The greatest benefit to having hospital privileges is the continuity of care that one can provide for women requiring antepartum or intrapartum referral. The woman needing antepartum hospitalization, or develops pregnancy complications that dictate a hospital birth, can remain in the birth center practice, with her care managed collaboratively by the physician and the nurse-midwife. This gives clients with many types of pregnancy complications the benefits and familiarity of continued midwifery care while adding the needed obstetrical care. The established relationship between the client and the nurse-midwife can be extremely valuable in helping the client to understand and to cooperate with management decisions such as bed rest and testing prescribed by the obstetrical specialist.
For the client requiring intrapartum referral, the nurse-midwife who cared for her during labor at the birth center can continue to manage her care at the hospital, either alone or in collaboration with the physician. The nurse-midwife who has been involved in her care throughout labor knows the clinical picture and what the management has been so far. This allows for much better continuity than if the client's care is taken over completely by someone who has not been involved in the management of her labor before the hospital admission.
Families are much less reluctant to transfer to the hospital if they know the nurse-midwife with whom they have been working in labor will continue to manage their care and most likely attend the birth. There is more trust that their needs will be met and less fear that they will lose control. Although we have always accompanied our clients to the hospital, the difference in the family's comfort with a situation in which "their" nurse-midwife is present merely as a support person and one in which she is "in charge" is tremendous.
As a result of this increased comfort, families are more relaxed, less defensive and respond better to hospital personnel. They don't feel as if they have to "fight" to get what they want. They are much more likely to view the hospital staff as people who are there to help them instead of as "bad guys." Families trust and respect the nurse-midwife with whom they have established a relationship and may respond defensively to what they perceive as the hospital staff's lack of recognition of the nurse-midwife's expertise. If there is a good and respectful relationship between the nurse-midwife and hospital personnel, the family is more likely to view everyone as working together with their best interests in mind.
Another advantage is that the nurse-midwife does not feel defensive because she has more control and is more familiar with hospital staff and procedures. Moving from managing labor at the birth center to a situation in which one completely turns over management to another provider is very difficult, even given the best of relationships between nurse-midwife and consulting physician. When the nurse-midwife is able to continue managing the care, either alone or collaboratively, she is less likely to feel that her management is being criticized or discarded. She can also ensure that the desires of the family are met to the fullest extent possible given the particular complication. She can communicate the family's wishes to the hospital staff without appearing to be critical since she is also "one of the staff." It is quite conceivable that the nurse-midwives and family's comfort with the hospital may affect decisions regarding transfer in those "grey" clinical situations.
The hospital personnel also feel less defensive, and are less likely to view the family's preference for an out-of-hospital birth as a direct criticism of the hospital. After all, some of the birth center clients actually choose to have their babies in the hospital. Consequently, the staff is more likely to be understanding of the family's desire for a birth center birth and more likely to be flexible about the family's desires. Since they are now more accepting of their need for the services of the hospital, the staff can respond by being more sympathetic about the family's disappointment with the need for transfer. Another subtle but important advantage of birth center nurse-midwives having hospital privileges is the opportunity for the hospital personnel to see the nurse-midwife practice, both managing normal labors and dealing with complications. This exposure leads to improved credibility for the nurse-midwife. Before we had hospital privileges, the only context in which the nurse-midwife's practice was seen was that of the physician taking over when there was a problem. This was often viewed by hospital staff as "rescuing" the nurse-midwife. Indeed, one of the nurses said to our consulting physician, "Every time those midwives come over here they have a complication!" The physician, of course, pointed out that if there was no complication, the midwife didn't need to be at the hospital! This nurse's statement illustrates the limited view one may have of nurse-midwifery practice and expertise if one does not have the opportunity to actually work with nurse-midwives.
The financial benefits of having hospital privileges are significant. Women requiring referral to the hospital usually can remain in the birth center practice, with the physician and hospital billing for the specific services that they provide. The birth center bills for the services that it provides, money that would have been lost if the client were transferred completely out of the practice. This is particularly significant when antepartum problems develop which preclude out-of-hospital birth but not nurse-midwifery care.
Practicing in the hospital provides the nurse-midwife from the birth center with many opportunities, both formal and informal, to be involved in changing policies and practices in the hospital. Informal discussions with nurses, residents, attending physicians, medical and nursing students offer wonderful opportunities to share philosophies about maternity care and to educate about birth centers and midwifery. These non-threatening, informal discussions plant seeds that can grow into significant change! Formal presentations of birth center statistics, research and birth center care can begin to correct misconceptions which are often held by health care providers who have no direct experience with a birth center. Participation on department and hospital committees also offers the opportunity to add a different perspective to the work of these groups, and perhaps to help bring about change. Working in these groups also broadens the nurse-midwife's perspective and teaches her about facilitating change in large, complex institutions.
When nurse-midwives have hospital privileges, the nurse-midwife and physician are able to do more collaborative management. This is challenging, interesting and a good learning experience for both nurse-midwife and physician. The two professionals learn from each other and both improve their practice. They learn to communicate well and to respect one another's expertise and philosophy. The client has the advantage of a team approach offering high quality care that is in everyone's best interest.
Access to hospital conferences, case reviews and medical libraries provides excellent educational opportunities for the birth center staff which might otherwise be unavailable.
The perils of hospital privileges are both practical and philosophical. On a practical note, more coverage is needed for call since more than one site must now be covered. While one nurse-midwife, with the help of a nurse, can usually care for two clients at the birth center, she cannot be in two places at once. Assuming that the philosophy of staying with clients in labor is maintained for those clients at the hospital by choice or by medical reasons, a second nurse-midwife must be available for back-up call. This can be difficult in birth centers with a small staff.
The birth center nurse-midwife is constantly reminded that, while the birth center is a place for the practice of midwifery, the hospital is a place for the practice of medicine. In the birth center, the whole system is designed to nurture the practice of midwifery. In the hospital, medical practice is the norm, midwifery is "different" and thus much more of a struggle. This is something that nurse-midwives in hospital-based practices have always known. The difference, however, can be glaring and quite uncomfortable if one is accustomed to the supportive environment of the birth center. It is simply easier to practice midwifery in a birth center. We continue to breathe a sigh of relief when we return to the birth center, and appreciate the ease with which we can practice according to our philosophy.
Since medical practice is the norm, it is easy to slip into a more medical model in the hospital, even for labors and births that are essentially normal. Because the nurses expect, and are more comfortable with, increased intervention, it can be easier to give in than to resist it. There is the ever present danger that some things which initially made one uncomfortable (and which should make one uncomfortable) in the birth center may become comfortable, or at least not acutely uncomfortable, because of repeated exposure in the acute care setting. Separating babies from mothers, routine continuous monitoring and the use of epidurals as a replacement for constant attendance in labor may begin to feel not so bad. This settling into a measure of comfort about such things makes the nurse-midwife less effective as a change agent, and can change her practice in substantial ways. Being able to practice primarily in the birth center helps to keep us firm in our philosophy and to remind us why we believe what we do.
Although being able to practice in both settings is important, switching back and forth can be difficult. One's practice can be substantially different in the two settings, an adjustment that can be hard, especially for the inexperienced nurse-midwife. The nurse-midwife may find that she feels a little less comfortable in either setting. Another risk of the birth center nurse-midwife practicing in the hospital, and doing more collaborative management, is that she may find herself managing things with which she is not totally comfortable. Without hospital privileges, the intrapartum referrals are "clean." It is perfectly clear that the physician is now totally managing her care. With collaborative management, there is a danger that there will not be clarity about who is managing and what the management is. The physician may overestimate the nurse-midwife's capabilities, and expect her to manage situations which she should not be managing. Or, he simply may not want to come in when the nurse-midwife is already there. Likewise, it can be very seductive when the physician says, "You can handle it." The nurse-midwife may be reluctant to say, "I don't feel comfortable with this." This pitfall is probably more likely to occur with the experienced nurse-midwife, who may be embarrassed to say, "I don't know enough about this." It is critical that the nurse-midwives and the physicians be aware of this potential risk and maintain open communication. The nurse-midwife must not be reluctant to tell the physician when she wants him to take a greater role in management. The physician must accept the nurse-midwife's need to take a lesser role and respond without impatience.
The addition of hospital privileges for nurse-midwives practicing in the birth center has many advantages and offers many opportunities. It is, however, a "character-building experience" which can be very difficult. An awareness of the potential risks allows the nurse-midwives to develop strategies for minimizing these risks.