Nurse-midwifery Practice Research Articles

Perinatal Telehealth: Meeting Patients Where They Are.

Prior to the coronavirus disease 2019 (COVID-19) pandemic, studies of innovative telehealth perinatal care models showed similar clinical outcomes and perceived quality of care between groups receiving a combination of virtual video and in-person visits. However, these studies included primarily White, English-speaking participants, excluding those who were economically disenfranchised or did not speak English. The purpose of this qualitative study was to describe perinatal patients' and providers' experiences with telehealth during and after the acute phase of the COVID-19 pandemic to inform future utilization of telehealth to drive the delivery of high-quality, accessible, and equitable perinatal care to diverse communities. This descriptive qualitative study included a purposive sample of 14 patients and 17 providers who received or provided perinatal care via telehealth in either a certified nurse-midwifery practice or the nurse-family partnership care model between March 2020 and April 2022. Maximum variation sampling offered a diverse population based on race, ethnicity, and rurality. Researchers conducted 2 rounds of semistructured interviews with a focus on understanding social and geographic context. Six themes were identified through inductive analysis: (1) unexpected advantages of telehealth, (2) patient empowerment, (3) providers' fear of adverse outcomes, (4) concern for equitable care, (5) strategies to enhance the telehealth experience, and (6) strategies to address access to perinatal telehealth. Patients appreciated the increased ease and reduced cost of accessing visits, which led to fewer missed appointments. Health care providers saw great opportunity in telehealth but expressed concerns about accessibility for patients with language barriers or limited resources. This study provides insight into priorities for continued telehealth utilization focused on providing equitable access to perinatal care. Rather than returning to practices from before the COVID-19 pandemic formed from longstanding routines and perceived limitations, providers are encouraged to capitalize on the rapid innovations in telehealth to build a more effective, equitable, and patient-centered approach to perinatal care.

Outcomes of Waterbirth in a US Hospital-Based Midwifery Practice: A Retrospective Cohort Study of Water Immersion During Labor and Birth.

Although the safety of water immersion during labor is largely supported by evidence from research, the risks to women and neonates during waterbirth are not well established. The purpose of this study was to generate evidence regarding maternal and neonatal outcomes related to water immersion in labor and during birth. A retrospective cohort study included a convenience sample of women receiving prenatal care at a nurse-midwifery practice. Participants were categorized into 3 groups: 1) waterbirth, 2) water labor, or 3) neither. Participant characteristics, maternal outcomes, and newborn outcomes were collected at time of birth and health record abstraction. At the 6-week postpartum visit, another maternal outcome, satisfaction with birth, was measured using the Care in Obstetrics: Measure for Testing Satisfaction (COMFORTS) scale. Analysis included effect size, descriptive statistics (sample characteristics), and maternal and neonatal group differences (analysis of variance and chi-square) with a significance level of P < .05. Women in the waterbirth (n = 58), water labor (n = 61), and neither (n = 111) groups were primarily white, married, and college educated and did not differ by age or education. Women in the waterbirth group were more likely to be multiparous. Nulliparous women who had a waterbirth had a significantly shorter second stage of labor than nulliparous women who did not have a waterbirth (P = .03). The most commonly cited reasons for discontinuation of hydrotherapy were maternal choice (42.6%) and need for pain medication (29.5%). Significantly more women in the waterbirth group experienced a postpartum hemorrhage, compared with water labor or neither (n = 5, n = 3, n = 1, respectively; P = .045); there was no difference in related clinical measures. Neonatal outcomes were not significantly different. Maternal satisfaction was high across all groups. The results of this study suggest that waterbirth, attended by qualified intrapartum care providers in hospital settings in the United States, is a reasonable option for low-risk women and their neonates.

Nature and scope of certified nurse-midwifery practice: A workforce study.

To describe the nature and scope of nurse-midwifery practice in Texas and to determine legislative priorities and practice barriers. Across the globe, midwives are the largest group of maternity care providers despite little known about midwifery practice. With a looming shortage of midwives, there is a pressing need to understand midwives' work environment and scope of practice. Mixed methods research utilising prospective descriptive survey and interview. An online survey was administered to nurse-midwives practicing in the state of Texas (N=449) with a subset (n=10) telephone interviewed. Descriptive and inferential statistics and content analysis was performed. The survey was completed by 141 midwives with eight interviewed. Most were older, Caucasian and held a master's degree. A majority worked full-time, were in clinical practice in larger urban areas and were employed by a hospital or physician group. Care was most commonly provided for Hispanic and White women; approximately a quarter could care for greater numbers of patients. Most did not clinically teach midwifery students. Physician practice agreements were believed unnecessary and prescriptive authority requirements restrictive. Legislative issues were typically followed through the professional organisation or social media sites; most felt a lack of competence to influence health policy decisions. While most were satisfied with current clinical practice, a majority planned a change in the next 3 to 5years. An ageing midwifery workforce, not representative of the race/ethnicity of the populations served, is underutilised with practice requirements that limit provision of services. Health policy changes are needed to ensure unrestricted practice. Robust midwifery workforce data are needed as well as a midwifery board which tracks availability and accessibility of midwives. Educators should consider training models promoting long-term service in underserved areas, and development of skills crucial for impacting health policy change.

Midwifing the Student: Creating an Effective Learning Environment

Midwifing the Student: Creating an Effective Learning Environment

Creating a More Diverse Midwifery Workforce in the United States: A Historical Reflection.

As nurse-midwifery practice expanded beyond areas surrounding early nurse-midwifery education programs, leaders in the profession wanted to establish a strong diverse, inclusive professional organization, a necessary step in creating a diverse workforce (defined here as open to nurse-midwives of all colors, ethnicities, and national origins) that would maintain standards, provide continuing education, and facilitate communication among nurse-midwives. This research presents historical context and organizational factors supporting and limiting development of a workforce reflective of communities served by nurse-midwives. Searches in the National Library of Medicine Historical Collection, American College of Nurse-Midwives (ACNM) Collections, and the Rockefeller Archives Center, as well as recorded interview data, provided primary sources for analysis. Secondary sources include research and opinions in scholarly publications including journals and books released from 1930 to the present. Nurse-midwifery leaders developed relationships with well-respected philanthropists, as well as maternal and child health administrators in state departments of health and the US Children's Bureau, to implement initiatives to recruit and retain midwives of color. Continued interest in the goal of inclusion, work of midwives of color, and commitment to creating a diverse workforce led to the creation of the standing ACNM Midwives of Color Committee in 1990 and the Diversity and Inclusion Task Force, which released its report, "Shifting the Frame: A Report on Diversity and Inclusion in the American College of Nurse-Midwives,"1 in June 2015. Over the past 60 years, ACNM leadership and midwives of color have continued to explore new and effective means to create a workforce that reflects the communities in which nurse-midwives practice.

Strategies for Providing Low-Cost Water Immersion Therapy With Limited Resources

At our university-affiliated medical center, a major renovation of the women’s health and birthing unit resulted in the temporary loss of the permanent tub used for water immersion therapy during labor. Because 40 percent of the women in the nurse-midwifery practice utilize hydrotherapy, we undertook a rigorous search for an interim solution. We developed a safe and cost-effective strategy that can be easily replicated and utilized by others to provide hydrotherapy for laboring women.

Trends in Practice Patterns and Perspectives of Colorado Certified Nurse-Midwives.

Healthcare resources are stretched perilously thin and the demand for primary healthcare services has never been greater. Despite this demand for service, relatively little is known about the practice environment of primary healthcare providers, particularly certified nurse-midwives (CNMs), where workforce surveys frequently include these specialists within the broader nurse practitioner category. A distinct professional discipline, nurse-midwives are one type of primary care provider recommended to enhance access to services. The objective of this study was to understand the nature of the nurse-midwifery practice environment in the state of Colorado. Online survey of Colorado CNMs (N = 328) found little ethnic/racial diversity and an aging workforce, with most providing care in an urban, hospital/medical center environment. Several key legislative issues were identified though respondents felt ill prepared to engage in legislative change. Overall, CNMs were optimistic about the future of midwifery and were largely satisfied with their practice.

Midwives as primary care providers for women.

Midwives certified by the American Midwifery Certification Board (AMCB) are prepared to provide primary care to women from menarche across the lifespan and to well newborns to 28 days using consultation, collaboration, and referral to other providers as needed. The scope of midwifery in the United States did not always include primary care for women, although imprecise definitions of primary care make this difficult to study. The expansion of the scope of practice occurred in response to population needs and research on nurse-midwifery practice patterns. The scope of practice of midwifery is tied to educational standards through the regulation and licensure at the state level. Although the current scope of practice includes primary care for women, many certified nurse-midwives and certified midwives are unable to practice to the full extent of their education due to state-level licensure restrictions. We discuss the addition of primary care to midwifery and the current state of AMCB-certified midwives as primary care providers for women.

Establishing a volunteer doula program within a nurse-midwifery education program: a winning situation for both clients and students.

The use of labor doulas is beneficial for mothers and newborns, but availability and cost can be barriers. The Nashville Volunteer Doula Program was formed to provide labor support to clients of a faculty nurse-midwifery practice. The volunteer doula pool is comprised of both nurse-midwifery students who have trained as doulas and community doulas. Training and coordination of volunteers are managed by nurse-midwifery students with faculty support. Students gain valuable exposure to providing supportive care during labor and birth, which augments their nurse-midwifery education. This novel program operates at a low cost and offers benefits to students as well as women who use the doula service. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Evaluation of the Implementation of the 75-gram, 2-hour Glucose Tolerance Test in a Nurse-midwifery Practice

Purpose/Aim Despite recent attempts at achieving international consensus concerning screening criteria for gestational diabetes, conflicting opinions and strategies persist. A clinical inquiry project described the implementation of the one-step, 75-gram, 2-hour glucose tolerance test (GTT) in a nurse-midwifery practice at an academic health center. Research Questions and/or Hypotheses The 4 aims of the inquiry project were to describe characteristics and outcomes of nurse-midwifery patients diagnosed with gestational diabetes using the newly implemented screening criteria, including: 1) demographic characteristics, 2) select antepartum measures, 3) select maternal and newborn outcomes, and 4) select indicators of utilization of resources. Significance/Background This inquiry project is the first known description of the implementation of the one-step, 75-gram, 2-hour GTT in a national nurse-midwifery population. Methods All nurse-midwifery patients who had been diagnosed with gestational diabetes using the International Association of Diabetes and Pregnancy Study Groups Consensus Panel's criteria between June 1, 2012 and February 28, 2013 were included. Local IRB approval was obtained. Descriptive statistics were used to report the data. Findings Thirty-three women were diagnosed with gestational diabetes. The gestational diabetes prevalence rate increased from approximately 4.6% to 15.6%. Forty-six percent of the women diagnosed with gestational diabetes had risk factors and were screened at less than 17 weeks’ gestation. Forty-seven percent of these women were diagnosed with gestational diabetes that required medication (A2GDM) and transferred to the perinatal diabetes clinic. Twenty-eight women had given birth by the time of the analysis. Twenty-nine percent (n = 8) were induced for gestational diabetes-related indications. One woman required insulin in labor. One preterm birth at 36 weeks’ gestation was not attributed to gestational diabetes. Thirty-two percent (n = 9) had previous cesarean births. There were 4 repeat cesarean births, 2 of which were for arrest of labor and 2 for fetal intolerance of labor. The unscheduled cesarean birth rate, including those who labored with a past history of cesarean, was 21.4% (n = 6). The mean (SD) infant birth weight was 3553 (477) g. There were no cases of shoulder dystocia, birth injuries, neonatal hypoglycemia, or infant-mother separation. Discussion A descriptive summary revealed a substantial increase in the prevalence rate in this nurse-midwifery population. Maternal diagnosis and outcomes varied by risk factor status. Neonatal outcomes were overwhelmingly normal. Utilization of resources was highest among women with A2GDM. The analysis is limited by a small sample size and provides a basis for future studies of screening criteria for gestational diabetes in the nurse-midwifery population.

Medicaid and State Regulation of Nurse-Midwives: The Challenge of Data Retrieval

This article discusses one of four findings of a larger descriptive correlational health policy study, the purpose of which was to investigate relationships among state regulation of nurse-midwifery practice, utilization of certified nurse-midwives (CNM) for Medicaid funded prenatal care, and maternal newborn outcomes. The larger study showed that use of accurate data about CNM practice and subsequent health care outcomes creates a challenge for researchers because of the paucity of data related to services provided by CNMs. Barriers to adequate data collection related to CNM services, specifically those funded by Medicaid, preclude legitimate conclusions about subsequent health care policy. Methods of workforce data collection need to be addressed by health care and health policy groups to facilitate further investigation of the relationships among state regulation of CNM practice, utilization of CNMs for Medicaid-funded prenatal care and maternal newborn outcomes as they affect access to care for vulnerable populations.

Toward Unification of the Midwifery Profession: Looking Back to Guide Us Now

Journal of Midwifery & Women's HealthVolume 55, Issue 1 p. 2-4 Toward Unification of the Midwifery Profession: Looking Back to Guide Us Now Rebeca Barroso CNM, MSN, Corresponding Author Rebeca Barroso CNM, MSN Rebeca Barroso, CNM, MSN, graduated from the Frontier School of Midwifery and Family Nursing Community-Based Nurse-Midwifery Education Program (CNEP, Class 4) and Case Western Reserve University Frances Payne Bolton School of Nursing, Cleveland, OH, in 1995. She has been in full-scope nurse-midwifery practice in Saint Paul, MN since that time. 908 Tuscarora Ave., Saint Paul, MN 55102. E-mail: rebecabarroso@comcast.netSearch for more papers by this author Rebeca Barroso CNM, MSN, Corresponding Author Rebeca Barroso CNM, MSN Rebeca Barroso, CNM, MSN, graduated from the Frontier School of Midwifery and Family Nursing Community-Based Nurse-Midwifery Education Program (CNEP, Class 4) and Case Western Reserve University Frances Payne Bolton School of Nursing, Cleveland, OH, in 1995. She has been in full-scope nurse-midwifery practice in Saint Paul, MN since that time. 908 Tuscarora Ave., Saint Paul, MN 55102. E-mail: rebecabarroso@comcast.netSearch for more papers by this author First published: 24 December 2010 https://doi.org/10.1016/j.jmwh.2009.10.007Citations: 1 Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume55, Issue1January‐February 2010Pages 2-4 ACNM Members ACNM Members: Click here to log in RelatedInformation

A Descriptive Study of “Being with Woman” During Labor and Birth

The objective of this study was to learn more about women's perceptions of the nurse-midwifery practice of "being with woman" during childbirth. The descriptive, correlational design used a convenience sample of 238 low-risk postpartum women in a hospital nurse-midwifery practice, with two childbirth settings: a standard labor and delivery unit and an in-hospital birth center. The main outcome measure was a 29-item seven-response Likert scale questionnaire, the Positive Presence Index (PPI), administered to women cared for during labor and birth by nurse-midwives to measure the concept of being with woman. Statistical analysis demonstrated women who gave birth in the in-hospital birth center or who began labor in the in-hospital birth center prior to an indicated transfer to the standard labor and delivery unit gave higher PPI scores than women who were admitted to and gave birth on the standard labor and delivery unit. Parity, ethnicity, number of midwives attending, presence of personal support persons, length of labor, and pain relief medications were unrelated to PPI scores. Two coping/comfort techniques, music therapy and breathing, were found to be correlated with reported higher PPI scores than those of women who did not use the techniques. These results can be used to encourage continued use of midwifery care and for low client to midwife caseloads during childbirth, and to modify hospital settings to include more in-hospital birth centers.

Treatment patterns and outcomes in a low-risk nurse-midwifery practice

Childbirth, which represents more than 20% of all hospitalizations for women, is often accompanied by technical intervention, and identifying best practices is crucial. This study analyzed data entered into the Nurse-Midwifery Clinical Data Set (ACNM, 1990) to ascertain treatment patterns and associated outcomes, using Kane's Model of Treatment and Outcomes (Kane, R. L. [1997]. Understanding health care outcomes research. Gaithersburg, MD: Aspen Publishers, Inc.). Low-risk women ( N = 510) received prenatal care from nurse-midwives and delivered at a university facility. Significant relationships were found between patient characteristics (age) and clinical factors (parity, body mass index, number of prenatal visits, comorbidities) and between treatment interventions (activity, intake, invasive monitoring) and outcomes (infant Apgar scores, complications).

Malpractice Liability Burden in Midwifery: A Survey of Michigan Certified Nurse-Midwives

A statewide survey was conducted among 282 nurse-midwives in Michigan to examine the extent of their current medical liability burden. Two hundred ten responses were received for an adjusted response rate of 76.9%. Data from 145 certified nurse-midwives (CNMs) who were currently engaged in clinical practice in Michigan were used for this analysis. Sixty-nine percent of CNMs reported that liability concerns had a negative impact on their clinical decision making. Most CNMs (88.1%) acquired malpractice insurance coverage through an employer, whereas 4.9% were practicing "bare" due to difficulty in obtaining coverage. Thirty-five percent of the respondents had been named in a malpractice claim at least once in their career, and 15.5% had at least one malpractice payment of $30,000 or more made on their behalf. CNMs who purchased malpractice insurance coverage themselves or were going bare were significantly less likely to include obstetrics in their practice than their counterparts covered through an employer (70.6% versus 87.2%; P = .04). These findings among Michigan CNMs call for further investigation into the consequences of the current malpractice situation surrounding nurse-midwifery practice and its influence on obstetric care, particularly among women from disadvantaged populations.

Survey of Connecticut Nurse-Midwives

Descriptive data on nurse-midwifery income, workload, job definitions, employment benefits, and clinical practices are limited. Information about nurse-midwifery practice today is important for the growth of the profession and for future policy initiatives. A survey of nurse-midwives in Connecticut was conducted in 2005. This article reports state-specific data about income, workload, job definitions, employment benefits, and clinical issues, such as vaginal birth after cesarean. Full-time midwives in Connecticut worked an average of 77 hours per week, had a mean salary of 79,554 dollars, and 87% had on-call responsibilities. A "typical" Connecticut midwife had an "average" full-time work week consisting of two 24-hour call days and three 7-hour office days, seeing 19 to 24 patients per office day. Most held Master of Science in Nursing degrees, worked in physician-owned practices, and attended births in hospitals or medical centers. Health insurance, paid sick time, and retirement plans were offered to most respondents. Almost all respondents provide gynecologic, antepartum, and postpartum care, but few offer newborn care. There is significant variation in restrictions on midwives offering vaginal birth after cesarean and on length of scheduled appointments. Data on expanded practices, such as first-assisting caesarean sections and endometrial biopsies, are reported for the first time.

Nuchal Cord Management and Nurse-Midwifery Practice

Nuchal cord, or cord around the neck of an infant at birth, is a common finding that has implications for labor, management at birth, and subsequent neonatal status. A nuchal cord occurs in 20% to 30% of births. All obstetric providers need to learn management techniques to handle the birth of an infant with a nuchal cord. Management of a nuchal cord can vary from clamping the cord immediately after the birth of the head and before the shoulders to not clamping at all, depending on the provider's learned practices. Evidence for specific management techniques is lacking. Cutting the umbilical cord before birth is an intervention that has been associated with hypovolemia, anemia, shock, hypoxic-ischemic encephalopathy, and cerebral palsy. This article proposes use of the somersault maneuver followed by delayed cord clamping for management of nuchal cord at birth and presents a new rationale based on the available current evidence.

A Description of the Management and Outcomes of Vaginal Birth After Cesarean Birth in the Homebirth Setting

Our objective was to describe the outcomes of intended home birth among 57 women with a previous cesarean birth. Data were drawn from a larger prospective study of intended homebirth in nurse-midwifery practice. Available data included demographics, perinatal risk information, and outcomes of prenatal, intrapartum, postpartum, and neonatal care. The hospital course was reviewed for those transferred to the hospital setting. Fifty-three of 57 women (93%) had a spontaneous vaginal birth, 1 had a vacuum-assisted birth, and 3 (5.3%) had a repeat cesarean birth. Thirty-one of 32 (97%) women who had a previous vaginal birth after cesarean birth (VBAC) had a successful VBAC; 22 of 25 (88%) women without a history of VBAC successfully delivered vaginally. Fifty (87.7%) of these women delivered in the home setting, whereas 7 (12.3%) delivered in the hospital setting. None of the women experienced uterine rupture or dehiscence. One infant was stillborn. This event was attributed to a postdates pregnancy with meconium. Certified nurse-midwives with homebirth practices must be knowledgeable about the risks for mother and baby, screen clientele appropriately, and be able to counsel patients with regard to potential adverse outcomes. Given what is presently known, VBAC is not recommended in the homebirth setting. It is imperative in the light of current evidence and practice climate to advocate for the availability of certified nurse-midwife services and woman-centered care in the hospital setting.

The theoretical basis for nurse-midwifery practice in the United States: A critical analysis of three theories

The relatively recent effort of midwifery scholars has resulted in the development of three middle-range midwifery theories in the United States. This article examines the three theoretical models that have been developed to describe the essential components of midwifery practice. The three theorists demonstrate remarkable consistency in the identification of concepts important to the discipline, which includes the following essential characteristics of the midwifery paradigm of care: 1) acknowledgment of connections between the mind and body and the person to the person’s life and world; 2) assuming the perspective of the woman to investigate meaning and her experience of symptoms or conditions, so that a plan of care is developed by midwife and woman together; and 3) protection and nurturance of the “normal” in processes related to women’s health, implying a judicious use of technology and intervention.

Generation of Health Care Policy: Using Evidence to Implement Change for a Nurse-Midwifery Practice

This article examines how a certified nursemidwifery practice used evidence-based practice data from 2000 to 2001 to influence health care policy in a managed care environment. Managed care has assumed an integral role in our ability to care for women and families. It affects not only our ability to directly provide care but also indirectly to provide care. Managed care is driving local, state, and federal policies. Health care policies can be changed through improved outcomes, cost-effective care, and good consumer relations.