Amelia Kiechle's first baby, a boy, was delivered 15 months ago at Rex Hospital by a doctor on rotation whom she had not seen before that day. Painkillers dulled the experience.
"It was a little clinical and not very personal," said Kiechle, 30, of Apex. "When they put you on the monitor, they're reading the machines instead of talking to you."
Determined to have a different experience with her second child, Kiechle is preparing her birth plan even before she's pregnant. Her first requirement: a midwife.
If the baby is born at Rex, Kiechle will have that option. Midwives are now delivering at the Raleigh hospital for the first time in more than a decade. She could also have a midwife-assisted delivery at WakeMed in Raleigh, Duke Raleigh and Duke University Hospital, too. The same will be true if she’s in Charlotte, Greensboro or many other large cities in the state.
"Midwifery is back, and it's more of us coming," said Cassandra Elder, a nurse midwife who has delivered at Rex since February. 'It's time to do what's right for women."
Hospitals are not necessarily being altruistic. Adding midwives is part of a strategy to keep costs down and appeal to the growing contingent of women who want deliveries with minimal medical intervention and plenty of personalized attention. But the transition has been met with skepticism from some doctors who don’t see the value of midwives and from some midwives who don’t think hospitals are truly embracing the midwifery model.
It doesn’t help that North Carolina has some of the nation's most restrictive licensing requirements for midwives. It's one of the few states where nurse midwives require a doctor's written permission to practice their profession, a requirement that midwives plan to once again try to get the state legislature to end in its next session. Meanwhile, credentialed midwives who lack nursing degrees can not practice legally here.
What hospitals are doing
That more mothers-to-be want to deliver with midwives is becoming increasingly apparent. Last year, nurse midwives assisted in 12.1 percent of the nearly 119,000 babies delivered in North Carolina. That’s up from 8.2 percent in 2000, according to the state Department of Health and Human Services. And while most of those births were in hospitals, the growth is coming largely from free-standing natural birth centers, which employ midwives and have expanded from just one facility in 2011 to seven this year.
Over the past six years, the number of babies born in birth centers has more than tripled, from 330 in 2011 to 1,193 last year. Over the same period, midwife-assisted hospital deliveries also increased but less dramatically — by 616, for a total of 15,338 deliveries.
“Women know that there are alternatives out there, through social media, talking to friends, just learning about it in different ways," said Pat Campbell, vice president for women's services at Novant Health.
Hospitals are responding in different ways.
UNC Hospitals in Chapel Hill had five nurse midwives in 2016 and have since expanded to a dozen, and plans to hire another midwife next year. Those midwives are employed by the UNC Medical School and most deliver babies, but several focus on providing pre-natal and gynecological care, and one is a “hospitalist” who does rounds in delivery.
In the Charlotte area, Novant recruits nurse-midwives to work for its company-owned OB/GYN offices, where low-risk pregnant women see a nurse midwife exclusively for pre-natal care and those midwives deliver the baby at the hospital. Novant recently expanded from a handful to 15 nurse midwives at three of its practices. The 14-hospital health care organization expects its team of midwives could double over the next five years.
Campbell said these specialty nurses reduce unnecessary medical interventions, such as C-sections and vacuum suctioning.
Rex Hospital, which doesn’t employ midwives but wants to increase their ranks in its maternity units, is urging private doctors who deliver at Rex to hire nurse midwives. The hospital's clinical manager for labor-and-delivery services presented a 21-page business plan to 10 local obstetrical practices last summer, showing health benefits such as lower C-sections, consumer demand and a financial payoff to the medical practice within the first year.
Since hiring Elder, Capital Area OB/GYN in Raleigh has added a second nurse midwife, is interviewing others, and plans to staff five midwives by the end of this year, said Katherine Barrett, an obstetrician with the practice.
"The hallmark of midwifery is being present with the woman and to be at the bedside and to talk them down, to support them and then to help engage their family to be a part of that so it doesn't feel like a runaway locomotive," Elder said. "You have people loving on them. You have people massaging them. Then you can say, 'OK, how do you feel?' "
Most of the state's 351 nurse midwives deliver in hospitals, but some work at the natural birth centers in the state, and about a half-dozen assist in private home births, which are legal but considered risky by many obstetricians and neonatologists.
The most active birth center is Baby+Co. in Cary, logging 330 births last year, or 28 percent of all birth center deliveries in the state. Birth centers don't require a license to operate in North Carolina and are not regulated, but that policy could change. State lawmakers plan to address licensing and regulation of birth centers because three newborns died in the span of six months at Baby+Co.
An economic advantage
Nurse midwives make sense economically for both hospitals and practices because midwives are paid roughly half the salary of an OB/GYN doctor.
That's important because Medicaid, which covers almost half of hospital births, doesn't cover all of a hospital's expenses, and some hospitals lose money on maternity care and delivering babies, said Haley Wiesman, a senior consultant at Advisory Board, a Washington, DC research and consulting firm that serves the health care industry.
Nationally, the birth rate has declined by almost 9 percent in the past decade; it has been stagnant in North Carolina over the past three years, according to state data. Those forces, Wiesman said, squeeze a hospital's profit margins and leave women's services inside a hospital even more sensitive to outside competition.
This often leads to hospitals investing where they can to improve comfort and the overall feel of their labor and delivery service. Construction or renovation projects are expensive and stagnant birth trends may not justify the cost in all cased. On the other hand, hospitals and private physicians practices can more readily afford to hire midwives.
"It's a very-well established model across the world," Barrett said. "We've lost patients through the years who wanted the midwifery model."
The fact remains, though, that most obstetricians are not hiring midwives, either because they don't think it makes economic sense, or they doubt there's much demand, or they are skeptical about their value.
"These practices that are more concerned with just getting patients delivered, and not being patient with deliveries, don't usually employ nurse midwives," said Karen Bash, medical director of obstetrics at WakeMed Physicians Practices, which has 28 doctors and seven nurse midwives in Raleigh and Cary. "The fact that we employ nurse midwives goes along with our philosophy of being non-interventional."
Robert Littleton of Raleigh's Centre OB/GYN practice is skeptical that midwifery represents a needed correction or an advance in maternal and neonatal care. Littleton said he learned to deliver babies from nurse midwives and loves the midwives he's worked with over the years. But he said where a doctor could err on the side of caution, a midwife could go too far the other way.
"I would think there's a little bit of pressure on a nurse midwife, more than on a physician, to maybe not follow some of the standard-of-care things they were trained to do for patient safety, just to please the mother," Littleton said. "Because that's the expectation — that they're not going to use forceps, or a vacuum extractor, or pitocin."
Culture shift needed
The midwife shift within hospitals is also met with skepticism from some nurse midwives who say it doesn't strictly adhere to a midwifery ideal of care which sees pregnancy as natural, not an illness.
A woman who delivers in a hospital with a midwife is still subject to institutional protocols that many midwives — and increasingly some doctors — consider overkill. For example, the woman typically gets an IV port stuck in her arm, just in case she later needs painkillers or other medications. She is generally not allowed to eat solid food, just in case she might have to have a C-section. Some hospitals still use continuous fetal monitoring, which requires abdominal straps and restricts a woman's ability to move around, although increasingly hospitals are using intermittent monitoring or wireless monitors.
"They all have really good intentions but what's really needed is a culture shift," says nurse midwife Suzanne Wertman, president of the North Carolina chapter of the American College for Nurse Midwives. "Midwifery could be taking care of 85 percent of women."
At Duke University Hospital, five nurse midwives work in shifts and attend to laboring women as they come in, having no previous relationship with the women, much like hospital obstetricians on rotation. The only exception to this practice are women served by the Durham County Health Department, who receive care from Duke University midwives throughout their pregnancies.
Midwifery advocates have long warned that treating pregnancy as a medical issue leads to a cascade of interventions that too often end up with a C-section. Those concerns are now resonating in the medical profession. The American College of Obstetricians and Gynecologists accepts midwifery as a valuable service in a hospital setting, and has said that continuous fetal monitoring is unnecessary for low-risk pregnancies. The organization has warned about the dramatic rise of C-sections, and the medical risks — from infections to complications — that women are exposed to from unnecessary surgeries.
Currently over 30 percent of deliveries nationwide result in C-sections, with North Carolina just below the national average at 29.4 percent last year. The U.S. Department of Health and Human Services recommends a rate of 23.9 percent, while the World Health Organization says that the ideal rate has long been thought to be between 10 to 15 percent. There's no data to show that midwives have cut down on the number of c-sections at North Carolina hospitals.
Elder has delivered — or "caught," in midwifery parlance — 28 babies at Rex since she joined Capital Area OB/GYN. About two-thirds of the moms requested epidurals to stifle pain, she said. But so far Elder has a 100 success rate with avoiding C-sections. Her boss, Barrett, said she would have C-sectioned at least two of those pregnancies had not Elder been there to draw on a deep reservoir of midwifery techniques to avoid unnecessary surgery and to deliver newborns safely and naturally.
As midwifery becomes more common, women are discovering midwives by happenstance.
Beth Sims, 37, had given birth four times in a hospital with the aid of a doctor. She assumed her fifth pregnancy would, too.
The game plan changed when Sims prepared for one of her first prenatal appointments on a busy day at Novant Health OB/GYN practice in Charlotte. She was offered a midwife and was intrigued by the option she knew so little about.
Thus Sims, who lives in Lancaster, S.C., became a patient of Tina Hayes, Novant's head midwife with almost 30 years of experience.
Sims says she felt an immediate difference in the care of a midwife during her first appointment compared to the health care she's received in the past from a doctor.
In May, Sims delivered her daughter, Abigail, at Novant Matthews Women's Center. For several hours after Sims entered the hospital, ultrasounds showed Abigail was breech— meaning her feet, instead of her head, were positioned to be delivered first. Hospital staff prepared for a C-section.
Sims held out hope that Abigail would change position for a vaginal birth. Just a couple of hours before surgery, Abigail maneuvered herself into a head-first position.
She labored for the next 22 hours, with her husband and other nurses at her side. But Hayes was the only person who was able to help her focus and calm her down when she experienced a panic attack during the long labor, Sims said.
"It's just such a comforting touch," Sims said. "She just gave me such a level of comfort that I don't think I could get anywhere else."