Monday, March 27, 2017

The rural health landscape (Part III): Interview with a midwife

Parts I and II of this series discussed, respectively, women’s health in rural America (generally) and the history of midwifery in rural America (specifically). This post provides a glimpse into modern midwifery.

Eva Warner is a Certified Nurse Midwife (CNM). She completed her undergraduate degree at the University of Colorado–Boulder. As an undergrad, she lived abroad in India, where she collaborated with the Institute of Health Management (IHMP) to study the socio-cultural determinants of maternal health in Pune, India. After graduating with honors in Sociology, Eva worked as a case manager at Clinica Family Health, a full-service medical provider serving disadvantaged and low-income patients in south Boulder, Broomfield and west Adams counties. In addition to receiving her Master’s from Columbia University’s Nurse Midwifery Program, Eva is also the recipient of the National Health Service Corps (NHSC) Scholarship. When she graduated from Columbia, Eva was offered positions in both Chicago (serving an underserved urban community) and New Mexico (serving an underserved rural community). She recently accepted the offer from New Mexico, and will spend the next two years serving rural and underserved women in and around Los Lunas and Belen.

The following transcribes my interview with Eva. Editorial additions and asides are bracketed and indicated with italics.

Hi Eva! Thank you so much for agreeing to share your thoughts and experiences. To start, please tell us a bit about your personal background. Who are you? Where are you from? Do you have any previous experience with rural communities?

I grew up in Colorado Springs, Colorado in a multiracial and multicultural family. Dinner table conversations navigated topics of social justice and politics, floating between English and Spanish. My worldview was shaped by trips to Mexico for Christmas and living in Chile in elementary school and high school. I come from a big family, full of cousins (mostly boys), teasing uncles and aunts in eclectic southwestern attire. We were all raised harmonizing around a campfire in the mountains of Colorado or under the stars in Mexico.

I was always interested in anatomy and physiology of the human body, but I knew that I wanted to pick a career where I was working with people and giving back. I entered undergrad with the intention of becoming a nurse. I felt that as a nurse I could care for the patient as a whole, their social context and their physical ailments. I knew that nurses were able to spend more time with patients, I liked that. During my first spring break, I shadowed doctors at a local hospital. I was fascinated by their ability to problem-solve and create solutions for patient care. I changed my trajectory to medical school, hoping to keep my nursing spirit as a doctor. After my sophomore year, I had an internship with midwives in Aurora. I was completely enamored with the profession. It was an integration of nursing philosophy and medical problem-solving. It was the marriage between social justice (the essence of “giving back,” feminism, fighting the patriarchy, serving the underserved) and reproductive medicine.

After working at a FQHC [Federally Qualified Health Center] as a case manager [referring to her work at Clinica Family Health], I moved to New York City to attend Columbia University for both nursing and midwifery school. I chose Columbia because I was interested in learning from the urban underserved patient population. For my Master’s degree, I was awarded the National Health Service Corps Scholarship [NHSC], a very competitive, full-ride scholarship from the U.S. government.

[The NHSC program is housed within Health and Human Services, and is specifically directed at addressing health professional shortages. In addition to certified nurse-midwives, eligible disciplines also include: physicians, nurses, dentists, psychiatrists and psychologists, family therapists, and professional counselors.]

In exchange for tuition and living expenses, I have a contract to work for two years in an underserved community. The NHSC rates hospitals and clinics based on many factors and gives them a score for how underserved the community is. I was required to find a job [in a community] with a certain score to satisfy my scholarship contract requirements.

[To become NHSC-approved, a site must serve populations in areas designated Health Professional Shortage Areas (HPSAs). Once approved via an application process, sites must recertify every three years. NHSC-approved sites may offer primary care, outpatient, or ambulatory services, and may not discriminate in the provision of services because of income level or because payments would be made under Medicare, Medicaid, of the Children’s Health Insurance Plan (CHIP).]

Tell us a bit about your job as a midwife. What do you do? What type of training and certification is required to do what you do? Have you received any rural-specific training?

A midwife is trained in the same way as a nurse practitioner. In most of the country, in order to be a midwife, you must first become a Registered Nurse and then receive your Master’s in Nursing with a specialty in midwifery. We are mid-level providers who care for women throughout the lifespan. This means that I am trained to care for well women, pregnant women, women with health conditions, and menopausal women. My scope of practice includes all primary care health screenings, including pap smears, breast exams, and full body physicals; birth control, including IUD and Implanon insertion; gynecological care, including treatment of sexually-transmitted and vaginal infections; prenatal care, including all necessary screenings and management of abnormal conditions (e.g., gestational diabetes, thyroid conditions and anemia); intrapartum care, including managing normal and abnormal labor with pain management (including epidurals) and delivering the baby; postpartum care, including evaluating for abnormalities, caring for the newborn, and assisting with breastfeeding; peri-menopausal care, including hormone replacement therapy.

I can make decisions about patients’ care and prescribe medication on my own, without a doctor’s approval. However, I am trained to know when something is beyond my scope of practice. I care for low and medium-risk women. If I think that a patient may be high risk, then I transfer care to a physician (this includes C-sections). More important than what I can and cannot do: everything I do is done with the utmost respect for the patient. We are trained in patient-centered, evidence-based care. Midwifery operates under the philosophy that women are wise; midwives are guides but our patients are the leaders. In birth specifically, midwives bring a reproductive justice angle to care. We push for policies that minimize unnecessary interventions and honor the idea that there are many variants of “normal.”

Unlike medical school, midwifery does not have government funding for residency programs. While we have complete hands-on training during school (for example, I have delivered 39 babies with my own hands and inserted more than 10 IUDs by myself), we are still nascent providers in our first jobs. Because of this, many employers have six-month orientation periods where a new midwife works with a “senior” midwife one-to-one. During my orientation, I will be practicing under my own license, but will work with a senior midwife, who will double-check my work and give me guidance if necessary.

Tell us a bit about the community you will be serving. Where is it located? What are the population demographics? Did you visit the community in advance of accepting your position? If yes, what were your impressions?

A midwife’s work has two parts. The first, clinic work, includes primary care, prenatal care and well women care. The second is hospital work, which is where we deliver babies and care for women postpartum. I will be doing my clinic work (three days a week) at two clinics south of Albuquerque, in cities called Los Lunas and Belen.


My hospital work will be in Albuquerque at University of New Mexico Hospital. The pregnant patients that I serve in Los Lunas and Belen will travel to Albuquerque when they are in labor. About 75% of my patients are on Medicaid, which can be a proxy for lower-class. I do not know the exact percentages, but most of the patients are a combination of Hispanic and White, and some of the patients are Native Americans.

[Los Lunas (population 14,835) and Belen (population 7,152) are the first and second most populous cities in Valencia County, which gives you a feel for the population densities in the surrounding areas. Though both communities are named in homage of their Spanish ancestries, today their populations are predominantly white, at 72.1 percent and 67.5 percent, respectively. Obviously, both qualify as NHSC-approved sites.]

I spent an afternoon in the clinic during my interview. First, I was impressed with how well-resourced the clinic seemed. Most of my rotations in midwifery school at Columbia were in underserved public hospital settings where paint was chipping, wait times were astonishingly long, and supplies were limited. The clinic in New Mexico seems like a well-oiled machine—it even had a great microscope, which is unheard of in the city hospitals! My impressions of the community itself were as I expected. The patients came in for routine care, a pap smear or a check-up. But by the end of the appointments, the midwife was counseling the patient about the domestic violence resources in the community or validating the woman’s fear about being an alcoholic and watching her dad die of liver cancer. Physical ailments were present, but the social ailments were staggering and center stage. I was also impressed with the relationship between the midwife and the patients. As the only prenatal provider (there is only one midwife in both clinics) in both cities, the midwife cares for the women with every subsequent pregnancy. Even more, the midwife cares for the patients’ mothers and sisters and daughters. There is trust and respect between patient and provider that you don’t see when there is less continuity of care.

What were the critical factors you considered when you were deciding on a geographic practice location? Were you specifically hoping to serve a rural community?

My job search was limited by the restrictions of my scholarship. You could say that serving the underserved was the most critical factor because it was my personal goal and a requirement of the scholarship. The next most important factor was the way that the practice provided maternal care. Some of the considerations that I used to evaluate clinics and hospitals during my job search were: C-section rates, availability of birth control, and pharmacy formularies for pain management during labor; midwife autonomy, and the professional relationship between doctors, midwives and nurses; how healthcare teams evaluate evidence-based care and how quickly clinical protocols are adopted; hospital set up (e.g., do the doctors, midwives and nurses all sit together? Or is a hierarchy apparent even in the structure of the seating arrangement?); resources for new midwives; and length of the orientation period.

My intention was always to serve the underserved, but as a NHSC scholar, I am required to work two years in a location that has a specific “underserved” score. I did not have a specific desire to work in either a rural or urban community; they represent different manifestations of underserved, and I was interested in both. But for rural work specifically, I was interested in the availability of a support system. When I do not know what dose of drug to prescribe, who do I call? University of New Mexico has a well-established call system for all rural providers. Their phone banks are staffed with providers 24/7 to help rural providers problem-solve if necessary.

What are your fears—and conversely, your hopes—moving from an urban metropolis to a rural area?

My fears, which I share with many of my new grad peers, is: “I AM GOING TO KILL SOMEBODY.” Of course, I, personally, am not going to kill anybody—I know that. But people do die, even in the world of birth. Statistically, it will happen within my first five years of practicing as a midwife. I think that this fear is amplified in the rural setting. For example, when I was shadowing at the clinic during my interview, the midwife noted that the baby’s heart rate was on the lower end. This could mean two things: (1) the baby has a normal low heart rate and is totally healthy, or (2) the baby’s heart rate is having a deceleration, meaning that it is dropping 15 beats per minute for 15 seconds or more. Decelerations can be a sign that something is not going well. When this happens in a hospital, we can hook the mother up to a machine that tracks the baby’s heart rate for 20 minutes, and we can see if the pattern of the heart rate is normal or if it is a deceleration. The rural clinic does not have this machine. If you think that it is a deceleration, then you send the woman to the hospital. But the hospital is 45 minutes away. Some women do not have cars. Or, they may be able to get a ride to the hospital, but have no ride home from Albuquerque if the test comes out normal. That puts a lot of responsibility on the midwife to make sure that you send the right people to the hospital. As a new midwife, I am sure that I will send many more people to the hospital than necessary. But I will practice under the “I would rather be safe than sorry” philosophy until my clinical intuition sharpens.

My hope is that I can make connections with my patients that empower them. Being a mirror of a woman’s own strength is my favorite thing about being a midwife. We have the opportunity, in a small room as a woman sits on crinkly paper, to validate women’s fears, to listen to their concerns, to provide care that will make them healthier individuals, and to celebrate their existence.

[There are two methods monitoring a fetal heart rate: external and internal. External monitoring is accomplished most often with a Doppler ultrasound device. The process involves attachment of an ultrasound probe (transducer) to the mother’s belly. The transducer sends the rate and pattern of the baby’s heart to a computer. Internal fetal monitoring is accomplished by running a thin wire (electrode) from the baby’s scalp through the cervix. Internal monitoring is more accurate, but it can only be done if the amniotic sac has broken and the cervix is open.]

[Access to healthcare equipment, particularly with respect to perinatal care, is a continuing problem in rural America, but the rise of new technologies, including portable devices and distance-based care, is offering promising steps forward.]

What types of special challenges do you think you might face delivering care in a rural community? 
  • I’m particularly interested in some of the issues recently raised in a Scientific American article—e.g., high rates of maternal mortality in rural areas, scarcity of resources and professional providers, access issues, etc.

Great article! I think it sums up the main concerns:
  1. Getting to the hospital with enough time. This not only means everything you think it means, but also requires enough clinic time for the provider to educate the woman about when is the right time. The article focuses on women getting to the hospital too late, but I think getting there too early can be harmful also. Most studies suggest that laboring at home until you are in active labor (6 cm) is best. When we admit patients too early, unnecessary interventions are more likely, which can also lead to increased C-section rates.
  2. Unhealthier populations in rural settings. I am eager to explore this issue in my work. In New York City, I worked with a lot of black and Hispanic communities. These communities are also more likely to have health concerns, some due to genetic predispositions and others due to public health or social concerns. I am interested to explore the differences in the cascade of causal factors for health concerns between the rural and urban communities.
  3. Lack of providers. This is exactly what my scholarship is trying to address! There is a bill in the works that suggests a new algorithm to assess the “underserved” score of hospitals and clinics with respect to maternal health. I have only seen headlines about this so I do not know much more about it, but the idea is that the algorithms we use now do not accurately evaluate maternal health in underserved communities. Maternal health is a different hue of primary care, so we can’t use the same proxies. My guess is that [a maternal health-specific algorithm] would reach more communities and expand the definition of underserved.
[For more discussion on maternal health-related bills currently before Congress, see this previous post, discussing the Improving Access to Maternity Care Act.]

7 comments:

ofilbrandt said...

This was a great experience to read and learn about the process a professional goes through in order to become a midwife. I found it particularly interesting that their speciality is taught from a patient-centered perspective. She says, "[M]idwifery operates under the philosophy that women are wise; midwives are guides but our patients are the leaders."

Reading this line, I think it is empowering to the patient to have a strong role in their own care plan. This likely has especially positive repercussions in underserved communities. Low and medium risk patients, I presume, have simpler and/or more mainstream health issues. This means complex explanations and multifaceted care management plans are not necessary, even if they are available. Patient-determined care enables consideration for accessibility, feasibility, and autonomy of the patient. Where the patient is aware of their personal limitations and the limitations of their community (e.g. living 60mi from the nearest pharmacy), patient-centered care definitely makes sense in rural communities.

This principle is also reflective of a core of rurality: local autonomy. Indeed, a number of articles on this blog have commented on the importance of self-sufficiency in rural communities. (See Right to Repair https://legalruralism.blogspot.com/2017/03/the-farmers-fight-for-right-to-repair.html; Preemption https://legalruralism.blogspot.com/2017/02/preemption-wedge-in-urban-rural-divide.html) Coming into a community with this sort of mentality in health care likely enables the midwife to be more quickly respected, heard, and accepted.

Anne Badasci said...

This was such a great post, Wynter! Thanks for taking the time to interview such a wonderful woman who is so passionate about serving underserved communities. My own grandmother is a nurse-midwife, who also began her career in the program that pays for your tuition based on a two year contract to work in an underserved area. She worked (and still does now) in Coalinga, California population of approximately 13,000 (https://en.m.wikipedia.org/wiki/Coalinga,_California). She has told me many stories over the years of her experiences working in small-town America, helping mothers give birth in often difficult situations. One of the things that struck me from your interview, and that I know we've discussed in class, is the difficulty of attracting well-trained professionals to rural areas, and once you attract them, getting them to stay. Midwifes are such an integral, valuable part of the health care hierarchy, and in communities where doctors are much fewer and farther between, they take on an increased leadership role in their efforts to provide care to mothers and children. I have an unbridled amount of respect for women like Eva, who work so hard to give women the care they deserve and otherwise may never have been able to obtain.

dnlauber said...

Thank you so much Wynter for this post and Eva for agreeing to contribute your time to our blog! It was wonderful reading about Eva's educational background and her path to becoming a midwife, as well as her dedication to providing health care to women in rural areas.

I think what stood out to me the most is, like Olivia, not only Eva's dedication to patient-centered care but also the services provided at the clinic where she will be working in Albuquerque. Specifically, Eva said regarding the clinic, "by the end of the appointments, the midwife was counseling the patient about the domestic violence resources in the community." This is awesome and it is great to hear that health care providers in rural areas are not only focused on the immediate health concerns their patients present with, but their overall well-being.

Because infant mortality rates are higher in rural areas, and the increase in birth mortality since 2003 (https://www.ruralhealthinfo.org/rural-monitor/ali-mokdad/), there is a strong need for health care professionals that focus on women's health in rural communities. This contract arrangement where Eva had the opportunity to get her tuition and living expenses waived while getting her Masters degree for her commitment to work in a rural community for two years seems like a great way to encourage competent and skilled health care professionals to work in rural areas. I wonder if this is unique to Columbia's program or if this is common for other Midwife Masters programs as well. Eva, if you happen to read these comments, I'd love to hear more about the contract!

Kyle Kate Dudley said...

Wynter,

I appreciated this post so much and it thrills me that Eva is doing exactly what rural communities need in two parts. First, she is migrating into rurality with multiple degrees and an interest in supporting the local community. Secondly, echoing Olivia's post, she is doing this with a respect and humility about the amount of local autonomy and self-sufficiency that rural folks are accustomed to. This is important because going into a community thinking you'll save them or change them is the fastest way to make enemies and fail. Eva seems to have an exactly opposite goal, which I appreciate. Her understand of women's inherent wisdom will stretch to her new client base, and I think we need more of this compassionate understanding and high expectation when educated urban folks enter our rural communities. Great interview!

EAG said...

Thank you, Wynter for a great post and Eva for participating on our blog and for her wonderful work! The NHSC scholarship sounds like a wonderful program to encourage trained medical professionals to relocate to rural areas. It is similar to some of the programs designed to attract more lawyers to rural America. For instance, Nebraska offers rural high school students full tuition scholarships and admission to University of Nebraska law school and South Dakota offers a five-year stipend for attorneys practicing in rural areas. (http://www.npr.org/2016/12/26/506971630/nebraska-and-other-states-combat-rural-lawyer-shortage). While the NHSC scholarship sounds amazing and brings young medical professionals to rural areas in need, I wonder how many of them stay in rural communities after their two-year contract expires. I think in the long-run it may be more beneficial to also encourage and support rural children from communities without medical professionals to go to get professional medical training of some kind. These children have a rural connection and may be more willingly to remain in rural communities. However, I think the NHSC scholarship is very important because it exposes urban medical professionals to the specific challenges of practicing rural medicine, like getting to the hospital as Eva mentioned.

Courtney said...

This was such an interesting post, thank you! For a time in my life, I considered going back to school to get a nursing degree and pursue midwifery, so this was especially interesting to read about. I'm wondering what the funding situation is with the program that she chose in New Mexico. Albuquerque is significant to me because that is where many Texas women go to get abortions now after so many clinics have closed and now that it can be so hard to get an appointment. Particularly, Southwestern Women's clinic in southern Albuquerque. I imagine that there is some correlation between the New Mexico's success in brining highly qualified midwives to prenatal programs and also having access to a full-range of pregnancy options services.

Jenna said...

Like everyone else in the comments I just wanted to say great post Wynter! Also, something I keep coming back around to in my comments (and in class) is the lack of anonymity in rural communities in particular contexts. Eva briefly mentioned that the midwife (or midwives) often not only serve the patient, but her sisters, mother, daughter, and other female family members. While I am assuming there are privacy guarantees like in other areas of medical practice, I do wonder about if/ how providing medical services to people who are all close and all know each other may effect how rural midwives have to go about their practice. This seems like it may be particularly tricky when it comes to the more sensitive issues of reproductive health such as pregnancy, child birth, domestic abuse, STIs, and abortions. Is it ever a concern for a midwife that someone in the patient's family or community will find out that they gave health advice to one of their patients that their mother, aunt, father, or brother wished they would not have shared? If so, I wonder if that would break the trust that these communities have in the medical professionals serving them and therefore undermine the medical treatment they are attempting to provide.