In 1985, five students became the first class of Certified Nurse Midwives (CNMs) to graduate from Case Western Reserve University when they earned Master of Science in Nursing – Midwifery degrees from the Frances Payne Bolton (FPB) School of Nursing.

Thirty-five years later, as the world celebrates National Midwifery Week (Oct. 4-10) and recognizes 2020 as the Year of the Nurse and Midwife, Shellie Hawk and Char Frires, two of the university’s original graduates, share their reflections on midwifery and the changes they’ve seen, and offer advice for nurses interested in pursuing midwifery.

When she was starting out in practice, patients told Hawk they chose a midwife because they were looking for a more natural birth plan. While patients still seek out midwives for that reason—though less than one may think-—now it’s more often for the type of care midwives provide.

“I think they choose us because we’re different. Midwives spend more time with patients and provide a different kind of care than what may be found in a traditional hospital experience,” Hawk said. “You don’t get lesser care, it’s the way midwives provide the care that’s different.”

Hawk is still as satisfied with her career as she was in 1985, but notes that the patients have changed.

Photo of five students sitting around a conference table
Nurse – midwifery students (prior to COVID-19)

“The acuity of the patients is much higher today than it was 35 years ago,” she said. “People seem to be sicker. There are more occurrences of high blood pressure, obesity and preeclampsia.”

For students considering pursuing a career in midwifery, Frires considers midwifery to be a welcoming community.

“FPB has a wonderful program and the community of Northeast Ohio midwives is deeply honoring of one another and our students,” she said.

But midwifery is incredibly hard work, and Frires said the downside includes long hours, state-imposed restrictions on practice and fighting old stereotypes.

[It’s tiring] explaining for the 10,000th time that I do not ride in on horseback to home births,” she said.

Mary Franklin, director of the Nurse Midwifery and Women’s Health Nurse Practitioner programs at the school of nursing, said beneficial changes in health care have occurred since midwifery began at the school, including the move to more standardized, evidence-based practice; expansion of reproductive health services covered under the Affordable Care Act; and recognition that midwifery care improves outcomes.

Franklin, a triple alumna of the school of nursing, says challenges facing midwifery are interrelated. Many states impose restrictions on the scope of practice for CNMs, and the varied pathways into midwifery, in both education and licensing, are confusing for patients and health care providers.

Of the 3,791,712 births recorded in the United States in 2018, CNMs attended almost 10%, according to the most recent data available from the National Vital Statistics Reports from the Centers for Disease Control and Prevention.

For the past 18 years, the nursing profession has been ranked the most trusted by U.S. adults in a Gallup survey, with honesty and ethics being top indicators. That strong relationship between nurses and patients, Hawk said, is the same for CNMs, but often that relationship is longer.

“Often a CNM has a long-term relationship with a family,” Frires said. “But just as often, we have to create that relationship on the spot and get very intimate, very quickly. RNs do this all day and all night. The team is integral … The rapport among team members and the families is what keeps us coming back for more.”

Franklin, Frires and Hawk agree that an interprofessional team is an asset midwifery care and general health care.

Five CWRU students pose for a photo
Current nurse – midwifery students (prior to COVID-19)

“It is important to discuss how the various roles in the health care team work together, rather than pointing out differences. All members of the health care team—physicians, midwives, other advanced practice nurses, nurses, doulas, therapists, etc.—have a role to play in providing the patients with the best care,” Franklin said.

Hawk, whose medical group includes 10 nurse midwives, has seen a shift in health care teams and the use of midwives from when she first started in the field.

“When I started practicing in Texas, I was working at the indigent hospital. We didn’t have a private practice of midwives; a lot of people saw us as serving the underserved but that is changing dramatically,” she said. “I think now our physician partners see us as a very valuable part of the team. We back each other up. Sometimes a physician’s patient is ready to deliver but their obstetrician is in surgery, so we step in and help their patients.”

Hawk’s group delivers more than 700 babies a year.

“It is not a choice for patients for midwives over obstetricians, but rather being cared for in a system of midwives and physicians or just physicians,” Franklin said. “In a system where midwives and physicians are on the care team, patients can benefit from the expertise of both.”

Within midwifery education, Franklin said there is a push for more midwives of color, something very much in need. 

“In the U.S. in general, the community CNMs serve is disproportionately represented by women of color, while the midwifery workforce consists overwhelmingly of older white females,” she said.

After spending the first seven years of her practice at a birth center, Frires shifted her practice to the inner city to work with teens and at-risk moms.

“There are so many ways to be a midwife,” she said. “I had a solo menopause practice for a year, and I loved being an NP in the fertility department for four years.”

After concluding her career in a large health system setting, Frires observed that some aspects of birth have become more medicalized while neonatal morbidity and mortality has increased.

“Cleveland is one of the highest centers in the nation for racial disparity in this regard,” she said. “The challenges remain: root out racism in our medical communities, re-establish community birth centers and doula programs, pass legislation that supports birth workers at all levels. Maternity care is the gateway to the rest of the system.”

The next generation of CNMs needs more diversity and more leaders, Franklin said.

“Midwifery as a profession needs pioneers and those willing to lead the way for full practice authority and the removal of other barriers to quality care for patients,” she said.

For Franklin, the best part about being a midwife is being able to improve a patient’s quality of life over time.

“It’s a privilege to be able to facilitate someone’s ability to achieve their reproductive health goals, achieving pregnancy when they want a baby and preventing pregnancy when that is the goal,” she said. “Midwives facilitate a woman’s experience through the birth process in a way that empowers her and starts her off on the path of confident parenthood.”

Hawk said midwifery can’t be just a job.

“When I was in school, students saw nursing as a calling. To care for patients was more than just a job,” she said. “If you’re going to become a midwife, a nurse practitioner or advanced practice nurse, I would hope students see it more as just than a 9-to-5. If you want to become a midwife it’s more than just catching a baby. There is a skill to this job.”