When Jessica Brumley showed up to record our recent
Discover Midwives podcast conversation wearing her
“Let’s Midwife the System” T-shirt, I knew we were going to have a fun and wide-ranging conversation.
Our planned chat was about intermittent auscultation (IA), but Jessica and I both know that IA is not just a fetal assessment technique. It's a microcosm of so much that is wrong and could be made right in our maternity care system, and of the important role of midwives in making that change.
Jessica and I came to this work from different directions. She led implementation of intermittent auscultation in a large academic hospital where almost everyone was getting continuously monitored. My own work began while helping scale a network of freestanding birth centers, where IA is already routine but the quality and approach can vary widely.
Despite these different care settings, we encountered many of the same challenges in implementation: creating standards, building staff competency and confidence, changing workflows, measuring whether practice actually changed, addressing concerns about staffing and liability, and, ultimately, changing culture.
We see this same opportunity through
Step Up Together transfer drills, where strengthening intermittent auscultation frequently emerges as a quality improvement priority. Because the drills bring community midwives, EMS, and hospital teams together, they also create an opportunity for midwives to share IA expertise across settings—one very concrete example of how midwives can help improve the larger system of care.
I encourage you to
watch or
listen to the entire episode, but below are some of my favorite moments.
[13:30] - We talked about what was lost when continuous electronic fetal monitoring became the norm in the 1970s. It wasn't simply a switch from one fetal assessment technique to another. The monitor changed where laboring people spent their time, how freely they moved, where clinicians directed their attention, and even how much care happened at the bedside.
I described how attention increasingly went “straight to the machine,” while the laboring person had to accommodate the technology, and reflected on how that shift also crowded out some of the continuous support, movement, and human connection that help physiologic labor unfold.
As Jessica somewhat accidentally summed it up:
“It’s tied to everything. Literally, you’re tied to everything, right?”
[28:00] Hospitals are working on some stubborn quality problems, including reducing cesarean birth and supporting physiologic birth. Yet midwives aren't always included in the conversations about how to solve them.
As I told Jessica:
“Midwives are often the last to be invited to the table when these health systems are trying to work on their quality metrics, and…midwives actually have a lot of the answers.... Like, you got this midwife right here.”
Why not let them lead?
[37:00] I share what we learned implementing IA across a network of birth centers. We disseminated guidelines. We changed policies. We developed simulation-based education.
And then we audited charts, and we kept finding opportunities to improve.
That experience taught me something I've carried into all of my quality improvement work since: evidence and education don't implement themselves. Changing practice takes measurement, feedback, reinforcement, and sustained leadership.
[47:45] Near the end, Jessica tells a story about seeing the work she started at her own hospital spread through other nursing leaders, into another hospital, and eventually into statewide quality improvement work.
Her reflection made me smile:
“We plant seeds out there sometimes and we don't even know how they're going to just grow and come back and flourish.”
That's what midwifing the system looks like to me: not just leading change, but building other people's capacity to lead it too.
These changes are long overdue. Sarah Kliff’s 2025 New York Times investigation, “
The Worst Test in Medicine Is Driving America’s High C-Section Rate,” brought national attention to what midwives and other advocates for evidence-based maternity care have been saying for decades: routine continuous electronic fetal monitoring has not delivered on its promise. We have an evidence-based alternative in intermittent auscultation, and midwives are well positioned to lead the work of putting it into practice.
Whether you practice in a hospital, birth center, or home birth setting, this is an opportunity to strengthen your own practice—and to help create the policies, competencies, and culture that make safe, evidence-based IA available to more families. We have the evidence, the guidance, and increasingly the tools to make that change. Now we need midwives to lead it.
Let’s midwife the system.
