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In this episode, I talk with certified nurse midwife Liane MacPherson. Liane has been working in women’s health for over 32 years – initially as a labor and delivery nurse, and for the past 19 years as a CNM. She is also a lactation consultant, a childbirth educator, and a midwifery professor with the Georgetown University graduate midwifery program, into which she introduced Evidence Based Birth’s Higher Ed resources. Liane is taking doctorate studies, and she has trained in a variety of places – including Canada, Haiti, Germany, England, Ireland – as well as the U.S. She served in a collaborative private practice in Texas for ten years, and is now currently the certified nurse midwife director for a large OB hospitalist program.

Liane and I discuss the career trajectory of certified nurse midwives in the U.S., and she compares the American systemic viewpoint of midwives to those in other countries. We also talk about options for students pursuing nurse midwifery in today’s health care system, and the evidence surrounding the midwife/physician collaborative model.

View the transcript

Rebecca Dekker: Hi, everyone. On today’s podcast, we’re going to talk with Liane MacPherson about nurse-midwifery as a career option. Welcome to the Evidence Based Birth Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world.

Rebecca Dekker: As a reminder, this information is not medical advice. See for more details. The World Health Organization has declared the year 2020 to be the international year of the nurse and midwife, and today, I am thrilled to feature a nurse-midwife on the Evidence Based Birth Podcast. Throughout this year, we’re going to be featuring a variety of nurses and midwives, and talking about the work that they do. In episode 112, we interviewed Nurse Jessica Hazboun, and today, we are interviewing Nurse-Midwife Liane MacPherso, so sit back and listen to Liane MacPherson talk about nurse-midwifery as a potential career option.

Rebecca Dekker: Hi, everyone. Today, I’m so excited to welcome Liane MacPherson to the Evidence Based Birth Podcasts. Liane has been working in women’s health for 32 years, initially as a labor and delivery nurse, and for the past 19 years, as a certified nurse-midwife. Liane is also a lactation consultant, a childbirth educator, and a Midwifery Professor, and she’s currently part-time faculty with Georgetown University’s Graduate Midwifery Program, in which she helped get the Evidence Based Birth Higher Ed resources into their program. Liane also is taking doctoral studies and she’s trained in a variety of places and settings, including Canada, Haiti, Germany, England, Ireland and the U.S..

Rebecca Dekker: Liane was in Collaborative Private Practice in Austin, Texas for 10 years, and is now currently the Certified Nurse-Midwife Director for a large OB hospitalist program. Welcome, Liane to the Evidence Based Birth Podcast.

Liane MacPherson: Thank you, Rebecca. I’m really happy to be here. It’s exciting opportunity. Thanks for having me.

Rebecca Dekker: You’ve done so much work in the birth world, reading [inaudible 00:00:02:12], all the places you’ve been. What got you started in this journey? How did you get into labor and delivery nursing, and then nurse-midwifery work?

Liane MacPherson: Well, like a lot of nurses that are first exposed to a variety of things, it was in my training, and I was in a diploma program in Canada in my teens actually, and in my second year, I was allowed to choose a specialty and wound up in labor and delivery, where I was instantly enamored and curious, and from that point on, I really knew I was destined to work within women’s health.

Rebecca Dekker: Where were you in Canada when you went to school for nursing?

Liane MacPherson: I was in Windsor, and eventually, once I graduated and worked a little bit in the Canadian maternity system, I crossed the bridge and started working in an inner city hospital in Detroit, which was quite a very different experience from my Canadian roots, but also did reveal a lot of opportunity and difficulties that were happening in these larger urban centers.

Rebecca Dekker: Tell us about what made you make the transition from a labor and delivery nurse to a certified nurse-midwife?

Liane MacPherson: Well, throughout my career and I traveled a lot in the first 10 to 15 years, I would run into midwives. They were very few in Canada. It was not legal in the province where I trained at that time. It is now, but it’s still not nationally, but I would run into midwives, and in Detroit, for instance, there was a midwifery unit that was strictly run by midwives, but it was just this polar opposite of the more intense unit where most women didn’t have prenatal care for instance. It was almost this magical corridor, and the women and the midwives worked there and nobody really knew what went on, but it was very different from the traditional obstetric unit.

Liane MacPherson: When I moved to the States, and eventually worked in California and realized that in some of the larger systems on the West Coast, that midwives were quite integrated into the system, and so I kept brushing into midwifery, and finally, had an opportunity when I was living in England to become a registered midwife in the U.K., so I did my basic midwifery education in England and Ireland, and then came back to the States knowing fully well I would have to make some additional steps to be licensed here in the U.S..

Rebecca Dekker: What was that training like for our U.S.-based listeners to become a registered midwife in the United Kingdom?

Liane MacPherson: It was fascinating and it was really quite different for their program as well. They’ve never had a North American trained nurse who had been a labor and delivery nurse, so in the U.K. system, there isn’t such a thing as a labor and delivery nurse. There are only midwives that staff everything, and so I was coming into their system to train with 10 or 12 years of labor and delivery experience, and a lot of the theoretical and functional knowledge I already had, but I wasn’t a midwife and so I had to take that on. In the U.K., their focus is typically the prenatal, postnatal and newborn window. For instance, you wouldn’t care for woman for an annual event or you wouldn’t see them outside of pregnancy related issues, and so that was quite different, but at the same time, you also, there was no prescriptive ability within that system, so you would be associated with a general practitioner or a GP in a small setting, and they would prescribe for you, for instance, and they would see women outside of the realm of pregnancy.

Rebecca Dekker: How were the units run differently? I think a lot of people are surprised to find that labor and delivery nursing was a North American phenomenon in which if you look at the history, there was this whole history of how doctors didn’t want midwives around to challenge them, so they created this kind of role of the labor and delivery nurse, where they would do a lot of the work of a midwife, but wouldn’t have the status of a midwife to make decisions. Can you tell a little bit about how a labor and delivery unit compares, say in the United States or Canada to laboring unit in the United Kingdom?

Liane MacPherson: Yes. Really, the backbone of the obstetric model in that part of the world is midwifery. Probably 90% of the vaginal births are attended by midwives, and you flip that on its head and it would be maybe 10% in this country. When you say you’re a midwife in the U.K., that’s understood. It’s that you might, more likely deliver in a hospital setting.

Liane MacPherson: You might deliver in a home setting. It’s not presumed, but the vast majority of births attended are in a hospital setting. The woman is at the center of that choice though, and she may choose and may arrangeme midwifery service to her home. There’s home-based care, which is much more integrated. The first visit, for instance, the intake of a new pregnant woman would happen in her home typically, and then follow-up care also happens in the home for the woman, and then the intrapartum care might be hospital-based or home-based, in the units themselves, so when you come on duty, for instance, like we do in the States, you come on in, there’s 20 nurses to get report.

Liane MacPherson: In the U.K., there might be 20 midwives to get report. In the same way, you’d start your own IVs, you do all of your own care. There would be technical support and medical assistant type role to support you. Very often, it would be just yourself, the laboring woman and the partner or the family to care for not only the woman, but the baby as well, and so you’re responsible for documentation, collaboration with any of the consultants in terms of the obstetric, if there were obstetric complications. The midwives were also involved in the newborn intensive care units, and then in the nurseries, as well as in the surgical suite, so if your client or your patient, for instance in the U.K. required a cesarean, you would be expected to attend and participate in a surgery with the consultant obstetrician.

Liane MacPherson: It was a much more solid thread typically, but there were shifts. You might spend some of your time as … The midwives, you might choose to be strictly in hospital, or you might be part in the community. There were variations of the model across the country as I remember.

Rebecca Dekker: Then, culturally, it sounds like then midwifery is highly respected in those units because the midwives are kind of running the show?

Liane MacPherson: Absolutely. Yes.

Rebecca Dekker: It sounds like they’re the ones doing the work and the ones in charge.

Liane MacPherson: Yes. [crosstalk 00:08:31].

Rebecca Dekker: Then, how does that compare to kind of a typical hospital hierarchy in the United States?

Liane MacPherson: I think that varies from place to place, and certainly there are geographic areas where I feel like nursing is more autonomous and more at the center of the care with the woman, but there are more restrictions. I think autonomy is a big piece of what midwifery model in the U.K. exhibits that we don’t have here, and I think there’s some compartmentalization in the U.S. of a midwife job, a physician job, and a nursing job, and those orders are more blurred and integrated in the European system in those countries anyway. Here, there’s maybe more challenges for nurses to ask the questions and to push back if there’s a question about the plan of care, to advocate might be more challenging. Midwives traditionally hold the normalcy of birth in high esteem and support it and protect it. When you think about a system that 90% of the carers and clinicians are midwives, you can see how that spills into outcomes in terms of lower cesarean, improved maternal and infant morbidity and mortality.

Liane MacPherson: I think we would do well to model more after those kinds of systems, and we’re working towards that obviously in a lot of places in this country, but it’s slow to change, and you’re right, there’s some turf issues. There’s some territorial things. There’s some competitiveness and confusion from state to state between what the roles look like in this country. In the U.K., everyone has the same … You’re a registered midwife and that’s it, or you’re a consultant physician. In this country, we have variations of, even within midwifery obviously, so it can be [crosstalk 00:10:21]-

Rebecca Dekker: And even within physicians?

Liane MacPherson: And within physicians. Within nursing. We don’t see LVNs, of course, but now we have specialties within the obstetric nurses. We have those that go on and do additional training and say, fetal monitoring or inpatient high-risk obstetrics, so we’re further maybe siloing a little bit our knowledge base.

Rebecca Dekker: Tell me about then your journey into graduate school after that. Did you have to … Once you became a registered midwife in the United Kingdom, did that transition to North America or what did you have to do to get the certified nurse-midwife credential?

Liane MacPherson: Right. The timing was good in that Philadelphia University, which had … The Institute of Midwifery rather, was looking to begin a program as a pilot to offer foreign-educated midwives a more expeditious route to graduate studies and not to be redundant in what they had already learned. When I came back from the U.K., I became the first actual student to enroll in this advanced placement option, they called it. What I did was any content or part of the curriculum that I felt like I had already covered in the U.K., I could exempt and challenge by exam and not repeat, so I wound up doing my Masters of Science in Midwifery in a year rather than two because there’s so much that I’d already covered.

Liane MacPherson: Most of what I needed in the graduate level course was the gynecologic care, pharmacology, some of those pieces that were missing in the U.K. model, and all studies in the U.K. for midwives begin in the bachelor’s level, and here in the U.S., they are at the graduate level, so trying to bridge that took some work between the bodies that oversee that type of foreign education transcript evaluation. It wasn’t straight forward, but it’s gotten easier. There is now a piece of that program that goes on, and does incorporate a fast-track for foreign-educated midwives from various parts of the world, not only the British system. It’s encouraging because I know of many labor and delivery nurses and birth workers in this country who are midwives in their home country and don’t have an easy mechanism to make that bridge without repeating things entirely, and that’s very frustrating. You’re going to have a very experienced, very wise midwife from another place that we’ve lost that opportunity by not creating a better mechanism to bring them into the fold here in the U.S..

Rebecca Dekker: What happened next? You finished your degree in midwifery in the U.S., and I assume you began practicing as a certified nurse-midwife?

Liane MacPherson: I did. I initially sort of went where it was comfortable and joined a large team of midwives at Fort Hood, and I say that because it was also, felt a little bit like socialized medicine in that, the soldiers and their partners would come in. It wasn’t so much of a business, it operated like a big HMO, and some people might disagree with that, but the midwives took care of the midwife patients. The physicians took care of the physician patients. There was a lot of collaboration.

Liane MacPherson: The women could move within the system quite seamlessly, and that was very comfortable and familiar to me, so I started working as a certified nurse-midwife there. There were about 16 nurse-midwives in that facility at the time, and it’s the largest obstetric unit in the Department of Defense. I don’t know if it still is, but very likely, and then joined a private practice sometime later and migrated out of that.

Rebecca Dekker: You had some experience caring for military families, and then migrated into a private practice. Tell us about your involvement in higher education. What sparked you to get involved in teaching new nurse-midwives?

Liane MacPherson: Well, in fact, the foreign education piece of my training was sort of what brought me the invitation to work for Philadelphia. I graduated in 2002, and about two years later, one of the faculty reached out to me and said, “We really think that your journey might translate well to other foreign educated midwives in our program. Would you be interested in coming to join this faculty?”, so I did. I taught in that system for about six years, and then took a small break, and then joined Georgetown several years ago. I think it just, teaching is so much of nursing.

Liane MacPherson: It’s just sort of innate to the job, but trying to connect with nurses who might be frustrated at their limitations or could see other things that they wanted to do, but really wanted to stay within the realm of women’s health, it was imperative to try and sort of pass the torch and ignite that spirit in other people that might leave nursing entirely. I still see this sometimes unfortunately, where nurses get frustrated with the system or the process, and so I try and encourage them to be part of the change either within nursing or certainly going back to school and pursuing advanced practice degrees.

Rebecca Dekker: Tell us about options for students who are pursuing nurse-midwifery. Also, obviously in U.S., we have a direct entry path, but I know that you are educated as a nurse-midwife so you’re probably more … We can talk, focus more on that for this podcast. Can you talk about nurse-midwifery as like a career option for people who are interested in becoming a nurse or are already in nursing and thinking about nurse-midwifery?

Liane MacPherson: Right. I think it’s probably more likely that nurses who are exposed to nurse-midwifery either in their education or in their work settings become more curious. A lot of nurses that are training with me now, in our hospital, they’ve always had that in their mind. It’s sort of the step to become a midwife is through the route of obstetric labor and delivery job, for instance, so their end goal, they may already know, but for those that aren’t really certain, I think traditionally, we’ve thought about midwives as only being inpatient or intrapartum specialists, and yet, a lot of midwives can choose office settings and outpatient settings, and family planning settings, and it’s less restrictive. The curriculum now incorporates the same pieces as the women’s health nurse practitioner would, so there’s not really limitations.

Liane MacPherson: I think the only caveat to that is that if you, say you’re a midwife for instance, could it close a door that the employer is looking specifically for a nurse practitioner perhaps, and in some states, that’s maybe more true than others, but I’d like to think that it expands the role of the obstetric nurse practitioner or the women’s health nurse practitioner because you’ll always have that potential or possibility to do intrapartum care if you choose to, but you don’t have to. There are a lot of dual programs now as well that will offer both again for that title and for that employment opportunity, really.

Rebecca Dekker: You’re saying that a choice a lot of nurses have to make is between a women’s health nurse practitioner and the certified nurse-midwife path, which are both advanced practice registered nurse roles, but they’re slightly different and different states may treat them differently?

Liane MacPherson: Absolutely, and I think the employer filter is maybe varied from place to place. I sometimes think that it would be serendipitous to say I’m a nurse practitioner who delivers babies, and I’m a midwife, but sometimes the devil’s in the details and the titles are complicated from state to state. When I say midwife, what that conjures up for one person, whether that’s someone from the community, a consumer, or whether that’s a physician or perinatologist, can really mean very different things. In any case, for nurses that obviously are looking at their next step if they choose to, they’re looking at nurse-midwifery most likely. I think also, the idea that midwives can only work in, and certified nurse-midwives can only be in one location is really quite untrue, but maybe misunderstood, so for instance, I can attend births outside of a hospital. About 95% of nurse-midwives are hospital-based when they do intrapartum care, but that’s not to say that we have restrictions necessarily either, so it’s kind of-

Rebecca Dekker: Unless your employer puts restrictions on you.

Liane MacPherson: Correct.

Rebecca Dekker: I hear a lot of newer nurse-midwives graduating and going to work for a clinic or a hospital, and they find out that it’s going to be in their contract that they’re not permitted to attend home births.

Liane MacPherson: Yeah, and I think that’s something that’s sort of we really need to keep our eyes wide open and be careful about restrictive verbiage and contracts and have it written for your intent. I think a lot of midwives or nurses who are becoming midwives have a clear idea of where they’d like to be. I’m very encouraged by the educational programs who promote a diversity in the training, so they would encourage, for instance, nurse-midwife students to attend out-of-hospital experiences if they can because it behooves us to understand all of the layers and locations because this is where we meet our women, and there’s no good point in being divisive and being judgemental about place of birth. I think we’ve learned that, but I’m always encouraging nurses that I work with in labor and delivery to not pass judgment too quickly, to try and learn more about all of the settings for birth and be maybe not supportive, maybe it’s not their cup of tea, but to be respectful and build bridges and try and understand why women might choose or why midwives might choose to work in the place that they do.

Rebecca Dekker: What about, a lot of nurses tell me that they’re thinking about going into nurse-midwifery, but they don’t have labor and delivery experience. I’ve often told them that both types of nurses go into nurse-midwifery, and sometimes labor and delivery nurses have to unlearn their model, and it’s not necessarily a detriment if you don’t have labor and delivery experience.

Liane MacPherson: Yeah.

Rebecca Dekker: Can you talk about that and how that relates to your work with the university?

Liane MacPherson: Agreed. Yes. I think that’s entirely true. I think if anyone listening is thinking about their first year or two as a labor and delivery nurse, there are a lot of firsts. There are a lot of, “Wow, I missed that,” and those kinds of opportunities, and those are going to come in those first months of anything, and that might be in your nurse-midwifery experience or that might be in your labor and delivery nurse experience.

Liane MacPherson: It’s going to happen. I’m never discouraging. I think it facilitates the learning, so not everything’s new. It’s not so much drinking from the fire hose if you do have some labor and delivery experience, but for me personally, I think I spent far too long in labor and delivery, and you’re right, I had to unlearn and start to just change my approach as a clinician as opposed to strictly as a labor and delivery nurse. I did a lot of armchair quarterbacking as a nurse, and as I [crosstalk 00:21:27]-

Rebecca Dekker: what do you mean by that?

Liane MacPherson: Thinking in my head what I thought the clinician should do, but not really having-

Rebecca Dekker: But not saying anything or not having the power to …

Liane MacPherson: That’s- Correct. Not having the power, maybe not having the backbone at the time, and I was a very young, new nurse and thinking, I think, and ultimately what I learned about that was it wasn’t about being right or wrong, it was about being in tandem with the women that I was working with and making those decisions together, that it really wasn’t my decision or the doctor’s decision, but that it should be a decision that is thoughtfully made with people, and not-

Rebecca Dekker: You weren’t always seeing that, and as a nurse, that was frustrating?

Liane MacPherson: Absolutely. It was one of the major reasons I went back to school, is that I didn’t see collaboration with the women, and that was the part that I didn’t think I was better. I just felt like the process wasn’t as it should be, and it inspired me to become a team with the women that I was trying to serve.

Rebecca Dekker: Yeah, and tell us a little bit more about … Pick students or new midwives, one or the other. What do you think are the biggest struggles they’re facing?

Liane MacPherson: I think unfortunately, they’re the same struggles we’ve always been facing. I think, I’m thinking first of new midwives. Still, there’s not a lot of role clarity in some settings. I’ve spent my entire career explaining what I do, not only to laypersons, but also to physicians, nurse administrators, marketers, everybody across the whole spectrum. That continues to be a challenge, but I think it’s getting better.

Liane MacPherson: I think there’s more dialogue. The world is a small place. There’s a lot of information available, maybe too much, but you now can find out information about midwives in this country and it’s becoming more popular. As people are accessing statistics, for instance, and accessing documents and journal articles that suggest that this collaborative model works and has some wonderful outcomes, that they have a right to ask for it, to seek midwifery service and care, and I think it’s, the consumer push has really helped our cause.

Rebecca Dekker: I agree with you about the role clarity, and it must be frustrating for our midwives listening who have to constantly explain what it is that they do and what their role is, and I’ve heard that, a nurse member of the American College of Nurse-Midwives, and so I get access to their community forums and I see that a lot of role difficulties with physicians in particular seems to be one of the challenges, and physicians not understanding their education as nurse-midwives or not respecting their autonomy and that sort of thing, it seems to be a big kind of daily struggle for a lot of midwives. Can you tell us a little bit about some of the strategies you’ve used in your career to kind of help tackle some of these problems?

Liane MacPherson: I think first and foremost, the most potent piece of what I’ve done in my work is it’s just about relationships. It’s just about the whole actions speak louder than words. You do your job, you demonstrate your commitment to the family, to the process of birth, and over time, that translates into trust. That translates into, “I would have that midwife care for my loved one,” “I would have that person cover my practice for a few hours while I step out,” and those things have evolved in the space where I am over the last 10 years in places that I didn’t expect it, so in a very tough, compartmentalized environment, we’re now starting to see, and that’s just coming from experience. That’s just coming from doing the work, following the evidence-based strategies that we know work and carefully changing minds.

Liane MacPherson: I think, also, having women and families be your advocate as well. If they’ve had a good experience, I encourage them to talk to other people, to get the community, sharing information and directing people if they find themselves in a practice that is not compatible with their style or their hopes that they seek other care. Then, one of the reasons I’ve returned to school currently is to try and bring education to physicians about what midwives do, and furthering this education module that ACOG and ACNM had put together to try and boost understanding about how we can work together and improve maternity care.

Rebecca Dekker: Yeah, I think there’s been a big push nationally in the United States to increase interprofessional education opportunities for students, but I know that even in my home university, because there was not a nurse-midwifery educational program there, they did not include midwives or nurse-midwives in those like educational opportunities, so physicians were graduating medical school without ever even being introduced to the concept of what a midwife was or what a nurse-midwife was.

Liane MacPherson: Yes.

Rebecca Dekker: Then, that’s one of the reasons I created the Higher Ed Program, is that I could create educational modules on things like that that could be integrated into nursing programs and physician programs in the hopes that faculty would start actually teaching these concepts in class, like, “What is a midwife?” It seems so simple, but if nurses are graduating from nursing school, never being introduced to the concept of what the midwifery model of care is and how it differs from the medical model, we’re basically graduating generations of nurses who don’t understand midwifery care or maybe have misconceptions about it.

Liane MacPherson: Yes. Yes. I think interprofessional education is absolutely the way forward, and planting the seeds in the residency programs of how this can coexist and really be synergistic, I think it’s hugely important. When I mentioned relationships earlier, I think too about all of the connections within the local community, the doulas, again, the marketers within the company I work for, administrators.

Liane MacPherson: I work closely with the hospital administrative team, and when the cesarean rate, for instance, became a hot topic over the recent years, the hospital administrators turned to the midwives within our facility and said, “Help us,” and so those opportunities to build bridges and enlighten and share the work and the task of improving outcomes is now, I think a time has come, and it’s exciting. Much more optimistic than I would have been say 15 years ago.

Rebecca Dekker: Liane, tell us a little bit more about … I know one of the strategies you’ve used in your career for sustainability, because we didn’t talk about this, but a lot of midwives struggle with burnout, and the hospitalist model is one strategy, and you’re really involved in a very large hospitalist program. Can you explain for our listeners what an OB hospitalist program is and how nurse-midwives can be part of that?

Liane MacPherson: Right. It sort of stemmed out of the idea of general hospitalist. That could be a pediatric hospitalist or internal medicine, and those were physicians that really became functional workers of the inpatient experience, and they became experts because that was what they were doing full-time. Many hospitalists didn’t have practices outside, and so the laborist model or the obstetric hospital, and I use those terms interchangeably, it really is a demonstration of the subset of hospitalist physicians who worked strictly with perinatal patients. Now, laborist maybe is a little too narrow because not all of their role is about laboring women.

Liane MacPherson: For instance, it might be antenatal care, or it might be emergency consults or GYN surgery, but nonetheless, they typically do not have private practices, and so the OB hospitalist group that I am employed by really started to see this opportunity and a need to alleviate some of the burnout in the physician part of the team and say, “If we can help your patient load say overnight, or if we can help you with a high-risk patient that we can share care with, it would improve their situation.” Midwives were then added as this programs became more popular, and the bandwidth was just insufficient to support all of the requests, so midwives now are helping in hospitalist programs to carry a lot of the load, and I think traditionally, we’ve been thought of as low-risk specialists. I don’t disagree with that, but we also have a seat at the table to help in moderate and even sometimes high-risk care with close collaboration from a physician, and we’re, really, I say breathing the same air, but we are inpatient side-by-side in many cases, taking care of women together. Not unlike a neonatal nurse practitioner and a neonatologist, for instance, or an anesthesiologist and a registered nurse anesthetist. We’re sort of joined at the hip in a lot of this care, but at the same time, I’ve had some of the attendings and private physicians within our facility come and ask for suggestions on a baby that’s now positioned, for instance, or a presentation, or a family challenge that maybe they would turn to me and say, “That’s a little different.”

Liane MacPherson: “I’m not used to that. I’m going to ask the midwife,” so we’re in a place where we can bring our own subset of skills to the table, and we’re seeing reductions in cesarean rates and facilities and programs where we’re working within our company, and it’s an exciting time. The other opportunity that opens is the idea of, “I can go to work, I can do my job, I can leave my work, and I don’t have my phone in my hand,” like most many midwives are forced to do. The on call life of obstetricians, as well as midwives can be quite brutal, and you mentioned burnout earlier. This is really just one other possible opportunity for nurses who might be looking at midwifery as a profession, but they think, “Gosh, I would be every other day on call for the rest of my life.” That’s pretty daunting, and it might be really a put-off, so having other opportunities for employment is really exciting.

Rebecca Dekker: Are there lots of opportunities for employment with these types of hospitalist programs across the country?

Liane MacPherson: It is a growing entity, so we have seen a substantial growth, specifically within the midwifery population. We know that we’re going to have a bit of a bottleneck in terms of numbers of obstetrician and numbers of women needing obstetricians in upcoming years, and midwifery is probably part of the solution to that in these programs where any program that has that collaborative model, we’re going to have a shortage of obstetricians and we’re probably going to need more midwives than we’ll be producing at the rate that we are, but hopefully we’re valued as we can be in that role. It’s a new frontier really for midwives.

Rebecca Dekker: Yeah. That’s so exciting to know that that is an option too, because not everybody, like you said, maybe is in the season of their life where they can have lots of call periods, so what you’re saying is the hospitalist is more like shift work, so you are assigned to certain shifts to be with families and caring for them.

Liane MacPherson: Exactly. When I first took on the role, I was a little apprehensive because I loved the longevity of the midwife relationships with my families. In private practice, I had known many of them for 10 years or more, and so I was a little hesitant, but what I realized as a hospitalist midwife is that I can also midwife in small increments, and midwives will connect with this, I hope, that I can be a midwife in a triage room in five minutes, I can still deliver the midwifery model of care in different ways in different roles. I can still honor and calm a room of a woman who’s come to our hospital who doesn’t have an attending physician, who doesn’t have any kind of birth plan, but I can still be a midwife to her regardless of the title that I’m carrying, so it’s really opened my eyes and it’s a different kind of work. It’s not the same thing we think of in traditional midwifery jobs, but it is a very unique opportunity and incredibly rewarding, much more so than I thought it would be.

Rebecca Dekker: Liane, is there anything I can help you with? Do you have any questions for me today?

Liane MacPherson: I was thinking about this and wondering what your thoughts are, and you’ve had your finger on the pulse of the trends within this country. How do you see the collaborative model? Are there parts of it that are inspiring to you, concerning to you? What’s your take on where we’re going?

Rebecca Dekker: What do you mean by the collaborative model?

Liane MacPherson: The midwife-physician collaboration.

Rebecca Dekker: Oh, where to begin? I think there’s a lot of geographic variation.

Liane MacPherson: Yes.

Rebecca Dekker: Not only around the world, but also within the U.S., and even within the same city. You can have one facility where there’s very good collaboration, one where there’s a very toxic environment, and I really do think it all boils down to education. There’s actually research showing that when you incorporate midwifery into physician residency education programs, that outcomes improve and the physician residents learn so much about the role of a midwife, but not only that, but they learn about things like how to facilitate breastfeeding, and how to attend a water birth, and how to catch a baby when the birthing person’s on hands and knees, so I think we have to start with our youth, with our students, because in many ways, it’s very difficult. I have this image in my head of a hill, going uphill with this giant, massive stone that’s like taller than me, like a boulder, and you’re like pushing it up the hill. In terms of trying to get physicians to collaborate respectfully with midwives in the United States, like I said, obviously there’s some places where it’s happening, but there are other places where it is most definitely not happening.

Rebecca Dekker: I think until we have a reorganization in addressing this problem in medical school, in residency, it’s going to continue to be a problem, but I think if you educated every medical student this year about nurse-midwives and direct entry midwives, and what they do and what their model of care is, and what their outcomes are, five or 10 years from now, the entire landscape could look different in our country. At this point, one of my struggles is how do we reach those people who are in charge of educating the new physicians? It’s incredibly difficult to connect with physicians on social media, although we have some amazing dedicated physician listeners and followers who subscribe to our emails. They are in the minority, obviously of our audience, but also in terms of their colleagues aren’t necessarily listening to us or following us. I’ve really struggled with how to connect with more physicians in a massive kind of way because obviously, one-on-one connections are important, but we can’t create massive culture change.

Rebecca Dekker: If we just reach one physician here and one there, it really needs to be done on a system-wide scale. That’s one thing I see, and if we have any listeners out there who are involved in medical school education or residency education, feel free to reach out to us at so we can help you get plugged in. I was talking with one physician who was saying they want all of their residents to read the Babies Are Not Pizzas book that I wrote, which includes a chapter all about the power hierarchy and explains the history of midwifery in medicine in our country, and I was like, “Yeah.” I mean, little things like that, like if we could just educate people about our history and where we came from, I think then we can move forward, but so often in this country, we make the mistake of just kind of living in the present, maybe griping about the present and complaining about the present, and we don’t fully look back on what has happened in the past and in our history, and how that has impacted things today, so we don’t learn lessons from our background, if that makes sense.

Liane MacPherson: Right.

Rebecca Dekker: I hope that answers your question.

Liane MacPherson: It did. Yes. Thank you.

Rebecca Dekker: All right everyone. Thank you so much, Liane for joining us today. We really appreciate hearing your journey and learning more about these career options for nurse-midwives.

Liane MacPherson: Thank you for the opportunity. I really appreciate it.

Rebecca Dekker: Hi, everyone. Thanks again for joining us for today’s interview with Liane MacPherson as we continue to celebrate the International Year of the Nurse and Midwife. If you’re interested in learning more about our Higher Ed resources at Evidence Based Birth that can be used in nursing schools, midwifery schools, medical schools and residency programs, as well as with doula trainers and childbirth educator trainers, just go to That’s, and you can learn more about our online resources for students. Thanks, everyone, and I’ll see you next week. Bye.

Rebecca Dekker: Today’s podcast was brought to you by the Savvy Birth workshops, developed by Evidence Based Birth. We have an amazing group of more than 150 Evidence Based Birth instructors who are teaching Savvy Birth workshops all around the world. I designed the Savvy Birth workshops to help parents who have to give birth in an imperfect healthcare system. Then, professionals started asking for workshops to help them too, so we created the Savvy Birth Pro Workshop to help professionals, doulas, childbirth educators, nurses and others who feel stressed by the limitations of the healthcare system their clients are facing. If you want to figure out how you can get better care, even if you’re giving birth in a broken system, then these workshops are for you.

Rebecca Dekker: Visit to find out if there’s an instructor in your area, and you can also find a list of our upcoming workshops for parents and pros by going to



Listening to this podcast is an Australian College of Midwives CPD Recognised Activity.

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