Michelle Djevharian, CNM, and Cheung Kim, MD

Nurse-Midwife and OBGYN Partnership Offers Best of Both Worlds

By on 02/28/2020

Hear the word “midwife,” and you might picture a woman delivering a squalling infant in a cabin on the prairie (probably in a snowstorm), or perhaps in a humble London flat (if you’re a fan of PBS’s Call the Midwife).

But these days a midwife birth is more likely to happen somewhere like the second-floor Labor & Delivery Unit at Einstein Medical Center Montgomery.

There, Michelle Djevharian, CNM, is one of five nurse-midwives on staff who are part of an innovative collaboration that delivers more than 2,000 babies a year. The team includes nurses, as well as both staff and private-practice obstetricians and nurse-midwives.

“People assume that midwives just deliver babies at home and that’s just not true,” says Djevharian.

In fact, 94% of all midwife-attended births occur in hospitals, according to the American College of Nurse Midwives.

Besides staff members, who are employed by Einstein, nurse-midwives from four local practices attend births at Einstein Montgomery. They are drawn by its welcoming attitude and patient-centered team approach to childbirth.

“The collaborative relationship between the midwives, doctors and nurses at Einstein is really lovely,” says Jennyfer Floyd, CNM, of WomenWise Midwifery in East Norriton. “It is really unusual. We’re like a unicorn, especially in this area. The hospital understands the benefit of midwifery and uses it to its full potential.”

Better Outcomes With Midwives

And with good reason, notes Cheung Kim, MD, chief of obstetrics and gynecology at Einstein Montgomery: The science supporting nurse-midwifery is overwhelming.

Study after study, he points out, shows that the low-intervention approach midwives take to childbirth produces the best outcomes: for mothers, babies, and the bottom line.

“One of our goals was to reduce our C-section rate,” he explains.  About one-third of all births nationwide are cesarean sections. While a cesarean can be lifesaving, it’s also associated with increased health risks to both mother and newborn and may boost health care costs by one-third.   

That’s why Einstein Montgomery became one of the first medical centers in the United States to join the Healthy Birth Initiative: Reducing Primary Cesareans Project. This national program was launched in 2015 by the American College of Nurse-Midwives to provide evidence-based tools to curb unnecessary C-sections.

One of those evidence-based tools, says Dr. Kim, turns out to be midwifery.

Low-Tech Approach

Integrating midwives into hospital childbirth can help reduce the use of invasive technologies that can often lead to unnecessary C-sections and may not improve the health and safety of mothers and newborns.

A study by researchers in Canada and the United States showed that in states where patients had access to midwives in all settings — private practice, medical centers, and for home births — there were:

  • significantly lower rates of C-section, preterm birth and low-birth-weight infants
  • far lower rates of infant death
  • higher rates of vaginal births, including vaginal births after C-section
  • higher rates of breastfeeding at birth and six months after birth.

The online journal PLoSOne published the study in 2018.

Midwives generally work with low-risk patients. Unlike doctors, they don’t use invasive technologies such as constant monitoring during labor, which can lead to unnecessary C-sections.

Other studies are confirming the value of the low-tech approach. A 2006 independent review of evidence by the Cochrane Collaboration found that constant monitoring doesn’t result in any significant differences in rates of cerebral palsy, infant mortality, or other measures of a newborn’s health.

On the other hand, deliveries with constant monitoring had a higher rate of C-sections and vaginal deliveries with forceps. The review was based on 12 studies involving more than 37,000 women.

Trusting Nature, Most of the Time

At one time, women became midwives by apprenticing with another midwife. Today, they are often highly educated. Most are certified nurse midwives (CNM), who are registered nurses with an advanced degree in midwifery.

One difference between midwives and obstetricians is their philosophical approach to childbirth.

“In medical school, doctors learn all the things that can go wrong, then they learn how to do a normal birth. Midwives learn about normal birth and then learn about all the things that can go wrong,” says Djevharian.

Midwives are less likely to intervene if labor is moving slowly or stalls out — a leading impetus for doctors to perform a C-section in the United States.

“Midwives are good at waiting, at letting nature take its course,” says Djevharian. “Of course, things don’t always go the way you expect, so it’s good to have an excellent surgeon you can call on. It’s the best of both worlds.”

While it’s tempting to assume that two professions that appear to be in competition might be at odds, that’s not the case at Einstein Montgomery. 

Cooperation and Consistency

“We didn’t want any barriers and lanes people didn’t cross,” says Dr. Kim. “We wanted to create a cooperative, collegial relationship. We wanted a homogeneous department with unified policies and principles for all groups.”

Consequently, there’s not such a strict division of labor or hierarchy on the labor and delivery floor. Everyone who works there, including the private practice OBs and independent midwives, is part of the team.

They’re all bound by policies that follow science-based best practices, including many of the methods nurse-midwives have been using for many years.

For example, for slow labor the front-line remedy is for a woman to perform specific movements using a birth ball, rather than receive the synthetic hormone Pitocin to speed things up.

Fetal monitors are portable or used only at intervals rather than continuously. This allows laboring women to walk around, even take showers, to help stimulate contractions. Nitrous oxide is also available for pain relief as an option instead of an epidural, which can slow labor.

“We support the nurse-midwives’ philosophy that things are normal until they’re not,” says Dr. Kim.

At Einstein Montgomery, no matter what kind of birth plan a patient has chosen — going the midwife route or the more traditional doctor-assisted birth — chances are good that she’ll encounter everyone at some point.

All Part of the Team

Team members talk, seek advice from one another, cover for one another, and meet each other’s patients. A nocturnist — an OBGYN who works at night — is available Sunday, Monday and Tuesday, and she’s spelled the rest of the time by a rotation of doctors.  Midwives are on duty for 12-hour shifts, seven days a week. A laborist — a midwife, like Djevharian, who handles labor and deliveries — is available day and night.

Nursing director Melissa Hewitt, MSN, who came to Einstein Montgomery five years ago, says this is the first time in her career she’s worked with midwives—and the first time she’s seen this unusual team approach to maternity care. She likes it.

“It really is a team,” says Hewitt, who oversees the labor and delivery nursing staff and nurse midwives. “The OBGYNs really see the midwives as integral in the care. They don’t treat them as their helpers, they treat them as their colleagues, and they rely on their input.”

The respect, trust, and regard go both ways. Floyd says the doctors support midwives’ autonomy but are always willing to collaborate with them and provide seamless care when necessary.

“Even when my private clients unexpectedly need to interact with the physicians,” she says, “they report feeling supported and safe because they can tell we all work well together.”

Skeptics Now Supporters

Even physicians who were a little leery when the changes were in progress are now on board.

“I was not a very big fan of midwives, but now I am,” says Dominick Giuffrida, DO, of East Norriton Women’s Health Care.

“I like the relationship of doctors and midwives working together,” Dr. Giuffrida says. “I trust their opinion and feel confident in their abilities. We communicate together, lay out management plans ahead of time, and we’re all speaking the same language, so it creates less confusion when talking to the patient.

“We can take our time and see more patients when a midwife is in the rotation. If I have to run to a consultation, I can do it because the midwife is there.

“I like it so much,” he admits, “that I added a midwife to my own office.”

Of course the proof is in the results.  “The collaborative relationship between doctors and nurse-midwives has contributed to the safety of delivery at this hospital, which is in the top 5% in the country for low mortality and high satisfaction,” says Dr. Kim.

At 17%, Einstein Montgomery’s C-section rate is the lowest in the region. It’s even lower than the target of 23.9% set by a panel of experts for Leapfrog, a national nonprofit that collects, reports and assesses data on hospital performance. These figures refer to cesareans among first-time mothers giving birth to a single full-term baby with the head pointing down.

Dr.  Kim credits the success of the Einstein program not just to the team, but to its individual members. “You can put a program in place, but the ingredients — the people — are what makes it successful.”

“We really do have team chemistry,” he says. “Everyone realizes that — doctors, nurses, midwives — we’re all pulling in the same direction.”

Learn more about Einstein Obstetrics Services.

Photo: Michelle Djevharian, CNM, and Cheung Kim, MD

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