RN Radio: Myths About Midwifery

Welcome to RN Radio, the podcast for nurses and nursing students with a passion for learning and staying informed and brought to you by Nursing@Georgetown, the online Master of Science Degree in Nursing from Georgetown University School of Nursing & Health Studies. We sat down with Julia Lange Kessler, DNP, CM, FACNM, director of the Nurse-Midwifery/Women's Health Nurse Practitioner program at Georgetown University School of Nursing & Health Studies, to discuss misconceptions widely held about midwifery. The NM/WHNP program is offered through Nursing@Georgetown. The podcast is accessible below and accompanied by a transcript of the conversation that followed.



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FIONA

Hello, this is Fiona Erickson. And you're listening to RN Radio. RN Radio is brought to you by Georgetown University School of Nursing & Health Studies and Nursing@Georgetown, the school's online master's degree program in nursing. Today our guest is Julia Lange Kessler, who is here to speak with us about midwifery and potential myths surrounding it. Welcome, Julia.

JULIA

Thank you.

FIONA

Could you go ahead and tell us a little bit about yourself?

JULIA

My name is Julia Lange Kessler, you've already introduced me. I am a midwife. I have been a midwife since 1981 and helping women with birth since 1981. I started as a doula, which is a professional labor coach. And I went on to be an apprentice midwife. I was a lay midwife. And then I got my certificate in midwifery from Downstate in Brooklyn and then went on for a master's in midwifery from the University of Philadelphia – my post-master's certificate from Penn State – my doctorate of nursing practice from Mass General Hospital in Boston. And now I am the program director at Georgetown University for the Nurse Midwifery/WHNP program, which is entirely online.

FIONA

That is quite a litany of educational experiences. You mentioned that you spent some time as doula. And for our listeners who may or may not be familiar with the term, would you mind expanding a little bit on what that means and what that scope of practice looks like as compared to, say, a midwife or your more standard OB/GYN doctor.

JULIA

A doula is a person who's a professional coach. They shouldn't do anything medical. They're not there to take your blood pressure or make any medical decisions. They are there for emotional support to maybe make suggestions in terms of maybe it's time to take a rest – maybe we should get up and walk together – maybe we need to rock on the birth ball – those types of things. So those are the kind of things that they would do. They are women that are knowledgeable about birth. And they may be able to help in all kinds of different emotional ways. That's really their primary focus because when a woman is in labor, she's very, very vulnerable. And while it's nice to have your partner with you, your partner may or may not have ever been at a birth before. And your partner may or may not know how to help you. And even if they go to childbirth classes, they may not know how to help you. So that doula is that woman or person who actually has some experience and will take you calmly through the birthing process and can give you backup education when decisions need to be made. So I think that kind of rounds out what a doula does. And I think doulas are fabulous. I love to work with them. I think that they're great. And it's always nice to have another pair of knowledgeable hands.

A midwife does all that a doula does. But she also helps to make the medical decisions and helps to interpret that you're safe and that you are stable. And then it's safe for you to continue with your labor as it is. So you might say to me, well, this labor is going on too long. And I can say, well, actually this is a very average time that you're having labor or we can make suggestions in terms of pain relief. We can offer pain medication. And also the difference between a doula and a midwife is that a midwife can care for you, of course, throughout your life span and can also do all of that prenatal care and everything else that goes along with pregnancy and birth and afterwards. So if you were to have your baby vaginally and you needed some stitches afterwards, a midwife can do that. If you need C-section, a midwife cannot do a C-section. But she can go in and first assist. So she stays with you throughout. And she helps the doctor who's doing the C-section, meanwhile still hopefully keeping you calm and that type of thing. And so midwives do take care, as I said, throughout a lifespan.

And we do all of the same things that doctors do except for we do not perform GYN surgery or we do not perform that C-section. So that's a bit of a difference that we have. And we also – we don't shy away from primary care. So that's a little bit of a difference that we have is that we're not going to do your C-section. But we certainly can make the decision and make the call that you need a C-section. And so that means I'm going to call my doctor and say, you know what? She needs a C-section. We hopefully are going to listen to you and stay with you a little bit longer in the birth. We may labor-sit, meaning that we'll sit there with you while you're in labor. We will offer suggestions. We support normal physiological birth. And that means that you need to have a presence. And that doula is one presence. And the midwife can be another presence. And that type of support – that type of female support around you when you're having a baby – studies have shown that it really reduces the risk of C-section. It really reduces the pain medication that's necessary. And you just need to know you're not alone and that what you're feeling is normal. And that's what we wanted to do, is support that normal physiologic birth.

FIONA

What brought you to midwifery and made you want to pursue it?

JULIA

Well, I saw through my own experiences that midwifery really makes a difference in a woman's life. So my first birth was in a hospital and with an OB/GYN. And my second birth was with a midwife at home – not that very many midwives delivered at home – hardly any of them do. Only about 15 percent of midwives do home deliveries. But my second birth was at home. And when I got done with that birth, I was so empowered by it, I felt like if I could do that, I could do anything. And I thought that was a very important aspect that other women should feel. And I wanted to be able to help other women get to that place where when they gave birth, they not only started out and got through it in a healthy place, but they also emotionally got through it and felt like they were a lioness, that they could become fabulous mothers and take great care of their children because they were powerful and strong.

FIONA

That's beautiful. Thank you for sharing that personal story. I guess, to elaborate on something that you mentioned-- the empowering nature of midwifery and the way that it empowers women and helps them to start their family strong. Stepping aside from your experiences, what do women in general stand to gain from access to midwives?

JULIA

Well, access to midwifery – they can gain quite a bit, actually. So midwives have a much higher satisfaction rate among females. And they also have a much lower cesarean rate. They have less medication, although if you want medication, a midwife will give it to you. We don't hold back on that. And they have just healthier outcomes all around. So in the rest of the world where in many other patient populations in other countries where midwives are the primary care providers, they have much better statistics than we do. And we are way down the list for maternal mortality and infant mortality.(*note below) So you just have a better outcome in my opinion. And not just a better healthy outcome, but a better emotional outcome because midwives partner with you in your health care. We don't say you have to do it our way. We work together to do not only informed decision-making, but shared decision-making for your health outcomes.

FIONA

Do you think that part of the satisfaction increases have anything to do with the sort of extended method of care where midwives are caring for the whole woman over her lifetime, not necessarily just in pregnancy scenarios?

JULIA

Yes, I do because midwives can take care of women throughout their lifespan. And I'm glad that you pointed that out, Fiona. So as midwives, we can do all aspects of women's health care starting from the time you get your first period right through menopause and beyond. So we do primary care, which means that we can take care of your common ailments that you have or help you with other chronic disease states – some of them. And we do GYN – all kinds of GYN care and pregnancy care, birth, postpartum care, newborn care up to 28 days. And then we can provide gynecological care for a woman throughout her life.

FIONA

You've obviously had a long and rather illustrious career in midwifery. What misconceptions have you encountered given that it's not a particularly well-understood field of work?

JULIA

Yes, not well understood here in the United States. I'll have questions like This: Oh, you're a midwife? That's legal? So that's one misperception that, yes, we're licensed in the United States. And we have quite an education, at the very least a master's degree. And a good percentage of midwives also have doctoral degrees. So beyond that, the other misconception that I would say to you is that, oh, midwives – they only do home births. And the reality is that, no, 85 percent of midwives practice in hospitals, in private practices – in all kinds of different settings. And only 15 percent are out of hospital settings, so that includes birth centers and home births. And we do believe that home births for the low-risk women are safe. And out-of-hospital births for the low-risk women are safe alternatives. And our professional organization – the American College of Nurse-Midwives – also supports that particular issue that we are safe no matter where we are. And it is within our scope of practice to make that call. So say you're at home. And that's the other thing. It's not do-or-die home birth. It's only home birth if it's safe to be there. So say something comes up like your blood pressure starts to go up. Or the baby's heart rate doesn't sound exactly right to us, or you start to develop a temperature, then you shouldn't be at home. We're going to take you to the hospital. We're going to make sure you get to a hospital and hopefully to another midwife in the hospital so that we can care for you. Or if we're really lucky, we have privileges in that hospital ourselves and we continue to care for you. So it's not do-or-die home birth. So that's one of the things that I'd like to say.

And the other thing – the other myth that I would tell you is that many people think, oh, if you go to a midwife, that you can't have medication while you're in labor. And while we will offer you alternatives, we will walk the hallways with you. I will rub your back. I will talk with you. I'll even sing every once in awhile. If you say to me I want my epidural in the parking lot before I even get in the door, then I will give you that epidural. So we support normal physiological birth. So we do offer alternatives. And we will help you with those if you want them. But if you don't, it's your choice. As long as you're making an informed decision about it and you understand the benefits and the risks, then I'm fine with that.

FIONA

To go back to the first point that you raised on midwifery and the misunderstanding about the qualifications that go along with practicing midwifery – in particular the education – could you offer some insights on what the tenets of that education are beyond the physiology and the biology, but what the core beliefs that you try to impart upon your students are?

JULIA

Well, let me just tell you a little bit about what midwives go through to become licensed. And then I can tell you the focus of our program.

FIONA

Perfect, that would be great.

JULIA

So, of course midwives have to come to the profession with a strong science background. In the United States, we have both CNMs – Certified Nurse Midwives – and Certified Midwives. And when someone is a CNM, it means that they came from a nursing background first. But in the United States, we also recognize that certified midwives could have very strong sciences. And then you can go into midwifery. It's just like you wouldn't ask a cardiologist to become a nurse first and then be a nurse cardiologist or a doctor to become a nurse doctor. We would ask them to have strong science background. So midwives have very strong science backgrounds, as you refer to all the -ologies I like to call them, as well as nutrition and pharmacology and a number of different sciences. And then they come to the master's program with a bachelor's degree in those sciences of nursing. And in our program here at Georgetown, they have to have a nursing degree. And then we do some advanced sciences. And then we go to our core clinical courses. So in the core clinical courses, they'll be taking a course in gynecology. And then they will also be doing a clinical course that correlates with that, or the next course will be pregnancy care or advanced GYN care. And there will also be a clinical course that will correlate with that. And at the very end of the program, we put them into a course called Integration where we integrate all of the other clinical courses together. And they get to be the midwife for that entire semester. And they are working and living the life of a midwife. So it's 40 to 50 clinical hours per week. And they are the midwife and their preceptor works with them to make sure that everything is safe and that they stay safe. Preceptors are midwives in a hospital or out-of-hospital setting that work very, very closely supervising students throughout their clinical rotations.

So at Georgetown, we really want our students to be, of course, excellent. We are very, very careful about where they are placed clinically. We want to imbibe all of the values of Georgetown with social justice and caring for the whole person and treating others the way that you would want to be treated. And then thinking about really specifically in terms of midwifery, we do want to take into consideration the entire person. So it's not just about that we can provide care for you, it's also what's going on with your family — what's happening in your life that this kind of stress is causing this condition. What can we do to get the services for you to alleviate some of that stress? Or what can we do to help to bring you to a place of self-care and taking not only good care of yourself? Because once a mom takes really good care of herself, the research shows that she is the lifeline for the rest of that family. And she is the entryway into health care. And she's the one that makes the health care decisions. And so we want to make sure that she's empowered with the best information and the best education. So we have a saying in midwifery that we "listen to women." And we do listen to them, but not only do we listen carefully, we also spend a lot of time in patient education and making sure that she has the information that she needs in a health literate type of way so that she understands.

FIONA

That's a lot to cover in one master’s program. I'm impressed. I have heard a little bit about the myths that you've mentioned from the education to the pain medication to the home birth, being sort of misconceptions that the public might have while making a decision about where to seek prenatal care. Who is the onus on to clear up those misconceptions? And how do we go about doing that?

JULIA

Well, that's a big question. As midwives, we work with our consumer groups to try to clear up those misconceptions. And as someone who's really involved with a professional organization, again, the American College of Nurse-Midwives, we also work on clearing up those misconceptions. But misconceptions have a life of their own, so to speak. And so it is a little bit hard to overcome in this country because we are not the largest profession. So in the midwifery profession, there are 11,000 of us. And so we're a small profession comparatively. And then there is this perception here in the United States that if you go to a midwife, you're going to someone who's lesser than rather than you're going to someone who will give you a full complement of care. I want to just preface that by saying, but we also collaborate. So if I need a doctor if a situation becomes high risk, then we're going to consult with our medical collaborators to make sure that we are getting the best care for our patients and taking the best care for them. So no one really practices in a vacuum. No one practices in a silo. We have to have interdisciplinary conversations because that's the way to keep people safe. And I would hope that as not only the public learns about midwifery, but also other health professions learn about midwifery that some of these myths can be dispelled.

FIONA

So interesting to hear. What is your hope for the future of midwifery? We’ve spoken a little bit about the interdisciplinary understanding and the ability to work together with other medical care professionals. And so if you were to look 10 years in the future, what would being a midwife look like in the field of medicine?

JULIA

Well, 10 years into the future, I would hope that given the focus right now on interdisciplinary education, that there's a lot more understanding about what midwifery is and what midwifery can do for women. And so that, I would hope, would be not only an easier way for midwives to practice because the easier it is for us to practice, the more women we can help. So I would hope that the interprofessional and the interdisciplinary way that we work together could become easier. And I hope that the Internet will help with that in the hospital systems and perhaps the Affordable Care Act will help that all to gel together 10 years from now. But if you're going to ask me 25 years from now or 30 years from now, maybe even sooner – let's put it out there that it could be sooner – that we could have a midwife for every woman that wants one and that we could grow the profession so that when you want holistic care for another woman, that you can get that. You can look and you can see a midwife in every town. I mean, we have some states that only have a few midwives in them — like three or four midwives. I mean, we need a lot more midwives across the United States. And I think we can really improve the quality of health care if we were to have midwives for every woman.

FIONA

You obviously were fairly initially drawn to midwifery. If you were speaking to, let's say, a listener who is contemplating where they'd like to go with their nursing degree and midwifery, nurse midwifery is on the table. What would you say to those prospective listeners who might be on the fence about it? What really was the deciding factor for you that brought you here? What would you impart upon them?

JULIA

I would say to them that if you're considering midwifery, find out something about the profession and about what it really entails. The reality is that when it comes down to it, you are making life-and-death decisions for two people. So it's not just the mom. It's the mom and the baby. So it's that dyad that you have to care for. And we can't just think about one part of that. But during labor and delivery, that part of your midwifery practice – that's the part where you put the pedal to the metal, so to speak. And you have to be ready for all kinds of different things that could come up. If you're somebody that panics a lot, then I would say that this is not the profession for you. But I would also like to say and like to just impart that midwifery is a really beautiful way to spend your life that for me, being at a birth is like being in church. It's holy. And it's miraculous. And it's pretty incredible. And so it's a really, really nice profession. It's a lot of fun. But it's not always fun. So you have to be prepared for the un-fun days, too. And you have to be ready to take them on. So in thinking about someone that's considering midwifery – and maybe I can say to you where I see people go wrong is that they get involved with the romantic notion of it, because it is rather romantic. But not realizing that really sometimes it's a lot of hard work. So when I said to you, I'll rub your back – I'll do this. Yes, and by the time I get done with your birth, I'm going to be sore too. So we'll both be sore together – and that kind of thing. But just helping women to – when you see somebody holding that baby in their arms, it's just magical. It's just really, really magical. And when you can help them with breast-feeding and help them just to realize what it means to be a woman and how incredible women are, it doesn't get better than that.

FIONA

Before we bring the audience to tears with the romantic aspect of midwifery -

JULIA

Let's get back to the … to the facts.

FIONA

To sidestep a little bit about a point that you mentioned earlier – the global aspects of midwifery – how some countries have more midwives than we do. And they're more prevalent and better understood and utilized. And then some countries have problems meeting skilled care needs at all in any fashion. Where you see midwives in the progression of medicine worldwide fitting in?

JULIA

So let's just talk a little bit about those countries that have a lot of midwives like in New Zealand and in the Netherlands and those European countries – many of the European countries. Midwives are the first layer of care. So before you can even get to a doctor, you go to a midwife first. And the midwife decides whether you are low risk or high risk. And if you're high risk, then OK, she may send you to a doctor or she may co-manage your care.

FIONA

Could you briefly elaborate just what low risk and high risk look like?

JULIA

So low risk would be someone who's essentially healthy and without disease state. I wouldn't want to particularly take care of someone without collaborating with a doctor or co-managing with a doctor someone who has epilepsy or someone who has insulin-dependent diabetes or somebody with some other type of disease state that would be out of the range of my scope of practice. So we stay within our scope of practice. If you become hypertensive, I'm going to call your doctor or call my backup doctor – my collaborating doctor. And I'm going to say to him this is what's happening. I think I should prescribe this. And do you agree with me? But if someone is too high risk from the beginning, we're going to pull the doctor in right away.

FIONA

Perfect. Thank you.

JULIA

So that would be high risk – someone with a genetic disorder – those kind of things. I would want perinatologist or an MD to be involved. So low risk is basically your healthy woman. And in those countries that I was talking about, you go to the midwife first, and then she decides whether you're low risk or high risk. And she is the first point of care. And those countries, if you take a look statistically, you'll see that they have much better outcomes for maternal mortality and infant mortality than we do. And we do see that the correlation between the number of midwives really impacts the country and their health outcomes. So in the countries where access to care is problematic – the recent Lancet series and a number of other reports that have come out really point to the World Health Organization, the list goes on and on – really point to midwifery as the solution in those countries where there are very, very high infant mortality and maternal mortality rates. So I've done some work in Haiti. I've done work in Rwanda. I've done work educationally in those countries trying to help educate midwives and to create more midwifery education in those places so that they have the skilled professionals that they need. And I do think that it's not only my opinion. It is the opinion of many, many scholars that midwifery is the solution. And so that's why we have to make as many as we can.

And that's what we do at Georgetown with our program. Women can practice in their own community. We call it community-based education. So we bring our educational program to you. And you still get to go to class every week. So you're in class. Like last night I taught from 6 to 9. And I brought the classroom to each person's home. And they sat in front of their computer. They could see me. I could see them. We could do our lecture. We could share PowerPoints. We could have discussion. And we could do all of the things that we needed to do just as if we were in a classroom together. And then tomorrow when they go out, they'll go out into their community, into the clinical placement, which we find for them. And they will have an educational experience in the clinic setting. And when they get done with their midwifery education, they will stay in their community and bring that great resource to the community.

FIONA

So we're really seeing pushes from, say, you mentioned the World Health Organization, to take that community-based learning model that Georgetown uses and expand it.

JULIA

We're hoping to take it international, yes.

FIONA

And bring the education to the people.

JULIA

Yes, exactly right.

FIONA

That's fantastic. So to just to wrap up what we've heard so far, there are definitely – and correct me if I misstep at any point here – definitely a couple of misconceptions, in America specifically, about the practice of midwifery. You personally, anecdotally, mentioned the prescription of pain medication or the use of pain medication, the practice of home births, and midwives’ educations. But as we've learned, midwifery is really about the midwife-patient mutual decision-making and education. We really appreciate the time that you've given us. Thank you so much for coming in, Julia, and speaking to us about midwives and clearing up all those misconceptions.

JULIA

Thank you. It's been my pleasure.

FIONA

I'm Fiona Erickson for RN Radio, the podcast for nurses and nursing students with a passion for learning and staying informed. For more information on Georgetown's online master’s nursing programs, please visit online.nursing.georgetown.edu. Join us next time for more on RN Radio.

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*In this context, "way down on the list" refers to our rankings on the world scale when it comes to infant and maternal mortality. Despite our technological advancement as a country, we continue to have poorer health outcomes than countries with more robust midwife populations.

Please note that this post is for informational purposes only. Individuals should consult their health care professionals before following any of the information provided.