by Candi Helseth
Juliana Fehr began her career as a special education teacher, working with severely handicapped children in rural Virginia. Mothers of her students seemed to know little about the importance of caring for themselves during pregnancy and told her stories about their babies being born limp and lethargic, stories that left Fehr wondering if the children might have had different outcomes if they’d had less traumatic births.
“I realized I couldn’t change the outcome for children unless I began before birth and to do that, I needed to work with the moms,” Fehr said. “Ideally, the change begins before they’re even pregnant.” Fehr returned to college for a bachelor’s degree in nursing and then a master’s degree in midwifery. She worked as a certified nurse midwife (CNM) in rural Virginia and West Virginia for 17 years.
CNM Gail Stamler says she spends more time educating her patients about healthy living than she does delivering babies. And she’s delivered hundreds of babies during the last 30 years in Silver City, NM. (Overall, midwives deliver about one-third of New Mexico’s babies.) For Stamler, the long, erratic hours associated with a rural practice are offset by the rewards of small town living. Although Silver City is ripe with unemployment, poverty and one of the nation’s highest teen pregnancy rates, Stamler said, the isolated community is also rustically beautiful, tranquil, friendly and culturally interesting.
“I like the low-key lifestyle and I love my patients and really getting to know them,” she said. “I’m meeting women’s needs and that feels good. I guess I’m just cut out for this.”
As rural areas grapple with shortages in obstetrical services, midwives may help fill those gaps. The number of family medicine physicians and OB/GYNs delivering babies in rural areas continues to decline. But nationwide, from 1996 to 2006 when the most recent data was collected, the number of births attended by certified midwives increased by 33 percent, reaching a record high of 317,168 in 2006, according to the American College of Nurse-Midwives (ACNM).
The original midwifery model focused on rural outreach. Frontier Nursing Service (FNS) founder Mary Breckinridge opened the first American midwifery school in Leslie County, in the mountain country of eastern Kentucky, in 1925. Midwives rode horseback into remote areas where there were no roads to deliver babies in the homes.
“Mary Breckinridge was a visionary before her time, able to see that the nursing degree brought public health and family skills into midwifery training, making a CNM a combination provider with unique skills,” said President Susan Stone, a Frontier graduate.
Today FNS’ outgrowth, Frontier School of Midwifery and Family Nursing (FSMFN) continues that rural emphasis with its operation of a college that offers graduate level nursing-related degrees and a rural health service that includes five clinics, home health, and a 25-bed critical access hospital where CNMs deliver babies.
While the term midwifery most commonly generates associations with labor and delivery, 90 percent of patient visits are for primary, preventive care, according to ACNM. CNMs provide physical assessments, gynecologic exams, family planning, prenatal and postpartum care, and care for the newborn infant.
The midwife model of care focuses heavily on prevention and education, said Fehr, who now heads the Nurse Midwife Initiative at Shenandoah University in Winchester, Va. “We guide women, educate them, counsel them and empower them. We provide evidence-based care. And we consider pregnancy and birth a normal process. We want them to have their babies the way they choose.”
Stamler spends much of her time educating patients. Like many rural areas, she said, their region has a poor, undereducated population with a high unemployment rate.
“My days can be 80 percent social work and 20 percent medical care,” she commented. “I spend a lot of time every day talking about getting good nutrition, getting off soda, getting exercise, getting dad to pay child support, getting an education to support that baby—things these women tell me doctors don’t talk about to them.”
Training Rural Midwives
To increase the number of rural midwives, several programs are providing long-distance courses to nurses already practicing in rural areas. Some ensure that their students take part in rural rotations, as well.
By offering distance education programming for midwives, FSMFN has students in all 50 states. About 80 percent of graduates work in areas HRSA has designated as rural or underserved, according to Stone.
“Our absolute goal is to significantly increase the number of CNMs over the next 10 years,” Stone said. “By taking nurses who already live in rural, underserved communities and educating them to be nurse-midwives, we can improve services in these regions.”
Midwifery students in Frontier’s distance education program do Web-based coursework at their own pace in their home communities. Students complete clinical rotations in their region under the direction of CNM preceptors approved by Frontier.
“The classroom is the community where these students live,” Stone said. “We have preceptor sites across the United States. We continue to add more.”
Midwives have long been a strong part of rural health care in New Mexico, said Julie Gorwoda, director of the UNM College of Nursing’s Nurse-Midwifery program. “Our mission at the University of New Mexico (UNM) is specifically to educate nurse-midwives to care for rural and underserved populations. Eighty-two percent of our graduates work in rural or underserved practices.”
One-third of New Mexico’s CNMs are UNM graduates, Gorwoda said. From 1988 to 2009, New Mexico went from having six communities with nurse-midwives to 18 communities and 20 hospitals.
“In New Mexico, we’re worse than rural, we’re a frontier state,” Gorwoda said. “All of our students know coming in that two of their three clinical rotations will be in rural or underserved areas. If we immerse them in a rural clinical experience, they won’t be afraid to practice in a rural area. And the learning curve won’t be as steep when they do.”
Gorwoda said UNM actively recruits students from rural areas. Students complete coursework on campus and through distance education programming. They do more than 1,000 hours of clinical rotations near their homes, working with any of 100 preceptors throughout the state who donate their time.
“We keep them as close to their homes as we can,” Gorwoda said. “If they don’t move their family away from that rural area to go to school, they’re going to go back there.”
Students’ mean age has dropped from 38 to 28. UNM previously required that midwives have nursing experience before beginning the graduate midwifery program. However, Gorwoda said, “Now, we accept exceptional applicants straight out of their bachelor’s program. Graduating midwives earlier means they are likely to practice longer.”
Shenandoah’s Nurse Midwife Initiative has begun a distance-learning program and has initiated collaborative arrangements with five other graduate nursing programs. Students in Virginia, West Virginia and Maryland complete the core nursing curricula on the campus closest to their homes. Virginia’s Old Dominion University telebroadcasts core curricula to local community colleges in southern and central Virginia where, Fehr said, there are greater access barriers. Students take graduate courses through SU, receiving graduate nursing degrees from their home university and a certificate of endorsement in nurse-midwifery from SU.
Currently, there are 38 graduate programs nationwide with plans underway to add three more, according to ACNM spokesperson Yolanda Landon.
For the last 17 years, Stamler has worked collaboratively in medical practices with family medicine physicians and, more recently, OB/GYNs in Silver City, NM. The medical group provides primary care for women at their clinic and delivers babies at Gila Regional Medical Center, a rural hospital that serves a tri-county area. Prior to that, Stamler worked in a solo practice doing home births for 13 years. While she still has irregular hours and weekend call, she believes midwives are more likely to stay in rural areas when they can work in team situations.
“In a rural practice, you can’t make plans to go anywhere because even if you’re only delivering a few babies a month, you must be available all the time,” Stamler said. “I love my patients and living here. But I also like being able to have some time off. I know people who left because their work schedule was so disruptive.”
Geographic and professional isolation, physician shortages, high malpractice rates and decreasing numbers of rural hospitals with maternity units are among factors adding to the challenges of being a nurse-midwife in rural America.
Some of those challenges could be addressed through legislative change, according to Fehr.
“Nurse-midwives and other advanced practice nurses provide cost effective, evidence-based care. But laws and regulations regarding midwifery practice still differ widely from state to state.”
“The medical system needs to include midwives with nurse practitioners, physicians and other medical providers as part of a health care network that works in collaboration as a team providing a safe place for the woman and baby,” Fehr continued. “The major gap in those teams right now in many states is the midwife. Too often, she’s still not there.”
Infant and Maternal Mortality in the United States
Although the United States is a developed country, it ranks high in infant and mother mortality compared to other developed nations.
- According to a report on Maternal Mortality published in The Lancet this year, mothers in the United States now die at a higher rate than in most other high-income countries—four times the rate of Italy and three times the rate of Australia.
- Among a total of 181 countries, the U.S. Maternal Mortality Rate (MMR) is 39th.
- A number of state-based studies have found increased rates in infant mortality among rural residents as compared to urban residents. Studies have also shown that the infant mortality rate increases with rurality. (Source: Rural Health Information Hub, Women’s Health Topic Guide FAQ, What challenges do rural women face related to childbirth?)
Back to: Summer 2010 Issue