Nurse-midwifery Practice Research Articles

Primary care in nurse-midwifery practice: a national survey

Providing primary health care is a relatively new addition to the scope of practice for certified nurse-midwives (CNMs)/certified midwives (CMs); thus, not much is known about how this component has been integrated into midwifery practice. The purpose of this descriptive study was to examine the type and extent of primary care education among CNMs/CMs and how various common health conditions are managed. In addition, perceptions of barriers to incorporating primary care into their practice were gathered. A small national survey was conducted among randomly selected members of the American College of Nurse-Midwives. No CMs participated. Although the sample size ( n = 63) precludes generalizing the findings, 65% of CNMs reported lack of formal education in primary care. However, when asked about specific health conditions, more than 50% stated that they had some form of education in treating 30 of 37 common health problems. It is noteworthy that 54% of the CNM respondents indicated that they do not provide newborn care despite the fact that more than 85% of them received newborn education. Barriers such as lack of insurance reimbursement, institutional rules, and a lack of understanding of the CNM’s scope of practice were cited by respondents as contributing factors. Unfamiliarity with primary care may be the most important factor in the reluctance of CNMs to incorporate primary care into practice.

Late entry into prenatal care in a rural setting

Social support, behavioral risk, and structural or demographic variables as well as acceptance of pregnancy were tested as determinants of late entry into prenatal care in a sample of 176 women in a rural county in California. The respondents were all those over age 18 served by four obstetric practices during a 4-month period ending in February 2000. One nurse-midwifery practice was included. Late entry into prenatal care during the first trimester occurred in 27.3% of the cases overall. Statistically significant independent variables in bivariate analyses were modeled in multivariate logistic regression. Stress, lack of family and friend support, Medicaid enrollment, age under 20 or over 34, low acceptance of pregnancy, and lack of a high school diploma were all predictors of late entry. Lack of family and friend support modified the effects of stress and Medicaid as payer. Although the determinants of late entry were remarkably complex in this sample, they have potential for public health intervention.

Measuring outcomes of midwifery care: development of an instrument to assess optimality

Research on the outcomes of midwifery care is hampered by the lack of appropriate instruments that measure both process and outcomes of care in lower risk women. This article describes an effort to adapt an existing measurement instrument focused on the optimal outcomes of care ( The Optimality Index—US) to reflect the contemporary style of U.S.-based nurse-midwifery practice. Evidence for content validity of the instrument was derived from literature reports of randomized clinical trials, synthetic reviews, and the clinical consensus of professional reviewers. Eleven perinatal health professionals and consumers, representing disciplines of obstetrics and gynecology, midwifery, epidemiology, and neonatology reviewed the instrument. The instrument was then applied to an existing data set of women who intended to give birth at home ( N = 1,286 women) to determine its utility in measuring events in the process and outcome of perinatal health care as managed by nurse-midwives. Results suggest that the tool holds promise for use in outcomes studies of U.S. perinatal care. Further testing of the instrument among diverse multicultural population groups, with various providers, and in diverse birth settings is warranted.

Challenges and opportunities for nurse-midwives

This article reviews the major indicators of the growth in nurse-midwifery practice and education over the past 10 years. The major issues the profession has addressed are identified, as well as future challenges and opportunities. These challenges and opportunities are identified within the major dimensions of nurse-midwifery, that is, in practice, education, research, and within the public sector. The two major issues facing nurse-midwives are legislative initiatives related to the practice of nurse-midwives, such as reimbursement, and the mixed societal image of midwifery as a contemporary, cost-effective practice versus a peripheral activity by “old fashioned,” informally educated individuals. The professional organization of nurse-midwives, the American College of Nurse-Midwives (ACNM), is addressing these issues through interdisciplinary and interorganizational legislative and marketing initiatives.Nurs Outlook 2001;49:213-6.

Serving women in need: nurse-midwifery practice in the United States

Objective: Nurse-midwifery practices in the United States were examined to study the relationship between certified nurse-midwives’ (CNMs) demographic, work setting, and practice characteristics in terms of clientele, practice size, and practice type. Factors that might influence the ability of CNMs to serve populations at risk for poor outcomes were given particular attention. Methodology: A total of 2,405 responses to a 1998 mailed survey of 6,365 nurse-midwives ever-certified by the American College of Nurse-Midwives were analyzed. Results: Study results indicated that CNMs continue to serve a population who are, based on a social risk profile, disproportionately at risk for poor pregnancy outcomes, including women who are uninsured (16%), immigrant (27%), adolescent (29%), and women of color (50%). It was also found that clientele varied according to practice settings: CNMs working in non-hospital, nonprofit settings served a clientele that was 65% nonwhite, 44% immigrant, 40% adolescent, and 29% uninsured; these CNMs received 61% of their client payments from Medicaid. CNMs working in private offices or for managed care organizations were less likely to serve women with these characteristics. Conclusion: Study results, taken in conjunction with research that documents the safety of nurse-midwifery practice, reinforce policy recommendations that support expanded access to nurse-midwifery services. Findings also indicate a need for further research in the areas of CNM workload and productivity in managed care settings and the association between CNM race and ethnicity and the race and ethnicity of their clients.

Obesity as a risk factor for cesarean in a low-risk population

Objective: To determine whether low-risk maternity patients in a nurse-midwifery service with prepregnant body mass index (BMI) above 29.0 are at increased risk for cesarean delivery. Methods: We studied 1881 women who delivered between 1994 and 1998 and were managed by an academic inner-city hospital-certified nurse-midwifery practice. We calculated prepregnancy BMI and weight gain during pregnancy by using clinical data from a comprehensive clinical database, and did descriptive analyses and univariate and multivariate logistic regression analyses. Results: The overall cesarean rate was 5.1%, but was 7.7% for obese women compared with 4.1% for women with normal BMI (19.8–25.9). The unadjusted odds ratio (OR) for cesarean for obese women was 2.02 (95% confidence interval [CI] 1.26, 3.25, P < .01). Other factors associated with increased risk of cesarean delivery included primigravidity, primiparity, maternal age 35 years or older, short stature (height under 155 cm), very low birth weight infant, failure to progress, breech presentation, abruption, fetal bradycardia, and severe preeclampsia. Maternal race and marital status were not associated with cesarean delivery. After adjustment for weight gain, short stature, advanced maternal age, primiparity, and intrapartum complications, the OR for obesity was 3.99 (95% CI 2.00, 7.95, P < .001). Conclusion: Even among low-risk women managed by nurse-midwives, the risk of cesarean delivery was higher for obese women. Short, obese women were at higher risk of cesarean delivery compared with women with normal BMIs, but were not high enough risk to preclude them from receiving nurse-midwifery care.

The evolving scope of nurse-midwifery practice in the United States

The purpose of this article is to review the evolving scope of practice of nurse-midwifery since its introduction in the United States in 1925. Factors that contributed to the profession’s evolution in practice are identified.

Access to midwifery care in the U.S.: Findings from the second national survey of nurse-midwifery practice

Access to midwifery care in the U.S.: Findings from the second national survey of nurse-midwifery practice

Cost Analysis of Prenatal Care Using the Activity-Based Costing Model: A Pilot Study

The cost of prenatal care in a private nurse-midwifery practice was examined using the activity-based costing system. Findings suggest that the activities of the nurse-midwife (the health care provider) constitute the major cost driver of this practice and that the model of care and associated, time-related activities influence the cost. This pilot study information will be used in the development of a comparative study of prenatal care, client education, and self care.

Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study

Objective: To describe the outcomes of intended home birth in the practices of certified nurse-midwives. Methods: Twenty-nine US nurse-midwifery practices were recruited for the study in 1994. Women presenting for intended home birth in these practices were enrolled in the study from late 1994 to late 1995. Outcomes for all enrolled women were ascertained. Validity and reliability of submitted data were established. Results: Of 1404 enrolled women intending home births, 6% miscarried, terminated the pregnancy or changed plans. Another 7.4% became ineligible for home birth prior to the onset of labor at term due to the development of perinatal problems and were referred for planned hospital birth. Of those women beginning labor with the intention of delivering at home, 102 (8.3%) were transferred to the hospital during labor. Ten mothers (0.8%) were transferred to the hospital after delivery, and 14 infants (1.1%) were transferred after birth. Overall intrapartal fetal and neonatal mortality for women beginning labor with the intention of delivering at home was 2.5 per 1000. For women actually delivering at home, intrapartal fetal and neonatal mortality was 1.8 per 1000. Conclusion: Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary. Intrapartal mortality during intended home birth is concentrated in postdates pregnancies with evidence of meconium passage.

Outcomes of Intended Home Births in Nurse-Midwifery Practice

Outcomes of Intended Home Births in Nurse-Midwifery Practice

Nurse-midwives’ use of and attitudes toward epidural analgesia

The use of epidural analgesia for labor and birth has risen dramatically in the United States, and nurse-midwives are caring for increasingly greater numbers of women who deliver under epidural analgesia. The authors of this investigation undertook a national survey by mailed questionnaire to explore the use of and attitudes toward epidural analgesia among certified nurse-midwives. A stratified, random sample of one-half of American College of Nurse-Midwives members was polled, and 1,605 (60.7%) questionnaires were returned. A slight majority of certified nurse-midwives (CNMs) (53%) reported a negative attitude toward the increased use of epidurals in CNM practice, and 64% reported concern over the increased number of their clients who desire epidural anesthesia. CNMs were almost evenly split on the issue of whether nurse-midwives should discourage the use of epidurals in nurse-midwifery practice. For those CNMs with epidural analgesia available at their primary birth site (87% of the sample), the mean CNM epidural rate was 26%. Various reasons for the increased use of epidural analgesia in CNM practice are explored, as are the possible implications of such increased use in contemporary nurse-midwifery practice. Suggestions for further research are offered.

Professional Autonomy for Midwives: An Essential Component of Collaborative Practice

Although full admission privileges are considered the hallmark of full practice autonomy, the majority of certified nurse-midwives (CNMs) are denied the right to autonomously admit and discharge patients or have access to privileges only through the authority of a physician. This practice jeopardizes the independence of certified nurse-midwives and identifies them as adjuncts to the attending medical staff. The situation can only become more complicated now that the American College of Nurse-Midwives certifies nonnurses (CMs). Midwifery has a unique and a once autonomous history that is separate in philosophy from medicine. Midwives require physician services for consultation, referral, and collaborative management, but not for authority to practice midwifery. State legislation is not consistent nationwide concerning the definition and governing of nurse-midwifery practice. The Joint Commission on the Accreditation of Health Care Organizations does not regulate admission privileges but provides standards for hospitals. These standards do provide an avenue for admission privileges. Recognizing the CNM/CM as competitive in the health care market is essential. Denial of privileges can be interpreted as a restraint of trade. Without professional autonomy, unfavorable economics may limit the professional practice of midwifery.

Interdisciplinary Teaching: A Survey of CNM Participation in Medical Education in the United States

Nurse-midwives have participated informally in the education of medical students and residents for many years, yet little is known about their formal involvement in medical education. A two-part survey was conducted to investigate the extent and characteristics of nurse-midwifery participation in medical education in the United States. The initial questionnaire was sent to every department of obstetrics and gynecology chair listed in the directory of the Association of Professors of Gynecology and Obstetrics and addressed the use of certified nurse-midwives (CNMs) as educators within their respective departments. A subsequent questionnaire was distributed to CNMs participating in medical education and addressed their demographic characteristics, roles within the medical school faculty, and attitudes regarding work in medical education. More than one half (54%) of U.S. allopathic medical schools are formally using CNMs as educators, with the strongest involvement reported in the West and Northeast. Nearly as many CNM respondents are participating in the education of family medicine residents (57%) as in obstetrics and gynecology (59%). Most CNMs (93%) involved in medical education are also involved in nurse-midwifery education. Eighty percent of CNM respondents perceived congruency between educating student physicians and their philosophy of nurse-midwifery practice.

A master's degree for entry-level ACNM-certified midwives: An option or necessity?

The health care industry is a massive system that is changing so rapidly that it is reinventing itself. With these changes, added demands have been placed on the knowledge base and practice of nurse-midwifery with emphasis on primary care, administration, and research as well as traditionally accepted nurse-midwifery practice. The American College of Nurse-Midwives (ACNM) has a history of being alert to consumer demands, sociopolitical forces, and the health care industry itself as stimuli for change after full dialogue with the membership and appropriate study. Because the ACNM Division of Accreditation will be requiring a baccalaureate degree upon entrance or completion of each midwifery education program by June 1999, dialogue should begin now about the benefits of requiring a masters degree as the entry-level credential.

Entry-level degrees for midwifery practice

The Governing Board of the ACNM Division of Accreditation (DOA) has been charged by the ACNM Board of Directors to consider requiring an entry-level degree for nurse-midwifery practice. This decision has far-reaching implications and must be considered with utmost care. The decision will not be based on the issue of clinical competence but rather, the political statement to be made through the imposition of a degree requirement. The author urges the DOA's Governing Board to consider the implications of its action on a variety of audiences, including potential students, potential consumers, other health professionals, current and future employers, our international colleagues, health insurers and managed care organizations, and policymakers and lawmakers.

How nurse-midwives define themselves in relation to nursing, medicine, and midwifery

The way members of an occupation or profession define themselves influences both their interaction with other occupations in the workplace and the future direction of their profession. In order to determine how certified nurse-midwives define their occupational identity, a two-phase study was done. In the first phase, 20 nurse-midwives were interviewed at length. It was found that they used traditional midwifery ideologies of advocacy, normalcy, and competency to differentiate themselves from physicians and nurses. A nationwide survey was then sent to 300 nurse-midwives in which they were asked whether they identified more with midwifery, nursing, or medicine. Their choice of identity was then examined in light of midwifery, ideologies, situational and background factors, and ability to tolerate ambiguity. The analysis of the survey, indicated that nurse-midwives identify occupationally with midwifery, rather than nursing or medicine, even though there is some alliance with both of the other occupations. The variables that were most predictive of a positive midwifery occupational identity were philosophical agreement with nurse-midwifery ideologies and increased years of nurse-midwifery practice. A short discussion of the implications of a midwifery versus a nursing identity concludes the article.

Care of the at-risk neonate born at home A model for nurse-midwife/physician collaboration

Because certified nurse-midwives (CNMs) who practice in the home lack the structure and boundaries provided in an institution, they must provide the elements of a safe environment for their practice, both physical and intangible. The relationship between the CNM who practices in the home and the physician(s) with whom s/he collaborates when women or neonates experience complications beyond the scope of nurse-midwifery practice is a critical element of this structure. This paper describes models for collaborative care for home birth, outlines the process of developing a collaborative practice agreement, and discusses specific factors to consider when forming a relationship. The care of the compromised home-birth neonate is developed as a model for collaborative practice. The paper discusses identification of the home-birth neonate requiring collaborative care, the preparation for potential newborn complications, and the initiation of emergency measures to be taken by the CNM when such a complication occurs.

Postcoital contraception: Has its day come?

Although postcoital contraception might aid in reducing the occurrence of some unintended pregnancies, it is seldom used. This review summarizes the development of postcoital methods, focusing on the Yuzpe regimen, the most widely used emergency contraceptive in the United States. The article discusses its mechanism of action, safety, side effects, and effectiveness. Reasons for its limited use are discussed, as are recent findings that RU 486 may be a superior postcoital agent. Finally, a protocol for integrating the Yuzpe method into nurse-midwifery practice is presented.

1994 Task analysis of American certified nurse-midwifery

The ACNM Certification Council is responsible to the American College of Nurse-Midwives for the development, administration, and evaluation of a psychometrically sound and legally defensible certification examination in nurse-midwifery. A task analysis study was conducted to investigate the knowledge, skills, and abilities that define American nurse-midwifery practice. A stratified sample of 825 American College of Nurse-Midwives members was asked to rate the frequency of performance and the criticality of 189 nurse-midwifery activities and 109 discrete diagnoses that the nurse-midwife might encounter while providing clinical care. The frequency and criticality ratings were combined to generate an importance weight for each activity. Study data will be used as the basis of the examination blueprint in order to ensure job-related content validity. Aggregate data can also be used for curriculum development, self-assessment, and evaluation research purposes.