The Role of a Midwife in a Today’s World

Interview with Kathleen Page, Certified Nurse-Midwife and Home Birth Advocate, November 2015


Becoming an obstetrician was once a career that Kathleen Page aspired to—until she discovered that an OBGYN’s time with expectant mothers was often limited to the moments before they gave birth. That realization inspired her to become a midwife. Page finds that her career as a midwife has given her the chance to make real connections with women during one of the most important times of their lives and to provide them with a birthing experience that is as calm, warm, and supportive as possible.

nurse midwives and home-births interview

Page began her educational journey by earning a Bachelor’s degree in health sciences from Randolph College, formerly Randolph Macon Woman’s College. She later attended Vanderbilt University where she earned a Master’s in nursing, with a specialization in nurse-midwifery. At Vanderbilt, Page spent her first year completing didactic and clinical training, followed in year two with specialty training in midwifery. Page also has the Certified Nurse-Midwife (CNM) qualification, which means she is considered an advanced practice registered nurse (APRN) and is licensed to work in all 50 states.

Page is happy to share her expertise of midwifery at symposiums, conferences and community presentations and panels. The breadth of topics she speaks on is vast and appeals to professionals in the industry and expectant or soon-to-be expectant mothers. Topics include the future of maternal-infant care, obesity in pregnancy, choosing a maternity provider, and menopause and wellness, among other issues. She has also been quoted as an expert in two “Parent” magazine features. Page is an ardent advocate for quality midwifery services for all women and serves on the Virginia Affiliate of American College of Nurse-Midwives. The “Motherhood Collective,” a community group dedicated to women’s health topics, turns to Page as a regular speaker/presenter, particularly on the issue of midwifery.

Enjoy our enlightening interview with Kathleen Page as she details the role that midwives play to ensure a safe labor and birth for every woman, be it in a hospital, the home, or a birth center.

GradSchools: Tell us a bit about your background, education, and what led you to this vital profession.

My parents worked in the clinical and technical sides of healthcare growing up. My mother is a lab technician and my father and step-mother worked in information systems for a large hospital system in North Texas. Growing up, there was an annual event called “Take Your Daughter to Work” day and I always went with my mom to the lab. From an early age I was comfortable in hospital and laboratory settings. I also had a deep desire to work with women and babies, specifically during birth – I have no idea where it came from.

In high school I was able to job shadow labor and delivery nurses on 3 separate occasions. My initial intention was to watch the OBGYNs because, at that time, I had my mind on becoming a doctor who worked with women and birth. I quickly learned that my vision of their work was not the reality. The physicians I saw spent little time with their clients in labor and showed up in the end just for birth. It was very limiting. I wanted to interact and connect more with the women. I turned my eye then to the nurses. But I still wanted more. I didn’t want to be constrained. I wanted to be able to work directly with women and families to make and coordinate their plan of care throughout the pregnancy. It was my smom (step-mom) who provided the solution: be a midwife.

I quickly learned that midwifery was exactly what I was looking for in this work: the opportunity to work with women and be their partner throughout the entire process. With midwifery, I am their care provider and their partner. Best of all, I get to work with women long before and after their child-bearing.

GradSchools: Can you discuss the training that went into becoming a certified nurse midwife? What does it take to become a midwife?

To pursue a career as a Certified Nurse-Midwife (CNM) in the US, you are trained and certified as a Registered Nurse and then receive additional education at the Masters level in Midwifery[i]. Nurse-Midwives have a foundation in both fields of nursing and midwifery. I was trained at Vanderbilt University where the program is open to people from many educational and professional backgrounds. This is a “bridge” program where the first calendar year is nursing equivalent (didactic and clinical training that would otherwise have been provided during nursing school at the baccalaureate level) that is followed by an additional 1-2 calendar years in specialty training (i.e. midwifery, family nurse practitioner, psychiatric mental health nurse practitioner, women’s health nurse practitioner, etc.) The bridge year provides the nursing knowledge between previous experience and the advanced training as nurse practitioner or midwife. At the completion of the Bridge year, all students are eligible for and must pass the state NCLEX exam to be Registered Nurses[ii]. As a CNM, I am also an Advanced Practice Registered Nurse (licensed by my state), with similar training as a Family Nurse Practitioner or Women’s Health Nurse Practitioner (also APRNs)[i].

CNMs are licensed to practice in all 50 states[iii]. During the child-bearing year, we are trained to care for women who are experiencing normal, uncomplicated pregnancy (including labor, birth, and postpartum), as well as evaluate, diagnose, and treat a wide range of complications including diabetes or hypertension in pregnancy, problems with fetal growth, and other medical conditions that may have some impact on pregnancy for mother or baby. We work as autonomous providers who collaborate with and sometimes refer care to other providers (like OBs or maternal fetal medicine, cardiology, endocrinology, and other medical specialties) when there are complications in pregnancy. When women are not pregnant, we provide a range of women’s health and gynecologic services including contraception/family planning, menstrual function, sexual health function, infertility, and women’s wellness. CNMs attend births in homes, birth centers, and in hospitals and have the ability to write prescriptions. The majority of midwife attended births in the US occur with CNMs in hospitals.[iv]

Certified Midwives (CM) in the United States are educated at the Masters level in Midwifery, like CNMs, but are not Registered Nurses. These midwives share the same midwifery education and scope of practice as CNMs. CMs are currently licensed to practice in 5 states. Their ability to practice in other states is often limited by the regulatory legislation that licenses CNMs and other APRNs who are licensed and regulated by Boards of Nursing. These boards seldom regulate and license non-nurses. Like CNMs, CMs attend birth in homes, birth centers, and in hospitals.[iii]

Certified Professional Midwives (CPMs) are another category of midwife in the US. CPMs are educated through schools of midwifery (certificate or diploma) and apprenticeship training. Many have bachelor and master degrees in other fields. CPMs are currently licensed to practice in 28 states with varying scopes of practice. These midwives have been trained to serve women in the community in homes and birth centers during the child-bearing year. They do not have the ability to prescribe, but in some states are able to use certain medications that are important during labor and postpartum including those that prevent or treat infection during labor and postpartum hemorrhage.[iii]

All midwives have education and training (to varied degrees between CNMs/CMs and CPMs) in emergency events that sometimes happen during birth and postpartum with mom or baby including shoulder dystocia, postpartum hemorrhage, and neonatal resuscitation.

GradSchools: In your opinion, what are the advantages of a non-hospital birth with the assistance of a nurse midwife?

Optimal labor and birth care for women is care that values and supports the normal, physiologic process that occurs for the majority of women. It is care that reinforces health while monitoring for illness/disease, educates women and their families about the process of their body, and is woman-centered within the context of her culture and community. Optimal care also provides timely recognition of changes from normal and treatments to help resolve those changes utilizing non-pharmacologic and low-technologic approaches first, when appropriate, and then scaling up to more high-tech and pharmacologic interventions as needed. This is midwifery.

In the US, obstetrical care is costly and high-tech and is perceived as more safe than lower-tech options. This has not been shown to be accurate. Maternal and newborn morbidity and mortality rates are most optimal when high-tech care is reserved for those whom low-tech approaches have not been successful or are not appropriate. Community birth (whether in the home or in a birth center) with midwives provide women who are healthy and experiencing a healthy, normal pregnancy to birth in a low-tech, safe place. Midwives working with women and families in these settings can continue to monitor and observe for changes from normal and treat accordingly, including transferring to hospital if needed. Out of hospital models are safe and cost-effective provided there are trained birth attendants and a system within the community for providers to refer and for women to be seen if complications arise.

We also know that labor is a stress-sensitive process and that birthing space/environment matters a great deal in how/when labor and birth happen. Women need to be in environments that are calm, warm, and supportive so that the body can proceed through the innate wonder that is labor and birth. In the hospital, the focus can shift from the needs of birthing woman and baby to the needs of the hospital staff and the policies and procedures that may serve the institution more than the woman and baby. At home or in a birth center, the space is created for the woman and baby. Everything happens in response to and in support of this unit. 

Women who are interested in home birth should meet with providers who attend these births in their areas to help determine if this is a good choice for them taking into account their unique health needs and desires.

GradSchools: When might you recommend a hospital birth?

Women who have medical conditions before or during pregnancy that can increase their or their baby’s risk for problems in birth may need to deliver in a hospital. This depends on the condition and how controlled or stable it is, and also with the training of the birth attendant and services available out of hospital. Additionally, women who are healthy but who feel more comfortable birthing in a space where specialized services are immediately available in the event of an emergency should be in a hospital. It is awesome that in the US women can still be cared for by midwives. In our practice, we attend births in a community hospital. We have worked hard to “de-hospitalize” our birthing space so that women can feel comfortable and safe. We support the physiologic processes of the body and do not routinely intervene unless there is medical condition with the mother or baby that would benefit from intervention. When intervention does occur, we recommend the lowest tech approaches first.

GradSchools: Do you see non-hospital births as a growing phenomenon? Why or why not?

There has been an increase in out of hospital births as more women have become educated on their options and as practices and centers have been opened in new areas of the country. Many women do not have access to non-hospital providers. As more midwives are licensed and regulated to practice as autonomous practitioners in accordance with our education and certification (instead of practice being restricted by written agreements with physicians as is the case now in most states), there will be more opportunity to provide these services. The hospital is too expensive to meet the needs of all healthy, birthing women. There has also been a trend to designing hospital labor and delivery units to be more home-like and comfortable – to meet the environmental/psychological needs of laboring women. I hope this continues. It also helps to remind those of us in the hospital of the normalcy of life – even when certain aspects may be abnormal.

GradSchools: What have been the most rewarding aspects of your career as a midwife? What have been some of the biggest challenges?

I am most rewarded when I can help a woman who has been unsure and fearful during her pregnancy, be educated about her body and her choices in care, and give birth to her child in a way that leaves her empowered.

I am most challenged when a pregnancy or birth may not be happening normally, when I have to work with a woman and her family to adjust to new plans or expectations, and still have her empowered to make informed choices. My role as a provider is not to make decisions—it is to give information and recommendations so that they can make the decisions that meet their family’s needs.  

GradSchools: What do you see as the role of technology in midwifery? What practices haven’t changed and maybe never will?

Our practice of listening to and advocating for women will never change regardless of where we provide care and what type of system in which we document. Technology in terms of computers and telecommunication helps us connect with other care providers and with our clients in a faster way. Ultrasound has helped us learn more about the babies growing inside the womb much earlier than before, and has helped us counsel and refer women for other services that have improved outcomes for them and their babies.

But any positive of technology can be negative when over-utilized and excessively relied upon to give all the answers. Midwifery at its core is about the human connection. What we learn when we watch and observe with our eyes, when we listen with our ears and spirits, and when we touch with our hands. That should never be replaced or taken for granted.

GradSchools: In your opinion, what are some personality traits or characteristics of an effective midwife?

Midwives are a group of men and women from a variety of backgrounds and personalities who have been called this work. To be a midwife, you should want to work with women and their families – to partner with them as you provide care. Creativity and critical thinking are important skills because no two women are alike – even when they have the same diagnosis. Midwives need a strong constitutional – we work long hours and birth is messy.

GradSchools: There are 3 different midwife certifications in the US alone. Which qualifications do you recommend that prospective midwives pursue?

I recommend programs that train CNMs and CMs. We are trained in all birth settings, have full prescriptive authority in the majority of places we practice, and have the most broad education and training in normal and abnormal pregnancy and birth of midwives in the US. We also are able to care for women throughout their life, before and after childbearing. 

GradSchools: What advice do you have for students who are considering a career as a midwife?

I love meeting and talking with future midwives. Welcome! I tell them our work is not just about pregnant bellies and newborn babies. We spend our time with the women and the families. Our work is hard – birth is messy and not always as anticipated. I tell them we spend long hours away from our own family. I tell them women are strong and powerful and our work is about them.

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References:

i. www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-p... | ii. www.ncsbn.org/licensure.htm | iii. www.amcbmidwife.org/amcb-certification/why-amcb-certification-iv. www.b...