Midwifery

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Barbara Nesbitt: "Hi, I'm here with Katy Dawley, and we're at ACOG in Philadelphia. Katy's with ACNM, and she's going to talk to us today about midwifery. Katy, tell me a little bit about your background."

Katy Dawley: "I am a certified nurse midwife. I became a registered nurse in 1981, and worked in maternity nursing for a couple of years and then got my masters degree in nursing with a specialty in midwifery. I started a practice here in Philadelphia, at Hahnemann University. That practice just delivered its five-thousandth baby this year."

Barbara Nesbitt: "How wonderful."

Katy Dawley: "We're very proud of that. I directed that practice until 1995, when I went back to school to get a Ph.D. in nursing, and I'm working on my dissertation now."

Barbara Nesbitt: "Wonderful. How does a woman make the decision to go to a nurse midwife? Why would she choose one? How would she find one? Just tell us a little bit about that."

Katy Dawley: "Nurse midwives are specialists in normal pregnancy. We take care of healthy women, and sometimes in collaboration with physicians, we take care of women who have certain problems with their pregnancy or in their health, and are co-managed by both the physician and a midwife because they want that special care that a midwife gives. We spend more time with our patients, we do a lot of education, we do a lot of just talking, and as I tell my patients - we go to the hospital or the birth center when you go into labor, and we stay with you until your baby is born."

Barbara Nesbitt: "So you don't do, or do you do, a lot of home births?"

Katy Dawley: "About 1% of the births in the United States are done at home, and midwives - nurse midwives - do some of those. Non-nurse midwives do some of the others, and there are some physicians who do home births as well, but we deliver about 6.5% of the babies in the United States now. In my hospital, we deliver one-third of the births at City Avenue Hospital, here in Philadelphia."

Barbara Nesbitt: "What is the difference between a certified nurse midwife or a nurse practitioner who specializes in home midwifery? What's the difference in training?"

Katy Dawley: "A certified nurse midwife is an R.N., she goes back to school for either a certificate in midwifery or a certificate in midwifery and a masters in either nursing or public health, those are the routes in. The midwifery education is exactly the same; it is a program designed by national standards, which are set by the American College of Nurse Midwives. All programs are accredited by that college. In order to sit the certification exam, which is a national certification exam - just like board certification for a physician - you have to graduate from an accredited program. Our standards for education and for certification are national. We learn how to care for women during pregnancy, provide prenatal care, provide care during labor and delivery, care for the mother and baby postpartum, care for babies through the first month of life, and regular gynecology and primary health care for women. So we, in some states, are licensed as advanced practice nurses. In my state here in Pennsylvania, we're licensed as midwives."

Barbara Nesbitt: "I think it's the same in Texas also."

Katy Dawley: "I think that's true. We are licensed in all states of the United States."

Barbara Nesbitt: "Yes, that's new and it's wonderful. A question that I've often thought about with expenses being such as they are and changing so since I had my first baby is - I think it was $200-$300 - what is the difference in going to a certified nurse midwife versus a physician? And is there problems or any problems or no problems with health insurance or…?"

Katy Dawley: "Most of the major health insurers reimburse nurse midwives for your total care. Most of the managed care organizations also have nurse midwives on their list as providers. So if you are insured there's no problem. If you are paying for your care out of pocket just like with a physician, we'll make an arrangement with you to make it affordable. If you choose to have a home birth, it's much less expensive because you do not pay for a facility. The interim is a birth center, and we have a whole network of birth centers across the United States that are certified by the National Association."

Barbara Nesbitt: "Kind of nice, instead of going into a hospital, you're just going to where people are having babies."

Katy Dawley: "That's right, it's just where people are having babies."

Barbara Nesbitt: "And a happy place."

Katy Dawley: "That's exactly right. It's designed like a home - there's bedrooms, kitchenettes, and living areas, and you usually spend a maximum of twelve hours after the birth of the baby there."

Barbara Nesbitt: "That's good."

Katy Dawley: "And your whole labor of course, and it's much less expensive than a hospital."

Barbara Nesbitt: "OK, interventions - do you do epidurals?"

Katy Dawley: "It depends on where you practice. I practice in a hospital, and the patients I take care of have the option of epidural anesthesia, of using water as a pain relief - we have Jacuzzis, or using some kind of I.V. medication, and breathing exercises - they have the full range."

Barbara Nesbitt: "What about the birthing centers - same thing?"

Katy Dawley: "Birthing centers - no epidurals."

Barbara Nesbitt: "At home?"

Katy Dawley: "At home - no epidurals. No, and in some birthing centers we'll use I.V. or oral medications, others won't, it depends on the center."

Barbara Nesbitt: "I had mine in the days of natural child birth, and I thought it was a wonderful way to have a baby."

Katy Dawley: "I did too."

Barbara Nesbitt: "They didn't have epidurals. I probably would have had one, I don't know, but those things fade out and now it's coming back again. I felt that old Dr. Grantly Reed from England…"

Katy Dawley: "He just passed away."

Barbara Nesbitt: "He just died the other day - but he had a wonderful instruction list there, and by the time you learned to have one - you knew what was going to happen next."

Katy Dawley: "That's exactly right."

Barbara Nesbitt: "Now is the Lamaze is similar?"

Katy Dawley: "Lamaze is similar."

Barbara Nesbitt: "You can go somewhere and be trained?"

Katy Dawley: "Right. You can go to Lamaze classes. They still have Grantly Dick-Reed classes you can go to. Now I'm going to be in trouble because I'm going to forget some of the others but there are childbirth education associations, and the Bradley method, are all different methods."

Barbara Nesbitt: "But they're a natural…"

Katy Dawley: "Yes, these are all without medication. I find in my practice that water is one of the best pain relievers. Women who are lucky enough to have a bathtub, Jacuzzi, or even just a shower get a lot of relief from water - it relaxes you. If you remember back, one of the biggest parts of prepared childbirth was being able to relax and not fight the contraction, and water does that for you."

Barbara Nesbitt: "So have you seen a great growth in women using midwives in our country in the last, say, five years?"

Katy Dawley: "Yes, when I started practicing in 1985, we were doing 2% or 3% of the births, and now we're doing about 6 ½% of the births in the country."

Barbara Nesbitt: "That's a good move forward."

Katy Dawley: "When I started at Hahnemann, we were doing maybe one-percent of the births, and now we're doing one-third. I'm at City Avenue now, but it's the same system."

Barbara Nesbitt: "We at OBGYN.net started off as an obstetric-gynecology based website but the doctors invited all women and health care providers to come in, and it's been a really nice mix. We have that forum that's wonderful, and I see a comraderie going on and sharing of information. And the women like doctors, they like midwives, and our site provides an avenue for everybody to be able to have an opinion or thought in the way they want to do things. Being that it's a world wide site, as we talked about earlier, most of the babies of the world are born by midwives."

Katy Dawley: "That's right, most of the births."

Barbara Nesbitt: "It's just we live in the United States, and here things are a little different but I thank you very much for coming."

Katy Dawley: "You asked me originally the difference between a nurse midwife and a nurse practitioner. A nurse practitioner who does obstetrics and gynecologic care does not deliver babies - so they provide prenatal care, postpartum care, family planning, and routine gynecology - but they don't do labor and delivery, whereas a nurse midwife does full scope practice. So that is the difference, and you know we have intensive education in health care for women."

Barbara Nesbitt: "So the nurse practitioner would work in an obstetric and gynecology office but at the time of delivery the doctor would deliver the baby."

Katy Dawley: "And also manage the labor, she would not manage the labor. The nurse practitioner would not manage the labor and would not be there for the labor or the delivery."

Barbara Nesbitt: "You are there from the first visit to the last visit."

Katy Dawley: "Right, and we do care for women throughout their life cycle, so we actually do perimenopausal care - we do well woman gynecology."

Barbara Nesbitt: "That's wonderful. I thank you very much for coming and sharing this."

Katy Dawley: "Thank you very much, I've enjoyed speaking with you."

Barbara Nesbitt: "And congratulations on your month of the midwife, the international celebration."

Katy Dawley: "Yes, thank you very much."