Article from the Allegheny Medical Medical Society Bulletin, June 9, 2001
Tammy Medsger, 33, of Bloomfield wanted a different experience for the birth of her third child. After delivering her first two children in a hospital with the assistance of obstetricians (OB) who were part of large practices, she wanted a more personal experience.
Medsger, a social worker, chose a midwife at the Midwife Center for Birth and Women’s Health, a free-standing birth center once attached to Allegheny General Hospital (AGH). Medsger said her prenatal visits were typically 30 minutes, compared to about five minutes with the OB she saw during her first two pregnancies. “I appreciated the more holistic approach. They (midwives) recognized my health was related to my whole well-being,” she said.
Medsger, a self-employed social worker, chose a midwife at the Midwife Center for Birth and Women’s Health, a free-standing birth center once attached to Allegheny General Hospital (AGH). Medsger said her prenatal visits were typically 30 minutes, compared to about five minutes with the OB visits for her first two births. “I appreciated the more holistic approach. They (midwives) recognized my health was related to my whole well-being,” she said.
And her birth experience was very different than a traditional in-hospital delivery. While in labor, she was allowed to relax in a hot tub—even after her water broke, and was permitted to light candles, listen to music, eat and even sip wine. “I got to choose what the birth experience would be like,” she said. Medsger had no fetal monitor, no IV, and no epidural, although she did have a shot of a mild narcotic. After the birth, she and her husband slept in the large bed where she delivered her baby.
But her birth experience was not without some conventional medical care. Medsger was seen by a perinatologist when she was diagnosed with gestational hypertension in her third trimester, and her son, Tyler, who was born with a cleft palate, was examined by a neonatologist after birth and ultimately admitted into intensive care at AGH.
Certified nurse midwives (C.N.M.) have worked in the Pittsburgh area for many years, and yet remain relatively uncommon, despite the fact that the practice is on the rise nationally. The Health Policy Institute at the Medical College of Wisconsin estimates there were 9,766 midwives practicing in 2000, compared with 5,150 in 1995.
Some believe their rarity is due to lack of demand from patients, while proponents of the practice counter it is due to pressure from the physician community.
Obstetrician Robert W. Ford, M.D., said he believes that the small presence of midwives here is directly due to lack of demand from patients. He believes that midwives may be qualified to deliver babies in low-risk cases, but that they don’t have the knowledge or experience to handle unexpected occurrences. “What about making an episiotomy, delivering a placenta? What about postpartum care? ” he asked. “Medical decisions are best made by an OB.”
Some physicians disagree. Perinatologist Ron Thomas, M.D., believes using midwives allows physicians to take care of the higher-risk cases and spend more time with their patients. His collaborative agreement with the midwives at AGH means that he signs off on their protocol and that he is willing to accept patients who are transferred to labor and delivery. Christine Tyndall, M.D., an OB who worked with midwives at Magee and UPMC Shadyside, also believes midwives can offer a viable alternative if the mother-to-be is having a normal delivery. But she knows that many colleagues—she estimates 80 percent—disagree.
Kathy McKain, C.N.M., who is one of five midwives at the Midwife Center, said working in Pittsburgh is more difficult than in other markets, like Philadelphia, where she received her master’s degree and midwifery certificate from University of Pennsylvania. “When you have a highly rated program you have more of those kinds of professionals,” she said. She believes the hurdles here are due to a myriad of factors. “In this city, there is less support for midwifery from physicians, insurance companies and hospital administrators, ” said McKain, whose midwifery group delivers about 200 babies per year.
Midwives are usually registered nurses with advanced degrees in midwifery who can deliver care in and out of hospitals. In Pennsylvania, all certified nurse midwives must pass state boards and be licensed by the State Board of Medicine. State law also requires all midwives to have a collaborative agreement with a physician. And they are licensed as nurses through the State Board of Nursing. Some direct-entry midwives, however, are not registered nurses, but are instead educated in midwifery through self-study, apprenticeship, midwifery school or a college-based program distinct from nursing. They usually deliver babies outside of hospitals.
Patrick Thorton, R.N., 43, a rare male C.N.M. who practices in Regent Square, worked for years as an obstetrical nurse prior to becoming a midwife. He agrees that the use of midwives is relatively low in the Greater Pittsburgh area. “We had a bigger presence in the healthcare community in Charleston, West Virginia,” said Thorton, who started his practice there and now delivers babies at Magee Women’s Hospital and UPMC Shadyside.
Thorton admits there are many misconceptions surrounding the practice of midwifery. One myth is that they do not carry malpractice insurance and that the responsibility for their work is carried by physicians. Unlike some limited licensed practitioners (LLPs), midwives do, in fact, carry mandatory malpractice insurance that amounts to $500,000 per occurrence and $1.5 million aggregate. Obstetrician/gynecologists, like all physicians, are required to carry $1.2 million in aggregate insurance. And midwives, like physicians, have to undergo a certification process and acquire admitting privileges at the hospitals in which they work.
Another misconception is that patients who use midwives must have a completely “natural” birth. Thorton countered that his patients can have anesthesia, including an epidural, but added that the use of medications is lower in patients who choose to be delivered by midwives. He credits this to the personal attention and emotional support that midwives offer their patients. “When the patient has support, their need for other kinds of pain relief diminishes.” He said that close relationship spurs some patients to stay in touch for months, even years, after their deliveries. Midwives, too, say that such a relationship is rewarding. “I love it. There’s nothing else I’d rather do,” he said.
Dr. Ford believes that midwives may provide more “attentive care” than some, but not all, obstetricians. He advises patients to be selective in choosing a doctor and said that women need to weigh whether the personalized attention is worth using a less-trained practitioner. Some patients also enlist the services of a doula, a non-clinical person who provides physical and emotional support during the birth, but Dr. Ford feels that sometimes they can “get in the way” of the skilled obstetrical nurse.
With Pittsburgh’s two free-standing midwifery birth centers having closed, including Birth Place, affiliated with West Penn, and the Midwife Center at AGH, whether midwives offer a viable alternative to traditional delivery is debatable, since most babies delivered by midwives are delivered in hospitals.
AGH spokesman Tom Chakurda said financial challenges caused the hospital to “channel resources into core programs.” He added that the hospital took time to phase out the center that ultimately closed last October in order to accommodate patients who were planning to deliver their babies there. The facility had been located in the hospital’s continuing care center adjacent to the hospital to make way for the development of a cancer center. “We can’t be all things to all people,” Chakurda said, adding that few hospital-based midwifery facilities exist.
McKain, who formerly worked at Birth Place, said her group still has privileges at AGH and conducts ambulatory care such as prenatal exams at an office near AGH on East Ohio Street until they can develop a new midwifery center in the Avery Building adjacent to the hospital. She said they are continuing to deliver babies at the hospital, as well as at patients’ homes. McKain said that midwives who delivered babies at the birth center had more autonomy and could offer their patients the use of special features, such as hot tubs in which to relax, options that are no longer available since the center’s closing.
Robert L. Thompson, M.D., obstetrician/gynecologist, maintains a neutral position on midwifery. He said he is not sure if hospital-based midwifery offers a real alternative to traditional physician-assisted deliveries, now that the birth centers have closed. He believes home births do offer an alternative, but with additional risks. “I don’t believe in telling people what to do, but there are some risks associated with those choices.”
Dr. Thompson likened the role of the obstetrician to that of firemen—there may be some time waiting, but when they’re needed, they’re needed quickly. Dr. Ford agrees that the nature of childbirth is unpredictable and the physician’s advanced medical experience may be called upon immediately. “Every OB case is potentially a high risk case,” he said.
Dr. Ford, who has been on medical missions overseas, said he knows that midwives in third world countries do a good job delivering babies, but he isn’t sure why a patient would choose one here when the standards in this affluent industrialized nation call for a highly-skilled OB. He also questions whether some procedures they use may be beyond the midwives’ scope of practice.
McKain said midwives in her practice have experienced emergencies and had to transfer a patient who was delivering at home to a hospital. She said the availability of 911 and ambulance services are always established prior to the birth. She said in complex cases, such as twins, she works along with Dr. Thomas. “Two sets of skilled hands are helpful,” she said.
Midwives say that statistics indicate their patients do not face increased health risks. According to Thorton, statistics from the National Center for Health Statistics through the Citizens Democracy Corps, show the risk of experiencing an infant death is 19 percent lower for certified nurse midwives, the risk of delivering a low birthweight infant is 31 percent lower, and that midwifery patients had fewer Caesarean sections and episiotomies.
Dr. Ford, however, believes those statistics are biased because of the low-risk type of patient the midwives see. Peter Schwartz, M.D., chair of the Pennsylvania Section of the American College of Obstetrics and Gynecology, and chair of the obstetrics department at the Reading Hospital and Medical Center, said he does not believe that any data is available that distinguishes the quality of care between physicians and midwives. “I believe midwives are an enormous adjunct to the practice of obstetrics,” he said, adding that his preferred model of care for patients is one in which the midwife collaborates with the physician. But Dr. Thomas believes those statistics are telling.
Both sides agree that physicians are the obvious choice for high risk pregnancies and any situation requiring surgery. Thorton said, “It is important that I can call someone with my questions.” Midwives are not allowed to perform Caesarean sections, surgical deliveries or use forceps in Pennsylvania. They may perform episiotomies, although they use them infrequently.
Reimbursement for child birth is also a hot topic in this realm, as it is throughout medicine. Dr. Ford believes that health maintenance organizations in some areas may encourage patients to use the services of a midwife, because they can reimburse a midwife less than a physician. But in Pittsburgh, midwives are paid comparably to an obstetrician, a point of contention with some physicians. Dr. Tyndall said one colleague commented at a UPMC Shady-side staff meeting, “Why did I go to medical school?”
Highmark spokeswoman Denise Grabner said, for patients with managed care, the company reimburses physicians and midwives the same amount for a delivery, an amount that is constant across all managed care products. Highmark also pays other LLPs the same fee as physicians when performing the same procedure on their managed care products. For instance, podiatrists, chiropractors and physical therapists are paid the same as orthopedic surgeons when performing the same procedures, as long as the procedures are within their scope of practice.
Physicians are paid approximately 30 percent more than midwives if the patient has indemnity insurance. Grabner said that is based on the usual, customary and reasonable (UCR) rates that reflect the fact that midwives charge less than physicians. She said the company is filing with the Commonwealth’s Insurance Commission to make those fees equal.
McKain declined to reveal what she is paid, but did say that midwives make significantly less than physicians because they see fewer patients. The American Academy of Nurse Midwives were unable to provide compensation information by presstime.
Both physicians and midwives say they are under a certain amount of pressure from the patient population to deliver what is not always possible—a healthy, perfect baby. Dr. Ford said the huge verdicts in obstetrical cases in Philadelphia are proof that the public is becoming increasingly demanding. He believes physicians are often sued for a birth defect when not to blame. “The public is demanding perfection, and obstetrics is a profession that deals with imperfection,” he said.
Lisa Petzel is director of communications for the Allegheny County Medical Society.
This article is reprinted with permission from the Allegheny County Medical Society. It first appeared in the ACMS Bulletin on June 9, 2001. Visit the Society on the Web at www.acms.org
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Featured in the Expectant Mother's Guide to Pittsburgh
What is a Certified Nurse Midwife?
When people think of midwives, they usually think of birth at home and without pain relief. Most women are surprised to learn that the majority of certified nurse midwives (CNMs) deliver in hospitals, have access to epidurals and other pain medications, and work cooperatively with physicians.
CNMs are registered nurses (RNs) who have graduate degrees in midwifery. This means that the same nurse who comforts you through labor, cares for you afterward, and helps you start breast feeding can also provide prenatal care, deliver your baby, and do yearly check-ups.
Licensed in all 50 states, CNMs are helping a growing number of babies into the world. From less than 20,000 (about 1%) of all American babies born in 1975 to almost 300,000 (9%) as of 1998, midwives are becoming fixtures in birthing suites around the country.
Most states (including Pennsylvania) require a formal agreement between midwives and a physician who can provide surgical care in emergencies. Obstetricians may also provide consultations for certain complications of pregnancy. Exact arrangements vary from practice to practice. Some midwives work as adjuncts to physician or hospital practices. Others own independent practices and are relatively autonomous.
Some unique values underlie midwifery education and practice. First, CNMs view birth as a healthy and normal process. While complications can occur, pregnancy and birth are not diseases. Even when medical intervention is needed, normal events take place which deserve support: the birth or growth of a family, the need for time out and bonding, and hundreds of household and lifestyle adjustments. CNMs are trained to focus on these healthy processes while keeping guard against possible medical problems.
Another value is family and woman centered care. Appointments are longer than average in order to facilitate personal rapport and communication. There is no short cut to getting to know who you are, how you feel about your pregnancy, and what you want for your birth. Midwives generally remain with women in labor rather than staying in touch with staff by phone. This allows close monitoring for problems while actively supporting the natural course of birth. That doesn’t mean you can’t have pain medication, just that you will have other kinds of support as well. This additional support can be lacking in busy, emergency oriented hospitals.
There is ample research indicating that this kind of close, personal attention from care givers is more than a pleasant luxury. It actually improves outcomes for moms and babies: fewer cesarean sections, less pain in birth, shorter labors, less physical trauma. Cesarean birth rates are generally under 10% among CNMs while the national average is over 20 percent.
Since differences exist in the style and scope of midwifery practices, they should be discussed before selecting one. Find out where the CNM practices and who the collaborating physicians are. How many people share in the call arrangements and who are they? Is there always a midwife on call? What situations would require physician collaboration, and how involved would the midwife remain? Examples might include preterm labor, high blood pressure, diabetes, or preexisting medical conditions. And certain questions pertain to choosing any provider such as: cesarean and episiotomy rates, insurance coverage.
From the Pittsburgh Boomers newsletter, August 2000 edition (used by permission):
Midwifery: Not Just for Babies -- An Alternative Choice in Women's Health Care
by Kim Anastas
When most people hear the word midwife, they think of a home birthing experience. While not untrue, midwifery is much, much more. And, not exactly what you may think.
Patrick Thornton, who has a master's degree in nursing from Case Western Reserve University, is a certified nurse midwife (CNM), who last year established Women's Health Options Network, the only midwife practice in western Pennsylvania.
As a midwife, Thornton does deliver babies -- although he does so in hospitals. He also offers a holistic approach to complete gynecologic care, including: health counseling; yearly exams and pap tests; lab tests and prescriptions; hormone and alternative menopause care; and treatment for infections and bleeding problems.
Since opening Women's Health Options Network in Regent Square last October, Thornton has delivered four babies and has another nine scheduled through the end of the year. He also has built his gynecologic client base to nearly 30 patients. He continues to get patients referred to him from other patients.
Pat Varlashkin, 56, of Glenshaw, recommends Thornton whenever she can. "He offers very individualized care. You feel as if you're involved in a partnership. I wish I had more friends to whom I could refer him," she says.
A registered nurse, Varlashkin says Thornton, is "very competent. And, as a nurse, I'm very hard to please about health care."
A menopausal patient of Thornton's since October 1999, Varlashkin recalls, "When I met him, I was so delighted with the way he viewed health care. He practices health care the way it should be practices. The amount of time and attention he gives his patients is unbelievable. My initial assessment (with Thornton) was the most thorough I've had in 50 years."
Even more important than the time he spends, Varlashkin says Thornton really knows a lot about menopause. She suffered with menopausal bleeding for a long time and sought help from several doctors to no avail. "Patrick talked to me for a long time about my problem and eventually he solved it with me. He's wonderful!"
Varlashkin is very happy with her choice of Thornton as her primary caregiver. She's also pleasantly surprised. "Being an R.N., I didn't even know midwives did anything beyond deliver babies."
At Women's Health Options Network, women can receive complete care, including annual gynecological exams, mammograms, cancer screening, bone density testing and hormone replacement therapy.
Thornton says certified nurse midwives can do "basically anything a gynecologist can do, except surgery."
Being a midwife has been very rewarding for Thornton. He considered going to medical school at one point, but did not want to give up the nursing aspects of his job. He enjoys the people contact too much.
That desire for human contact has become the cornerstone of his practice.
Thornton is the sole care provider in his practice and spends a lot of extra time "focusing on communication."
A midwife is with a woman in labor from beginning to end which, in some cases, can be a very long time. Thornton's philosophy is that when you spend that much time with someone during a very personal experience, you want to know them rather well.
In a delivery room, nurses do most of the preparation for delivery, as well as the handholding. A midwife does that plus the delivery.
"I spend the entire time with the patient and her family or significant others, dealing with the labor, answering questions, talking about how the patient's doing.
The one-on-one human care is very important. People are more relaxed, less stressed and typically need and ask for less medication" in such an environment, says Thornton.
Christine McFarland, 29, of Swissvale, agrees. Thornton was McFarland's midwife and delivered Jake in January. She says Thornton was exactly what she wanted -- and needed -- from beginning to end.
"He typically spent 45 minutes to an hour with me during every visit," says McFarland of her prenatal visits. when the delivery day came, "Patrick met us at the hospital at 6:00 on a Friday night. He stayed all night, even though we knew I wasn't going to be induced until 7 a.m. Saturday. He checked on me throughout the night and was great throughout the delivery.
"Patrick even gave me a nice foot massage," recalls McFarland. "He's very compassionate. I plan on going back to him to have the rest of my kids."
McFarland says Thornton's commitment to her and her baby's care did not end after the delivery. When she had trouble breastfeeding, Thornton helped her during an office visit. He also made a house call and put her in touch with a lactation consultant.
Thornton says his network of experts, including lactation consultants, physicians, pharmacists, yoga and massage therapists and dietitians is vital to making his patients feel like they are in good hands. Collaboration with a physician is especially important if there's a risk-factor involved.
Midwives are required by law to have a written agreement with physicians to collaborate with midwives to share the patient or accept referrals (for surgery, for example).
McFarland says Thornton's confidence in what he does is evident but also evident is his concern that he is giving his patients the best care that he possibly can.
McFarland developed pre-eclampsia during her pregnancy. Although Thornton's advice was always correct in McFarland's case, he continued to confer with a physician to make sure he was giving the right advice and following the proper course of care.
Women's Health Options Network accepts most insurance plans. Office hours are by appointment.
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