Building a Modern, Evidence-Based Midwifery Practice

In advanced practices, contemporary nurse-midwifery is an evolving, inclusive and welcoming service that supports the whole family. Historically, nurse-midwives have focused primarily on delivering newborns and are sometimes erroneously thought of as primarily lay attendants to births.

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At Massachusetts General Hospital, the clinicians who comprise the Midwifery Service in the Department of Obstetrics and Gynecology are regional and national leaders who bring an expansive community health focus to an evidence-based practice that addresses patients' needs long before and after a due date. The service includes more than 20 certified nurse-midwives who deliver more than one-quarter of the babies born each year at Mass General, which totals more than 10,000 babies in the past 25 years.

"Our nurse-midwives have a deep and broad commitment to the community because they were part of the original team in 1994 that brought obstetrical practice back to Mass General after an absence of nearly 40 years," says Susan Hernandez, CNM, MSN, chief of the Midwifery Service. "That shows our commitment to serving the community and to the tight integration of midwives into the Mass General medical and surgical obstetrical practice."

Continuum of Care

Nurse-midwives at Mass General provide the full spectrum of reproductive health care for patients, from family planning to helping to establish breastfeeding, from care for pregnant women with substance use disorder to services for gender non-conforming parents in collaboration with the Transgender Health Program.

In addition, the nurse-midwives are the only advanced practice clinicians at the hospital who have been granted Harvard Medical School faculty status. Katherine Rushfirth, CNM, MSN, associate chief of the Midwifery Service, notes, "This is highly unusual for a medical institution and speaks to the value placed on midwifery within the obstetric practice."

Nurse-midwives also participate in discussions on quality and safety within the department and take part in quality assurance simulations alongside their physician colleagues.

Interdisciplinary Practice

It is commonly assumed that nurse-midwives are appropriate caregivers only for low-risk pregnancies, but because of the robust resources and integrated practice at Mass General, they routinely care for moderate-risk patients as well. If a patient develops complications during pregnancy that necessitate escalation of care, the integrated practice model means that the patient can be smoothly transferred from one clinician to another.

"Because of our multidisciplinary, collaborative practice, we can provide whatever birth experience a woman chooses, from no- to low-medication to epidurals and everything in between," Hernandez explains. "This has allowed us to serve a huge diversity of women, a much broader population than most midwife practices."

Rushfirth points to the low rate of cesarean sections at Mass General as one indicator of the effectiveness of this interdisciplinary practice.

"We have an 11% primary C-section rate, and this is a testament to our nurse-midwives and our physician colleagues working together and trusting one another," she says.

Pushing the Practice Forward

In addition to the clinical care they provide for patients, the nurse-midwives at Mass General have been at the forefront of initiatives to improve the Obstetrics Program for all patients. They have been leaders in the Baby-Friendly Hospital Initiative, which calls for postpartum practices like skin-to-skin and rooming in that promote breastfeeding and early bonding between babies and families.

The midwives helped initiate the use of nitrous oxide during labor, helping to expand the options available for mothers interested in natural childbirth and partnered with local doulas to support patients throughout pregnancy and labor. They have also been involved in research initiatives within the department, including a study that sought to decrease the number of opioids prescribed to mothers during the postpartum period.

Community Health Values

Mass General's clinical practices include three community health centers that serve very heterogeneous populations with a wide range of needs in surrounding communities. The nurse-midwives have long been the primary providers of obstetric care in these practices, and today they deliver approximately 80% of the patients from them.

Hernandez serves on Mass General's multidisciplinary team that assesses patients with social high-risk factors for complications, such as a substance use disorder.

"There are certain very high-risk medical conditions, such as poorly controlled diabetes and high blood pressure, that many midwife practices don't typically handle. Because of our integrated practice with physician colleagues, we play an active role in triaging these sorts of obstetric complications and helping address other risk factors, such as drug and alcohol use," she says.

The team has brought this expertise into new initiatives within the OB/GYN Department to meet emerging areas of patient need, such as the HOPE Clinic, a multidisciplinary program that helps patients navigate pregnancy, early parenting and substance use recovery.

Serving the Whole Family

Nationwide, supporting families adjusting to parenting demands and a new baby is an emerging priority area of care during what is often called the "fourth trimester."

"The U.S., in general, has a pretty poor postpartum system. We don't have paid parental leave or a system of home visitors that they do in Europe," says Rushfirth. "In our practice, there is more emphasis on the fourth trimester, the transition to parenthood, and we strategize with public health providers to make it effective."

Part of this involves getting the gender culture right—meeting the needs of LGBTQ+ families and patients of all gender identities in a welcoming, inclusive, affirming environment. At Mass General the team accomplishes this through staff awareness trainings, site visits to establish positive relationships and careful attention to using inclusive language in consults with patients and in written materials.

"We are moving away from 'moms and babies' to engaging with whole families," Rushfirth explains. "It's all part of the historical evolution of midwifery."

Learn more about the Obstetrics Program

Learn more about the Midwifery Service