When she reflects on her experience having kids, Abby Zamora chuckles and admits many women, and even traditionally minded men, probably think she’s crazy.

“I love pregnancy, labor and delivery,” she says. “If you love something, you do it.”

She’s had ample opportunity to test that love. Zamora, 36, and husband Steven have three children of their own – daughters 7 and 4, and a son, 5. She’s also been a gestational surrogate for intended parents. She delivered a baby boy for a couple in January 2019, and is now in the fourth month of a second “gestational surrogacy journey” for another couple.

“Being able to give the gift of a child to someone is beyond words,” Zamora said.

Not that she romanticizes pregnancy. Zamora was in labor for 48 hours with her boy, one of her three “keepers,” as she put it, and finally chose an epidural to manage the pain only in the last two hours. She had little pain with her first daughter, but was in labor for 36 hours and delivered after three hours of pushing. Those kids both arrived past their due dates. She jokingly calls her youngest “her favorite” because she arrived three days early – the other two were past due – after “only” 10 hours of labor.

Insisting on a nurse midwife-assisted birth

Aside from the unswerving supportive presence of Steven, one factor unites Zamora’s deliveries. They all happened under the care of certified nurse-midwives at UCHealth University of Colorado Hospital on the Anschutz Medical Campus. These midwives are part of the UCHealth Center for Midwifery, which along with other sites provides care from certified nurse-midwives across the metro area (see box).

When the attorneys for the couple whose unborn child Zamora now carries told her they wanted her to deliver with an obstetrician, she, in turn, delivered a simple message. “I said, ‘It’s my midwives or I’m walking,’” she recalled, and held her ground successfully.

The mini-confrontation begs a couple of questions. Just who are these nurse-midwives and why should there be resistance to them? It’s an especially opportune time to pose the questions. October 4 marks the start of National Midwifery Week. In addition, the World Health Organization has declared 2020 the Year of the Nurse and the Midwife.

Specific training and roles

As to what they are: Certified nurse-midwives are registered nurses who complete master’s-level midwife education programs approved by the national Accreditation Commission for Midwifery Education. They receive certification after passing an exam through the American Midwifery Certification Board.

Certified nurse midwives assist during childbirth, but they provide a range of services encompassing women’s health before, during and after pregnancy. In so doing, they “augment” the care provided by maternal and fetal medicine specialists, obstetricians, and family medicine physicians, said Jessica Anderson, director of Midwifery Services and associate professor of Clinical Practice at the University of Colorado College of Nursing (CU Nursing). Anderson noted that 2020 marks the 40^th year of the midwife education program at CU Nursing, which was recently named one of the top  midwifery programs in the country.

“We are a unique profession and serve different purposes,” said Anderson, who delivered Zamora’s third keeper. For example, nurse-midwives refer their high-risk pregnancy patients to physician specialists, but physicians also refer low-risk patients to midwives.

“Patients want options to choose what is best for them,” Anderson said. “They also have the ability to move around the spectrum of care based on their health care needs. We augment each other rather than compete.”

Setting aside stereotypes

The reality of midwives stands in stark contrast to stereotypes Zamora says some people still cling to.

“When you mention nurse-midwives, people may think of a hippie chick coming to your door, giving everyone a shot of vodka and you have a baby in your living room,” she chuckled. But she admits her decision in 2012 to have a nurse-midwife assist in her delivery concerned even husband Steven at first. “Everybody’s stigma is that you’ll have a home birth, unmedicated, with someone with no medical training,” Zamora said.

That’s far from the reality. All women who receive care from nurse-midwives at UCHealth and the University of Colorado deliver at University of Colorado Hospital, where higher-level care is readily available if it’s needed. (About 94% of certified nurse midwife-assisted births nationwide occur in hospitals.) That fact, and a few visits with Abby’s nurse-midwives, quickly allayed Steven’s fears and, later, the concerns of the attorneys for the intended parents of her current surrogacy.

Why choose a certified nurse midwife-assisted birth rather than an obstetrician? It’s still a relatively uncommon choice, representing only about 9% of births in the United States. Anderson said midwives use their nursing and midwifery skills to create a “personalized” experience for women that focuses on meeting their individual needs and expectations for childbirth and their health as a whole.

Individualized approach

Zamora said she appreciated the “quiet strength” that her nurse-midwives projected during each of her births. They stood ready to call in additional medical care if a problem arose, like the baby’s heart rate decelerating with contractions. With her second biological child, her prolonged labor led her midwife to warn she might need induced labor or a C-section instead of the natural birth she wanted. But after she agreed to medications to help her sleep, she emerged “re-energized” to get through the rest of her labor. She asked for an epidural, her midwife checked her progress and approved, and Zamora delivered her baby about two hours later.

The example illustrates her midwives’ consistent commitment to letting her listen to her own body and make the calls on how her labor should proceed, she said.

“They let me labor and do what I needed to do and what I felt I was comfortable with,” Zamora said. She could move from the tub used for water births to a birthing ball to the bed – anywhere that made her most comfortable while the midwife and her team “let it roll” and did whatever they could to help her.

“They made me feel I was in control of the situation,” Zamora said.

Midwife-mom partnership

Anderson characterized the relationship between mother and midwife as a “partnership” based on “shared decision making” that allows women “to make decisions that are best for them.” The idea is to find “a happy spot” where higher-level interventions are available but used “at the right place, at the right time and with the right patient.”

That might mean, for example, needing to go to a cesarean delivery because of concerns for the baby’s heart. Or it might mean support interventions like water labor to avoid an epidural if the mother doesn’t request one.

There is some evidence that this approach has pay-offs that extend beyond patient satisfaction. Some studies show lower rates of C-sections for women cared for by nurse midwives, resulting in significant cost savings. Anderson noted that while epidural pain medication is always an option for women, a “significant chunk” of women assisted by certified nurse-midwives don’t choose that option, another resource-saving. A 2012 summary by the American College of Nurse Midwives outlined other benefits of certified nurse-midwife care, including reduced use of anesthesia, higher rates of breastfeeding and fewer instances of complications, like perineal tears during childbirth.

Wanted: more nurse-midwives

These benefits and ongoing pressures on health care resources point to the need to expand the number of midwives and the places they provide care, Anderson said. It’s no easy task to accomplish.

“It costs money to start practices,” she said. “We need institutional support and we need to find ways to engage more physicians to hire and collaborate with midwives in their practices.”

Another important challenge, Anderson added, is educating enough midwives to meet the needs of the communities they care for.

“We think part of the answer is to expand the midwifery workforce and support more midwives of color,” Anderson said. She noted that the American College of Nurse Midwives issued a position statement on racism and racial bias that in part commits to “increasing racial and ethnic diversity within the profession.”

Anderson said work is underway on the Anschutz Medical Campus to find ways to “recruit more diversity into our faculty and educational programs. We want to impact the future and have programs that are sustainable. Ultimately, we need more midwives.”

In the meantime, UCHealth continues to expand the number of practices offering certified nurse-midwife services within its system. The newest site, at UCHealth Highlands Ranch Hospital, opened in March. Despite the challenges of the COVID-19 pandemic, the midwife practice there is “talking about adding more clinic days,” Anderson said. That would add to the nearly 20,000 visits and more than 1,500 births handled by UCHealth midwives in 2019, she noted.

Important option for women

Abby Zamora, preparing for her fifth birth, believes women stand to benefit from greater access to midwife services. She continues to meet regularly with a rotating cast of midwives for her pregnancy care, which continues to six weeks after she gives birth. But she’s now taken that a step further and has moved all her women’s health care to the Center for Midwifery.

After four previous births, visits with the midwives for her current pregnancy are “like coffee with a friend,” Zamora said. She’s still deciding on her final birth plan. She had a water birth for her first surrogacy but hasn’t yet decided if she will do that again. She knows that whatever happens, her midwife will be prepared to adapt to the situation.

“They don’t give false hope that the birth is going to go the way you want it to happen,” Zamora said. “You’re not surprised if it doesn’t happen that way.”

The idea is to help families have a “healthy, empowering launch into the next phase of parenthood,” Anderson concluded. “We are here to help individuals achieve the birth experience they have envisioned.”