addition, some maternity-care trends in this country are associated with an increase in adverse outcomes. For example, the rate of Caesarean deliveries continues to increase annually despite evidence that this major surgery is overused and has associated health risks for both the mother and newborn.”

Nurse-midwives have the potential to save money for mothers, hospitals and society by providing low-intervention, high-quality health care for less money. “Certified nurse-midwife patients have shorter lengths of stay, fewer NICU admissions, lower C-section rates, fewer low-birth-weight infants and higher breastfeeding rates,” says Moore-Davis. “Those are all measures that translate to less health-care expense.”

According to the ACNM, certified nurse-midwives and certified midwives assist in 11 percent of vaginal births. If midwifery is safe and cost effective, why isn’t it more widespread?

“Nurse-midwives face several barriers to practice, particularly in the Southeast,” says Professor Schorn. “Some insurance plans don’t cover our services. Tennessee laws mandate that nurse-midwives must be under a physician’s supervision to write prescriptions. In addition, hospitals are not required to grant us admitting privileges even with appropriate credentials.

“The ACNM is working with Congress to remove various barriers in order to improve women’s health care and allow nurse-midwives to practice to the full extent of their education and training,” she continues. “But it’s very important that our alumni become involved in the current health-care debate.”

The current debate is more about health-care financing than health-care reform, says VUSN Dean Conway-Welch. “Before we address health-cost reform, we must address the non-system of health care in this country. We need to have the right provider at the right time giving the right care to the right patient for the right reason at the right cost.”

For women with low-risk pregnancies, that provider just might be a certified nurse-midwife.