Obstetricians and nurse-midwives: The team approach in private practice T. SCHLEY GATEWOOD, M.D. RICHARD B. STEWART, ivi.D. Americus, Georgia
Much has been written about the need for help for the overworked obstetrician. Two obstetricians delivering over 500 babies annually had insufficient time for their gynecology practice. Two nurse-midwives were employed and in the first year they delivered 61 per cent of those patients who delivered vaginally. All normal patients had the privilege of choosing their accoucheur; patients, nurse-midwives, and obstetricians were very well pleased with the team approach.
Materials and methods
A "] o r N T S T A T E M E N T on maternity care" was released in 1971 by the .A.. merican College of Obstetricians and Gynecologists, The Nurses' Association of the .t'~.. 1nerican College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives, suggesting the cooperative efforts of teams of physicians, nurse-midwives, obstetric registered nurses, and other health personnel to correct the deficits in availability and quality of maternal care. 1 In 1911 50 per cent of deliveries in the United States were attended by midwives 2 but they were not doing an acceptable job, and physicians succeeded in banning most of this type of maternity care. For many years the generalists delivered a large majority of the parturients, but as our specialty developed, many generralists have happily and voluntarily resigned from providing maternal care. The "1970 ACOG Report on the :-.Jational Study of Maternity Care-a Survey of Obstetric Practice and Associated Services in Hospitals in the U. S." revealed 51 per cent of the births attended by specialists, 31 per cent attended by generalists, and 17 per cent attended by physicians in training. 3 Many generalists in our large rural area stopped practicing obstetrics and we found trying to persuade young specialists to come to a rural area became a recurring frustrating experience.
-rhe ~A'""mericus and Sumter County Hospital is the only hospital in a town of approximately 16,000 population~ there are 135 beds at present but soon a building program will be completed that will increase this number to 200. It serves a population area or· 88,000: there are seven other smaller hospitals in this large rural area (70 by 100 miles). Prior to 1974 there were three obstetrician-gynecologists and one pediatrician on the staff. Because of our rural location, and the known frustrations of being unable to find help, we were invited to attend the Southeastern States Perinatal Cr•nference in Jackson, \1ississippi, in November 1972. Mississippi had an infant death rate of 41.5 per 1,000 live births compared to 24.2 nationally, and the maternal mortality rate was double the national rate in 1965. In less than 3 years ( 1968-71) in one large countv in \1ississippi the infant mortality rate was dramatically reduced to 21.3 per thousand.' At this perinatal conference it was announced that this remarkable achievement by the Midwifery Program of the Un,versity of \1ississippi Medical Center had brought .tbout the expansion of their training program to serve as a resource for five other southeastern states-Louisiana, Alabama, Florida, Georgia, and South Carolina. Forty students are now being trained each vear. In November, 1972, the decision was m.de to employ. a nurse-midwife. The recruitment. was not easy, but the final happy result was to find two that wanted to work together; they were on the job on October I, 1973.
Presented at the Thirty-seventh Annuai Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, Fellruary 2-5, 1975. Reprint requests: Dr. T. Schley Gatewood, 205 S. Lee St., Americus, Georgia 31709.
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The recruitment had seemed difficult, but obtaining approval of the Medical Staff and the Hospital Authority was much more difficult. A voluminous policy manual defining a certified nurse-midwife and her functions, including a list of drugs that she could prescribe, was written and finally approved by the Medical Staff. The Hospital Authority was concerned about the quality of care she might render and the legality of her activities, especially as related to possible malpractice. This was understandable, since their knowledge of midwifery only related to the "granny" midwife. After 5 months our proposed obstetricianmidwife team program was approved. Many nurse-midwives have had years of experience and many have baccaulaureate or master's degrees before entering the program. 5 The two new members of our obstetric team are graduates of the Mississippi Medical Center program. Before entering this program each had a bachelor of science degree and one had a master's degree. They had several years' experience as nursing supervisors in medical, surgical, pediatric, and obstetric units. They have membership in the American College of Nurse-Midwives, the American Nurses' Association, the Nurses' Association of the American College of Obstetricians and Gynecologists, and the International Childbirth Education Association. To gain patient approval a brochure was placed in the waiting room announcing their coming, describing their training, and giving assurance that all normal patients had the option of choosing delivery by the obstetrician or the midwife. It was stressed that the midwife delivered only normal obstetric patients and that she was trained to recognize any variations from the normal, in which case the obstetricians was always immediately available. Assurance was given regarding analgesia and local anesthesia; the nurse-midwives do paracervical and pudendal blocks. A curriculum vitae of each midwife was included in the brochure. When a new obstetric patient makes an appointment by telephone she is told that the midwife will see her on her first visit and that a brochure will be mailed to her. When her first examination is completed the midwife calls in the obstetrician and the team approach is discussed, all questions are answered, and any variables from the normal are checked by the obstetrician. Each patient is encouraged to attend "preparation classes for childbirth," which the midwives teach. Her remaining visits are scheduled with the different team members in an alternating manner. On arrival in the labor suite, if all appears normal, the obstetric nurse ascertains the patient's choice of accoucheur and notifies the one on call. If she chooses the midwife, she
soon discovers the ~1iddle English meaning of this old word, mid-wif, that is, "with woman," 0 for the nurse-midwife will remain "with this woman" all during active labor and delivery and the fourth stage. When on hospital duty the nurse-midwife spends much time giving instructions to postpartum patients regarding breast feeding, exercises, and home care. At the office she does the history and physical on each new patient, giving excellent advice and instruction, in a pleasant unhurried manner: prenatal recheck visits are handled in the same fashion; postpartum examinations are done and family planning instructions are given to each patient they deliver; the obstetrician also does a pelvic evaluation at this visit so that future gynecologic care might be discussed. Every team member is involved in the care and management of each patient so we are remunerated as a team and in this arrangement we have had no problems. The midwives are paid a salary plus fringe benefits, e.g., health insurance, a retirement plan, and expenses for medical meetings.
Results In the first year of our team approach there were 716 deliveries by the obstetric staff of the Americus Sumter County Hospital. Of these, 671 (94 per cent) were vaginal deliveries; the two nurse-midwives delivered 267 patients ( 40 per cent) and the four obstetricians delivered 404 patients (60 per cent). Of the 671 vaginal deliveries the M.D.-C.N.M. team had 436 deliveries (65 per cent), the two obstetricians delivering 169 patients (39 per cent) and the two nurse-midwives delivering 267 patients (61 per cent). The two other staff obstetricians delivered 235 patients (35 per cent). The teams' total number of deliveries was 467; vaginal deliveries were 436 (93 per cent); abdominal deliveries were 31 (7 per cent), with 19 primary sections ( 4 per cent) and 12 repeat sections ( 3 per cent); there were 52 forceps deliveries (12 per cent). There were 10 perinatal deaths (21/1,000), three stillborn infants (6/1,000), and seven neonatal deaths (15/1,000). Our obstetric population is divided almost equally, 51 per cent white and 49 per cent nonwhite. Our prematurity rate was 8 per cent. Four courses of "preparation classes for childbirth have been taught. Each course consists of six classes of 2 hours' duration. Fifty-four couples attended. The second year of classes commenced with 24 couples enrolled. We are pleased with these statistics but there are many tangible factors that we cannot measure. 1. If an "aggravation" chart could be used it would
Obstetricians and nurse-midwives 37
show telephone calls being reduced the first 3 months to 50 per cent and leveling off at about 10 per cent in the ninth month. We are relieved of many telephone questions pertaining to prenatal symptoms, constipation, medications, common colds, rubella exposures, prodromal labor discomfort, "what do I do now?" ad infinitum! An aggravation chart would show that our sleeping pattern is disturbed only about 20 per cent as compared to a previous 50 per cent incidence. 2. When you discover repeat patients on morning rounds, having been delivered by the nurse-midwife during the night, apologizing to you for not calling you during the night because they did not want to bother vou, you realize how patients often refrain from bringing questions and problems to their busy doctor; now we see them relating and enjoying this new team approach, where the midwife always has plenty of time to talk and respond to their whims. 3. The advantage of preparation classes for childbirth is appreciated most by the labor room nurse as she admits a prepared patient who is calm, relaxed, frequently with the cervix dilated 4 to 6 em., with no evidence of apprehension; without fear she has less pain. And when she receives support from the labor room personnel, and frequently from an accompanying sympathetic, prepared, and supportive husband, she terminates her pregnancy in a very exciting, appreciative manner. \!lother and father are effusive in expressing their thanks for allowing them to see and participate in the birth of their baby. Friedman 7 suggested that the stress of labor ( parturiphobia) due to adverse conditioning can be overcome in three ways. As educators, we must teach, as psychologists decondition. and as physicians support and encourage wornen to enjoy this supreme achievement. Our midwives have excelled in this challenging concept. 4. Patients are corning 40 miles from a nearby city of 72.000 because they have heard of our team approach. Couples are very appreciative of the preparation classes and the opportunity to share together the birth of lheir baby. 5. Shortly after the midwives carne to work, a new obstetrician began practice here. He soon told me that as a competitor he was at a disadvantage because of the nurse-midwives. We have been permitting his patients at their request to attend the preparation classes, and he has been negotiating for the employment of a nurse-midwife.
Comment In 1925, working with physicians, the Frontier Nursing Service employed the first nurse-midwives to work
in the mountain counties of Kentucky 8 ; thev had been trained in England. This demonstration project brought nurse-midwifery to fruition. The first school for nurse-midwifery was established in ~ew York City in 1931 and the first nurse-midwives were graduated in 1934. However, entrance into the organized -;ystem of medical care did not occur until 1955, 21 years after the first nurse-midwives were graduated. Columbia-Presbyterian-Sloan Hospital was the 'irst to open its doors to the nurse-midwife. Hellman 9 in 1962 wrote, "the motht:rs of America would be better off if each at the time of labor and delivery were continuously attended by a bm rd-certified obstetrician." Logistics showed this goa! to be unattainable, so he suggested expanding the efficiency of the obstetrician by the use of paramedical personnel, the most obvious personnel being the nurse-midwife. At that time he reported the favorable results of one year's experience of a training program at King> County Hospital under the supervision of the State U niversity of New York. He continued to report in 1964 10 and I 967 11 favorable experiences and acceplance of the nurse-midwifery service bv patients as bt ing satisfactory. A retrospective study 12 in l 971 of a demor,stration program in Madera County, California. adds •·vidence to the value of the nurse-midwife. Due to a ;hortage of physicians two nurse-midwives were empl•Jyed for 3 years (1960-63 ); they managed and deliv•·red the vast majority of the patients; prematurity and neonatal deaths c!ecreased significantly. A state law ne< essitated discontinuation of the program. The retr•>spective study showed a significant increase in the pnmaturitv and neonatal mortality rate after discontinuing the mid-wiferv services, and it was concluded that nursemidwives should be used more extensivelv. After reviewing the "1970 ACOG Repon on the Nationai Study of Maternity Care-A Survey of Obstetric Practice and Associated Services in the Hospitals of the U. S.," Gold 3 suggested six improved 'herapeutic services. one being that the role ol the nurse-midwife "be markediv expanded." in this sam~ vear, in Springfield, Ohio, a physician-sponsored community hospital nurse-midwife program 1:' was initiated and found favorable patient and phvsician acceptance. ln 1971. in the Kaiser Foundation Hospitals 14 , Portland, Oregon, two nurse-midwives were added "O the obstetrics-gynecology staff and were readily a• cepted by 91 per cent of the patients calling for appointments (5 I 2 of 562 patients who called during the first 18 weeks). The little that has been written about obstetricians' attitudes toward nurse-midwives has been favor-
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able. 15 • 16 The American College of Nurse-Midwives* has in its standards that they do not work as independent practitioners but within the framework of a medically directed health service, recognizing that the physician has the ultimate responsibility for patient care. McCall's 17 magazine reports, "the good news is getting around, mostly by word of mouth. Women are telling other women about nurse-midwives and the immensely satisfying new dimensions of skill, sympathy, and personal care they can bring to normal pregnancies. What began not long ago as an expedient plan to relieve overburdened obstetricians of routine uncom*50 East 92nd St., New York, New York 10028.
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plicated maternity cases h~ld quickly come into its own as a first class 'quality' medical style-often preferred outright by mothers-to-be." This we have found to be true. Considering experiences in California and Mississippi, where neonatal mortality rates were markedly lowered, and realizing that Norway, The :'\letherlands, and Sweden, who boast of the best relative neonatal mortality rates, have most of their babies delivered by nurse-midwives, we in the United States must seriously consider adopting the nurse-midwife into our program of obstetric care; we believe they have much to offer in the total care of the pregnant patient.
REFERENCES 1. Joint Statement on Maternity Care: American College of Obstetricians and Gynecologists, Jan. 14, 1971. 2. Schneider,].: Clin. Obstet. Gynecol. 15: 293, 1972. 3. Gold, E. M.: Obstet. Gynecol. 41: 461, 1972. 4. Meglin, M. C., and Burst, H. V.: Nursing Outlook 22: 386, 1974. 5. Beck, M.: Clin. Obstet. Gynecol. 15: 357, 1972. 6. Eastman: Ed. 11, p. 1, 1956. 7. Friedman, D.: AM. J. OBSTET. GYNECOL. I18: 130, 1974. 8. Harris, D., Dailey, E. F., and Lang, D. M.: Am. J. Pub. Health 61: 64, 1971. 9. Hellman, L. M.: AM. J. OBSTET. GYNECOL. 83: 421, 1962.
Discussion DR. ALLAN G. W. McLEOD, Miami, Florida. Our goal as obstetricians and members of this association is optimum care for all pregnant women. It is obvious to all of us that we are a long way from achieving it and equally obvious that we are not going to do so by current methods of delivery of maternity care. We do not have at present nor will we have in the future a sufficient number of obstetricians to care for and deliver every pregnant woman. There are many reasons for this. One problem in recruiting into obstetrics is the feeling expressed by some physicians who have selected another career specialty that the obstetrician is merely a technician and therefore a second-class citizen. It is high time we began to act more as skilled professionals, which we are. I cannot think of another specialty in which the physician spends 4 years in postgraduate training and then spends the majority of his working hours taking care of patients undergoing a normal physiologic process. Physicians have a great tendency to resist anything which will result in change in habits and patterns of practice, but, if we do not accept the challenge of the times and use new and innovative methods that are good, we deserve to retain the image of second-class citizens.
10. Hellman, L. M., and O'Brien, F. B., Jr.: Obstet. Gyne\:ol. 24: 343, 1964. II. Hellman, L. M.: Obstet. Gynecol. 30:883, 1967. 12. Levy, B. S., Wilkinson, F. S., and Marine, W. M.: AM. j. 0BSTET. GYNECOL. 109: 50, 1971. 13. Burnett,]. E., Jr.: Obstet. Gynecol. 40:719, 1972. 14. Record, J. C., and Cohen, H. R.: Am. J. Pub. Health p. 354, March, 1972. 15. Goldsmith, S. B., Johnson, J. W. C., and Lerner, M.: AM. J. OBSTET. GYNECOL. I 11: 11 I, 1971. 16. Long, W. N.: J. Med. Assoc. Georgia 63: 56, 1974. 17. McLaughlin, M.: McCalls 100:67, 1973. The authors were faced with the problems of a need for providing obstetric care and a lack of available physician help. I congratulate them for having the courage to climb out of the rut in which so many obstetricians still languish and incorporate the trained nurse-midwife into their obstetric team. My only question is, why did it take so long? They have demonstrated, as have others, that the team concept provides a high-quality, personalized type of care which private patients will accept just as readily as indigent groups. It has also been shown that the obstetricians were able to function in the role of skilled professionals to a much greater extent than in the past. Introduction of the trained nurse-midwife into the mainstream of obstetrics in the United States has been slow and there is still resistance by many obstetricians and physicians, some of whom continue to iive in a dream world and have the egotistical belief that only they are capable of providing good care. Reasons for this vary from a genuine concern that there would be a deterioration of care, to an inability on their part to accept the nurse-midwife as a trained professional colleague capable of using her skills independently. Usually such physicians do not fully understand the background of the modern trained nurse-midwife and