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Dr. Jones: "I don't know nothin' about birthin' babies, Miss Scarlett." That is something no mother should ever hear, except on the big screen. Trained midwives have helped women and their babies safely through birth for a long time here in the West. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Utah Health. No, it's not "Gone With The Wind."

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Building on the rich tradition of midwifery in the intermountain west, the Certified Nurse Midwifery program at the University of Utah is one of the top 10 programs in the U.S. Certified nurse midwives at the University of Utah help women with their choices in their birthing experience. Today in the Scope studio we're talking with Celeste Thomas, a certified nurse midwife and Clinical Director of Birth Care Healthcare at the University of Utah College of Nursing. Welcome, Celeste.

Celeste: Thank you so much.

Dr. Jones: So are there other kinds of midwives who practice in Utah?

Celeste: Yeah, so there are three types of midwives here in Utah. I am a certified nurse midwife, so I have gone through a master's or doctoral program after becoming a registered nurse to become a certified nurse midwife, and that's similar to a nurse practitioner.

And there are also midwives who are licensed by the state of Utah that are called licensed direct entry midwives. These are midwives that primarily do out of hospital births, so that would be home and birth center births. And they are also licensed by the State of Utah, and they usually go through an educational program but can also do a portfolio-based apprentice program as well in order to sit for their board exams. And then there are midwives who are not licensed in the state of Utah, and Utah allows midwives to practice even if they are not licensed. It's one of the few states that does that.

Dr. Jones: So your training, as you mentioned, was you had an undergraduate degree and then you got a nursing, an RN.

Celeste: I got an RN.

Dr. Jones: And then a special extra three or four or five or however many years it might be with a lot of hands-on training. I'd see the midwives in our program on labor and delivery at the U pretty frequently.

Celeste: Yeah, and a lot of their training is hands on. About half, 50% of their training is hands on and the other 50% is didactic or in the classroom.

Dr. Jones: Well, let's talk about that hands-on part. There are some aspects of the natural birth experience that women are kind of afraid of. Many women are worried about their bottoms. Getting a baby through there's no small task, and they might be choosing a midwife for many reasons, but one might be that they don't want an episiotomy, a cut that makes their vaginal opening a little larger. Now as we OBs don't commonly do episiotomy for a normal vaginal birth, but even we think that midwives might have a knack for getting the baby out without a tear. What is your magic?

Celeste: Oh, well, it's not magic. It's research.

Dr. Jones: Okay. Tell me about the research. You mean, you don't pass it down from midwife to midwife for the last 300 years?

Celeste: Well, it is very interesting. Maybe 20 years ago a lot of OBs were still doing episiotomies, and as the research came around to show that that was really not helpful to keeping that perineum, which is that skin between the vagina and the anus intact, that really has fallen out of favor and it's pretty rare to find an OB nowadays who does an episiotomy. Now as midwives, we rarely did episitomies, so we just kept rarely doing them and that's worked for us.

Dr. Jones: Oh. That was your knack?

Celeste: But the other things that we know about keeping the perineum intact, there are some things that we know in the research do work. So one is perineal massage. So this sounds really lovely, like massage.

Dr. Jones: Well, it sounds a little X-rated.

Celeste: It might. It really is gentle stretching. And doing that before you go into labor in the studies has been shown to decrease the number of tears, especially for moms who are having a baby for the first time.

Dr. Jones: So moms do it at home?

Celeste: Moms do it at home and with their partner. This does not have to be done by a health provider. So starting at 35 weeks and they only have to do it about once or twice a week. It doesn't have to be all the time in order for it to have the benefit.

Dr. Jones: Oh, well, that's good news.

Celeste: Yeah, so that's something kind of easy they can do.

Dr. Jones: Well, when you think about how much stretching actually, and often it happens over a period of just maybe 15 or 20 minutes. And for someone who hasn't had a baby to see where they are before and then see what has to happen, you're amazed that that tissue can stretch so easily and then come back to its almost before state.

Celeste: It's pretty miraculous, but we like to help it out if you're a first-time mom. And the research is pretty strong on that one too.

Dr. Jones: Okay, now let's talk about water birth. What is that?

Celeste: Well, water birth, it has been getting more popular recently, and really women laboring in water is the thing that seems to be supported in the research. So we know from the research that women who labor in the water have shorter labors. They have less need for any medications or an epidural, and they have greater satisfaction and greater mobility to be able to move, because as you know when you have a baby inside you, it can be difficult to kind of get into certain positions, right? It's hard enough just tying your own shoe.

So being able to move in the water is really lovely. And for a lot of women who don't want to use medication, being in the water during labor is really beneficial. The question is then when the baby comes out, is there a benefit to being under water? And from what we can see in the research there is no benefit.

Dr. Jones: But there's no harm either?

Celeste: For low-risk women, we don't have a lot of evidence, but from what we have there doesn't seem to be a lot of harm. We have a study ongoing here at the University of Utah about water births specifically to look at potential harms. But yes, it is a good option as far as we know for low-risk women, and a lot of women just don't want to get out in that really intense moment when the baby's head is kind of maximally stretching things.

Dr. Jones: How deep is the tub?

Celeste: So the tub in order for it to have its benefit needs to be at least 27 inches deep.

Dr. Jones: I would think it'd have to be deeper if you really want to have some buoyancy.

Celeste: You have to at least be immersed usually up to your chest in order to have those benefits.

Dr. Jones: Okay. Now the next question is, do you have to come as the midwife in your bathing togs, or do you have to just get your scrubs right in there or you just bend over and get back pain? How do you get in there?

Celeste: This is a good question. So body mechanics is important. The thing to remember is that you don't have to support the baby's body in the same way as you do when baby's born with gravity. So when you have a woman who's delivering, it's important to be able to get to the baby if you need to, but you're watching for that baby and you really are not doing a lot of hands-on in that moment when the baby's coming out. You just need to be able to reach the baby and bring the baby up above the water when the baby comes out.

Dr. Jones: Well, I was thinking again, if we go back to the episiotomy question when we are delivering a woman in a bed, this is OBs, we're careful to kind of support the head and make sure it doesn't come out too fast and gentle the head out. But that's kind of a low position to be in in the tub.

Celeste: Which is why we don't get into that position in the tub. It's pretty hard to get there, and depending on the mom's position. We do try to coach her through that crowning process so that she does it nice and slowly.

Dr. Jones: Crowning, when the baby's head is just about to be born but isn't it quite born yet.

Celeste: Yes. But in general she is letting the baby out, and then we are bringing the baby up to the surface when baby comes out.

Dr. Jones: Okay. But you don't get to have an epidural in the tub?

Celeste: No epidurals in the tub, no.

Dr. Jones: Okay. No narcotics in the tub?

Celeste: No narcotics in the tub because of the risk of dizziness. And currently at the University of Utah we also don't allow people to have nitrous gas also in the tub because of that risk of dizziness.

Dr. Jones: Right, right. Well, we have tubs at the U.

Celeste: We do. We have four rooms with tubs, but only one of them is technically deep enough to push your baby out under water. But you can absolutely use them . . .

Dr. Jones: For laboring.

Celeste: . . . and sit in the tub for labor, and that really is where the benefits come from.

Dr. Jones: Right. So getting back briefly to certified nurse-midwives, you primarily practice inside the hospital but create an environment which we'll talk about a little bit more that you think is as homey as you can be, given that you're close to all the other things that a hospital can offer.

Celeste: Yeah, so the majority of certified nurse-midwives give birth in hospitals, but there are certified nurse-midwives who do home birth and birth center births as well. We can catch a baby anywhere.

Dr. Jones: Oh, you can catch a baby anywhere. I'm glad to hear that.

Well, so whether you choose a physician, a certified nurse midwife, or a team of both, because sometimes people have complications, they need the entire team to be with them. For your OB care and delivery, our goal is to provide the safest and most comfortable passage for moms and their babies through pregnancy and birth. And thanks for joining us on The Scope. Thanks, Celeste.

Celeste: Thank you.

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Interviewer: Why should a mother to be choose care from a midwife? We'll be discussing this next, on The Scope.

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Interviewer: I'm talking today with Debra Penney. She is a certified nurse midwife from the College of Nursing. Debra, first of all, we want to establish that you are a midwife.

Debra: Yes.

Interviewer: A certified midwife. That is actually a real thing that mothers-to-be actually choose for care. Tell me some reasons why mothers, or mothers-to-be, should be choosing midwives for care.

Debra: Well, actually, there are several reasons and I can name the top few. One is we see women prenatally, just as a physician would, and we do some of the same tests, but we actually have longer visits. So, we spend that time communicating, getting to know the woman and really understanding what this birth means for her and her family.

Interviewer: So, it's a kind of a customized care.

Debra: Yes, we center in on the woman and her choices. And, we can't guarantee that she'll have all her choices. But we really want to honor those choices, respect the woman, communicate clearly with her and develop a relationship so that we know what she needs in labor and during her postpartum period. And, we try to address all those needs.

Interviewer: So, what are some of the personal choices, then, that you are talking about that she may not be able to get from a normal doctor?

Debra: Well, I think that she can get most of them, but what she may not get is the lack of unneeded intervention.

Interviewer: Got you. Okay.

Debra: We try to really manage labor according to the evidence, and try to not intervene with routine things that are known not to really help labor, to facilitate normal labor. And, also, we want to help her understand her body and what's happening physiologically through the pregnancy and birth and postpartum process. So, we do a lot of education. And, as nurses, we really like to focus in on her cultural differences, as well, and how those play in to her birth plan and her birth choices.

Interviewer: So, with that said, do you guys have the different knowledge of each culture and how they birth their babies?

Debra: Well, actually, culture is very variable, but we like to get to know the woman personally first, and then we can modify what she needs. For example, we had a lady from, I think it was southern Sudan, and it was her first time ever in a birthing hospital, here in the United States. So we took off the monitors because she was having a normal birth and used an intermittent monitor, let her move around the room freely.

Interviewer: Kind of natural?

Debra: Yes, and she could also choose her own birth position. So, I think as midwives, we can adapt more and we also, as nurses, just really key in to what this lady needs culturally as much as she can express that to us.

Interviewer: So, with doctors, I've noticed that when a woman gives birth, they kind of come in, check up on you a little bit, and then they walk out. Then they come in about, like, a half an hour later, and then, it's another, like, 30 second, "Hey, how are you doing?" I'm assuming that's different with midwives?

Debra: Yes, and since we're nurses too, our scope of practice does overlap nurses a bit. That, we're in the room, helping this lady find the best position to help her baby come down and come out. And, also we can offer a lot of different choices as far as comfort measures, acupressure, massage. We're with her the whole time in labor. Now, if she wanted an epidural, that's fine.

Interviewer: Oh, so she can get an epidural if she wants to?

Debra: Yeah, there's a common misconception that women with midwives, birthing with midwives, cannot have...

Interviewer: It's all-natural?

Debra: Yeah, and it's really not all-natural. We try to keep it as much as she's willing to keep it natural, but it's her choice to have an epidural.

Interviewer: Got you. Okay. I know that you said that you stay with the mom-to-be before she gives birth, the months leading up to it. You're kind of there holding her hand, being her best friend, and then you're there with her during labor. What's your role after labor?

Debra: So, after labor, we see them a little more frequently, perhaps, than a physician would. We like to see them at two weeks and at six weeks, and we really love if they call us. So, we're really available to them all the time that they need. And, we also do, as part of their postpartum care, we offer contraception. And, I think we have one of the highest levels of contraception with our patients.

Interviewer: Why isn't midwifery a more common thing?

Debra: I'm not really sure. I think a lot of people just naturally think that a physician is the way to go, when they don't realize they have the choice for a midwife.

Interviewer: So, the people interested in finding a midwife for their pregnancy, where can they find you?

Debra: Our practice is located here at The University of Utah, and they can find us, if their insurance covers us here. But, actually, there are midwives in every major hospital here in Salt Lake Valley.

Interviewer: See, I did not know that. That's, just, like a myth.

Debra: So, that's a really good thing. Choosing a midwife should be a more common thing, because they really save on medical dollars because of lack of interventions and they have a better outcome for a lot of the women that they serve, so less c-sections. Our c-section rate here is only 8% where it's 30% in the U.S. So, that's another good reason to have a midwife. So, midwives deliver about 10% of the births in the U.S. and that really needs to increase.

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Interviewer: We've all heard of midwives, but what do they do and what services do they actually provide? We'll find out, coming up next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use, for a happier and healthier life. You're listening to The Scope.

Interviewer: We're here in the studio today with Debra Penney, she's a certified nurse-midwife from the College of Nursing, and she's actually going to tell us a little bit about the types of midwives and what services they provide. I feel like there are some misconceptions going on. I've heard that there are two types of midwives; the direct entry midwife and then the certified, nurse-midwife, correct?

Debra: Correct. So, here in Utah we have certified nurse midwives, and they're nurses that have an advanced degree. And we also have the direct entry midwife, and she is apprenticed or she can have a formal education, but she has a little bit less of a scope of practice.

Interviewer: How does she differ from somebody who would be a certified nurse-midwife, like you are?

Debra: Her background is going to dictate her scope of practice; and her scope of practice mainly is around childbirth and postpartum care. She does about 1% of the births and she usually does the home births. She doesn't usually come into the hospital, doesn't have hospital privileges. So, the certified nurse-midwife does most of the births in the hospital and she has hospital privileges here in Utah. She also is educated to do home births, or birth center births as well, but majority of them are in the hospital.

Interviewer: So that is actually the large misconception because I've always figured the midwife helped deliver, or helped birth the baby at home, and doesn't really come to the hospital, doesn't really interact or mingle with the doctors and nurses in the hospital. But, from what you're telling me, that's actually not true.

Debra: Right, that's correct. So most of the midwifery births here are done by certified nurse-midwives, and we actually collaborate with the doctors in the hospital because, of course, we don't do C-Sections. But we do work as an integrated team within the hospital that we're working with, and most of us have a plan of care for backup in case the lady does need a C-Section.

So, we try to work along with nurses, doctors, pediatricians. And our scope of practice also includes not just birth, but prenatal care and well-women care, treating infections, common illnesses, doing some primary care, and then also menopause. So the whole lifespan basically. Also, a little care of the newborn in the first weeks of life.

Interviewer: Okay, so let's clear the air here, first of all because I'm still a bit confused as to... your telling me what midwives do, it sounds very similar to what a regular doctor here would do in the hospital for a pregnant mother. So, what is the difference?

Debra: So, basically. It boils down to our philosophy of care and how we look at pregnancy. We see pregnancy as a normal process, and it basically is for about 90% of the women who are pregnant. So we encourage the physiological processes that contribute to normal birth, like letting labor start on its own, and trying not to interfere with labor and not trying to push it to be faster than it needs to be. So we have a little more patience in the labor process.

The other thing I always tell patients is that, we're with them in labor. So actually the word, "midwife," means "with woman." So, we are with women throughout their labor, which makes a huge difference and we get to see the big picture of how things are progressing. We also have a toolset of little things that we can do to help the baby come down and be positioned correctly, and so changing position, and helping the mom in certain ways. We do less interventions, as well, as the doctors because we only will do those if it's necessary.

Interviewer: If there is a mother who's interested in having a midwife, walk her through her nine months of pregnancy, how does she get one, where can she find one?

Debra: Well, we are on the website, she would also want to check with her insurance and we are covered by insurance. So, she would want to check both of those, to see where there is a midwife in her community.

Interviewer: And does it vary? Because, I know that in Utah, we have specific names for our entry level and our certified midwives, but does it vary between states or countries?

Debra: So, across the US, certified nurse-midwife is recognized. There is also a midwife that is called a certified-midwife that we don't recognize here in Utah but she's everything that a certified nurse-midwife is, without being a nurse. She essentially passes the same board exams and these are national boards. In other states, the direct entry midwife might be called a certified professional midwife, and she may be required to go through special training to have her license.

Interviewer: So, to sum it up, midwifery is an actual process or a method or option, that pregnant woman can actually choose.

Debra: Right. Here in the US certified nurse midwives had prescriptive authority and have been marketed since the '70s with the women's movement, and we've kind of reemerged. But we have a history here since the 1920s, or even earlier. But as certified nurse midwives, we have been around for quite a while in the US.

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