Jessica Schwarz CNM,
Practicing midwifery in a tertiary or quaternary care
environment can be challenging. At the Children’s Hospital of Philadelphia
(CHOP), midwives are members of an interdisciplinary team comprised of health
care professionals from many fields, from pediatric surgeons to respiratory
therapists to maternal-fetal medicine physicians. We care for women whose pregnancies
have been complicated by a prenatally diagnosed birth defect or genetic
condition. What is the role of a midwife in such a setting? What value can
midwifery care offer to patients who have chosen to deliver at CHOP, not
because they wanted midwifery care, but because of the high level of technology
available to their babies? What can a midwife offer to a family who may have
already been offered a detailed ultrasound, genetic counseling and testing, an
MRI, a fetal echocardiogram, and maybe even fetal surgery? Midwives in
less unique settings may ask themselves similar questions. What does midwifery
practice look like in institutions where normal birth is not the norm? To what
extent are we even practicing midwifery?
These questions were in the forefront of our minds as we
submitted our statistics to the ACNM
Benchmarking Project last year. We received the results with a degree of
sheepish amusement. Thirty-eight percent vaginal delivery rate? Yup, that’s us.
Eighty-four percent induction rate? Yup, that’s us too. VBAC rate: 0. Vaginal twins: 0.
So our contribution to our practice, to the care of our
patients, and to our institution may not be reflected by typical midwifery
statistics. But in reviewing the results of the project, our group of 7 midwives
and 2 nurse-practitioners was inspired to begin a dialogue about the shared beliefs
that guide our practice. We realized that we could use the data collection
process as a tool in ensuring that our practice reflected our shared beliefs. For
example, when we looked more closely at our statistics, we found that among
patients who had no anomaly-related contraindication to vaginal delivery, 70%
went on to have a vaginal delivery. That particular statistic has been extremely
helpful in providing patient-centered
care and enabling informed choice
in delivery planning. In addition to the benchmarking data, we have begun to
track some measures that will specifically reflect our contribution to the
practice, including number of antepartum encounters with the advanced practice
provider group, success with intention for pain relief, and vaginal delivery
rates among inductions and spontaneous labors.
More broadly, participating in a national midwifery survey has
allowed us to share a non-traditional midwifery practice model. In a complex
and changing health care system, midwives may more frequently be called upon to
care for patients outside of our traditional area of expertise (low-risk and
normal). Recognizing that midwifery practice may look different but can still
be midwifery and can be measureable is
essential to demonstrating our value in such settings.
Finally, as members of a team which is defining a cutting-edge
care delivery system for patients with prenatally diagnosed fetal anomalies, we
hope that the data we are collecting may eventually inform an evidence-based, woman-centered
model of care for these patients. And is that not midwifery?