Baby Boon

This article originally appeared in the Fall/Winter 2018 issue of Columbia Nursing magazine.

At Tséhootsooí Medical Center in Fort Defiance, Arizona, Rebecca Willis ’09 ’13, MS, MPH, serves as a nurse-midwife on the Navajo Nation. In Albany, Georgia, a small city 180 miles south of Atlanta, Lodz Joseph ’16 ’17, MS, works as a nurse-midwife among vulnerable populations. And in rural Lancaster County, Pennsylvania, Sheilagh Cullen ’00 ’01, MS, provides care to Old Order Amish women who give birth at home.

While these graduates of Columbia Nursing’s nurse-midwifery program specialize in providing maternal health services and newborn care, they do more: they also provide family planning and gynecological care, collaborate with MDs to screen for and treat pregnancy-related high blood pressure and diabetes, counsel the people under their care about obesity and other health risks, and educate and advise patients on wellness and self-care. Working in communities all over the United States, Columbia-educated nurse-midwives embody the success of the school’s nurse-midwifery program, which prepares graduates for independent clinical careers in evidence-based women’s healthcare.

Columbia Nursing created the nation’s first graduate program in nurse-midwifery in 1955, through a partnership with the Maternity Center Association of New York. And in 1956, Columbia Nursing awarded the nation’s first master’s degree in clinical nurse-midwifery. Today, the program’s rigorous curriculum — accredited by the Accreditation Commission for Midwifery Education (ACME) — combines health sciences fundamentals with training in clinical skills, professional practices, and the impact of policy on clinical practice. Upon completion of the program, graduates take the national certifying examination administered by the American Midwifery Certification Board to become a certified nurse-midwife.

In addition, the program cultivates critical thinking and cultural sensitivity, laying a firm foundation for careers in healthcare delivery, policy, and education. Given the inequities in access to care and outcomes that affect pregnancy and childbirth in the U.S., Program Director Laura Zeidenstein ’05, DNP, urges all graduates to pursue careers that balance clinical practice and advocacy. “To become a midwife in our program means developing a deep awareness about disparities,” she says, “and the ways in which midwives can address the effects of racism and poverty, which too often result in high maternal mortality and morbidity rates.”

For Willis, this means honoring the longstanding cultural practices of the women who seek care at Tséhootsooí Medical Center, which in 2010 became the fourth self-determined, tribally administered hospital on the Navajo Nation — a 27,000-square-mile reservation. “We try to incorporate traditional practices,” she says of the 300 to 400 births at the hospital each year, 90 percent of which the hospital’s eight midwives attend. By conventional metrics, the center’s maternal outcomes are more than solid — a cesarean-section rate of just 10 to 12 percent (nationwide, the rate hovers at close to 30 percent) and a similarly low epidural rate that, in part, reflects local values. (Local values are also a factor in Cullen’s practice among the Amish; see the sidebar below for insights into the population she works with.)

According to a nationwide analysis published in February by PLOS ONE, in states where midwives and obstetricians work together to provide integrated care, the way Willis and her colleagues do at Tséhootsooí Medical Center, newborns and their mothers have better outcomes, including reduced rates of premature births, C-sections, and newborn deaths.

Such data should come as no surprise, says Sylvie Blaustein ’88, MS, a clinical nurse-midwife who has attended more than 2,000 births over the past 31 years and also served for two decades as a clinical preceptor for Columbia Nursing midwifery students. “The team model of midwives collaborating with obstetricians has been proven time and time again to increase good outcomes and increase satisfaction,” she says.

As a student, Blaustein recalls having learned as much about the practice of humility and empathy as she did about the clinical skills associated with pregnancy, labor, and delivery. “There’s something about nursing in general and midwifery in particular that cultivates a curiosity and interest in other people,” she says. “Our education keeps reminding us what it’s like to be on the other side, imagining what it is to have the fears and anxieties and joys of pregnancy and birth that are so universal.”

An emphasis on humility, empathy, and cultural sensitivity also guides Lodz Joseph, a Haitian-American who works with medically underserved black, white, and Latino populations at the Mirian Worthy Women’s Health Center, a division of Albany Area Primary Health Care. “Women are looking for women providers who look like them and take time to explain things,” says Joseph, who speaks fluent French with her clients from West Africa and has already attained intermediate fluency in Spanish to enhance her ability to communicate effectively with the growing number of Central American immigrants in her care. “I tell my patients, ‘I want to give you the best care possible, as if we were in a posh, private practice,’ even though I’m at a federally qualified health center.”

And providing the best care possible means treating the whole woman — including the array of conditions that can complicate pregnancy, labor, and delivery and that are prevalent among Joseph’s patients, many of whom are considered high risk. “Midwives connect with our patients, and there really is significant follow-up, explaining what’s going on with their bodies and why we want to follow up so aggressively,” she says. “I’m always asking, ‘What have we missed?’ because this is our snapshot and opportunity to provide people with optimum care.”

Jessica Tsipe Angelson ’13 ’14, MS, also keeps her eye on the big picture. Angelson works with a high-volume, private-practice midwifery group with admitting privileges at Maimonides Medical Center in Brooklyn, New York. And, like Joseph, she leverages every bit of her preparation as a primary-care provider to scrutinize each encounter with a patient for clues she might be missing. “If you only see a person’s pregnancy, you’re missing this huge opportunity to care for her in other ways that she might need,” Angelson says.

The majority of Angelson’s patients rely on Medicaid to cover the cost of their care. In addition to clinical concerns, Angelson sees clearly how birth outcomes among her patients reflect social determinants of health — the strength of their interpersonal relationships, for example, or whether they have access to reliable transportation and healthy food, or the effects of discrimination and violence. “Some of the people at highest risk for having babies born too early or sick are at risk because of their social circumstances, such as poverty and unstable housing,” she says.

Moreover, the nine months of pregnancy and the six postpartum weeks are, in many cases, the only times in her patients’ lives that they have healthcare coverage. “Often,” says Angelson, “insurance is not the norm for people in my care. They suddenly feel like they have abundance in healthcare. It’s heartbreaking, because you understand that they exist within an environment of tremendous scarcity.”

While some midwives, like Willis and Joseph, opt to work in medically underserved regions where systemic and socioeconomic inequality amplify health disparities, some Columbia Nursing graduates work on the other end of the spectrum, caring for people unbound by such structural constraints as underinsurance or limited access to competent healthcare providers. Nationwide, midwives attend approximately 10 percent of births, practicing at hospitals, in freestanding birthing centers, and in homes across the U.S. In high-resource countries affiliated with the Organisation for Economic Co-operation and Development — such as Canada, France, Germany, Israel, Japan, and Australia — midwives attend between 50 and 75 percent of births. “The prime minister of New Zealand chose a midwife, and so did Kate Middleton,” says Blaustein. “These are women who could have anyone, and they chose midwives.”

For many such women, says Blaustein, the profession’s emphasis on pregnancy as a healthy and normal process feels particularly appealing. “Midwives are experts at taking care of basically healthy women with low-risk pregnancies,” she says. “We look at the whole woman, not just her uterus.”

For 14 years, Blaustein had a private practice in Manhattan, where her clientele included movie stars, lawyers, and MDs — the vast majority of whom had the freedom to choose among multiple birthing options covered by their private insurance carriers. Frequently, says Blaustein, demand was so high that she had to refer prospective patients to her midwifery colleagues elsewhere in the city. “There’s a huge need among women of means who seek out midwifery care because they want personalized, respectful care where the woman is really listened to,” says Blaustein. “Everyone wants to be listened to, and midwives do that.”

To cultivate the conditions for candid conversation, Blaustein created a homey environment in her midtown office, complete with a couch in each exam room, where patients and their partners — and even their children, on occasion — could chat with their midwife at each visit. Despite her conviction that such unhurried conversations enhance birth outcomes, says Blaustein, she closed her private practice in 2017. “When you’re spending that kind of time with a patient and limiting the number of patients you can take in,” she says, “it’s a financial catch-22.”

Now working part-time as a nurse-midwife at St. Joseph’s Children’s Hospital in Paterson, New Jersey, Blaustein credits the experience of juggling her practice’s rent, malpractice premiums, and patient insurance reimbursements with cementing her commitment to an overhaul of healthcare economics in the U.S. “I’m a real supporter of single-payer,” she says, “so the profit motive is removed and the priority is care.”

Over the last 30 years, Zeidenstein, who has led Columbia Nursing’s midwifery program since 2002, has practiced in a variety of settings — in public health practices in Brooklyn, the Bronx, and Manhattan;  as the founder of a freestanding birthing center in Manhattan and the clinical director of two others; and in private practice with Blaustein.
And, like Blaustein, she credits that breadth of experience with galvanizing her drive to participate in reimagining healthcare delivery in the U.S. “Midwives are in a great place to be politically active,” says the associate professor, who regularly pens commentaries on midwifery for peer-reviewed journals and also co-chairs NYC Midwives, the
local chapter of the American College of Nurse Midwives. “We are able to see, one on one, the results of working in a way that is humane and respectful of all people. It’s about speaking out, standing up for people, never closing your eyes.”

In the three years since she arrived on the Navajo Nation, says Rebecca Willis, she’s had increasing opportunities to bear witness to the resilience of the people she serves. This summer, the reservation’s first annual Pride Festival featured so-called two-spirit dancers performing in front of the Tribal Council Office. Young people are returning to the reservation in greater numbers than ever before, intent on transforming and uplifting the community; a native woman plans to launch a birthing center, for example. The medical center, too, has made great strides, with a new mobile unit that is taking sexual and reproductive healthcare on the road, a paid fellowship in midwifery to increase training opportunities for tribe members, and early-stage plans for a clinic tailored to the needs of two-spirit and transgender members of the community. It’s been a tremendous honor to work among the Navajo people, says Willis, and yet she yearns for a time when people from the community have full access to the educational opportunities she had growing up in Connecticut.

“My hope,” says Willis, “would be that a native midwife would one day take my place.”

A Closer Look: Midwifery in Rural Amish Country

Working in rural Lancaster County, Pennsylvania, since 2001, Sheilagh Cullen ’00 ’01, MS, has seen firsthand how midwives are uniquely equipped to honor their patients’ values. Among the Old Order Amish families she serves, community, simplicity, and frugality make home births with few interventions the cultural norm. “It’s a little like wilderness practice, even compared to the rural hospitals,” says Cullen, who partners with a fellow nurse-midwife. They share an office they rarely use that still contains metal file cabinets crammed with manila folders in lieu of a computer and electronic records.

While the vast majority of the births Cullen attends have healthy outcomes, she says there are high rates of congenital anomalies — including a condition known as Amish lethal microcephaly, an invariably fatal genetic condition that leads to death within a baby’s first six months and affects one in every 500 births among the Old Order Amish. Cullen sometimes wishes her patients were more inclined to consider prenatal testing, so she could be more prepared for each newborn. But, she notes, for her patients, the results would be irrelevant. “The baby is who the baby is,” says Cullen. “Sometimes they’re okay and sometimes they’re not, and always they’re cherished.”

Jasmine Banks and Sharon Tregaskis provided reporting for this article.