Interview with Dr. Susan Heinz on Becoming a Nurse-Midwife

NPSchools.com: How does the role of a nurse-midwife differ in a hospital versus a birth center setting?

Dr. Heinz: Nurse-midwives in a hospital are employees of the hospital, and [they] generally work in co-management—a co-working responsibility with an obstetrician.

Birth centers are the domain of the midwife. Midwives work independently. Obviously, we have to have referral sources and we work under criteria, but we work much more independently…[as] the sole responsible providers for the women that we take care of. I think that’s one of the biggest differences.

I also think it’s a difference of just setting in general, in terms of relationship with the families, relationship with the community. It is different than when you’re in a hospital-based practice where it’s really about hospital protocol and the development of programs. So I think [working in a birth center is] a much more community-focused practice and more independent.

Birth centers are regulated by state rules; we are a state-licensed facility, so we do have limitations. My birth center is nationally accredited by the Commission for Accreditation of Birth Centers, which is a national organization, and so there are oversights, which is really just about being sure that there is a certain quality of care that is provided to clients.

[Something] specific to my birth center—but I think to most birth centers that are staffed by nurse-midwives—is that we’re also nurse practitioners. Our scope of practice is a little bit broader and we do more extended care: care of babies after birth, and wellness and gynecology services as well. While hospital-based midwives may do that, that is really a focus of our practice.

And that actually brings me to another thought: one of the biggest differences—and I was part of a hospital-based practice for years before I opened the birth center—is that in a hospital-based practice, almost always, the nurse-midwife is responsible for the woman in labor and the fetus.

But once the baby is out, the baby is no longer part of her domain. That becomes part of the pediatric practice at the hospital, whereas at the birth center, we care for the baby after birth as well, and generally do extended care. We do all the newborn screenings and home visits, and all the monitoring and support of the neonate and the mom.

NPSchools.com: Would you say that in the hospital setting the scope of the midwife may be more limited?

Dr. Heinz: It’s different. In the hospital, the nurse-midwife is also doing things like inductions; she’s managing and caring for women whose labors are being induced. She may be caring for women that are in a higher risk category than at a birth center.

[It] really does require that someone remain low-risk in order to continue to be in the practice and birth at the birth center. In the hospital, because there is more of a co-management style where obstetricians are involved, there may be a woman who needs an induction or even someone with preeclampsia—the midwife is still managing her labor, with the obstetrician managing the preeclampsia piece.

So I would just say it’s a different scope of practice. In some ways, it’s a more expanded [role] in terms of being able to take care of women with higher risk pregnancies. On the other hand, the birth center has a much more independent role in management and decision-making.

NPSchools.com: Are there certain midwifery skills that are more utilized in one environment versus the other?

Dr. Heinz: Yes, absolutely. In the hospital, there are more people, in general, involved in somebody’s care. So when someone is there in labor, truly, most of the labor support and monitoring is done by nurses. The midwife is the person that the nurse may call or consult with if there’s a concern, and certainly, depending on the situation, she is there for some labor support.

But in the birth center, it’s really all on the midwife. If someone needs an IV, it’s the midwife who starts the IV—not the nurse at the hospital. We are the labor support, so it’s not only about the observation.

I always say my main role is to make sure that people are healthy and safe, but it’s also about protecting their memory of the birth and wanting people to feel that they have a voice, and then action, and then involvement in their birth that supersedes a lot of rules and regulations.

It’s not all about, ‘I have to get this kind of data,’ which is what tends to happen at the hospital. At the birth center, you’re doing a lot of different roles. You are the doula; you are the labor support person; [and] you are the nurse, in that if there’s medication, you need to provide it. It’s just a bigger piece in some ways.

The nature of birth centers is that we really consider the hallmark of care to be shared decision-making. We’re not there to say, ‘At this time you do this, [and] at this time you do this.’

It’s like, ‘Here are your options. How do you feel about this? How do you feel about these routines with your baby afterward? Here are the things that we can offer.’ There’s much more conversation about the process rather than the assumption that things are going to go in a certain way or be handled or done in a certain way.

NPSchools.com: Thinking about nurse practitioners that are contemplating their employment options, what kind of individuals would you say are best suited for the birth center environment?

Dr. Heinz: You have to be flexible and not have a strong need to control. You have to be incredibly patient in a birth center and really be willing to step back and let things unfold.

Super linear people don’t often do well in a birth center because it’s not as linear of a process. You have to be somewhat intuitive and flexible. You also have to be really good at losing sleep. Not that people in hospital practices don’t lose sleep, because they do, but they work shifts.

They know that they may work 24 hours, but they also know that then they’re going to have 24 hours off. In a birth center, it often isn’t that way because it’s a more limited staff. We generally have fewer clients in terms of numbers per month, but it can sometimes really group up and you have a really long week where you spend a lot of time there.

Also, at a hospital, if somebody comes in and they’re there for 24 hours in labor, they’ve probably experienced two shifts. At the birth center, that isn’t true. So I think the ability to lose sleep is really important, the ability to be flexible, and sincere belief and appreciation.

Belief, I think, is really key, that normally birth unfolds in a healthy normal way. There has to be some real belief in normal, physiologic birth—that you don’t always have to intervene in order to have a birth.

And as funny as it sounds, I think that in the nurse-midwifery profession, a lot of times people are still more drawn to a more traditional obstetrical approach than a classic midwifery approach, whereas in the birth center, it is a very classic midwifery approach.

If you think that most hospitals have a 70 percent epidural rate, seeing a woman going through the process of labor is sometimes startling for them. Whereas at a birth center, all we see is people naturally, if you will, progressing in their labor and not being numb, not being medicated.

And therefore, you have to have a real appreciation that normal physiologic birth really does happen. And you have to love that. You have to really love and feel that there’s value in it.

I always tell my hospital colleagues, ’Sometimes periodically, you should come to the birth center and just watch somebody labor’ because they really don’t get a lot of opportunities to see the sort of natural progression—what women do and how it all really unfolds—in the hospital because it’s just a different setting. And so part of that also is you have to really believe there’s value in it.

I have women who come into our practice, and they say, ‘My aunt thinks I’m crazy. Why on earth would I have an unmedicated birth?’ My doctoral work was about why women choose physiologic birth. And the woman, as well as the midwife, really needs to have a strong belief that there is value in it. That there is a reason for it.

That doesn’t mean that there aren’t times when I recommend somebody go to the hospital and have an epidural. It’s not like I think epidurals are the root of all evil, but I also think there is value and safety in not messing with the process. And I think as a midwife, you really have to believe that.

I’ve been doing this a long time, and I really do believe that that is a huge part: people really need to believe there is value in unmedicated, physiologic birth. Otherwise, why do it?

When women come to the birth center, I always want to know, Why are you here? What makes you want to have a birth without intervention? What do you perceive as the value? And I do believe it is not only a safety issue because we know that intervention begets intervention, and that’s not always a bad thing, but that once you start to intervene, you do increase your intervention.

But also emotionally and psychologically, I think there is a lot of value in feeling that you did this. Your body grew a human being and then had the power and ability to labor and push this human being out of your body.

And then, not only did you do that, but then you actually feed them. You make milk and you support them. And I think that there is strength in that and that it is a great place to start a parenting life. Because parenting pushes us—it pushes us to all kinds of levels of insecurity and worry and frustration and joy and love and all of those things—but if you start from a place of feeling strong and capable as a person…what a great way to start your parenting life.

NPSchools.com: What advice do you have for new nurse-midwives deciding between hospital or birth center?

Dr. Heinz: Know who you are and what it is that draws you to the profession. If you are a person who loves labor and loves women and supporting women and has lots of energy and is a creative thinker—that you’re okay with things not always being overly prescribed—consider a birth center.

If you are a person who really loves the challenge of a more complicated, high-risk pregnancy and birth experience—if you also feel like you need that extra security of having more people to kind of lean on and depend on—consider a hospital practice.

Although I will say, one of the things that I think that you get at a birth center also is a very strong collegial relationship with your other midwives in the practice. When I was at the hospital, never did I work with another midwife. I did my shift; I was there by myself and there were always pediatricians, an obstetrician, nurses, and other people, but I never worked with another midwife.

At a birth center, you are always working with other midwives, and so it’s a great way to get a mentor and to have that experience of working with a more experienced midwife. I think that’s a really big difference, too.

I know lots of people who want to start in the hospital and feel like they just need to get the numbers, the volume, and the experience. And I think that you’re going to see a lot more things and a lot more complications in a hospital, but you’re also going to lose a certain perspective about birth and how birth unfolds.

We have done some shared clinicals with nurse-midwives who are doing their training through the hospital to have them come and spend a month or two at the birth center. They attend some births and even if they don’t have any responsibility, just being present at some births really helps people to decide where they would like to practice.

The other thing that’s interesting in a birth center is that we do laundry and we cook food. We have a house we take care of. People are hungry after birth, and we’re cooking food for them. I think that’s also important that people see. It’s a full-service deal. I have scrubbed a lot of toilets and cleaned a lot of bathtubs, washed a lot of floors, and done enormous amounts of laundry.

We actually laughingly call us a “B&B&B”—Birth & Bed & Breakfast—because we do definitely take care of people on that level, too. After birth, we’re feeding them, tucking them in, letting them take a nap, and loving on them. It’s pretty lovely, but it’s really hard work. Midwifery is hard work.

And here’s one thing I always tell people who are thinking about midwifery: you don’t do it because you love babies. We are certainly there to physically take care of the baby, but we’re not sitting around rocking babies. That’s not quite what we do.

Midwifery is hard work, and I think that’s the bottom line. Anyone thinking about going into midwifery—whether they’re thinking about a hospital or they’re thinking about a home birth practice or a birth center practice—they have to realize that it’s really hard work and the responsibility is awesome. It is intense. You have responsibility for the life and well-being of two people and that is intense at times.