Will Women Have a Voice at the New Women's Hospital?
The fight for midwives and reproductive choice at Brack
Most nurse midwives tend to be peaceful, holistic sorts, not inclined to raise a public ruckus, even if their livelihoods are threatened by the loss of hospital privileges. Fortunately, theirs is a profession -- one of a few in the health care industry -- that comes equipped with a vocal following of consumer advocates who can raise a ruckus for them.
Midwives and their supporters are embroiled in a yearlong struggle with the city's public health care officials to find a way for midwives to practice at the new Women's Hospital at Brackenridge. It's an argument expressed in economic, political, medical, and legal terms, and it's not just an isolated issue. The argument over midwives is emblematic of a larger dispute over the proper role of the city of Austin in the rules governing its own hospital -- and over whether women, especially low-income women who rely heavily on Brackenridge for reproductive services, will have the option to choose how those services are delivered.
The midwives' vocal advocates -- themselves mostly young, white, middle-class moms -- leapt into action a year ago after two private physician groups decided to cancel their sponsorships of midwifery programs at Seton Medical Center and the Seton-run Brackenridge Hospital. The two separate groups -- Women Partners in Health at Seton and Capital Obstetrics and Gynecology Associates at Brack -- each cited financial reasons for pulling the plug on the otherwise successful programs.
But the midwives, advocates, and doctors interviewed for this story argue that the underlying reasons for canceling the sponsorships go well beyond the neat and tidy explanation of economics. "The docs will always have that argument of, 'Well, it's just not cost-effective,'" said Dr. John Day, a family practice physician who trained at Brackenridge under an obstetrician/gynecology fellowship. "And unless something fundamentally changes in Texas laws that give midwives more independent privileges, they'll always have economics as a plausible argument."
(In light of a state attorney general's investigation into possible antitrust violations -- prompted by a consumer complaint filed in the wake of the canceled sponsorships at Seton and Brack -- neither Seton nor Capital Ob-Gyn at Brackenridge would comment on the nurse midwife situation. The AG's office declined even to confirm that the investigation is continuing.)
In a similar fashion, "economics" is also routinely cited as the reason certified nurse midwives won't be allowed to deliver babies at the new Women's Hospital, at least not in the immediate future. The redesigned facility -- the fifth floor "hospital within a hospital" at Brackenridge -- will open in January to provide the reproductive services for indigent women that Seton, under a directive from the Catholic Church, can no longer provide at Brack. The University of Texas Medical Branch at Galveston will run the new facility for the city, but will provide emergency contraception only to women who are victims of rape or sexual assault. Seton forced its hand on the abortion issue when the city amended its lease agreement in 2002. (See "The City, the New Women's Hospital, and UTMB," p.32.)
With midwifery services idled at Seton and Brack, and with only a slim possibility of St. David's Medical Center initiating such a program, Austin -- despite its progressive reputation among Texas cities -- is currently the only major city in the state that does not offer midwife-attended deliveries in any hospital. As midwife supporters see it, limitations placed on a midwife's ability to practice in local hospitals similarly limit a woman's right to choose who delivers her babies and under what circumstances. That's why local advocates looked to the open-minded city administration as their best chance, in theory, of getting a midwifery program into the new hospital.
"When Brackenridge closed its practice, we were told that the city couldn't force Seton to bring this service back because it wasn't required in their lease," said Amy Chamberlain, president of the Austin chapter of Texans for Midwifery. "Because of this, [we] felt it was important to try and address the issue of midwives before a lease was signed with UTMB."
City Council members and staff insist they support midwifery services at the new hospital, but to consumer advocates like Chamberlain, the city has been reluctant to press the issue with UTMB, even though UTMB offers a nurse midwifery educational program and allows midwives to practice at its medical branch in Galveston. UTMB rejected the inclusion of midwives in its contractual agreement with the city, and, without a physician staff in place yet at the new hospital, UTMB officials remain circumspect on when, or if, midwives will be able to deliver babies at Women's. "It's too soon to tell," said spokeswoman Cathy Nall. "There are too many factors out there right now that need to be reconciled before we know what is going to happen with that particular situation." One of those factors, no doubt, is the outcome of the AG's investigation.
Talking in Circles
The City Council approved the five-year UTMB contract last month without discussion, and the UT System Board of Regents is expected to give its approval today (Thursday).
Chamberlain, a former legislative aide to Houston Sen. Rodney Ellis, has met several times with Trish Young, executive director of the Austin/Travis Co. Primary Care Department's Community Health Centers and the point person on Brackenridge and the Women's Hospital. Thus far, they cannot even agree to disagree. Young is admittedly growing weary of the midwifery argument. "We just go 'round and 'round. It's a circular argument," she said. "[The city] is supportive of having midwifery at the new Women's Hospital -- it's the same thing that we've been saying all along. But the city cannot obligate the hospital to provide midwifery services," she said. "A hospital can't direct a doctor to have a relationship with a midwife, so there's no legal basis or premise for that to occur. We have asked for it, and they've said they're supportive of it. ... What I don't understand is, how much more supportive of midwifery can we be?"
Why midwifery programs are successful in some Texas hospitals but not others is a question that's answered with varying responses. The local chapter of Texans for Midwifery asserts that Seton's and Brack's programs were too restrictive to produce uniformly good outcomes. The group surveyed 23 public and private hospitals with midwifery services and found that of all the physician-sponsored programs, Seton and Seton-managed hospitals were the only ones with departmental rules that not only required physicians to be on-site for all midwife-attended births, but also for all midwife-attended labor. It's a system clearly set up to fail, Chamberlain believes, when compared to other facilities like Harris Methodist Fort Worth Hospital. There, physicians and midwives operate in a more collaborative spirit, with four nurse midwives carrying a practice that is 90% Medicaid, according to a profile Chamberlain's group did on the hospital.
By contrast, the city's study took a different path and narrowed its focus to eight public hospitals (including Brackenridge), and four private hospitals in the Austin area (including Seton and St. David's). None of the private hospitals offer midwifery services, while five of the eight public hospitals do -- with the requirement of a physician's presence during midwife-attended births. (The city's survey did not extend to midwife-attended labor.) Moreover, only two hospitals in the city's study had been included in the one conducted by Chamberlain's group -- and the surveys show conflicting data, apparently based on differing interpretations of teaching hospitals that are already set up with around-the-clock obstetrician coverage. Even in their use of statistics, the midwife advocates and the city staff seem to be talking at cross purposes.
Attorney advocates for midwives insist that state law does not specifically prohibit nurse midwives from practicing in hospitals as nonsponsored "allied health professionals." Instead, they say that it's the hospitals' medical staff (motivated in part by the current malpractice climate) that requires physicians to assume the liability for midwives. Susan Jenkins, a Washington-based lawyer and former general counsel to the American College of Nurse-Midwives, says that Brack and Seton's rules on nurse midwives were the most extreme in the state, particularly with respect to the requirement that physicians be on site for midwife-attended labor. "Doctors don't even come in for their own [patients'] labors," said Jenkins. "Why do they think they have to be there for nurse midwives' labors?" Jenkins has provided counsel to the local chapter of Texans for Midwifery, and was in Austin last month to attend the annual conference of the Midwives Alliance of North America. (See "Midwives and the Law in Texas," below.)
It's a Catch-22 situation, in Austin at least, when physicians' self-imposed rules for nurse midwives begin to wear on the physicians' own nerves. Dr. Martha Schmitz, an ob-gyn who formerly worked for Women Partners in Health at Seton, said several factors should be considered when trying to assess what went wrong with the program at Seton. "It's not just the physicians, it's not just the hospital, it's a lot of things," she said. "It's the malpractice environment, it's the fact that physicians have to be in-house for delivery and therefore there's a bigger time requirement, it's the fact that the hospitals are very hesitant to take on any extra malpractice risk ... a lot of things culminated in this effect."
On a personal level, Schmitz (who was not involved in the decision to terminate midwifery services) described her work with midwives as a "wonderful experience. ... I learned a lot and I'd like the opportunity to do it again." While midwifery is not a big moneymaker, Schmitz added, "It's not about making the money, it's about providing the service and the choices for the patients. There are people like myself and Dr. [Geoff] Cox who are willing to back up the midwives, but you have to have a hospital to do it with, and we don't have that currently."
By and large, midwives in the U.S. have a good track record. According to the National Center for Health Statistics and the Centers for Disease Control and Prevention, infant mortality risks for births delivered by certified nurse midwives are lower than for babies attended by physicians. Midwives generally provide extensive pre- and post-natal care and attend births of women at low risk for complications.
Four years ago, with Women Partners in Health's midwifery program showing good results at Seton Medical Center, Brackenridge Hospital administrator Sue McClernon launched a midwifery program at Brack. She hired two (and later a third) certified nurse midwives to serve Medicaid and uninsured patients by providing prenatal care at outlying clinics, and delivering babies at Brackenridge. Eventually, Capital Ob-Gyn -- the private physician group runs ob-gyn services at Brack -- successfully pushed to have the midwives brought under their direct employment and supervision. According to sources close to the program, the physicians insisted they be on hand for all midwife-attended labor and delivery -- and then subsequently bemoaned the time and money they lost by attending to these labor and deliveries. Nevertheless, the midwives' practice was getting busier and growing more successful. Tensions ensued between the doctors and midwives, and there was discussion among the midwives of finding outside physicians to sponsor them at Brack. Did the physicians feel threatened by encroaching competition?
Something Bad Might Happen
"It's not as simple as that," said Dr. Day. "There is some sort of really strong territoriality that comes along, and I think that it goes beyond competition. I think that, particularly with OBs, they're in a situation where there is inherently a limited amount of control, and that can be very frustrating. And there's always this fear that the sword of Damocles is going to fall on your head, and something bad is going to happen, and you're going to get sued because the resident didn't wake you up to tell you something bad was going to happen. ... It's all these things. So there's a tendency to want to strike ... and anyone who is not an ob-gyn is fair game."
There were other conflicts, too, the doctor continued. "The nurse midwives under their supervision had minds and opinions, they had life experiences, and they weren't automatons."
In April 2002, the Capital Ob-Gyn physicians summoned the midwives and Seton administrators to a meeting and told them that the doctors were terminating their sponsorship of the program because it wasn't cost-effective. "I was stunned," recalled Lynne Loeffler, a lawyer and certified nurse midwife who has been delivering babies for 18 years. "And I was angry." She believed that, apart from the financial issue, the physicians had privately tried to undermine the midwives' professional credibility, although between them they had 80 years of combined experience delivering babies. "I was angry that false statements were made that were allowed to stand by [Seton administrators and other physicians] who knew they were false." Other sources echo Loeffler's claim -- but for now, Seton and Capital Ob-Gyn aren't willing to comment.
Despite the success the Brackenridge midwives had with working with medically underserved women, this same population will not have the option of those services at Women's Hospital. Trish Young points out that the women currently advocating for these services are not the uninsured or underinsured women who would qualify for the services at Women's Hospital. And the women who do qualify haven't yet shown a demand for midwifery services.
Who Will the Hospital Serve?
Yet Alicia Perez-Walker, president of Latina Mamí, an Austin support group for low-income Hispanic mothers, argues that poor women are the least likely to lobby for such services, but they should at least have that option made available to them. "I understand what Trish Young is saying, and she's right. But the women we serve are in survival mode. They're worried about putting food on the table and transportation needs. They don't have the luxury of organizing and lobbying to get midwives in the hospital. And it's a challenge to ask a whole group of disenfranchised women to come out and speak at rallies."
Additionally, she continued, it's the underserved women of color who often have unfortunate experiences with the mainstream route. "Some of the women feel like they're just training material. They don't get the personal touch that they could get with a midwife."
But with the city's public health care budget operating on a shoestring, Young says the city-county clinics' current model of care works best because the physicians who deliver the babies independently bill other funding sources such as Medicaid. "I already have a fully staffed clinic system, with nurse practitioners, including a nurse midwife, taking care of the patients," she said. "We are struggling to take care of the bare basic medical needs of people. Where do I find the money to now pay for the deliveries [by midwives] when I've got someone else who is taking up that share of the burden?"
The circular argument continues. Midwives and their supporters counter that if allowed to practice independently, but in collaboration with an OB, they too could bill Medicaid and save taxpayers more money because reimbursements to nurse midwives' are 85% of the rates that physicians are reimbursed.
Young returns serve. "No, they will not be able to work independently. There's no legal basis for what they're asking for. The laws in Texas do not support them practicing independently." Young later acknowledged that physician sponsorship, or supervision, is not a state law, per se, but rather a standard of care that most Texas hospitals apply with respect to nurse midwives.
Which brings us back to the crossroads of an argument that never seems to get resolved, at least not in Austin's public hospitals.
The city has gone out on a $9.3 million limb to ensure that most, but certainly not all, reproductive services are available to poor women. Even in its currently empty state, the new 12-bed Women's Hospital is warm and spacious and bright. The birthing rooms have a sort of Comfort Suites hotel feel, with additional feminine touches of wallpaper, faux-wood floors, and comfortable chairs. Given the city's limitations (perceived or otherwise) on what it can and can't force Seton and UTMB to provide at the city's own hospital, indigent women can at least be assured that they'll have basic reproductive health care available to them.
Now all they need is a choice.