Midwifery Care from the Client’s Perspective

by Melissa Garvey, ACNM Writer and Editor

Our friends at Science and Sensibility have an interesting post that should be generating more discussion. The post explores certified nurse-midwife Mary Ellen Doherty’s study in the Journal of Perinatal Education called “Midwifery Care: Reflections of Midwifery Clients.”

Doherty conducted her study to describe the experiences of women who chose midwives as their health care providers throughout the lifespan. She and her team interviewed 12 women who had received prenatal, birth, postnatal, well-woman gynecologic, contraceptive, and primary health care services from midwives.

Five themes emerged from the data. As a member of the ACNM communications team, I’m particularly interested in two of them: 1) decision to seek midwifery care and 2) midwives as primary health care providers throughout the lifespan.

What Makes Women Choose Midwives?

That’s the million-dollar question here at ACNM. We exist to support and promote certified nurse-midwives and certified midwives. We know midwifery patients are extremely satisfied with their care. But how do we get a woman who has never considered a midwife to realize what she’s missing?

The women in Doherty’s study said they chose a midwife because of:

• a brochure from a midwifery practice along with one from ACNM that exuded “competence, confidence, compassion, and kindness.” (Go, ACNM Communications Department!)
• the recommendation of friends who had already given birth and had a positive experience with midwifery.
• an obstetrician’s recommendation.
• an insurance company’s recommendation.
  

Midwives as Primary Health Care Providers

All 12 of the women in this study discovered that midwives provide services beyond prenatal, birth, and postnatal care. Just among this sample of 12 women, midwifery services included:

• Contraceptive care
• Treatment for vaginal infections
• Flu shot administration
• Throat culture
• Annual exam
• Pap smear
• Treatment referral and support for postpartum depression
• Other health care referrals and recommendations for both patient and family members
  

Because this study was a phenomenological study, small sample size is not considered a limitation. However, Doherty notes that because her study focused on a “self-selective and purposive sample,” its results are not representative of all women. The majority of women were Caucasian, highly educated, married to their child’s father, and self-identified as “middle class.” Still, there’s a lot to learn from their answers…

…and a lot to add! Here’s where you chime in. What made you decide to choose a midwife? And what health care services do you receive from your midwife?

Hit the Holiday Sales at ShopACNM.com

by Melissa Garvey, ACNM Writer and Editor

Looking for the perfect gift for that special student, midwife, or parent in your life? Visit ShopACNM.com for unique gifts that promote and support midwives.

Now through December 15, all ACNM logo wear and ACNM and midwife branded products are marked down 15% for ACNM members. Log in with your ID and password; then enter promotional code HOL1 at checkout to receive your discount.

Not a member? Join now, or support ACNM with your regularly priced purchase.

How to Brand Midwifery

by Melissa Garvey, ACNM Writer and Editor

This week I came across an interesting post by Sam Ford about the problem many midwives and their supporters struggle with every day. How do you clearly communicate what a midwife is? It’s a loaded term with all sorts of cultural baggage and preconceptions, which typically triggers associations like home birth and no pain control.

Ford’s post didn’t grab my attention merely because of the subject matter. Many people who have come before him have astutely pointed out that the midwife brand needs a makeover. In fact, ACNM members say that limited public awareness of midwifery is the number-one barrier to practice. What impressed me is that Ford actually took a stab at evaluating why existing advocacy campaigns and PR initiatives have not made a large impact on the US public.

The biggest hurdle to overcome is that many have painted midwifery in extremes: as only for parents who completely oppose medical intervention, almost as eschewing all that modern medicine and technology has given us.

A thoughtful follow-up post at Babble.com further articulates the problem:

As a culture, we tend to see only the extremes. We love a good, clear fight, even at the expense of facts. When it comes to birth, there are “the crunchies” and there are “the medicalized maniacs.”

In between these two extremes is where you’ll find the majority of modern midwives. What does that look like? It depends. Midwives serve as primary care providers, giving annual exams, reproductive health services, and family planning counseling to women of all ages. Most midwives work in hospitals. Some work in birth centers or homes. They can order medications, ultrasounds, and epidurals. They exercise those privileges when needed or when requested by the mother. Most midwives spend a longer amount of time with their patients—just like nurse practitioners tend to give longer annual exams than OBGYNs.

How do you boil that down into a brand? It’s complicated. Try choosing a picture to represent midwifery. Should the midwife be a woman or a man? Should s/he be wearing a white lab coat, scrubs, professional attire, or casual dress? Should his or her patient be a teenager, a pregnant woman, or an older woman going through menopause? Even among ACNM staff, there are wide variations of opinion on this topic.

It’s almost as if there’s too much information to shove into a brand. At ACNM, we’re pouring resources into raising public awareness of midwifery. We just launched Evidence-Based Practice: Pearls of Midwifery. Last year we released midwifery postage stamps We’re vamping up our media relations and social media efforts. But there’s still more work to be done.

In your view, what is it that defines midwifery? Do you think it’s possible to rebrand midwifery in America?

How to Present Evidence-based Midwifery Care Like a Pro

by Melissa Garvey, ACNM Writer and Editor

This week we launched an exciting project that has been in development for more than a year. Evidence-Based Practice: Pearls of Midwifery is a professionally developed presentation featuring nearly 100 fully referenced slides to assist midwives and their advocates (expectant moms, active dads, other health care providers, everyone!) in explaining the science and art of the midwifery maternity care model. Designed to showcase the evidence-based foundation of midwifery practice, Pearls of Midwifery emphasizes the proven benefits of physiologic labor and childbirth for mothers and their newborns.

Pearls of Midwifery is a long-overdue resource. In the words of ACNM President Holly Powell Kennedy, CNM, PhD, FACNM, FAAN, “Despite the recent plethora of information on evidence-based maternity care practices, there continues to be an underuse of many beneficial interventions while some harmful practices persist. We must continue sharing the evidence with our clients and other health care providers to ensure that all women receive the safest and most effective maternity care.”

Evidence-Based Practice: Pearls of Midwifery includes suggested speaking notes for each slide and a checklist that can be printed and shared.

Pearls of Midwifery is free to ACNM members and available for nonmembers to purchase in the ACNM Live Learning Center for just $69. Where do you plan to use this new resource?

Access to Midwifery Care Improves Maternity Outcomes

by Tina Johnson, CNM, MS, ACNM Director of Professional Practice & Health Policy

The Patient Protection and Affordable Care Act will bring millions of newly insured citizens into the health care system. In order to meet the country’s needs, leaders are calling for high value, evidence-based solutions. Let’s start with the health condition that affects 100% of all Americans...childbirth! How can we provide high quality, high value maternity care for all women and families? The answers are in the evidence: midwifery care improves maternal and newborn outcomes and patient satisfaction, reduces health disparities, and saves money and resources.

The U.S. grossly outspends every other nation per capita on health care, yet our maternal and newborn outcomes lag far behind those of other developed nations. Childbirth is the number one reason for hospitalization, and its related hospital charges surpass those of any other health condition. Resource-intensive interventions like labor induction, epidural analgesia and cesarean section are overused, often without indication or consideration of alternatives, resulting in increased risk of maternal and newborn harm.

Cesarean section is the single most common operating room procedure in the U.S., and the rate is steadily climbing. Incredibly, in 2007, nearly one-third of American women delivered their babies by cesarean section. Maternal mortality has risen dramatically, and glaring racial disparities in maternal and neonatal outcomes persist.

How can we reverse these disturbing trends? Ensure that all women have access to maternity care providers and practices that support the normal processes of birth. Labor support, freedom of movement, intermittent monitoring, alternative birth settings, vaginal birth after cesarean...all have been identified as evidence-based practices that are underused.

Midwives truly are the experts in supporting healthy vaginal birth in all settings. Midwives caring for low-risk women improve infant mortality rates in both hospitals and birth centers when compared with physicians caring for equally low-risk women. Midwife-led models of group prenatal care reduce preterm and low birthweight rates and improve patient satisfaction. Birth centers provide improved outcomes for even the most at-risk women, reducing preterm birth, low birthweight and cesarean section rates, and reducing costs to our health care system. Skilled midwifery care is the gold standard among nations with the best maternal and neonatal outcomes, and has been identified as essential to reducing maternal mortality worldwide.

It’s time to bring that message back home. The time is now to promote and support midwifery in America—and to follow the evidence.

This post was originally published on the the Center to Champion Nursing in America (CCNA) blog. Visit CCNA to join more conversation about this post.

Patient safety, disciplinary action, and the marginalization of midwives

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International)

It sounded like an April Fools joke, except the story broke two days early. Doctors in North Carolina induced and ultimately performed a cesarean on a woman who wasn’t pregnant.

The case happened in 2008 but we all learned about it this week because the North Carolina Medical Board finished their investigation and issued “letters of concern” to the doctors involved. Public letters of concern appear to be the least punitive disciplinary action performed by the state Medical Board, according to their list of published board orders (PDF).

To which I respond: Letters of concern? Seriously???

The consensus on Facebook and around the web was that if midwives had been involved in an incident of this magnitude, they would have had their licenses revoked post-haste. Why? Because all kinds of disciplinary actions are made against midwives, whether they are practicing safely or not. Very often, the complaint is issued by a physician rather than a patient. It’s all part of what Marsden Wagner, perinatal epidemiologist and former director of Women’s and Children’s Health in the World Health Organization, in an editorial in the Lancet, called:

a global witch-hunt…the investigation of health professionals in many countries to accuse them of dangerous maternity practices. This witch-hunt is part of a global struggle for control of maternity services, the key underlying issues being money, power, sex, and choice.

Midwives practicing in states that refuse to license direct-entry midwives are the most vulnerable. Consider the case of Ohio Mennonite midwife, Freida Miller, who was jailed for appropriately administering a life-saving medication, pitocin, to a woman experiencing a postpartum hemorrhage. For cultural and religious reasons, the women in the community Miller served would be unlikely to accept routine hospitalization for childbirth unless the benefits clearly outweighed the risks, which for many women they don’t. Rather than equip the midwife with a drug (pitocin) that is considered so essential for women’s safety that it is given routinely to all women birthing in hospitals, the government removed the community’s midwife altogether. In the name of public safety.

Even when midwives are licensed, they are not immune from predatory disciplinary action. A licensed midwife in California was issued a cease and desist order at gunpoint and ultimately had to surrender not just her midwifery license but her licenses to practice as a registered nurse and a nurse practitioner. The complaint was made by a physician in the community, not a patient. Among the board’s findings: she performed a vaginal exam before labor (routine practice in most obstetric offices), failed to obtain informed consent before performing an episiotomy (true of approximately 25% of all episiotomies performed in hospitals, according to the Listening to Mothers II survey), and failed to clearly chart the course of treatment for a patient (Didya ever hear the one about the doctor with bad handwriting?). To be fair, the investigation revealed evidence of other, more serious transgressions, but the scale of the disciplinary action seems out of proportion with the evidence, especially when we consider what obstetricians have to do to have their licenses revoked. (Seriously, googling “obstetrician license revoked” yields surprisingly few cases and most include drinking on the job, having sex with patients, or having a pattern of many preventable bad outcomes.)

Midwives who have avoided disciplinary action by state boards may be arbitrarily deemed unsafe by hospital administrators. By publicly citing safety concerns but keeping the details sufficiently vague, hospitals succeed in forcing midwives out. Cases that have been analyzed in the research literature reveal economic motives, however. A hospital in California recently suspended the privileges of a group of nurse-midwives, stating that the absence of a neonatal intensive care unit at the hospital rendered its patients safe only in the hands of obstetricians. Never mind that the only randomized, controlled trial reporting admission to a special or intensive care nursery showed higher rates in the physician group than the midwife group (9.4% vs. 7.9%).

Photo courtesy of Birth Action Coalition

Is Disciplinary Action the Best Way to Protect Patient Safety?

We need to stop the predatory use of state and hospital disciplinary action against midwives, and equalize the process for all categories of care providers. But whether disciplinary action is against midwives or physicians, is punishment the best way to deal with breaches in patient safety? After several high-profile cases in which health care professionals went to jail for making medical mistakes, the patient safety community is rallying around alternatives to punishment, and producing evidence that these alternatives are in fact more effective.

As nurse and patient safety expert, Barbara Olson, argues in one of the posts that made me fall in love with her blog (the other post being her birth story), punitive actions, especially when they are the only actions taken, do not address the root causes of unsafe care, nor do they make care safer.

We can and will argue about what constitutes the safest kind of care. But perhaps we should instead be asking what kind of maternity care system can most reliably deliver safe care. Achieving such a system will take a collaborative effort among all types of health care professionals and the women they care for. Fortunately, some brilliant minds have been hard at work determining what kind of collaborative effort might produce a safer maternity care system. The Institute for Healthcare Improvement is sponsoring a webinar on April 8 to discuss the findings, titled, “Momentum for Maternity of the Safest Kind.” The speakers, who include Maureen Corry and Rima Jolivet from Childbirth Connection, will discuss the recent work of the Transforming Maternity Care Project. If you have been eager to hear more about this work, this is a great opportunity.

So, should the doctors who performed the ultimate in unnecesareans have gotten more than letters of concern? Probably. Maybe. It’s hard to know without knowing what the root cause analysis – please tell me they did one - revealed. But there must have been other opportunities for such a breach of safety to have been avoided. A system that can so completely lose sight of patient safety desperately needs to have its assumptions, routines, and safeguards examined.

When preventing avoidable harm is a fundamental aim of a maternity care system, the logical strategy is to address the root causes of injury, and to arrange care and resources to keep women and babies safe. That’s exactly what midwives do, yet instead of embracing them, our system marginalizes them.

Are You In The Know?

Straight from the ACNM Communications Department, here are our top picks for happenings in midwifery for the week:

Authors of an Obstetrics & Gynecology article say they encourage midwifery care and “support future randomized trials to compare” home vs. hospital births. The statement comes in response to a letter from certified nurse-midwife Judith Rooks and Our Bodies, Ourselves Executive Director Judy Norsigian.

A midwife wrote an interesting article for Tuesday’s New York Times entitled “In a Lifeless Birth, a Midwife’s Opened Eyes.”

A fatal Metro collision happened between Washington, DC, and Silver Spring, MD—home of ACNM. Thankfully, the one ACNM staffer in the accident escaped with only a few bruises.

Saturday, June 27, is National HIV Testing Day.

Health reform is still hot, and ACNM is involved. We just posted legislation of interest to ACNM members here.

What else is going on in your world? Feel free to add to our list!