"I tell everyone who comes in: 'You belong here. This is your program,'" says Felina Ortiz, a student success coordinator for graduate advanced practice programs at the University of New Mexico College of Nursing in Albuquerque. Ortiz is an assistant professor at the college and a practicing nurse midwife. She's also a first-generation college student and familiar with the obstacles encountered by nursing students from underserved communities, particularly communities of color.
"I tell them they bring something very important to this program and the profession," she says. "I've had students cry when I've said those words, because they don't feel like they belong."
A PATHWAY TO MIDWIFERY
Ortiz's own educational journey highlights the complicated and sometimes overlapping challenges that can confront students, including a lack of awareness of educational options. "I understand the struggle of not having the family structure or background for higher education, and the fear and challenge of finding a place within an academic institution," she says.
Ortiz grew up in a large Hispanic family in Utah and says, "Education was not in my elders' path, although hard work and dedication were." This work ethic propelled her through a pipeline program at the University of Utah, which she was accepted into during her sophomore year of high school. "I still remember the day the recruiter came into my school, looking for students of color who had a good GPA," she says. "She called us in and talked to us about a medical minority enrichment program the university was offering. I applied and got in." The program, which Ortiz attended each summer, exposed participants to different medical professions. "Before that, I had no idea about even going to college, or having any knowledge about how to do it," she explains. The experience led Ortiz to participate in a nursing assistant program during high school.
Several years later, while Ortiz was considering studying to be a health educator, her close friend passed away from leukemia. A nurse in the ICU made a big impression on her, she says, teaching her that nurses have an opportunity to make a terrible situation bearable. She decided to study nursing and recalls how a family NP describing advanced practice nursing programs "told me there was such a thing as a nurse midwife and that I could help with birth. As soon as she said that, it was like 'ding, ding, ding-that is what I'm going to do.'" Ortiz made the decision to pursue a certified nurse midwife (CNM) degree as her family was growing. Pregnant with her second child at the time, she subsequently completed her prerequisite courses and gave birth to her third child during the first semester of nursing school. Despite the challenges of raising a family while working toward a degree, Ortiz says, "Once I was on the road to nursing, everything seemed to fall into place."
EFFORTS TO DIVERSIFY
Midwifery and nursing weren't always linked, but nurse midwifery has become the dominant U.S. model in the past century. A graduate degree is required for entry into practice as a CNM, who is licensed to attend births in all settings and prescribe in each state, and who provides a range of essential care to women throughout their lives. The profession has historically lacked racial and ethnic diversity, notes Ortiz, with midwives of color making up about 5% to 6% of the workforce, statistics that haven't changed much in the past 30 years, according to the American College of Nurse-Midwives (ACNM). Heightened awareness of the need for culturally appropriate care and to address maternal and child health disparities-which disproportionately affect communities of color-have propelled diversity and inclusion efforts in the profession and in Ortiz's work.
Last fall, she was appointed chair of the ACNM's Midwives of Color Committee. As one of the founders of the New Mexico Midwives of Color chapter, Ortiz understands the importance of connecting students and midwives of color at the local level. She has sought to bridge local and national efforts by appointing regional ambassadors who support and report on this work. These ambassadors may help create new chapters or recruit students and midwives to an existing group. After a network is established, they can provide education on relevant local health concerns. "There's a lot of work we can do within this structure," Ortiz says.
THE IMPORTANCE OF TRUST
Ortiz also continues to recruit students and provide assistance as they navigate their studies. "I try to help people from communities at the margin find the pathway to becoming successful within our institutionalized system, so they can go back and serve these communities." Ortiz points to her advocacy work in the Navajo Nation, which tends to have fewer educational sources than surrounding areas, to illustrate some of the challenges. Even students who are successful within these educational systems, she says, often face test-taking problems in higher education. This has less to do with their academic ability than with fear, anxiety, and a lack of trust in the system, she explains. Distrust is perhaps the biggest obstacle to overcome when helping students to start and successfully complete a higher education degree program, she says. "But those that make it, they do wonders when they go back into their communities and care for their people. They make change."
The biggest and most obvious benefit of midwives serving the communities they're from is the heightened level of trust. Ortiz sees this in her own midwifery practice. "From my cultural background and all that I've experienced, I often practice with medicine and spirituality mixed," she explains, noting this is a common approach among her Latina patients. "The language I use to treat these women is very similar to the language they use, and it helps to promote trust." A recent visit she had with a patient highlights the importance of trust and the vital role of midwives in primary care. The woman told Ortiz she'd visited the ED the previous weekend with significant abdominal pain and was given antibiotics for a urinary tract infection. "But she hadn't taken the medication yet," Ortiz says, "because she was afraid and wanted to ask me first."
A CULTURE OF RESPECT
Understanding the importance of a diverse workforce and culturally appropriate care, says Ortiz, requires a greater appreciation of the history of midwifery and the United States. "It's an issue for many professions," she says. "There are many things about our country that we don't acknowledge. Within midwifery, I think the first step is to acknowledge our history and make visible those that provided this care within our communities before structuralized medicine."
In New Mexico, she explains, informally trained midwives historically "provided excellent care in their communities and were often not only valued but sought after, because they shared the same language, culture, and social and economic background as the patient." As medicine became professionalized, relatively few physicians practiced in the state, leading the health department to work with midwives. CNMs were taught to gather health statistics and sent into indigenous communities, where they educated traditional midwives and collected vital health information, helping to improve health outcomes and data collection.
The result has been a culture of respect for midwifery that persists today, says Ortiz, who explains that CNMs and other midwives, such as licensed professional midwives, are integrated into the state health system. CNMs even help to educate physicians. "At the University of New Mexico, we work with them for the first month of their residency, teaching them about normal birth and midwifery and why we're different and do what we do." In their third year, these residents who've had extensive experience working with midwives serve as the midwives' consultants. Many physicians transfer their low-risk, healthy patient to midwives' care, says Ortiz, "because they know we have the best health outcomes for these patients, and it frees them for more high-risk obstetrical care."
MIDWIFERY'S POTENTIAL
Ortiz calls the World Health Organization's declaration of 2020 as the Year of the Nurse and the Midwife "a wonderful opportunity to highlight the work of midwives." She points to the outcomes associated with nurse midwifery care and the integration of midwives into New Mexico's health system as evidence of the profession's value and potential.
"We've played a really important role within our society," says Ortiz. "We now have work to do to make that space even larger and more inclusive, to provide even better care to the communities we've always been known to care for."-Corinne McSpedon, senior editor