The Role of a Nurse Midwife: Podcast Episode #227

Kristin Revere and Kristin Mallon discuss how certified nurse-midwives support women in all stages of life.  They also chat about how Kristin Mallon transitioned to supporting menopause and feminine longevity when she co-created FemGevity.   

Hello, hello!  This is Kristin Revere with Ask the Doulas, and I am so excited to chat with Kristin Mallon today.  Kristin is the CEO and co-founder of FemGevity.  She is a CNM, MSRNC OB and is a highly accomplished and passionate board-certified nurse midwife with over 20 years of experience in women’s health.  Her expertise in menopause and feminine longevity has made her a respected and sought after expert in her field.  Kristin is dedicated to providing the highest level of care to her patients. 

Welcome, Kristin!

Thank you so much for having me!

I am so excited to chat with you about your background.  From what I read on your bio, you actually started as a DONA doula in Maryland.  So let’s explore your passion and pivot in so many different ways in women’s health.

Yeah, so I started as a doula.  I knew I wanted to be a midwife, so while I was in school, I worked as a doula, and then once I got my nursing degree and then ultimately my midwifery degree, I transitioned from that type of support because now I was able to work as a midwife.  There’s a lot of blending and lot of understanding both roles really well because I had been a doula before I became a midwife.

Yes, so that emotional support and physical support and just being with women in pregnancy and then transitioning to more of the medical aspect of care.

Right.  Exactly.

So for our listeners who are not familiar with nurse midwifery, would you mind sharing a bit about how you work with women in pregnancy, childbirth, and the postnatal phase?

I think unfortunately “midwife” and “midwifery” is really confusing in the United States.  When you go outside of the United States, I think most of the people of whatever country it is – Central America, South America, Europe, Asia – they understand midwife kind of means midwife, and there’s one word for midwife, which is someone, a medical professional whose sole job is to help women during pregnancy, maybe a little bit of the time getting pregnant, delivery, labor, and the postpartum period.  It’s a very specific medical role, a very specific niche.  In the US, it’s really confusing, and most of the time when I meet people, they’re like, oh, you’re a midwife?  You deliver babies at home.  You have no medical training.  You were trained by a group of women in the Amish country.  That’s a very common misconception that people have about midwives.

Most midwives in the US, over 90% – I think some years it’s even as high as 96% of midwives – work in the hospital setting.  They work in a very acute care setting, and only about 6% or 4% or 5%, depending on the given year and depending on the state, are actually working in the home.  So the majority of us are working in hospitals.  I think even that is confusing for the average American.

And then within midwifery, we have certified nurse midwives, which is what I am.  I’m technically a board-certified nurse midwife.  Midwifery does have a certification board.  We have certified midwives who have the same type of board certification that I have, but they don’t have a nursing degree.  They’re not a nurse.  We have lay midwives, which are midwives that are just trained in the communities, very similar to doulas, but they tend to have a little bit more understanding of the medical aspects of things.  And we have professional midwives.  Not all states recognize all of those.  All 50 states recognize a certified nurse midwife.  Not all states recognize all of those other types of midwifery.  And so it’s very confusing and I think overwhelming for the average consumer.  It’s hard in the US, I think, to understand midwifery fully.

I agree.  And I definitely agree about the assumption that most people think of midwives as a homebirth midwife versus a CNM or working in a hospital.  A birth center could be freestanding or attached to a hospital, for example.

Right.  And now a lot of hospitals – I mean, we’ve evolved so much.  I’ve been working in this field for 20 years.  We’ve evolved so much.  Now we have birthing pavilions.  We have birthing adjuncts.  We have birthing wings.  We have birthing hospitals.  There’s so many different venues for birth to take place.  And I think it’s even people that I know very personally – I don’t think they have a full breadth of understanding of all the options that are really available to women in the US when it comes to birth.

Exactly.  In one of my area hospitals, we have a birthing suite which looks less like a hospital room.  It’s pretty cool, and it’s attending only by a CNM.

Right.  There’s so many different opportunities.  And my experience – I’ve really only worked in the New York City Metro area, so New York City, and I’ve worked in New Jersey, northern New Jersey, which is where the bulk of my practicing has been.  For my schooling, I went to NYU.  I went to John Hopkins, which is in Maryland.  Very limited experience in Maryland during my schooling.  But it’s very regionally based as well.  So my friends that I went to midwifery school with – I know a lot of midwives.  I’m very fortunate to know a lot of them.  When I hear about what it’s like in Chicago versus what it’s like in LA versus Boston and San Francisco, it’s very different than what it’s like in New York, and even it’s incredibly different from New York to New Jersey, and we’re four miles apart.  We’re separated by a river.  So it’s really hard, I think, for women to understand their options.  A lot of women don’t think about their options until they’re already pregnant, and it’s kind of like this rush to get it situated and to get it sorted out.  Some women do think about it ahead of time, but I think the majority are kind of trying to put together the pieces of what childcare looks like in the US during pregnancy.

Yes, good point.  So Kristin, who would be eligible to work with a certified nurse midwife as a patient?

I was a high risk midwife.  I’ve attended over 2000 births.  I did the majority of the births in the hospital setting.  Very few in a birth center and even less at home.  And I never risked – very, very rarely did I risk anyone out.  I had the fortunate opportunity to work with a maternal fetal medicine specialist as my collaborating physician.

That’s amazing.

So we were only sending people out of our practice that had really complicated things.  You know, needed fetal surgery.  Almost zero.  And in a year, sometimes zero people got risked out.  Some midwives can only take low risk women, the absolutely low risk women.  Sometimes anemia will make a woman need to transfer.  Diabetes, high blood pressure, breach – the baby being in a breach position.  So I would say that any woman – and I know a few midwives who work like myself and work with a maternal fetal medicine specialist.  They work with a very high risk doctor.  Anybody is eligible for midwifery care.  Really, any woman.  I mean, very few – less than 0.01% of women would be ineligible for midwifery care.

That is amazing.  And as you mentioned, it depends on the hospital policies, the state, and it can be very different in other areas.

Yeah, and a lot of it really has to do with the collaborating physician.  So what the collaborating physician’s comfort level is with that particular midwife.  This is just kind of a generalization, which I think there isn’t really in birth.  I think it’s almost impossible to make any generalizations.  But most of the time, the longer a midwife works with any given doctor or any physician group, the comfort level between the two of them or the groups of them in terms of what they can handle is going to only increase exponentially as the years go on.

That makes perfect sense, yes.  Thank you for that explanation.  And of course, insurance covers nurse midwives in the hospital.

Yes, so insurance – we were very fortunate to get a bill in legislation passed in 2022 called the No Surprises Act.  This means that pretty much any woman with insurance can go to a midwife in or out of network.  The way that bill works, labor and delivery is considered an emergency.  So it pretty much has opened up the field.  Even if your midwife is out of network, you can still use that midwife.  And I think a lot of midwives and consumers, patients, don’t fully understand this bill and don’t understand the full benefits of this bill.  This is a bipartisan bill that was passed by both sides.  Not many bills are so bipartisan.  Patients were getting surprise bills.  You would go to a hospital.  You would see an anesthesiologist.  You would see a plastic surgeon because you busted your lip open and you needed some stitches.  And then you were getting this huge bill from an out of network provider.  Because that has stopped, that has enabled birth workers to have access the benefits of this bill, which include being out of network and being able to bill an insurance that has in network only.  So I think it’s a really – and I’m happy to talk to anybody so that they can understand it, or they can have it explained to them.  But for midwives and consumers both, your insurance now will cover an out of network midwife.

Wow.  Well, you are definitely educating our listeners and certainly myself, so thank you, Kristin!

My pleasure!

As far as the role of a doula, how do doulas and nurse midwives work together during labor?

I think this is another kind of big, convoluted understanding in the birth community to people who are outside of it.  A lot of people think midwives are doulas, and it’s just – they’re not the same.  Doulas, as you know, being a doula, are really nonmedical professionals that really are about emotional, physical, spiritual, mental support.  And the midwife is really more about the physiological process of labor, the path of labor, the progression of labor, the safety of the labor, and kind of the captain of the labor ship, making sure that it’s on the right course, safe, effective.   I think that these two roles get confused.  I think every woman should have a doula.  So whether they have an OB-GYN or they have a doula, I think every woman should have a doula.  I think that should be standard of care.  I think that should be a no brainer.  I think we would see a huge shift in birth from a cultural perspective if that was the case.  So how doulas work with midwives is they really kind of work as part of the birth team.  The birth team usually consists of a medical professional – either a midwife or an OB-GYN – the family or whatever family members that entails; it could be one, could be friends, could be ten people – and then a doula is there to kind of be the bridge between the world of medicine and family.

Beautiful.  And as far as prenatal visits, how are visits with a nurse midwife different than an OB appointment?

So I don’t know that they necessarily have to be.  The practice that I had was called Integrative OB-GYN.  I was the only midwife in that practice, and there were four doctors.  The visits were no different between myself and the OB-GYNs.  Very comprehensive, 30 minutes to an hour each, really about making sure the woman and her family and support network felt comfortable, educated, understood what was going on, and we gave her tips and tricks to prepare along the way.  So I don’t know that they necessarily have to be.  I do think there’s a difference between the in-network model of birth and childbirth care, which is more of a number.  You show up.  And I think that can happen in midwifery or OB-GYN, where you show up, you come in, you get your heartbeat checked, you get your blood pressure and weight and urine, and then you’re kind of just moved through and you’re kind of like a number in a system.  I think that’s a very in-network model of care that doesn’t support how birth is really meant to be, which I think is much more in the out of network model of care where the clinicians, midwives or OBs, have the luxury, because the reimbursement rates are higher for providers in an out of network model, to take the time with women that they really need.  I am such a big proponent for having birth move to an out of network model, especially because we had this gift given to us from the 2022 No Surprises Act.

Yeah, that makes sense.  I certainly had the latter experience, out of network, and had longer appointments and worked with both nurse midwives and OBs with both of my pregnancies.  I just felt like there was a lot more time for questions and a lot more emotional connection in some of those appointments.

Absolutely.  And I think that’s the number one difference between the two models of care, midwifery or physician based.

That makes sense.  And then as far as the postnatal care, what does that look like?  It sounds like it depends on the model and may not be much different.  In my community, I know that some of my clients are able to see their nurse midwives sooner after delivery rather than waiting for that six week appointment.   But it may be, again, different depending on the practice.

Yeah, I think that the postpartum care in our country is pretty atrocious.  We give women, if you’re in a birthing center or at home – I mean, home is probably a little bit better, but in a birthing center, you’re given 24 hours of support, and then you’re seen once or twice in a six month window after that.  I think pediatricians, to be honest, are picking up a lot of the slack that’s left by the significant dearth in the postpartum care that we have in the US.

Absolutely.

Generally, it’s the same thing like you said in an out of network model.  Physicians and midwives are doing the same thing when it comes to labor, birth, pregnancy, childbirth, postpartum, typically.  So when people ask me what’s the difference, I’m like, there’s really no difference.  The difference between a midwife and an OB-GYN is that I’m not doing advanced gynecology.  I’m not doing fibroid removals, myomectomies, ovarian cyst removals.  I’m not doing any type of high end fertility, IVF, those types of things.  So when it comes to the pregnancy and the care, they really kind of do the same thing.  It’s kind of about what type of provider or what culture within a group of providers do you more resonate with, versus it being midwife or doctor.  And then for postpartum care, like we said, in the out of network model, you’re going to get a little bit more than in network model, but not much.

And nurse midwives can certainly see patients beyond that postnatal visit, with well woman care.  Can you explain a bit more about the role of a nurse midwife beyond the birth?

Yeah, so nurse midwives are very similar, like I said, to your regular OB-GYNs.  They can do anything that has to do with wellness, prevention, and your average gynecological care, like a yeast infection, a UTI, need birth control, need for birth control counseling, and mild primary care work.  A lot of us are very well versed in the management of blood pressure postpartum or hypo- and hyperthyroidism, very similar to our OB-GYN counterparts, just because of the sheer volume of women that we work with and their health challenges that come up with them just naturally being a woman and being 44 when they give birth or 34 when they give birth or 24 and the sequelae of what happens after that.  So it’s really more about – I think for midwifery versus an OB-GYN, it’s really about finding and connecting with a person or a group of people, a group practice, that you like and that you resonate with because a midwife can do pretty much what a lot of internal medicine can do; not all, but a lot, and then also what an OB-GYN can do in a primary care setting, like in a wellness, preventative, annual, yearly check in kind of setting.  I think that providers specifically all kind of sometime have different niches, and this is where I also kind of tell my friends and family, like, if they do have more of the complications that go along with gynecological care or women’s health – breast concerns, fibroids, ovarian cysts, endometriosis – that’s really when you want to seek out a specialist within that type of medicine, anyway.  So if you have endometriosis or suspected endometriosis, you don’t really want to go to an OB-GYN or a midwife.  You want to go to an endometrial specialist, someone who is an OB-GYN and then within their day census of who they’re seeing on any given day, they’re seeing 20 patients in a day, half of them are endometriosis cases that they’re working with, and then that’s really their expertise and their specialty.

The same thing with ovarian cysts or PCOS or menopause, perimenopause.  Those are really niche specialists that I think the general OB-GYN or the general midwife is probably not the best person to go to when those kind of issues arise.

That makes sense.  Speaking of perimenopause and menopause, how did you come to found FemGevity?

I’ll be honest, I don’t think that – again, there’s so many things in our system – and I try to be an optimist in my life.  Maybe I’m not coming across that way right now.  But I think that unfortunately, the US does not support birth workers in the way that it should, and so burnout is very high.  And I’m no exception.  I fell into that kind of category where it’s very difficult for birth workers to kind of continue because there’s no respite.  The system, in terms of making a living out of this job, does not have built in respite where you can rest and rejuvenate and refresh and then come back to the system renewed and able to continue a career that could be 20 years, 30 years, 35 years.  I, like most birth workers that I know, unfortunately, had to kind of hang up my hat of birth and transition.  It worked out well for me because my clientele that I had worked with for 15 years was older, and they were kind of in their post-reproductive years.  It kind of made sense for me, and it worked out.  I always believe everything works out, anyway, so it kind of worked out that my clients who I’d had for years and decades were asking me different questions.  They were asking me questions more about perimenopause, menopause, post-menopause, the longevity medicine.  And so I was able to morph my practice into that type of practice and then become a specialist and niche into that field and that area.  So now I would say, if you’re looking for someone in perimenopause and menopause, I am that type of expert, whether it’s OB-GYN physician or midwife, I am that clinician to come to when you have questions about those issues and concerns because I’ve been doing it as an overlap of my birth practice for about 10 years.  And so that’s kind of where FemGevity was birthed, no pun intended, because of that transition ramping up so much in my own practice and in my own life.

So as far as working with you, how do our listeners connect, and what is the process like?  Is it a mixture of in person and virtual?  Fill us in a bit more.

What we’re doing now – so what FemGevity Health is doing – anyone can go to the website, femgevityhealth.com, and take a look at what we’re doing.  But it is a virtual type of care because we’re not meant to replace OB-GYNs and not meant to replace primary care physicians.  We’re not the go-to for a pap smear or any of those types of situations that need hands-on and need in-office.  We’re very specifically managing hormonal shifts that happen after 40.  And that kind of looks different in lots of different areas.  All of our visits are virtual, and so we’ll have a virtual appointment, an initial consultation, usually advise lab ordering, depending on what’s going on.  Most of the time, we’re recommending labs.  We also have functional medicine or longevity medicine labs that we offer, like gut microbiome tests, micronutrient testing, allergy and food sensitivity testing, genomics.  And those tests help us put together all of the pieces about how to properly balance hormones in different decades of a woman’s life.  It’s all done virtually because we can mail the kits to women’s homes or if they need bloodwork, we can send them to their local LabCorp or Quest Diagnostic or a BioReference lab and get the bloodwork done, and then we’re able to kind of consume all of that information virtually and then come up with treatment plans and recommendations based on what’s going on.  It enables us to keep the cost down for women because we don’t have the overhead of a brick and mortar practice, and we don’t have to have a whole bunch of staff and a lot of overhead that goes with having an in-person office.

That’s fantastic.  And you do offer free consultations?

Yes.  We offer a ten-minute free consultation at FemGevity Health if women aren’t sure if what they’re experiencing is something we can help them with.  And we also do Instagram Lives on most Monday nights around 8:30 or 9:00 p.m. Eastern time where we also answer questions live that people send us, as well.

Perfect.  So you’re on Instagram, as you mentioned, @femgevity.  And you have a website.  Where else can our listeners find you?

We’re on all socials.  We’re on Facebook.  We’re on TikTok.  We’re on LinkedIn.  I’m on LinkedIn personally as Kristin Mallon.  And we also have live chat on our website.  We have a Contact Us form.  We have email.  So it’s really easy for people to reach out.  People can call or text us, as well; call or text FemGevity Health if they want to have a chat conversation via text about what they’re experiencing or going through and they don’t want to get on a free consult or they don’t want to make a phone call.  Lots of ways for people to reach out and get the information they need.

And the website is femgevityhealth.com?

Yes.

Any final tips for our listeners, Kristin?

Yeah, I think we’ve really covered a lot.  What I say about birth specifically, so for the people who are more interested in birth and childbirth, the real experts to kind of consult with are people like yourself, like the doulas of the community or a lot of times there’s – I know it seems kind of strange, but WhatsApp, Facebook, or some sort of communal chats that have a lot of really good information about birth, birth workers, who to go to, what type of places to go, and it’s usually very regional.  So I always kind of encourage women to get involved in their regional group chats, doulas, birth workers, because a doula from Ohio isn’t going to be able to really tell a woman in Oregon a lot about opportunities, resources, support, et cetera.  I think that’s my best tip for birth.  For perimenopause and menopause and hormone balancing specifically, which can happen – some women have unbalanced hormones, unfortunately, in their 20s, even – you really want to seek out an expert like ourselves.  For women that are 40-plus, a lot of what they’re experiencing is probably perimenopause or changes in their hormones or shifts in their hormones because I think a lot of women just sweep it under the rug.  They’re tired; they’re fatigued; they’re not sleeping well; they’re having more anxiety or depression or night sweats or insomnia, and they just think it’s aging or they just think it’s having little kids.  And there’s usually something shifted that we can help them balance.  It’s not always HRT and hormones.  A lot of what we do is with diet, lifestyle, supplements, nutraceuticals, to help them get back on track.

Fantastic.  Well, it was wonderful to have you on, and thank you so much for sharing your wisdom, Kristin!

Thank you so much for having me!  It was great to talk with you.

IMPORTANT LINKS

FemGevity

Birth and postpartum support from Gold Coast Doulas

Becoming A Mother course