Once when certified nurse-midwife Lisa Summers assisted at a birth, the laboring woman stood up to deliver her baby. So Summers had to kneel at the woman's feet. "I was overwhelmed by the power of it," recalls Summers. "This is what women do all over the world." From her humbling position on the floor, Summers was struck by how women themselves are capable of taking charge of their labors. "If women have faith in the process," she says, "they can birth their babies rather than us birthing them."
Midwives, she believes, are the ideal assistants for normal deliveries, which occur most commonly, while obstetricians are best suited to handle high-risk pregnancies (involving Caesarean sections, diabetic mothers, or women expecting twins, for instance.) Thus, says Summers, instead of the roughly 35,000 obstetricians and 5,000 midwives now in the United States, we should have 35,000 midwives and 5,000 obstetricians.
Many obstetricians oppose that viewpoint, while others say the change is not feasible. "We should make every effort to increase the number of primary care providers, including midwives, but I don't know what the numbers should be," says Timothy Johnson, former chairman
of obstetrics and gynecology at Hopkins and now department chairman at the University of Michigan Medical School. Hopkins had a midwifery training program that ended in 1982.
The fact remains: increasing the number of nurse-midwives and decreasing the number of obstetricians would save money. Training a nurse-midwife (which involves one to two years of training in addition to the R.N.) costs a quarter of the price it takes to train an obstetrician. And midwife-attended births also cost less--$1,200, as compared to $4,200 for a physician-attended delivery. Those figures are one reason President Clinton has called for increased training support for nurse-midwifery.
Summers practices with two other certified nurse-midwives at Johns Hopkins Hospital and at a branch office in Lutherville. About half their patients are healthy insured women, some pregnant and others seeking routine gynecological care. But at the hospital, the nurse-midwives "co-manage" with obstetricians certain high-risk cases that nurse-midwives in the private sector normally would not see, notably HIV-infected women, whom they care for under a federal grant from the Health Resource Services Administration. Almost all these women are indigent and on Medicaid, and would otherwise be seen in the clinic by a different group of residents every eight weeks. "HIV women really need continuity of care," says Summers.
Although the group has practiced midwifery at Hopkins since 1984, Summers believes that many potential
clients do not know they exist or understand what they do. The public has many misconceptions, she says. "People think midwives only practice in the home, that they don't use technology or medication, or use only natural childbirth."
The reality is that certified nurse-midwives are doubly trained, in both nursing and midwifery, and they can do most of the things obstetrician/gynecologists do. They perform Pap smears, prescribe birth control pills, and provide other routine gynecological care. They see a woman throughout her pregnancy, order the required lab tests, and deliver the baby in a hospital or birthing center. A physician is on call in case a normal pregnancy turns "high-risk" once the patient is in labor. Midwives are not allowed to do Caesarean sections and forceps deliveries. They call in an anesthesiologist to administer certain types of anesthesia, as an obstetrician would do, but generally can administer local anesthesia.
The midwife's philosophy, however, tends to be different from that of an obstetrician, says Summers. She calls her group's practice "high-touch care." While most obstetricians spend only about 10 minutes on a routine prenatal visit, says Summers, she and most midwives tend to spend an hour on the first visit and 30 minutes on subsequent visits. They talk extensively about preventive care, especially exercise and nutrition (subjects many obstetricians only skim). If a woman exercises and eats well during her pregnancy, Summers explains, she is more likely to deliver a healthy baby. That saves money because healthy babies do not require costly intensive care.
The biggest difference comes during labor and delivery. "Traditionally," says Summers, "a woman in labor is put in bed and a monitor is put on her. She cannot eat or drink. She is given intravenous fluids, and often is given an epidural anesthesia. During delivery, her legs are in stirrups, the doctor stands over her, she has an episiotomy, and the baby goes to the warmer. In this culture, women don't birth babies. Doctors deliver babies."
Summers stresses that midwives do use anesthesia and other interventions. "We just don't do them routinely," she says. Instead, before suggesting that a patient be given anesthetics, a midwife might rub the woman's back or suggest that she shift position. Midwives encourage a woman in labor to walk around if she can. They monitor the fetus intermittently, encourage eating and drinking fluids during labor, and do not routinely use IVs. Once the baby's head and shoulders have emerged, the mother is even encouraged to pull out the rest of the baby herself. For most births, says Summers, low-tech and high-touch is all that is needed.
Agreement on that seems to be spreading. There are currently 36 nurse-midwifery training programs in the United States, which train about 300 nurse-midwives a year, a figure that is steadily increasing as the demand for nurse-midwives increases. From 1990 to 1994, membership in the American College of Nurse-Midwives increased 68 percent, from 2,800 to 4,600.