Nurse midwives find area hospitals unfriendly

Friday, April 13, 2001 | 3:32 a.m.

Specialized medical professionals who are licensed by the state to deliver babies say they are having difficulty gaining privileges to work in Southern Nevada hospitals.

Certified nurse-midwives are perhaps the most misunderstood health care specialists. They are registered nurses who are affiliated with obstetrician/gynecologists, certified by a national association and licensed by the State Board of Nursing to provide gynecological services, prenatal care and normal delivery.

But only two local hospitals, University Medical Center in Las Vegas and Lake Mead Hospital Medical Center in North Las Vegas, allow these practitioners to assist in deliveries.

Certified nurse-midwife Sally Eakerns, chairwoman of the state chapter of the certification association American College of Nurse-Midwives, described efforts to gain privileges at the other hospitals as "a big political football."

"Anytime it goes before their OB/GYN departments, they usually vote against it," Eakerns said. "Some of their departments of anesthesiology don't want to give our patients anesthetics. They may choose not to work with us out of fear of being responsible for us, which they're not.

"I'm not in a fight with them. I just want to practice the way I was trained to practice, but in this town we cannot do that."

Hospital representatives gave various reasons for their positions. At Sunrise Hospital and Medical Center, spokeswoman Ann Lynch said there is not enough demand for the delivery services that nurse-midwives provide. Also, many births at Sunrise are considered high-risk and too complicated for nurse-midwives to handle.

"We have 450 to 500 deliveries a month, and so far we've not had any problems," Lynch said. "We have 120 OB/GYNs on our staff. We've never needed anybody else. We've been able to meet the demands of our patients."

St. Rose Dominican Hospital in Henderson granted delivery privileges to a nurse-midwife, but that individual is no longer affiliated with the hospital. St. Rose spokeswoman Shauna Walch said a nurse-midwife would have to be sponsored by a physician affiliated with that hospital, but did not know why such affiliations don't exist there now.

Mike Tymczyn, marketing director of Valley Health System, which owns Valley Hospital and Medical Center, Desert Springs Hospital and Summerlin Hospital Medical Center, said the decision to deny privileges was made by each hospital.

"Valley Health System has not extended credentials to nurse-midwives because the boards of the three hospitals do not recognize midwifery care in their medical classifications," he said.

"We have hundreds of OB/GYNs on our staffs and these physicians are of the highest level of talent available. To offer credentials to anyone of lesser experience or with a lesser degree of services wouldn't make sense to us. The physicians we have are certified to handle any emergency situation that comes up."

Lack of access is not confined to Las Vegas. Portland's Oregonian newspaper reported that a nurse-midwife sued the medical community in Roseburg, Ore., because she cannot get physicians to back her in that city.

But certified nurse-midwives Angela DeTie and Patricia Waters of Las Vegas said Nevada has few such licensed practitioners -- 14 to be exact -- largely because hospital resistance make it hard for them to offer a full range of services. They said they lose many patients who want to have their babies at hospitals other than UMC or Lake Mead.

"It's patient choice," DeTie said. "A lot of patients want to go to the newest places to deliver. Some people see UMC as a county hospital and give it a negative connotation. And Lake Mead is in the middle of North Las Vegas, far away from where many of them live."

According to 1998 figures -- the latest available -- certified nurse-midwives delivered 1,408 of the 28,699 babies born in Nevada, the Journal of Midwifery & Women's Health reported. But that represented only 4.9 percent, well below the 7 percent national average that year. Among vaginal births, Nevada nurse-midwives participated in 6.3 percent -- 50 percent below the national average of 9 percent.

"There are few physicians here who are willing to work with us in a collaborative relationship," Waters said. "Medicine in this town is very political, and the medical community in this town is tight-knit and closed."

But one physician with high praise for nurse-midwives is Dr. Donald Roberts, a UMC specialist in maternal fetal medicine. He has established a working relationship with five nurse-midwives, which means he has agreed to take over their patients who develop health-related complications or are expected to have high-risk deliveries.

"I feel that there are not enough certified nurse-midwives in this city," Roberts said. "They are a valuable adjunct to obstetrical health care."

But Roberts said he thinks one reason hospitals deny privileges to nurse-midwives is a fear among physicians that their malpractice insurance will increase if they affiliate with a midwife. Upholding the "image of the hospital" may be another reason, he said.

Image

Midwives have always been part of the nation's health care landscape. But Waters said that by the time medical schools emerged by the end of the 19th century, midwives were portrayed as uneducated "drunken prostitutes" and their competency was questioned.

That negative image was reinforced in the 1960s during the anti-establishment era when many women opted to have their babies at home. "It was seen as part of the hippie movement," Waters said.

To the extent that the negative image still exists is unfair to certified nurse-practitioners because they hold college degrees and received classroom instruction in midwifery, DeTie and Waters said. The two have a combined 30 years of experience as registered nurses.

"What we offer is personalized care," DeTie said. "If a woman gets common pregnancy discomfort, she may hear from a physician that it's normal. But from a midwife she might get an explanation for why that is occurring."

Fees charged by certified nurse-midwives are often lower than physicians' partly because the former do not rely as heavily on scanners and other hospital equipment.

Waters said some health insurance plans will not cover work performed by nurse-midwives -- another reason it's hard for them to keep patients.

"The insurance may only cover part of what a midwife does," Waters said. "It may cover family planning and Pap smears, but not delivery. The insurance problem for midwives is a national issue."

Few midwives

Part of the confusion about midwives is that it remains legal to perform that function in Nevada without formal education, licensing, certification or contractual relationship with a physician. There are an estimated 15 direct-entry, or lay midwives, who practice in Nevada under that category. Nearly all of their deliveries are at the home of the patient or a relative.

But Margie Dacko of Las Vegas, one of those midwives, said voluntary certification is available through the Midwives Alliance of North America. Dacko, president of the affiliated Nevada Midwives Association, also said that she and most other direct-entry midwives in Nevada have informal relationships with physicians who will take their high-risk clients.

"No doctors want to have contracts with direct-entry midwives because there is peer pressure against the doctors doing this," Dacko said. "But I've never had a client turned away by a physician."

Roberts, however, said he believes direct-entry midwives ought to be regulated by the state.

"We are unfortunately one of the few states that allows lay midwives to practice without supervision," he said.

Waters and DeTie said there are roles for both physicians and midwives in reducing the number of pregnant women with little or no prenatal care.

According to 1998 figures, Nevada ranked 48th among the 50 states because 7 percent of its births are to women with little or no prenatal care. That was almost double the national average of 3.9 percent, according to a study by the nonprofit Child Trends of Washington and Annie E. Casey Foundation of Baltimore.

But for every physician such as Roberts who is willing to affiliate with nurse-midwives, there are others who want nothing to do with the profession.

"There are only 34 midwifery programs affiliated with medical schools so a lot of physicians don't have any idea what a nurse-midwife can do unless they went to a school with a midwife program," Eakerns said.

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