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Week of 20 September 2002 · Vol. VI, No. 4

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SPH midwife program delivers lessons in primary care, cultural sensitivity

By Hope Green

With growing frequency, American women are enlisting the services
of nurse-midwives to coach them through childbirth. But these specially trained professionals do a lot more than deliver babies. In the course of her day, a midwife might check a patient for strep, offer advice on postpartum depression, or even help someone with a substance abuse problem.

Mary Barger, an SPH assistant professor, directs the Nurse-Midwifery Education Program at the School of Public Health. Photo by Donna-Marie Rios

  Mary Barger, an SPH assistant professor, directs the Nurse-Midwifery Education Program at the School of Public Health. Photo by Donna-Marie Rios

Catherine Walker recalls visiting a pregnant woman in jail who had turned to prostitution to support her cocaine habit. After her release from prison, the client kept in touch with Walker’s Boston practice, Urban Midwife Associates, where another midwife guided her to a local drug treatment center.

“This woman was absolutely set up to get out of prison and fail,” Walker says, “but she was committed to succeeding and pulled herself together with the goal of having a healthy baby. A relationship with a midwife helped her take control of her life. She is still enrolled in the treatment center, and we’ll stay with her to make sure she keeps clean.”

Walker (SPH’93) is one of 65 graduates of the School of Public Health’s Nurse-Midwifery Education Program (NMEP), which was established in 1991 in response to a rising rate of infant mortality in Boston.

Administered by the SPH department of maternal and child health, the five-semester program is open to registered nurses, who pursue a master of public health degree and receive clinical training. By the end of the program they are eligible to take the national certifying examination for nurse-midwives.

NMEP is the only program in the country that combines nurse-midwifery training with a public health degree. Its courses provide insight into societal issues affecting women and children, and teach analytical methods to help students solve health problems in their communities.

On the clinical side, the program emphasizes the role of primary care in promoting good health habits throughout a woman’s childbearing years, so that even if a pregnancy is unplanned, her chances of bringing a healthy fetus to term will improve.

“The midwife model of care aims to educate women to stay healthy,” says Mary Barger, an SPH assistant professor and NMEP director. “It’s the same paradigm we use in all of public health, because it’s a lot easier to do primary prevention than secondary care.”

Barger says the feedback from employers of NMEP graduates has been consistently positive. “Employers appreciate their public-health perspective,” she says.

Frontiers of care
Midwifery is an ancient practice, but was not established as a profession in this country until about 80 years ago, when pioneering nurse Mary Breckinridge founded the Frontier Nursing Service in eastern Kentucky. She sent public health nurses on horseback to care for poor Appalachian families, and later she brought nurse-midwives over from England to join the program. The first American school for midwives opened in 1933.

Even so, it was not until the women’s health movement of the 1960s and 1970s that the practice blossomed. “Midwives,” Barger explains, “were seen as an alternative to the medical-interventionist model of pregnancy and birth.”

Since then the profession has changed dramatically, and today more than 7,000 certified nurse-midwives practice in the United States. Modern midwives work with physicians in hospital delivery rooms, home births being the rare exception.

Although midwives have become popular with women of all economic backgrounds, they can be especially valuable in low-income areas. A cultural competence module in the SPH program, says Barger, focuses on “what we call vulnerable populations -- women who are immigrants, poor, or adolescent, who might not have normal access to health care.”

Intensive training
Between 8 and 10 nurses complete NMEP each year, and 15 are currently enrolled full- and part-time. They acquire basic clinical experience in a variety of sites around New England, including Boston Medical Center; later, in the last eight to nine weeks of the program, they are placed in a different setting for a term similar to an internship, where they work alongside a full-time nurse-midwife from 40 to 60 hours a week. Clinical settings range from upstate New York to an Indian reservation in Arizona.

Every NMEP student is required to complete either a research project or a policy evaluation related to maternal and child health. One student, for instance, is conducting a focus group to determine why many Vietnamese women stop breastfeeding when they immigrate to the United States. Another is surveying emergency medical technicians to evaluate the quality of their training in childbirth. She will use her findings to make recommendations to their supervisor.

“Students in a regular nursing program might not have the skills to conduct an assessment and a program evaluation,” Barger says. “These are two important things we teach our students.”

Improving the odds
Walker, a clinical instructor in obstetrics and gynecology at the School of Medicine, was one of NMEP’s first alumnae. The profession called to her after she had worked as a registered nurse and witnessed firsthand the limits of urban health-care systems.

“I grew up in Dorchester at a time when neighborhoods were being redlined and physicians were leaving the city,” she says. “I was affected personally by the growth of the neighborhood health center movement, yet I saw how options for women were still quite limited.”

After completing the SPH program, Walker and other alumnae cofounded Urban Midwife Associates, an independent private practice affiliated with BMC. The organization takes patients regardless of their ability to pay. Walker draws satisfaction from helping women succeed in bearing healthy children, even when the odds are against them.

“Whether a woman is a doctoral candidate in the department of biology, as one of our clients was last year, or whether she’s incarcerated at MCI-Framingham, to have that powerful life experience of giving birth is life-transforming,” Walker says. “And women don’t grow up learning that.

Instead of seeing glory and empowerment and strength, they see pain. Achieving the mastery of pain with the end result being a baby is an amazing experience for women, and to be there when women go through that process is a tremendously rewarding career. Hard work, but tremendously rewarding.”


20 September 2002
Boston University
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