21st Century Midwives
As registered nurses with special training in childbirth, CNMs (Certified Nurse-Midwives) provide a wide range of health services for female patients and their families. Fisch, who is of Puerto Rican descent, resides and works in Harlingen, Texas, a town located in the Rio Grande Valley near the Mexican border. She is one of only two nurse-midwives of color working in the valley, she estimates, out of approximately 30 local CNMs. “We are such a small group,” she says of minority midwives in general. “Midwifery itself is small group, but it is growing. Yet, there are still very few nurse-midwives of color.”
That is a trend Fisch would like to see changed. “Patients need to be spoken to in their native languages,” she explains. “It’s important for nurses to know [their patients’] culture. I’m not saying that Caucasian nurses can’t learn that, but people of color feel more comfortable when they see faces that look like their own.”
Fisch works in private practice with Harlingen OB/GYN Associates, which employs four obstetricians as well as one other CNM. Ninety percent of her patients are Mexican American, she estimates. When she first came to Texas as a CNM, she worked at an out-of-home birth center and eventually became its director. “When I came down here to practice, the majority of births were happening at home with traditional midwives,” she says. “That is what people associate with midwifery.”
As these traditional midwives began to age and leave the profession, nurse-midwives stepped into their shoes. “We started to replace them as our profession grew,” Fisch remembers. “It was really easy to attract patients to nurse-midwifery because [traditional midwives] had been here for a long time and were respected by the community.”
A Spiritual Approach
Since Fisch started her private practice in 1983, all of the births she has assisted in have been hospital deliveries. But, she stresses, her philosophy of midwifery sees birth as a natural process. “I don’t consider it an illness at all,” she says. “I consider it a spiritual experience for families. If you harness the energy that a newborn produces in the birth process, you can have a wonderful family event; it can be the bond that holds a family together for years to come. If more people concentrated on that, we would probably have more stable families.”
This philosophy, Fisch continues, is what separates nurse-midwives from obstetricians. “Because the basis of midwifery is family and tradition, we tend to focus more on the family’s spiritual needs,” she explains. Midwives are also concerned with the physical needs of the mother and child, she adds, but the focus is more on support and nurturing instead of medications and interventions. “You are not focused on the technology. You are focused on the patient.”
However, some of the care a midwife provides is the same as what an obstetrician offers. “I tend to perform fewer episiotomies than doctors do, but if it is needed, I can do it,” says Fisch. “And I am ready to move a patient to someone else’s care, if necessary. Midwives know there are limitations to the practice.”
Because midwives emphasize the natural and spiritual aspects of childbirth, their goal when assisting at a delivery is to have a drug-free birth. But, says Fisch, “that can be difficult in a hospital setting because people have developed expectations that modern medicine means no pain.”
This is not the case in every country, though. This spring, Fisch traveled to Honduras to teach life-saving skills as a consultant for the American College of Nurse-Midwives (ACNM)’s Global Health Division. The hospital she visited there had no pain relief medicine available for women giving birth. “Delivering in the hospital was no different than delivering at home, except that you were in a medical environment,” she relates. “Those women did not request pain relief. Unlike Americans, Honduran culture does not think labor should be painless.”
In her own practice, Fisch will use epidurals, albeit rarely. While medication will reduce the pain associated with childbirth, Fisch is quick to point out that it also takes away some of the mother’s control over the birth process. “It can also have potential side effects,” she says. “If things are normal and the patient is not at risk, I don’t think epidurals are the solution for a good birth experience.”
According to H. Frances Hayes-Cushenberry, CNM, MSN, most nurse-midwives would agree with that assessment. “If you practice the true art of midwifery, then you don’t do any intervention,” she says. “You don’t have to use invasive techniques. You are allowed to let the process take place naturally.”
Developing Minority Nurse-Midwives
Hayes-Cushenberry, who is African American, teaches nurse-midwifery at Charles R. Drew University of Medicine and Science (www.cdrewu.edu/) in Los Angeles, a historically black college. Its midwifery program is dedicated to educating minorities and underprivileged students and increasing the number of OB/GYN primary health care providers who work in underserved communities. Hayes-Cushenberry estimates that 70% to 80% of the university’s midwifery graduates work in rural and inner-city areas.
Because of the university’s midwifery program, there are now a number of minority nurse- midwives working in the Los Angeles area, Hayes-Cushenberry reports. But on a national level, the number of minority nurses in the profession is very low, says Anne Richter, CNM, MPH, co-chair of the Safe Mother Initiative, USA (SMI-USA). She points to a recent ACNM survey which found that only 3.8% of the nurse-midwife population is African American, 1.9% is Hispanic, 1% is Asian and 0.4% is Native American. The survey, which polled 5,410 CNMs, was published in the Journal of Midwifery and Women’s Health.
Richter feels the profession clearly needs more minority nurses, particularly African Americans, because minority women tend to have more complications from childbearing than Caucasian women. She cites research indicating that African-American women are four times as likely to die during childbirth as Caucasians, and that Hispanic women are 1.6 times more likely than non-Hispanic white women to die from pregnancy-related causes.
Another major issue minority mothers face is lack of access to health care services. According to SMI-USA, Hispanic women are 2.5 times more likely to be uninsured than Caucasian women; African-American women are almost twice as likely to not have insurance. African-American and Hispanic women are also more likely to receive late or no prenatal care.
Culturally Competent Midwifery
Still another barrier expectant minority women can face is a lack of cultural and linguistic competence from their health care providers. Studies have shown that when African-American women receive care from providers who are not African-American, the level of communication suffers, Richter says. “Nurse- midwives spend a lot of time listening to their patients,” she adds. “If we could get more nurses of color educated as midwives, it would be a wonderful opportunity for them to empower minority women to reach out and get prenatal health services.”
The American College of Nurse-Midwives is attempting to address such issues through its Midwives of Color Committee. “Our goal is to heighten awareness within the ACNM of the health issues that impact minority populations and to create a supportive environment for student nurse-midwives of color,” says Victoria Fletcher, RN, CNM, MSN, the committee chair. For example, ACNM has a mentoring program that matches minority student nurse-midwives with practicing nurse-midwives of color.
The committee has also provided input to the U.S. Department of Health and Human Services’ Office of Minority Health, which is in the process of drafting recommended national standards for providing culturally and linguistically appropriate health care services (CLAS). Such guidelines have been lacking in the past, says Fletcher, who is African American, because “our nation’s health care system is based on a Western and European model. It wasn’t set up to be inclusive of different races and ethnicities.”
Depending on where they work, part of the cultural competency challenge for nurse-midwives is being able to go beyond just looking at the physical aspect of a patient’s care. “[The patients] may come in once a month and the rest of the time they are living in situations that we don’t get involved with or don’t think of getting involved with,” Fletcher explains. “You may not know that a patient is living in a place without electricity or heat, or that she may not be getting adequate nutrition. Nurse-midwives need to broaden their perspective and deal with some of those issues if we are to ultimately make a difference in reducing maternal health disparities.”
Many health problems have a strong socioeconomic component, Fletcher adds. “What’s missing [in underserved minority communities] is patients who feel supported and who have the education they need to maintain their health,” she says. “Nurse-midwives are trained not only to care for patients based on a symptom or a disease but also to consider them as individuals and to promote health by educating them.”
A Lifetime of Care
The role of midwives often extends well beyond working with pregnant women. “Nurse-midwifery is a versatile profession,” Fletcher emphasizes. “I think people would be surprised to see the continuity of care midwives provide in most settings. We work with women not only through their childbearing years, but throughout their entire life cycles. Pre-menopausal, post-menopausal and even elderly women can be cared for by nurse-midwives.”
While some nurse-midwives choose to limit their practice to a certain portion of this life cycle, their educational training prepares them to work with women at all stages of life. Fletcher’s own practice, for example, does not focus on maternal health. She works for the Bremerton-Kitsap County Health District near Tacoma, Wash., in a clinic that specializes in family planning and sexually transmitted diseases. “I focus more on women’s health issues,” she says. “About 60% of the patients I see are teen-agers.”
There are other things nurses might be surprised to find out about midwifery as well. “I think many nurses feel that going back to school [to learn midwifery] would be very difficult. In reality, it is no more difficult than a regular RN nursing program,” Fletcher asserts. She strongly encourages other nurses of color to look into midwifery careers: “I think they would find this to be a very rewarding profession, and one in which they are definitely needed.”
Fisch feels the rewards of her work every day in her Rio Grande Valley community. “[Because of my job,] I have lots of friends and lots of godchildren,” she says. “My car can stall anywhere in the county, or even the next county, and I wouldn’t be out there for more than five minutes without someone stopping and helping me out. I feel loved by my community. I have a feeling of self-esteem and self-respect that is incredible. I don’t think many people can say that.”
For More Information
Over the past 10 years, the number of Certified Nurse-Midwives (CNMs) has risen steadily, with approximately 400 new CNMs certified in the nation each year. The American College of Nurse- Midwives (ACNM) Certification Council administers the national examination for CNM certification.
To be eligible to sit for the exam, a midwifery student must graduate from an educational program accredited by the ACNM. There are currently 47 such programs offered in the United States.
The ACNM has a membership of approximately 7,000, of which some 5,700 are in clinical practice.
To find out more about nurse-midwifery, contact:
The American College of Nurse-Midwives
818 Connecticut Avenue, N.W., Suite 900
Washington, DC 20006
Phone: (202) 728-9860
Fax: (202) 728-9897
The ACNM Web site has information about accredited midwifery programs, licensing, state laws and regulations affecting midwifery, job openings, scholarship opportunities, fellowships and awards, and more.