Midwives in the military offer extra level of care
January 25, 2009
YOKOSUKA NAVAL BASE, Japan — Late last fall, as Mindy Adorador was just beginning to show during her first pregnancy, she told a midwife at U.S. Naval Hospital Yokosuka about the slight whispers in her belly.
"It feels like a little butterfly," Adorador, a Navy spouse, said.
"That’s movement," said the midwife, Lt. Cmdr. Andrea Hiles.
"How funny!" the expectant mother said, laughing.
For Adorador, it was a reassuring answer in the midst of the excitement and confusion of a first pregnancy. For Hiles, a Navy nurse for 17 years, including two as a certified midwife, it was part of her military job.
The military has more than 70 midwives, according to military health officials. These registered nurses do much of the same work as gynecologists and obstetricians — providing prenatal care, performing women’s wellness exams, administering birth control and delivering some of the thousands of babies born in military facilities each year.
More than 23,000 babies are born annually in Army facilities, spokeswoman Margaret Tippy said. The Air Force handles 8,000 births each year, according to one official.
But where doctors more often diagnose and treat medical complications, midwives help their patients navigate through the routines of life — including pregnancy.
"Our job is to know normal," says Hiles. "Pregnancy is normal. With problems, you see a doctor."
Unlike civilian midwives who may offer home births, military midwives work in hospitals or clinics. Yet they see their role as more alternative or holistic than that of medical doctors, according to Hiles and others.
Mostly, midwives say, they are nurses first and, as such, often play counselor or coach while helping women better understand how to care for themselves.
Their patients — uniformed and civilian alike — find comfort in the mix.
"Sometimes, it’s very hard to talk to a doctor," said Kiriko Satele during an exam with Hiles last fall.
She was expecting her first baby and her husband, assigned to the USS Ohio, was away often.
"But she is so friendly," Satele said. "I can tell her anything."
Military midwives are warriors as well. They deploy downrange as nursing unit supervisors or health care providers, where servicemembers need Pap smears and even, sometimes, pre-natal care. They also go on humanitarian missions to help treat women in countries in crises.
And because they deliver so many babies — Hiles and her counterpart, Lt. Cmdr. Kim Shaughnessy, oversee many of Yokosuka’s 50 or so births each month — they are often more practiced at handling crises such as hemorrhages than other nonsurgical nurses, according to Air Force Lt. Col. Linda Case, a midwife at Eglin Air Force Base, Fla., whose job includes tracking midwifery missions throughout the Air Force.
Midwives’ ability to care for patients from puberty to menopause helps them augment the ranks of military doctors and helps them cover delivery wards that have only two or three obstetricians, according to Case.
"It’s a 24/7 job," she said. "Nobody delivers unless it’s 3 in the morning."
‘Every pregnancy is different’
Shaughnessy stops a conversation just before 8:30 a.m. to run to the delivery room. Her shift began at 7 a.m., when Hiles’ ended. Hiles had delivered two babies during the night. The third woman, Hiles had warned Shaughnessy, would deliver before there was time for morning coffee.
Fifteen minutes later, the baby was born. An hour later, after moving from the delivery room to the nursing station to finish paperwork, Shaughnessy was ready to start her day.
"I need caffeine desperately," she said, two and a half hours into a 24-hour shift.
The midwives’ work schedules vary from daily clinic appointments on weekdays to a weekly 24-hour shift on the delivery ward. Once a month, each woman works most of a weekend, a shift that starts on Friday with 24 hours, allows some time off on Saturday, and runs another 24 hours from Sunday to Monday morning. Obstetricians and family practice doctors at the hospital cover the remainder of the shifts.
"We probably see 95 percent of all the pregnant women here," says Shaughnessy, who has been a Navy nurse for almost 12 years and a midwife for four.
Their patients span all ages and ranks at the Yokosuka base, which has more than 9,000 sailors and is the largest U.S. Navy base overseas. Over the course of a pregnancy, they get to know some patients well.
Often, because of changing military assignments, patients come and go in the midst of prenatal care. Hiles and Shaughnessy say their nursing skills help them get to know a patient quickly, and the midwives help newly arrived mothers figure out their surroundings.
"Every pregnancy is different," Shaughnessy said within a couple of minutes of meeting Kathy Trevino, a new patient at Yokosuka and pregnant with her sixth baby.
Trevino was complaining of headaches, something she never had with the other babies. Shaughnessy reminded her about preeclampsia, a serious condition characterized by high blood pressure and headaches.
But Shaughnessy also suggested that Trevino wasn’t eating enough throughout the day. She soon learns Trevino home schools her five children and just moved with her husband, a military contractor, from Italy.
"I’m so busy," Trevino said.
Shaughnessy also learned that Trevino, at 39 weeks, was living in Zushi, about an hour from the base by car. When Trevino had slight contractions on base later that afternoon, she called Shaughnessy, who told her to come back to the hospital.
After the contractions stopped, Shaughnessy sent her home with a reminder about her new commute.
"Just in case," she said.
The personal aspect
Most patient visits with Hiles and Shaughnessy last 15 to 30 minutes, depending on the stage of pregnancy.
Sometimes the expectant mothers come with questions — what, for instance, to do about a navel ring?
Sometimes they come in tears, exhausted.
"The novelty has worn off," one sleep-deprived, first-time mother said.
Always, Hiles said, they just want to know that everything is OK.
Other times, it’s the doctors who come to the midwives.
Lt. Cmdr. Amy Redmer is a family practitioner at Naval Air Facility Atsugi, a smaller base also close to Tokyo. Redmer must provide prenatal care to her patients before they transfer to Yokosuka’s hospital for delivery.
To refresh her knowledge, she spent a morning last fall seeing patients with Shaughnessy, who reminded her of questions to ask expectant mothers, of ultrasound procedures and of how to find the baby’s head.
"I learn more from the midwives," she said while checking a patient.
Both Hiles and Shaughnessy became midwives well into their military careers as registered nurses. Both made the switch after working in delivery wards, and after becoming mothers.
"These are intimate appointments," Hiles says of the times with her patients. "Other things will come up if you are willing to ask the right questions. Infidelity. Rape. I always feel like you can make a difference. There are sad times. But you really feel like you’re there for someone."
Not all mothers-to-be get to have the same experience, however.
Sarah Clifton and her husband, Air Force Staff Sgt. Joshua Clifton, are stationed at Yokota Air Base in Japan. Clifton, who is pregnant with her second baby, was surprised and disappointed to find that the Air Force has no midwives at Yokota.
"I can already tell the difference," she said of the appointments she’s had with Yokota doctors compared with the stateside midwives she used during her first pregnancy.
At Yokota, she said, "the main focus is to identify problems in the pregnancy. With the midwives, the appointments were longer and looking for all aspects of the pregnancy and delivery. They seemed interested in developing a relationship and getting to know me."
The Air Force, along with other services in the military, place their midwives at bases in proportion to birthrates. Yokota’s delivery numbers aren’t high enough to compete for a spot, Clifton was told.
Still, she said, she’s pleased with the treatment at the air base. It’s just different. She said she hopes the medical staff understands she wants to avoid certain medications during delivery, including an epidural painkiller.
"I just want the doctor to be as hands-off as possible," she said. "My initial appointment went much better than expected. So we’ll see."
Shaughnessy, at Yokosuka, understands the sentiment. Recently, she’s begun babysitting for one of her patients so she can run errands on base.
"You’re not going to find an OB anywhere in the world that would do that," she said.