Joan Bryson: Community Midwifery

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.