The Alabama Experience; With Women: Alabama Nurse Midwives

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . And that seems to be the primary factor that's been involved in having nurse midwives become more accepted as partners by physicians that there are these people that need care and

they may not be women who can pay for care for private insurance. So even though in our service here in Birmingham we have a private practice component where we take care of women who also have private insurance or who are private paid. It's a real positive factor from the system's point of view that we also provide some care, a lot of care in fact, to the women in Jefferson County who are dependent on Medicaid or who don't even have Medicaid. The feedback from patients thus far has been extremely positive and the nurse midwives are being sought out by public and private patients alike to give you a quick example. We have a patient that is now about 25 years old pregnant with the second baby. She had her first baby on the less than optimal condition at age 15 and had the opportunity to be delivered with a nurse midwife.

Okay, young teenage is scared as any 15 year olds will be 10 years later. She came to search for the nurse midwife to see if that service was still available because they have made such a positive impact on her life. The private practice that we have now is small and it's small because we've had to limit it. We haven't advertised at all. We've done nothing to let anybody know that we have this private practice and we get phone calls. We get phone calls from people of a town, other parts of the state, of the state. We just have a new patient who ran from the Virgin Islands, I'm not sure how she found about this but she was coming to Alabama and she wanted nurse midwifery care. Nurse midwives are professionally trained and educated. They've completed nursing school, either a certificate or a master's based nurse midwifery training program and passed a national certification exam. In Alabama, nurse midwives have been allowed to practice since 1976 but under strict guidelines. The physician has to be within a 30 minute access to wherever the nurse midwives deliver

in case of an emergency and of course that's a safety factor for the air again for the consumer, knowing that this is available. It also has some limitations as to one physician can be responsible for one nurse midwife. Well, we have a lack of physicians in the state so we are doing a one-to-one but that's not sufficient. There's more need that one physician can offer for a nurse midwife and that is starting to be a real problem with us here at the university and can really be a problem in other places where there aren't that many physicians and that's not part of the law it's just kind of an unwritten rule that's been enforced and it should be changed. It's perfectly reasonable to think that a physician can work collaboratively with a group of nurse midwives.

There you go. Drew Stealth was a brawner grew up in Europe where midwives have always been an important part of the healthcare system. In this country she's been something of a pioneer in her profession. In West Virginia, Drew's was the first nurse midwife to be granted hospital privileges. I graduated as a nurse in 1969 so I've been a nursing for twenty-plus years. I started out as a pediatric nurse. It did not really like it, it was not what I had hoped it would be and so I felt my next logical sequence was mommy and babies, I always enjoyed being with them and transferred to Labor and Delivery and I worked Labor and Delivery for eight years before I went back to school. It's a matter of fact when I first started in Labor and Delivery, mommy's were put to sleep. Daddy's were sent home, mommy's were sedated tremendously and woke up two or three days later and they told them they had a baby and they said, oh, big deal. But knowing from where I came from, where midwives always have been on the foreground

of delivering the babies, I thought this wasn't fair, this mommy's were missing something. So then the first nurse midwifery option was the most logical next sequence even though it was different in the United States and I was in Europe where I had grown up. Patient choose the nurse midwifery services because they prefer the one-to-one care. A nurse midwives on the average has more time to spend with the patient and takes more time because we do a lot of education, we feel if the patient is more educated, she is much better in compliance with our suggestions and will therefore have a better outcome. During the 14 years she's practiced, choose has delivered somewhere between a thousand and twelve hundred babies. Most of these birds, she says, have been smooth and without intervention. How smooth the delivery goes and the amount of intervention required depends largely on the expected mother.

First of all, I need to eliminate most of her fear. The fear makes her very tense, makes her very agitated and the more relaxed she is, the better and the faster this labor will go. So I need first of all to eliminate death and we usually try to do that by the prenatal classes. Then as labor start and she's starting having contractions, can in discomfort explain to her what is happening to her body, why is this hurting, what the baby is doing at that time, how the baby is probably even feeling even though that's a projection and then working with her each contraction, making the best of it, if she's uncomfortable on the right side, that's roller over to the left side, she would let her sit up, let her sit up, whatever is most comfortable, so trying to accommodate her needs and at the same time not compromising the well-being of this baby. And the fact that we are there and constantly we enforce, yes, you are doing a job you're

making, this much progress, it's, nobody say you can have a party, it's hard work but it's not the end of the world and I think this constantly we enforce when being with them when they need your most and they have to put your head on the shoulder or rub their back, then that can take the place for the medication that is otherwise used when the mommy is frightened and they don't have that support. Okay mommy, I need a little tiny push, it doesn't have to be a big one, we'll slow it up.

You can see it with a little bit of... It's from the bottom right here. You can see it with the bottom right here. That's Mewkuss. Oh, oh my god, you're a whole baby. And he is a boy! He is a baby. A little bit of a bear. A little bit of a bear. He's horrible, baby. Oh, he's supposed to be horrible. Give me a chance to breathe. We have a boy at 12.58. there you go give us a little more oh my god what's this? what's this? do you want to do a baby pearl? is this a baby pearl?

is this a baby pearl? is this a baby pearl? is this a baby pearl? yeah after all this year and I'm not talking about 14 years of delivering the babies at every time I get these pimples. It's almost like a miracle, again, every time, again when you have this complete, little, normal, you were being that, you know, you're the first one to hold. And so it's exciting every time you cannot take that away. I think that's the thrill and probably the personal satisfaction as we get doing this. Susan Rice is a Maryland native who's been a practicing nurse midwife for the past six years. My first job was in a community hospital in Salisbury, Maryland. They're the midwives delivered about 500 babies a year. It was an all-public patient's note. We did not have a private practice. I got some wonderful experience there because there wasn't a doctor in-house with us all the time. We always had someone back on our backup call

for consultation but they weren't always in the hospital. So we had a lot of freedom and we had to take a lot of responsibility. I worked there for two years and then I decided I wanted some international experience because ultimately that's my goal. It's to work overseas so I spent five months in the Marshall Islands as a consultant to the hospital there. Then I worked in Delaware for a year teaching nursing. Actually, that was my full-time job and then my hobby job was catching babies on the weekends. That was my fun job. But it also was to keep my hand and keep up to date on my skills. And then I came here after that. Well, I love my profession. I especially like taking care of these pregnant women and actually the low-income women because they need a lot more personal attention even than the private sector because they don't get a lot of personal attention. And often their knowledge level is not the same.

And I like teaching them things about their bodies and about their pregnancy. But my favorite part is catching the babies. Afterwards, I get my after-baby high and I'm just all excited and I can't go home and go to sleep. It's just really special. I still think birth is a miracle. I've caught over 300 babies now. And I still look at it as a miracle what this body, this woman's body can do to get this baby out. And I just think it's really special to be able to catch a baby. This little baby's born into my hands. I consider that a real privilege that the parents would trust me and let me share that intimate moment. I've been told that I probably shouldn't use that term because it makes it seem like my job's easy and there's nothing to it. But I really feel like the woman does the most of the work. She's the one who's in labor and uncomfortable and she's the one who pushes the baby out. And although there are interventions that I do to help her

and of course my biggest job is to monitor her for any problems and deal with those, she delivers the baby. And I catch it. I don't know that I have a favorite birth. They're all different and they're all special. But I have a funny story. When I was working in Maryland, we had very high labor beds. They set way high off the floor and I'm short. So in order to examine a patient internally, I had to sit on the bed with the patient. And I had a young teenager in labor one night having her first baby very frightened. And I went to do a vaginal exam on her and she kicked me off the bed. And I landed on the floor. I just picked myself up and actually it was pretty funny. We were trying not to laugh because we were afraid the patient would think we were laughing at her. Actually I was laughing at me. I thought it was great. She was a very strong young lady. So I learned from that experience the next time I did a vaginal exam on her.

I took three nurses with me and they helped me. One talked to her and the other two held her legs so she couldn't kick. One other story which is not a labor delivery story. When I was in Maryland, I had a woman come in for a normal prenatal visit and she brought her little five-year-old daughter with her. And so whenever I listened to the baby's heartbeat with a special Doppler, with stethoscope attached, I always asked the little kids if they want to hear. And this little girl said sure she wanted to hear. And she listened to the baby and she had a very puzzled expression on her face. So I was trying to get her to understand what she was listening to. So I asked her if she wanted to listen to her own heartbeat like the baby. Which she said yes. So she pulled up her shirt and we put the Doppler on her chest. And so every time after that, whenever I was in that clinic and she came with her mommy, as soon as she saw me she'd grin and pull up her shirt for me to listen. She was really cute.

The patient that leads, she was almost termed and her little boy came with her to a prenatal visit and we let him hear the baby for the first time and he was fascinated. And I think he was old enough, I believe he was about seven or eight. He was old enough to really understand what he was listening to. And he just thought that was great. That's his heartbeat. What do you think of that? Pretty neat, huh? Back in 1988, Susan's dedication to her work led her some 7,000 miles from home. She spent five months practicing in the Marshall Islands. There are about 2,000 miles southwest of Hawaii just north of the equator between the zero and tenth latitude. So it's very hot there, it's tropical, plenty of palm trees, beautiful palm trees, women labor differently there. They have adopted some of the American customs because there have been Americans on the island for years and years and years that started with the missionaries years ago.

Usually they come in active labor, very active labor. They lie flat on their back on the stretcher and they don't move anything. In fact, it was eerie, I had trouble getting used to not even knowing that they were having a contraction unless I put my hand on their abdomen. They don't make any noise. And in their culture, to make noise during labor or thrash about is viewed as the woman is weak and everybody laughs at her. Since there are Americans there, mostly white skinned Americans who they call rebellies. That means white skinned person. Anytime a rebellion was in labor, when I was there, they made me do the delivery because they don't know what to do with these women that are making noise. And so they'd say, you know, why do you people do that? Why do you rebelies do that? Why don't you just come in and have the baby? They were much more a matter of fact about it. And actually, I think they were able to relax well and it probably shortened their labor. The point he makes that I think...

Nancy Neal has been a nurse midwife for 11 years. These days, her time is split between teaching and doing research at UAB School of Public Health and taking care of patients in the nurse midwifery service. I grew up in Mirianna, Florida and went to college. I went to Auburn for a couple of years and then decided I wanted to become a nurse so I transferred to Emory in Atlanta. And while I was there, there were some nurse midwives and they got a nurse midwifery educational program started on the graduate level at Emory and I learned while I was here as an undergraduate what nurse midwives are and what they do. And I had a wonderful woman who was an instructor in maternal child nursing, Dr. Gene McGinity, and from working with her as an undergraduate and knowing about the nurse midwives and what they were doing on the graduate level I decided then that I wanted to be a nurse midwife. So I guess I graduated from Emory in 1977. And in 1979 went to University of Miami to get a master's degree in nurse midwifery. So I did that and when I finished I came here to Birmingham.

There was a private practice at the time, two nurse midwives who wanted to third nurse midwives and they were working at UAB. And I thought that this would be a great place to get some initial practice as a nurse midwife out of school because there was ready physician backup but it was easy to do the things that nurse midwives do without having physicians there in close proximity. There were there if you needed them but they weren't there hindering things. I came for a year maximum in 1918 and still here 11 years later. I think there's a real special connection that you build up with a family especially when you take care of the family during a prenatal vac course and then you're there for the birth. There's a real special connection. You share an incredible experience in the life of this family and there's still kids running around Birmingham who are 10 years old now. And they know that I'm the person who is there when they were born and it's really neat.

I haven't delivered that many because I've had a long span. Probably around 200, total. But the biggest baby was one that was born in the birth center in Florida when I worked there and this baby weighed 10 pounds above an ounces. It was born to a woman who was having her first baby and she did great. She had no PCI and no tears. She just had this huge baby. She did this and then this hand turns like this. She can kind of turn your body around so that you end up with both fingers pointed down. One other aspect of Nancy's job involves working with med students and nurse midwifery students in clinical practice. And with one hand on each side, you can feel a little more firmness on the side, complete firmness that goes from top to bottom, and more spaces here. Because it feels like the back is here and there would be spaces between feet and hands on that side. In addition to her work at the School of Public Health and in the nurse midwifery service,

Nancy, along with the other nurse midwives, has also assisted in UAB's nurse midwifery educational program, which began last fall. What I've done in the past with the one class who just finished is give some of the lectures and then with some students in the clinical practice area. The part that I enjoy the most is having students in the clinical practice area. That's just a lot of fun. And I anticipate that this program continues. That's often had the same sort of involvement. The service nurse midwives pretty much will be support for the educational practice. Because of the nature of their practice, it's impossible for a nurse midwife to deliver every patient she takes care of during the prenatal course. For Nancy, this is one of the tougher aspects of her job. Yeah, that's the hard part, because it would be fun to be able to complete the whole process with all of them and just can. And you'd be fun to be able when they say, well, you'd be there to do with my baby.

You'd be able to say, yeah, and know you're going to be there. So that's the downside. But until we can have enough nurse midwives here that we can staff, labor and delivery 24 hours a day, seven days a week for the public sector patients, we can't do it anymore than we're doing now. But hopefully we'll get to that point. I would hope that in 10 years that, first of all, all those counties that currently don't have any type of obstetrical service will at least have one or two nurse midwives to provide the prenatal care with the association of a physician to take over in case of an emergency. In other states, sure, midwives own birth centers. They have home birth practices, and they run it. And what they do in some instances is they employ a physician to act as their consultant. They're back up doctor for problems. So they pay him or her to be a consultant. But the midwives set everything. They run the whole business.

All the states that surround us geographically have out of hospital birthing centers. And they offer a real wonderful alternative service. The cost is usually lower because there's less intervention. The kind of care that's given here is almost a compromise to people who would want a home birth because the setting is more home-like than a hospital setting is. So my point of view is that one thing we need to work on here in the state is to change the law so that we can have some birthing center alternatives to offer birthing families. . . . .

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