Nurse-midwives are an essential part of maternal health, but there is often confusion about the role and who can do it. UNLV Nursing professors Jennifer Vanderlaan and Kate Woeber explain the differences between a nurse midwife and registered nurse; why midwives have had trouble with representation in Nevada; and common misconceptions about the position.
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Joe Gaccione 0:03
Welcome to Vital Views, podcast for UNLV School of Nursing. I'm Joe Gaccione, communications director for the School of Nursing. The role of a midwife in healthcare, let alone nursing, is not always best represented in our society. Many times, it's a misunderstood position that has great importance in maternal health, specifically in those intimate emotional moments among mothers during the birthing process. We have two very special guests to talk midwifery and why it's so essential. First, Dr. Jennifer Vanderlaan, UNLV Nursing professor returns to the show, but we also have Dr. Kate Woeber, who just joined UNLV in October 2022 as a new associate professor in residence. She hails from Frontier Nursing University and Emory University School of Nursing before that. Like Dr. Vanderlaan, Dr. Woeber is a certified nurse midwife. She's also a fellow of the American College of Nurse Midwives. Drs. Vanderlaan and Woeber, thank you both for coming.
Jennifer Vanderlaan 0:54
Thank you, Joe.
Kate Woeber 0:54
I'm glad to be here.
Joe Gaccione 0:56
What makes a nurse midwife different from a registered nurse?
Kate Woeber 1:01
Well, we get this question so often, so I'm glad you're asking it. So, registered nurses generally have bachelor's degrees or associate's degrees in nursing, and when they do their, when they complete their education, they cover the whole range of healthcare, every body system, all of the different possible units where they may be working in a hospital or in a community setting. And then when they go into practice, they sort of settle into their favorite place, or they may rotate around during their careers. For certified nurse midwife, we have a nursing education, and then we also have a master's in nursing or a doctoral degree in nursing in addition to that. Our education as midwives focuses on normal, healthy reproductive healthcare from the time of adolescence all the way through menopause, but obviously with a really heavy emphasis on, on pregnancy and birth. We also, we're, we spend a lot of the time during the education talking about how to do a really thorough assessment and establish the degree to which each person that we're caring for is healthy and how much risk they have. And so, our priority is kind of, number one, promoting health, and really supporting those body systems that are working well and in ways that we know how to promote health. Nutrition, exercise, vaccinations, things like that, sleep, stress management. We also focus on early detection of complications and on managing common health issues and routine health, health issues. And then consulting with the rest of our team for the parts that need care that's not specifically what we focus on most of the time. So, we work with doulas, we work with physicians, we work with registered nurses. It's sort of like a nurse practitioner, but focusing on reproductive healthcare. And then did you ask about certified nurse midwives or midwives? Because those are different answers.
Joe Gaccione 3:08
That was gonna be my next question.
Kate Woeber 3:10
Okay. So, Jennifer, or Dr. Vandelaan, sorry, and I are certified nurse midwives, so all of what I just said is our background, but there are several different kinds of midwives. Actually Dr. Vanderlaan might be the right person to answer this question.
Jennifer Vanderlaan 3:26
Sure. Thank you. In the United States, we have several pathways for a person who wants to focus on women's reproductive care to become a midwife. Some of them are what we call direct entry, and that means that you can become a midwife without first training to be a nurse. Some of those midwives focus on care of women who want to give birth at home, and some of those midwives are trained to provide care for women who are in the hospital. We use different terms for them just to make sure that we categorize the credentialing differently, but it's not, it's, I guess the term that we would use in midwifery is scope of practice. The scope of practice is a little bit different, so the midwives who are trained primarily to care for women at home and in birth centers have a scope that includes a limited amount of, of medications that they can prescribe a, a limited amount of things that they can do, but the other direct entry midwives, we call them certified midwives, have the same training as certified nurse midwives, but, but they don't have to be nurses first. And so, they can be in the hospital with a woman, they can order an epidural for a woman if they want that, they can manage all of the care and do all of the same prescribing, and then would do the same risk assessment and bring in an obstetrician or maternal fetal medicine specialist if the woman needed.
Joe Gaccione 4:47
Dr. Woeber, you mentioned doulas before. Doulas and midwives sometimes get confused because there is some overlap in skill sets. What are the primary differences between the two?
Kate Woeber 4:56
Simplest way for me to describe a doula is that it's like a really well informed family member. When I work, and most, most certified midwives, certified nurse midwives work in a hospital setting, although lots of us work in community settings, birth centers and home home practices, doulas, so we generally have a focus of place where we have our care. We, some midwives work solo, so they have someone who, a patient who works with them always knows who's gonna be their mid midwife. A lot of midwives work in bigger practices, most work in bigger practices, so we rotate who's in the office that day and who's at the hospital that day or in the birth center that day attending births. So, when we work with patients, a lot, most often, patients who work with a certified nurse midwife or a certified midwife are going to be working with whoever is there and they try to get to know everybody in the practice so that they can be familiar with whoever's there when they come into the hospital or the birth center for birth, for example. Doulas, however, they usually work one-on-one with a family. So, when I work as a midwife, I might have a 24 hour shift and I show up at the hospital at 8:00 AM and I leave at 8:00 AM the next day. The doula is just with the family, so they're there until the baby is there and, you know, if they breastfeed or, you know, whatever else happens for a short period of time after that, the doula is there. The training is different too. The process for becoming a doula is much quicker. They're not nurses, they're not midwives, they're not actually medical staff. They provide comfort care and try to use all of their magic to, to help with coping during labor, and they really are focused on labor and birth, although there are doulas who do different kinds of work. They assist with abortions or they, a lot of doulas are, also assist with death care, actually, not, obviously, with maternity patients.
Joe Gaccione 7:03
Dr. Woeber and Dr. Vanderlaan have worked extensively. Most recently, you were both part of a select group of researchers tabbed for a midwifery workforce study through the American College of Nurse Midwives. Can you both explain what this workforce is looking for?
Jennifer Vanderlaan 7:16
Sure. This is a study that the American College of Nurse Midwives put together because we don't actually have good data about the midwifery workforce in the United States, and without good data, we can't advocate the way we need to to expand the midwifery workforce so that every woman who wants a midwife can have a midwife. So, our purpose is to try to find out what is the size of the workforce, what is the optimal size of the workforce, and what do we need to do to get the midwifery workforce to the optimal size? And that includes how do we scale up training of midwives and how do we stop attrition from midwifery so that midwives stay in clinical practice longer?
Joe Gaccione 8:03
You've also cited before Nevada’s among the lowest in the nation for births attended by nurse midwives. I believe it was 44th. Why is that a significant statistic and how does that change?
Jennifer Vanderlaan 8:13
Well, the reason it stands out is because Nevada is what's called an independent practice state. That means that the regulations in Nevada allow nurse midwives to practice without having to have a written collaborative agreement with a physician. In states that require that written collaborative agreement, we generally see a smaller midwifery workforce and the midwives do fewer births. But, Nevada has an independent practice regulation. We still have one of the smallest proportions of midwife births in the country, and it's, it's because we have other regulations that are restricting midwifery practice and making it hard for midwives to work in the state.
Joe Gaccione 8:52
What are some of those obstacles to access?
Jennifer Vanderlaan 8:55
Well, one of the big obstacles is that our Medicaid reimbursement for midwives has an adjustment. That means that when a midwife provides the same care as a physician, a midwife is paid 75% the rate that a physician is paid for caring for the patient. And what that means is that for a midwife to open a practice and accept Medicaid insurance for the people they care for, they lose money.
Joe Gaccione 9:20
What are some common, we talked earlier about misunderstood position, being a midwife, what are some common misconceptions that both of you have encountered?
Kate Woeber 9:28
A really common one, a lot of people have never heard of midwife until they are pregnant and looking for someone to attend their birth and provide their care during pregnancy. And a lot of people ask us, “So do you only perform births in the, in the home?” and, “But can I have an epidural?” because they think that the birth has to be in the home and that midwives don't believe in pain medicine, and neither of those things are true. Like I said, lots of midwives do attend births in the home, but the vast majority are, are centered in hospital based care. And our patients, we, you know, number one, want them to be safe and to have a healthy experience, but also we want them to have a fantastic experience that's really empowering and that helps kind of support the, the strength of the family unit. So, sometimes you can have a great birth without medication and with lots of other strategies employed to help people cope with labor pain, and sometimes the best birth has an, is, you know, involves having an epidural and it’s just a different, a good birth means different things to different people, so we try to facilitate that.
Joe Gaccione 10:39
Did you have any, Dr. Vanderlaan?
Jennifer Vanderlaan 10:40
I do. Another myth about midwives, specifically nurse midwives, is that all they do is birth care, and that's not true. Actually, in our scope of practice as a nurse midwife, we can care for any patient, any woman, is it age 14 and older? And newborns up to age 28 days, which means that for a state like Nevada that has some frontier counties and communities that have a small population, bringing a midwife into the workforce provides you with somebody who is qualified to do well-woman care, to do STI testing, we are allowed to do testing reproductive health for, for men as well, so we could do STI testing for men and women, but that primary care is a huge issue in a lot of states and midwives are underutilized for their primary care.
Kate Woeber 11:31
Can I add something else to that?
Joe Gaccione 11:32
Kate Woeber 11:33
I keep, I will probably keep thinking of myths because there are so many. What I was thinking about also is that especially if you've ever heard the term mid-level applied to nurse practitioners or nurse midwives, it sort of insinuates that maybe it's a lower level of care, and what we have, decades of data on midwifery care and the health outcomes that our patients can expect, and midwifery care is the kind of care that we wish everybody could have access to. Obviously, we focus on the care of people who have low risk, but we also, some of the best, the best way to provide reproductive healthcare in the US is with a team-based approach. So, if we can work with physicians, even for patients who are very complicated, we're adding, we're being another person who's there, supportive, another set of brains on, on the task, and another person communicating with the patient and their family about what's going on. So, our health count outcomes are amazing. People who have midwives for their births are less likely to have cesareans, they're less likely to have a severe vaginal laceration or a perineal laceration, they're more likely to breastfeed. There's data on centering pregnancy, which is group prenatal care that shows there's a lower rate of low birth weight and a higher rate of breastfeeding for people who use our model of care. We, we don't always have group care, but group care is midwifery model birth centers. There's some really, really interesting data from the last, I don't know, five years or something that they studied Medicaid patients, which typically are people who have some increased likelihood of having like a preterm birth, for example, so it's not the lowest risk population possible. And they had a lower rate of preterm birth from birth center care and increased rate of breastfeeding, lower rate of cesarean and the severe lacerations. So, there's a super high satisfaction rate with people who use midwives. They really appreciate the extra time they have from the care they get when they have midwives. Midwives are, we spend most of our training, you know, like I said, on supporting normal processes and helping people through those kinds of situations, where physicians spend a lot of their time learning how to save people from, who have really complicated problems and learning how to do surgery. And so, having a midwife allows their, the, the physician's expertise to be focused on the people who they, who really, really need that care. And we specialize in care of people who are low risk. So, I think I might have wandered there a little bit or maybe a lot.
Joe Gaccione 14:15
No, it's okay. It's all valuable.
Kate Woeber 14:18
But it, you know, the Institute for Healthcare Improvement calls it the triple aim, where you have great health outcomes, great, great patient experience, and lower costs. And midwifery care costs less, it has great patient experiences, and the outcomes are awesome. So, it's kind of a no brainer to try to build up a midwifery workforce, especially in a place, in a country where we have problems with our maternal, maternal and newborn health outcomes and problems that are actually getting worse over the, over the last year, so we should be building up the midwifery workforce, so that's why we're here.
Joe Gaccione 14:52
I mentioned before that Dr. Woeber, you are new, fresh to UNLV. What are you looking forward to as a Rebel nurse?
Kate Woeber 14:59
I'm looking forward to so many things. This is my first time in Las Vegas and it's been just incredibly fun to be here. I'm so excited to work with Dr. Vanderlaan. We've been doing research together for a couple of years, and we both do workforce research, and I think just being able to work together in this way, I think we'll really be able to focus our efforts even more on Nevada, number one, and midwifery, you know, expanding the midwife, midwife workforce everywhere. We have a dean who's incredibly supportive and really understands what the issues are and what needs to happen and that makes a huge difference when you’re trying to do this kind of work. My understanding is that the legislature is really highly motivated to make a difference and that's not true everywhere. You know, I think legislatures are generally motivated to make a difference, but I think this legislature is really listening to what Dr. Vanderlaan has had to say and what the dean has had to say, and so I think we can make some significant change.
Joe Gaccione 16:06
Dr. Woeber, Dr. Vanderlaan, I appreciate you so much for coming by and talking with us.
Kate Woeber 16:10
Thank you so much for having us.
Jennifer Vanderlaan 16:11
Thank you, Joe.
Joe Gaccione 16:13
Thanks for listening out there. Hope you all have a great day.