Updated March 26 at 7:54am
Health care

Five Questions With: Elisabeth D. Howard


For as long as women have had babies, other women have helped them through pregnancy and delivery. Midwives today, however, are not just women in the community – they are expertly trained professionals who work primarily in hospitals.

Elisabeth D. Howard, Ph.D., a certified nurse-midwife at Women & Infants Hospital, and her colleague Edie McConaughey have been researching midwives’ growing role not just in health care, but in the education of medical students and residents.

Howard answered questions about their findings, which have been published in The Journal of Midwifery & Women’s Health.

PBN: The term “midwife” is very old; what does it mean today in terms of education and expertise?

HOWARD: The standards for education and certification in midwifery are stringent and generally include having a nursing education, along with training in a specialty program accredited by the American College of Nurse Midwives. Nationwide, approximately 80 percent of CNMs have a master’s degree, and 5 percent have a doctorate. All the midwives in our department have a master’s degree, and half hold a doctoral degree.

Contrary to how many people perceive midwifery, 97 percent of CNM-attended births occur in hospitals, 2 percent in freestanding birth centers, and 1 percent in homes. CNMs have prescription-writing authority in all 50 states. … Additionally, midwives are prepared do more than deliver babies; 90 percent of visits to CNMs are for primary, preventive care.

PBN: How big a role do nurse midwives play at Women & Infants?

HOWARD: We play a large role in supporting the educational goals of both Brown University medical students and obstetric residents at Women and Infants regarding obstetric triage and low-risk labor and delivery. In addition, our department augments the clinical services provided by obstetric residents with timely and expert care within labor and delivery, operating room and obstetric triage. This service was developed 20 years ago by our director, Diane Angelini, and has grown to seven nurse-midwives in our department. [We are] recognized nationally as a model for midwives as educators of medical students and residents; numerous programs have consulted with our director, including the medical schools at Duke and Vanderbilt University.

PBN: What roles do midwives play in medical education at Brown/Women & Infants?

HOWARD: We conduct many of the skills workshops, participate in core lectures, and do the introduction to labor and delivery lectures for the medical students. The medical students and first-year residents do the majority of their normal deliveries with a midwife as their teacher. Additionally, there are opportunities for them to interact with private-practice midwives, who attend 15 percent of the hospital’s deliveries. [Students are also exposed] to the hospital’s unique Alternative Birthing Center, which is located right on labor and delivery.

PBN: Tell us about your study and your findings. Why has the number of midwives in medical education grown so fast, and how might this affect women’s health care?

HOWARD: Our study found that midwives play a significant role in medical education. The number of midwives involved in medical education nationally has tripled in the last 10 years. There are many possible reasons: For example, in 2003, the Accreditation Council for Graduate Medical Education … limited all residents to an 80-hour work week. [Research is also showing] midwifery care is safe, effective, and cost-effective; learners have improved clinical experiences [when] taught by midwives; and there is a recognition of midwives as excellent teachers, evaluators and mentors.

While the advantages of midwives in medical education are numerous, the most significant is the introduction of the midwifery philosophy of care and expanded awareness of the normalcy of birth in [hospitals]. Further, interdisciplinary education is based on the assumption that collaboration [across] disciplines will not only improve the quality of patient care, but also foster communication between providers. Positive relationships with physicians in their training will ideally create respect and appreciation of midwifery management and philosophy and may foster collegial future relationships.

PBN: Are there specific areas where you see immediate opportunities for improvement in medical education at Brown, at Women & Infants and in general?

HOWARD: Improving the quality of patient care and safety in women’s health is an ongoing venture. … [It] includes using emergency drills; using evidence-based practice and standards of care; respecting all members of the team; valuing input in decision-making; and replacing hierarchical relationships with teamwork, cohesiveness and mutually agreed-upon goals. These are all in place at Women and Infants, so improvement is ongoing.

One of the many opportunities for medical education is learning from a patient-centered model of care, … and both nursing and midwifery are integral to that goal.


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