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VOL. 41 | NO. 19 | Friday, May 12, 2017

Natural way: Midwife aided, mother approved

More women push back against the medicalization of birth

By Jeannie Naujeck

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Zoë Jamail is looked after by certified midwife Sheryl Shafer, left, and her doula, Joy Shaw.

-- Michelle Morrow | The Ledger

When Zoe Jamail first became pregnant, she was interested in the idea of a natural home birth, but unsure how her body would respond.

So she entered Vanderbilt University’s nurse-midwifery practice. Accompanied by a doula, Jamail spent 43 hours laboring at home before going to the hospital, where her daughter Nova, now 2, was born an hour later.

But this summer Jamail will get her home birth. She’s due to deliver her second child in late July in the comfort of her East Nashville home with the help of a certified professional midwife and a doula.

“With a first-time birth I felt a little more comfortable going to Vanderbilt, but we labored at home for so long that it felt like a home birth in a lot of ways,” Jamail recalls.

“Once I realized, I can do this, I don’t need an epidural, I’m strong, that was a really empowering experience. We didn’t have any complications and now I know what to expect.

“And now I’m excited about, logistically, not having to go to a hospital, because getting there was the only stressful part of the labor.”

Jamail, who turns 33 next week, is part of a growing trend of women choosing non-hospital and low-intervention birth.

They’re eschewing physician-attended births in hospitals in favor of a midwife, a concept that may seem quaint and Old World to Americans, but is as common and natural as childbirth in the rest of the world.

While hospital births are the norm for even routine births in the United States, that’s not the case in England, Canada, Europe, and the rest of the developed world, where midwives attend the majority of ordinary, uncomplicated births - even royal births.

Midwifery got a boost when it was revealed that Kate Middleton, the Duchess of Cambridge, had delivered baby Charlotte with two midwives facilitating and no epidural.

“It’s no longer just a fringe movement, with hippie moms in Birkenstocks. It’s more of a mainstream option, which is really exciting,” certified nurse-midwife Lauren Drees says.

“I’ve seen a drastic shift of women beginning to explore their options – and they’re not waiting until they’ve had a bad first experience and want a better second. It’s first-time mothers too.

“Women are waking up, and they’re beginning to be their own advocate.”

In Middle Tennessee, moms-to-be have more options than ever for labor and delivery, including births at home assisted by a midwife, at a hospital but facilitated by a nurse-midwifery practice such as Vanderbilt’s, or at a birthing center such as Baby & Company in Nashville or The Farm in Lewis County, which has a longstanding midwifery practice.

Relationship model care

In most of the world, people do not regard birth as a medical event requiring a trip to the hospital, except in cases requiring physician oversight or intervention, such as a high-risk birth or a mother with a condition that needs monitoring.

That’s in stark contrast to the U.S., which is virtually the only industrialized country where hospital-based childbirth became the norm, starting in the early 1900s when hospitals began marketing anesthetized births to women and making epidurals, induced labor, elective cesarean sections, and delivery in the unnatural lying-down position common practices. Before that, most babies were born at home.

“Europeans have used midwives since the dawn of time. The U.S. took a turn, and they didn’t,” says Michelle Collins, head of the Nurse-Midwifery specialty at Vanderbilt University’s School of Nursing.

“At some point it became ‘in vogue’ to go to the hospital and that’s where women who could afford it went, even though the outcomes were worse.”

Now the tide is turning. In the past quarter century, the number of midwife-facilitated births has nearly tripled. And although it is still a relatively low eight to nine percent, demand is on the rise, driven in part by a questioning of current cultural norms.

Sheryl Shafer certified professional midwife

-- Michelle Morrow | The Ledger

“Our goals and our choices of how we raise our families have changed a lot,” says Sheryl Shafer, midwife, CPM-TN.

“We’ve seen the outcomes of some of our cultural changes, and some families want something different. And this has really driven people to individualized care, and recognizing that the hospital is not always the best place to have a baby.”

The range of women seeking a non-hospital birth is huge and no longer fits the “Birkenstock” stereotype. Shafer has longstanding relationships within conservative communities such as Amish, Mennonites and fundamentalist Christians, but her clientele also includes wealthy Nashvillians, and she has even assisted delivery on the 14th floor of a high-rise in The Gulch.

And while Jamail concedes she has some “earth mama” tendencies, she was also a licensed attorney practicing civil litigation in California before moving to Nashville three years ago with her husband Mike Luginbill, a touring musician.

She says she believes the ready availability of information is empowering women of her generation to make different choices.

“I think women are realizing that there’s not as much within their control when they’re in a hospital setting,” Jamail explains.

“We’ve been conditioned to think that this is how birth goes, but childbirth is so doable, and it’s the most empowering thing that you can do, in my experience. And so now that there’s more information out there, that’s why women are choosing it.”

Midwifery is a low intervention care model based on giving women the information they need to make educated choices and facilitating the normal, natural processes around pregnancy, labor and delivery, rather than interfering with or changing their normal course.

“Midwifery is relationship model care so we don’t make decisions for our patients,” Collins adds. “Our job is to make sure they are well informed to make important decisions about their own pregnancy and their own birth. That’s what women are looking for.”

In addition to being with and supporting the mother during natural labor and childbirth, midwives provide a schedule of prenatal care to the mother, as well as postnatal care for both mother and baby.

Zoë Jamail with her 2-year-old daughter Nova Luginbill.

-- Michelle Morrow | The Ledger

Many complications during the birthing process are caused by medical intervention, which often starts when someone feels that labor and delivery need to proceed on an arbitrary time schedule, leading to premature inducement of labor and what Collins calls a “cascade of interventions.”

“There are all these things that have to go on in your body to go into labor, so when we try to play Mother Nature and bypass those things it involves a lot of intervention,” she says. “And once you do one intervention, you’ve bought another intervention, and another intervention.”

Those interventions drive up the cost of birth in often-unnecessary medications, surgeries and extended hospital stays. But while the United States spends three times as much as other industrialized countries spend on pregnancy and birth, it ranks at the bottom for outcomes.

The U.S. has one of the worst rates of maternal mortality in the developed world – three times the rate of Canada – with increases across all age groups, according to the Seattle-based Institute of Health Metrics and Evaluation. It also has some of the highest preterm birth and infant mortality rates of developed nations, though that has started to come down as hospitals end the practice of unnecessarily inducing labor.

“If you bought something really expensive, you’d expect it to be really good, wouldn’t you? That is not the way it is with maternity care in this country,” Collins says.

“We provide care that is very expensive, but we don’t have the outcomes to show for it. As economists look at this, they’re saying, what do they do in other countries? One of the solutions is the midwifery model of care.”

Studies show that midwife-led care leads to fewer cesarean sections, lower rates of medication and anesthesia in labor, fewer episiotomies, fewer drug-induced labors, less vaginal tearing during delivery, fewer pre-term births, and lower rates of miscarriage before 24 weeks gestation.

Women also report much higher satisfaction with their birth experience when they have a good relationship with their provider and feel involved, empowered, and listened to.

The desire to empower is what led Lauren Drees to midwifery. Drees originally entered nursing school planning to become a labor and delivery nurse, but that changed after she witnessed her first hospital birth.

“The way it was done, the way the woman was treated, it was just so far from what I envisioned that experience to be for a woman,” Drees recalls.

“I was shocked, and that’s how I started on the path to becoming a midwife. I wanted to bring dignity and empowerment to a process that is so life-changing for women, and what I saw couldn’t have been further from that.”

Mitigating risk

One of the most important factors in a woman’s comfort with a midwife is her emergency backup plan. Women delivering at Vanderbilt’s nurse-midwifery practice have ready access to obstetricians and other specialists should a medical intervention become necessary.

For those delivering at a birth center or home, nurse-midwife Drees addresses safety concerns right off the bat by talking about the facts and actual risks.

“That’s when I enlighten them to the fact that the large majority of complications that occur in a hospital are related to something that was done to the woman,” Drees explains.

Midwife info

Midwife births generally cost much less than physician-hospital births. Many women pay cash. Midwife Sheryl Shafer estimates most midwives charge $3,500 and $4,500 for the full package of services, including pre- and post-natal care, labor and delivery, lab work and newborn screenings. She says she is not in-network with any insurance plans but will bill insurance if it is covered.

Birth centers such as Baby & Co. generally charge more. Vanderbilt has a nurse-midwife practice at West End Women’s Health Center, where most major insurance plans are accepted, including Medicaid/Tenncare.

Depending on insurance plan, some doula services also may be reimbursed - as pre- or post-natal care, for instance. Vanderbilt provides free doula services to women who use their nurse-midwife practice. Some doulas work on a sliding fee scale.

“The drama that we see around birth is often not spontaneous. It’s the result of induction, of medications, of epidurals. So we bring awareness to that, and acknowledge that problems can arise but we have a plan in place if they do. I’m very committed to being integrated into the system, so that if and when transfer arrives, there’s a smooth process and there’s safety in place for the moms.”

For Shafer, who often works in homes that are an hour or more from an obstetrics unit, relationships with the medical community are paramount when a complication arises that requires a transfer.

“I’ve been with Sheryl in those situations,” doula Joy Shaw says.

“It wasn’t a crazy, hectic situation; it was just her saying, ‘Okay, I think this is where this is headed,’ communicating it to the family, and then in a very sort of orderly fashion doing that.

“I’ve also transferred to hospitals with midwives who didn’t have a good backup system in place and it’s completely different. That relationship Sheryl has cultivated with medical professionals is very key to her giving good care to her patients.”

Shafer, a mother of eight, says she has delivered more than 1,100 babies in more than 30 years as a midwife. She travels within an hour and a half radius of her Perry County home to serve a broad range of clientele – from Amish and Mennonite communities and poor rural families to young professionals in East Nashville, Brentwood and The Gulch. Her work sometimes keeps her away for days at a time.

Because of her training and years of experience, Shafer is comfortable facilitating breech (rear-first) births and vaginal birth after cesarean (VBAC) – cases that few other midwives handle, and virtually no physicians are trained in or even see. Her clients have even included a 52-year-old woman who delivered twins.

“They are accepting a degree of risk, but they are trading it for different risks than they would have in the hospital,” she says.

“That’s not a question that we can answer for everybody,’’ Shafer explains. “It’s not something that we can legislate. At the same time, there are some things that are not wise and that I’m not going to do. Even if the mother can’t evaluate that risk and think that through, that’s my job to understand the risk and help her understand it.”

Midwife education

Midwives may have one of three designations. A certified nurse-midwife has a graduate degree in nursing and can be licensed in all states. In Tennessee, a CNM is licensed as an advanced practice nurse.

A certified midwife has a graduate degree in a health-related field other than nursing, and can make as much as $100,000 annually, according to salary.com. CMs are currently authorized to practice in only five states: Delaware, Missouri, New Jersey, New York and Rhode Island.

Both a CNM and a CM must pass the same exam to become certified by the American Midwifery Certification Board.

A certified professional midwife is certified by the North American Registry of Midwives. It is the only credential that requires knowledge about and experience in out-of-hospital settings. Most CPMs like Shafer own or work in private home or birth center based practices. There are about 50 CPM licensees in Tennessee, according to the state’s Council of Certified Professional Midwifery.

Demand for midwifery training is strong and growing, Collins says. Vanderbilt’s Nurse-Midwifery program is ranked No. 1 in the country, according to the 2017 U.S. News & World Report rankings. There are only 40 programs total, and Vanderbilt’s is one of the largest, graduating about 25 students each year.

“There are not enough spaces in nurse-midwifery education in the country to accommodate the numbers of students who want to go into it,” Collins points out.

“The national trend is midwife-attended births are on the rise. We would like to see, just like in other countries, where the midwifery model of care is the norm. That would be beneficial for women, certainly.”

When Shafer began training as a midwife with a doctor who did home births, midwifery was in “the infancy of its renaissance.” Fathers were a regular presence in delivery rooms, Ina May Gaskin had begun The Farm’s Spiritual Midwifery practice, and parents were beginning to look for more natural alternatives to hospital delivery.

However, midwifery also was largely unregulated, and there were few licensing bodies. Credentialing organizations didn’t exist.

Over the decades, Shafer has seen the practice change from its homespun beginnings to a regulated, licensed profession – and she’s strongly in favor of the latter.

“In the states that don’t have licensure and regulation yet, you have an assortment of midwives that aren’t necessarily well trained and that aren’t necessarily practicing safely,” she says.

“Now we have regulations and practice guidelines, and it means more accountability and it means my hands are tied more, but the days when midwives picked themselves up by their bootstraps and did things that are definitely higher-risk or not necessarily wise care, those days are over in this country.

“And they should be over, because we have a model of something that works better and that is safe, and that’s where midwifery as a profession is heading.”

Hospitals are changing

More options are opening up for women as lower intervention birth gains visibility.

Along with Vanderbilt’s nurse-midwifery practice, Saint Thomas Midtown Hospital now offers midwife services as well as more mother-friendly choices such as a warm tub soak during labor, nitrous oxide for labor pain, and limited separation from the baby after delivery.

Another delivery option is Baby & Company, an expanding national franchise that two years ago opened a freestanding birth center in Nashville staffed by registered nurses and certified nurse-midwives.

Its collaborating hospital is Vanderbilt University Medical Center.

“I think we’re going to see more in-hospital birthing centers throughout Nashville’s hospitals soon because that is what clients are wanting and that’s where the demand is,” Drees says.

“I hope they will do them all well. I think it’s a win for everyone, the more options there are, because it’s not a one-size-fits-all. Having all of these options is really wonderful because it can allow families to find the right fit for them.”

Drees, who graduated from Vanderbilt’s nurse-midwifery program and worked in its practice before moving to Baby & Company’s Arkansas and Nashville locations, is starting a new venture this month.

She has launched her own home birth practice, Haven Birth and Wellness, and will be one of only two certified nurse-midwives in the Nashville area offering home birth.

“Nashville has such a strong birth community; there’s a lot of support around birth and the options women have,” Drees says.

“I say the birth center is a good ‘gateway drug’ - it gets you out of the hospital and increases your trust, and usually with baby number two women are more comfortable choosing a home birth when they realize that you don’t necessarily need to be in a hospital.”

Drees says she hopes her credentials and experience in a variety of settings will put her in position to build a stronger bridge between the midwife and medical communities, so that one day home births will become as common and accepted in the U.S. as it is in the rest of the world.

“One thing that I believe makes Canada and Europe so successful with outcomes is that home births are so integrated into the medical system. They work closely with hospitals, and if they need to transfer they are welcomed,” she says.

“So, for us to improve options and access, conversations have to start between midwives and doctors and hospital administrators recognizing that we all have the same goals - safety, support for the moms and babies, and improved outcomes.”

“I’m really passionate about that and excited to be stepping into an arena where I can advocate for change,” Drees adds.

“I want to believe that I can change the world, one baby at a time.”

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