Delivery of Care

From pioneer to recognized national leader, with midwives at the center

Midwifery program at Women & Infants Hospital celebrates 26 years of cultivating collaboration, with its team approach to inter-professional medical education

Photo by Richard Asinof

Elisabeth Howard, the director of the Midwifery Program at Women & Infants Hospital, a national leader in collaborative medical and clinical education.

Courtesy of Women & Infants Hospital

A nurse midwife provides instruction to a resident on birthing at Women & Infants Hospital.

Courtesy of Women & Infants Hospital

The Midwifery Program at Women & Infants Hospital promotes a collaborative, team-based approach to care delivery and medical education.

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By Richard Asinof
Posted 3/13/17
The Midwifery Program at Women & Infants Hospital, in partnership with the Warren Alpert Medical School at Brown University, has become a national leader in inter-professional medical education, with nurse midwives teaching medical students and residents in birthing. The collaborative approach recently celebrated its 26th anniversary.
Can the collaborative approach to medical education be replicated in other specialties? Will there be research undertaken in Rhode Island to quantify improvements in clinical outcomes correlated with such a collaborative approach? At a time when there is renewed competition between Lifespan and Care New England over market share of where newborns are delivered, does the midwifery program provide Care New England with a clinical advantage? How will efforts by Congressional Republicans to de-fund the women’s preventive health activities by Planned Parenthood change the delivery of health care in Rhode Island? Will the R.I. General Assembly be willing to fund the difference?
It was surprising to learn that the folks driving the State Innovation Model plan to transform health care delivery in Rhode Island, in looking at population health metrics for maternal and child health, had apparently not been in contact with the Midwifery Program at Women & Infants Hospital, who are very much on the front lines of clinical practice and education.
The apparent gulf between health policymakers and actual practitioners emerged as a key factor in the botched roll out of the $364 million Unified Health Infrastructure Project, with top administrators at the R.I. Executive Office of Health and Human Services ignoring what practitioners in the field were warning them.
The gap between investing in health vs. investing in health care delivery is very much at the nexus of the debate over the Republican plans to repeal and replace Obamacare.

PROVIDENCE – Giving birth is a primal experience where the connection between the mother and her medical team serves as a dynamic relationship of call and response, involving trust, communication, empathy, and listening and caring.

Who, then, would be better than nurse midwives to help train medical students and residents to facilitate patient care in birthing than certified nurse midwives?

It was a question asked and answered in 1990, when Diane Angelini, a certified nurse midwife, was hired to serve as the directory of midwifery in the Department of Obstetrics and Gynecology at Women & Infants Hospital by Dr. Donald Coustan, the chair of the department.

Together, Angelini and Coustan created a pioneering program in inter-professional education, a team approach where midwives served as instructors for medical students and residents in a variety of clinical areas, including labor and delivery and mother/baby care.

The midwifery program recently celebrated its 26th year anniversary. It has become a national model for innovations in medical education, and the model has been replicated at other medical school programs, including Vanderbilt and Duke.

In June, Elisabeth Howard, Ph.D., CNM, FACNM, the director of the program, and one of her colleagues, Linda Steinhardt, CNM, FNP-C, MS, will present a paper at the International Confederation of Midwives in June in Toronto on the success of the program at Women & Infants, entitled, “Cultivating Collaboration: A Sustainable Model for Inter-professional Education.”

“Different than other rotations, obstetrics is a more dynamic kind of specialty, in that it is a little bit unpredictable,” Howard explained in a recent conversation with ConvergenceRI. “There are a lot of different players – nurses, physicians, specialists. A medical student can get lost in that experience.”

What the midwives do, Howard continued, is to ground that experience for medical students, making it “more connected, more predictable.”

Here is the ConvergenceRI interview with Elisabeth Howard, the director of the Midwifery Department at Women & Infants Hospital, talking about building upon the legacy of a pioneering program that has become a national leader in collaborative medical education.

ConvergenceRI: How long have you been a member of the Midwifery Department at Women & Infants?
HOWARD:
I started 13 years ago.

I came here because of the work of the former director, Diane Angelini, who was someone I really wanted to work with. When the opportunity came up for a job here, I really jumped at it.

I knew about the model because the first physician I got to work with at a hospital, which had never before had nurse midwives as practitioners, had been trained here as a medical student by the midwives.

The physician welcomed me, and that was really important.

ConvergenceRI: Can you explain the model? How does it work? What makes it so significant?
HOWARD:
The way the program works has evolved over the years. The way it started, a midwife was hired, Diane Angelini, to teach medical students and help them with their experience on the labor and birth unit.

As you can imagine, it’s different than other rotations; obstetrics is more of a dynamic kind of specialty, in that it’s a little bit unpredictable.

Once the residents at that time got wind of what the midwives knew about normal birth and that the quality of teaching was really high, they started to demand [that the program be] extended to residency.

Diane built a practice of six midwives, and over the years, expanded the practice into the obstetric triage unit, the labor unit, as well as the mother-baby unit.

We work side-by-side with our physician colleagues. Our learners have grown over the years to include the ob students, the residents, and now family medicine residents.

ConvergenceRI: Now, the program has become a national model for innovation in medical education. Is that accurate?
HOWARD:
That is true. A lot of our physician colleagues actually trained here, either as medical students or more likely as residents. They stayed on and returned to Women & Infants Hospital because they were [attracted] to the supportive culture. Even our chair of the department, Dr. Maureen Phipps, was educated here as an OB resident, working with Diane Angelini.

ConvergenceRI: Are you invited to give talks about your work around the county?
HOWARD:
Yes. We talk quite a bit on how we developed this program.

Midwives are excellent observers of women in labor. But we’re also very meticulous observers of how people learn and what is normal for them.

What we do is to take some very complicated, amorphous types of things, such as labor management, and make it grounded and understandable, less ambiguous, for the learners.

We teach them, in the first year when they come in as residents, one very safe way of doing something, but then let them, in the next year, expand their perspective.

As they transition to the third and fourth year of residency, they have developed into someone who is actually our consultant, because they are the surgeons, they are the physicians, and we are not.

They respect our expertise in normal, and we in turn, respect their skills as surgeon and physician, someone we are very much interdependent on as a practitioner.

ConvergenceRI: It becomes an interesting transformation, to go from the learner to the co-equal, and the mutuality that is involved.
HOWARD:
Yes, they are someone we rely on for their knowledge and expertise.

What we have really enjoyed in working with residents, in particular, is that we get to see them grow in their profession, to become, say, a chief resident, to be literally running the hospital. They’re smart; they have incredible interpersonal skills, they know how to manage a very complicated health system.

To see that kind of professional and personal growth in one person in four years is really rewarding.

ConvergenceRI: How do the patients respond to all this? Are they aware of the team approach? Or, are they so wrapped up in delivering a baby that they may not be aware of the difference?
HOWARD:
I think that patients always appreciate having a midwife on the team. I don’t think they necessarily know what it means [in regard to] residents and medical students education.

When we are there, we are very much part of the team, taking care of the patient. The patient appreciates the skills that midwives bring to the birthing experience – a lot of labor support, a lot of anticipatory guidance – which is what they get in the obstetric triage unit and the mother baby unit.

ConvergenceRI: I recently attended a committee meeting of the State Innovation Model transformation project, which focused on integrating the population health model with maternal and child health metrics. Has anyone involved with SIM reached out to you as a practitioner?
HOWARD:
They haven’t. I find that interesting, because I have been one of the delegates to the national quality forum in efforts to reduce primary Cesarean births.

I am involved in a project on reducing primary Cesarean births in Rhode Island that is using outcomes data to drive better care. We have a lot of educational efforts in parallel to that effort.

ConvergenceRI: Can you explain the work?
HOWARD:
We are looking at the birth outcomes in women who have not yet had a baby. That’s a good solid metric, reported to the Joint Commission. It’s a metric across the country that has the biggest variation.

ConvergenceRI: What is that metric here in Rhode Island?
HOWARD:
At Women & Infants, we have one of the lowest Cesarean delivery rates. [The SIM folks] should be talking with us, if they are not already.

ConvergenceRI: What is the focus of the work with the mother and baby unit?
HOWARD:
We want to make sure that the mom and the baby are doing well as a family, that whatever feeding method the mom prefers, they are having success with that. And that they also have a plan for their family, with the [optimal] birthing interval, that allows the mom to replenish and nourish.

ConvergenceRI: What do you see as the challenges moving ahead? Having established a national model for medical education, where do you go from here?
HOWARD
: Looking ahead, the future is really bright. As midwives, we are quality conscious. Not just with teaching young physicians, but as members of the [medical] community. What we do is very evidence-based and helpful to improve the quality of care.

Our work is very collaborative now.

ConvergenceRI: You’ve talked about the importance of communications that happens between midwives and residents training to become doctors. Can you talk a bit about the importance of the interaction with nurses?
HOWARD:
Nurses are the most important part of the health care team. The nurses are the ones who take care of the patients, they are at the bedside. Physicians come in and out, with specific time points when they interact with the patient; the nurse has that repeated measures experience of noticing incremental changes in a patient’s status.

We all rely on the nurses’ place on the team. That being said, we work as a team.

On the team, there’s the nurse, there’s the midwife, there’s the attending physician of the day, there’s the chief resident, the first-year, second-year or third-year resident.

We rely a lot on the nurses’ judgment.

ConvergenceRI: What kinds of research would you like to see undertaken here in Rhode Island that would focus on the work that nurse midwives do?
HOWARD:
I think it would be interesting to look at the outcomes related to inter-professional teaching. What are the impacts that it has, not just on the way that physicians learn, but on the way that nurses learn, and how does that increase sensitivity to each other in understanding one another’s role.

I would like to see more research on specific outcomes around that.

ConvergenceRI: When and where is your paper on the midwifery program being presented?
HOWARD:
We are going to the International Confederation of Midwives in June in Toronto. We are presenting a paper on “cultivating coloration, a sustainable model for inter-professional education.”

Editor's Note: Dr. Jay O’Brien, Women  & Infants’ medical director of inpatient obstetrics, worked on the SIM Maternity Measures Group, according Amy Blustein, communications spokeswoman with Care New England.

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