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Nurse Midwifery as an Alternative Approach to Maternity Care


Is it safe? Is it effective?






Lindsey Franks

PSY 268: Health Psychology

September 20, 2006


What is a nurse midwife?


When one thinks of a “midwife,” one almost always thinks of a woman who has no


formal medical training yet declares herself proficient enough to go around to women’s homes


and deliver their babies. Perhaps this stereotypical idea of what a midwife is, is what contributes


to the fear and controversy that surrounds nurse midwives. What few know is that while lay


midwives still exist and always will, a new breed of midwife, the Certified Nurse Midwife


(CNM), has emerged as a qualified and competent health care provider educated to give routine


maternity and newborn care to low-risk pregnant women with uncomplicated pregnancies.


Unlike the stereotypical lay midwife, nurse midwives are trained in both nursing and


midwifery, which culminates in the attainment of a bachelor’s degree, if not a master’s or


doctoral degree (Ural, 2004). Even with a degree in hand, the nurse midwife must still pass state


and national exams before obtaining licensure to practice (Ural, 2004). Once licensed, the


majority of nurse midwives go on to practice in a hospital setting. Here again we see a difference


between the home-bound lay midwife and the certified nurse midwife, as 96% of nurse-


midwives work in hospitals alongside obstetricians (Ural, 2004). In fact, the number of hospital


births attended by nurse-midwives mushroomed ten-fold from approximately 20,000 births in


1975 to nearly 200,000 births in 1994 (Gabay & Wolfe, 1997). Clearly, the use of nurse-


midwives is increasing significantly – yet oddly enough, even after a ten-fold increase in their


use, the question continues to be asked: “Are nurse midwives a safe and effective alternative


approach to maternity care?”



What is the nurse-midwife’s philosophy?


The nurse midwife’s philosophy is that pregnancy and birth are normal and natural events


in a woman’s life – events that should require little if any intervention unless something goes


wrong (Ural, 2004). In the case that something does go wrong, the midwife is trained and


prepared to intervene to the extent that her scope will allow (if it becomes clear that a woman


needs the surgical obstetric care that only an obstetrician can provide, she is referred


accordingly) (Ural, 2004). In the usual case of a low-risk and normally progressing woman,


however, the nurse midwife is interested in escorting the woman through an individualized,


comfortable, and enjoyable birthing process. Midwives are intent on maintaining the historical


outlook that pregnancy and birth are normative as compared to the present day “medicalized”


outlook that pregnancy and birth places both mother and baby in a high-risk situation that poses


potential threat to their health (Parry, 2006). In response to this current outlook, obstetrician’s are


trained to view pregnancy as a condition to be cured and not a normal event to be celebrated


(Loos). As a result, modern obstetric medicine has come to rely heavily on extensive prenatal


screening, patient objectification, and consistent use of technology and surgery (Loos). That said,


as more and more women become disgruntled with the cold, insensitive, technology-reliant, and


“fetocentric” (Parry, 2006) approach of modern obstetrics, more and more women want to


know… do nurse midwives provide a safe and effective alternative approach to maternity care?


Before that question can be answered, the alternative approach itself must first be explored.



What is the Midwives Model of Care?


Midwife means “with woman” and that they are – before, during, and after a woman’s


birthing experience (Diamond). As discussed earlier, midwives take a different approach within


this role, however, than does a medical doctor. This approach and its objectives are neatly


outlined in the “Midwives Model of Care,” a model built on the view that pregnancy and birth


are normal events in a woman’s life ( The


model was created in May of 1996 when the Midwives Alliance of North America (MANA), the


North American Registry of Midwives (NARM), the Midwifery Education Accreditation


Council (MEAC), and the Citizens for Midwifery (CfM) came together and collaborated on the


following objectives for midwifery care (



·         “Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle”


          Nurse midwives are interested in providing a holistic care that is centered around the


woman’s needs – not only her obvious physical needs, but also her psychological and social


needs. From a psychological standpoint, the midwife is interested in how her patient feels


about her pregnancy and what she anticipates for her own birthing experience (Ural, 2004).


Midwives respect the informed decisions that their patients make and desire to incorporate


them, along with the woman’s own instincts, into the care plan (Ural, 2004). For instance, a


woman can express her desire to either have medication or not to have medication during


labor – to undergo a medical test (e.g. amniocentesis) or not to undergo a medical test – all


with the knowledge that whatever decision she makes will be respected and implemented


into her individualized treatment plan. Such an approach places the woman at the center of


the decision-making arena and not the midwife. This approach gives the control back to the


woman, can be empowering, and may help to alleviate some of the pain, fear, and anxiety


that accompanies pregnancy and birth (


          From a social standpoint, the midwife acknowledges the effect that birth has on not


only the woman, but also her family ( With


that in mind, the midwife desires to foster an environment that is socially supportive for the


woman. This means including the woman’s family into the collective partnership be it in


terms of the decision making process or presence at the birth itself





·         “Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support”


          One will note the use of the word “assistance” in the objective above as it relates to

labor and delivery. Unlike obstetricians, nurse midwives view themselves as a “present but


nondominant force” (Kennedy, 2002) whose job it is to support and monitor (versus merely


facilitate and direct) what is a very normal and natural process. One nurse midwife reflects,


“I was a guest and I was invited to be an expert, but only if they needed me to be one… I


would talk about how, ‘Here’s the circle of safety, and as long as you give me normal


[maternal and fetal assessment during labor] within it, my job is to just stay outside the


boundaries. When you bump the boundaries, my job is to gently guide you back’”


(Kennedy, 2002).


In other words, the midwife assumes a stance that allows nature to take its course until


intervention (be it technological or not) is necessary.


                Nurse midwives are also trained to give postpartum support. Nurse-midwives are


trained in lactation and will not leave a mother and her new-born infant until a quality breast-


feeding routine has been established that is comfortable for the mother and promotes mother-


infant bonding (Diamond). Nurse-midwives also monitor recovery through post-natal check-


ups and serve as a continuing source of support throughout the initial months of motherhood





·         “Minimizing technological interventions”


          In their commitment not to disturb the natural process of child birth, nurse midwives


rely heavily upon non-pharmaceutical methods of pain relief including walking, position


changes, back rubs, showers, and access to deep water tubs to manage progress through the


birthing process (Diamond). Midwives may also use warm compresses or massage to gently


stretch the perineum (thereby reducing the need for an episiotomy) (Diamond). Additionally,


nurse midwives may encourage light fluids and foods to maintain the woman’s energy during


labor (Diamond). In the midst of the nurse midwife’s “high-touch and low-tech” (Gibson,


2006) approach, however, technological interventions may become necessary. In the event


this should happen, nurse midwives are not opposed to relying on such interventions as the


mother and baby’s health is of primary importance (Kennedy, 2002).



·         “Identifying and referring women who require obstetrical attention”


          Nurse midwives are trained to identify problems during pregnancy and throughout the


birthing process (Ural, 2004). When and if trouble is detected that is outside the scope of the


nurse-midwife’s practice, the nurse-midwife is quick to transfer the care of her patient to that


of an obstetrician. In cases where the nurse-midwife works closely with an obstetrician, the

woman’s care may be co-managed (Ural, 2004).


          When and if something does “go wrong” and it is beyond the nurse midwife’s scope of


practice to treat (e.g. the need for a cesarean section arises), the patient is referred to the


obstetrician with whom the nurse midwife has a practice contract. This transfer of patient is


easy to do seeing as 97% of midwives work in a hospital (not the patient’s home) and thus an


attending obstetrician is right down the hallway.



^ When the four objectives described above are followed, proponents of the Midwives Model of


Care declare the results to be “less chance of complications, fewer interventions, and a healthier


birth for you and your baby” ( Can the research


confirm this? Is nurse-midwifery as safe and effective and its proponents declare?





What does the research show?


Macdorman & Singh (1998)



STUDY OBJECTIVE: Macdorman and Singh wanted to determine if significant differences


existed in birth outcomes and survival among infants delivered by certified nurse midwives as


compared with infants delivered by physicians. They also wanted to know if these differences, if


they exist, remain after sociodemographic and medical risk factors were controlled for.


PATIENTS: The study included all single-baby vaginal births at 35-43 weeks gestation delivered


either by physicians or certified nurse midwives in the United States in 1991.



MAIN RESULTS: After controlling for social and medical risk factors, the risk of experiencing


an infant death was 19% lower, the risk of neonatal mortality was 33% lower, and the risk of


delivering a low birth weight infant 31% lower – all for births attended by a certified nurse


midwife as compared to births attended by a physician. Also, mean birth weight was 37 grams


heavier for babies delivered by a certified nurse midwife as compared to babies delivered by a





CONCLUSIONS: “National data support the findings of previous local studies that certified


nurse midwives have excellent birth outcomes. These findings are discussed in light of


differences between certified nurse midwives and physicians in prenatal care and labor and


delivery care practices. Certified nurse midwives provide a safe and viable alternative to


maternity care in the United States, particularly for low to moderate risk women” (Macdorman


and Singh, 1998).



Buhler, Glick, & Sheps (1988)



STUDY OBJECTIVE: Buhler, Glick, and Sheps wanted to know if nurse-midwives who cared


for low-risk women would provide better care than family physicians. Their hypothesis was that


nurse-midwives would provide better care.



DESIGN: Utilizing updated criteria of the Burlington Randomized Controlled Trial (BRCT),


data was abstracted from each patient’s perinatal record by a trained nurse who was blind to the


study and its objectives. Each perinatal record (as taken by either a nurse-midwife or a family


physician) was rated as indicating “adequate care,” “superior care,” or “inadequate care”


depending on how much of the record’s contents aligned with the standards of care outline in the


BRCT (shown below).




Table I - Updated criteria of the Burlington Randomized

Controlled Trial. (BRCT)8 used to compare obstetric

care provided by nurse-midwives (NMs) and family

physicians (FPs)


Adequate care

Pelvic assessment, if no previously successful delivery

Taking of obstetric history

Complete physical assessment within 2-year period

Determination of hemoglobin level at least once during

the prenatal period

Urinalysis at each visit

Frequency of subsequent visits: monthly to 4-week

intervals from 6 to 32 weeks' gestation; 2-week

intervals from 32 to 36 weeks' gestation; and weekly

intervals from 36 weeks' gestation to term

Recording of weight at each visit

Measurement of blood pressure at each visit

Record of Rh factor and antirubella titre

Statement of gestation


Superior care

An adequate score and one of the following criteria

Record of psychosocial interview

Joint meeting with mother and father during the


Record of Papanicolaou smear

Measurement of blood glucose level if family history of

diabetes mellitus or personal history of glucosuria or

large babies


Inadequate care

Absence of any of the criteria for adequate care




PATIENTS: The final study sample contained 44 nurse-midwife patients and 88 family


physician patients, all of whom were initially assessed before 20 weeks’ gestation to have no


medical or obstetric problem that would adversely affect the pregnancy; in addition, the

pregnancy had to be considered likely to progress to full term normally.



MAIN RESULTS: On the basis of the updated BRCT criteria: 84% of the nurse-midwife patient


charts earned a score of at least “adequate,” whereas only 40% of the family physician patient


charts earned a score of at least “adequate.” Also, nurse midwife charts indicating a “superior”


level of care were 2.3 times higher than that of family physician charts. The updated BRCT


criteria clearly indicates that patients of nurse-midwives received significantly better care than


patients of family physicians.



CONCLUSIONS: “Nurse-midwives provide more adequate and comprehensive care to pregnant


women than family physicians do. … The finding of our study suggest that nurse-midwives, with


appropriate support, can provide safe and adequate prenatal care to low-risk women … that is


comparable, if not superior, to the care provided by family physicians” (Buhler, Glick, & Sheps,





McGinnis (2004)


In her article “Nurse-Midwives Pass Safety Test” in Prevention, Anne McGinnis


discusses a recent study of 3,000 low-risk pregnant women published in the American Journal of


Public Health.


The study was described as concluding 1) that deliveries by certified nurse midwives


were as *safe* as deliveries by doctors, and 2) births attended by doctors involved nearly triple


the number of episiotomies as births attended by certified nurse midwives, and were twice as


likely to utilize inducing medications and cesarean sections. (Further information regarding the


study was unavailable as the original article was unable to be accessed without an account.)





Gabay & Wolfe (1997)


In an article entitled “Nurse-Midwifery, The Beneficial Alternative” in Public Health


Reports, Mary Gabay, MS and Sidney M. Wolfe, MD, briefly discuss three recent studies which

“document that nurse-midwives are less reliant than physicians on technological interventions in


the birth process, with no adverse effects on outcomes” (Gabay & Wolfe, 390). The studies


within the article are briefly summarized below.



Study 1


In this study, 1,056 low-risk patients managed by nurse-midwives were compared to


3,551 low-risk patients managed by physicians. All participants, regardless of type of provider,


delivered in the same setting.


The study found that patients managed by nurse-midwives were significantly less likely


to  receive an epidural anesthesia, were significantly less likely to undergo an operative delivery,


and experienced a lower incidence of cesarean delivery (9.8% of patients managed by nurse-


midwives versus 12.3% of patients managed by physicians). The cesarean delivery data


remained stable even after adjusting for ethnicity, age, parity, and birth weight. Among all the


babies delivered by nurse-midwives in this study, none of them were at a higher risk for any of


the infant outcomes observed.



Study 2 and Study 3


In a Canadian study all low risk women who requested and qualified for nurse-midwifery


care were randomly assigned to receive care from one of two groups: a group of nurse-midwives


(experimental group) or a group of physicians (the control group). Similar to the results of the


previous study discussed above, all women who received their maternity care from the group of


nurse-midwives were less likely to experience cesarean delivery, episiotomy, and intravenous


drug administration during the birthing process.


This Canadian study was then mirrored by the same researchers among 1,299 pregnant


women in Britain. The results were comparable to the twin study in Canada as obstetric


interventions between the experimental and control groups were similar or lower in favor of the


group of midwives (the experimental group).


The authors of these two studies concluded that “midwife-managed care resulted in


similar or reduced rates of interventions, similar outcomes, similar complications for mother and


baby, and greater satisfaction with care” (as cited in Gabay & Wolfe, 1997). The key results in


this study are midwife’s producing “similar outcomes” as those achieved by physicians yet


producing a “greater satisfaction with care.”





Conclusion: Is nurse midwifery care safe and effective?


Clearly, there exists a large body of research that confirms the safety and comparable


effectiveness of nurse midwifery care as compared to that of physician maternity care. Whether


viewed in terms of quality of prenatal care, outcomes at birth (in reference to a lack of reliance


on technological interventions or operative deliveries), or infant outcomes (i.e. risk of infant


death, risk of neonatal mortality, and risk of delivering a low birth weight infant), all studies


point toward the positive (if not superior) results that accompany the use of a nurse-midwife.


After looking at the research, one could easily say that the midwife’s philosophy of birth as a


natural and normal process along with the Midwives Model of Care are accomplishing their


claimed intent of reducing the chance of complications, reducing the need for interventions, and


allowing for a healthier birth for both mom and baby. Thus, women should indeed consider


nurse-midwifery as an alternative approach to maternity care as it has proven itself to be 


both safe and effective!












































Buhler, L., Glick, N., Sheps, S. B. (1988). Prenatal care: a comparitive evaluation of nurse-

midwives and family physicians. Canadian Medical Association Journal, 139, 397-403.


Citizens for Midwifery (1996-2005). The Midwives Model of Care. Retrieved September 17,

2006 from Web site:


Diamond, M. A.  Nurse-Midwifery Care. Retrieved September 17, 2006 from Expectant

Mother's Guide, Web site:


Gabay, M., Wolfe, S. M. (1997). Nurse-Midwives, The Beneficial Alternative. Public Health

Reports, 112, 386-394.


Gibson, F. (2006).  Midwifery in the Modern World -The Bell that Can't Be Un-Rung.

Retrieved September 17, 2006 from San Francisco State University, Holistic Health Program Web site:


Kennedy, H. P. (2002). The Midwife as an "Instrument" of Care. American Journal of Public

Health, 92(11), 1759-1760.


Loos, Kristin.  Between Two Worlds: Approaches to Midwifery in an Era of Medicalized

Childbirth. Retrieved September 17, 2006 from University of Rochester, Web site:


MacDorman, M. F., & Singh, G. K. (1998). Midwifery care, social and medical risk factors, and

birth outcomes in the USA. Journal of Epidemiology and Community Health, 52, 310-317.


McGinnis, M. (2004). Nurse-Midwives Pass Safety Test. Prevention, 56(9), 129-130.


Parry, D. C. (2006). Women's Lived Experiences With Pregnancy and Midwifery in a

Medicalized and Fetocentric Context: Six Short Stories. Qualitative Inquiry, 12(3), 459.


Ural, S. H. (2004).  Midwives. Retrieved September 17, 2006 from Kids Health for Parents,  Web



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