(00:00:00) Midwifery is the act of assisting at childbirth and for centuries the only overseers during the delivery of a child were women known as midwives. Now at one time midwives may have been more proficient at their work than Physicians and that was because of all of the importance attributed to the work of midwives and today on midday were going to spend about the next half hour talking about Nurse Midwife programs specifically but Midwifery in general and with us is Bonnie stickles, who is a nurse Midwife at st. Paul Ramsay hospitals in st. Paul and on the line with us to is University of Minnesota education director of the nurse Midwife program Kathleen Dineen. I want to begin Bonnie by asking you what sort of training you received to become a nurse Midwife. (00:00:46) I spent about two and a half years working in labor and delivery area when I was in the service following graduation from the University of Wisconsin's basic nursing program and decided that I Enjoy the OB area but there was more to it than just a basic nursing education. So I then sought further education at Columbia University in New York and spent a year there learning Midwifery received my certificate in the master of science degree there. (00:01:13) The point of education for nurse midwives is one that probably escapes a lot of people and I've been told by others that the education program is quite complex and fairly rigorous and on the line with us right now is part of midday is Kathleen Dineen who is education director for the University of Minnesota's nurse Midwifery training program and Kathleen. I was wondering would you describe the University's training program for nurse midwives? (00:01:38) Yes, the program at the University of Minnesota is a part of the graduate program in nursing our applicants to our program. Our registered nurses who have a college degree the into our program and it's approximately five to six quarters long and we focus on nursing and nursing Midwifery. (00:02:00) Well, I'm impressed Kathleen and Bonnie with the amount of interest that I have heard lately in nurse Midwife programs. And even though there is growing interest there does not seem to be that many nurse Midwife programs available in many parts of the country Kathleen. What is your experience with the placement of nurse midwives are there first of all many more applicants for the program than ever before and are there are many more places expressing interest in having them. (00:02:26) Yes, there are just from April 70 Acres 79. We had 251 inquiries about the program and to date we have 43 applicants for 12 slots for our next admission in September and this is a national problem. There are there are about Perhaps twenty three programs in the states nine of them are Masters or graduate programs such as ours 7 our certificate basic programs. And then the others are refresher programs for nurse midwives who haven't been practicing or for foreign trained nurse midwives and then there are some internship programs also. (00:03:12) Oh Kathleen as you look towards the future of your program at the University of Minnesota. What do you foresee is the program going to continue to grow? (00:03:21) Yes. I think it will the interest in the program is very great the supporting the university is good. We are we do have the constraints of funding which is perhaps the problem for all Nursing education right now right now. We are funded on your Grant. From the division of nursing which tells us to get additional faculty. You see these programs require a very high faculty-student ratio because students receive intensive clinical supervision usually 8493214123 ratio. (00:04:00) So the people who are interested in nurse Midwife programs and our registered nurses as you pointed out, but their training after that could take as long as what two to three years. (00:04:10) Well, I would say a year to a year and a half in our program two years in some of the program's you see they do have a baccalaureate degree and they do have the nursing but I think a lot of the emphasis on our program is on communication study of family systems interpersonal relations, and then over above more of the theory relating to ascetical management and your singular free care. (00:04:38) I'm curious Kathleen have all of your applicants for the nurse Midwife program. University nursing school been women so far have there been any men (00:04:46) you all are Africans have been wearing. There are some in fact I spoke to one recently. He's in South Dakota right now, but perhaps they're about three or four Across the Nation. (00:04:58) All right. Well thanks to Kathleen Dineen who is education director for the nurse Midwife program at the University of Minnesota in Minneapolis. Thanks for joining us today as part of midday and Bonnie stickles was listening to that phone conversation. And as we were talking about the training for nurse Midwife programs Bonnie, I was curious about the history of Midwifery. It is a long history throughout the ages midwives were perhaps more throughout past two centuries midwives were perhaps more important than doctors. Why did we free decline? (00:05:33) I'm gonna have to be careful with that one Midwifery. As you said has been predominantly a women's art because there was no one else to do this for many many years then with the Advent of obstetrics as a medical field in the time of the Chamberlain's when the forceps and things like that were brought about Midwifery was seen as a medical specialty and Physicians began to train and to move into it and for some years they still were there still was the practice of Midwifery and person was spoken of as being in Midwifery, then it began to be more obstetrics medical obstetrics and the physician physicians in this area grew and had reason to believe that they were giving better quality Care within the medical system. And so That there was some some problem with actively trying to do away with Midwifery and other attrition natural attrition kind of problems that set in for some years. (00:06:37) Well what you've just said seems to me to get at the heart of one of the questions that I imagine many people raised about Nurse midwives and that is will I be getting as good a quality Care from a nurse Midwife as I would from a medical doctor and what's your reaction to that question. (00:06:52) My personal reaction is that you certainly are getting as good a care from a nurse Midwife. My many of our patients are quite Prejudice and they think they're getting better care. We are specialists in the normal OB area we focus on that. We spend a great deal of time in that area as Kathleen was saying there's a 123 faculty to student ratio. So no one is doing anything sort of on his or her own and sort of bumbling along. It's a very supervised very structured situation. So things are learned and then done in the clinical area under supervision and hopefully done well and quickly that way so You're finding that we as I say are specialists in the normal low be area would concentrate on that. We do not care for the ill mother so that doesn't take up time. We do not do surgery of any kind. So that doesn't take up our time and we have the time to spend with well women. (00:07:40) You've been a nurse Midwife for how many years going on five years. And in fact, you were an instructor at the University of Minnesota nurse Midwife program for a (00:07:46) time. Yes between 74 and and summer 75. Well, (00:07:50) what do you think is the principal benefit to a woman of having a nurse Midwife for a pregnancy as opposed to a medical (00:07:55) doctor as I was saying somewhat just before our focus is on normal obstetrics. In other words. We look at the woman as well until proven. Otherwise, our time is available for the care of the Well Woman, whether it be in a pregnancy state or a non-pregnant State just a well woman needs like pap smears and breast exams and health education because we do not have the other obligations of surgery and of the extensive and intensive care of the mother with an illness. Our Focus can be on needs of the well pray. Woman or the Well, Woman in education, her knee individual needs her learning needs her stages of her development. Her family needs her financial needs and in pregnancy the growth and development of the fetus the family how they interact those kind of things that are very important (00:08:42) to I think it woman I get the impression that means Bonnie that nurse midwives might be inclined to spend a bit more time considerably more time perhaps with pregnant women than a medical doctor could justify spending is that your reading of the situation? (00:08:55) I think because of the nature of our commitments indeed that is the case, I would guess that most of us spend between 20 and 30 minutes with return visits for our mothers. Where's the physician has got some other time constraints with his various activities and possibly can only give 10 to 15 minutes to her (00:09:10) as to specific duties. Now a nurse Midwife would see a pregnant woman presumably at the beginning of pregnancy and on through up to the delivery rooms and (00:09:19) right on through the birth. Let's say yeah with most of us if we can manage it do not use the delivery room. (00:09:26) So the doctor would be in the delivery room for the delivery of the child is at it. (00:09:31) There are some areas of the country where that still is required either from the the lack of total trust or the requirements of the hospital. Whatever those might be or the desire of the physician the nurse Midwife. However are one of our basic roles, is that of being a physician extender so it would be wasting his time essentially to come and attend the normal birth. So many instances there is not a physician right there. There's one in the institution or there is one within easy call and quick a success but not sitting right there wasting his time watching a normal (00:10:06) birth as you mention before we begin our conversation on the air the public often has many questions of nurse-midwives because while we're free is very old concept the nurse Midwife programs that are available are perhaps not well known we're going to give out some telephone numbers that listeners can call to ask questions of Bonnie's. Those who was a nurse Midwife at st. Paul Ramsay hospital and st. Paul and in the Twin Cities listeners can call to to 11550. That's two two one one five five zero. If you have a question to ask of nurse Midwife Bonnie stickles listeners, in other areas of Minnesota outside. The Twin Cities can call us toll-free and the toll-free number is 1-866-560-4440 Hicks 529700. If you have a question for Bonnie stickles money, I was interested in the point the relationship between nurse midwives and doctors and I'm wondering how that relationship works. I can imagine a lot of doctors being threatened by the increasing interest in nurse-midwives because well for one thing they may be worried about losing (00:11:20) business. That has been a problem in that certainly would be naive to say it isn't going to be a continuing problem for some time. But I guess it's my personal opinion that many times problems arise out of a failure and communicating in some way. I have found that there is hostility and resistance when a good understanding of what I'm all about and what the physician is all about and that it's a team effort is not well understood nurse midwives do work in conjunction and direct consultation with an obstetrician at all times. We realize that possibly if I can say for this area about 80 percent of pregnancies will turn out well without any difficulties at all. There are those 20% as a bit of a global figure to give out that can and will have some difficulties from minor to very serious problems that need a physician. So we as I say, we do work in close conjunction with the physician and what I find is that if indeed we as nurse midwives explain ourselves well to The Physician and the physician Community as to this team Relationship and that ultimately that the patient still has to remain under a physician's care. If you will in some manner shape or form then seen as a shared effort and more and more references now is going on to the partnership establishment of Partnerships where you have several nurse midwives and several Physicians. So it really is their patient rather than minor he is or whatever (00:12:43) midwives of centuries ago were lay people people who perhaps had no specific medical training you are a nurse Midwife. What is the distinction then between a nurse Midwife and Al a (00:12:52) midwife years ago, the lay Midwife tended to be an older woman in the community who either by choice or by accident sometimes attended began attending Versa that another more experienced Midwife was was conducting and then after some experience began to be that person for that Community little by little various or educational facilities did come about there is a group In Tennessee on What's called the farm that has an educational preparation for the lay Midwife and the University of Mississippi has worked rather closely and conjunction with their Lee midwives there to help them gain some skills and to provide some backup and some supervision so it can go from no education to reasonably. Well organized comprehensive education and licensure in some states. (00:13:45) The time now is about 27 minutes before one o'clock. This is midday on Minnesota Public Radio and we're talking with nurse Midwife Bonnie's tickles and we gave out a couple of telephone numbers that you could call to ask questions of Bonnie about Nurse Midwife programs. We have a couple of callers on the line right now. We'll get to the questions in just a moment. Remember the Twin Cities. Telephone number is 2 2 1 1 5 5 0 the toll-free telephone number for listeners outside the Twin Cities. But living with in Minnesota is 806 529700 and there are some lines open right now. We'll go to the first questioner and Bonnie. Put on the headphones and good afternoon. You're on the (00:14:24) air. Well, I'd like to know where I could get Care by a nurse Midwife in the Twin Cities. St. Okay. The group health plan has six nurse-midwives functioning currently. So if you're covered by that program, you can seek care in any of their clinics. I am helping the plan provide Care by being at Group Health Maplewood one day a week and two of our physicians are also there one day a week from st. Paul Ramsay. There's a program at the childbearing and child-rearing center of the University of Minnesota. There is a program at the Hennepin County Medical Center. And our program at Ramsey (00:14:58) so four locations in the Twin Cities. Now, I understand by way of the childbirth education Association that there are some nurse Midwife programs in other areas of the state. Is that (00:15:09) right? Jan quali is functioning with her husband in Long Prairie. Mmm, and I heard the other day that there were there might have been another person that joined the practice there in Central North Central Minnesota. There are some in northern Minnesota in the Eau Claire area in the La Crosse area. I'm sorry little color across area (00:15:30) and the childbirth education Association would be a source for that (00:15:33) information away. We have given information to the State Medical Society to so they would (00:15:36) have some we should mention that this discussion is taking place during healthy baby week as recognized by the Minneapolis City Health Department. So it's somewhat timely in that regard. Well, we have other callers on the line with more questions of nurse Midwife Bonnie stickles and we'll take the next one. Good afternoon. You're on the (00:15:51) air. Thank you. I'd like to ask Barney to comment about lay midwives and a home birth. I have assisted a number of friends of my birth. Some of them have been at home with a midwife and one was it a hospital with the nurse Midwife of birth in which the doctors took over and it really became a disaster. And also what I hear Some Scandinavian countries Denmark and other countries where all majority of their births are home births and the lady midwives work with doctors who are on call hear about mobile units that they have that are ready to, you know, come to the home. Should there be any need for him? And I just I guess would like have her comment about on that. Okay. I had the Good Fortune several years ago of having Margaret Myles being a guest in my home. She is if you will number one nurse Midwife in the United Kingdom and she was commenting about this fact that England has essentially had to move away from home births and home care because of the cost. This is something that we've looked into here in the Twin Cities to with the help of several Physicians and consumer groups and what have you in that trying to establish a backup system in a city like this where we have numerous hospitals the cost to the couple for a home service would be about double what What we can provide within the the institutions themselves. I hate the word institutions. I'm gonna call it my hospital. So we those of us in with in hospital settings have gone about setting up birthing rooms that can come as close as we can to a private home situation, but with be within access of a hospital facility that has the things that might be needed should a problem arise and can be taken care of quickly. I think I do not know that the majority of the births in Scandinavia are still at home because I have gotten the feeling from some Scandinavian nurse-midwives again that the cost is a problem (00:17:53) and that is assuming this that is that cost assumes I suppose that they must have the same level of care the same quality of care that a hospital would be able to (00:18:00) provide exactly especially in Scandinavian countries were socialized medicine. Yeah, (00:18:04) and I suppose part of the appeal of Home births is that they can forego some of the backup and thereby reduce their cost to some people are attracted to home births for that reason. I suppose we have other callers waiting and we'll The next question or good afternoon. You're on the air. (00:18:19) Thank you. I would like to know a little more about the main Midwife specifically. What is the legal status of a midwife practicing where can a person get training to become a Layman wife that good training and Dule midwives work with physicians in the state very much. Currently. There is a law still on the books here in Minnesota that did license Layman wives at the moment. There have been some attempts on the part of our group the nurse midwives and the Physicians through the State Medical Board to refine or update the relay Midwife law and to include the nurse Midwife in it currently, it's my understanding that the the bill that was recently presented has sort of gotten stuck in committee and may not find itself out again. So we may have to begin again next year on it. They're from my own personal knowledge there have been several physicians in the area who have acted as backup for the Layman wives in the area and have also conducted home births themselves. I've gotten the impression lately that I'm not at Liberty to mention those physician. So I don't think I'll get into that right now. There is a group in the city functioning in the new school of Family Birthing that is attempting to clarify the law and to figure out find out what the criteria are for licensure under it and they have also put together an education program and I think at the moment if I'm correct, they have either 8 or 10 students enrolled in the (00:19:56) program the new school for Family (00:19:57) Birthing, right? (00:19:59) I want to return for a moment to an issue. We talked about earlier Bonnie and that is the renewed interest in Midwifery and nurse Midwife programs. What do you think marks the beginning point for the renewed interest in nurse Midwife programs? Typically all the Care came from doctors and it took place in But also and would you say that it was about a decade ago that there was renewed interest. (00:20:22) Let's see, I would say it's probably going on a decade and a half by this point possibly even in some areas two decades by now. The thing that I think revived it in this area, we think the childbirth education people a great deal because they're consumer-oriented the the gist of the movement was that there as I say if I can use say an eighty twenty percent split 80% normal pregnant women twenty percent that get into some kind of difficulty those 80% began to say that if I'm going to pay for care. I want care that meets my individual needs and needs of a healthy woman having a healthy child that includes my family and in which I can feel comfortable ask questions to participate participate in care and just really know what's going on and feel like I'm in control of the situation The Physician is trained in it. He is an expert diagnostician and caregiver of the ill mother or the ill woman and that limits his time and it limits also his ability to pick up other courses like the nutrition course, we take an interpersonal skills and things like this family dynamics that leave him a little bit short and answering some of the questions and put him at a (00:21:33) disadvantage. When I ask you some of the reactions you get from the public when you tell them that you are a nurse Midwife and we'll get to that in a moment. But now we have a question from a caller and we'll get to that good afternoon. You're on the (00:21:45) air. Thank you. I just have a question about the qualifications to get into the nurse Midwife training program. You mentioned that a ba was necessary. Can you tell me more about why that's why that's necessary requirement. Just a for your nursing program here at the University of Minnesota as Kathleen was saying it is a degree program in that you have to have a bachelor's degree and then you get a masters degree on completion of the program. However, she was mentioning that there are basic programs around the country to where you may enter. Primarily at the moment with a three year nursing certificate and then you get a certificate in nursing. So it is not required that you have a degree. We realize that there are many people whose interests and talents lion being a staff person and this may not involve a degree. However, we would like to reward people for their educational efforts by trying to get them some credits toward a degree at least in our educational programs today (00:22:38) and that would be an alternative if somebody is prepared to move away from Minnesota because at least as far as we know or as far as you know, there is no program in Minnesota where a degree is not required. I was interested body and the reaction you get from the public what do people think generally of nurse midwives in this renewed interest. (00:22:57) Well, I had an interesting reaction last night. I was teaching a course in couples communication at Ramsey and a woman. I am helping with recurrent pregnancy said that somehow or another she was assigned to one of our physicians at Maplewood due to the fact that I just don't have enough time slots at the moment. To care for the ladies. I've got on my caseload because of the holiday times coming in here in a limited Clinic space and her reaction to it was that she was disappointed and upset that she had to see a physician how even though our physicians out there. I feel a Very Good Fellows and I'm enjoying working with him. Her husband's reaction. However was very interesting in that. He said oh, well, you'll get a thorough checkup and then you can go back to the nurse Midwife and she and I both decided stood there 100 for a few minutes. So there are still some misunderstanding amongst family and friends and husbands as to what we're all about it. But again, it's education we get them involved all the family members explain who we are what we are that the supposition readily available and whether training isn't things things settle down then (00:24:01) we have another question for you from a caller and we want to get to that before we run out of time a good afternoon. You're on the (00:24:06) air. Rice County we've got problems here with hospitals threatening to take away physician hospital privileges if they participate or work with midwives. I got that kind of problem to that. We're facing. Can you give some suggestions on how we can approach what the hospital or other groups to help us put a program together as you're seeing other groups usually are very helpful to you like childbirth education Association or the lychee League consumers that are actively involved in wanting quality care, but care of the woman who is assumed to be well until proven otherwise, so first of all, you certainly could go about mustering the support of the voters and the people who have money and that spend it in that community and will verbalize that the other thing you might do is certainly to write me a letter. I'm a national chairperson for our College the American College of nurse midwives for one year yet and I deal with these kind of Affairs issues the one assistance we have behind us now is that the Federal Trade Commission is looking into illegal Restraint of trade activities and we have been documenting and providing them with data in regard to hospital privileges being withheld insurance payments being withheld pressure being brought to bear on Physicians who are working when there's midwives and things like that so I can I might possibly be able to help you if you want to write to me directly at the hospital. (00:25:49) All right, and let's give people a chance to grab a pencil or pen and piece of paper so they can write down your address which will give in just a moment and I'm glad you brought up the issue of insurance payments because that's a question. My wife encouraged me to ask of you Bonnie and that is not all insurance companies will reimburse for maternity benefits. If a nurse Midwife has been consulted for carries that correct. That's (00:26:10) correct currently in the state of Minnesota right now. We are not being covered in Name by Blue Cross Blue Shield. Since we work directly with a physician in most cases in my case. Dr. Hawkinson is my chairman apartment. Their billing does go out as part of the group OB department at Ramsey and this helps a great deal. However, we're all very much concerned about the fact that there may be some legal difficulties about this. And so therefore we were trying to make inroads and getting hospital privileges which do indeed make us part of the medical staff and therefore the hospital can legitimately bill for us as a staff member and then I also am responsible for this kind of thing in the insurance area that I send out information to insurance companies. Tell them who we are what we are what we're doing and encourage them as part of the private enterprise system to seriously consider paying us. (00:27:04) That's a that's a serious question. We want to get your address now to the listeners who are interested. Your last name is spelled STI ckle s stickles Bonnie stickles and give them your address (00:27:14) st. Paul Ramsay Hospital. Department of OBGYN 640 Jackson Street St. Paul 5/5 101 (00:27:28) 55101 that's Department of Ob-Gyn right and there I have it all down. All right, that's Bonnie stickles nurse Midwife. We have another caller on the line who we'd like to have a chance to get to you with their question. Good afternoon. You're on the air. (00:27:48) I'd like to ask a nurse Midwife two episiotomies. And if they do what percent of first births are required this procedure, it's interesting question. We just compiled some information from around the country to take a look at our episiotomy rates of because we wanted to make sure that our rates are not getting to be out of line from what would be expected and I found in my area here that I'm running some place between a 20 to 22 percent rate of episiotomies, especially for first-time women. We try to work with the woman and her tissues and have a slow controlled delivery so that indeed the episiotomy met Is not a routine situation. However, it does depend on the area where in the tissue type the muscular structure things like this set that sometimes do not respond to massage and slow controlled deliveries. And I find our athletic ladies Minnesota. Sometimes have a superficial muscle problem that many times necessitates an (00:28:48) episiotomy. Meaning they get too much Ecker their body tone is so good. The muscles are just too tight. All right, let's conduct a little quiz here. Bonnie will see how good you are on your percentages that one question reminded me of a few other questions that many expectant fathers and mothers often have what is the approximate percentage of cesarean births in Minnesota (00:29:08) for my service at Ramsey? We run between an 8 and a 12% cesarean section rate depending on the nature of the women were working with at times. I get a demand from women from the maternal infant care project, which tend to be women who maybe have some dietary difficulties. Some other health difficulties and there that may put them at a greater risk for cesarean section. All (00:29:33) right. Now another question is part of our continuing quiz on percentages. What is the use of rate of use of forceps? And I'm sorry is it forceps not forceps. I'm thinking of the clamps yes forceps in (00:29:45) birth for my service itself. I have been running again depending on the nature of the the woman. I'm working with between let's say about a three and an 8% force of rate (00:29:59) considerably lower than in the past. Is that right? (00:30:03) Well my first year I was doing a little less well than that because again of the nature of the women that I was see mine has dropped off. I think they vastly just a little bit but from talking to my colleagues at the the percentages I'm giving are somewhat close to what we're seeing elsewhere. (00:30:20) All right. Well we have time for just one more question to you in a caller is on the line with us right now. Good afternoon. You're on the (00:30:25) air. Yeah, I'd like her to come. Little more about this Aryans. I hear that they're on the increase. I have a friend who is a nurse and she said that in Middle School school now doctors don't learn how to deliver a breech birth and non-typical birth except by cesarean and and I just like to comment on that data that has been able to be gathered now for a few years shows that by watching children who are born of a first-time first pregnant first time pregnant woman by the breech mechanism are running a greater risk of having some learning disabilities because the after coming hit is the largest portion of the infant and time may be lost in trying to successfully deliver this head through a pelvis. That was fine for the body but not too fine for the head the needs to get the child out May necessitate forceps and as skilled as a physician can be and is gentle and patient as he can be there can be some difficulties. What physician with the application of forceps and the mere fact that the head undergoes trauma in an untested pelvis the learning disabilities are something that we don't feel that we should saddle a couple with today. So many many places are going to cesarean section for a perm gravida breech delivery. (00:31:45) Thanks very much. Bonnie stickles nurse Midwife at st. Paul Ramsay for joining us today as part of midday. Thanks to all the listeners who called in with questions. We appreciate your attention and your good questions one listener did call Bonnie to notify us that in Long Prairie. Minnesota Susan block is a certified nurse Midwife and she works in a clinic Susan blocked us which serves Sauk Centre in the area around there. So that information from a listener.