I became a midwife because I understood that women were not being listened to.

I need to listen to women.

In order to give them the help they need, I need to listen to them.

Midwifery for me was just a driving force and I think it was about the family.

It just was such an exciting time and to be there and witness birth and how that, you know, the mother and the family would just enfold that new baby into them, it was wonderful.

Until we have the ability for every woman who wants a midwife to have a midwife, I feel like the morbidity and mortality crisis for moms and babies is going to persist.

We have maternal care deserts that are so desperate and we need more midwives to solve that problem.

Midwifery has been a profession since ancient times, but is as relevant today as it has ever been.

We must make sure that everyone receives skilled maternity care, no matter where they live.

That's essential.

Bringing a baby into this world, it's a mixture of joy, fear, risk, and ultimately beauty.

One of the most troubling trends in the United States today is the continuing rise in maternal mortality and morbidity.

This is a growing crisis and it becomes even more urgent when thinking of underserved populations and people living in rural areas.

Being able to comfort, empower, and provide quality care to people at this special and critical time, that's what certified nurse midwives do.

We chose to have a nurse midwife because I wanted professional care, but the main focus throughout was of the health and well-being of me and my child.

This is the story of the rebirth of an ancient tradition of midwifery, infused with new ideas.

It's a story of human touch.

It's also a story of a critical healthcare need and using modern technology to meet that need.

But at its core, it's the story of a remarkable group of women and men who believed things could be made better for people and whose work over generations has not only improved maternity care but is literally reshaping the landscape of 21st century healthcare through distance learning to ensure a healthier future for people and their families.

Funding for this program made possible by The Van Sloun Foundation, saluting the accomplishments of nurse midwives and nurse practitioners taking healthcare to rural and underserved communities around the country.

The United States has the highest maternal mortality rate among wealthy nations.

Over 80% of pregnancy-related deaths in the US are preventable.

According to national data, 1,200 women around the US die of pregnancy complications per year, while another 50,000 women have life-threatening complications.

And maternal mortality happens with women of color three to four times more than it does with Caucasian women.

Sometimes I wonder if people really know the problem of the rising maternal mortality rate.

Particularly for women of color or women in rural areas, the maternal mortality rate has risen consecutively for the last 20 years.

As a matter of fact, it has doubled in the last 20 years.

In the 1970s and 1980s, the majority of nurse midwifery education programs resided in universities where the clinical teaching was, for the most part, conducted in large medical centers dominated by the medical model of birth, a model from which women of that time were seeking an alternative.

Amid the many social changes that swept America in the 1960s and 1970s was a growing belief that the typical medical management of maternity care, childbirth, and other women's health needs was overly interventionist, overly controlling, and often disrespectful to women.

Interest in natural childbirth, childbirth without routine interventions such as anesthesia grew, as did other alternatives to the physician-controlled hospital birth.

Our Bodies, Ourselves, a bestseller in the 1970s, brought women's healthcare to the masses.

I became a midwife because I already knew I wanted to either be a family nurse practitioner or something where I could lay hands on but help make change and growth in a patient.

And midwifery was the perfect melding of the two.

Pregnancy is a time when, it's not a time of crisis, but it is a time of openness to change.

It kind of opens the top of your lid because you're willing to change for somebody else.

So, I recognized it was the perfect combination of the ability to lay hands on a patient but also, more importantly, most importantly to me, to help them grow and evolve and to be complete as a person.

I became a midwife because I knew that women were not being provided the care that they deserved, that the childbirth system was controlling and was not really meeting their needs and I knew there had to be a better way.

Women were sedated, tied down in sterile operating rooms without support of their family and positioned in such a way as to be comfortable for the medical providers who were delivering the child.

So decisions were being made for you and you were not always included in those decisions.

Women wanted a better childbearing experience.

They wanted to be involved in their care.

They wanted to be involved in taking care of themselves, taking care of their babies and making the decisions about where they would give birth and how they would give birth.

The treatment of women during childbirth infuriated not only mothers but nurses.

A young nurse in Massachusetts, Kitty Ernst, witnessed firsthand how women were treated during childbirth.

But I had had a very, very traumatic experience in my student nursing days when it was a period of time that obstetrics was called the knock-em-out, drag-em-out method of obstetrics which meant you knocked the mother out and you took the baby out with the forceps and the mother sometimes would not recover for two or three days so the baby had to go to the nursery.

To me, the whole thing was barbaric.

But when Kitty heard about Mary Breckinridge and her Frontier Nursing Service in Hyden, Kentucky which provided comprehensive family medical care to the mountain people where nurses rode horses to provide home care.

She decided this was an adventure she wanted to experience.

I didn't really answer her call.

I came down to the Frontier Nursing Service to ride horseback.

[Dog Barking].

When I asked when was I going to get a horse from the Dean of the School of Midwifery?

She said, "Well, you have to have a district to get a horse."

And I said, "Well, how do I get a district?"

Then she said, "Well, you have to be a midwife."

But before Kitty became a nurse midwife at the Frontier Graduate School of Midwifery, she saw a woman give birth in a mountain cabin attended by nurse midwives.

This experience had a lasting impact on her.

The father was there and he was tending the stove, keeping water boiling and so forth and there was a picnic table here and then there was a double bed here with four children asleep across it.

And then, there was a bed here with the mother sitting on the edge of the bed in labor and her youngest, 18-month-old asleep behind her.

Well, the first thing I noticed was that the midwives came in and they knelt down in front of the mother.

An hour or two passed and the mother finally just sort of leaned back and said it was time for the birth and they propped her up with some pillows and knelt down before and caught the baby and everything.

I was just blown away because my image before that had always been the mother flat on her back with her legs in the air with her most private part exposed to all.

Here was this mother, strong, in charge telling them what they could do and couldn't do and the midwives were her servants.

That's when I was called.

That mother called me.

As she put it, it was my aha moment.

Soon afterwards, Kitty became a nurse midwife.

She got her horse and began to take healthcare to the mountain people of Appalachia.

Thus began her lifelong journey to change the modern approach to childbirth.

That strong mountain woman, she later said, "Showed me the extraordinary difference between being supported in giving birth and the institutional practice of obstetrics in a typical hospital setting to which I had been exposed as a student nurse."

Kitty became a passionate and tireless advocate for the importance of nurse midwives and freestanding birth centers as a crucial component to improve maternity health and she was far from alone in her belief in the importance of nurse midwifery.

During the early 1980s, Ruth Lubic and Kitty Ernst, co-founders of the National Association of Childbearing Centers, looked for ways to increase the number of nurse midwives and prepare them to establish and staff birth centers.

The birth center is founded in the midwifery model of care.

Kate, Kitty's youngest daughter and Executive Director of the American Association of Birth Centers, explains the importance of a freestanding birth center.

It begins with your first prenatal visit and continues through your postpartum care.

Freestanding birthing centers were developed based on what women wanted in their childbirth experience.

The birth center was a place where you could have your family come, where the woman made the decisions about the birth.

And the midwife was there to assist her, to advocate for her, and to assure that it was a safe environment for her.

Here's what was new about Kitty's concept of birth centers.

How do you make the birth center and midwifery have gravitas in the healthcare system?

How do you make it matter and make a difference?

Ruth Lubic co-founded two legally sanctioned freestanding birth centers in New York City.

So we opened the birth center in 1975.

And who came to us?

Well, who came to us were generally young professionals and who were seeking change, who had advanced education, who had the ability to listen to us, to look at our materials, to look at how we decided whether a woman was eligible for care out of the hospital, because not every woman is.

You know, and we wanted to be very, very careful about that and not put anybody at risk.

Lisa Uncles worked with Ruth at the Morris Heights Birth Center.

Her birth center is in an area where the women literally have control over very little in their lives.

They, um, there's not a lot of resources.

And so, they come to the birth center because they know, number one, we're listening to them.

And it's a place where they can have some control over their healthcare, the healthcare of their children, the healthcare of their babies.

Being able to exercise that, that control over your birth gives you a feeling you can do anything.

If you can give birth, you can do anything.

And I've had them say to me, you know, I didn't think I could do it.

And now that I have, I know I can do anything.

For Ruth Lubic and Kitty Ernst, the top priority was to change the system to better support mothers, babies, and their families.

And Kitty knew nurses across the nation were interested in becoming nurse midwives.

And the problem that Kitty was trying to address is that we don't have enough midwives.

And so, Kitty started to look for ways that we could create exponential growth.

We were graduating about 300 midwives a year in the whole United States at that time.

That is not enough.

That was not enough to make the change that needed to be made.

It became quite clear that there were literally hundreds of nurses that wanted to become midwives and serve their local communities, but they weren't able to do so because they could not leave their families or jobs to attend an on-campus program.

The challenge was how to provide that education.

So, they had to create something different.

It was Kitty Ernst's idea to create the Distance Education Program.

She's the one who really thought through all the pieces of it that actually made it work in the end.

Representatives of four leading organizations in the field came together to consider this unprecedented idea.

Ruth Lubic, Director of the Maternity Center Association, Kitty Ernst, Director of the National Association of Childbearing Centers, Ruth Beeman, Dean of the Frontier School of Midwifery and Family Nursing, and Joyce Fitzpatrick, Dean of the Frances Payne Bolton School of Nursing.

Frontier School of Midwifery and Family Nursing in Hyden, Kentucky agreed to award the certificate in Nurse Midwifery, and Frances Payne Bolton's School of Nursing at Case Western Reserve University in Cleveland, Ohio would offer the additional credits in nursing theory and research necessary for completion of the Master of Science in Nursing.

It was the 1980s and nobody had ever tried to educate clinicians, healthcare providers through distance education.

We didn't have any Internet.

We did not have the technology that we have today, so how could it be done?

Perkiomenville, Pennsylvania, 1988.

At her farm in rural southeastern Pennsylvania, Kitty Ernst has received a disturbing phone call.

Booth Maternity Center, the training site and office for this new pilot distance learning program, was closing for good.

Today, if anything needed to be removed from the center, it needed to happen now.

Kitty knew there was plenty that needed to be saved.

Equipment, curriculum, and records.

Without hesitating, she said to her husband Al and son Ted, we must go to Philadelphia tonight.

[thunder rumbling] The rain and lightning were intense, but Kitty was determined to make the 50-mile journey.

At Booth, they packed up the furnishings, equipment and records and brought everything back to Perkiomenville.

What are you going to do with all this stuff?

Kitty's husband asked.

Ruth Lubic asked her the same question the next day when Kitty called to tell her that they had moved the distance learning experiment named the Community Based Nurse Midwifery Education Program, or CNEP, to Perkiomenville.

I don't know, she replied, but I'll figure it out.

Kitty and her family knew how to make the best of a tough situation.

They went to work to add a workable space for the CNEP pilot program at the farm.

An office was constructed, staff added, and faculty recruited.

[phone ringing] Kitty received a second phone call.

This time it was Jamie Bollain [ph], the founder of Childbirth Graphics, a childbirth educator with a massive following from nurses throughout the country.

In typical Kitty style, she asked Jamie for help.

With an emphatic yes, Jamie announced the program in her 1989 Childbirth Graphics catalog with a small ad, which was mailed to 35,000 nurses and childbirth educators.

And that's when the phone began to ring.

Nurses called all the time to say, this is what I've always wanted to do, become a midwife.

And the applications started flowing in.

I think we logged over 3,000 phone calls.

When the ad came out in Childbirth Graphics for CNEP, it was like, wow, this is my opportunity.

It was the chance I had.

Because I knew there were midwifery programs around the country, but by then I had a couple of kids, and you know, my family was there.

That's my home This would allow me to become a nurse midwife, not leave my home, not leave my family and my three children, and yet fulfill my dreams right in my own community.

Everyone was to meet at the airport and ride the bus, Kitty said.

That way, we can begin to build a community immediately, a crucial component to the success of the program moving forward.

When we got there, there was a bus with Kate Ernst with a little CNEP sign.

I was on the bus, the school bus, that met the students at the airport, brought them to the farm, and then on to Camp Unami.

This ride on a yellow school bus to Camp Unami in rural Pennsylvania would have a lasting, far-reaching impact on 16 nurses from across America, nurses who wanted to become certified nurse midwives.

Each of these nurses hoped this was the path.

They all wanted to be midwives, and they all wanted to be part of improving care for women, babies, and their families.

The nurses who applied for the first class of the pilot program didn't know each other, but they knew one thing when they arrived.

They wanted to be nurse midwives and were willing to take a chance on an unconventional pathway to get there.

I was really excited when I heard about this program.

I wanted to be a midwife so bad, and I had three little kids at home, and if I didn't have to drive four hours round trip to go to school, I was all in.

I had always wanted to be a nurse midwife.

I never thought that there would be any way that I could become a nurse midwife, and I had children, and lived on a farm in Iowa at the time.

We all wanted to be nurse midwives so badly that we would have done anything to become a midwife.

Honestly, the students in those early classes were as much pioneers as were the women who started CNEP.

It was a huge leap of faith for them to enroll in a midwifery program like this that had never been done before.

As unlikely as it seemed, Camp Unami was transformed into Midwifery Bound, a weekend that would build self-confidence and a collegial community spirit, something Kitty hoped would cause the nurses to believe in the program.

She turned to her eldest daughter, Rosie, an Outward Bound instructor, to help build student community and commitment to the program.

These exercises helped to overcome fear and promote trust in oneself.

Key traits needed to be an effective nurse midwife.

And so we repelled down some hills, having to trust one another along the way.

Over the course of the weekend, an ambitious vision was presented.

So Kitty had the idea to exponentially grow the midwifery workforce and promoted the idea of 10,000 midwives by the year 2000.

These nurses believed in their hearts that they could be part of the change, a change that would address how women were treated in childbirth.

It was just an amazing bonding experience, because it was just so intimate.

Everybody involved in the program were so invested in making it work, and they were invested in making us the best students they could put out into the community to make it work.

That first class left excited and inspired with their first course packet in hand.

The foundational courses had been divided into modules that would be sent directly to students' homes, with graded learning assignments that were mailed to faculty.

There was also a plan for preceptors, experienced practicing clinicians that would serve as teachers and mentors for students during their clinical experience.

These nurse midwives or other providers worked at local practices or clinics that would serve as clinical sites in or near a student's home community.

This was a critical component for making the program work and ensuring long-term success for the student nurse midwives and later nurse practitioners.

Nurse midwifery students are highly educated.

They attend programs that include both academic coursework along with a clinical practice component.

The requirements are rigorous and must meet national accrediting standards.

Meanwhile, Kitty and her family transformed the former chicken coop at their farm [hammering] into a learning center and laboratory setting in preparation for clinical bound that would take place in the fall.

They explained to us this was a chicken coop and that was the school.

You know, there were bays where there were beds so.. you could do physical exams.

There was a place where you could use the microscopes.

There was a great big table and a huge whiteboard where we had classes.

This in-person clinical lab experience gave the students practical hands-on experience and instructions and the confidence they needed to begin the clinical phase of their education with their local nurse midwife preceptors in their home communities.

When we went to our level three, which is where we learned how to suture and where we learned how to deliver babies and all the hand maneuvers, we got to go to Perkiomenville where Kitty lived and she and her husband Al had changed the chicken coop that was in their backyard into a classroom.

And the chicken coop was a long building and they were able to put up doors and walls that you could take down so we could have a big room for gathering and then they could put these walls up so that we could have separate exam rooms with drawstring curtains and we actually did exams and practiced our skills on one another and she brought to her home also the wonderful faculty that taught us so we have chicken coop faculty as well as chicken coop students.

In April 1991, that first group of graduates took their national nurse midwifery certification board exam and everyone passed.

The memories that I have were of courageous, dedicated, and really compassionate women who networked, who took chances, who took risks, and the students were hand-picked.

They were women who wanted to be midwives, but really didn't have any opportunity or chance to do that until Kitty created a pathway and we all knew that if we didn't complete the program, the program would not be able to continue.

CNEP grew quickly.

Year-after-year, as more and more applications came in, the four sponsors of the pilot program agreed that it was time to move the certificate program to the Frontier School of Midwifery and Family Nursing in Hyden, Kentucky.

So, impressed with the results, the Frontier Board of Directors voted to adopt CNEP as its sole offering.

The vision for creating advanced degrees via distance learning worked.

So, foreign to us now as we can hardly imagine a time without the Internet.

Though 10,000 nurse midwives were not educated by the year 2000, the community-based Nurse Midwifery Education Program proved beyond a doubt by its outcomes that it would provide the quality standard necessary for nurse midwifery education via this new model.

Today, the graduates of CNEP are serving families across the nation and around the world, providing care that is especially critical in areas where maternity care options are scarce.

I became a midwife because of my passion for caring for women across lifespan.

Being an immigrant, I came to America 22 years ago, and midwifery is a model of care in my community.

I saw how they cared for women and the whole family, and I decided that when I came to America, I would become a midwife.

Alaska, the largest state in the United States, with one person per square mile.

That means many Alaskans live far from cities, far from resources, [dogs barking] and far from healthcare.

Accessing healthcare in Alaska can be difficult and stressful, often requiring hours of travel.

And that's equally challenging for those seeking care for one of the healthiest of reasons, having a baby.

Just ask Kristina Amundson, a CNEP graduate who is making a difference for Alaskans.

Pregnant people need good information.

They need answers to their everyday questions that are evidence-based.

They need professional consideration to all of their healthcare concerns.

And the options in Alaska are sparse.

I find that access to healthcare in Alaska is a huge challenge.

I take care of families that drive 4 to 8 hours just to see me.

Amundson attends 70 to 90 births a year, typically treating from 60 to 70 pregnant people at any one time, in addition to providing women's healthcare to those not pregnant.

She urges her patients to continue an active, healthy lifestyle and to call her if any other concerns arise before their next appointment.

I love catching babies and taking care of their families.

Like Amundson in Alaska, certified nurse midwives are making a difference, providing care where it is needed most, and giving families expanded options in meeting their healthcare needs.

As the community-based nurse midwifery education program transitioned from using the U.S. Mail and telephone to online education, it found a new generation of women and men ready to carry the benefits of certified nurse midwifery care to every corner of the globe to meet the still pressing challenges of accessible community care.

Some people think midwifery is something from the past.

I think it's required for a healthy future.

Becoming a nurse midwife today, I feel like I am building on the efforts of so many in the past to make the future better for people everywhere.

I became a nurse midwife to make a difference for mothers and babies and provide them the best care possible.

Even today, with so much progress, there is still a lack of healthcare services, especially in rural and underserved areas.

All across America, there are underserved communities that may not necessarily be rural.

There are urban communities that have underserved populations, new immigrants, people that don't speak English.

This is all an important community to serve as well.

More and more, we are seeing women with more medical complications when they enter labor.

Hemorrhages, hypertension, gestational diabetes, and obesity are contributing to the factors.

The C-section rate continues to climb in this country, and although it can be a life-saving operation, in many cases, it's just not necessary.

We know when you add nurse midwives to a practice, the C-section rate drops.

With a diverse pool of practitioners that matches the diversity of the patient populations they serve; healthcare outcomes are improved as patients have more trust and confidence in the care provided to them.

Because I'm from Africa, we are tribal.

I'm used to living in rural communities.

I get to live in a community where I feel comfortable.

I get to take care of women that look like me, that feel like me, so it's easy for me to communicate and take care of women in their rural areas.

Even though our healthcare system can do many, many things, hip replacements, heart care, all kind of wonderful things that we need, we are not taking care of those social determinants of health that women really need in order to be healthy.

Do they have enough food?

Can they get to the physician or the nurse midwife or whatever it is they need that day?

Do they have enough money?

Do they have access?

Do they have health insurance?

And the answer to those questions in our country in many cases is a resounding no.

Gainesville, Alabama, rural.

Population less than 200.

There is only one freestanding birth center in Alabama.

But there are no birthing centers in or near Gainesville and there is also no access to family planning services, midwifery care, or obstetric care.

More and more people are having less access to quality healthcare in rural communities.

If you're pregnant, it's a desert.

If you are pregnant here in Gainesville, Alabama today, it is what the March of Dimes would like to consider a healthcare desert.

That means the closest healthcare touch point is a healthcare facility that can determine if you're pregnant, then give you a pregnancy test, and that's it.

After that, you're going to have to travel 37 miles to the closest community-based hospital or you're going to have to do 45 miles one direction or 47 miles the other direction, either to Tuscaloosa, Alabama or to Meridian, Mississippi in order to have access care.

Dr. Stephanie Mitchell is a certified nurse midwife who began her path working as a pediatric nurse, a labor and delivery nurse, and then as a midwife in a collaborative midwifery group in one of the largest and highest volume hospital systems in Boston.

In 2020, Dr. Mitchell moved to Gainesville, Alabama, where she was surprised to find zero freestanding birth centers serving her region.

Midwifery was eliminated almost completely from this state.

Today, we have less than 30 certified nurse midwives in this state.

We know the solution to being able to intersect this maternal mortality crisis in this country is to attack the root problem and provide access to care in comprehensive ways that allows for a safety net for people to pass through this normal physiologic process unscathed.

The reason why this is so important, because in other states, midwifery is incorporated in through the healthcare system.

And in Alabama, not only is that not the case overwhelmingly, but midwifery is still so novel.

Dr. Mitchell's plans are to restore this historic house in Gainesville into what she calls a birthing sanctuary.

Nurses like Mitchell who want to be certified nurse midwives can enroll in a distance education program and remain in their communities and help those areas where there are not many physicians or other providers.

While there can be many unanticipated complications during a pregnancy, spotting them is an important part of prenatal care.

The premise of nurse midwifery care approaches each pregnancy as a normal healthy event unless proven otherwise.

Well, I decided to become a nurse midwife actually after I had my first baby and really embrace that natural aspect of pregnancy as being normal, making sure that the mother has what she needs so then she can be the best mother for her baby.

And I think the mission of Frontier, that protector of normalcy and then also knowing when you need to collaborate and refer, it was just so much again from our education of knowing where we can be the experts in normal and then also where we might need to ask for additional collaboration.

Equally important is the idea that nurse midwifery would become an integrated part of healthcare, working in partnership with hospitals and other care institutions.

There's a misconception that nurse midwives only attend home births, but actually the goal of nurse midwives is to serve women, respecting their choices.

And since 98% of women in this country have their babies in hospitals, most nurse midwives attend births in hospitals.

At the University of Kentucky Hospital in Lexington, Kentucky, the UK Midwife Clinic is well established in the community as one that provides quality care and evidence-based midwifery practice and primary healthcare in an environment that emphasizes kindness and personal service, characteristics of the nurse midwifery model of care.

One of the things that is so special about this clinic is we have seven midwives here who practice independently.

If a patient comes to this clinic, they expect to see a midwife.

It's my job as the midwife to provide the evidence and the research on what the recommendations are and give that information to patients so that they can make the decision that makes the most sense for them.

We have really close relationships with physicians who respect our profession.

They know we're really good at what we do, and when we have issues that fall outside our scope, we are very easily able to access them and give our patients the care that meets their needs.

This practice at the University of Kentucky gives patients access to the region's most advanced medical healthcare.

A collaborative partnership between nurse midwives and physicians provides a safety net in the unlikely event medical intervention is needed.

The benefit of having this collaborative model where we can offer low intervention birth, that is going to be so important moving forward.

We have access to everything at UK, every specialist.

We have access to maternal fetal medicine specialists, geneticists, low-risk OBGYN or general OBGYNs like myself.

We have access to kind of pretty much anything you could need during your pregnancy, but just because you need those interventions during pregnancy doesn't mean you need them during childbirth, and I think that, that is one of the main ways that we collaborate with the midwives.

The UK Midwife Clinic is designed to empower people to create the birth experience that is right for them.

I can't do what I do without knowing that if I run into a woman who falls outside of my scope of practice that there's somewhere for her to go.

If she's a little bit outside, I work with the doc.

The doc and I collaborate on her care.

When she gets to that place where she's outside of normal, then I will refer her on.

We know that today there are many, many rural communities that have absolutely no access to physicians or primary care.

Nurse practitioners can provide that care in a very high-level, high-quality way.

To reach more people in communities with health disparities and low access to healthcare, the community-based education program format was expanded to include the family nurse practitioner specialty.

McCreary County, Kentucky, home to 25 waterfalls and 640,000 acres of timberland.

Yet there is no hospital.

The nearest hospital is 30 miles away.

For patients seeking care, it's a scenic but not necessarily an easy commute.

But nearly half of the county's population is considered to be in less than good health.

Our area is burdened with a high rate of smoking, heart disease, respiratory disease, and cancer.

With a robust online distance learning program, James Corder became a family nurse practitioner.

He opened two clinics to meet the healthcare need in rural Appalachia.

Because there are no hospitals, nurse practitioners often have to treat things that they normally wouldn't in a bigger urban area.

And sometimes we have to treat more aggressively because we don't have access to a hospital.

[drilling buzz] Part of diving in is understanding the residents and culture of the area.

That came naturally to me, Corder says.

My father was a coal miner and he died in a mining accident.

Corder understands the culture and population is very important.

The things that you might be faced with here as a nurse practitioner provider is quite different than what you might see in Florida or some other big urbanized area because of the culture.

People's diet may be high in fat, fast food restaurants, and that sort of thing.

And because of the mining and trees and in the natural forest, you have a lot of molds and things like that cause a lot of respiratory issues.

That's why we need nurse med wives and nurse practitioners in these rural areas, in clinics and even doing home care or telehealth to provide the services that these people need.

As the Internet evolved and more and more people understood the value of learning online, it was important to expand and further address the healthcare needs of women.

The women's health nurse practitioner specialty was added to the distance education options.

Women's health nurse practitioners focus on health promotion, disease prevention, health education, and helping people make smart lifestyle choices.

While issues such as emotional mood changes during pregnancy and postpartum depression have long been recognized, the mental health challenges in pre and postnatal care are in reality much more complex.

In my practice, many people come to see me or other practitioners with pre-existing diagnosis.

They worry about the effect of medication on the developing baby, or they may choose to discontinue their medication, a potential damaging or even life-threatening action.

Mental health providers must weigh benefits versus risk.

What's the benefit and the risks of taking medication versus what's the benefit and risks of not taking medication?

Often, medication is only a small part of the treatment plan.

Non-pharmacological treatment approaches can be very effective.

And that makes me wonder, am I going to be a good mother?

Just as the nurse midwifery specialty and family nursing specialties were offered through the distance education model to meet the needs of communities nationwide, the psychiatric mental health nurse practitioner specialty was added to the distance education program offerings to prepare specialized mental health providers to meet the growing demands for mental health services.

Having actors simulate patients with real-world problems is a unique approach to education and learning.

On this day, actors portray patients struggling with mental health issues.

I always wanted a baby, but I was afraid that I wouldn't be a good mother.

Rose is currently receiving mental health services from a psychiatric mental health nurse practitioner at an outpatient mental health clinic.

She had given up on the possibility of becoming a mother due to her constant struggles with anxiety.

Diagnosed with generalized anxiety disorder, Rose currently takes Zoloft, 50 milligrams each day.

I know that treatment has helped me, but when I think about having a baby, my mind just starts to race.

It's important to examine the evidence for those what-if questions.

Let's work on some techniques that can help you work through these anxious thoughts.

But I'm afraid, what if something goes wrong?

What if I can't be a mother?

As Rose and the provider talk, Rose explains to him that her current treatment plan has significantly improved the symptoms of anxiety, but she still struggles with a tendency to automatically think of the worst case scenario.

Expectant mothers may also struggle with opioid addiction or other substance abuse disorders, or even develop substance issues during pregnancy.

Patty has been experiencing feelings of depression and has decided to see a psychiatric mental health nurse practitioner.

Her opioid addiction, brought on after she broke her hip, continues to be an issue.

I don't feel like I have a purpose.

I get up each morning and I go through the day.

I just don't enjoy life anymore.

Can you tell me more about that?

Well, to be honest with you, I really feel like using again.

That's in my head.

I need to use again.

The impact of an individual's mental health often causes stress within the overall family system.

You know, and my family's worried about me, and I feel so guilty about that.

I just, like, I've put them through so much anyway, and now I don't have feelings.

I don't feel anything sometimes.

I don't even want to be here.

I just, I'm just so down sometimes.

I just need that lift, just that little lift of using.

At first, you know, I dismissed how I was feeling as I was just tired.

And I thought, if I can make myself get up, if I can go through the motions of life, everything, everything will be okay.

Years ago, Jackie was treated for postpartum depression, attempting to dismiss the feelings as just being tired.

She spent her days trying to force smiles just to pretend that everything was fine.

You know, the days, days were just so exhausting, and I dreaded getting up.

And then, that made me feel like a really horrible person because my family deserves so much more of me.

Jackie had to admit her depression had returned.

She withdrew, feeling she was useless to her friends and family.

You know, I actually thought that my family might even be better off without me.

Extremely worried about her health, Jackie's husband persuaded her to visit her primary care provider, who referred her to a psychiatric mental health nurse practitioner.

The reason I'm here is because I haven't been feeling well.

I've been so sad, and you know, I'm a first-time mother, and I thought I should be happy for that, but I don't, I don't feel that happiness that I should.

This is a difficult time for Sarah, who is seven weeks postpartum.

I just feel these urges to cry for everything.

I just feel irritated.

I just get these horrible, like really negative thoughts that I just wish I didn't have my baby.

Sarah is open to medication and psychotherapy.

However, she's concerned of the effects of medication while she's breastfeeding.

The period of time before, during, and after pregnancy is a crucial time.

It is a well-established fact that maternal mental health is strongly associated with the mental health of the child and family.

Mental health issues are especially challenging in rural and underserved communities where there's a shortage of mental health providers.

This is true in African-American and Native American communities.

Historically, it's been difficult, it's been a hurdle for women to access mental healthcare.

So, my goal is to provide a safe, a safe non-judgmental environment where women can also have access to mental health and maybe free care.

Because of this critical need, many nurse midwives like Ify choose to also obtain certification as psychiatric mental health nurse practitioners.

They enroll in graduate nursing programs to study mental health because they want to have the skills needed to address mental health issues with their patients.

The lack of mental health services is a crucial problem for us.

Much of the maternal mortality is caused by issues such as postpartum depression, suicide, and opioid addiction.

We really must have more psychiatric mental health services in this country.

What has impacted my career the most from coming to this particular program was instilling us to be change agents, that we basically could accomplish whatever we set our minds to.

I think the overarching experience that I took from CNEP was this sense of feeling so connected and so part of midwifery unfolding.

The steps that I took to achieve what I achieved were all very deliberate in terms of getting to the goal of what I really wanted was to have nurse midwifery in the hospital and in the mainstream and available to more women and families.

When Kitty really stressed to us that you are to go out and make a practice, hopefully start birth centers, really get midwifery care in your community, I took that to heart.

We had only a few midwives in Indianapolis, Indiana at the time, and so I really wanted to be part of a service that was just starting.

So, I became a practice of only one other midwife and then it really grew and then throughout my career whenever I questioned should I do this, could I do this, I always had that confidence level that was instilled in us and almost an ethical level that we needed to do this.

I had forgotten that every student is asked how are they going to make a difference in the world?

How are they going to make a difference for women and children and men?

And that is something that I carried with me, not really consciously thinking, oh yes, I learned that at Frontier, but for me being of service and being part of making a difference of the world, in the world, is a reason for being.

The data is evident.

In countries where midwives are leading the care, their numbers speak for themselves.

Their lower morbidity and mortality numbers show that midwifery care is safe, effective care.

It's what's appropriate for the low-risk birthing person and low-risk women, and creating more midwives is what is going to be the solution to this crisis.

Every year, thousands of nurse midwives and nurse practitioners are serving thousands of people and their families throughout their careers, living proof that where there is a will to change the world and improve healthcare outcomes, nurse midwives and nurse practitioners are proving every day that they are part of the solution and are ready and willing to lead the way.

Really, my goal is to help people access midwifery care wherever that happens to be, and wherever the highest need is.

So, I can totally see myself in a hospital setting, bringing some of that philosophy of normalcy to an otherwise very medicalized setting.

I can also see myself practicing in a birth center, trying to create that environment from scratch to help give people a different idea of what birth and pregnancy care might be like.

I live in a small, like it's a rural underserved community in southern Colorado, and so that's the community that I will be working in.

If everything goes really well, then I really hope to work with pediatrics and their families by doing a mobile school-based business, and hopefully that will help to reduce some of the disparities that we experience in our area.

The maternal mortality rate in Birmingham, and specifically in the southeast United States, is depressingly high for a first small country, and that, it shouldn't be that way, and it can change.

So, I want to be part of that solution, and I want to help women have better access to improved care.

I think that the midwifery model of care is poorly represented in my state, and I felt called, I guess, to bring that model into our state and to help our patients who really, really needed better healthcare and better representation.

That is why I kind of chose to go back to school to become a nurse midwife, so that I could better represent and better serve different populations of underserved women in Birmingham, Alabama.

I'm so proud of our graduates.

They are fulfilling our mission.

They're out there providing care to people all over our country, especially in rural and underserved areas, but we've only just begun.

We have so much more to do.

We've made some progress, but it's not enough.

We can't do it alone, and we need to work within this whole healthcare system of the United States to make the changes that are needed so that we can have a healthy population, and we can make it happen.

[chorus singing] # And therefore we have come # # To join hands and hearts together # # To be 10,000 nurse midwives by 2001 # For the babies and for the mothers The fathers and for the brothers The sisters and all the others We come here to learn And when we have completed this test that we have before us We'll know that we have succeeded What we said back in the chorus!

[cheering] [clapping] Funding for this program made possible by The Van Sloun Foundation, saluting the accomplishments of nurse midwives and nurse practitioners, taking healthcare to rural and underserved communities around the country.