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Delivering Babies… And Much More: Profile of Barb Boehler

Barb Boehler CNM
If we waited for all the causes and conditions to be right, and weren’t motivated as, ‘this is the right thing to do it, let’s do it, and we’ll figure it out as we go,’ we wouldn’t have done anything.
Delivering Babies… And Much More: Profile of Barb Boehler

When Barb Boehler, CNM, first began caring for pregnant women as a perinatal coordinator in the Northern California town of Davis in the early 1980s, undocumented women were not covered for any kind of care in California, including prenatal. But her clinic, called the Davis Free Clinic at the time, obtained a grant from the State of California to provide prenatal care to this population. “We saw all of our patients on Wednesday nights. It was a madhouse, and it was wonderful,” Boehler said, noting that, on many nights, Boehler and her staff would see patients up until midnight.

The grant didn’t provide funding for the births. To give birth, the women were sent to a hospital in Sacramento, 30 miles away. The hospital was willing to serve the women, Boehler says, because it benefitted the hospital’s residency program. “One night, this young woman came in [to the Davis Free Clinic] and she was exhibiting signs of maybe pre-term labor,” Boehler said. “We little middle-class ladies said, ‘Get yourself to the med center and they’ll monitor you.’”  That night, Boehler called the hospital to check on the patient, but the hospital hadn’t seen her.  Boehler discovered that the patient was still in her home. “She couldn’t go to the med center because she didn’t have enough gas in her car,” Boehler said. The patient was waiting for the 3 pm to 11 pm shift to end at the local canning plant, for a family member to drive her to Sacramento, the patient told her.  The experience left a strong impression on Boehler.

“There was something so fundamentally wrong about that scenario, that because a mother had limited resources, and was not born in the United States, just because of that, this baby was born too soon, and spent the first month of its life in a NICU,” Boehler said, referring to the neonatal intensive care unit.  That night, she made the decision to become a certified nurse midwife and to begin delivering babies in Yolo County, to prevent just such situations in her community. She also vowed never to make assumptions about her patients’ resources. “All of us learned the lesson that our lives were very different than our patients’ lives. No matter how culturally competent we thought we were, we weren’t,” Boehler admitted. “To this day, I always ask people if they have gas.”

YEARS OF STUDY AND PRACTICE

The ensuing years of studies while working as a nurse – and while trying to maintain a home life with a young family – were grueling, she confessed, but she was motivated, knowing that at least “poor babies in my little neck of the woods would be born with love and respect.”

Boehler had been practicing as a lay midwife for a decade prior to her return to school for certification.  When Boehler finally returned to the Davis Free Clinic as a certified nurse midwife, she and several other midwives found their shared experiences as homebirth midwives shaped their vision of birth in the hospital. “Our philosophy was we are going to bring the experience of homebirth into the institution,” she recalled. At the time, women entering the hospital to give birth “were victims,” Boehler contended. “They didn’t feel that they had any power [over] their birth.  They went into the institution, and things … just happened to them. They were just glad to have a baby at the end that they could leave with, finally.” 

As Boehler began her long career in delivering babies at the clinic, the Davis Free Clinic was growing, and soon moved to larger facilities.  In the ensuing years, in response to rapid patient population growth, the clinic grew quickly, with three clinic sites throughout Yolo County. The clinics formed the newly-named CommuniCare Health Centers, a family of health centers designated as a federally-qualified health center and a migrant health center. 

Today, Boehler is entering her 34th year with CommuniCare, now as the Director of Perinatal Services.  CommuniCare now has the largest Medicaid obstetrics program in the country.  At a time when other community health centers are dropping their midwifery programs, says Boehler, CommuniCare’s team is delivering around 600 babies a year.  She estimates that her team there has delivered around 18,000 babies in the last three decades; she has personally delivered around 3,500 babies. Her department includes seven midwives, a registered dietician, two social workers, a lactation counselor, three full-time health educators, and three case managers. 

“It’s com-pre-hen-sive,” Boehler emphasized. Expectations around birth in her 100 percent low-income, 60 percent Spanish-speaking-only patient population have gone up dramatically, Boehler explained. “Women expect to have a midwife, to have a water birth, to have labor support, to have their babies stay with them,” and women anticipate birth being a “sacred event.” Boehler's vision more than 30 years ago of what a hospital birth should be is now the level of care her patients assume they will receive.

CONTINUING CONCERNS

Although any pregnant woman in California can now obtain prenatal care, most states do not provide prenatal coverage to undocumented women. California extended its Medi-Cal services to provide prenatal services to all pregnant women through a policy mechanism called Presumptive Eligibility, in which providers may assume a pregnant woman will qualify for Medi-Cal based on her self-reported income. Providers may then provide services on the expectation that the patient will apply for Medi-Cal within a specified time period. Several other states have implemented an amendment to the Children’s Health Insurance Program (CHIP) within their state, extending coverage to unborn children, which allows any expectant mother to enroll an unborn child in CHIP and thereby receive prenatal and labor and delivery services.  Multiple states continue to deny any prenatal services to unauthorized women. Although Boehler and her team do not ask about immigration status, Boehler believes a high percentage of her patients are unauthorized. She also contends that immigration status should not affect coverage; prenatal care is necessary to reduce the risk of birth complications and to assure maternal and fetal health before, during, and after birth.

And, says Boehler, prenatal coverage is not enough. “They’re not insured,” she repeated. “They’re insured for their pregnancy, but we give this super detailed comprehensive prenatal care—so, what if we discovered a heart defect? They can’t get the follow-up care,” Boehler said, adding that the US needs to provide “coverage for everybody that is working in the United States, not just people that have a social security number. Our patients are working. They deserve health care. It’s a basic human right.”

FUTURE ENDEAVORS

Boehler continues to forge ahead in replicating the homebirth experience in the hospital. In January 2015, CommuniCare launched a home visit component. “When you do a home visit, you get a depth of information that you just wouldn’t otherwise. I’ve been trying to get it back for many, many years,” she explained. The program doesn’t have a template to follow; Boehler is just “making it up,”—a style of innovation she contends is the only reason she’s gotten so far.

“If we waited for all the causes and conditions to be right, and weren’t motivated as, ‘this is the right thing to do it, let’s do it, and we’ll figure it out as we go,’ we wouldn’t have done anything,” Boehler contends. “Nobody was paying for births for those women when they started.”

She calls this enthusiasm a big component of her personal style: “I ready, fire, and then I aim.”  Boehler’s footprint can be seen throughout CommuniCare’s prenatal programs, and she says CommuniCare’s footprint is equally important in her own personal life: “I’m having so much fun. Why would I leave?”

30 CLINICIANS MAKING A DIFFERENCE is a project celebrating Migrant Clinicians Network's 30th anniversary through the life stories of 30 clinicians making a difference in migrant health. Learn more about Migrant Clinicians Network.

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