References for:

B. Fostering an Optimal Womb Environment

1A. Honor pregnancy as a natural event (not a medical condition) and recognize the importance of the mother's emotional, mental, and physical wellbeing; a safe environment; and a strong support system.

3. Fundamentals include supportive, sincere, and caring partnerships with prenatal care providers, including access to a midwifery model of care and information about potential risks and benefits of medical procedures (e.g., ultrasound, amniocentesis, or extended bedrest).

References:

1. MacDorman, M., & Singh, G. (1998). Midwifery care, social and medical risk factors, and birth outcomes in the USA. Journal of Epidemiology Community Health, 52, 310-317. (abstract)
2. Kennedy, H. P. (1995). The essence of nurse-midwifery: The women’s story. Journal of Nurse-Midwifery, 40(5), 410-417. (abstract)
3. Maloni, J., Cheng, C., Liebl, C., & Maier, J. (1996). Transforming prenatal care: Reflections on the past and present with implications for the future. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 25(1), 17-23. (abstract)
4. Oakley, D., Murray, M., Murtland, T., Hayashi, R., Anderson, F., Mayes F., & Rooks, J. (1996). Comparisons of outcomes of maternity care by obstetricians and certified nurse-midwives. Obstetrics and Gynecology, 88, 823-829. (abstract)

Abstract 1:

Premise: Certified nurse-midwives provide a safe and viable alternative to maternity care for low- to moderate-risk women.

Research Question: Are there significant differences in birth outcomes and survival for infants delivered by certified nurse-midwives in comparison to physicians? Do the differences still exist after controlling socio-demographic and medical risk factors?

Background: Proponents of midwifery care have often claimed that better outcomes result from the midwifery model of practice. Those who disagree contend that the data this conclusion is based upon is skewed. However, because the birth outcome data of physicians includes all of the high-risk patients they deliver (such as the extremely preterm infants and the severely distressed fetuses), their data cannot avoid skewing from "physical risk." Nurse-midwives, on the other hand, attend a greater proportion of "socially high-risk" women, such as adolescents, women living in poverty, women with less than a high school education, and socially disadvantaged ethnic minorities. A need exists to standardize the social and medical risk factors of groups of women attended by nurse-midwives and physicians before valid comparisons can be made regarding their relative "successes."

Subjects: This study included all single vaginal births at 35-43 weeks gestation delivered by certified nurse-midwives in the United States in 1991, as well as a 25% random sample of women from the same population delivered by physicians in the United States in 1991. The study used statistical data from the National Linked Birth/Infant Death Data Set for the 1991 cohort.

Study Design: Logistic regression models were used to examine differences in infant, neonatal, and postneonatal mortality, low birth weight, and mean birth weight between babies whose births were attended by certified nurses-midwives and babies whose births were attended by physicians. Ordinary least squares regression models were used to examine differences in mean birth weight after controlling for the following risk factors: maternal age, race, education, marital status, birth order, month of pregnancy prenatal care began, and gestation age at delivery. Certain medical risk factors, as well as obstetrical complications, were also controlled.

Findings: After controlling all the medical and social risk factors, the risk of experiencing infant death was 19% lower for certified nurse-midwives attending births versus physicians attending births. The risk of neonatal mortality was 33% lower and the risk of delivering a low birth weight infant was 31% lower. The mean birth weight of a midwife-attended birth was 37 grams heavier then a physician-attended birth. In spite of differences between physicians and nurse-midwives in their approaches to delivery care, the midwives had excellent birth outcomes. A primary factor contributing to the excellent outcomes of nurse-midwives is likely the personalized care that they provide to the women they serve. They are with their patients on a one-on-one approach during the entire process, while a physician’s care is more episodic. Other studies have indicated that, with such continuous support, these women have shorter labors, lower cesarean-section rates, lower rates of anesthesia and oxytocin use, and more positive birth experiences. While such outcomes are "softer" than neonatal mortality, they, too, indicate that births can be improved under the care of a nurse-midwife. Two primary conclusions are drawn in this article. First, nurse-midwives are associated with better neonatal mortality than that of physicians in matched populations of low- to moderate-risk women. Secondly, the most likely reasons for this success are the counseling, emotional support, and empowerment of women that characterize the midwifery model of care.

Research reviewed by Tracie Mudge, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.

Abstract 2:

Premise: Women’s experience of pregnancy and childbirth is different when they are attended by midwives.

Research Question: What is the "experience of the woman [during pregnancy and childbirth] cared for by a nurse-midwife" within a feminist philosophical framework?

Background: When women feel that the context of their lives is recognized and respected in their care, they feel more empowered to make decisions regarding their pregnancy and birth.

Subjects: The participants for this study were recruited from two practices chosen because of their diversity in clients, both ethnically and economically, as well as in birth settings. All participants were over the age of 18 (mean age, 31) and had the majority of their care from nurse-midwives during their childbearing year and birth. Three women were primiparas and three women were multiparas.

Study Design: Phenomenology (a descriptive, inductive methodology that explores the essences of experience) is a qualitative research approach. Each participant was contacted by telephone to set up an interview, which was unstructured and lasted 30-60 minutes. Each woman was asked the following, "Please describe what your experience was like to be cared for by a nurse-midwife during your prenatal visits, birth, and postpartum contacts. Describe all your thoughts, feelings, and perceptions of these experiences that you remember, until you have no more to say." Their statements were supplemented with probing via open-ended questions when additional clarification was desired.

Findings: Nine theme clusters emerged as a result of this study:

1. The woman, as an individual, determines and directs care. The nurse-midwife consistently validated the woman’s ability to cope with birth and her changing family. The willingness to explore all possibilities was highly valued.
2. Development of a caring relationship built on mutual respect, trust, and alliance emerged. The women felt that the nurse-midwife shared in their experience and provided a personalization in their care.
3. The qualities and behaviors of the nurse-midwife laid the foundation for the richness of the woman’s experience. The nurse-midwife composure prevailed, her aura of calm that exuded experience and knowledge assisted in the confidence building of the mother.
4. A sense of safety encompassed the women’s trust in the nurse-midwife’s knowledge and ability. The sense of trust that was built between the mother and the midwife added in a positive outcome.
5. The woman felt cared for within the domain of her family and her family’s needs, and potentials were always considered in relationship to her. The children and partners were encouraged to participate in the care.
6. Time was both given and respected by the nurse-midwife. The midwife accommodated the mother’s needs and the mother didn’t feel rushed.
7. The woman (and her family) felt guided in her decision-making and actions based on the information provided by the nurse-midwife.
8. The health and normalcy of pregnancy were the presiding focus of care. Interventions were an option, but not pushed.
9. A continuous link with the nurse-midwife was repeatedly demonstrated. The nurse-midwife was there for the woman—whether at the end of the phone or in the labor room—and her presence was felt and valued.

The women deeply appreciated the respect that they felt from the nurse-midwives. Also, the women felt empowered by this respect, which helped lay a foundation of an enriched self-confidence and willingness to take on more of the responsibilities for making decisions regarding themselves, their pregnancies, and their childbirths.

Research reviewed by Tracie Mudge, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.

Abstract 3:

Premise: Our present model of prenatal care may be outdated and focused on pre-eclampsia rather than on our current outcome problems.

Research Question: Is the current model of prenatal care effective for positive birth outcomes?

Background: Two-thirds of all infant deaths and neonatal deaths in the United States occurs in low birth weight (LBW) infants. Nineteen other industrialized countries have lower rates of infant mortality than the United States. Our pattern of prenatal care originated 100 years ago when pre-eclampsia was a major concern.

Study Design: The article is a compilation of over 10 separate studies pertaining to the history of prenatal care, areas of prenatal care that are identified as deficits, and government statistics of pregnancies and birth outcomes.

Findings: Low birth weight is the primary risk factor related to infant mortality and morbidity and has not declined in the last 10 years. The number of LBW babies triples when women receive no prenatal care. Between 1980 and 1987, the percentage of women who did not receive prenatal care increased by 17% for white women and 26% for black women. For every dollar spent on prenatal care, $2 to $11 is saved in the costs of treating premature infants and their complication. Forty-four percent of physicians who provide obstetric services do not accept Medicaid patients, a group that includes patients with the highest rates of LBW. The current model of prenatal care has not attracted women at high risk, such as women who are younger than 20, unmarried, from ethnic minorities, poorly educated, or with high parity. Lack of private transportation, poor weather, and unreliable public transportation add to some women’s lack of attendance. The lack of prenatal care results in an increase of LBW infants, which in turn increases costs related to premature births and their complications.

Research reviewed by Tina Hill, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.

Abstract 4:

Premise: A nurse-midwife-led delivery will ensure a better outcome at birth at a lower cost.

Research Question: Do pregnancy outcomes differ by provider group when alternative explanations are taken into account?

Background: This study was conducted at a Midwestern tertiary-care center and its ambulatory care satellite and hospital clinics. All deliveries were at the medical center’s hospital.

Subjects: Pregnancy outcomes were compared among 710 women cared for by private obstetricians and 471 women cared for by the nurse-midwife group. All women cared for qualified for nurse-midwifery care. All were retained in the original group for analysis, even if they were later referred to physicians.

Study Design: Infant and maternal mortality, 30 clinical indicators, satisfactions with care, and monetary charges were studied. The study site had a history and philosophy of honoring consumer choice of provider-precluded random assignment. Multivariate analysis was used for this study.

Findings: Significant differences were found in seven factors in this study between obstetricians and nurse-midwifes. Infant abrasions were higher with obstetricians by 3%. For physicians, infants remaining with mothers throughout hospital stay were 15% versus 27%. Third- and fourth-degree perineal lacerations were 23% versus 7%. The number of postdelivery complications was lower in the nurse-midwifery provider group than in the obstetrician group. Hospital stays and professional fees on average were less with the midwifery group. To improve outcomes and control costs in maternity care, a reduction needs to occur in the following areas: women’s pregnancy and intrapartum risks, the number of medical procedures, and the women’s preferences for the more expensive interventions. Both obstetrician and nurse midwives could contribute to these goals.

Research reviewed by Tracie Mudge, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.