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nurses job growth

Midwifery offers
nurses job growth

If so, read on. The name of the midwifery game has changed significantly in the last 20 years. Since 1971, when the profession officially was recognized by the American College of Obstetrics and Gynecology, the number of certified nurse-midwives in this country has grown to approximately 5,600–4,000 of whom are in active practice. Also since 1971, the number of nationally accredited midwife educational programs has grown from just nine to nearly 50.
The profession had suffered decades of decline due to few educational opportunities, isolation from the rest of the medical community and a mistaken perception that midwifery was the cause of high infant-mortality rates among early European immigrants. But interest was renewed when statistics accumulated showing improved infant- and maternal- mortality rates, notes a November 1995 study conducted by the Public Citizens Health Research Group.
In fact, this same study suggested that nurse-midwives were a key, positive determinant in the future of obstetric care in the United States because of the profession’s contribution to cutting health care costs while providing quality patient care.
The midwifery profession began gaining strength in the Rochester area due largely to the efforts of Henry Thiede M.D., former chairman of the department of obstetrics at Strong Memorial Hospital, says Elizabeth Cooper, director of midwifery services for the University of Rochester Medical Center and the first midwife in Rochester.
Cooper says Thiede was sold on the benefits of midwifery during a stint at the University of Mississippi, where midwives succeeded in halfing infant-mortality rates among poor rural women. Originally from Rochester, Thiede returned to Strong in 1974, bringing with him his fervor for the midwifery profession.
He recruited Cooper as the first Rochester-area midwife. She joined him in private practice and became a member of the faculty of Strong’s Department of Obstetrics and Gynecology, where she has been ever since.
Cooper describes the 1980s as a rough time for the profession due to the unavailability of government funding and difficulties in obtaining malpractice insurance. The 1990s, however, have resulted in an “enormous upswing.” There are five full-time and two part- time nurse-midwives on board at Strong.
In addition to their private practices treating middle-class insured women, the midwives staff and deliver all babies for Strong’s teen clinic, and rotate house duty with Strong’s residents, serving the large medically indigent population.
Phyllis Leppert M.D., chairwoman of obstetrics and gynecology at Rochester General Hospital and another local leader in developing the profession, says midwives are licensed professionals who handle normal obstetrics, with doctors trained to handle complicated births.
“(Nurse-midwives) are very much involved in working collaboratively with physicians. Normal births are their scope,” she says.
Normal is the operative word. According to the Public Citizens study, the profession’s philosophy revolves around the concept of the “normality of childbirth and the judicious use of technological interventions.”
Indeed, Caroline Burtner, director of midwifery for Rochester General, maintains that the profession has attracted an unusually high number of anthropology majors who choose midwifery because of its role in a social context, specifically that birth is a normal, social event, not the “medical event” into which it has evolved during this century. People want more control over their entire lives, including the birth of their children, Burtner says.
Some local obstetrics practices choose not to offer a midwife’s services, citing demographic factors–not much of a demand among their patients–or a belief that the practice already offers holistic care.
Judith Kerpelman M.D., whose practice in Greece and Webster does not include a midwife, adds that when complications develop, she feels it is advantageous for patients to remain with the original caregiver, rather than be transferred from a midwife’s care to that of a physician.
“(We do not offer midwife services) not because we don’t believe in midwives,” says Kerpelman, who calls herself pro- midwife, “but because we feel we offer patients comprehensive-enough-type care.”
Midwifery in either a hospital, freestanding birth center or home setting offers continuous one-on-one care and coaching throughout the entire birth process. But, unlike the midwifery myths of backroom home births, Burtner says 95 percent of the local births attended by nurse-midwives acting as primary-care providers occur in the hospital.
Still, she notes: “There is a fear, a false sense that the hospital is a safer place to be during birth. According to studies by the National Academy of Sciences, it is the practitioner at birth that makes the birth safe.”
Technology’s role, as described in the Public Citizens study, can vary:
“Certainly, the appropriate use of obstetric procedures has added an important measure of safety to the labor and delivery process for both mothers and infants who demonstrate need. It is the near blanket use of technologies developed (specifically) for high-risk cases that gives us pause.”
For example, the study claims that the American College of Obstetrics and Gynecology does not recommend the use of ultrasound for routine pregnancy; yet, in 1992, 58 percent of expectant mothers had one. Nor does ACOG recommend electronic fetal monitoring for routine labor; yet, in that same year, 77 percent of laboring women had the procedure while they labored.
Leppert says the Rochester General obstetrics program includes 10 nurse-midwives who take rotation turns and function at an equal level with first- and second-year medical residents. In addition to hospital care, the program offers services at the women’s center in the medical office building adjacent to the hospital, at a satellite office at Bay Creek in Webster and at the Rochester Birthplace on Culver Road, the only freestanding birth center in the area.
Leppert stresses that the Rochester General program is collaborative in nature, and that the nurse-midwives function primarily within the scope of normal obstetric and gynecological care, sometimes co-managing higher-risk cases with a physician.
St. Mary’s Hospital, which has offered midwifery for 13 years, currently offers the services of three nurse-midwives, one of whom performs home deliveries, says Ann Wright, nurse manager for the hospital’s obstetrics unit. Midwifery services are available at the hospital’s Corn Hill, Family Health Associates, Thurston Road and Cameron Street satellite facilities.
Spokeswoman Nadia Bolalek at the Genesee Hospital says availability of a nurse-midwifery program at the hospital is imminent. She says development of the program is consistent with the hospital’s overall goal of expanding women’s health-services options.
Highland Hospital does not offer a nurse-midwifery service. Park Ridge Hospital does not have a maternity unit.
Burtner points to a variety of reasons for the profession’s impressive growth.
For one, she notes, though time is a precious commodity in today’s medical profession, midwives spend a considerable amount of one-on-one time with their patients. In fact, she says the average patient visit lasts a half hour, and includes discussions with patients about diet, lifestyle, exercise and tests. Burtner also points out that the midwife stays with her patient throughout the birth.
Burtner attributes growth as well to the fact that many educated women go out of their way to seek the services of midwives because they like their one-on-one approach, which serves to empower women through education.
“It’s not just a “I-will-take-care-of-everything, don’t-worry’ approach,” Burtner explains, adding that the partnership approach midwives encourage gives women confidence that they can birth successfully with minimal intervention.
Minimizing unnecessary medical intervention is another reason for the rapid growth of the profession, advocates say. Many insurance carriers support midwifery with significant reimbursement policies because of their proven track record in reducing costly and sometimes unnecessary procedures, including Cesarean sections, episiotomies, oxytocin use to stimulate labor, and administration of epidural anesthesia.
One of the reasons midwives are more cost-effective, Burtner says, is that their liability costs are significantly less since they are not involved in complicated, high-risk procedures and surgery.
However, she adds, though some local insurance carriers have included nurse-midwives in their plans with full reimbursement, others have not been as generous. Blue Choice, for instance, offers only a two-thirds reimbursement for midwifery services. Burtner says the National Physician Payment Review Commission recommends a 90 percent reimbursement for nurse-midwifery services.
Another factor in the profession’s growth is a need for care among what Burtner describes as “vulnerable” populations–those in lower-income brackets who may or may not have health insurance. Traditionally, this segment of society has experienced worse than normal birth outcomes because of little or no care due to a lack of insurance and the refusal of many doctors to take them on.
But the nurse-midwives take them on, and because of a professional fee structure that averages 30 percent to 40 percent less than their physician counterparts, their practices have grown. So, too, have this population’s chances for positive outcomes–because midwives know when to consult with a physician and when to proceed with business as usual.
“A high percentage of the physicians deal with the middle class where the competition is keen. This is not so with the uninsured and vulnerable,” Burtner contends.
The American College of Nurse-Midwives cites the following growth factors as well: parents wanting more control over the birthing experience; and nurses who see midwifery as an opportunity to advance within the nursing profession as well as practice a gratifying career.
Interestingly, according to the Public Citizens study, all of the developed nations that have lower infant-mortality rates than the United States–the United States ranks 22nd among countries with populations greater than 2.5 million–have some form of national health care, and most use midwifery to provide much prenatal and labor and delivery care.
Burtner sums up: “For 100 years physicians have been at the helm of health care. Midwives are an important part of (obstetric) care. They could be utilized even more to contain health care costs by providing primary care within their scope of care–(to) legally, safely manage women with low risk.”
(Mary Anne Wentworth is a Rochester-area free-lance writer.)


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