When Janice Scaggs joined the University of Mississippi Medical Center in 2020, she became part of a growing effort by the state’s largest public hospital and academic medical center to reintroduce midwifery into Mississippi’s maternal health care.
Certified nurse-midwives like Scaggs are educated in graduate-level midwifery programs and also hold an active registered nurse credential at the time of certification.
In the last three years, Scaggs, as the hospital’s only midwife, attended a little over six percent of births at UMMC each year.
In June, a second certified nurse midwife, Kim Rickard, joined the team. As part of the nurse midwifery clinical advisory committee, she and Scaggs plan to integrate a minimum of eight new nurse midwives into UMMC hospitals and clinics to offer round-the-clock midwifery care by 2027.
Midwives advocate for autonomy and comfort over efficiency for their patients, and have been proven to decrease unnecessary interventions such as cesareans in low-risk mothers – thereby improving morbidity and mortality, as well as postpartum mental health, and lowering the overall cost per capita of care.
Doctors and OB-GYNs are experts when it comes to abnormal pregnancies, Scaggs explained, but they don’t always know how to stand back and let a normal physiological birth unfold.
“Midwives … are the experts in normal, and have always been educated on a patient-centered model of care, really advocating for the patient and family, and empowering them,” she said.
Unnecessary cesareans and their increased use in Black pregnancies are not only a large contributor of preventable maternal deaths, but also a large contributor of maternal health disparities. Maternal mortality and morbidity after emergency cesarean birth is nearly five times than after vaginal birth.
Midwives are proponents of simple, but successful, low-intervention practices during labor – such as mobility and intermittent auscultation, or a technique of listening to and counting fetal heartbeats for a short period of time during active labor.
Editor’s note: This interview has been edited for clarity and length.
Mississippi Today: The term “midwife” translates to “with woman.” How do you see your role as a midwife, and how does it differ from that of, say, a doctor?
Janice Scaggs: We have so many similarities that sometimes that’s a really difficult question, but then on the other hand it’s really not.
If you look at the midwifery-led model of care, it really focuses on the individual, on putting them at the center of care, midwives being advocates for their patients and families – they want to empower the woman.
We focus on normal and healthy, certainly recognizing the abnormal. I look at us as the experts of that normal (births), whether it’s OB care, birthing, or gynecologic care, as well as family planning. I would say that that differs from our physician colleagues, because they really are focused on what the abnormal is, and they are experts when things are not going right.
MT: Tell me about the evidence around midwife-led care in reducing maternal and neonatal morbidity and mortality.
Scaggs: It’s well documented in other countries where midwifery is integrated into the health care system that it improves outcomes. We now have some good evidence in the U.S. to look at those evidence-based benefits, as well, including decreasing unnecessary interventions, improving the overall outcome of health – mental health as well as physical health – and decreasing the cost of health care, as well.
We increase breastfeeding rates, decrease preterm birth rates, and then (use) that approach of not using intervention unless absolutely necessary. We end up not performing interventions that can lead to morbidity, when maybe they didn’t need to be done, such as an unnecessary primary cesarean section.
MT: So, in today’s world, more women give birth in hospitals, and around technology, than ever before. But that hasn’t necessarily led to better outcomes. We know that because of infant and maternal mortality rates, and also high cesarean rates – across the country but particularly in Mississippi. Tell me about your non-pharmacological approach to birth and your philosophy around that.
Scaggs: I look at non-pharmacologic support as being an option that can either be done on its own or can be integrated with medical technology and pharmacologic options for women, as well. So they don’t have to stand separated.
But if we’re focusing on non-pharmacologic, we know from research that mobility, upright positions in the first stage of labor, decreases the length of labor, it decreases other interventions, it decreases cesarean rate. It improves comfort for moms who are trying to cope with labor without pharmacologic methods.
So, giving women permission and opportunity to move in labor – they will and they want to. If we put them in a bed and don’t encourage them to move, they won’t, because they feel unempowered, they don’t feel like they can safely move around.
That non-pharmacologic approach to giving women options, having them understand they are safe options in most settings, and we’re talking about primarily low-risk births with midwives. And then looking at things like acupressure points can be extremely helpful, using heat and cold in different aspects can be helpful. Touch – we know that there’s therapeutic touch for all aspects of health care, and that includes in labor and birth.
Using things like birthing balls when women are either in the bed, when they may be tired, either with epidurals or without epidurals, for positioning, can be extremely helpful in opening the pelvis to its most optimal position so that the fetus can get into the most optimal position. Babies come out a lot easier if they are head down and looking down, in relation to mom’s body, as opposed to what I would call sunny side up or coming down a little bit crooked. Changing the shape of the pelvis and having mom moving, whether it’s in the bed or out of bed, does lead to better outcomes, insofar as getting baby in a good position and having a faster labor.
It als just helps mom to cope better. When you’re hurt, you want to move. And if women stay in one position and don’t move, then we know that they’re not going to cope as well. I always talk to students and moms about how part of my job is to help you recognize when you’re suffering and to help you cope and to limit suffering. We know that doing that for women in labor actually improves our mental health outcomes and in the postpartum period it decreases anxiety and depression. And we know that that is something we should all be focusing on, and we’re just beginning to see more attention to that mental health aspect of the process of labor and birth.
MT: So, midwives primarily use intermittent auscultation, as opposed to electronic fetal heart monitoring, to listen to fetal heartbeat. Can you explain the difference between the two and how EFM can increase one’s chances of an unnecessary cesarean?
Scaggs: Continuous electronic fetal heart monitoring has two small, round devices – plastic devices that fit on mom’s belly. One graphs on a computer system to show when (the mother) is having a contraction. The other one is a little ultrasound piece. It’s not an ultrasound visually; it’s for hearing. We hear the heart rate, or auscultate the heart rate. And on these monitors, you can have continuous monitoring of the fetal heart rate, as well as uterine contractions.
We introduced this thinking we were going to decrease the overall cerebral palsy rate and we didn’t quite have the evidence to support that. And we have found now, 25, 35 years later, that for high-risk women, it’s extremely advantageous to have continuous electronic fetal monitoring. But for low-risk women, who are in spontaneous labor, who don’t have risk factors, we many times actually offer or perform interventions that aren’t necessary because (the continuous electronic monitoring) really sometimes provides more information than we need to have.
If we use intermittent auscultation, which is using either a handheld little Doppler which is another ultrasound device to hear heart tones, or even the old fashioned fetoscope that looks like the ear trumpet, that we can use to listen on mom’s belly. We listen before a contraction, throughout a contraction and one minute after the contraction, and we do that every 15 minutes during labor and five minutes during active labor and every five minutes when they’re pushing. And in doing that, if we hear anything abnormal we then can transition to more continuous monitoring to find out how the fetal heart is and to assure that we actually have a healthy baby. But you’re not having to be strapped down and continuously monitored. It may be that if everything sounds good and normal, that you never have to utilize the continuous electronic fetal monitoring.
MT: Tell me more about that relationship between a traumatic birth and postpartum depression.
Scaggs: Well, I can’t define trauma for somebody else, but if I don’t ask the right questions I’m not going to know if there’s been trauma.
I’ve had women who have come to postpartum visits, who I thought had the most beautiful birth and labor experience ever, and who seemed wonderful, and I find out a couple weeks later that there was something that caused them a trauma – whether it was terminology that was used, whether it was moving forward with a plan that maybe was not clear to them.
I’ve seen women have emergency cesarean sections who really needed them who show no signs of trauma, and then women who have planned cesareans who have trauma related to that. I think there are so many small things we can do to decrease trauma for women and that’s going to be, number one, communicating and finding out what helps them the best, not necessarily ourselves.
And as a provider, of any kind, whether you’re a midwife, a physician, a nurse, you can love your job so much and impose what you think somebody else should need. Being very self aware and self reflective, having humility of the process of labor and birth, is one of the best ways I think we can eliminate severe trauma.
MT: Do you think Mississippi will ever have a birth center? Would that be helpful here?
Scaggs: I think it would be wonderful if we could have regional freestanding birth centers that are supported by nurse-midwives with, you know, appropriate consultation, collaboration and referral to OB-GYNs and maternal-fetal medicine physicians for care as needed.
It would give us a better sense of community support in places where we don’t have as good of access. It could provide prenatal care, as well as care for labor, birth and postpartum period, as well as family planning.
MT: What do you think is needed to shift the paradigm from the hospital model of birth, which relies so heavily on technology, to a model of fewer interventions for low-risk pregnancies and empowering women to give birth according to their own plan when safe?
Scaggs: That’s a big question and I think it has a multifaceted answer. I think it always comes down to: what is the culture for supporting intended vaginal birth? What is the culture for putting women in the center of care? And what the relationships are between health care providers and nurses within a hospital, and support from administration for the type of training that is needed to be able to do things like intermittent auscultation. There’s a specific way to do that. So there needs to be education for nurses to be able to learn that; there needs to be a better nurse to patient ratio. So, we have some workforce issues. There’s also financial issues, educational issues. The bottom line is it’s really difficult to change culture. It takes time.
The more we can lean into family-centered, patient-centered, care, the more we can use the evidence that we currently have around us to improve outcomes.
If Mississippi can integrate midwifery into the health care system, that’s going to be the simplest answer. Who better to change the culture than midwives, who are the experts in normal, and have always been educated on a patient-centered model of care, really advocating for the patient and family, and empowering them, as well. The more we can empower women to have these choices and to understand they have these choices is really going to help.
MT: Is there anything else you’d like to add about midwifery in Mississippi?
Scaggs: I would like to say that I have been very supported within the university and from the chair of the department (Dr. Marty Tucker), to be able to grow midwifery. He’s the one who initially reached out to me when I had moved to Mississippi and was trying to navigate and figure out where jobs were and not finding many. He believes in midwifery being integrated into our model of care.
And I think if we had more physicians and administrators who understood midwifery and were open to hearing about it and really looking at the evidence, that we would have more midwives in Mississippi. But it takes us partnering to do that. I need them, and I need for them to realize also that they need my profession in order to best care for women in the state.
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