Every now and again, my mother will look at my sisters and me with a self-satisfied little smile and declare, “I grew you girls!” Technically, she’s correct. She successfully performed one of nature’s coolest party tricks and produced three other healthy human lives. Furthermore, she suffered no birth-related injuries or residual complications (except for the mild mental derangement that most parents develop). Mom has every right to feel proud of her achievements. But the odds for such happy outcomes were stacked in her favor.
To begin with, my mother is one of a lucky handful of women in the history of the human species who received adequate prenatal care during her pregnancies. Even more remarkable, all of her births were attended by health care providers. At 42 years of age, my mother delivered her last baby, the hulking 10-pound newborn known as my little sister Margaret. “It was like pushing out a cinderblock,” Mom reminisces fondly. She acknowledges that it took a team of people in scrubs to see her safely through that delivery.
Numerous factors contribute to the health and well-being of moms and babies across the globe. But the link between professional birth attendants and happy delivery outcomes like my mother’s is so strong that the World Health Organization uses the proportion of births attended by skilled health care workers as a proxy measure of global maternal mortality. The more births monitored by someone who knows what they’re doing, the fewer disasters such as maternal death happen.
Unsurprisingly, poor countries with the lowest number of skilled birth attendants suffer the highest rates of maternal death. But even rich countries like the United States are not immune to this tragedy. In March 2010, Amnesty International published a scathing analysis of what it calls America’s “maternal health care crisis.” The report, titled “Deadly Delivery,” cites lack of access to care as one of the reasons behind the “public health emergency” of American’s rising maternal death rate.
It’s a multifaceted problem. Julie Gorwoda, director of nurse-midwifery education at the University of New Mexico’s College of Nursing, cites geographic isolation as one of the most important reasons behind New Mexican women’s lack of access to prenatal and childbirth services.
“We aren’t just rural,” says Gorwoda. “We’re frontier; 42 percent our counties have fewer than six people per square mile.” This means that about one in 10 New Mexican women must travel 100 miles or more to access maternity services.
Gorwoda also points to poverty or fear of deportation as issues for moms needing care in the state. The keys to increasing access to maternal health care services in New Mexico, she explains, are midwives.
The term “midwife” can conjure images of some medieval healer practicing folk medicine on village women. This mental picture doesn’t sit well with most Westerners, who have been taught to trust serious-looking clinicians in lab coats over traditional healers. A 2010 study out of Florida found there’s public confusion and some mistrust over the word "midwife." More often than not, this is due to misinformation about what the heck a midwife is anyway.
“We immerse our students in these communities because you cannot learn how to care for rural and underserved populations from a textbook.”
Julie Gorwoda, director of nurse-midwifery education at the University of New Mexico’s College of Nursing
“Midwife” is a word derived from middle and old English that translates to “with woman.” Being “with woman” captures the philosophy midwifery retains today. In part, it's the art of guiding women through the normal, healthy process of childbearing. Whenever possible, midwives believe women can and should be active givers of birth rather than passive recipients of unnecessary interventions. Gorwoda says this doesn’t necessarily mean that options like epidurals are off the table. Rather, midwives give women the opportunity to make a fully informed decision. There are certainly times when interventions are appropriate, so midwives work with each woman to arrive at the best individual decision. This means that midwives incorporate up-to-date, evidence-based medical care into their holistic, woman-centered philosophy.
Numerous studies show midwives provide safe and effective care to women. A 2009 Cochrane meta-analysis (a type of scientific research that compiles data from multiple other studies) evaluated more than 12,000 women and found that midwife-led care increased a woman's chance of feeling in control during labor, having a spontaneous vaginal birth and initiating breast-feeding. Midwife-led care was found to be as safe or safer than care by physicians or other providers. The study concluded that women without medical or obstetric complications should be offered midwifery services.
In New Mexico, certified nurse-midwives are independent health care practitioners regulated by the Department of Health who can diagnose diseases and prescribe medications. In order to become certified nurse-midwives, they must first become registered nurses with bachelor’s degrees. They then complete Master of Science degree in nursing with a concentration in midwifery. Midwives provide prenatal and childbirth services, as well as primary and gynecological care for women of all ages. Midwives can also care for newborn babies up to one month of age.
The mission of UNM’s certified nurse-midwifery program, which involves six terms of full-time study over two years, is “to educate nurse-midwives to care for rural and underserved populations.” The program requires students to live and work in areas such as Shiprock, Silver City and Las Vegas.
“We immerse our students in these communities because you cannot learn how to care for rural and underserved populations from a textbook,” says Gorwoda.
UNM’s innovative approach to nurse-midwifery education is paying off. U.S. News & World Report has ranked the program third in the nation for eight years running.
New Mexico doesn’t just lead the nation in education. The Land of Enchantment also leads the nation in practice and research. Midwives attend a greater percentage of New Mexico deliveries than anywhere else in the country. Nearly one-third of all New Mexican babies are delivered by midwives, with more than 37 percent of vaginal deliveries attended by midwives. The majority of these deliveries occur in hospitals. UNM also boasts the nation’s leading certified nurse-midwife researcher on faculty: Leah Albers has published extensively on topics like obstetrical interventions, length of labor and maternal health.
Not all midwives are certified nurse-midwives. The state also enjoys a robust population of non-nurse-midwives, called Licensed Midwives (L.M.s) or direct-entry midwives. Jaymi McKay, the maternal health program manager for the state of New Mexico, explains that L.M.s undergo a two- to four-year apprenticeship before they are allowed to sit for the national certifying exam. L.M.s must also take a state licensing exam to practice in New Mexico.
The Department of Health licenses and regulates non-nurse-midwives in order to ensure that New Mexican women have access to a variety of safe and effective birthing options. While certified nurse-midwives do provide homebirth services, McKay notes that the majority of babies born at home here are delivered by L.M.s.
Like certified nurse-midwives, L.M.s believe pregnancy and childbirth are normal physiological processes and advocate for a woman-centered approach to care that involves informed decision-making. The World Health Organization has advocated for the use of non-nurse-midwives here in America, saying that independent midwives are an important counterbalance to physicians in preventing excessive interventions in the normal birth process. This view is especially relevant today, given new National Center for Health Statistics data showing that American Cesarean section rates have reached a record high. A third of all U.S. babies are now born via surgery, representing a 53 percent increase over the 1996 rate.
Midwifery is widely accepted in New Mexico, which is not necessarily the case in other states. Gorwoda points to the state’s long history of traditional Hispanic midwives, called parteras, as one reason behind New Mexico’s strong scene. She also notes that nurse-midwives were incorporated into the academic setting early on in New Mexico, with America’s first university-
The national health reform legislation may further strengthen midwifery in New Mexico. It includes a provision that will demand Medicaid pay for births at birth centers. The state's only freestanding birth center is in Taos, but McKay says the provision will encourage providers to open more.
The legislation also increases Medicare reimbursement of midwifery services from 65 percent of what a physician gets paid for the same service to 100 percent. In New Mexico, many third-party payers reimburse closer to 100 percent already. Still, some say this legislation will encourage all third-party payers to begin reimbursing at 100 percent as well. The increase will help midwives build sustainable practices that can afford to care for the underserved.
However, this is seen as a double-edged sword. Some say increasing midwife reimbursement will negate the cost-savings that midwifery offers over tradition physician services. Yet midwives may still offer cost-savings by performing fewer expensive interventions, offering more effective teaching and prevention, and increasing access to less costly out-of-hospital deliveries.
Either way, efforts designed to increase the public’s access to quality women’s health care providers are sorely needed in New Mexico. New Mexican certified nurse-midwives have made substantial progress. Yet huge gaps in care still exist. Although midwifery services are expanding into the rural locations most in need of providers, other services are evaporating. Three New Mexican labor and delivery units closed between 2005 and 2008, leaving women with fewer care options.
Increasing the number of midwives in rural and underserved areas can help combat problems of availability and affordability. Eight of the 120 nurse-midwifery graduates from UNM have already opened practices in rural New Mexico, and Julie Gorwoda expects more. UNM grads are likely to work where they are needed. “Thus far, 82 percent of our nurse-midwifery graduates work in rural and underserved practices,” Gorwoda notes. One-third of the certified nurse-midwives practicing in this state were educated at UNM. And since the early ’90s, certified nurse-midwives have expanded from six cities to 18 cities and 20 hospitals throughout the state.
Still, challenges remain. UNM’s midwifery program is the college of nursing’s most expensive. The student-to-faculty ratio needs to be low, and a lot of travel to rural locations is necessary. Gorwoda explains that the program needs a permanent source of funding to sustain this model of nurse-midwifery education. She says the program is trying to establish an endowment.
At a time when people have built telescopes that can see to the far edge of the universe and mapped the entire human genome, it doesn’t seem like providing a skilled birth attendant at side of every laboring woman should be out of our reach.
One of the World Health Organization’s global priorities is to ensure that every single woman has a skilled birth attendant when she delivers her child, given the enormous benefits that such a service provides. As Amnesty International points out, this isn’t just a public health issue. This is a human rights issue.
My mother was lucky to have so many trained hands helping her birth my cinderblock of a sister. Here’s to hoping all of the world’s women, from Africa to Artesia, can one day benefit from the same basic service.
Data from New Mexico’s Pregnancy Risk Assessment Monitoring System (PRAMS) shows only 63 percent of New Mexican women received adequate prenatal care in 2004-2005. This makes New Mexico one of the worst states in the nation for prenatal care. Women most often cited inability to get an appointment as the primary reason for lack of prenatal appointment. The second most common reason was inability to pay.
The PRAMS data shows us there is a lack of available, affordable providers in New Mexico. The PRAMS report recommends group prenatal care as one strategy to help address affordability and availability issues. A model for group prenatal care called Centering Pregnancy was developed by a nurse-midwife named Sharon Schindler Rising in 1993. Research shows it is an effective and affordable model of prenatal care, and mothers often prefer group prenatal care because of the support and increased time patients get to spend with the provider.
The PRAMS report also recommends informing middle-income women without prenatal coverage of the state’s Premium Assistance for Maternity program. Call (888) 997-2583 for information.
Globally, the maternity care situation is dire. WHO estimates that the world needs 700,000 midwives to ensure universal coverage, yet we face a shortfall of 50 percent. We also need 47,000 doctors with obstetric skills. Overall, the globe faces a shortage of a whopping 4.3 million health care workers. The World Health Organization’s comical-sounding Department of Making Pregnancy Safer offers information and resources for those interested in exploring this problem. Visit who.int/