PROVIDENCE – Business is booming, so to speak, when it comes to the practice of midwifery at Women and Infants Hospital. Four new midwives have been recruited to join the staff at the state’s premier maternity hospital, where more than three-quarters of all the births in Rhode Island occur.

Last week, Care New England celebrated National Midwifery Week, which ran from Sept. 29 through Oct. 5, an event created by the American College of Nurse-Midwives to celebrate and recognize midwives and midwife-led care.

“We’re experts in normal,” treating pregnancy as a typically healthy, positive life experience, one that the midwives try to optimize, said Elisabeth Howard, Ph.D., CNM, FACNM, Associate Professor of Obstetrics and Gynecology, Clinician Educator and Director of Midwifery, Women & Infants Hospital, in a 2016 interview with ConvergenceRI.

But, Howard continued, “We’re able to recognize when something’s not normal,” and then work collaboratively with obstetrical clinicians. Midwives not only deliver babies safely, with excellent outcomes, but also attend to the mother’s emotional and psychological needs, Howard said of her profession.

Busy being born
In the news release about National Midwifery Week, Howard retold the story of how the midwifery program at Women and Infants came into existence, a tale of dedication and persistence worth sharing.

“In 1975, Mary Dowd Struck, the former Chief Nursing Officer of Women and Infants Hospital [1976-2006], graduated from Columbia University’s midwifery program and came to Rhode Island, where she was told by the R.I. Department of Health that a midwife had not been licensed in [the state] since 1934, and that they did not have a mechanism in place and no interest in developing one.”

Howard continued: “Dowd began working with the Rhode Island Women’s Health Collective to make midwifery a viable option for women and families throughout the state. They joined together to conserve a traditional woman-centered birth option and to promote women’s health. The Collective was an outgrowth of the Boston Women’s Health Collective, which [had] published Our Bodies, Ourselves, in 1978.”

With the help of the Collective and Gov. Joseph Garrahy, Howard further explained, “The mechanism to practice midwifery in Rhode Island was put in place. Women and Infants Hospital then became the first hospital in Rhode Island to credential midwives. Midwives continued to work to pass state legislature measures in 1988 and 1990 expanding the scope of practice and authority of midwives. In 1993, a federal grant enabled the University of Rhode Island to open the first training program for nurse-midwives in the state.”

Today, there are approximately 27 midwives credentialed to practice at Women and Infants Hospital, serving clients both in the hospital’s Alternative Birthing Center and the Labor and Delivery Unit.

ConvergenceRI recently interviewed Linda Nanni, a certified nurse midwife who has been practicing in Rhode Island for 37 years, to talk not only about the past history but the challenges ahead for the practice of midwifery. Nanni had just finished a busy shift.

ConvergenceRI: Where will the next generation of midwives come from?
NANNI: Rhode Island is very attractive place to work for a midwife. It’s a well-accepted, established part of women’s health here. There is a very good practice law from the state of Rhode Island. And we now have three very established practices at Women and Infants.

This year, we expanded our services and hired four new midwives, attracting young, bright, talented women from all over the country, from Colorado, New York and Tennessee.

Midwives in this new generation are willing to move around and relocate fairly easily.

I have been in this job long enough and done a lot of recruiting. Thirty years ago, you had to have some connection with Rhode Island before you would move here. Not anymore.

I think Rhode Island has gotten on the map nationally; Providence is a very exciting small city to live in. It’s close to New York and Boston.

ConvergenceRI: What are the traditions for honoring midwives for their service in Rhode Island?
NANNI: Well, there are fewer than I think there should be. National Midwifery Week is one of them. Rhode Island Monthly, in addition to doing a Top Docs issue, now does a Top Nurses issue, and there is now a subcategory of midwives. I was honored two years ago.

ConvergenceRI: Earlier this year, there was a gathering in front of Women and Infants, a Black Moms Matter rally. Did you participate in that?
NANNI: Not in the actual rally. I knew it was going on and I was very supportive. Since then, we have had many internal meetings about how we could do a better job in support of women of color. It prompted a lot of good reaction from the administration within the hospital. I know that the heads of Care New England and the Care New England Medical Group met with the leaders of the Black Lives Matter group to talk about what specifically we could do at Women and Infants.

ConvergenceRI: Has there been any follow up as a result of the rally and those meetings?
NANNI: There is now a director of diversity and we have had several grand rounds to talk about diversity. There has also been a number of workshops about becoming more aware how we as providers could be more aware.

ConvergenceRI: Providence has become involved in promoting the work of doulas, particularly for women of color. Is there a collaborative nature of work between midwives and doulas?
NANNI: Midwives and doulas have always worked together to help women through their labor and birth. In fact, I had a birth today where a lovely doula worked with me with this first-time mom.  There is a lot to do to help a woman go through labor, particularly with an un-medicated labor.

Doulas are trying to get recognition from insurance companies to be able to be reimbursed. There are many, many underprivileged women who could do really well with the services of a doula.

We have an active state affiliate of the American College of Nurse Midwives, and we had a lobbyist working on that bill for them, trying to get it through [the R.I. General Assembly].

ConvergenceRI: A retired pediatrician has often prompted me to ask: Why hasn’t Rhode Island adopted the Centering Pregnancy program?
NANNI: You know, that is an interesting question. Because, I would say, about eight years ago, our practice [Women’s Care] was very interested and excited about the idea of having a centering pregnancy program. We actually got a grant from the March of Dimes, who was, at that time, being supportive of getting a centering pregnancy program off the ground here in Rhode Island.

We really tried to do it at our practice, but we found it very difficult to get people to come to one place and to have the women mesh together. Because we had such a diverse group of women, some had kids, some couldn’t come at certain times, some liked nights, some liked days, and we just found it very difficult to do it pragmatically. We did try.

ConvergenceRI: There are two large, I don’t know if “competing” is the right word, but two large ob-gyn practices that are aligned as physician practices, one at Lifespan, the other at Care New England. How do the different practices interact? Is it collaborative? The reports I have heard is that on the ground floor, everyone gets along, but that they may not get along well on the higher corporate floor.
NANNI: [laughing] For midwifery services, I direct the one from Care New England. And there is the Lifespan practice; we are the two largest midwifery services in the state. We all get along as midwives. There is nothing adversarial about us. We take care of the same pool of women.

Women have a choice to make about whom they see, and they make that choice. We’re just happy to have the women being exposed to midwifery. So, if you want to go to that service, because there is something about that service that appeals to you more, great. And likewise, if you want to come to our service, for the same reasons, great.

And that’s where it stands on the level of midwifery. The corporate thing is another matter.

I am sure you know now that there is talk of a merger between Care New England and Lifespan. We are all looking forward to see how that might impact our service, but that is years away.

Now, everybody is working together to try and create a new entity to serve the people of Rhode Island.

ConvergenceRI: What are the long-term trends and challenges for improving the quality of care around women giving birth in Rhode Island?
NANNI: One thing we have gotten some traction on over the years is how to make Women and Infants a better place. It does an excellent job for high-risk pregnancies. But there was concern about losing the ability to attract women who were potentially normal physiologic births.

Since the beginning of the “new building” in 1986, there was an alternative birthing center, and it was a very special place that was promoted by a community group, the Rhode Island Women’s Health Collective. The R.I. Department of Health put that in the certificate of need for the new building. Women were able to have low-tech, normal physiologic births.

But, slowly, over the years, that concept has eroded. As midwives, we are always seeking these options for women, and we make it work, and we get it to happen. But it’s happening on less of a scale.

I think there are less women who are looking for that option today, and more women looking for the option with no pain. We in the midwifery community at Women and Infants have kicked and screamed and fought to keep this option available.

Before the rug got pulled out over the financial situation, we had a lot of meetings about how the labor and delivery unit, including the birthing center, was going to be physically changed. Our thinking was, if you change the physical environment, the culture will change.

ConvergenceRI: Yet, you seem to be expanding midwifery services at Care New England.
NANNI: Yes, we are involved in many more births than we were just a year or two ago. Care New England is supportive of our work. Once women come to the labor floor, if they are low risk, they are first-line managed by midwives. So we have midwives working as laborists. We manage the low-risk labors.

We think we are doing an excellent job of providing care for these women. We think we are decreasing the interventions, both epidural and caesarian. We are promoting vaginal births after caesarian births, and having success at that.

For me, with over 35 years of working here, I know what I can offer women. We just do our thing, because what we do best is one-on-one, taking care of women in labor and birth. Midwifery is an integral part of good obstetrical care, and we have a lot to offer. And the results are better outcomes. And it matters.