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Collaborating with Local Midwives to Provide Patient-Centered Care

Parents are no longer faced with a choice between using a midwife or heading to the hospital for a birth. Midwives can provide birthing services in the home or at a birthing clinic. Obstetricians can advise risk for home birth.

Midwife Tiffany Dietrich and obstetrician Dr. Danny Lickness discuss how their teams work together for optimal maternal and newborn care.
Collaborating with Local Midwives to Provide Patient-Centered Care
Tiffany Dietrich | Danny Lickness, MD
Tiffany Dietrich received her midwifery training in the Pacific Northwest and has been attending births for the past 20 years. In 2010, she opened The Santa Lucia Birth Center, the first freestanding birth center on the Central Coast. She has dedicated her life to promoting the health and wellness of mothers and babies, providing healthcare, education and community support programs for families in San Luis Obispo.

Danny Lickness, MD is an OB hospitalist at Sierra Valley Regional Medical Center. Dr. Lickness is former Chief of Staff of SVRMC and past President of San Luis Obispo County Medical Society.

Prakash Chandran (Host): Trying to decide whether to give birth at home with a midwife or in a hospital setting led by a doctor? Well a common misconception is that it has to be one or the other. And in today’s panel style discussion, we’ll be talking about how you can get the best of both worlds. Here to discuss is Dr. Danny Lickness an OBGYN at Sierra Vista and Tiffany Dietrich a licensed midwife at the Sant Lucia Birth Center. Happy to have you both here today. Tiffany let’s start with you. What are the responsibilities of a midwife?

Tiffany Dietrich (Guest): So, a midwife is an independent healthcare provider licensed by the state so, we are licensed in the state of California and we provide prenatal care, birth care and postpartum care for women that have low risk, normal, healthy pregnancies. And that can be in the setting of a birth center or that can be a home birth.

Prakash: Okay, got it, so just speaking practically, what do you most often see sticking with you Tiffany, when do people come to you? What are they really looking out of a midwife relationship here?

Tiffany: So, typically, clients that seek us out are wanting a natural birth experience, minimal interventions and more home like atmosphere for their birth where they have longer appointments with their provider so that they feel like they can have their questions answered, get a lot of education in the process and be integral in the decision making for their care.

Prakash: Okay and one more thing is we are talking today about this collaboration between the hospital and yourself as a midwife; what are some of the benefits that patients can expect and why are we discussing this today?

Tiffany: It’s actually wonderful to be able to have collaborative care. We know that out of hospital birth is increasing. It has increased about 70% in the last decade. And our rates of safety for out of hospital births are proven in the data but we also know that our outcomes are actually further improved if we have access to not only an obstetrician or obstetricians in the community but also a hospital system that is supportive of our patients.

Prakash: Well, that’s fantastic. It seems like kind of providing people with the best of both worlds. So, let’s move over to Dr. Lickness. So, why don’t we start with just the basic differences between what your role is as an obstetrician and what Tiffany does as a midwife.

Danny Lickness, MD (Guest): The obstetrical care that we provide is inclusive of those families, those women who choose to deliver in a hospital setting and who are low risk, all the way from that point to a very complicated high-risk pregnancy situation. So, the obstetrician and the team of people that surround that care do low risk and we do what we call high-risk or complicated obstetrical care. And we do that in a hospital setting where we have the tools and resources to help us achieve the best possible outcome. The best possible results.

Prakash: I see, so if I could just reiterate you are kind of saying that one of the things that the obstetrician takes care of is no matter where you are on the spectrum of low risk to high risk; you have the tools and the techniques and the team to be able to handle that. And with a midwife, Tiffany, is it fair to say that you might deal with relatively low risk pregnancies like what are the type of pregnancies that a midwife would take care of here?

Tiffany: Absolutely. So, our clients are low risk meaning they don’t have complicating factors like gestational diabetes requiring medication, high blood pressure issues, things like that. So, our clientele is screened through the course of the pregnancy to make sure that everything is progressing normally, that they are healthy, that their babies are healthy and that is all in an effort to minimize the risk in the birth setting. There are times when we do have complications either prenatally when we are consulting with doctors or in a labor setting, if the labor is not progressing so 10% of our clients having a first baby will require transport to a hospital to augment or enhance their labors and it’s in those situations where the collaboration is so key for us to be able to have seamless care in a situation where our patients are welcomed into the hospital, the doctors understand what our needs are and we are able to accomplish that.

Dr. Lickness: And I would like to add that when those situations do arise where referral and transfer to a hospital setting occur; we already have a family who have been through a lot during their labor experience, there’s anxiety, there’s some fearfulness that goes into that situation and to be able to bring alongside us in the hospital setting the midwife and their team who have been caring for these patients throughout their pregnancy and now through the initial labor experience, to bring them into the hospital setting with us, to be a liaison to that family as we now deal with whatever complication occurred, that caused this hospital referral to help that happen to achieve the best outcomes, not only for the family and their level of anxiety and care and confusion; but we want to make sure that the mom is taken care of and the baby is taken care of and that the end result is a healthy baby and healthy mommy at the end of this experience. So, again, this collaborative care is so key. We have seen these models so successful in Europe. We have not been able to achieve it in the past historically here in the Untied States. But certain hospital systems and certain hospital groups such as Sierra Vista Regional Medical Center over the last 18 months has made this commitment to achieve this level of collaboration with our community midwives and the hospital doctors and their teams.

Prakash: Yeah, it sounds like this collaboration can really provide better outcomes and happier and healthier babies. Dr. Lickness sticking with you just for a second, when do you normally like to see the patient, or a family engage with you about bringing in a midwife? Like when do you normally see that this works best?

Dr. Lickness: Generally speaking, that decision is already been made by the family. They have reached out to the community midwives and we are so fortunate here on the central coast to have so many quality, skilled midwives. They have already made that decision and they have reached out to them. What we hope for in the hospital setting is that as questions arise even during the pregnancy care, we want the midwives and the families they take care of to know that they can always call us at the hospital and even run questions by us regarding whether there is some pending complication or what to do in terms of some special testing. We want to have an open door policy for these families and for the midwives in our community to know that we are there for them for the best possible results for the pregnancy care of their patients.

Tiffany: And I’d like to add something to that. So, we are looking at with the increase in out of hospital births, this is somewhere in the neighborhood of 60,000 women a year in this country that are choosing these options and it’s very progressive in our area to have this collaboration with Sierra Vista and with doctors like Dr. Lickness, Dr. Monroy who have fostered this relationship with us. It’s the best possible situation for us to provide good care. And also to point to the people seeking midwifery care should ask of their provider when they are doing a consultation what kind of agreements do you have, working agreements with obstetricians, with hospitals, what kind of care is there if complications arise because that is very telling about how much support a midwife has in the community and the best possible care that they can provide.

Prakash: Yeah, that definitely makes a lot of sense. And I think being proactive and asking those questions to get sense because when I hear the two of you speak, it seems like you have an amazing working relationship together and you understand how one another works and I imagine that there needs to be that proactive conversation about philosophy, about roles, about boundaries. Tiffany can you talk a little bit about your framework with how you would like to deal with an obstetrician and how you and Dr. Lickness have gone about structuring that relationship to make sure there is no overstepping?

Tiffany: Absolutely. Well it’s to Dr. Lickness’s credit absolutely that they reached out to us, came and toured our facility, wanted to understand the specifics around our practice, the ways that they could support us and our patients in that practice. I came from a model in the Pacific Northwest where licensed midwives are a part of the healthcare system. It isn’t necessarily the case in every state. That that is in place and it is somewhat of a barrier for midwives to be able to provide optimum care. Sierra Vista I think is very cognizant of their role in the community and that they are trying to support not only families but healthcare providers that interact with their system and that has been wonderful for us for being in this community for nine years, so that has really taken our level of care to the next level because the hospital system and Dr. Lickness have reached out and established that relationship.

Prakash: So, Dr. Lickness I’d like to just go over to you. It sounds like you and your team have been really proactive about this and as Tiffany mentioned that’s not necessarily the norm across the industry. So, for people listening to this, let’s get a little bit specific. I’d love to hear about some of the main benefits that you see with having a midwife as part of the process like what are some of the main things that people can look forward to when they opt in for this collaboration?

Dr. Lickness: We clearly understand that 90% of pregnancies and birth experiences occur naturally and normally and we as obstetricians we truly do trust birth. We really believe that childbirth is a natural process and we support that and there is nothing better. There is nothing better than a successful vaginal delivery. There are times however, when that may not work out as wanted. Some of our patients now have diabetes or high blood pressure. We have a somewhat older population that are becoming pregnant. We have more assisted fertilization patients who have had IVF and each one of these medical situations can lead to complications during the pregnancy. So, there’s about 10% of pregnancies that end up with some type of complication either maternal or a fetal problem that needs just to be managed as best as possible. And so by having the resources of a hospital with having the perinatology and neonatology resources needed for these difficult pregnancies, we still achieve a remarkably high success rate of healthy babies and healthy mothers. In fact, California is leading the country in its decrease in maternal morbidity and mortality and I think California through its various health departments and hospitals just deserve a lot of credit for the steps we have taken in the hospital setting directed towards those more difficult pregnancies. But again, most commonly, it’s going to be a normal vaginal delivery which can be very successfully done in a home or birthing center setting with the hospital back up if needed and again, with Tiffany and her team and the other midwives in our central coast area; we just feel so privileged to have such talented, dedicated people as part of this umbrella of care for our families here.

Prakash: Yeah, it absolutely sounds like it and the collaboration, it’s really incredible to see. So, Tiffany, I want to move to you just to wrap it up a little bit. Is there anything else that you would like the community to know around this collaboration for people that are interested in getting started, like maybe some of the first steps that they should be taking?

Tiffany: Absolutely. So, typically, we recommend a documentary called The Business of Being Born which helps sort of illuminate the differences in care. Most people will come into pregnancies not having a lot of information or exposure to what the different types or providers are. Whether they want to go with an obstetrician, a nurse midwife, a licensed midwife in what setting they want to have their baby, so that’s just kind of good jumping off point in order to get a sense for the kind of care that each of these providers has to offer. And then consult – we do consults with our clients to let them come and see our facility, if they are interested in birthing at the birth center, answer their questions and then part of that consult experience, we do talk about how do we handle complications. Who do we consult with as far as obstetricians in the community? What hospital do we transfer to? And under what circumstances? And then folks can also get lists on the internet of things to ask their midwife because it’s always wonderful when we have clients come in having done a little bit of homework as far as getting a sense for what kind of care we provide and the right questions to ask to make sure that this particular midwife is the best person for their care.

Prakash: And Dr. Lickness what about you, is there anything else that you would like to leave us with before we wrap up here?

Dr. Lickness: I think that a healthy pregnancy outcome starts with a healthy lifestyle. So, for our patients who are prepregnant; we certainly recommend exercise, avoiding smoking, excessive drinking, good diet and a pre and an early pregnancy consultation with their provider of choice, whether that’s a licensed midwife, a certified nurse midwife or an obstetrician. Getting off to a good start will help ensure a good outcome and a healthy baby.

Prakash: That’s definitely good advice so be very proactive, take care of yourself and also just be aware of this amazing collaboration that’s going on at Sierra Vista and between the midwife community. It seems so amazing that you all are working together to produce happier, healthy babies and I really appreciate your time today, so once again, my guests have been Dr. Danny Lickness and Tiffany Dietrich. For referral to a board-certified physician please call the Sierra Vista Regional Medical Center and Twin Cities Community Hospital physician referral line at 866-966-3680. I’m Prakash Chandran. Thanks so much for listening.