Midwives help lead the fight against maternal mortality in Indiana
Feb. 25—"It's a tale as old as time, supporting women during childbirth," said Megan McDonald, a certified nurse midwife at Community Hospital North in Indianapolis.
McDonald has been a midwife for 10 years now, a field she said she enjoys because she gets to see women feel empowered.
And it's that similar feeling of empowerment that prompted Tina Doyle, a certified nurse midwife from Ascension St. Vincent Carmel, to also get into the profession.
Like McDonald, Doyle has helped deliver too many babies to count in her 19 years of being a midwife, she said laughing.
"The term midwife means with woman," Doyle said.
But there are also misconceptions associated with midwifery too, she added.
Indiana ranks among the worst in the nation for maternal mortality rates, and that reality has prompted action from state health leaders and those in the medical field.
And some of those helping to lead the charge in the fight against maternal mortality are midwives.
Midwifery is a field of medical care that has been around for thousands of years, but some experts say it's needed now just as much as it's ever been.
"I think there's just not a lot of education about what midwives do," Doyle said. "Midwives are actually the original maternity care providers and still are throughout the rest of the world. ... We care for women throughout their whole life (mainly teenage years through menopause). It's not just for maternity, pregnancy and delivery. ... And so you create really special relationships with your patients, and it's just that with woman aspect, being with them wherever they are in life."
But in terms of maternity care, around 10% of all babies in the United States are delivered by midwives, according to the American College of Nurse Midwives, with many of those children birthed in a hospital setting.
Because midwives don't typically handle high-risk situations or perform surgeries — though many are trained to assist in them — they often work inside hospitals in co-management with other certified physicians in obstetrics or gynecology.
Community and Ascension St. Vincent have had midwife programs at several of their hospitals for a few years now, McDonald and Doyle said.
That's another misconception about midwifery, the experts said. Many people think it's still predominantly home births.
"Some of it is probably TV, how the TV portrays it," said Jennifer Shook, a nurse practitioner and certified nurse midwife at Ascension St. Vincent Kokomo. "Some of it is probably just lack of knowledge."
But what midwifery does do is provide a pregnant woman with options, Shook noted.
"I think the power of midwifery is, number one, women helping women. But then the second piece of that is that we're giving women the power to make choices. We're giving women the power to make choices about what she's experiencing."
That ability to provide options in maternity care is what often prompts women to utilize midwifery in the first place, Shook added.
"The ideal goal with midwives is to give the patient more autonomy, especially during labor," she said. "We have this culture of how we have to give birth. We have to give birth in lithotomy. It has to be on our back with our legs up in stirrups."
Shook admitted she's seen that practice change through the years, especially with the increase of women in the fields of obstetrics and gynecology, but she noted midwifery care is more likely to allow women the freedom to choose how they want to deliver a baby.
"One of the things that some patients want to do is give birth in a squatting position in the bed," she said. "Or they want to give birth on their side. And those are definite possibilities and options. ... The midwife model is let's try to utilize all other resources besides pain medicine for instance. Let's utilize the birthing ball, getting up and walking. And then when it's time to give birth, let's try some positions that might be more comfortable for the mom."
Because in the end, midwifery is just about providing women an opportunity to take control over their own maternity care, the experts all agreed.
And it's that medical care that also has tremendous health benefits for a mother and her baby too, they added.
DECREASING THE RISKS
Anytime a mother is pregnant, there's always the risk of a complication.
Since 2018, the Indiana Department of Health and its Maternal Mortality Review Committee has researched the issue of maternal mortality across the state.
In 2020, Indiana saw 78,500 births, according to the committee's latest report that came out last year.
But 92 of those women died while either in pregnancy or up to a year after giving birth, per the report, with 18 dying from what the committee referred to as "pregnancy-related" deaths — complications directly tied to pregnancy.
Unfortunately, 79% of them were preventable, the committee noted, with issues like maternal obesity or substance abuse possibly playing contributing roles in those deaths.
According to the website americanpregnancy.org, midwifery can help reduce those risks, especially in key categories.
Take the need for caesarean sections, for example.
"Midwives, we encourage patients to listen to their body," Doyle said. "With less intervention, we have them get up. They're moving more. Get them in the tub, the shower, walking, on the ball. When women are able to listen to their body and move in a way that their body tells them to, they're more likely to progress more quickly in labor.
"So I think having a midwife, the reason we have less C-section rates, one is that we're very patient," she added. "We let labor progress. Not everybody progresses at the same rate. ... I don't tell patients you only have two hours to push out your baby. It might take them four hours. It's about being patient and letting the woman lead in her birth."
Midwifery has also been proven to decrease the risk of preterm birth, labor induction, regional anesthesia and perineal tears and episiotomies too, the experts noted.
"If women feel safe, if women feel heard, that cortisol level goes down," McDonald said. "Their stress level goes down. Their anxiety goes down. And when someone feels safe, their body is going to function more normally like we want it to."
And it's evidence-based care that the experts said they hope will be able to help in the fight against maternal mortality in Indiana.
SOLUTIONS THAT WORK
According to the IDOH's Maternal Mortality Review Committee's recent report, pregnancy-related deaths occurred in 22.9 per 100,000 live births in 2020.
In 2018, the committee reported a maternal mortality rate of 12.2 deaths per 100,000 births for that same category.
In 2019, that number was 18.6.
"We don't measure up to other industrialized countries," McDonald said. "And in Indiana specifically, within a country that's not doing so great, we're not doing so great either."
Doyle agreed with McDonald.
"I think overall there's just always a low supply of midwives and OBs across the nation right now," she said. "And I think women not having as good an access to care affects outcomes."
Doyle was alluding to the fact that 34 counties in Indiana don't even have a hospital with inpatient delivery services, per state officials.
And over a dozen of them don't even have any hospitals at all.
Indiana officials, led by state health commissioner Dr. Kristina Box, are currently working to find solutions to that issue, rolling out specific requirements for a certain level and standard of care that will be consistent throughout all of Indiana's 92 counties.
"So if we had midwives in some of our rural clinics and areas, then those women would have better access to care," Doyle said. "And that would hopefully improve that mortality rate."
That's why education about the field of midwifery is so important.
"I think it's critical to get the word out because I feel like it's the way that we're going to turn around this mortality rate," Doyle said. "If you look at it, countries that are midwife led care, they have about a 3 in 100,000 maternal deaths. We have 24, and for black women, that number is more in the 40s. That's a seven- or eight-times difference. I feel that speaks for itself.
"Midwife-led maternity care is crucial," Doyle added. "And that doesn't mean instead of physicians. We need physicians. We need that partnership, that relationship, that high-risk care. But normal births, midwives are the experts in normal birth, and it's so important that we get that out there. ... Every woman deserves a midwife."