The real midwives of Glenwood Springs
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GLENWOOD SPRINGS, Colo. — Lindsey Bischoff believes she was born to be a midwife.
Bischoff traveled the world as a labor and delivery nurse for nearly two decades before landing at Valley View Hospital in Glenwood Springs where she said she can practice midwifery care.
“I probably worked in 20 other hospitals, and this is one of the first hospitals that has an abundance of midwives,” said Bischoff, who is a certified nurse midwife.
“Anybody who walks in the door, they get a midwife.”
The hospital’s labor and delivery floor is primarily staffed by certified nurse midwives, which is not the norm at most hospitals where physicians attend 90% of hospital births.
At most hospitals in the United States, pregnant people decide between a physician or a midwife – if a midwife is an option at that practice – to help them deliver their baby. But Valley View Hospital is unique.
A physician is called in if the pregnancy is high risk and requires intervention, but certified nurse midwives, or CNMs, provide the bulk of the hospital’s obstetric care.
The hospital adopted this shared model of care in 2014.
“In a more physician-led model, you're going to have a lot more medical intervention early on,” said Shannon Dilley, director of the women’s health clinic at Valley View Hospital.
“That's one of the main reasons why we're doing this model is because it's just a lower intervention, more natural model from the outset.”
The hospital’s cesarean delivery rate is about 24%, which is lower than the Colorado average of about 30%. Dilley attributes the hospital’s midwife-first model of care with the lower number.
Cost-savings was another important factor in the decision to staff more midwives, Dilley said. There are eight CNMs and five obstetrician-gynecologists on staff and a midwife’s salary is typically one third of what it costs to hire a physician.
Dilley said offering a traditional physician model with the same level of care and services offered by the midwives would increase the cost of the program by almost 30%.
“We could not afford to provide the level of service that we do if we had a more traditional physician-based model,” she said.
“It allows us to maintain a lower cost of care model and provide a lot more care to our lower income patients, our Medicaid patients, and also provide superior care to our patients with more traditional commercial insurance,” she said.
What is a certified nurse midwife?
Bischoff said she doesn’t deliver babies, she catches them.
The pregnant person does the delivering, she said.
“It's a very special career because you're helping these souls come earthside and helping these women be empowered,” Bischoff said.
Bischoff described the midwifery approach to birth like being the lifeguard at a pool: keeping a watchful eye on the situation, ready to jump in if something goes wrong, but otherwise letting the birth take its natural course.
Bischoff first became interested in birth when she helped her childhood dog deliver puppies. She attended nursing school and worked as a labor and delivery nurse for 16 years.
While assisting physicians in hospital births, Bischoff felt like the people giving birth were not given much choice or voice in the process. She decided to return to school to become a certified nurse midwife so she could help people deliver babies on their own terms.
Certified nurse midwives work in hospitals, birthing centers and patient’s homes. At the beginning of her midwifery career, Bischoff worked in a birthing center, which is a facility separate from a hospital that provides a more home-like environment for people with low-risk pregnancies.
A certified nurse midwife is different from a certified midwife. Both require a graduate degree and have generally the same knowledge, Bischoff said. But certified midwives are not nurses, and they are not licensed to independently practice in every state. (They can practice in Colorado.)
Bischoff said finding a job as a CNM is difficult. In the early 20th century, childbirth in the United States moved largely from the home to the hospital, and people became more familiar with physician-led models of obstetric care.
Midwives are commonly used in other countries, including Germany, where doctors are required by law to consult a midwife during delivery.
In the United States, people are still much less likely to call the midwife, though midwifery is growing in popularity. In 2021, midwives attended 12% of U.S. births, which is up from almost 4% in 1990.
“We kind of got a little hip checked by the doctors to say that birth is scary [and] birth can cause issues,” Bischoff said. “We're kind of making a comeback saying, ‘No, you can take the high risk moms that have issues. Let us still continue to do the low risk moms.’”
“When you're pregnant, you're not sick. When you're having a baby, you're not sick,” she said.
Carmen Mendez is eight months pregnant with her fifth child, a boy after four girls. Her first two children were born in a California hospital with a doctor attending the birth.
Mendez decided to go to Valley View because the hospital is just 10 minutes from where she lives now. This is her second pregnancy under the care of midwives.
“I've had that really, really nice care after delivery which is a way different experience than I had with my other two that I had in California,” Mendez said. “Here, it's amazing. It's the care that they give you, [and] the way they treat you.”
Mendez said Bischoff doesn’t make her feel rushed through her appointments or like she’s in a hurry, which is not what she had come to expect at the doctor’s office.
Annie Edgecombe also chose Valley View Hospital because it’s 30 minutes away from her home on the highway. Edgecombe gave birth to her toddler son, Morris, at Valley View Hospital and is 24 weeks pregnant with her second child.
Edgecombe, whose mom delivered her with a midwife in the early nineties, was open to being cared for by a midwife during her pregnancy. Though she was surprised by how medical the process still was under a midwife’s care.
“I feel like a lot of people, when they hear midwives, they think of herbs and gongs and crystals and that kind of thing,” Edgecombe said. “[The midwives] prescribed all of my medication through my pregnancy. They did all of my blood work.”
Certified nurse midwives also provide general women’s health care, such as birth control, pap smears, mammograms and annual exams.
At Valley View Hospital, that’s the kind of work that Bischoff and her fellow CNMs do at the women’s health clinic, which is just steps from the hospital’s labor and delivery unit.
Accessing obstetric care in a rural area
Both Mendez and Edgecombe were able to find the maternity care that they wanted relatively close to where they lived. That’s not the case for everyone living in rural areas.
Edgecombe said she has several friends driving to Grand Junction or Aspen, both more than an hour away from Glenwood Springs, for their obstetric care.
“This is one of our only labor and delivery units within an hour of here, and it serves people who live within three hours away,” Edgecombe said. “I know some people drive hours, and when you're in labor, it's not always a time sensitive thing, but it's something you want to consider.”
Dilley said access to public transportation in the region is pretty limited, making traveling far for medical care difficult for those without their own vehicle.
More than half of rural hospitals across the United States do not have a labor and delivery unit. This is because more and more rural hospitals can’t afford to keep them open, due to high staffing costs and inadequate payments from insurance and Medicaid plans.
Dilley said that even with the hospital’s cost-effective model of midwife-first care, her department loses money every year.
“It's very costly to run an obstetric unit because it has to be staffed 24/7,” Dilley said. “It requires a really heavy nursing presence in a way that a lot of other units don't.”
In response to the dwindling number of labor and delivery units in rural Colorado, the University of Colorado Anschutz Medical Campus launched an initiative last year to train more certified nurse midwives to work in rural hospitals.
The initiative covers tuition and fees for about three to five students each year. One of those students, Tessa Huizenga, worked at Valley View Hospital over the summer, learning from the certified nurse midwives there.
Huizenga grew up in rural Wyoming, where she said her mom had to drive two hours for her prenatal appointments. In high school, she shadowed physicians and nurses at the clinic in town, which she said were “constantly on the edge of getting shut down.”
“It definitely emphasized how important it is to have care where you live still,” Huizenga said. “I just really wanted to get back to a smaller town and having the option to get the extra training and the scholarship and stipend was a huge bonus.”
Valley View Hospital’s labor and delivery unit is the largest within a 100 mile radius, Dilley said. It’s also one of the few that doesn’t cap the number of Medicaid patients it accepts.
In Garfield County, where Glenwood Springs is located, about 40% of residents earn less than $38,000 annually, which the county considers its “low-wage earning group.”
“Patients are coming here to deliver,” Dilley said. “So we need to make sure that we're providing the most comprehensive service that we can. I think that's why it's so important that we maintain this mixed midwife model.”
Dilley said many patients are recent immigrants. About half of the patients Bischoff sees in a day at the women’s health clinic are native Spanish speakers.
Before she became a midwife, Bischoff spent three months in Peru learning Spanish. For the last year, she attended weekly Spanish classes to better communicate with all of her patients. Bischoff said education is a key part of the care a midwife provides.
“Just because she speaks a different language does not mean she doesn't get a midwife that is talking to her for hours and encouraging her,” Bischoff said. “I need to learn her language so then I can help her and encourage her and make her feel calm and comfortable.”
A model for the future
Valley View sees about 700 deliveries each year. Dilley said she hasn’t found a similarly-sized hospital practicing the same model of care as them yet.
“I could absolutely see midwifery as a future of rural health care,” Dilley said.
“Especially in places where you have enough deliveries to support both that midwife-first model and an appropriate number of physicians to make sure that you're maintaining the holistic nature of the OB/GYN practice in your community,” she said.
Labor and delivery units are not big money-makers. But Bischoff said the labor and delivery experience is often her patients’ first impression of a hospital.
The experience they have – whether in the hands of a midwife or a physician – might determine their decision to seek out that hospital’s care for future health events or concerns.
When Annie Edgecombe arrived at Valley View ready to give birth to her son Morris, the midwife asked her what kind of birth she wanted to have. A joyful birth, she said, was her only request.
That’s the experience Edgecombe said she had, and it’s what Bischoff hopes to send all of her patients home with – along with their new baby.
“For me, it's another day. But for them, it's one day,” Bischoff said. “How she felt with her body and [whether she] had a voice will determine the way she tells her child that birth story forever and ever.”