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Community-based midwives are held to particular and sometimes unjustifiable standards by the healthcare community. They are under tremendous pressure to have perfect outcomes while serving the same communities who face the disparities that lead to premature birth, infant mortality, and maternal morbidities experienced so often in the hospital system. Wanting or needing access to technology and resources is often seen as a failure of the midwife or as a nuisance to the system, even when those same resources which can prevent the same outcomes are distributed in medical care in an effective and timely manner.
The methods and standards by which Midwives determine that a patient is “safe for midwifery care” are not protective against these needs or outcomes. A set of good vitals and an uncomplicated medical history are not remedies for social inequities or lifelong lack of access to healthcare education and navigation, or accessible, timely, and effective therapeutic interventions. When well-networked, midwives can be a leverage point for patients to receive guided access to the larger healthcare system. There they can receive the interventions and medical support necessary to achieve positive outcomes. In other words, when a patient presents with a medical complication, a midwife can identify it and ensure access to appropriate care if she has access to those who would provide it.
Failure of a patient to stay healthy enough to remain under the sole care of her midwife, or to qualify for an out-of-hospital birth is often seen as both a shame on the patient who could not achieve optimal health or reach her birth goals, and shameful of the midwife. Midwifery consumers work hard to address their health concerns, and there are times when all of the lifestyle interventions, guidance and education cannot overcome lifelong health disparities. We work hard to prepare for labor and birth and the most common reason we transfer during labor is for a patient who is just tired and needs an epidural, a nap, and will wake up and push her baby out just fine. This is normal and reasonable and there is no shame in it—either for the patient, who is equally deserving of pain relief and rest as a patient who planned a hospital birth nor for the midwife who supported the efforts and goals of a family.
In community-based midwifery care we use the continuity of carer model, with hour long prenatal visits. Three-quarters of this time is used to address healthcare prevention, education, and social support. The midwifery model of care recognizes that technical improvements in healthcare delivery are irrelevant without addressing the places where unjust and deeply impactful emotional and social determinants drive the experience of a patient’s life. These are the soil in which the patient is growing from and nurturing both herself and her pregnancy in. These are the hardships, griefs, and burdens of absorbing the responsibilities of her family and community. These are the anxieties over how to achieve perfection or avoid failure at every turn. And these are the sheer terror for many due to the likelihood of their pregnancy resulting in their death or the death of their child simply because of the color of their skin. This is intensive work, achieved on a platform of preventative healthcare that views each mother as vested in her own health and capable of change. It recognizes that she needs access to resources too long withheld and hidden from her until this point and it provides those freely. This work results in trusting connections between patient and midwife. Indeed, at the time that hospital staff or a physician meets the patient, she may be experiencing a very real grief over the potential change in this relationship with her provider and hopes for a unique and well-planned birth experience.
When a risk factor develops that requires entry into the hospital system, the patient has an acute sense that they must relinquish emotional and physical safety in healthcare. This may very well be a contradiction from the midwife’s perspective because we are in the hospital due to a physical safety issue at the direction of the midwife because of her clinical judgment. However, statistically speaking, every parent this patient knows who has lost a baby was in the hospital when that baby died or had a hospital birth. Every mother they know who died or was harmed during childbirth was in a hospital when that event occurred. While these events have been normalized in a broad sense, it is impossible to mitigate the very real fears that arise from personal exposure. Every social message about the safety, especially of being a black pregnant patient, has taught them that their odds are not very good. Every cell in their body and that most powerful function of our minds, the implicit memory, brings on a full red-alert for them in that space. No one anticipates that the nurse or physician standing before them will do harm, but how likely is it that they will see you as an ally in their care when you take a stance of juxtaposition and even mockery of the one provider who has ever truly listened to, heard, and understood them?
We know that once the sympathetic system is activated in this way, people become hyper-alert to whatever is in their realm of focus. This tunnel-vision is most often directed towards hospital staff—the nurses and doctors who she interacts with in triage before she regains access to a state in which she is ready to learn, engage, and process information. These are basic principles applicable across many fields of medicine, and even more so when there is a sense of needing to protect one’s baby.
In the instant that you are introduced to the patient, she will see your response to her decision to use midwifery care, she will note how you greet or ignore her midwife, and she will read a thousand cues from your actions and responses. How you treat the patient for her choices and the midwife for asking for an evaluation or intervention matters. Her body will decide very quickly: Fight, Flight, or Rest. Can you ensure that she is never alone and has her partner or midwife with her at all points during care—especially those first few moments when she is most susceptible to panic? These first interactions set the table for the rest of the patient stay and experience.
Midwives have extensive training and evaluate ongoing data sets from blood work, ultrasounds, clinic visits, and interactions over many weeks or months of care. She is in your hospital because she wants to be—because you are a resource and have access to resources her patient needs. Like any community-based or rural provider, she relies on you, on hospital staff, systems, and technology to be there when her patients need it. Ignoring or belittling the midwife or any community-based provider for accessing those resources will make them hesitant to enter into the system in the future. It is this behavior that pushes midwives to move patients further away from safe and timely interventions.
The burden of community-based hospitals is to receive what the community brings and to provide basic medical care. However, the ideals of community-based hospitals, so richly developed in many places, is to open the doors and welcome what the community brings, and to share the fullness of knowledge and technology from a place that recognizes the humanity of each patient and the irreducible needs of each person with whom it interacts.
The work of community-based midwives exists on the preventative pathway of maternal child healthcare. The work of hospitals and obstetrics is on the therapeutic pathway of maternal child healthcare. There are many opportunities for these pathways to cross, and at all points of intersection patient health improves when they can easily step from one to the other as is appropriate for their needs.
Midwives and the families and communities we serve are your families and your communities. We share the work of seeking health and access to healthcare for all people. We know that the impact of technical interventions is effective and wonderful but it is reliant on hospital policies that make these interventions accessible to the community.
We understand that relationships between community-based healthcare providers like midwives can be seen through a transactional lens—and if so, then view the midwives as great business. They rarely bring a patient who does not require interactions and interventions that are highly billable and great for the bottom line. We must address the scarcity mindset—that somehow allowing midwives to access resources will play a role in the diminishing of patient numbers for the hospital. The number of patients that midwives see is negligible to larger healthcare institutions. As stated, the patients midwives do bring in for care will typically increase the hospital census and income. While this is a very low-level view of the potential relationship between the hospital and community-based midwives, it is very real and just fine to rely on.
If we can look together beyond the responsibility of the hospital to the community and financial interest in receiving midwifery patients, here are some ideas that lead to beneficence:
- You receive patients every day who arrive in labor, screaming and incoherent, possibly drug-addicted. You have no history, no labs, no ultrasounds and no idea who that patient is. You follow your guidelines and do the best you can for them. Midwifery patients arrive with loads of documentation. They come in with labs, ultrasounds, a known history, and notes about how this patient learns best and the stressors and norms of their lives. That is a lot to work from! Use your guidelines and do the best you can for them, too.
- Greet patients warmly regardless of where they arrive from. Use simple statements that have been shown to be effective in other teaching hospitals, “I’m so glad you are here today. I see you were receiving your care from a midwife so this might all be new to you. I want to assure you we are going to do our best for you today” or “I see you were in the middle of a planned homebirth. I’m sorry that didn’t go as you wanted it to. We are going to do the best we can for you here today”.
- Greet the midwife with kindness—she will expect you to take the lead. She has decided based on clinical information or a concern that this patient is safer with access to you and the resources that you have. Talking to her about your thoughts and plans (when it is not an emergency) or being inclusive will help foster good will with the patient and out in the community
- Adapt policies to allow consulting, referring, partnership and education for community-based physicians to include midwifery-led clinics. Seek community rotations in midwifery clinics for your residents. Learning from and with each other allows providers to get to know each other and deconstruct ideas of “other” so common from both sides to this relationship.
- Provide credentialing for Nurse Midwives who operate in community-based clinics so that they can follow patients and manage care for those that want to plan or are in need of a hospital birth
Joining efforts to achieve the common goals of good health and easy, timely access to healthcare resources can only lead to improved outcomes and the development of a model that can truly serve the consumers and the providers in our community. To learn more about midwives in your area, and to find out how your institution can ensure easy access to resources for the community, contact your local midwifery-led clinic or midwives association.