Psychology Department |
Health Psychology Home PagePapers written by students providing scientific reviews of topics related to health and well being |
| Search | Home | Weight Loss | Alternative Therapy | Supplements | Eating Disorders | Fitness | Links | Self-Assessment | About this Page | |
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 (http://www.cfmidwifery.org/mmoc/define.aspx). 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 (http://www.cfmidwifery.org/mmoc/define.aspx):
· “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 (http://www.cfmidwifery.org/mmoc/define.aspx).
From a social standpoint, the midwife acknowledges the effect that birth has on not
only the woman, but also her family (http://www.cfmidwifery.org/mmoc/define.aspx). 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
(http://www.cfmidwifery.org/mmoc/define.aspx).
· “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
(Diamond).
· “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” (http://www.cfmidwifery.org/mmoc/define.aspx). 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
physician.
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 carePelvic 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 pregnancy Record of Papanicolaou smear Measurement of blood glucose level if family history of diabetes mellitus or personal history of glucosuria or large babies
Inadequate careAbsence 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,
1988).
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!
References
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.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=3214491
Citizens for Midwifery (1996-2005). The Midwives Model of Care. Retrieved September 17,
2006 from Web site: http://www.cfmidwifery.org/mmoc/define.aspx
Diamond, M. A. Nurse-Midwifery Care. Retrieved September 17, 2006 from Expectant
Mother's Guide, Web site:
http://www.expectantmothersguide.com/library/philadelphia/EPHmidwives.htm
Gabay, M., Wolfe, S. M. (1997). Nurse-Midwives, The Beneficial Alternative. Public Health
Reports, 112, 386-394.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1381945
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: http://www.sciencebasedbirth.com/WebPublishing_05/Web_resources_SFSU_Mar06.htm
Kennedy, H. P. (2002). The Midwife as an "Instrument" of Care. American Journal of Public
Health, 92(11), 1759-1760. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1447324
Loos, Kristin. Between Two Worlds: Approaches to Midwifery in an Era of Medicalized
Childbirth. Retrieved September 17, 2006 from University of Rochester, Web site: http://www.courses.rochester.edu/foster/ANT292/Projects/student-2/Midwif99.htm
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. http://jech.bmjjournals.com/cgi/content/abstract/52/5/310
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
site: http://www.kidshealth.org/parent/pregnancy/birth/midwives.html
