On the Rise

Under Cara Busenhart’s direction, KU’s nurse midwifery program continues to grow

Photo of Cara Busenhart, Ph.D., CNM, APRN, FACNM, program director of advanced practice and midwifery education programs at the KU School of Nursing.

SELDOM A DAY GOES BY that Cara Busenhart, Ph.D., CNM, APRN, FACNM, program director of advanced practice and midwifery education programs at the KU School of Nursing, doesn’t have to explain what her job is to a well-intentioned but misinformed curiosity-seeker. For the record, Busenhart is not a doula – she’s a nurse-midwife.

The jobs of doula and midwife might seem similar because both involve child birth, and usually neither is a doctor. But that’s pretty much where the similarities end. A nurse-midwife is a trained medical provider certified in nursing and women’s health care. They can deliver babies and dispense pain medications along with a host of other women’s health care services. Doulas, on the other hand, are more like childbirth coaches, offering support and advice to families during the birthing process.

The history of midwifery dates back thousands of years, and for centuries the role of midwives in childbirth has been shrouded by mysteries, myths and folklore. In 16th and 17th century Europe, for example, rumors about midwives flourished and consequently these women were high on the list during witch hunts. Although remnants of the mysteries still prevail, modern midwifery myths come more in the form of misinformation than being mired in mystical magic.

“When you say the word ‘midwife,’ people think of peasant skirts, incense and home births,” said Busenhart. “While that does describe some nurse-midwives, it doesn’t describe the majority of us and certainly not me.”

Midwifery: More than just delivering babies

Nationally, midwives started making a comeback in the 1970s and ‘80s as more women began seeking more intimate alternatives to traditional hospital births. And the number of women opting for a midwife today is still small but growing. In 1989, the first year data was kept, midwives were the lead care providers at just 3 percent of births in the United States, according to data from the Centers for Disease Control and Prevention. In 2014, the National Center for Health Statistics reported that the number had risen to 8.3 percent, or 332,107 births nationwide.

While delivering babies, either at home, in a women’s clinic or in a hospital, is still a big part of their practices, today’s nurse-midwife treats a much broader range of women’s health care issues. In addition to attending childbirths, midwives provide well-woman care, family planning and gynecological and annual physical exams for women across a vast spectrum of ages. In addition to birthing duties, midwives often times help care for the babies through their first month of life along with tending to the health care needs of their mothers.

“People don’t understand that we do the whole realm of women’s health care across their lifespan,” Busenhart said. “They really think all we do is pregnancy, but it’s much more than that. It’s so rewarding when you take care of a woman across her lifespan: you see her when she’s not pregnant; then you see her through a few pregnancies, and you build a relationship over time.”

“As an advanced practice nurse, the nurse-midwife brings the nursing perspective into the care of women,” added Sally Maliski, Ph.D., RN, FAAN, dean of the KU School of Nursing. “The care is provided within the context of her stage in life, family, community and unique circumstances.”

Most prevalent among the misconceptions about nurse-midwives are the beliefs they aren’t formally educated, restrict the use of some pain-management techniques, and accommodate only natural childbirths for babies delivered in birthing centers or private homes. Busenhart said most people are shocked to learn is that 95 percent of births attended by certified nurse-midwives are performed in hospitals. But the lack of knowledge doesn’t stop there.

“And then some people think they can’t have some of the usual pain management,” she said. “Certainly, we can help women who choose not to have a lot of interventions, but we can offer pain management and support as well.”

Surprise beginnings

Busenhart came into the world as part of a set of surprise twins born in Kansas City, Missouri, to Nancy Gower and Robert Cochran, and to this day, the sisters are seldom far apart. Her sister, Diana Richter, is a pulmonary/critical care nurse practitioner at a The University of Kansas Hospital.

A regular on the Dean’s List at Truman State University, Busenhart graduated in 1998 magna cum laude with a Bachelor of Science in Nursing and departmental honors. Her father’s tragic death in an auto crash the next year solidified Busenhart’s belief that she had made the right decision becoming a nurse. It also gave her a profound respect for the difference that nurses can make for a patient and family.

“I had been a labor and delivery nurse for several years when I went back to school, because I knew I wanted to do something more than staff nursing the rest of my career,” said Busenhart, who earned a master’s degree in nursing from the University of Missouri–Kansas City (UMKC) and a certificate of nurse-midwifery from a collaborative program between KU and UMKC. “I actually started in the nurse practitioner program, and I knew when I was in advanced training that I didn’t want to get away from women and labor. I knew I wanted to work at the advanced level in that area, and that’s how I found my way to be a nurse-midwife.”

After working in a large OB/GYN practice in Johnson County, Kansas, Busenhart joined the graduate faculty in the UMKC School of Nursing in 2008, but her career took an abrupt turn when midway through that first year of teaching, Ginger Breedlove, her mentor and program director while a midwifery student at KU, informed her she was leaving and would like Busenhart to take her place as director.

“While I had always dreamed of a position like this, I never imagined it would occur so early in my career,” she said. “I was honored that she would think of me and leapt at the opportunity to teach in the only nurse-midwifery program in a six-state region.”

Taking charge

There are currently 25 students in the KU School of Nursing’s nurse-midwifery program, with graduation numbers going from five this upcoming May, followed by a class of nine and then 11.

“When I was a senior in high school, I had the opportunity to see a birth when I was shadowing on a maternity unit,” said Amber Clark, a midwifery student originally from southwest Kansas who is in her final year of the program. “It was the single most amazing life experience I ever had up to that time. The mother, husband and two small children were present in the room together when they welcomed the newest member of their family. I remember thinking ‘this is how it is supposed to be.’”

And as the numbers continue to build in the KU Midwifery Program, the totals for nurse-midwives working throughout the Kansas City metropolitan area are growing as well. Even with the increase in popularity, Busenhart realizes they have a way to go when it comes to educating the public about their chosen vocation.

“We have more midwives in the city, particularly since the time I was a student,” said Busenhart, who estimates that in her years of practice she has delivered nearly 500 babies. “But we’re still not to the place where when you say nurse-midwife people know what that is. But we’ll get there eventually.”

Historically, doctors and midwives have clashed on a variety of issues, but primarily over philosophical differences in their approaches pregnancies and births. Whereas many doctors see pregnancy as if it were like an illness in that the mother needs medical interventions so the birth can advance as safely and quickly as possible, midwives subscribe to the belief that things should progress in a more natural manner on a timetable dictated by the mother and child, resulting in a less-stressful experience.

“I’d say that’s pretty good,” said Cathcart-Rake.

Perhaps Busenhart’s most rewarding personal breakthrough as program director came in 2013, when her efforts led to midwives being granted practice privileges at The University of Kansas Hospital ‒ a first for both the school and the health system. In fact, her primary practice is currently conducted on Friday afternoons in the OB/GYN unit at KU Hospital where she manages triage, attends births and supervises medical students, residents and nurse-midwifery students. There is a nurse-midwife on staff, and Busenhart has a collaborative agreement with OB/GYN department.

“I feel very supported here, but I know in some places it can be a struggle. The physicians here [...] do such a wonderful job of respecting the normalcy of pregnancy and supporting the values of midwifery.”
- Cara Busenhart, Ph.D., CNM, APRN, FACNM

“My proudest accomplishment is attending births at KU Hospital,” said Busenhart, who also remains a women’s health care provider for JayDoc Free Health Clinic once a month. “It took many years and individuals to make this happen, but I’m proud of the relationships that I built and nurtured to bring this to fruition.”

In her practice at KU Hospital, Busenhart says the physicians and staff have been positive and supportive. She said one of the reasons for the mutual respect is because as a teaching hospital, nearly everyone is up to date on the most recent literature. That allows them to follow the research and clinical practices that have proven to be the safest and most effective procedures, whether the job requires a doctor, a midwife or a labor and delivery nurse.

“I feel very supported here, but I know in some places it can be a struggle,” Busenhart said. “The physicians here, even with the high-risk population they deal with, do such a wonderful job of respecting the normalcy of pregnancy and supporting the values of midwifery.”

Home on the range

As it has for decades, the need for additional health care practitioners in rural and underserved areas continues to pose a problem, especially when it comes to caring for women and newborns. Among U.S. states, Kansas ranked 27th with an infant mortality rate of 6.2 per 1,000. In 2014, data showed 77 of Kansas’ 105 counties did not have a doctor specializing in obstetrics and gynecology or a nurse-midwife. As a result, in many places family practice physicians are delivering most of the babies. The scarcity of health care professionals trained to meet the medical needs of women before, during and after pregnancy shines a bright light on one of the starkest realities facing rural states now and in the foreseeable future – something must be done to meet the needs.

“There are vast areas in the state where there is no OB provider, and so nurse-midwives could really help out in that respect,” Busenhart said. “Unfortunately, some of these areas are the most resistant to midwives. But we’re working with the legislators to remove some of the barriers.”

Busenhart is not alone in her belief that university-trained nurse-midwives could help ease the shortage of health care professionals for women in a state as geographically large as Kansas, where a trip to the physician can often takes hours.

“As we strive to address the shortage of health care providers in the state, particularly in rural areas that are experiencing an acute shortage of primary and specialized providers, educating nurse-midwives is one of the ways that the KU School of Nursing can contribute to solving the problem,” Maliski said. “We continue to support excellence in the education of nurse-midwives for the state and advocate for opportunities to grow.”

Currently there are approximately 70 practicing midwives statewide, most of whom are currently clustered in metro areas. And the number of freestanding birthing centers statewide can be counted on one hand. So, it appears there is room for potential growth in the nurse-midwife population, and the need is such that it could greatly benefit Kansans across the state.

Under current law in both Kansas and Missouri, nurse-midwives need to have a signed collaborative agreement with a physician stipulating that they work closely together in order to practice. During the last few years, Kansas legislators, like those in many other states, have grappled with desire of some to grant nurse-midwives more autonomy in their practices as a means of potentially easing the burden of a lack of health care providers, with the safety concerns of some in the medical community.

Generally speaking, nurse-midwives are involved primarily in what are considered medically low-risk pregnancies and deliveries. As the leader of the only nurse-midwifery program in a six-state area, Busenhart is doing her part to help educate the state’s leaders as they debate the pros and cons of the health care shortage issues.

“While most educators don’t love interacting with legislators, I know that it’s work that I must do to support the health of my patients, the health of Kansas and the future of my profession,” Busenhart said. “In recent years, much of my education and patient support has been in front of policy makers and legislators.”

Midwives making a difference

To see how a nurse-midwifery center can benefit communities in rural Kansas, one need only travel to the tiny Amish farming community of Yoder just south of Hutchinson in south central Kansas to experience the atmosphere of a nurse-midwife-run clinic, where more than 600 babies have been born in a cozy, home-like environment during the last 14 years.

In addition to delivering babies, the clinic also provides an array of health care for women, including annual exams, gynecological care, family planning and prenatal and postpartum care.

Women throughout the central and western parts of the state have made the trek to this unincorporated town of 194 people, which is home to the Birth and Women’s Health Center. Lois Yoder, CNM-APRN, who has attended more than 3,400 births, including 17 years as a rural missionary in South America, and Angel Schmutz, CNM-APRN, are advanced practice nurses and certified nurse-midwives who share in the delivery of babies with the support of a nursing staff.

The average stay for a birth is about six hours, and the mothers generally walk out of the clinic without the need of a wheelchair. The center is even set up to accommodate water births. During the 48 hours after the birth, the midwives check in with the mother periodically to make sure everything is going well. If problems do arise, the clinic is affiliated with hospitals in both Hutchinson and Lyons.

A not-for-profit facility owned by a community of 10 Amish and Mennonite churches in the area, the Birth and Women’s Health Clinic has ties to the KU Nurse-Midwifery Program. Schmutz earned her master’s degree in midwifery from KU in 2003. And over the last 10 years, students from KU’s Midwifery Program have attended births at the clinic.

“I have a nurse-midwifery student with me whenever I’m on the unit for labor and delivery, but most of the student midwife placements are with midwives across the state working in their private practices,” Busenhart said. “All of our students can have out-of-hospital birthing experiences if they want to. We’re lucky to be able to offer that.”