Joan Bryson: Community Midwifery

JoanwithJavonn.jpg
Joan with Javonn, one of the many babies she helped deliver
Joan Bryson became a midwife in 1991, and between her nursing experience and midwifery practice, she’s assisted in more than 1,000 births.
At her private practice in Brooklyn, NY–Community Midwifery–she provides midwifery and health care for women in their teens to post menopausal years, including regular gyn exams, breast exams, primary care screening, preconception counseling, STD screening and prevention and family planning.
She is also an active member of New York City midwives. Here’s Joan…


How did you get into midwifery?
In my mid-20s my brother and his wife were having a baby and were doing a home birth with a lay midwife. They were so in love with the pregnancy and having a home birth. It really called to my heart. I began reading voraciously about midwifery and birth. But I was intimidated about doing it. Later, several years, I decided to plunge forward. I went to nursing school. I did get sidetracked with life for a long time, but after the birth of my daughter, I got a new job and met my first practicing midwives. Two years later I went back to school, and the rest is history.
What is the role of a midwife for those who are not familiar with the practice?
Midwives care for healthy women, independently from physician care. Their ‘role’ or scope of practice depends on route of entry into the profession.
Midwives are healthcare professionals who are educated in a variety of ways. There are nurse-midwives (CNMs) and certified midwives (CMs) who are certified by the same certifying exam as nurse-midwives are even though they’re referred to as CNMs and CMs they are essentially the same. The difference is CNMs enter through nursing and CMs enter through an equivalent science background. Their scope of practice includes gynecology, primary care, birth and early newborn care and usually have prescriptive privileges depending on their state laws.
There are also certified professional midwives (CPMs) who study midwifery in a variety of ways but take a different certifying exam than CNMs/CMs, it is rigorous. They are usually licensed by their state’s department of education. Their scope of practice is limited to pregnancy and birth and to my knowledge none have prescriptive authority. CPMs are not recognized by all 50 states.
Midwives do not do surgery. Most CNM/sCMs work for hospitals, or in private practices and deliver their clients in hospital. A very small percentage, like myself, provide homebirth services. CPMs almost exclusively do homebirths, as their scope of practice prohibits hospital privileges. The philosophy of midwifery, regardless of route of entry into practice, is woman-centered, focusing on well being and holistic approaches to care.

Can you discuss a midwife-assisted birth, and how it differs from many of the births that take place in today’s hospitals?

Midwives who provide homebirth services are committed to humanistic, individualized care that focuses on the needs of the woman. Because care during birth is in the home, authority shifts to a shared status. We believe in a woman’s ability to birth normally without pharmaceutical pain relief. Women feel their most supported, private and empowered in their own homes, and this really affects the process of labor. Any person at the birth is totally there for that woman alone. There are no other distractions. There is usually deep trust. Women don’t have to ‘ask’ permission to shower, be in the tub, go to the bathroom, walk around. She is her own boss. In hospitals, there is an inherent assumption that the hospital rules and physician orders are to be followed without question. The rules are made to keep the unit running smoothly and personnel utilized efficiently. Any attempt to bend them to an individual’s needs is viewed as unfair and unsafe. In my 17 years of experience, I have never had a mother ask to do something unsafe.
What are the benefits of a midwife-assisted birth? What are the challenges?
Remember that midwifery care is complete maternity care as well as gyn care. In homebirth, the prenatal visit is scheduled to meet the client’s needs outside of the routine blood pressure, weight, growth measurement and fetal heart. Time is spent getting to know this woman, her family, what her fears may be, preparation of the home, as well as time to discuss labor, birth and care of the baby afterwards. I spend a fair amount of time opening up discussion around what this is really preparation for: Parenthood! How does life change. How might they begin during the pregnancy to discuss those changes and how will they face those changes.
I think the challenges are mainly trying to practice humanistic care in a system that is mechanistic and often cruel. Midwifery care and homebirth with trained midwives have been shown to be safe, satisfying, cost effective, and have incredibly lower C-section rates and other interventions in numerous studies over decades of time. People were told midwives were uneducated and causing all of the infant mortality at the turn of the last century by a very effective PR campaign and it has stuck. The truth is that the safety in childbirth has largely come about because doctors finally started using aseptic technique (i.e. hand washing, etc., that midwives and nurses kept telling them to do!), antibiotics, improved nutrition and spacing of pregnancies. Not much has really changed since these ‘discoveries,’ especially in this country.
We rank highest of all industrialized nations in maternal and infant mortality and morbidity, in spite of the fact that we spend more money per capita than any other country on maternity care. And we use the least amount of midwives (11% vs. 71% in most European countries).

What is one of your favorite delivery stories?

I have so many favorite delivery stories. Women are so beautiful and strong in labor. They are so unconscious of how they look, and would probably say that they looked terrible. But they all must reach deep inside themselves and discover their true strength to deliver the baby. To me, this is profoundly beautiful.
What advice do you have for expectant mothers?
Research your options and exercise them. You are intelligent beings who know how to take care of yourselves. If something doesn’t feel right, change providers. My opinion is that the first most important decision you make, is the provider you choose. If you feel free to be yourself, safe to discuss the most personal of issues with your provider, and that who you are and the things you find important for your birth are important to that provider, then where you have your baby will be secondary. Unfortunately, most providers, even midwives, often are unable to challenge the system they work in to do this. That is why homebirth is such an important option.
Is there anything you would like to add?
In New York state, CNMs and CMs are the only legal midwives. And our practice is severely hampered by a provision in our practice act requiring a ‘signed’ practice agreement with a physician or hospital. We are the only health care professional required to get ‘permission’ to practice by our financial competitors. Consequently, many of us are unable to practice outside an ‘employment’ setting because we are unable to satisfy that provision of the law. And the few physicians who will sign these agreements are told by their malpractice insurers that they can only work with one or two midwives or not at all. The signature increases their liability for clients they are not even caring for.
Can you imagine a family practice physician needing a signed agreement with a cardiologist in order to refer or consult a patient with a heart problem? And the cardiologist thinking it was too risky to take patients from another doctor? While we are not doctors, we are OB/GYN providers under the law and should be afforded the same rights to practice, consult and refer as any other provider. The safety of care primarily relies on smooth, seamless transfer to a higher level of care when indicated. The implication that midwives cannot be relied upon to do that without a signed agreement with a physician is insulting and ridiculous.

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69 Comments

  1. annajcook
    Posted February 3, 2008 at 8:30 pm | Permalink

    Medical Student29,
    I would suggest that you take a look at the work of Marsden Wagner on the subject of ob/gyn and midwifery care in the United States. He is a physician and scientist, and a former Director of Women’s and Children’s Health at the World Health Organization and has a recent book out on this subject (as well as numerous scholarly articles). The book is called Born in the USA. He is not against ob/gyn care, but argues persuasively that in the United States it is grossly mis-applied, over-medicalizing childbirth in a way that is detrimental to both women and infants.
    Currently, the majority of women with low-risk pregnancies in the U.S. do NOT get their prenatal and birthing care from midwives, but from ob/gyns. And data as well as anecdotal evidence are showing that many American women are suffering the consequences of this mis-application of care in the form of unnecessary and often harmful medical intervention. This is NOT the case of high-risk cases skewing the outcomes. This is the result of uncomplicated cases being turned problematic by procedures that do more harm than good.

  2. SassyGirl
    Posted February 3, 2008 at 9:11 pm | Permalink

    “I never considered home birth mainly because I knew I’d be too tired to clean up all the mess!”
    Oh, my midwife and her apprentices not only cleaned up the “birth mess”, they also did a load of laundry, swept up the living room, did the dishes, made me something to eat, made me some iced tea (it was August), packed up my placenta in the freezer and they got me all tucked in and ready to sleep!
    The mess isn’t bad. They gave me a list of supplies to buy before the birth, which includes a plastic shower curtain liner, sheets and LOTS of towels. We bought some extra sheets and towels at a yard sale so that they could just ball it all up and throw it in the garbage.

  3. Posted February 3, 2008 at 10:49 pm | Permalink

    A male, my point was more that let’s not fault people for following their training. Let’s just understand the training and decide what we want more from there.

  4. leah
    Posted February 3, 2008 at 11:31 pm | Permalink

    Medical Student29,
    You are mistaken about the funneling in this study, and it is right in the abstract:
    “After controlling for social and medical risk factors, the risk of experiencing an infant death was 19% lower for certified nurse midwife attended than for physician attended births, the risk of neonatal mortality was 33% lower, and the risk of delivering a low birthweight infant 31% lower.”
    The first part of that sentence again, because it is very important, “After controlling for social and medical risk factors,”.
    This means that the risk factors (i.e. high-risk v. low-risk pregnancies) were approximately equivalent between the two study groups (physician or midwife attended), therefore the differences found in this study could not be attributable to higher-risk pregnancies being funneled towards physicians (which they certainly are).
    Like others have said, each option (midwife v. physician) has it’s place but, unfortunately, it is up to us women to research our options because the medical industry does not fully disclose this information to patients who are delivering. The maternal and fetal effects of pitocin, epidural, EFM, episiotomy and C-section are generally poorly explained to patients (for instance, EFM has shown no effect in outcome for the fetus, and in approximately 33% of C-sections the baby is cut so badly it needs stitches).

  5. Erica B
    Posted February 4, 2008 at 9:52 am | Permalink

    I don’t understand why the discussion of midwives seems to turn into an attack on giving birth within a hospitals.
    Me neither. My CNM only delivered in hospital. Midwife doesn’t mean home birth.

  6. Mina
    Posted February 4, 2008 at 7:15 pm | Permalink

    “Certified-Nurse Midwives are Master’s educated nurses who completed a four year Bachelor’s degree in addition to 2 to 4 years of advanced coursework in nursing and midwifery.”
    Yeah, I got the impression that CNMs get criticized both for “being unprofessional” because they’re professional nurses instead of MDs and for “selling out to the system” because they earned graduate degrees. o_O

  7. Medical Student29
    Posted February 4, 2008 at 7:40 pm | Permalink

    Leah, you didnt read the study. The OB/GYN group had higher rates of placental abruptions, fetal distress, and other complications.
    Its in the first and second tables in the article. The odds ratios they calculated in the last table also showed that OB/GYNS were more likely to get these patients and that those factors by themselves were independent risk factors for low birth weight and neonatal mortality.
    Like I said before, midwives are perfectly fine for 90% of births and I think more women should use them. But its wrong for people on this board to imply that ob/gyns dont know how to deliver babies as well as midwives and they only thing they can do is c-sections, because thats clearly a load of crap.
    Midwives are better at establishing a more “patient friendly” environment, but they are no better (or worse) at vaginal deliveries than ob/gyns are from a technical/procedural standpoint.

  8. Posted February 4, 2008 at 8:53 pm | Permalink

    I have to say, this is the first weekly-interview post here at Feministing for a long time that has generated an actual debate. :) A lot of good opinions here on both sides.
    Certified-Nurse Midwives are Master’s educated nurses who completed a four year Bachelor’s degree in addition to 2 to 4 years of advanced coursework in nursing and midwifery. That’s hardly “just about anyone” who feels like delivering babies.
    Yes, advanced-practice nurses including nurse midwives require a BSN plus a master’s. That’s usually 4+2=6 years or so if they go to school fulltime. Lay midwives require considerably less coursework or qualifications.
    An OB/GYN M.D./D.O. needs a bachelor’s, a 4-year medical degree, and must complete a 4 year residency. That’s 4+4+4=12, or twice the amount of years as the highest level of midwifery.
    Also, and I really don’t want to be demeaning NPs or their various iterations such as nurse midwives at all but… NP school is a bit easier to get into than med school.
    Finally, the coursework of med school and residency is strictly regulated by a number of entities, including the federal government via Medicare, and tough universal board exams that every OB practicing in the U.S. must take. There is no such level of standards for advanced nursing schools, let alone lay midwives.
    Sure, they may be superstars like Ms. Bryson, no question; there are certainly physician quacks; and I have met more than one NP who could put most MDs to shame… but there are a lot fewer barriers to prevent a complete moron from entering NP/nuse midwife practice compared to actual OB/GYN physicians.
    Which means to need to be even more careful selecting a midwife than an OB/GYN.
    That’s really all I’m saying. They can provide a wonderful service to any woman with a low-risk pregancy… and enough money not to be on Medicaid. (but that’s a subject for another post.)

  9. A male
    Posted February 5, 2008 at 3:40 am | Permalink

    “Sure, they may be superstars like Ms. Bryson, no question; there are certainly physician quacks; and I have met more than one NP who could put most MDs to shame… but there are a lot fewer barriers to prevent a complete moron from entering NP/nuse midwife practice compared to actual OB/GYN physicians.”
    Maybe you are explaining yourself to try to appear understanding, but now you are implying that it is possible for a “complete moron” to be a practicing nurse [practitioner] or midwife (particularly lay midwife) because of an alleged lack of standards. Threads about childbirth or visits to the OB/GYN may not be friendly to people in the health care profession, physicians or nurses like myself, but geez. Are you this friendly to the hospital nurses you work with?

  10. leah
    Posted February 5, 2008 at 4:05 am | Permalink

    Medical Student29,
    You have made two erroneous assumptions:
    1. That I have not read the paper cited. Perhaps you assumed I do not work for and am a student at a world-famous medical institution in southern Minnesota (of which I cannot legally say the name) and am not part of the medical field and therefore do not have a subscription to this journal?
    2. That just because, in this study, the physicians experienced more medical complications, that this means the two study groups differed significantly in risk factors from the onset. Please read the materials and methods section, and if you don’t understand it please get one of your MD-PhD classmates or profs to explain it to you. This was a prospective study with two groups that DID NOT differ in medical or socioeconomic risk factors, only in the choice to receive pre-natal and labor care. Those individuals that switched from midwife-attended to physician-attended births due to complications WERE NOT INCLUDED in this study, meaning that the “funneling effect” meme that so many doctors love to espouse and indoctrinate their students with did not occur in the patients included in this study (in fact so many studies where these pregnancies and labors are not included has pretty much disproven the funneling effect. It was a problem with studies done in the early-mid 80′s but since then no study will be published that fails to control these factors). That the physician-attended births experienced more complications does not mean the two groups differed significantly from the study onset. Granted it can explain some of the results, however it does not mean that the study design did not have the proper controls. What the authors did not address is *why*, when the two groups were medically and socioeconomically equitable to begin with, the physician-attended births experienced more complications. Sampling error? Use of interventions that can lead to complications (pitocin use has been shown to increase fetal distress, membrane rupture and pitocin use have also been shown to increase incidence of membrane rupture)? Dunno. There are many possibilities.

  11. leah
    Posted February 5, 2008 at 4:11 am | Permalink

    Oops it’s too early. I meant “membrane rupture and pitocin use have also been shown to increase incidence of placental abruption”.

  12. Medical Student29
    Posted February 5, 2008 at 10:02 pm | Permalink

    Leah, drop the patronizing attitude. I dont care who you are or what you do, and its irrelevant to the debate.
    The bottom line is that the physician group had higher complication rates that GREATLY affect infant mortality and this paper was not designed to determine whether this was a selection bias artifact or a real difference in quality of care between ob/gyns and midwives. It did NOT control for all medical confounders (gestational DM, pre-eclampsia, and gestational HTN come to mind immediately) so its not true that “everything” was controlled for.
    As for the “funneling” argument, what you fail to understand is that mid-pregnancy shifting to ob/gyn care is only ONE FORM of funneling, and the only one that hte paper controlled for. Other types of funneling happen at the very beginning of pregnancy when a woman chooses her provider from the outset, or when a primary care doctor shifts her to either midwife or ob/gyn care based on things like previous high risk pregnancies which this paper did not account for.
    Also, this paper failed to properly split the two provider groups. It notes that a “sizable minority” of midwives co-practice with ob/gyns and they failed to account for this kind of split practice.
    This paper showed us two things that we already knew (increased infant mortality and complications) and certainly doesnt prove what the other poster said it does (that practice patterns account for increased infant mortality and complications in ob/gyns).
    This retrospective study has too many confounders that were not accounted for, and thus the mortality statistics they cite are meaningless.

  13. Posted February 6, 2008 at 11:55 pm | Permalink

    Maybe you are explaining yourself to try to appear understanding, but now you are implying that it is possible for a “complete moron” to be a practicing nurse [practitioner] or midwife (particularly lay midwife) because of an alleged lack of standards.
    This is precisely what I am implying. There are few standards to block a complete moron from practicing as an advanced nurse (NP, midwife, or othersise), compared to the barriers that exist to keep morons from being phyisicians.
    You forget that the hardcore standards that real medical professionals are subject to, exist in order to protect patients from incompetent providers. The public deserves to count on some minimum standard of skills from their doctors, no matter who that doctor is.
    If you are in an emergency situation, after all, you won’t have a whole lot of time to run background checks, right?
    Advanced practice nursing decided to do away with such standards because they felt that the standards might hurt the feelings of incompetent people who would otherwise be unable to practice medicine.
    And you know what? Such people really should not be able to practice independently. I’m sorry that such tough rules hurt the feelings of Jane Doe, ARNP, but the patient is more important. At least in my humble opinion.
    Same thing with midwives. Many if not most midwife practices exist less to benefit the patient, and more to assuage the ego of some person who was not able to cut it in actual med school.
    This is not to say that (competent) midwives don’t have any advantages.
    Midwives have more time to spend with each individual patient, compared to M.D.s and D.O.s., since they only cater to well-heeled patients with cash to spend and who do not have to worry about Medicaid. No question. (Yep… Ms. Bryson doesn’t have too many low-income patients. How else do you think she has so much time to spend with each individual? I guess there aren’t too many poor people in your women’s studies course at college so that doesn’t matter eh?)
    And I do not deny that it is a huge flaw of the U.S. medical system that real phyisican OB/GYNs have such little time to spare per patient due to the realities of the current system.
    But that does not change the fact that midwives have a vastly inferior skill set compared to an actual physician OB/GYN.
    But please, pretty please, don’t believe that your midwife’s lower IQ and inability to cut it in medschool somehow makes them better providers for your childbirth experience.

  14. Posted February 6, 2008 at 11:55 pm | Permalink

    Maybe you are explaining yourself to try to appear understanding, but now you are implying that it is possible for a “complete moron” to be a practicing nurse [practitioner] or midwife (particularly lay midwife) because of an alleged lack of standards.
    This is precisely what I am implying. There are few standards to block a complete moron from practicing as an advanced nurse (NP, midwife, or othersise), compared to the barriers that exist to keep morons from being phyisicians.
    You forget that the hardcore standards that real medical professionals are subject to, exist in order to protect patients from incompetent providers. The public deserves to count on some minimum standard of skills from their doctors, no matter who that doctor is.
    If you are in an emergency situation, after all, you won’t have a whole lot of time to run background checks, right?
    Advanced practice nursing decided to do away with such standards because they felt that the standards might hurt the feelings of incompetent people who would otherwise be unable to practice medicine.
    And you know what? Such people really should not be able to practice independently. I’m sorry that such tough rules hurt the feelings of Jane Doe, ARNP, but the patient is more important. At least in my humble opinion.
    Same thing with midwives. Many if not most midwife practices exist less to benefit the patient, and more to assuage the ego of some person who was not able to cut it in actual med school.
    This is not to say that (competent) midwives don’t have any advantages.
    Midwives have more time to spend with each individual patient, compared to M.D.s and D.O.s., since they only cater to well-heeled patients with cash to spend and who do not have to worry about Medicaid. No question. (Yep… Ms. Bryson doesn’t have too many low-income patients. How else do you think she has so much time to spend with each individual? I guess there aren’t too many poor people in your women’s studies course at college so that doesn’t matter eh?)
    And I do not deny that it is a huge flaw of the U.S. medical system that real phyisican OB/GYNs have such little time to spare per patient due to the realities of the current system.
    But that does not change the fact that midwives have a vastly inferior skill set compared to an actual physician OB/GYN.
    But please, pretty please, don’t believe that your midwife’s lower IQ and inability to cut it in medschool somehow makes them better providers for your childbirth experience.

  15. A male
    Posted February 7, 2008 at 12:25 am | Permalink

    “But please, pretty please, don’t believe that your midwife’s lower IQ and inability to cut it in medschool somehow makes them better providers for your childbirth experience.”
    Holy shit. I guess you are one of those asshole doctors nurses talk about who think they are God’s gift to patients.

  16. A male
    Posted February 7, 2008 at 12:32 am | Permalink

    And by the way, doctor – it seems your superior IQ has not figured it out for you: people don’t become nurses, APRNs or midwives “because” they can’t cut it as doctors. Even if I were cut out to be a doctor, I wouldn’t want to be one. I prefer spending my time with patients, not acting like an asshole.

  17. EG
    Posted February 7, 2008 at 1:07 am | Permalink

    Something tells me that the sort of doctor who goes on about IQ scores could never cut it in nursing school.
    Forbidden Comma, you are the reason many of us loathe OB/GYNs. Feel proud of your IQ now?

  18. A male
    Posted February 7, 2008 at 2:14 am | Permalink

    “Something tells me that the sort of doctor who goes on about IQ scores could never cut it in nursing school.”
    I will allow that I am also amazed and sometimes appalled that nursing students in my program are allowed to begin practicing on real human beings after just eight weeks of lecture and textbook study, or allowed to give injections, start IVs, etc., after a few hours of practice and an adequate demonstration for an instructor. This just further demonstrates that there is much more to nursing than what can be learned out of books, i.e., the ability to work with their colleagues to get the job done as well as gain knowledge and skills to become effective nurses themselves (over the course of 2-5 years on the job), and an ability to empathize and bond with patients. Because patients in recovery wards and long term care spend considerably more time with nurses than doctors (in local long term care, doctors are required to show up for exams only once a year; in my school’s wellness center/women’s health clinic, there is no doctor at all), it is more important for nurses to have good “bedside” manner, as the “face” of the facility. I am always disappointed to hear of how some nurses in OB/GYN or L+D have contributed to the trauma of many posters. Nurses are supposed to be patient advocates, well versed in the rights of patients particularly when it comes to choice, dignity and privacy; and sensitive to the needs of women in particular, as women’s health is such an important issue, and 95% of nurses being women (and likely mothers, at an average RN age of 46.8) themselves.

  19. Posted February 15, 2008 at 3:57 pm | Permalink

    So what does a pregnant woman who is also a pain-o-phobe do?

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