Cutting the Cord
Bayview Midwifery Program Faces Cuts
Sixty-six years later, a midwifery was launched at Johns Hopkins Bayview Medical Center in a similar spirit. The program--which started with two nurse-midwives in 1991 and grew to six at its peak earlier this year--primarily serves East Baltimore, home to many poor women who have difficulty getting access to even basic medical care. Many are also drug addicts, and in its first year the midwifery teamed up with Bayview's mental-health staff to open the Center for Addiction and Pregnancy (CAP), where for 10 years now the nurse-midwives have provided around-the-clock prenatal care and performed more than 100 deliveries annually.
But like Breckinridge and her colleagues, who in the wake of their early efforts were displaced by doctors, the nurse-midwives at Bayview are now being supplanted by physicians. Back in the 1930s, distrust by doctors dramatically reduced the number of midwife-attended births across the country; Bayview officials say budgetary constraints forced them to slash the midwifery earlier this month.
Coming off three years of losses and facing a deficit again in the new fiscal year, Bayview administrators began a belt-tightening spree this past spring, implementing freezes on hiring and raises. The moves didn't suffice, and on April 2 all five nurse-midwives learned their jobs would be eliminated July 1. The measure was later revised to retain two nurse-midwives part time to provide prenatal care only.
Dr. Reuven Pasternak, president of Johns Hopkins Bayview Physicians, the doctors group that runs the Eastern Avenue facility, maintains the move--the only actual budget cut for the year--will save "several hundred thousand dollars" without sacrificing the personal and continuous care midwives provide. But Bayview's nurse-midwives contend they've been stripped of the very core of what they do--care for women throughout an entire pregnancy--and they worry CAP patients in particular will suffer. The nurse-midwives, who specialize in treating substance-abuse problems, will no longer be on call to assist women in crisis; as with deliveries, physicians and residents will assume that function.
Some local midwives view the cut as the latest in a series of steps doctors across the country are taking to squelch advancement of nurses in the medical field, a claim Bayview doctors deny.
"We're taking the total number of deliveries and balancing the most economical staffing model that provides appropriate services against the ideal. Nobody disputes that if [money] weren't an issue, we would love to have the nurse-midwives continue in [their previous] role," Pasternak says. "In no way was this a proxy to try to eliminate the nurse-midwife role."
"Then why aren't they doing births?" counters Lily Fountain, a professor at the University of Maryland School of Nursing and co-legislative liaison for the American College of Nurse-Midwives' Maryland Chapter. "They have been pushed out. This has happened a lot to us, it's called the pat-on-the-head syndrome. We've been told, 'Your services are very good, but the practice is being closed.'" Fountain says several other Maryland midwiferies have closed in recent years. Last year the Bayview practice represented five of the 160 nurse-midwives practicing in the state.
While for the most part Bayview's nurse-midwives have found other jobs, the pink slips have triggered a campaign to salvage the midwifery. And following a July 3 meeting of nurse-midwives and doctors, prospects for not just a reinstated but an expanded midwifery are now taking shape.
Bayview, which is run separately from Johns Hopkins Hospital and is financially self-sustaining, is reeling from a managed-care system that has left hospitals nationwide responsible for services that are only nominally reimbursed by insurers. With a large number of indigent and uninsured and underinsured patients, the hospital has become increasingly dependent on federal Medicaid reimbursements that are much skimpier than those of private insurers. And because CAP patients, who accounted for 43 percent of all midwife deliveries at Bayview in fiscal year 2000, fall within that uninsured category, the midwifery became an expensive program to operate and, by extension, a likely program to cut, Pasternak says. Besides, with residents rotating through the obstetrics unit several times each year, there are already employees capable of performing deliveries, he says.
Bayview's nurse-midwives--who earn between $64,000 and $68,000 a year and are registered nurses in addition to being certified as midwives by the American College of Nurse-Midwives--challenge Pasternak's logic. Nurse-midwife Debbie Doerfer, who recently lost her job at Bayview, wants to know who will pick up the CAP phone in the middle of the night and know that the patient calling is in pain because of her abscesses from intravenous heroin use. Who will tend to her toothaches, earaches, sexually transmitted diseases, domestic-violence wounds, and hunger, and understand that due to addiction they're all related? Doerfer doubts it will be the busy attending physician or inexperienced resident, and she argues that the constant, attentive care a nurse-midwife can offer saves money over the long term.
"A continuum of care, ultimately, it's to have a positive outcome--to keep the baby in [utero] longer so that when it's born it's more at-term and a healthier baby," Doerfer says. "And the continuity comes with building a trustful relationship with all patients. We stay with them throughout their labor. To be delivered by a resident that they've never met before, it's disheartening. That's when you need us the most."
Since April the nurse-midwives have been arguing that case, and in recent weeks doctors who control Bayview's purse strings have begun listening. (It hasn't hurt that state senators Paula Hollinger [D-Baltimore County] and Barbara Hoffman [D-Baltimore City/County] have also contacted ranking Hopkins physicians, patients have penned dozens of postcards, and WJHU radio talk-show host Marc Steiner has dedicated an hourlong show to the subject.) On July 3 both sides agreed to work to "reinvigorate" Bayview's midwifery, Pasternak says.
"Over the next four to five weeks, [we hope] to come up with a solution," he says. "What we decided to do was explore with them alternatives for expanding the nurse-midwife service beyond CAP so that patient volume can help sustain the nurse-midwife program and the [hospital's] teaching program."
Stressing that such a solution hinges entirely on funding, Pasternak says Bayview officials are angling for private grants, and for untapped Baltimore City Health Department drug-treatment dollars. They also hope that with the planned Jan. 1 merger of Bayview with Johns Hopkins Hospital, Bayview will enjoy a larger pool of possible funding sources. Meantime, the doctors have asked the nurse-midwives to draft a proposal for expanding their patient base, and a plan to increase midwifery services at Bayview clinics that serve high percentages of privately insured patients (namely, White Marsh) is currently underway.
"I think there is still a lot of skepticism; I think the budget is still the bottom line of what's important to [Hopkins officials], beyond patient satisfaction," Doerfer says. "But they would like us to build the private practice or the quote-unquote paying patients, and I think we do have a market. I'm guardedly optimistic."
Fountain, meanwhile, remains mostly guarded. "We haven't seen anything definite," she says. Even Bayview's back-pedaling away from the cuts makes her wary. The back-and-forth, she says, "tells me that it was a very sort of whimsical decision, and that, I think, shows the perceived lack of power of nurse-midwives, which is something we're working very hard to counter."
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