Ep 120: An Overview Of Midwifery Care


In this episode you’re going to get an overview of midwifery care. I was inspired to do this episode after hearing Heidi (episode 119) talk about how her midwife worked so well with a physician in order to help her have a beautiful birth. 

I’ve been working with midwives since my residency training and currently work with midwives today. I fully support working collaboratively with midwives to help provide the best care for patients.

In this Episode, You’ll Learn About:

  • What midwifery is and what values midwives uphold
  • What makes each category of midwifery different: certified nurse midwives, certified midwives, and certified professional midwives
  • How education and training varies across classifications
  • How the scope of midwifery extends beyond pregnancy and birth
  • Whether insurance covers midwifery
  • How models of midwifery vary from state to state
  • What collaborative agreements are and how they can help or hinder the care midwives provide
  • Why it’s so important for physicians and midwives to work together

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Transcript

Ep 120: An Overview Of Midwifery Care

Nicole: In this episode, you will learn about midwifery.

Speaker 2: Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Well, hello there. Welcome to another episode of the podcast. This is episode number 120. Thank you so much for spending some of your time with me today. As always, I so appreciate it. So in this episode, you can all learn about midwifery. And I thought about doing this episode because in the last episode of the podcast episode 119, it was a birth story episode with Heidi. Definitely go back and check that out, if you haven't. She talked about how her midwife worked so well with the physician in order to help her have a beautiful birth. And it inspired me to go ahead and do this episode covering midwifery. I have worked with midwives since I was a resident at Duke way back in the day, and at various points in my career, I've worked with midwives. And now today I work with midwives certified nurse midwife hospitalists.

Nicole: So I'm an OB hospitalist meaning. And what an OB hospitalist is sort of side note is I work 24 hour shifts at a time, and I do seven of those shifts every four weeks, roughly. And during that 24 hour shift, I care for whoever happens to be in the hospital during my shift on labor and delivery and needs to have their baby. And I work side by side with certified nurse midwife hospitalists who do the same thing, where they work shifts just in the hospital. And I want to be clear that I, 100% support midwives and I support that we should work collaboratively together to help provide the best care for our patients, including working with home birth midwives. I don't do home births. I've never been to a home birth. Home birth is not my lane. Hospital birth is my lane. That's where I stay, but I do know the research regarding home birth.

Nicole: And I know that home birth is a perfectly safe and appropriate option under certain circumstances for low risk people. One of the important circumstances surrounding home birth is having a good backup plan in place where people can be transferred from home to the hospital seamlessly and get the care that they need. So I, 100% support being a backup on the hospital side, if a home birth transfer needs to happen. So with that being said, in this episode, you are going to learn what is midwifery? So what are the tenants of midwifery? You'll learn about the different types of midwives certified nurse midwives, certified midwives, sort of professional midwives, the differences in the education and training, scope of practice, the legal status, because it actually differs by state. I'll give you a little bit of information on how midwives practice practically in the U S and I should say all of the information I'm covering in this episode applies to midwives in the U S and then the different types of practices and collaborations that happen with physicians is that little bit of controversy about that.

Nicole: Now, one of the things that I know for sure that midwives support is child birth education, and I of course have a great option called the Birth Preparation Course, my signature online childbirth education class, that gets you calm, confident, and empowered to have a beautiful birth. Now, I know one of the reasons why many people choose midwifery care is because of the more holistic approach and the level of care that they provide a bit more time and attention during pregnancy. But I also know that not everyone has access to midwives. In fact, most people don't, most people still deliver with a doctor and great childbirth education can be something that helps to fill in that gap. Helps you feel a bit more secure, actually, a lot more secure when you take the Birth Preparation Course, going into your labor and birth as a student who recently had her baby said about going through the course, she said, Dr.

Nicole: Rankins, I truly feel like you were one of my docs through the process and your words and advice were in my head throughout the entire pregnancy and birth. She had a beautiful, beautiful delivery. So you too have me in your head during your labor and birth, if that's what you want in order to help you have that beautiful birth experience. So check out all the details of the course at drnicolerankins.com/enroll. All right, so let's get into midwifery. So let's start off with what is midwifery. And I should say most of the information that I'm getting from this episode comes from the website from the American College Of Nurse Midwives. That's kind of similar to ACOG, which is the American College of Obstetricians and Gynecologists. It ACN, M A C N M is the specialty organization for midwives. And they talk about the art and science of midwifery being characterized by several hallmarks.

Nicole: And I'm just going to read right through them. It's, it's a bunch, so recognition, promotion and advocacy of menarche, that's the start of your period, pregnancy, birth and menopause, recognizing those things as normal physiologic and developmental processes, advocacy of non intervention and physiologic processes in the absence of complication. So not intervening in a physiologic process, unless we need to. Incorporation of evidence-based care into clinical practice, promotion of person centered care for all which respects and is inclusive of diverse histories, backgrounds, and identities, empowerment of women and persons seeking midwifery care as partners in health care, facilitation of healthy family and interpersonal relationships, promotion of continuity of care, utilization of health promotion, disease prevention, and health application of a public health perspective. Utilizing and understanding of social determinants of health to provide high quality care to all persons, including those from underserved communities, advocating for informed choice, shared decision-making and the right to self-determination integration of cultural safety into all care encounters, incorporation of evidence-based integrative therapies, skillful communication, guidance, and counseling. Acknowledgement of the therapeutic value of human presence.

Nicole: I really love that one. The ability to collaborate with and refer to other members of the interprofessional healthcare team, and then the final hallmark of midwifery as put forth by the American College of Nurse Midwives is the ability to provide safe and effective care across settings, including home, birth center, hospital, or any other maternity care service. So those are what encompasses midwifery again from the American College of Nurse Midwives, as you can see, it offers a more holistic approach to care. And then in practice, I would say midwives usually take a lot more time with their patients compared to physicians. So let's get into the types of midwives, the training that they go through, education, the legal status, all that good, great stuff. So I'm going to talk about certified nurse midwives, and those are C N M's certified midwives cm, and then certified professional midwife CPMs.

Nicole: Okay. So for certified nurse midwives and certified midwives, as of 2010, a graduate level degree is required for certification as a CNM or ACM. And so a graduate level degree would be a master's level degree or a doctoral degree, approximately 82% of CNS have a master's degree. About 4.8% of CNS have doctoral degrees. I think that number is going up and typically it is a doctor of nursing practice. Now this can cause some confusion because yes, it's a doctoral level degree, so they could be called doctor, but it's a doctoral level degree similar to like a PhD is a doctoral level degree and be called doctor a doctor of nursing practice. That level of doctor is not a clinical level of being a doctor. So there's a lot of controversy as, uh, as to whether or not someone who has a DNP should call themselves doctor in a clinical setting, because it can be confusing to patients because in a clinical setting, when patients hear doctor, they think medical doctor with that attached knowledge and level of experience and training, and that's not the case, and I'm not throwing shade or anything like that, like yes, you earned the title, but I do think it can be confusing in clinical settings to call yourself doctor, if you don't have an MD, um, it can be confusing for patients.

Nicole: And again, there's a little bit of controversy around that. All right. Now, as far as the minimum requirements to get into a midwifery program, you have to have a bachelor's degree or higher from an accredited college or university. And to be a CNM, you also have to have earned an RN license or a registered nurse license prior to, or within the context of the midwifery education program. Now, the certified midwife program is a little bit different. This was developed in 1994 in order to expand access to midwifery, through creating another educational pathway, to get a midwifery degree. So the certified midwife pathway, you do have to have a graduate degree in midwifery from an accredited program, and you have to be board certified through the American Midwifery Certification Board. However, they differ from certified nurse midwives. CMs are certified midwives do not also have to be licensed as a nurse.

Nicole: Okay. They don't have to be licensed as a nurse. That's the only difference. Certified nurse midwives license as a nurse, certified midwives not. Okay, CMs and CNMs meet the same core competencies. They sit for the same exam. They have identical scopes of practice. Um, so they are otherwise identical, except CNM has also had that RN license. Now CNMs are licensed in all 50 states. So certified nurse midwives are licensed in all 50 states plus the district of Columbia and US territories. And sometimes they're licensed under different names. They practice as midwives, but they may be licensed as a midwife, a nurse midwife, an advanced practice registered nurse, or a nurse practitioner. They also have full prescriptive authority to prescribe whatever, including controlled substances as well. Now, whereas this certified midwife credential is actually only recognized in a handful of states. So it is only recognized right now in Delaware, Hawaii, Maine, New Jersey, New York, Oklahoma, Rhode Island, and Virginia.

Nicole: Now we look when we look at the scope of practice for certified nurse midwives and certified midwives. Again, those are the same. A lot of people think of midwifery in relation to birth, but actually it encompasses a full range of primary health care services for women all the way from adolescence to beyond menopause. So certified nurse midwives certified midwives can do preconception care, care during pregnancy, childbirth, post partum period. They can actually do care of the normal newborn during the first 28 days of life. Although I don't think that's very common. They can do primary care. I do know plenty of midwives who do gynecologic care and family planning services as well. And they can even treat male partners for sexually transmitted infections. They do initial assessments, ongoing assessments, diagnosis, treatment, physical exams, per prescribed medications. Again, including controlled substances. They can prescribe contraceptive methods. Some midwives will place IUD.

Nicole: For instance, they can admit patients to the hospital, manage patients in the hospital, discharge patients from the hospital, order and interpret laboratory studies, order the use of medical devices, and of course, midwifery also includes education, health, promotion, disease prevention, all of those things. Okay. So it's actually more than what people realize. Although most are focused around pregnancy and birth, many, many do more, and they practice in all settings, hospitals, homes, birth centers, offices. The majority of nurse midwives though, and certified midwives attend births in the hospital. And then finally for insurance coverage, almost all private insurance will cover care by a certified nurse midwife. Medicaid, which is insurance coverage for people who have financial need is actually mandated in all states to cover certified nurse midwives, Medicare, and also Tricare, which is military insurance. Medicare is insurance for people who are disabled, who, who are elderly.

Nicole: Will also cover certified nurse midwifery care. For certified midwives, um, most private insurance will cover it. And then it's only covered in a handful of states for, uh, Medicaid. Now, as far as education and training to become a midwife, the Accreditation Commission for Midwifery Education is the official accrediting body who, uh, certifies, uh, or credits nurse midwifery and certified midwife and certified nurse midwife programs. Right now, there are 38 accredited midwifery education programs in the United States. Midwifery school is roughly two to three years between two to three years. So you're going to have to do the undergraduate degree for four years, and then midwifery school for two to three years, and then you can go out into practice as a midwife, that's a bit different than medical school or for me as a physician and my training.

Nicole: And I'm going to say specifically about OB. So I have to do four years of undergraduate, four years of medical school, and then an additional four years of OB GYN residency training. Now keep in mind as an OB GYN, there's obstetrics and there's gynecology. And so I'm learning more than just pregnancy and birth. And although midwives are as well, I'm also learning how to do surgeries and procedures and hysterectomies. So it's a longer and more involved training process. Um, certified nurse midwives and certified midwives are certified by their, uh, board organization. And they get recertified every year. It's kind of like a rolling certification process, same thing like physicians. Okay. So let's talk about, about certified professional midwives. Those are C P Ms okay. Now certification as a CPM does not require an academic degree. It's just based on demonstrated competency in specified areas, knowledge and skills related to pregnancy and the postpartum period.

Nicole: So the minimum education requirement to get admitted into a certified professional midwife program is a high school diploma or equivalent and prerequisites for accredited programs vary. But typically it includes some courses like microbiology, anatomy, physiology, and also some experience with childbirth education or being certified as a doula. Now the organization that kind of oversees certified professional midwives is North American Registry of Midwives NARM. And there's no specific or specified requirements for entry to that, that program in general, it's an apprenticeship process that includes verification of knowledge and skills by qualified preceptors. Now they do require that the clinical component of the educational process. So the actual hands-on of being part of birth must be at least two years. And it must include a minimum of 55 births. Okay. The clinical education also must occur under the supervision of a midwife who must be nationally certified, legally recognized, and who's practiced for at least three years and attended 50 out of hospital births after their certification.

Nicole: Okay. Now the scope of a certified professional midwife is a bit different. They offer care, education, counseling, and support to women and their families throughout the caregiving partnership, including pregnancy, birth and the postpartum period. They provide ongoing care throughout pregnancy and continuous hands-on care during labor, birth, and the immediate postpartum period. And, uh, mom and well baby care through six to eight weeks, roughly postpartum. So they're primarily focused CPMs on pregnancy and that immediate postpartum period, they can do initial assessment, ongoing assessment. They can do some diagnosis, some treatment they're trained to recognize abnormal or dangerous conditions that require a consultation with another healthcare professional, like a physician. They do do things like physical exams. They can administer some medications as allowed by state law, but most do not have a prescriptive authority. Some examples when a CPM may be able to administer some medications is for group beta strep GBS.

Nicole: If a woman is GBS positive and needs antibiotics during labor, then they may be able to administer that. But they typically do not have prescriptive authority in, uh, in any states. They almost exclusively practice in home birth centers and offices, the majority of certified professional midwives attend births at home or birth centers. You will not see a certified professional midwife in the hospital. Now, one of the things is insurance coverage. Most insurance, private insurance does not cover a certified professional midwife hence doesn't cover home birth. In most states. It is mandated in a few states, I think like five or six. I don't know the states off the top of my head, but it's only a handful that were private insurance will cover a certified professional midwife. And, um, some states about 10 states or so sort of our professional midwives are covered by Medicaid, which again is insurance for folks who need financial assistance.

Nicole: Okay. So let's give some just facts about midwives and how they practice in the U S. So the American College of Nurse Midwives. And again, this is where most of this content from this episode comes from. They're the professional association that represents most CNMs and CMs in the United States. And I, again, I'm focusing on midwifery care in the United States, midwifery care outside of the United States is completely different. Outside of the United States, midwives, um, are in much higher numbers. They take care of almost all of the low risk people and physicians are only reserved for complicated cases. Um, the reason that it's different in the United States really is because of the way physicians lobbied and kind of discredited midwifery back in the early 1900s. And, um, that's how physicians kind of came to be the ones who were more prominent in birth. It is not that way in other areas of the world.

Nicole: Okay. So as far as numbers of midwives in 2019, uh, last time they had data available, there were 12,218 CNM, and 102 CMs or certified midwives. So you can see that the vast majority are certified nurse midwives, especially practicing in the hospital. Now that has compared to about 40,000 OB GYNs in the U S so 12,000 nurse midwives, 40,000 OB GYN. Now keep in mind that not all OB GYN do pregnancy and prenatal care, some OB-GYNs are specialists, but what would still fall under the category of OB GYN? So like a fertility specialist, or do gynecologic surgery or gynecologic cancer surgery. So it's not a direct comparison, but that just kind of gives you an idea of the numbers. And in 2019, from the National Center for Health Statistics, 9.8% of births were with a certified nurse midwife. So that's going to translate into about 400,000 births a year, roughly that are done by midwife.

Nicole: They're about 400, I'm sorry. There were about 4 million births in the U S every year. So 10% of those would be 400,000 births done by a certified nurse midwife. Of those 94% of those occurred in hospitals. And 3.2% occurred in free standing birth centers. And 2.6% occurred in homes. So hospitals still tend to be the place where birth happens the most. Now, of course, is that, as I said, multiple times, although we know midwives are very well known for, for pregnancy and birth care, actually about half 53% of CNMs and CMs identify that they do reproductive care as well. And 33% identified that they do primary care as the main responsibility in their full-time position. So that may include doing things like annual exams, writing prescriptions for contraception and reproductive health visits, things like education and counseling. So there are midwives who do a lot more than just pregnancy and birth.

Nicole: Now, as far as where midwives work, more than 50% report that they work with a physician practice or with a hospital or medical center as their employer. It's not as common that you're going to see independent midwifery practices. And I'm going to talk about why that is right now, because there are different types of practices and different types of collaborations depending on the state. Okay? So when you look at how midwives practice and how they collaborate with physicians, uh, there are some good collaborations and relationships. There are some not so good collaborations and relationships there's tension on both sides. There are some physicians who fully embrace with midwifery like myself. Some physicians do not like working with midwives at all. Some are worried about liability. And what I mean by that is if we're in a collaborative relationship and a midwife does something that is considered dangerous, or it is harmful to a patient, am I at risk for being sued?

Nicole: Because I am in this collaborative agreement relationship with this midwife, the short answer is actually no. Midwives have their own separate malpractice insurance. So practically you're, you're not responsible, but, um, technically there's nothing that could, could stop someone from suing. In that instance. Also, some physicians have some hesitancy to forming relationships with home birth midwives, worried again, that they're taking on some liability that if something goes wrong, that which which can happen in, in, in home birth, um, it's not without risk that if something goes wrong, then the physician is going to be blamed or held at fault because they entered into this relationship with the midwife. So not saying that that practically happens, but that certainly is a concern, and it's not something that can be completely excluded as a possibility. And then some midwives don't like working with physicians, they feel like they should have more independent, um, responsibility and ability to practice.

Nicole: And so there's good relationships, there's bad relationships, tension on both sides. I think we're working together to try and do better. But the honest reality is that it can be a little bit complicated. So when you think about the ways that midwives and physicians work together, there are three different types of, um, ways that things can happen. So midwives can be in a state where they can have independent practice, meaning that they have no need, they there's no requirements that they have any sort of formal agreement to work with a physician. Okay. So they can be an independent practice, no formal agreements to work with the physician. Now keep in mind that midwives need to have some sort of connection with physicians because they need to have some place to send complications to. That's how systems outside of the U S work very well is that when midwives aren't comfortable with low risk things and they send them to physicians, so they need to have some sort of relationship.

Nicole: And in some states it's required that you have those agreements in place for midwives to even practice. But in 28 states, they can practice independently. They don't have to have any sort of formal agreement in place. Okay. Now in 17 states, they have to have a collaborative agreement in order to practice. And this is a bit of a sticking point. I'm going to tell why I'm just a minute. And then the rest, just a handful of three states have a hybrid model where they're like some restrictions in place, but not quite as much as a collaborative agreement. And three states actually have a supervision requirement in place where a physician has to actually supervise the practice of the midwife. And that adds another level of, um, documentation and responsibility and things for the physician whereas collaborative doesn't doesn't require that. I don't, I don't supervise the midwives.

Nicole: I don't like oversee like their, their day-to-day practice and a collaborative agreement where a supervision requires more. So again, 28 states midwives are, can practice independently. In 17 states, they're collaborative agreements. Three states have a hybrid model. Three states require supervision to practice. Now for collaborative agreements, there's as I said, some controversy. And the controversy is that when you break it down ACOG, the American College of Obstetricians and Gynecologists believe that collaborative agreements need to be in place. American College of Nurse Midwives does not. So AC N M the American College of Nurse Midwives says that regarding collaborative agreements, safe quality healthcare can best be provided to women, their babies when policy makers develop laws and regulations that permit CNMs and CMs to provide independent or free care within their scope of practice while fostering consultation, collaborative management, or seamless referral and transfer of care when indicated, okay, so they want midwives to practice independently, but also have the ability to transfer care seamlessly when indicated.

Nicole: And they note that requiring a signed collaborative agreement with the physician doesn't guarantee effective communication between midwives and physicians. And that is true. It also doesn't assure that the physician is available when needed also true. And there's no evidence that having these signed collaborative agreements increases safety or quality of patient care. Okay? So there's no evidence that it's it's, you know, is necessarily of benefit. Also collaborative agreements that are signed by physicians, wrongly imply that they need supervision. This is, uh, that CNMs need supervision. This is definitely a sticking point that I hear a lot that people think that nurse midwives have to be supervised and they don't. And collaborative agreements do not mean that you are supervising the certified nurse midwife in their day to day care. But based on that misconception, sometimes nurse midwives are restricted from being able to practice because they can't receive hospital credentials.

Nicole: They can't get clinical privileges. They can't get reimbursement from insurance from services that would normally fall within the scope of their training within the scope of their license, because they don't have these collaborative agreements. This is actually a bigger problem or big problem in the south, where there are not a lot of access to nurse midwives for this very reason. And that physicians don't feel comfortable or finding a physician who is comfortable signing a collaborative agreement can be challenging. And so it limits their ability to have practices in, in those settings. They've also been used. These collaborative agreements been used, um, as a way to limit the number of midwives who can practice collaboratively with any one physician. And it creates these ratios of nurse midwives to physicians. Um, it can restrict access to care, restrict, uh, choice of provider for women, and this particularly of a concern in underserved areas where physicians may not always be as likely to go.

Nicole: There may be midwives who are more willing to go into these underserved areas, but they can't because of being hampered by the need to have a collaborative agreement. So when we look at ACPGs position or rephrase a little different, so ACOG says that they support an integrated maternity care system that facilitates collaboration among licensed and accredited clinicians across all birth settings. They support standardized safety transfer and transport protocols and risk appropriate carrier designated facilities. Now they do say this: safety concerns are greater in states where there is no requirement for midwives to work collaboratively with hospital-based clinicians or under common practice guidelines and transfer protocols. So ACOGs stance is that it is not safe to not have these collaborative agreements in place or requires some sort of collaboration. So that there's, uh, a known person that can be on the receiving end of a transfer if need be.

Nicole: Now, they do go on to further say that ACOG respects a pregnant person's right to make a medically informed decision about their birth attendant and place of delivery. They believe hospitals and licensed accredited birth centers are the safest setting for a birth. And that is where ACOG and ACNM differ because ACNM also supports home birth. ACOG does support the standards use by the American midwifery certification board. And that's the board that certifies nurse midwives and certified midwives. So ACOG does support those standards. And then further goes on to say that they support the worldwide midwifery education standards set by the international Confederation of midwives. In 2010, they support those standards as a baseline for midwifery licensure in the U S and those standards. They're just, it's a lot of specific and detailed language. I'm not going to go into it in detail about what is required for someone or what should be required for someone to be considered a practicing midwife.

Nicole: So ACOG believes that all midwives, including certified professional midwives sometimes referred to as lay midwives or direct entry midwives, they believe that all midwives should meet global standards. And that birthing persons in every state should be guaranteed care that meets those important minimum standards set forth by the International Confederation of Midwives. Okay. So a little bit of a difference there in terms of ACOG wants to come out really strongly and say like all midwives, including CPMs need to have more stringent standards. So we know that people are getting a minimum standard, and then that there should be collaborative agreements in place. The American College of Nurse Midwives, uh, is a bit more that, uh, midwives should be able to practice independently. Now, despite the differences, the two organizations actually do want to work together because they both know that they need each other, and that they both know that they need to come together in order to provide the best care and best options for our patients.

Nicole: So they have actually issued a joint statement that it was first released in 2011, the joint ACOG ACNM statement. And it's been reaffirmed several times. And what it says is, uh, ACOG and ACNM are from our shared goal of safe women's health care in the United States through the promotion of evidence-based models provided by OB GYN, certified nurse midwives and certified midwives ACOG, and ACNM believe healthcare is most effective when it occurs in a system that facilitates communication across care settings. And among clinicians, OB GYN and CNMs are experts in their respective fields of practice and are educated, trained, and licensed independent clinicians who collaborate depending on the needs of their patients. So basically recognizing each other's expertise and the need to work together, and then further goes on to say ACOG and ACNM advocate for healthcare policies that ensure access to appropriate levels of care for all women.

Nicole: Quality of care is enhanced by collegial relationships, characterized by mutual respect and trust professional responsibility and accountability and national uniformity and full practice authority and licensure across all states. They recognize that shortages and maldistribution of maternity care clinicians cause serious public health concerns for women, children, and families. Um, there are many areas in the U S that are like, uh, where to call it care deserts, where you can barely get any OB GYN care. There's no OB GYN there. And it's been thought that certified nurse midwives, that would be a great gap that they could fill is going into some of these rural areas and taking care of patients there. So the statement then goes on to say, OB GYN and CNMs CMs working together, optimize women's health care and ACOG, and ACNM AC N M O that's a tongue twister recommend increasing the number of OB GYN and CNMs CMs utilizing interprofessional education to promote collaboration and team based care.

Nicole: And then the final thing that they say is that working together does require that OB GYN and CNMs have access to affordable liability insurance that's malpractice insurance, that they both have hospital privileges, that they have equivalent reimbursement from private payers and under government programs, and then access to support services. Okay. And they really just need to, we need to create a system where we work well together. So both organizations are saying that we need to create a better system where we communicate, where we work well. Um, collegialy, you know, not with animosity, things like that, so that we are providing the best care for our patients. The one area that they do disagree on one, and as mentioned in that joint statement is that they hold different positions on home birth. Like I said before. Okay. Now practically, the models that you will see will vary for midwifery care based on where you are.

Nicole: So you may be in a state that has independent nurse midwife practices, meaning which means it could be a group of midwives, and there are no physicians in the practice. They probably have some sort of backup physician agreement available, even if it's not formal, but you may be in a model where it's just a group of independent nurse midwives. I have not seen that in my state because it's not possible in my state in Virginia. Now, I think what's more common is that midwives are a part of a physician practice and they all are work under a practice together and midwife see low risk patients and see their own patient pools and deliver their own patients. And then some models actually have it where midwives attend all, all of the births and physicians only participate in cesarean births or, um, operative vaginal deliveries, like with the vacuum or forceps.

Nicole: So the practice model may different. If you happen to be in a practice that has midwives, that's something you want to get clarity on because it really just depends. Or finally, you may see something like what I do, but does midwife hospitalist that is becoming more and more common, especially since data shows that midwifery care helps improve outcomes, helps reduce the cesarean birth rate, um, helps, you know, uh, people have a better experience potentially during labor and birth. So we're seeing more and more midwife hospitalists as well. Okay. So my thoughts on the midwives, as I said in the beginning is that we need to work together. All right. And I actually personally believe that nurse midwives should always have an established relationship, whether formal or informal with the physician or some sort of group of physicians, there need to be those relationships in place, because that is what best benefits patients.

Nicole: I think it's not a good idea for your midwife to not have someone who she knows that, Hey, if something is going wrong or I need to bring my patient into the hospital, or if we're part of an independent group and a patient needs to be transferred, you want those things to be set up ahead of time and be seamless. Because again, that is in the best interests of our patients. I think we're getting better. Um, we still have some work to go, but I definitely think we're getting better. All right. So just to recap, midwifery in general, emphasizes a more holistic and patient centered approach. We can definitely learn some of the pearls of midwifery. I've taken away some of the things from midwifery, for sure, in order to help improve the care that I provide for patients. As far as types of midwives, there are certified nurse midwives, certified midwives who are the same.

Nicole: They require GRA and they are the same in terms of the scope of practice and what they can, what they can do in their practice. The difference is that certified midwives do not have her nursing license. And then there are certified professional midwives who attend home birth, birth center births. The practice structure is really going to differ depending on your state. So if you have a friend in a different state than her midwifery care might be different than what you experienced. It really depends on what happens in their state. And then finally, again, midwives and physicians must work together in order to provide the best care for our patients. Those relationships should be seamless. They should be collegial. We should be able to work together. Um, mid midwives provide great care and a great asset to our patients. Shout out to all the midwives I've worked with in my career and continue to work with on a day to day basis.

Nicole: I definitely believe that we can get there where we provide the best options and things for our patients. Um, it'll take time, but again, progress is slow, but it's, it's possible. All right. So there you have it. Be sure to subscribe to the podcast in Apple Podcasts or wherever you're listening to me right now. And I would really love it. If you leave that honest review in Apple Podcast in particular, it helps other women to find the show and helps the show to grow and do check out the Birth Preparation Course, my signature online childbirth education class, that gets you calm, confident, and empowered to have a beautiful birth. It is crazy affordable for everything that you get inside of the course lifetime access, access to me and a private Facebook community with Q and a sessions. Um, really the most important part of the community is the other pregnant moms you get to interact with and bounce questions off and all of those kinds of things. So check out all of the details of the course at drnicolerankins.com/enroll. So that is it for this episode, of course, please come on back next week. And until then, I wish you a beautiful pregnancy and birth. Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast, head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, the Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.

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