Growing number of midwives venture out on their own

SPRINGFIELD, Ore. - Three years ago Michele Bouche and another nurse-midwife were summoned to a meeting with the office manager of their employer, a group of five obstetric-gynecologic (ob-gyn) doctors in Springfield.

"He said, `Give us your keys and your pager, and don't come back after lunch,' " Bouche recalled. The physicians said that it no longer made sense to keep midwives on staff because managed-care plans were cutting their fees.

Bouche, 49, decided to take a shot at running her own business. Her McKenzie Midwifery & Women's Services became profitable in August, after 2 1/2 years.

Bouche is among nurse-midwives who have ventured out on their own, providing routine gynecologic care and delivering babies in hospitals.

"It's just so much more personal, and they take your needs so much more seriously," said Jessica Walker, 26, of Springfield. When she went into labor with her second child, Marissa, a year and a half ago, her midwife met her at the hospital and stayed at her side, massaging her back, applying hot towels and giving words of encouragement until the baby was born.

The obstetrician who had attended the birth of her 4-year-old, Shane, provided technically skillful care, Walker said, but was there only for the final pushing. And she felt pressured to agree to electronic fetal monitoring and other interventions.

Nurse-midwives emphasize more hands-on time with women than do most physicians. But unlike traditional "direct entry" midwives of the home-birth movement, nurse-midwives must have graduate school credentials to practice, and in all 50 states they are licensed to prescribe drugs and work in hospitals.

In Oregon, nurse-midwives attended 13 percent of hospital deliveries in 1997, more than double their share 10 years earlier, according to the Oregon Health Division.

Research suggests that women with nurse-midwives fare at least as well as those cared for by physicians.

Such findings help explain why nurse-midwives are attracting growing numbers of women who are educated and well-off, in addition to their traditional clients, the poor and uninsured.

"We're not talking about the home-birthers," said Helen Gordon, a business consultant and former nurse-midwife in Raleigh, N.C., who specializes in women's health care.

"These are women who want to deliver in a hospital but want to be the captain of their own ship in terms of their health-care needs."

Most nurse-midwives work for a physician group or a hospital and draw a salary of typically about $60,000 to $80,000 a year. But a busy midwife can collect more than $250,000 a year in patient billings.

"A lot of midwives don't understand the revenue picture," said Karen Parker, an entrepreneurial Portland nurse-midwife who has become a role model for midwives across the country.

For 13 years, Parker worked as a home-birth midwife. Then she enrolled in the nursing school at Oregon Health Sciences University and in 1994 earned a master's degree, a requirement for certified nurse-midwives in Oregon and a few other states.

Rather than apply for a salaried position, Parker made a bold pitch and joined a group of ob-gyn physicians in Portland as an independent associate.

Parker keeps total control over the dollars coming in to her practice. She pays for her share of the office overhead.

But starting an independent nurse-midwifery business takes work, and complications do arise. Among them: gaining privileges to work in a hospital, a domain run largely by physicians, some of whom view nurse-midwives as unwanted competition.

But midwives still must find obstetricians willing to take responsibility for any patients who might require specialized care, such as an emergency Caesarean delivery. Some have problems doing that.

Katherine Jensen, a nurse-midwife in Roseburg, Ore., is suing Mercy Medical Center, the independent practice association of local physicians and Roseburg Women's Health Care, her employer for 14 years until the group of ob-gyn doctors fired her in 1997.

"I want an avenue for the independent practice of nurse-midwives in this town," Jensen said. "I think women need to have a choice."

Mercy Medical Center's president, Vic Fresolone, said he agrees that women deserve the choice of midwifery. Two nurse-midwives employed by Roseburg Women's Health Care have privileges at Mercy.

Fresolone said the hospital will grant privileges to Jensen as a self-employed practitioner, but only if she can arrange to be backed up by another ob-gyn physician.

Jensen's dilemma is that no local doctors will take on that responsibility.

She has opened her own birth center but said she still hopes to gain admitting privileges to Mercy, the only hospital in town.