1A. Consider all birthplace options, recognizing that birth experiences are enhanced in home, birth center, or hospital settings that support parent's informed choices for the labor, birthing, and postpartum process.
References:
Abstract 1:
Premise: Exemplary midwifery care will have a positive effect on birth outcomes.
Research Question: Describe exemplary midwifery practice by asking the following questions: 1) What are the essential characteristics of the exemplary midwife? 2) What are the specific outcomes of exemplary midwifery practice in the health of the woman and/or infant? 3) What is the process of care provided by exemplary midwives? 4) What aspects of the process of exemplary midwifery practice are related to specific outcomes in the health of the woman and/or infant?
Background: In 1998, the Pew Health Professions Commission/UCSF Center for the Health Profession Task force on Midwifery, outlined 14 recommendations, including a call for extensive research that analyzes midwifery methods, processes, and outcomes.
Subjects: A total of 52 midwives and 61 recipients of midwifery care from six regions in the United States (one Canadian midwife and one Canadian care recipient were included in the study).
Study Design: A qualitative study was used, utilizing the Delphi Method. This method was used in order to obtain a consensus among experts for defining exemplary midwifery practice.
Findings: A model of exemplary midwifery model of practice was proposed, using the following dimensions: therapeutics, caring, the profession. Optimal outcomes and qualities and traits of the midwife were analyzed. In the dimension of therapeutics, the leading outcome was optimal health of the woman and/or infant. Researchers found that, as a group, the midwives believed that, by supporting the normal birth process while remaining vigilantly attentive to detail, the best possible outcomes for mother and child could be achieved. In the dimension of caring, the outcome sought was that the woman and/or family have health care or a birth experience that is respectful and empowering. This was best achieved by 1) respecting the uniqueness of the woman and family and 2) creating a setting that was respectful and reflected consideration of the woman’s needs. Recipients felt important and valued as a result of this dimension. The researchers found that both the midwives and the care recipients believed that the exemplary midwife must be accountable for her actions and strive to achieve excellence in the practice of midwifery. Midwives believed that their profession would be enhanced and accepted by exemplary practice.
Research reviewed by Karla Batten, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 2:
Premise: A medical model of practice tends to control, manage, hasten, and standardize, while a midwifery practice supports and responds to individual needs and patterns, thus avoiding unnecessary medical interventions.
Research Question: How do midwives in out-of-hospital settings help women avoid cesarean births?
Background: The rate of cesarean birth is unnecessarily high in the United States and other industrialized countries.
Subjects: Fifteen midwives (71% of those eligible) who lived and worked in Utah (The Utah Independent Midwifery Study), many of whom are members of the Church of Latter-day Saints.
Study Design: Open-ended interviews lasting approximately three hours.
Findings: These midwives reported the belief that medical practice often deals poorly with many situations that lead to cesarean birth. From the midwives’ perspective, a large number of women who received surgical intervention could have been treated with less drastic measures. These midwives believe that prevention is the greatest priority. When medical personnel are oriented toward pathology and dysfunction, they believe that births should take place in the hospital. The midwives believe that birth is a "normal" and "natural" process and that a woman should give birth vaginally without excessive medical interventions. The midwives emphasize moving, changing position, and encouraging relaxation. This is enhanced by being in a comfortable place with supportive people as part of the therapeutic element. They believe prenatal messages are important rather than creating a climate of doubt about pelvic adequacy. They encourage building prenatal stamina with nutrition, exercise, and avoidance of harmful substances. They are less likely to treat slow labor as problems; rather, they accept individual patterns for a woman. They use rest, massage, music, car rides, nutrition, herbs, breast stimulation, and removal of environmental disturbances as a method to aid in uterine function. All the surveyed midwives lived in Utah and were members of the Church of Latter-day Saints, which may restrict the generalization of findings. Although the interviews were lengthy and well-documented, they are still fairly subjective.
Research reviewed by Ruthie Forehand, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 3:
Premise: Home-birth mothers are more likely to give birth as a normal event.
Research Question: Do women view their pregnancy as a natural event?
Background: Controversy exists between medical and "natural" models of childbirth. The natural childbirth model emphasizes the rights and responsibilities a woman has to her body, whereas the medical model emphasizes the application of medical intervention.
Subjects: Three hundred ninety-five mothers in Sydney, Australia, were polled one year after giving birth.
Study Design: Mailed questionnaire responses were obtained from 239 mothers who gave birth in a hospital labor ward, 35 who gave birth at a birth center, and 121 who gave birth at home.
Findings: Only one of the homebirth/birth-center mothers used analgesics during birth (this avoidance was a prime reason for choosing the site of birth). In contrast, 70% of the hospital births used labor analgesia or anesthesia. Home-birth/birth-center mothers chose this setting so they could have an active birth with control and no intervention, as well as the presence of family and friends. Those who chose the hospital commented 50% of the time that the hospital was safer and their doctor was influential in their choice. The mothers who gave birth at home were more likely to say that the birthplace affected bonding (F (2, 178)=7.20, P=0.001), to admit that the gender of the midwife was important (F (2, 157)=5.44, P=0.005), to have been self-employed (X2 (2)=8.45, P, 0.02), and to report being unconventional in regard to gender roles (X2 (8)=73.5, P=0.000). The first variable predicted doctor satisfaction, the second predicted doctor and midwife satisfaction, the third and fourth variables indicated midwife satisfaction, and the last predicted personal satisfaction. Homebirth and birth-center mothers consistently indicated greater satisfaction than labor-ward mothers did.
Research reviewed by Ruthie Forehand, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.
Abstract 4:
Premise: Many women are not aware of the nurse-midwifery model of care.
Research Question: What similarities and differences exist between obstetricians and nurse-midwives in specific processes in the management of perinatal care in order to assist women to choose from among the options of childbirth provider and birth setting?
Background: The obstetrical health care system is undergoing change and women need to understand the options available to them so they can make decisions concerning the type of care available to them.
Subjects: A total of 70 certified nurse midwives (CNMs) and 358 obstetrician/gynecologists (OB/GYNs) who were in active practice in San Diego, CA. Responses from 20 CNMs and 57 OB/GYNs were used.
Study Design: Descriptive. The National Perinatal Epidemiology Unit in Oxford, England, developed a list of perinatal care procedures that have been shown to reduce the frequency of adverse outcomes during pregnancy and childbirth. Twenty-four items from this list were used as the study instrument. Both the specific intervention and the benefit of this intervention were examined.
Findings: CNMs (100%) were more likely than physicians (55%-75%) to believe that social support should be available to most or all of women in labor. More CNMs than OB/GYNs favored the use of alternate birth positions during the first stage of labor (95% CNMs vs. 52% OB/GYNs) and the second stage (95% CNMs vs. 43% OB/GYNs) rather than the recumbent position. Physicians preferred the use of an epidural for management of pain rather than systemic narcotics. Physicians and CNMs were in agreement concerning the use of genetic amniocentesis and availability of ultrasonography to confirm fetal life. CNMs (80%) believed much more than OB/GYNs (39%) that external cephalic version should be an option to reduce the possibility of a cesarean section. CNMs favored the use of exhalatory versus sustained bearing down for all women during the second stage of labor and late versus early pushing with an epidural. OB/GYNs were far more likely to use electronic fetal monitoring and scalp sampling.
Research reviewed by Karla Batten, RN, while a student at Virginia Commonwealth University, School of Nursing, in Richmond, VA.