More Nurse Midwives Filling Gap as Obstetricians Decline in Numbers : Medicine: About 4,500 are now practicing in rural areas and poorer states and 250 more are certified every year.

When Barbara Hubbell was pregnant with her first child, Tiffany, she says her obstetrician treated her “more like a number than a person.” His busy big-city office was cold and antiseptic and his nurses scowled at her Medicaid card.

She couldn’t find another obstetrician closer than 40 minutes from her mountain farm.

“It was so frustrating,” Hubbell said. “It was hard finding a doctor and then they think, ‘Well, do I really have to give this (Medicaid) person the same treatment as everyone else?’ It makes you feel pretty low.”

So when Timothy was due about a year and a half later, Hubbell decided to seek out a nurse midwife. She said the midwife’s warmth and kindness made her feel like she hadn’t left home.

“Midwives treat you like you’re a person, like you have feelings,” Hubbell said. “They’re women who have had babies. They know what you’re going through and they treat you, well, like you matter.”

Hubbell chose midwifery in part because of the shrinking pool of physicians who deliver babies, especially in poor, rural areas.

West Virginia, for example, has lost more than 150 obstetricians since 1989. Only 70 physicians still practice obstetrics in the state, which has about 1.7 million people.

The situation is mirrored in other poor states, such as Mississippi and Arkansas, said Ken Pittman of the Mississippi Department of Health.

“We’re standing on the edge of a cliff,” Pittman said. “It’s basically a burned-out situation. In rural areas, the physicians are so overworked there could easily be a collapse of the whole system.”

The average rural physician delivers about 250 babies a year, Pittman said. The others must pitch in when one quits, causing more overwork and more dropouts.

The problem will worsen as more general practitioners stop practicing obstetrics because of the high cost of malpractice insurance, said George Rider, executive director of the West Virginia Medical Assn.

A growing number of nurse midwives will help by handling uncomplicated births, said nurse midwife Martha Cook of Barboursville.

About 4,500 nurse midwives practice in the United States and about 250 more are certified every year, according to the American College of Nurse Midwives of Washington, D.C., which sets professional standards.

Nurse midwives are formally schooled in nursing with a concentration in prenatal and postnatal care and managing births. They are required by law in all states to call on physicians in emergencies.

Nurse midwives and obstetricians work together. The doctor gives professional advice and handles emergencies, such as a newborn who doesn’t breathe. The midwife helps healthy women deliver.

“Midwives are experts in the ‘normal,’ ” Cook said. “Physicians have much more medical experience and may consider themselves experts in the ‘abnormal.’ ”

“I’m not saying we’re all starry-eyed ‘We-can-have-this-baby-in-the-ocean’ kind of folk,” said Julia Ludwig of Barboursville, a nurse midwife. “We’re safety-minded. Our main priority is the safety of the mother.”

Nurse midwives carefully screen mothers so they avoid high-risk pregnancies, such as multiple births or abnormalities requiring Cesarean delivery. They will provide prenatal and postnatal care for these women, but the deliveries are attended by obstetricians.

The American Medical Assn. considers births at home or in alternative birthing centers without staff physicians dangerous, said spokeswoman Kate Ruddon. But about 85% of all nurse midwife-attended births are in hospitals and are approved by the organization, she said.

The AMA and many nurse midwives and physicians frown on lay midwives who typically deliver babies in private homes, without access to medical equipment. Lay midwives are not trained and certified as nurse midwives are, Cook said.

Some overworked physicians have been recruiting nurse midwives to share their practices, Pittman said.

“Obstetricians have always been reluctant to use nurse midwives because they felt they’d be held liable for them,” Pittman said. “Now, with nurse midwives carrying their own liability insurance, there’s been a change in attitude. Nurse midwives are in demand.”

But, he said, there are still relatively few nurse midwives to recruit.

Using grant money from the Robert Wood Johnson Foundation, West Virginia is paying tuition and living expenses of nurse midwifery students, said Brian Loshbaugh, a nurse practitioner who coordinates the program that administers the funds. In exchange, the graduates are obligated to practice nurse midwifery in the state for three years.

Besides West Virginia, the foundation targeted Alabama, Arkansas, Mississippi, New Jersey and Puerto Rico to receive grants to improve maternal and child care services, said spokeswoman Amy Mone.

Its Healthy Starts program administers up to $1.2 million over four years to each of the states.

West Virginia is the only state using the money for midwifery training, Mone said.

“This is definitely alleviating the under-staffing problem,” Loshbaugh said. “It’s not that physicians will be supplanted. But nurse midwives give cost-effective sensitive caring and are able to reach people who can’t reach doctors.”

Many nurse midwives accept major health insurance and can work with health maintenance organizations. Cook said most of her clients receive Medicaid.

“It’s such a good step that one small, poor state has taken,” Ludwig said of West Virginia’s midwifery program.

“Motherhood and apple pie are the epitome of what’s American, yet there are no dollars spent on it in terms of funding for access to prenatal care,” Ludwig said. “The health of women bearing the next generation of society should be a priority.”