August 2022
This month we talk with Sarah Stetina, CNM, and Director of Burr Ridge Birth Center, on her advocacy and championing work within midwifery. Sarah discusses the role midwives play in partnership with OB/GYNs and healthcare specialists, and how inclusion of evidence-based practices can significantly improve reproductive health outcomes.
Sarah Stetina is a Certified Nurse Midwife with a commitment to providing evidence-based and trauma-informed healthcare in a community setting. She serves as the Director of Midwifery at the first free-standing birth center in DuPage County, Illinois: Burr Ridge Birth Center. Sarah believes birth center models are a solution to achieving birth equity and optimizing reproductive health for the communities they serve.
Sarah's midwifery career is preceded by birth work as a doula, home birth assistant, and Labor and Delivery nurse. While working in the hospital setting, Sarah was a change agent for evidence-based practices such as implementing skin to skin in the OR, delayed bathing for newborns, and educating others on supporting physiologic labor and birth. While practicing hospital-based midwifery, Sarah continually championed for the preservation of waterbirth as an option for birthing families, as well as for the revisions of restrictive, non-evidence-based policies surrounding VBAC, elevated BMI, and fetal monitoring. She has supported hundreds of births, including VBACs, during that time with stellar outcomes.
Trauma-informed care has become a hallmark of the care she provides. Serving as the Director has afforded the opportunity for policy development and culture creation of a space that is welcoming, evidence-based, radically inclusive, and trauma-informed in every interaction. Sarah hopes Burr Ridge Birth Center will be an example of exceptional care and outcomes for families and help to close the gap in health care disparities for BIPOC families.
SHWI: How did you become interested in reproductive health and midwifery? What inspired you to open Burr Ridge Birth Center?
I stumbled upon my passion for reproductive health care, specifically midwifery, while I was in nursing school. I had witnessed birth as an undergraduate nurse and knew intuitively, even as a 19-year-old, that our perinatal care system was falling short for families. When I lamented to my professor regarding the harms I felt I was observing, she introduced me to the concept of Nurse Midwives. I fell quickly and deeply in love with all facets of the profession. Once I learned that midwives were linked to improved health outcomes, I knew midwifery should be the standard of care in the U.S, rather than the exception; I wanted to be a part of that shift. I fully immersed myself in the world of reproductive health and midwifery from that moment forward.
I have had the opportunity to care for birthing people for the last decade across many roles and settings but found myself continually pulled towards a community-based setting. As I was starting my midwifery journey, free-standing birth centers were finally legalized in Illinois, and this model felt best aligned with the type of midwifery I admired and wanted to practice. Birth centers have phenomenal birth outcomes across the country, provide deeply individualized care, and support midwives to practice with autonomy and evidence-based policies. Shortly after joining a hospital-based midwifery practice I started exploring the ways I could create a birth center that encompassed everything I envisioned healthcare could look like. With the support of Birth Partners Inc, we were able to make Burr Ridge Birth Center into a reality in 2021. BRBC is the third birth center in the state and the first in our county.
SHWI: For those who aren’t familiar with midwifery, can you share more about its background and the role it’s played throughout history? Also, how do midwives interact with other healthcare providers during pregnancy and birth?
Midwifery is a distinct and separate profession from obstetrics that specializes in a low intervention approach for healthy, low-risk pregnancies. The Nurse Midwifery’s scope of practice also includes well body care, gynecological care, abortion care, contraception, and in some settings the co-management of high-risk pregnancy and birth with physician’s partners.
Today, in most of the world, midwives serve as the primary maternity care providers, outnumbering OBGYNs by several fold, specifically in countries that reserve the expertise of obstetricians for high-risk, complicated pregnancies only. However, historically in the U.S, midwives have been underutilized and their ability to practice has been restricted or limited for decades. Even with a steady rise of midwife-attended births annually, midwives still attend a fraction of the births in the country (about 8-10%). Research shows that this low utilization and access to midwifery is severely impacting the U.S. maternal and newborn morbidity and mortality rates, which continue to rise. The Lancet Series on Midwifery found that “national investment in midwives and in their work environment, education, regulation, and management is crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health.” Unfortunately, the majority of the U.S. public remains misinformed or unaware of the benefits of midwifery care and many states’ legislation make it difficult for midwives to practice at the full capacity of their training and skill level.
Ideally, midwives should function as any other member of the interprofessional healthcare team. Outcomes are best when midwives have professional and collaborative relationships with obstetricians and other physician specialists that allow for collaboration and coordination of a client’s unique health needs. Mapping Integration of Midwives found that when states have integrated midwives into their maternity care system the indicators for maternal and newborn health improve significantly. Midwives are well integrated into the healthcare system when they can easily facilitate access to hospitals, equipment, medication, and physician care when necessary for their clients. “An integrated maternity care system facilitates the full exercise of scope of practice, autonomy, self-regulation, and collaboration across disciplines.”
In my current midwifery role, we have the benefit of a well-integrated midwifery practice in a community birth setting. We have great professional relationships with our physician colleagues and are in partnership with our local Level III hospital for transfers when indicated. Additionally, we collaborate regularly with maternal fetal medicine, obstetricians, endocrinologists, neonatologists, nursing, etc. when necessary.
SHWI: Tell us about your birth center Burr Ridge and your team. How do you and your midwives empower and support clients in their birthing choices? Additionally, what approach do you take to include trauma-informed care in your services?
Burr Ridge Birth Center is a free-standing facility that focuses its care on the foundation of client-autonomy, evidence-based policies, and trauma-informed practices. All these buzzwords essentially convey that we are being intentional to create a healthcare space that is safe, empowering, and personal in order to achieve excellent outcomes. We are a small knit team of highly skilled nurse midwives, registered nurses, educators, and an essential administrative team. We also have an incredible Medical Director, OBGYN, who wholeheartedly supports the midwifery model of care and is a fantastic resource to our clinical team.
The hallmarks of midwifery care, such as longer visits, education, and health promotion, paired with a relationship-based approach, leads to clients feeling empowered and confident in their healthcare experiences. We have longer prenatal visits, lower client caseloads, and a smaller midwifery team which allows clients to build strong relationships and trust with our team. We take a holistic approach and try to make each health encounter personal and individualized. Our midwives and nurses make informed consent and client autonomy the gold standard of their care, which means providing clients with all their options, educating them on the risks and benefits of interventions, and supporting them through decisions, even if the client deviates from our recommendations. The process of informed consent and respecting client autonomy are both examples of a trauma-informed care approach as well.
Trauma-informed care means creating a clinical environment that is safe, trustworthy, compassionate, and empowering. We consider that each client that comes through the door may be bringing with them past traumatic experiences, from medical trauma, sexual assault or abuse, birth trauma, and more. We try to create a space that clients feel safe to disclose, but even when they don’t we approach our conversations and physical exams with a “standard precautions” approach. In action it might look like eliminating the use of “stirrups'' from practice, offering self-insertion of speculums, only performing pelvic or cervical exams when medically indicated, learning to perform mindful gentle vaginal exams and providing clients the language to withdraw consent and end exams at any time. Something as simple as considering the way our exam table is positioned in our clinic rooms, so clients never feel exposed in the direction of the door, and providing them with real fabric robes and sheets to be covered and comfortable instead of thin paper gowns that rip. Every aspect of the way we have come to expect our health care experience can be reevaluated to provide a more positive experience.
SHWI: During the pre-pregnancy stages, how do you support women in their fertility journey? Additionally, what are some of the ways you provide postpartum support for your clients?
Although we are a “birth center”, our midwife team provides full scope midwifery care including preconception and well body care. We are able to support clients who are preparing for a pregnancy with education about their cycles and health promotion/risk reduction. We help support them with troubleshooting basic fertility concerns and will soon be implementing a IUI program for clients who desire initial fertility attempts in a lower intervention, holistic setting, rather than a fertility clinic. Regardless of whether clients need lab work, imaging or referrals to community professionals like chiropractors, herbalists, reproductive endocrinologists, or mental health specialists, we can provide it.
In regards to postpartum support, this is where birth centers shine. Postpartum support in the U.S is notoriously poor compared to other countries, commonly offering only a single visit with their provider six weeks after the birth. We know that in those first few days and weeks postpartum, families need much more support and are at high risk for complications to be missed if not being seen (preeclampsia, postpartum hemorrhage, postpartum depression/anxiety, lactation and feeding issues, and more). Our birth center sees clients and their newborns at multiple touch points following birth, seeing them four times prior to the traditional 6-week visit. Those visits are an hour long and focus on lactation, newborn growth, sleep promotion, mental health, physical healing, education, and emotional support. We often identify problems early, leading to earlier intervention, and our families feel much more held during what is a very challenging transition in someone’s life.
SHWI: What are some changes you’d like to see more widely addressed within the standard healthcare model, particularly as it relates to sexual health, pregnancy, or birth?
As I mentioned previously, the underutilization of midwives feels like the biggest issue in regard to improving reproductive health in the U.S. That isn’t a problem that can be fixed overnight and will take significant policy and healthcare culture changes. However, in the meantime, reproductive health providers can make changes immediately to improve sexual health, pregnancy and birth, starting with what happens inside of their own clinic rooms. I mentioned some suggestions of ways we implement trauma-informed care at Burr Ridge Birth Center, but there are many resources available for providers who are unfamiliar to learn more about how they can make small changes that have a big impact on client experience and health. Stephanie Tillman, of Feminist Midwife, is a trauma-informed care expert whose work I deeply admire. She is a great resource for any providers looking to learn how to implement trauma-informed care and why it is important.
Resources
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30397-1/fulltext
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0192523
https://www.feministmidwife.com/