The New Generation of Providers

CNMs: "We don't just catch babies"

These nurse midwives had a hard time winning physician acceptance. Now they're not only accepted, but sought after.

By Anita J. Slomski
Group Practice Editor

Sandra Williamson's birthing center in Orlando, FL, had been running for four years when she and the midwives she employed applied for admitting privileges at the local hospital. That was in 1990. Three years later, the hospital finally said Yes—but with the stipulation that Williamson pay a doctor to be present when any of the midwives delivered a baby.

Only after she sued the hospital for engaging in antitrust and restraint of trade did Williamson gain no-strings-attached admitting privileges. By that time, another two years had passed. The opposition to her was purely economic, Williamson explains: "There is a glut of ob/gyns in Orlando, and nurse midwives are seen as competition."

While Williamson was fighting for admitting privileges, Kathryn Harrod was commuting 117 miles round trip to a physician's practice in Milwaukee because no doctor in her community would hire a nurse midwife. After enduring the commute for 10 years, Harrod, who has a doctorate degree in nursing and teaches in the nurse midwifery program at Marquette University, found a job with a small, multispecialty practice owned by Aurora Health Care. The practice's ob/gyn had worked with midwives in the Air Force and wasn't threatened by them. "He actually calls me his partner on occasion," says Harrod.

Not all the area doctors were as open-minded, as Harrod discovered when she applied for hospital privileges. "A few physicians told the hospital administrators that they wouldn't assist me if I had an emergency on the unit," Harrod recalls. But when she quietly delivered a teenage mother for an obstetrician who hadn't yet arrived—and didn't charge for it—she earned the physicians' respect. "I had to show them that I was safe and wasn't doing crazy things," she says. "Now these doctors provide backup care for my patients." And the hospital has added a whirlpool and double bed to the unit she uses to attend births.

Although her ob/gyn partner has 65 percent of the OB patients in the practice, Harrod estimates she handles 60 percent of the births, since she delivers all her own patients and splits call with the doctor. Practicing with a physician widens, rather than limits, her practice's scope, she says. "I'm doing things I never would have done on my own. I'm his first assist for C-sections, and I do circumcisions now, which I swore I'd never do. And instead of referring diabetic patients out, I co-manage them with the physician."

Harrod also gives public lectures about perimenopause, which brings more patients to her practice. "I allocate 50 minutes for new patients, and I spend much of that time listening to them," she says. "I've had 50-year-old women say that no one has ever listened to them so attentively before." That willingness to spend time with patients is why FPs refer women with difficult-to-treat yeast infections to her, as well as women who want a midwife-attended birth. (In 1997—the most recent year for which data are available—nurse midwives attended 7 percent of all births in the US.)

Pregnant women who request a midwife are generally those who ascribe to a no-interventions philosophy of birth. But not always, according to Harrod. "One of my pregnant patients recently went on and on about how she appreciated the amount of time I spend with her, then said she wanted an epidural during delivery. My jaw dropped, but this is her pregnancy, not mine. I was, however, able to talk her into at least trying to deliver without the big-gun interventions."

At Williamson's Special Beginnings Birth and Gynecology Center, which does 15 to 25 deliveries a month, midwives stay with patients throughout labor, even if the mother is transferred to the hospital. "We don't rush in and catch babies at the last minute like some OBs do," says Williamson. "We also don't separate mother and baby after the delivery." Williamson boasts of a C-section rate of only 4 to 5 percent (in contrast to an almost 21 percent national rate), and equally low episiotomy and medication rates. About 16 percent of the birthing center's patients transfer to the hospital to deliver, primarily for oxytocin induction.

Williamson can't say enough good things about the group of ob/gyns she and her midwives consult with. "Midwives and OBs working together are a great team. A physician and I recently handled a marvelous breech birth at the hospital." And doctors also benefit from close association with midwives. "We are a significant source of patients to physicians because we refer all our abnormal gynecology problems and surgeries to them," says Williamson.

Nurse midwives do manage to spark ire in physicians because their goal is not to duplicate what doctors do, but rather to change the birthing process. So it gives Williamson immense satisfaction to report that one of the ob/gyns who led the battle to keep her out of the hospital 10 years ago is now seeking a nurse midwife for his own practice.

As for Harrod, she's happy she's finally able to realize the "gift of taking care of women in my community. This is my dream."

. CNMs: "We don't just catch babies".

Medical Economics

2000;6:186.