Giving birth to her two daughters was an exhilarating and empowering experience for Kim Baraona, CNM, MN. She also loved helping other women having babies in her job as a labor and delivery nurse.

"I taught Lamaze childbirth classes and would take a woman through the hardest part of the labor process and then would have to turn over the delivery to the doctor, who often wasn't as attuned to the woman's needs as I was," she said. "I became a certified nurse-midwife, so that I could give women the continuous care they deserved."

After 15 years, Baraona still loves participating in one of the most joyous moments in someone's life. "I still feel like each and every birth is a miracle," she said.

Baraona practices at Maternal Gynerations, a private practice of physicians, certified nursemidwives and nurse practitioners in Lawrenceville. The group delivers about 100 babies a month at Gwinnett Medical Center.

"Our practice provides the best care for women because each of us has a different set of skills to meet their needs. We're a team," she said.

Certified nurse-midwives provide prenatal, delivery and postpartum care for women with normal or low-risk pregnancies. But their scope of practice has expanded over the years to include collaborating on high-risk pregnancies, assisting with Caesarian sections, and providing gynecological care for women of all ages. Most work autonomously but collaboratively with physicians.

"Our aim is to form a partnership with the woman and her family, to educate them about the options and to listen. What's important to her becomes important to me," Baraona said.

"Certified nurse-midwives stay with their patients throughout labor. If a woman needs me sitting at the bedside, then that's where I am."

Having a birth attendant boosts a woman's confidence and decreases the risk of complications, she added.

Baraona's "evidence-based" practice means staying abreast of research, managing each case individually and knowing when to call a physician for an opinion.

"If a mom is doing well and on top of the contractions, then I keep encouraging her," she said. "If she feels like she's in a nightmare and it's getting worse, then it's time to pull out the tricks. When you use medication, you're always weighing the negative with the positive side effects."

Adding to the challenge, patients today come from many cultures and speak various languages. Practitioners find themselves working with employees who can speak Spanish or Vietnamese, using language translation lines or relying on a patient's relative to interpret.

"When all else fails, I try and explain through pictures," Baraona said. "It's hard because we're so verbal and believe so much in education. Sometimes, you learn to be quiet so you don't confuse people."

She also has learned that Hindu fathers can't see the baby until after a religious leader comes and chooses the baby's middle name and that Jewish fathers aren't supposed to see the baby's birth.

"I'll deliver the mother turned on her side (away from the father) and covered with a sheet, so that the father can still be there and hold her hand. You're continuously learning about what patients want and what is culturally acceptable," she said.

Culture shock

Desiree Clements, MS, CNM, said that one of the most difficult cultural differences she deals with is working with African women who have been circumcised.

"You might have to break open scar tissue to deliver," she said. "I've learned a lot about different cultures, family dynamics and child-birthing views. Normally, we try to get fathers involved to foster bonding, but Muslim men can't be in the room, so you respect their culture."

Clements, who practices at Southern Crescent Women's Healthcare and delivers at Southern Regional Medical Center in Riverdale, said nurse-midwifery has taught her patience and compassion. She loves giving women options and being able to develop bonds of trust over time.

Nurse-midwives deliver about 10 percent of births nationally, according to the American Academy of Nurse-Midwives.

"Georgia has one of the highest percentages of certified nurse-midwives in the country (about 380 practitioners), but occasionally we have a patient who doesn't understand what we do," Clements said.

In the South, where there's a rich history of granny-midwives, many people don't realize that certified nurse-midwives have been educated at the master'sdegree level and have passed a national certification exam.

When Clements explains the training, the focus on women and education, most patients are willing to work with her.

"We're delivering more babies as more people get to know about us and learn that we're not about home birth with no medication," said Jane Mashburn, CNM, MN, FACNM, specialty coordinator of the midwifery program at Emory University's Nell Hodgson Woodruff School of Nursing.

In fact, certified nursemidwives deliver about 97 percent of their babies in hospitals and most patients choose epidurals or IV pain medication.

"There's a lot of good data to show that women have better experiences and outcomes when there's someone continuously present to help them cope through labor, and I like the feeling of being able to empower women," Mashburn said.

Practicing at the Emory Clinic at Crawford Long Hospital in Atlanta, Mashburn offers mothers choices during labor: walking, different positions, bouncing on a birthing ball, sitting in a tub, back rubs, cool cloths, hot or cold drinks.

Mothers may choose to have family members present or may bring their masseuses, aroma therapists or favorite music.

Mashburn, a graduate of Emory University's first midwifery class in 1978, has seen the popularity of nurse-midwives grow, especially as studies have shown that they have helped to decrease medical interventions during birth, to lower C-section rates, to reduce hospital costs and to improve access to care for underserved populations.

Mashburn also has seen the scope of practice expand into primary care and gynecology.

Challenges ahead

While she's often as tearyeyed as the parents when babies are born and considers it a privilege to share their experience, Mashburn never loses sight of the fact that the lives of the mothers and babies are her responsibility. Describing the job as "physically and emotionally draining," she has real concerns about recent challenges to nurse midwifery practice.

"The nation's 41 programs used to certify about 500 midwives a year, and now it's dropped to 250 to 300. That's worrisome. There may not be enough midwives to meet the future demand, and with nurse-midwives so busy, we have trouble finding preceptors for our students," she said.

Mashburn said that the nursemidwife population is aging and finding it harder to stay up all night and keep office hours the next day. Baraona noted that nurse-midwives aren't always adequately compensated for all the hours they work.

Economic issues are, by far, the greatest threat to the profession, said Michael McCann, CNM, with WellStar South Cobb OB-GYN.

"Because of managed care, capped reimbursement costs and the steeply rising cost of liability insurance, most OBs have had to move into volume obstetrics, " McCann said. "We have to deliver 150 babies a month for our practice to be profitable. If you're in a situation where you can't make an income, you can't practice. That's the bottom line."

Some physicians have closed their doors. Smaller groups have let nurse-midwives go, and patients have less time with their providers.

But at the same time, the number of patients is growing. McCann has learned what he calls "obstetrical espanol" - enough Spanish to support the growing Hispanic population that comes to the practice through the county health department's Green Plan Program.

"Every institution has to take some responsibility for treating the underserved; that's a part of what we do," he said.

The increasing number of patients can make it tough on nurse-midwives.

"You have to learn to triage your time based on who needs you most," McCann said. "Some nights feel like an episode of 'ER.' As you move from patient to patient, it may be 18 hours before you sit down.

"The labor and delivery nurse who looks at what we do, the hours, the malpractice risks ... has to take a deep breath before deciding to become a certified nurse-midwife. It takes a lot of self-confidence and a real desire to do this job."

Despite the challenges and the additional stress of being a man in a nontraditional role, McCann said that he still likes helping to bring babies into the world after 24 years.

"It's rewarding," he said. "This week, I had the unique experience of delivering the baby of a woman whom I had delivered years ago. I'm into my second generation."