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August 14, 2010

Union Hospital ending midwife nurse services

Arthur Foulkes The Tribune-Star

TERRE HAUTE — Jessica, a new mother living in Vigo County, wanted to have a natural childbirth.

After reading several books on having a baby, Jessica and her husband opted to use the services of a certified nurse midwife during pregnancy and delivery.

“You do get a lot more personalized service” with a nurse midwife, Jessica said. Nurse midwives — relative to physicians — tend to avoid interventions in a childbirth, such as induced pregnancies or cesarean sections, she said, adding, “midwives have very good health outcomes for mothers and babies.”

Jessica’s child, a healthy baby girl, was born earlier this year and the experience was one Jessica said she would repeat if she becomes pregnant again.

“I would definitely want a natural childbirth and a midwife, as well,” she said.

If things don’t change, however, Jessica, who asked only her first name be used, may not have the option of using a hospital-based nurse midwife in Terre Haute in the future. Later this year, the contract between Union Hospital Health Group and Heartland Midwives at Union’s Maternal Health Clinic will end — meaning a halt, at least temporarily — to hospital-based midwife services in the city.

“Current Economic Conditions”

The decision to end certified midwife services at Union Hospital’s Maternal Health Clinic was the result of “current economic conditions,” according to a statement released last week by the hospital in response to a Tribune-Star query.

“We, too, are disappointed to not be able to extend contracts for our midwives,” the statement read.

The move comes as Union is reorganizing the Maternal Health Clinic and moving it from its current location at 1801 N. Sixth St. to the hospital’s Family Medicine Center at 1513 N. 6 1/2 St.

Other maternal health services traditionally offered at the clinic, which mostly serves low-income women, will continue in the new setting. However, “there will not be midwife services offered through the Maternal Health Clinic any longer,” said Kristi Roshel, a hospital spokeswoman, in a telephone interview.

When it started, the Maternal Health Clinic was subsidized by federal grants, Roshel said. In recent years, those grants have ended and the hospital has had to subsidize the clinic, she said.

The Maternal Health Clinic “is basically for low-income women and now it’s just Union Hospital subsidized,” Roshel said.

Petition

The hospital’s decision to end its midwife services triggered a passionate response in defense of the Maternal Health Clinic’s midwife services among many people in the community. Rebecca Hughes, a registered nurse at Union Hospital’s postpartum and labor and delivery section, started an on-line petition to “save our midwives!.”

As of 5:30 p.m. Friday, the petition, which was launched Aug. 7, had 179 signatures. It can be viewed at www.ipetitions.com/petition/terrehautemidwives/.

“I started the petition because I knew there were a lot of people who were upset about the decision and felt they had no way to speak out about it,” Hughes said, adding she used midwife services when she had her two children.

“My two children were brought into this world with the support and guidance of the midwives of Terre Haute Union Hospital,” Hughes said. “To eliminate midwifery in our community would be taking a very regrettable step backwards. I feel I would have no choice but to look outside our community for prenatal care in the future. Not because OB doctors aren’t capable, but because I know the difference a midwife makes and I wouldn’t want it any other way.”

Less costly

While Union Hospital states the decision to end its midwifery services was based on economic considerations, it seems having fewer midwives could actually increase overall health care costs in the Wabash Valley by eliminating a lower-cost child delivery option.

Because midwives tend to use fewer interventions in a delivery, the costs of midwife-attended births tend to be lower than physician-attended births, said Christina Johnson, director of professional practice and health policy for the American College of Nurse-Midwives in Silver Spring, Md.

“There’s a lot of data out there that [certified nurse midwife] care is, indeed, less expensive,” Johnson said. “It costs less to have a birth by a midwife than it does by a physician just because midwives are trained to do things normally and avoid unnecessary interventions,” she said. “That is one of the hallmarks of our care.”

What’s more, in the American health care system, doctors and hospitals are usually paid on the basis of the specific services and the procedures they provide. As a result, a birth with several interventions will cost more than a natural birth.

“That’s one of those systemic things,” Johnson said. “We have a system that rewards interventions and rewards procedures instead of what we really need to do is reward the outcome.” Because of their training and limits on their time, many physicians almost automatically fall back on C-Sections and other interventions while nurse midwives have a very different care-delivery model in mind, she said.

Oct. 29 Deadline

Residents training to become family practice physicians at Union Hospital are also disappointed by the decision to end midwifery services through the Maternal Health Clinic, said Nick Dahl, a resident physician at the north-side hospital.

“I think, in general, from a resident’s standpoint, it’s a tragedy to lose them,” Dahl said. “For the city of Terre Haute it’s kind of like a loss of an option of who can provide your care for your soon-to-be born baby.”

Anne Mishler, one of the two certified nurse midwives practicing with Heartland Midwives at Union’s Maternal Health Clinic, agreed that, once their contracts have expired on Oct. 29, hospital-based midwifery services will be unavailable in Terre Haute.

“We’re the only certified nurse midwives in town,” Mishler said. “The only ones that deliver at the hospital. We’re the only game plan there is, I guess.”

To practice in Indiana, hospital-based certified nurse midwives must have a collaborating doctor. To begin assisting in deliveries again, Mishler and Helen Beane, the other certified nurse midwife at the Maternal Health Clinic, would need to work through a hospital, physicians group or MD.

Safer, too?

At a national level, medical leaders are calling for more collaboration between physicians and midwives, the ACNM’s Johnson said. This is because of a growing shortage of doctors to deliver babies and evidence that midwife-supervised births are at least as safe and less costly than physician-attended births.

“The data really support the safety, effectiveness and certainly the cost effectiveness of midwifery care,” Johnson said. “Unfortunately, the national leadership doesn’t always trickle down to the local level at the speed we would like it to.”

Some countries use midwives to a much larger extent than the United States and actually have better health outcomes, Johnson noted. In many European countries, a large majority — up to 85 percent — of births are handled by midwives. In America, on the other hand, only 7.4 percent of births were attended by midwives in 2006, according to data provided by the American College of Nurse-Midwives.

Using more midwives in the United States “would have a huge impact on maternity care because the vast majority of women are normal and can delivery babies normally,” Johnson said. In the U.S., nearly 32 percent of all births are done using C-Sections, which “vastly contributes to higher morbidity and mortality” among newborns, she said.

“There are places in the world where midwives do most of the birthing of low-risk women in their pregnancies,” Union third-year resident physician Dahl stated. “That’s one way a lot of these places have better health care systems than we do and are more efficient than we are because they use certified nurse midwives.”

Training doctors

The nurse midwives at Union Hospital delivered about 10 percent of the hospital’s 1,508 newborn babies in 2009, according to data provided by the hospital.

But that number does not reflect the births attended by midwives in the role of instructors for resident physicians, Mishler said.

“They are essentially faculty,” Dahl agreed. “They are kind of like the people you are apprenticing with.”

Most residents feel the loss of the midwives is equal to the loss of two faculty members from their training, Dahl said. “I think the residents, almost every one of us, think it’s a huge loss.”

Union Hospital also regrets the end of its midwife services, Roshel noted, adding that this may not be the end of the service for Terre Haute.

“We were disappointed, too, not be able to renew the contract. But people are assuming, I think, that that service will disappear,” Roshel said. “It doesn’t necessarily have to disappear.”

The nurse midwives could form an independent practice or could partner with another physician or health practitioner, Roshel said.

“We hope that is what the case will be. That would be the best outcome for the community,” she said.

Reversing the trend

Mishler said she and Beane have not given up on practicing in Terre Haute.

“There have been some contacts made between physicians and hospitals and all of that about us and with us, but … I can’t tell you anything is in the works,” she said.

“Midwives with appropriate credentials and privileges are welcome to practice at Terre Haute Regional Hospital and we understand they can be a valuable community and patient resource,” said Brian Bauer, CEO of Terre Haute Regional. “We currently do not employ any midwives,” he added.

So, unless things change, after Oct. 29, hospital-based, certified nurse midwife care will be unavailable in Terre Haute.

This is a step “backward,” Johnson said.

Increasing collaboration between doctors and midwives is “really sort of where the country is headed and so for places like this to be going backwards is very frustrating,” she said. “It’s usually just a lack of knowledge and understanding on the part of [some physicians] who have never worked with midwives,” she said.

“Unfortunately, the way the system is currently, it’s still very much physician-driven, physician-led and there’s not a lot of room sometimes for other providers” such as nurse practitioners or midwives, Johnson added. “That’s not new. That’s an old trend, we’re trying to reverse it.”

Arthur Foulkes can be reached at (812) 231-4232 or arthur.foulkes@tribstar.com.

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