My interview with Naomi Drucker, a Certified Nurse Midwife (CNM) in Los Angeles

1. What led you to your career as a certified nurse midwife? 

My journey to midwifery started with my first birth. I had my first baby at a Kaiser hospital and was very surprised at how impersonal and rough the experience was. I was 21 years old at the time and had the same midwife throughout the pregnancy. She had told me that she would be there at the birth and had given me her cell phone. When I went into labor, she did not answer her phone, and I remembered that we had not discussed a plan B. I was completely bewildered and upset silly as that may sound.

Being young and clueless as I was, it was uncomfortable having to meet, build rapport and negotiate with different providers that I had not met before, i.e. different doctors and nurses that would change shifts every 12 hours. Coming out of that experience, although physiologically it was an ideal birth, I felt indignant, even though I knew very little, I knew that I had been treated poorly. That was when I started delving into the birth world and discovered different options for women. I found out about doula services, and midwives. A year after my first baby, I became a doula - it was great work! In my heart, I knew eventually I wanted to be a midwife so I could take care of other women during their pregnancy and birth  better than I had been cared for during mine.. 

After some time and as much of a difference I was able to make as a doula, the work was sparse and not regular enough to meet my family's needs. I decided to return to school and become a registered nurse, because I saw first hand that labor and delivery nurses can make a significant impact in the patients’ hospital birthing experience. I became a labor and delivery nurse a couple years later. By then I had my second child and had had a wonderful experience with a midwife at a birthing center. This experience recommitted my path to becoming a midwife, I felt so well taken care of and empowered.. 

I worked as a labor and delivery nurse at a major hospital in LA with the highest volume labor and delivery unit in the city for fourteen years. I participated in approximately three thousand births over the course of my career and impacted many, many families. As my children grew up, I decided it was the right time to pursue my master’s degree in midwifery. Currently, I work in private practice and can attend birth at home, at the birthing center (Gracefull Birthing Center), or at that same hospital that I worked at for all those years.

2. Can you describe the similarities and differences between an OB/GYN and a midwife? 

An obstetrician and a midwife are both trained in normal pregnancy and childbirth as well as abnormal births. Both can conduct complete prenatal and postpartum care,attend births and perform annual check ups. OB/GYN’s often have bustling practices and may have one or multiple partners sharing call and covering for each other. They may have an ultrasound machine in the office and offer many different tests and surveillance of the baby.  They will refer patients out to specialists for certain things like anatomy ultrasound or genetic counseling. Midwives work in groups in hospitals, or in birth centers, sometimes they partner together for home births and many midwives work independently arranging coverage from their professional network when necessary. We too refer to specialists when needed and collaborate with doctors frequently. Many midwives do not offer ultrasound or fetal surveillance and would refer to the OB for that. Nurse midwives must have supervising physician she can count on in order to practice midwifery in California. As a midwife, I have to be cognizant of complications that arise outside of my scope of practice and to refer to a physician when necessary. OB/GYN’s are surgeons and can perform surgery if needed. Both  nurse midwives and OB/GYN’s can prescribe medications and attend births in the hospital setting. I do not know a lot of physicians who do home births — I know a couple, but overall it’s pretty rare. At some point in my career I would like to do additional training to be an assistant in the operating room so if a C-section is needed so I can still be there and assist. Currently I feel lucky to be able to accompany my patients to the operating room and offer support and comfort in the case of an unplanned cesarean. Another difference between OB/GYN and midwives is that a midwife may be able to spend more time with their patients during pregnancy and in the postpartum period due to the smaller practice size. Many private midwives and groups offer hour long routine visits- which creates a very deep connection and sense of trust and safety. Most OB/GYN’s accept insurance and are in network with some plans, many midwives are considered out of network by insurance companies.

2. Can you clarify the different types of midwife certification: certified nurse midwife (CNM), certified or licensed midwife (LM) , and certified professional midwife (CPM)? 

You do not necessarily have to be a nurse before you proceed to a career in midwifery; however, I have found that my experience as a doula and labor and delivery nurse has been very helpful on my personal journey to become a midwife. I felt very comfortable assessing pregnant women and taking care of newborn babies for many years prior to being a certified nurse midwife. Furthermore, with my background in nursing, I was able to detect abnormalities and intervene appropriately and expeditiously during the labor and delivery process. Currently, certified nurse midwives can practice in the hospital setting whereas other midwives cannot for the most part. My license as a certified nurse midwife comes from the CA BRN (California Board of Registered Nursing) and can only be obtained after completing an acceptable and accredited masters program and specialized clinical training both in the clinic and at births and passing the national certification exam by the AMCB ( American Midwifery Certification Board). A nurse midwife in California requires relationship with a supervising physician, whereas a licensed midwife does not require that. A nurse midwife is able to prescribe medications, such as birth control and antibiotics; whereas a licensed midwife cannot prescribe. 

Licensed midwives and Certified Professional Midwives are not required to hold a registered nursing license. Their licensing comes from the medical board and can only be obtained after completing an acceptable course of study, a requisite list of clinical experiences and passing the North American Registry of Midwives (NARM) exam. 

3. You are the only private midwife in Los Angeles with privileges at the Hospital, explain how this can be beneficial when patients choose their providers? 

For a planned home birth that needs to be transferred, I can go with her to the hospital and continue the care there, versus passing her off to another team and losing the continuity of care. For women who want an epidural and prefer a hospital setting but still desire the continuity of care and personal touch, working with private midwife is a great option. 

My practice is different in that I do complete prenatal care, including home visits as well as postpartum care. I am able to attend births in the hospital which is unique. I have modeled my practice after the late Debbie Frank CNM who was my mentor and inspiration from the moment I met her. Having worked at the hospital for the time that I did, I was able to develop relationships with many physicians so for routine ultrasounds or tests or if pregnancy becomes complicated and my clients do need the care of a physician, I have at my fingertips wonderful referrals. With a physician on board who is supportive of midwifery, I can still stay in the picture and continue with your care, which is really nice for patients. 

4. What are some different avenues that prospective patients will typically find you? 

Some of my patients start to look for a midwife either before they become pregnant or when they are newly pregnant, they might start googling, look on Yelp or ask their friends. I do get referrals that way. More frequently, women will come to me in the second or third trimester when they are under the care of a physician but decide that midwifery might be a better fit for their vision of birth. 

5. Describe your services and how might that be different than midwifery at the hospital setting? Also, what providers do you also like to collaborate with to augment your patient’s experience? 

 Hospital based midwives in the city including Kaiser and UCLA are large groups, within that setting there are four to ten midwives. Often times, you do not see the same midwife at each visit. Each visit is approximately fifteen minutes, quality time is very limited in the hospital setting. In my private practice, my patients and I get to know each other very well and develop a trust. If you’re interested in a natural, non-medicated birth, it’s extremely important to trust your provider and to know that they will be there. It is also important to develop a back up plan since of course things happen and sometimes you might need it. I always discuss this at length and provide a back up midwife, share her information with the client and can invite her to a prenatal visit if they wish.  

Typically, I will set up an in-home interview which usually takes one hour. During our meeting, I will explain my services, and the client explains what her priorities and wished are and we start to develop trust and connection. It’s very simple to transfer care from the previous provider to me — you just have to obtain your medical records and have them sent to me. Prenatal care is comprised of monthly visits up until you are twenty-eight weeks, then every two weeks up until thirty six weeks, and at thirty six weeks we see each other every week until you have the baby. Each prenatal visit consists of nutritional counseling, mental health assessment, pregnancy screening (including vital signs, belly measurement, baby’s heart-beat, urine test, lab work, referral for ultrasound when indicated - that’s when my connections at Cedars Sinai comes in handy). 

During pregnancy, I refer to chiropractic very frequently. I find that chiropractic can be helpful throughout pregnancy and especially towards the end when you’re ready to give birth, it’s important to be in alignment and quite loosened up at the end. I also like to refer to acupuncture — a lot of people use acupuncture to help them get into labor towards the end, to be able to do that without medicine is incredible. 

My postpartum care is very different than a typical MDs, sometimes with an MD you get an appointment at six weeks which gives you clearance for sex and exercise. Upon request, you would get your birth control medications and then you’re on your way. My postpartum care consists of three visits plus phone check-ins: 

A) The first visit is within forty-eight hours of the birth — I come to your house for that visit if it is a home birth or at a birthing center, and if it is at a hospital setting, I will come visit you there as well. 

B) Another visit will be between one to three weeks postpartum, depending on your preference and any issues that arise. I like to see patients one week postpartum, at this time we can ensure that breastfeeding is well established. If needed, I can refer you to a lactation consultant within your area, certainly pediatricians, mental health specialists if needed. We want to make sure postpartum depression is addressed and treated in a timely manner.

 C) At six weeks I can order birth control medications if needed, perform pap smears, and perform a general pelvic exam to make sure any stitches or trauma to the tissues are healing well. I can assess your vaginal muscle tone, and I will refer you to pelvic floor physical therapy as well. A lot of women after having a baby can greatly benefit from that! 

6. Once patients have chosen you as a provider, do they have a concrete idea of where they want to deliver or is that a decision that you can help your patients with? 

Typically when patients have chosen me as a provider, they have already chosen a place where they want to give birth — either at home or in the hospital setting. Sometimes throughout the course of the pregnancy, as we start talking about a planned hospital births, patients will start to warm up the idea of home births instead. The opposite can also happen, patients can shift from planned home births to a hospital setting. Planned home birth is easier to transfer to hospital birth versus the other way, as some preparations are needed in a home setting. For example, if you plan on having a water birth, you need to arrange for a tub. 

My fees are the same whether it’s at a hospital or a home birth; however, you have to keep in mind that hospitals will have a separate fees usually covered by medical insurance. Some insurance companies will reimburse part of my fee, so I encourage folks to submit a claim when our care is complete.

7. Describe the rewards and challenges associated with attending births at home, at a birthing center, and at a hospital based setting. 

Some of the many advantages of a home birth are, you do not have to go anywhere when you are in labor! You are in a safe environment with the food that you would like to eat, privacy, comfy clothes or none at all. If you want to shower or take a bath your products are handy. Everything is there! You can have as many or as few visitors as you want. You are in control of the physical climate and psychological/emotional vibe. Some of the challenges with a home birth include being responsible for arranging birth certificate versus at a hospital can be done before you check out. The baby can receive a hearing screen and newborn metabolic screen at the hospital as well. Of course when the plan changes due to circumstances beyond our control and the difficult decision is made to transfer, that can be disappointing. Part of our prenatal preparation includes going over many potential scenarios and having a plan in place so that you don’t have to scramble at the last minute. A bag packed just in case, on call dog walkers etc..  The sudden shift from an all-natural birth to a medical birth, including a C-sections can be challenging and we will process the whole experience bit by bit in our postpartum visits.

At the birthing center, you can have many of the comforts of home without the sterility and coldness of a hospital setting. You are less likely to meet providers you have not met before. Some people choose this setting  because they are not entirely comfortable at home and this can be for a number of reasons: extended family members, too many animals, some women are concerned about the mess or limited space. At a birthing center, you will not be admitted until you are in active labor. Most of the early labor is done at home, and assuming all is well, you are often discharged within four to six hours after giving birth. Some people would rather not travel in active labor or so soon postpartum. The equipment are all the same whether it is a home birth or at a birthing center; however, you do have the option for nitrious oxide at the birthing center which can be helpful for pain management. 

At the hospital if any complications arise they can be managed quickly and easily. If you need pain management, an epidural is available, if you need to augment labor for any number of reasons, Pitocin can be provided. You also have the convenience of having the birth certificate and hearing screening for the baby. If you are a person who believes strongly in western medicine then the hospital may be where you feel safest- which is essential to a successful birth. As a midwife my priorities are safety of mother and baby, honoring the families wishes for labor and birth and this is often best accomplished through shared decision making. I believe that women can birth babies with very little or no intervention most of the time, and am delighted when I can provide an undisturbed experience so all the hormones can be released naturally contributing to efficient and satisfying births. Some people put their guard up at the hospital if they are wary of western medicine or have had negative (even traumatic) experiences in that setting before. Your experience can be disturbed as different people come in and out of your room to take your vital signs and monitor the baby. Sometimes the shower or tub at the hospital are not too appealing either. 

8. What has been the most rewarding aspect about your career? 

I love taking care of women and being present for their births. Especially if they were doubtful or had had a bad experience previously and were able to repair a part of themselves and grow. It is such a deep connection that develops when I spend so much time getting to know a woman and empower her to make the choices and plans that feel right to her throughout her pregnancy and her birth. To empower women to give birth the way that they want is an incredible responsibility and I take it very seriously, each woman must be seen and heard as an individual. To be a witness to the birthing experience, to support and see it to the end as I transition with her into motherhood is the most rewarding aspect of my career. 

9. What has been the most challenging aspect about your career? 

As hard as it is for my clients, it is also very hard for me when the birth plan does not go our way. During the initial evaluation, we discuss all the challenges that may come up during birth and pregnancy. My practice is unique in that I am able to to continue to participate in care even if it extends beyond my scope of practice. I can co-manage with the doctor and be present every step of the way- even in the operating room. Working within the medical system is a delicate dance. Shared decision making is emphasized in midwifery training but sometimes other members of the team can be more authoritative when making suggestions and the client and I may feel left out of the decision making process. I am very grateful to the doctors that support me and are open to learning more about my practice and how to support my clients.

10. As a community and society, what can be done to advance your profession in the next twenty to twenty-five years so that midwifery can be more accessible to women? 

CNMA ( alifornia Nurse-Midwives Association) is working to have the physician supervision law removed so that we can function more independently and work in areas where there are a shortage of providers for women. That being said, if there are complications, a midwife must refer to a physician. Just as a general practitioner cannot treat cancer and must refer to an oncologist, I have to do the same in my practice when there are complications. So I think the removal of the physician supervision law would make midwives more accessible to more populations while maintaining the strict safety standards that are at the core of our practice. It would also relieve the physicians of the burden of responsibility for patients that are low risk and able to be cared for by a midwife.  Insurance companies also need to get on board for proper reimbursement. A typical hospital bill for a normal birth is $30,000 billed to insurance. A typical home birth or birth center birth is between $5,000 and $10,000 and that includes comprehensive postpartum care that addresses breastfeeding issues and screens for postpartum depression as well as infection and other difficulties that often lead to emergency room visits by new moms and their babies when left unchecked. Traditional care with a doctor usually includes just one postpartum visit and very little in the way of contact and support in between.

11. What other services do you offer outside of midwifery? 

Outside of  traditional midwifery care, I offer “labor checks”. For women desiring unmedicated low intervention birth it is beneficial to avoid going to the hospital too early. If you labor at home and go to the hospital at the right time, you can avoid much of the discomfort of being in the hospital setting like no food, limited mobility etc... How do you know it is the right time? It is hard to know! With labor checks, I come and do an assessment at home, I can listen to the baby and check your cervix to let you know that baby is safe and where you are in your labor. I will let you know if you should spend more time at home or go to the hospital. Concurrently, you would have to be in touch with your provider to let them know what’s going on and hear out their recommendations but it can be a useful tool for women to avoid going to the hospital too early. I also will offer doula services for some clients desiring to remain with their provider or when there are complications beyond my scope as a midwife- like twins, breech, pre-eclamsia, diabetes requiring medication. I offer pregnancy and birth consultation.

12. What is your most memorable experience as a midwife? 

I was recently at a birth where it was a woman’s first pregnancy. Often times a seed of doubt can creep in when things do not go as smoothly or quickly as anticipated. I was at this birth that somehow came to a halt — I was getting worried as well as the woman. We made an adjustment that gave her extra time to make any changes in cervix because she was at six centimeters for several hours. She was getting tired and the pain was becoming too much for her to handle. She started talking about going the hospital and getting an epidural and I was feeling that might have to be the case. Again, we continued to give extra time to labor, and when I checked her again, she had made significant change. Suddenly her mood and attitude quickly shifted for the better. I reminded her that in my contract, it states that patients and providers need to be honest and comfortable with each other. I needed her to feel comfortable asking me questions and vice versa. As a patient, you are trusting me with your life and your baby, and as your provider, I am entrusting you with my reputation and my license. This woman had a complicated medical history, having gone through cancer and some fertility issues, she wanted an out of hospital experience with the support that she wanted. Her birth ended up being so empowering and healing for her. For me it was a truly memorable experience so far in my career. 

13. What do you enjoy doing outside of your career? 

I enjoy continuing education courses a lot. It has been more challenging now that I am on my own versus when I was a nurse at the hospital, there are always conferences or meetings to attend when I was in that setting. Currently, I have to actively seek different continuing education courses to make sure I stay current with evidence based practice. I also love networking with other providers who take care of women, including other midwives, physical therapists, mental health specialists, and so on. I love spending time with my family. My schedule is crazy, and since I am always on call, I try to grab what quality time that I can with them. I also love my dog Royce- a giant golden doodle who needs lots of exercise. He gets me out hiking and to the beach often!