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Warner Huh, MD (Host): Hello everyone. This is Dr. Warner Huh, the Chair of Obstetrics and Gynecology at the University of Alabama in Birmingham. Welcome to this monthly episode of Women's Health with Dr. Huh. So today we're going to talk about something that I think is going to be notably impactful, both for current and future obstetrical care. And that topic is nurse midwifery care. I'm really excited to announce that we actually have four nurse midwives that have recently joined the department, to provide this type of care. And with me are two of the nurse midwives who I'll introduce shortly.

They'll talk about why nurse midwifery care is important. So with me today are Sheila Lopez and Anna Floyd, who were previously at the Simon Williamson Clinic at Baptist Princeton. They deserve really significant credit for really building out a really enormously successful nurse midwifery program here, in the city of Birmingham. Probably really the only program of its kind. We were lucky enough for them to come over and join us here in the Department of OBGYN at UAB Medicine to really provide nurse midwifery services here, for the greater Birmingham community and abroad.

In addition to that, the two of them are going to be centrally involved with the other two nurse midwives in terms of relaunching the CNM or Certified Nurse Midwifery Training Program through the School of Nursing here at UAB.

I'm super thrilled to have both Ms. Lopez and Ms. Lloyd with me today and welcome to this month's podcast.

Sheila Lopez CNM : Thank you for having us. We're excited to be here.

Anna Floyd CNM : It's definitely good to be here.

Host: Well, that's great. So again, as I mentioned earlier, some of our listeners may have a very sort of limited knowlege about what it is that you do, and so, one of the questions I had for you, Anna, was can you describe briefly what exactly a certified nurse midwife does and how this care, or this model of care perhaps differs from a nurse practitioner or a physician assistant?

Anna Floyd CNM : Yeah, for sure. We are similar in some ways to nurse practitioners and physicians assistants, in that we are kind of what's considered mid-level providers. We are advanced practice nurses. We do specialize in women's care through the lifespan. So that means as soon as someone starts to have their period, and then all the way through menopause and beyond, we can take care of, um, basic GYN things.

And then specifically, what differs from a nurse practitioner, is that we are able to continue that care through labor and through birth as well, mostly taking care of low risk families. Similarly to nurse practitioners and physician assistants, we do have prescriptive authority, which means that we can order medicine, we can order labs and ultrasounds, and then we can do evaluation and diagnosis of our clients.

Host: So what I'm hearing from you is that there's overlap in terms of the services that you provide when compared to like for instance, a nurse practitioner, of which we have many here within the department, but what maybe is markedly different is that you actually have the capacity to provide what we call intrapartum care or care in labor and delivery. So when a woman comes in with suspected labor or they're actually in labor, you actually manage those patients and even deliver them. Is that correct?

Anna Floyd CNM : That is correct. Yep. A few things that I feel make midwives different as well, there's obviously many pillars of we believe and what we've been trained in, but two of the main pillars are shared decision making, and in viewing birth as a physiologic process. So a lot of times we've been called like the gatekeepers of normal, in that a lot of times, we view birth as this normal natural process. But as the gatekeepers of normal, we are there to pay attention to risk factors that may need intervention, and work closely with the other parts of the care team, which we're, you know, so thankful for. So if there's something that's abnormal labor is going on so we can bring in Pitocin. If there's an obstetrical emergency or something that we need oversight in, we have our physician partners that we work very closely with as well.

Host: No, I love that. Gatekeepers of normal. I'm not sure I've heard that before. That's a fantastic way to describe it, and the majority of women that go into labor, they have normal physiologic labor, which is, I think you're trying to say and let nature take its course.

And you're basically guiding them through that. And so, I think that's a great way to describe it. The one thing that I remember as part of my training is that nurse midwives actually provided fairly comprehensive gynecologic care as well. So I thought maybe you might want to comment on that for our listeners as in addition to that.

Anna Floyd CNM : Yeah. I think that's something that surprises people a lot of times. They think, okay, I don't need a midwife now. You know, I've had people kind of laugh when I've gone in the room. They've said, oh no, I don't need a midwife. I had my babies years ago. But we're able to provide cancer screening services like those general GYN visits that someone would come in for, as well as a lot of gynecological problem visits as well.

So we can manage irregular bleeding, contraceptive, issues with infections, in a similar way to any GYN provider, a primary GYN provider that you would go to.

Host: Yeah. So again, so for the people listening to this podcast, I think this is really important to stress. I mean, I think one of the best aspects for why any provider that goes into women's healthcare is really the continuity of care. And I just think it's important to recognize that that is no different for a certified nurse midwife.

And I think that's a really key aspect for our listeners to understand. While we're on this topic, Anna, I just could you comment, what kind of training is required to be a certified nurse midwife? And like, how does one go from being a, a non-certified nurse midwife to being one. If you could just kind of share with the audience what that path looks like.

Anna Floyd CNM : Yeah, good question. So, is confusing because here in the United States especially, there has been different camps of midwifery. Certainly since the early 19 hundreds, where there was this differentiation between nurse midwifery and then other types of midwives, like often certified as well, but in a different route.

So certified nurse midwives, we're typically nurses first. And then have a master's degree, in nursing or master's degree in midwifery. So typically it's those four years or so for nursing school and then typically a couple more years for the midwifery. And of course we have the bookwork portion and then clinicals as well for that. One thing that I feel like has been really confusing, especially here in Alabama, a lot of people tell me, oh my gosh, you guys are legal now. Because there was the law that passed in 2017 that allowed certified professional midwives, which is different than certified nurse midwives to practice.

And the professional midwives are allowed to do birth outside of the hospital. So we're thinking home birth, whereas, nurse midwives, we've been legal here in Alabama, the whole time. There just haven't been many of us in practice within the hospital system.

Host: I, I'm glad you raised that distinction because I think often confused. I think the one thing that our patients ask is whether the nurse midwives work collaboratively with let's say an ob gyn. I'm assuming that's fairly standard in most practice settings. Is that correct?

Anna Floyd CNM : Yes, it is. We work closely with the OB GYNs. And like I said before, we can independently manage clients. But so often there are things that come up that we work with. And then our collaborating physicians review our cases as well. And that's all under the Alabama Department of Nursing and the Alabama Board of Medical Examiners, oversee those collaborations.

Host: That's great. I, that's why I'm asking the question is I just want the broader audience to understand, exactly what kind of training is required and it's significant training, but also sort of that somewhat team environment that you guys are in, in terms of collaborating with other providers and providing care.

And so I think it's a cool, very neat model of care. So Sheila, let me, the question I have for you is this we've all met previously and we've had a broader vision as it relates to the importance of nurse midwifery care.

But could you just comment on why you think nurse midwifery is important for obstetrical care and maybe beyond obstetricall care to Birmingham and perhaps the entire state of Alabama. I think that the listeners would probably be kind of fascinated to hear your response on this.

Sheila Lopez CNM : Yeah, so we know that it's been a really hot topic lately to talk about maternal mortality and neonatal mortality in the media abroad. And it's also not unknown that Alabama tends to rank pretty poorly in those rankings. In Alabama in 2021, our maternal mortality rate was 3.29 deaths per a hundred thousand live births, which has been increasing since 2020, and even before that. But what we do know though is that integration of midwives into a regional healthcare system is a key determinant for optimal maternal newborn outcomes. And we know that from some really significant research, one of which in 2018 where a group looked into levels of integration by state, according to the midwifery, to midwives scope of practice, their autonomy, prescriptive authority, and also looked at whether or not there were restrictions put on them through regulations.

And they also looked at the density of midwives, and then they assigned a score to each state. Higher scores were associated with significant higher rates of spontaneous vaginal deliveries, vaginal birth after C-section, and increased breastfeeding rates and significantly lower rates of C-section, preterm birth, low birth weight, so small babies, and also for neonatal death.

Alabama was second lowest in that score at 18 and Washington State was actually the highest ranking with 61, and we can look at some of the statistics comparing Alabama and Washington, where in the same timeframe, the neonatal mortality for Alabama was 5.6 per 1000 births. And at the same time where Washington has better midwifery integration, their neonatal mortality, was almost half that at 3.1 per 1000 life births. And the same goes for maternal mortality in the same, timeframe where Alabama had 36.4 compared to 11.2 deaths per 1000 live births. So I think that having midwives in Alabama, and particularly at UAB, where we are able to really integrate into the system and teach and train alongside the state's top OBGYNs in maternal fetal, specialists and the residents and midwifery students, everybody, that whole interdisciplinary team learning alongside each other, really them getting exposure to the midwifery model will be huge for expanding midwifery across the state of Alabama as they go out into their own practices and start advocating for that model, to be brought to other hospitals besides just UAB at large.

Host: Yeah, I mean, you said it perfectly. And what needs to be stated is that we have a serious shortage of providers when it comes to obstetrical care in this entire state. And I would argue that it's at a, it's at crisis level.

Sheila Lopez CNM : Absolutely.

Host: And there needs to be a coordinated solution. And I think one of the solutions it's, it's a really, really good one, is to look at the role of certified nurse midwifery in the state. And I think that we needed to look much broader in terms of the impact. So that's really the reason I asked you the question and you answered it exactly the way I thought you were going to answer it, so thank you.

Similarly, I know Sheila, like you were a labor and delivery nurse here at UAB for many years, and then flipped over to nurse midwifery, and you're very familiar with the obstetrical care that we provide here at UAB. I thought maybe you could just kind of provide your own unique personal perspective about why you're excited about kicking this program off here.

Some of that may tie into what you just said related to the broader reach, but why UAB and why are you excited about bringing it here to this community.

Sheila Lopez CNM : Yeah, definitely the broader reach is a strong driving force of why we're excited to be here. But also just the fact that we know that UAB is an innovator and is the leader in obstetric care in the state and across the country, that we're excited to be here and to bring that lens of normal physiologic birth, and to add just another layer of expertise to the team.

Host: That's great. I'mgoing to ask the same question of youAnna, why are you excited about bringing this program here to UAB?

Anna Floyd CNM : Similarly to how Sheila said, I feel like in so many ways, all eyes are on UAB, because of the research that we do. And because people hopefully, will follow evidence-based care. And so if we are able to successfully integrate midwives here at UAB, I think other places it won't sound so crazy to, and that the residents that we get to work with, that will one day be the leading doctors in the state, we will have all worked with each other.

We're going to have better relationships. We're going to have more trust in each other, which is, I think is just going to be helpful. I think it's only going to bring more growth and reduction in maternal mortality to Alabama.

Host: Yeah, think you said it perfectly as well. From my perspective, for what it's worth, I've been in Alabama for about 20 plus years. I worked with an amazing core of nurse midwives when I was a resident in Boston, and that experience pretty much still is central to how I look at obstetrical care.

And I think for us, it's about providing options at different modes of care and, I think the community wants that, the rest of the country provides it. There's no reason that we shouldn't provide that same type of care to at the minimum, the UAB community and beyond.

That's what I think is really important. But not only that, as I mentioned earlier, I mean you all are enormous advocates for women's healthcare. And I think that comes in different shapes and forms that are equally important to traditional models of care. To be able to bring this in as an option for our patients is for me, a priority.

What's also a priority, as we mentioned earlier, is how to best serve the entire state. And I do believe that if we figure out how to make it work here at UAB, that the groundswell interest in the entire state, including the Birmingham metro area will be significant in the next five years. So you guys are in many ways, kind of on the leading edge of this, and so I want to congratulate both of you, but you really, your entire team for taking this on.

It's like an exciting time but I think that we'll look back and maybe even look back as this podcast and play it again and say, wow, that was a sentinel event. So that's why I'm personally excited. For our audience again, Anna, Sheila and her team have just joined UAB, they have just started.

The goal is to broaden out nurse midwifery services here in the upcoming years, and you all will hear more about the services that they provide and how to make appointments, et cetera. They're just getting the lay of the land here, but again, I'm just absolutely thrilled that they're joining the group, so thank you for taking that leap to both of you.

Sheila Lopez CNM : Thank you for taking the leap of bringing us on.

Host: So again, in closing, I'd like to thank, Sheila Lopez and Anna Floyd for discussing nurse midwifery and its future importance here at UAB, Birmingham and the state of Alabama. Please rate this podcast and we welcome any comments, particularly on topics that you all are interested in.

And for more information on obstetrical services and care and other clinical services that UAB provides, check out uabmedicine.org. And until next time, thank you. Have a great day and be good. Bye-bye.