Tara Miller, 22, was living in a shelter for pregnant women when she walked into Barbara Hughes’ midwifery clinic. Before long, the Colorado clinic became Miller’s second home.

Hughes, MBA, MS, RN, CNM, and her fellow midwives counseled Miller about her rocky relationship with the baby’s father and connected the expectant mother with local food pantries and clothing outlets.

When the father showed up for the delivery, Hughes knew the birth could be instrumental for the struggling couple. Hughes asked the father if he would help with the delivery.

"He was crying by the time the baby was out," Hughes said. "It was such a beautiful, powerful experience."

For Hughes, nurse-midwifery gives her a freedom that hospital obstetric units can’t deliver. Rather than focusing solely on the birth, she prefers to work with women from the early months of pregnancy through to the delivery. Midwifery also allows her to continue working with women long after the end of their pregnancies.

This field of nursing has been growing rapidly, with a 25 percent increase in certified nurse-midwives per year since 1991, according to the American College of Nurse-Midwives.

Hughes, one of 7,000 certified nurse-midwives throughout the nation, started her nursing career in a hospital labor and delivery unit. But she didn’t enjoy relinquishing the final delivery moment to physicians.

"When you establish a rapport with a woman after spending time with her, and someone else walks in and catches the baby, that leaves something missing," Hughes said.

After two years in the unit, she returned to school for two years to become a certified nurse-midwife. But she had an even bigger dream of opening her own clinic. To gain business savvy, she earned an MBA. Three years ago, she opened Aurora Nurse-Midwives, a clinic of 15 nurse-midwives and two obstetricians.

Hughes wanted to open her clinic to women who were on Medicaid or who had no insurance. All nurse-midwives on staff are bilingual.

"Instead of being treated like a number, I felt like I was giving birth in front of family," Miller said. "Barbara seemed to be almost at my beck and call, and she was there the whole time during the delivery."

Hughes constantly is met with the misconception that midwives commonly perform deliveries in the home. About 96 percent of the deliveries by certified nurse-midwives take place in hospitals, according to the ACNM.

Insurance providers in some states also can be reluctant to cover nurse-midwives who run their practices independently, according to nurse-midwives. Hughes avoided these problems because her clinic is owned by a large health care company that has clout when negotiating with providers.

Like Hughes, B.J. Snell, Ph.D., a women’s health care nurse practitioner, was drawn to nurse-midwifery because she wanted to work with women in all stages of pregnancy and life. She was a perinatal clinical nurse specialist for six years and then a neonatal ICU nurse for six years, but she grew increasingly disillusioned.

"The model was to treat all women as high-risk until they had proved otherwise," she said. "I was frustrated with a system that treated a healthy life transition as a disease. The midwifery philosophy is to trust in a woman’s ability to give birth."

This difference in approach is reflected in national statistics. Certified nurse-midwives have a cesarean rate of only 12 percent, compared to the national average of 23 percent, according to the ACNM. Nurse-midwives also have a vaginal birth rate after a previous cesarean of 69 percent, compared to the national rate of 25 percent.

The different philosophies, however, can create tensions in hospital delivery rooms, Snell said. She gives her patients the choice of having an IV, for example, but IVs are standard procedure for delivering mothers in most hospitals, she said.

"There seems to be almost a competition within our profession of nursing," said Snell, who runs an independent practice. "What I would love to see are nurses who are receptive to nurse-midwifery."

Another challenge for Snell is obtaining coverage for her services from insurance companies. She has to turn away about 20 percent of her business when patients discover providers will not reimburse her for services.

Although the majority of nurse-midwives deliver in hospitals, about 1 percent still specialize in home births. Becky Burpo, MSN, RN, CNM, hadn’t planned to pursue this area—until she witnessed her first home delivery.

Burpo had worked as an RN in labor and delivery for 17 years when she decided to return to school to study midwifery. She was a student when her preceptor asked if she was interested in watching a birth in the home.

"I was expecting to see the mother in bed," Burpo said. "When I got there, the woman was at 5 centimeters and fully clothed. She went on a walk around the block!"

Burpo was shocked when the nurse-midwife allowed the woman to go into the backyard pool when she was at 7 centimeters. Burpo was so amazed by the experience that she had trouble sleeping for a week, she said.

"It’s a very spiritual event," Burpo said. "All the family is around crying, and you are there with them."

To prepare for an emergency, long before the due date Burpo outlines a plan for transportation to the nearest hospital. In the case of a cesarean, for example, a physician takes over. She has had no emergency transfers in her eight years of practice, though. One reason for this may be that she carefully screens patients before she agrees to perform a home delivery. She does not accept clients who have had a cesarean or are unmotivated about taking care of themselves through pregnancy with proper nutrition and exercise.

For Burpo, one of the greatest challenges of home birthing is learning to operate in an unfamiliar environment each time she delivers in a new house. "You also drive all over creation," she said.

Sister Angela Murdaugh, RN, CNM, also has picked a less-traveled path in nurse-midwifery. She runs a birth center in a rural area of Texas, and is among the 2.4 percent of nurse-midwives who perform deliveries in birth centers rather than hospitals, according to the ACNM.

Murdaugh opened the Holy Family Birth Services center 19 years ago outside the town of Weslaco at a time when pregnant women had to drive 25 miles to give birth at the nearest medical facility.

The majority of her patients are Hispanic wives of field workers or people who operate small businesses.

"I love the pace here," she said, "and I love the people. They value family so much."

She struggles, though, to find physicians who will treat problems she detects in her patients. One time, she performed a routine tuberculosis test on a pregnant woman, and the patient tested positive.

Murdaugh couldn’t find a nearby physician who would treat the woman, because she was uninsured. About 80 percent of her patients aren’t insured.

Murdaugh receives most of her compensation through grants, donations and sometimes patients who perform jobs at the center in exchange for her services.

Murdaugh admits that the small-town atmosphere has its drawbacks at times. She misses the freedom to see quality theater productions, but she wouldn’t give up the chance to work with the underprivileged.

"It’s a source of great satisfaction," she said. "I like not having bureaucracy and the fact that everyone knows your name."