An exploratory metasynthesis of midwifery practice in the United States

An exploratory metasynthesis of midwifery practice in the United States Holly P. Kennedy, Amy L. Rousseau and Lisa Kane Low Objectives: to conduct a metasynthesis of six qualitative studies of midwifery care and process; identify common themes and metaphors among the six studies for further exploration and theory development; and create a framework for further metasynthesis of qualitative studies of midwifery practice in the USA. Design: a qualitative metasynthesis to analyse, synthesise, and interpret six qualitative studies on the process and practice of midwifery care. Sample and Setting: hospital, birth centre, and home birth settings were represented across all of the studies. Participants included nurse- and direct-entry midwives who provided both childbearing and gynaecological care. Recipients of midwifery care also received both childbearing and gynaecological care. Findings: four overarching themes were identif|ed: the midwife as an ‘instrument’of care; the woman as a ‘partner’ in care; an ‘alliance’ between the woman and midwife; and the ‘environment’of care.These were interpretively and conceptually arrayed into a helix model of midwifery care.

Holly P. Kennedy PhD, CNM, Specialty Coordinator, NurseMidwifery Education Program, Assistant Professor, Department of Family Health Care Nursing, University of California, 2, Koret Way, Box 0606, San Francisco, CA 94143- 0606, USA Amy L. Rousseau PhD, CNM Director, Claire M. Lintilhac NurseMidwifery Service, Fletcher Allen Health Care/ University of Vermont, USA Lisa Kane Low PhD, CNM, Faculty, OB/ GYN and Women’s Studies, University of Michigan, USA (Correspondence to HPK, E-mail: holly.kennedy@ nursing.ucsf.edu) Received 19 September 2002 Revised 15 January 2003 Accepted 5 April 2003

Key conclusions: the f|ndings from this exploratory metasynthesis clearly indicate that the practice of midwifery is a dynamic partnership between the midwife and the woman, and reflects an environmental perspective. In a country that has a standard of highly technical childbirth care, perhaps the most outstanding concept of this model is that of the midwife as an ‘instrument’of care.The signif|cance of the f|ndings will be determined by their ability to guide further research efforts to support a standard of midwifery care for all women in the USA. Implications for practice: this model offers a benchmark and a structure for considering the dynamic elements of midwifery practice and key roles that the midwife plays in the health care of women and babies. & 2003 Elsevier Ltd. All rights reserved.

INTRODUCTION Numerous studies have explored midwifery practice in the USA over the past decades, however, few have examined specific processes used by midwives, or have attempted to link them to health outcomes. Raisler (2000) conducted an extensive review of 140 studies about nurse-midwifery practice from 1984 to 1998. Her findings provided a partial overview of the state of the science of midwifery in the USA. Although the safety and efficacy of nursemidwifery practice have been firmly established (Oakley et al. 1995, Harvey et al. 1996, MacDorMidwifery (2003) 19, 203^214 & 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0266 - 6138(03)00034-2/midw.2002.0361

man & Singh 1998), few researchers have tried to measure and/or describe how midwives achieve the remarkable perinatal and women’s health outcomes for which they are known. A survey conducted by the American College of Nurse-Midwives (ACNM) with the Maternal Child Health Bureau examined the perceptions of nurse-midwives about the effect of managed care on their practice (McCloskey et al. 2002). Several of the most commonly cited changes to practice were an increased client load with a focus on higher productivity. The nurse-midwives believed that these changes directly affected their ability to practise a midwifery

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model of care. Some articulated increasing unwillingness to teach future midwives because they felt the student would not see ‘true midwifery’. This study points to a growing concern about changing practice in the current health-care arena. These nurse-midwives did not believe that their model of care was valued in an environment focused on economic outcomes. However, they did not have the evidence to effectively argue how their model of care was unique, cost-effective, or linked specifically to perinatal outcomes. This gap in evidence limits the ability of the midwifery profession to counter current economic pressures and health policies in the USA. Despite the increasing number of qualitative investigations of midwifery care in the USA, there has been no attempt to synthesize the research findings into a collective interpretation of current knowledge. Sandelowski et al. (1997) express a concern that unless there is a systematic approach to examine qualitative findings (about a specific phenomenon), they can have little impact on practice and/or policy-making. Clear delineation of a theoretical link between unique midwifery care practices with specific outcomes in the health of women and babies continues to be elusive. It underscores the critical need to articulate their relationship in order to support policy development in the health care of women; it must be a research priority.

MIDWIFERY PRACTICE IN THE USA The profession of midwifery in the USA is complex, from both historical and current contexts. The profession almost completely disappeared by the early 1900s with the takeover by modern obstetrics, but began a constructed resurgence beginning in the 1920--1930s as it aligned with nursing and public health to attend poor women with few services (Varney 1997). That focus of care has changed somewhat in current times reflecting both demographic and economic forces. Today midwives enter the profession from two general directions in the USA. The majority come with basic qualifications in nursing and obtain post-graduate work in midwifery leading to certification as a certified nurse-midwife (CNM). These midwives are certified through the American College of Nurse-Midwives (ACNM) Certification Council and must possess a baccalaureate degree; however, 70% achieve masters level preparation by graduation (Davis-Floyd 1998). In the mid-1990s an additional mechanism was created for nonnurses to achieve basic education as a midwife through the ACNM leading to the credential of certified midwife (CM) (Rooks 1997). Midwifery, as practiced by CNMs, is legal in all of the 50

states of the USA. There are currently over 10000 certified nurse-midwives and certified midwives with 7000 having membership in the ACNM; they attended 10% of the births in the USA in 1999 with almost 98% of those occurring in the hospital setting (Shah 2002). The other route to midwifery is termed ‘directentry’ in which future midwives usually apprentice with another midwife to learn the skills to attend women during birth, primarily in the home setting. In addition, there are some more structured educational routes to enter midwifery through this venue. Midwives choosing this route may be certified through the North American Registry of Midwives (NARM), the certifying arm of the Midwives Alliance of North America (MANA), and are called certified professional midwives (CPM). Approximately 700 of the 1300--2300 direct-entry midwives in the USA are CPMs (MANA 2002). MANA is the organisation that represents many direct-entry midwives, although one-third of its membership is comprised of CNMs and CMs. One of the philosophical concerns of MANA is that midwives who enter through nursing may be schooled in a more medical approach to birth. It is difficult to assess how many direct-entry midwives are in practice since they are not always legally recognised, licensed, or able to achieve reimbursement from insurers. Practice by direct-entry midwives is legal in 14 states, unavailable due to lack of licensure in eight states, and illegal in nine states and the District of Columbia. The status in the other states is often termed a-legal because the judicial interpretation is not clear (Davis-Floyd 1999). The current approach to pregnancy and childbirth in the USA is highly technologically oriented, characterised by soaring caesarean birth and epidural rates. In the current reimbursement system, midwives and doctors must compete to provide care for women; it is not a system in which women have access to providers based on the appropriate of level of care they need or desire. Health care provided through managed care organisations determines a woman’s health-care provider and rations health care by geography, employer, level of reimbursement and prior contractual obligations instead of assigning appropriate type of care by risk. Furthermore, the complexity of the Federal system of care for uninsured mothers has encouraged the privatisation of some aspects of care while using public health clinics in others. This has resulted in the shift to private-sector care for the population cared for over many decades by midwives, often without the multilayered resources found in the public sphere of services (McCloskey et al. 2002). Midwives are then in competition with doctors, who

Metasynthesis of midwifery practice in the US

outnumber midwives dramatically, in both the public and private sector of health care. In summary, while midwifery practice in the USA has grown slowly, but steadily over the past decades, most of those births occur in the hospital and smaller and smaller numbers occur in birth centres or at home. The challenges of the profession are reflected in the larger health-care arena of the USA; one in which growing utilisation of technology and complex reimbursement structures takes precedence over individualised, risk-based, personal care. The purpose of this study strives to understand more completely the unique attributes of midwifery practice in the context of that arena.

KNOWLEDGE DEVELOPMENT IN MIDWIFERY In an effort to identify theoretically based midwifery processes of care, it is first important to understand the foundation of knowledge upon which midwifery practice is grounded. Carper (1978) identified four fundamental patterns of ‘knowing’ in nursing that can be used to understand knowledge development in midwifery. The four patterns are: (a) empiric or scientific knowledge; (b) aesthetics, or how the art of practice is made visible; (c) personal knowledge, or that which is experiential and/or subjective; and (d) ethics, the knowledge of morality in practice. Of these four patterns it is the ‘art’ or aesthetics of practice that many midwives consider to be unique to the profession (Davis 1995). However, this is an assumption that is not grounded in scientific inquiry. Therefore, efforts to identify and measure the art of midwifery practice are essential to linking the process of care to outcomes. In an initial effort to understand a phenomenon or experience, qualitative methods are used to explore the complexity of a phenomenon. Qualitative inquiry initially allows detailed descriptions of the phenomenon and provides explanatory evidence to substantively develop a coherent model reflecting the area of interest (Kennedy & Lowe 2001). Through this process, the phenomenon is better understood and described. Thus exploratory studies begin to develop the evidence base upon which theory is grounded (Steeves et al. 1996). Moving to confirming evidence requires the identification of discrete variables or concepts, and eventual measurement of their interactions and effects. Through the use of quantitative methods, developing theories can be confirmed, refined or refuted. Prematurely moving towards confirmatory methods without a solid theoretical foundation limits the strength and credibility of the findings (Stevenson 1990). Furthermore, the

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potential to overlook aetiological or explanatory factors is increased. Our gaps in knowledge about the linkages of midwifery practice and health outcomes are best studied with confirmatory methods once the theoretical base has been established. ‘Efforts to synthesize existing qualitative research studies are seen as essential to reaching high analytic goals and also to enhancing the generalisability of qualitative research’ (Sandelowski et al. 1997, p. 367). The purpose of this study was to continue to synthesize a theoretical base for midwifery practice. This metasynthesis was conducted as an exploratory study to (1) examine the collective findings from qualitative studies about midwifery practice and care, (2) develop a prototype for a broader and more exclusive metasynthesis of midwifery practice in the USA, and (3) develop a theoretical foundation for future confirmatory research.

METHODS Metasynthesis, a research method that analyses, synthesises, and interprets a specified body of qualitative research, possesses the potential to provide valuable insight and knowledge about the distinctive aspects of midwifery care and how they may be related to specific outcomes. It provides an organised, yet interpretive approach to a specific group of qualitative studies (Noblit & Hare 1988). Sandelowski et al. (1997) define metasynthesis as ‘the theories, grand narrative, generalizations, or interpretive translations produced from the integration of findings from qualitative studies’ (p. 366). Noblit and Hare (1988) describe the process as a research method that creates an interpretation of other studies. As such, it is much more than a review of the literature because it results in a broader interpretation; it is a research study unto itself. Conceptually it might seem similar to a metaanalysis of quantitative studies, yet it is far more than an aggregate evaluation; it is an interpretive move toward theory development. Without the conduct of such work, researchers are at risk of only replicating qualitative findings without ever advancing the state of the science. Metasynthesis has gained regard over the past two decades as a method of systematically interpreting qualitative studies following a prescribed and rigorous approach. Most notably, the Cochrane Collaboration and Campbell Methods Group have added it as a strategy for systematic review to establish a database of relevant methodological papers, to include evidence from qualitative research into systematic reviews, to provide a forum for discussion, and to link expertise in qualitative research and training (Finch 2003). We chose to use Noblit

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Table 1 Steps in the conduct of a metasynthesis (Noblit & Hare1988 1. Identify the area of interest that a set of studies could inform. 2. Decide which studies are relevant to the area of interest. 3. Repeated reading of the studies noting interpretive metaphors. 4. Determining how the studies are related. 5. Translating studies collectively. 6. Synthesising the translations. 7. Expressing the synthesis.

and Hare’s (1988) steps for conducting a metasynthesis for our research design and these are outlined in Table 1. This strategy has been well employed in many studies and provided us with a systematic, yet interpretive methodological approach. A further description of the procedural implementation of the steps follows. Firstly, identify the area of interest that a set of studies could inform. Each of the authors was involved in an area of qualitative inquiry on various aspects of midwifery practice and care. Commonalities were noted during individual presentations of the authors’ findings at national conferences. Based on this experience and a review of the literature, we believed that a metasynthesis of qualitative studies of midwifery practice was the next logical step in theory development. Secondly, decide which studies are relevant to the area of interest. One of the most critical steps in a metasynthesis is the decision on which studies will be included. Criteria for inclusion must be carefully reasoned based on the purpose of the study, and then systematic literature searches must identify those that are appropriate and discard those that are not. To conduct this metasynthesis on the processes of midwifery care we chose to examine our early qualitative studies in this area of interest. This approach enabled us to fully learn and grasp the method, and prepare us for a broader future study. Of our nine

studies, three were fully excluded and only partial results were used of a study that had two arms, based on the inclusion criteria that the study had to be conducted about midwifery practice from perspectives of midwives and/or women receiving midwifery care. The studies used for the metasynthesis are shown in Table 2. Thirdly, repeated reading of the studies noting interpretive metaphors. Each researcher read the six studies independently and wrote memos to reflect their thoughts, metaphors, and interpretations. Through systematic repeated readings each researcher exhaustively identified the themes and concepts of each study. This step requires an ability to absorb, reflect, and step away from each study as it is examined first in isolation, in preparation for the next step in which relationships are explored. Fourthly, determining how the studies are related. The Atlas.ti t qualitative software program was used to organise and manage the written memos. Eighty-seven initial codes were identified through content analysis of the memos. The memos and coding structure were then systematically analysed and conceptually organised to ascertain commonalities and themes. Fifthly, translating studies collectively. Independently, the three researchers returned to the original studies and examined them using the coding structure developed from the interpretive memos. This required attention to the metaphors and concepts in each of the individual studies to respect the particular aspects of the original findings, but also allowed comparisons across the studies. Sixthly, synthesising the translations. Noblit and Hare (1988) describe this step as translating metaphors and concepts across the studies into a new interpretation of the whole. The interpretive analysis was completed at this stage and the findings of the metasynthesis were identified. Finally, expressing the synthesis. The findings of the metasynthesis can be disseminated by the

Table 2 Studies included in the metasynthesis Study

Sample

Qualitative Design/Data Analysis Method

Kennedy (1995)

Phenomenology (Colazzi)

Powers & Kane Low (2002)

6 women who had been cared for by nurse-midwives 3 women cared for by nurse-midwives 15 videotaped interactions between women (14) and nurse-midwives (5) 52 midwives nominated as ‘‘exemplary’’ in the United States (1 from Canada) and 61 recipients of care by the midwife panelists 25 adolescents (11cared for by nurse-midwives) 12 women cared for by nurse-midwives

Total studies=6

Total participants in sample=174

Levi (1996) Levi (2000) Kennedy (2000)

Kane Low (2001)

Phenomenology (van Manen) Content analysis Delphi method (3 rounds, qualitative and quantitative data); content analysis Extended case methodology Semi-structured interviews; content analysis Total methods=5

Metasynthesis of midwifery practice in the US

usual methods for sharing research findings. However the findings are expressed, they must ‘enable an audience to stretch and see the phenomena in terms of others’ interpretations and perspectives’ (Noblit & Hare 1988, p. 29). The findings were independently reviewed by a group of researchers for clarity and cogent meaning resulting in minor alterations of wording and syntax.

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FINDINGS Four overarching themes and their unique attributes were identified as a result of the metasynthesis process (Table 3). These four themes were conceptually arrayed into a helix model to portray their dynamic and overlapping nature (Fig. 1). Selected key exemplars for each of the themes are provided with a general description of its essence.

Sample The study sample consisted of six initial inquiries of midwifery practice and care by the authors (Table 2). These six studies were chosen because they had a common focus: the elucidation of the process of care provided by midwives. Human subjects approval is not required for this kind of study because it is akin to a review of literature and does not sample research participants directly. Most of the studies were conducted in the Northeast, Eastern Seaboard, and Midwest regions of the USA and one was conducted with a national sample. Five of the six studies were with nurse-midwives. One study (Kennedy 2000) included both nurse- (80%) and direct-entry midwives (20%). All types of birth settings and types of midwifery care (childbearing and gynaecological) were represented. Hereafter, the term ‘midwife’ will refer to all kinds of midwives represented in the study and will not differentiate by type. All of the research participants (midwives and recipients of care) were women; the use of the feminine pronoun ‘she’ reflects the sample and is not meant to be exclusionary of men, who were often present as partners and family members to the women in the studies.

The midwife as an ‘INSTRUMENT’of care The term ‘instrument’ is used to identify how the midwife, as a unique individual, is able to affect the process of care in varied ways through the use of herself. Key attributes of this theme included being non-judgemental, intelligent, and clinically competent, as well as holding a knowledge and awareness of her limitations. Additional attributes, unique to the midwife as a person, included being compassionate, calm, confident, ethical, and humorous. Sharing information, advocacy, and being ‘present’ to the woman when she is in need were also identified. Finally, experiencing joy in the practice of midwifery was evident. The following exemplars demonstrate the manner in which midwives strategically use themselves as an ‘instrument’ of care. One midwife described this in terms of body language saying: I always sit like that with peopleyI hunch forward someyI try to make people feel like they’re equal. This is actually just to listen to [her] story in a way that’s going to make [her] realize that [she’s] done a lot . . . [she’s] really

Table 3 Interpretive themes and attributes The Midwife as an ‘instrument’ of care

TheWoman as a partner in care

An Alliance between the woman and the midwife

The Environment as a factor in the process of care

 The Midwife as a unique individual  Presence

 Woman &/or family as a unique individual  Care is tailored to meet her, or their needs

 Relationship

 Non-judgemental

 Self-determination of care  Sense of satisfaction

 Normalcy of pregnancy & birth  Interventions only when necessary & individualised to the woman’s needs  Creating a sense of safety

 Intelligent  Competent (clinical skills & judgment)  Knowledge of self & limits  Advocate  Compassion       

Commitment Calm Conf|dent Ethical Humorous Information sharing Joy in the work of midwifery

 Feels safe  Feels respected

 Partnership  Trust  Respect within and for the process  Common goal

 Respect  Time

 Shared control &  Family centred decision making  Dynamic process  Spiritual  Able to both ‘take control & let go’ as needed

208 Midwifery The midwife and woman in alliance

Continual flow – ‘taking control and letting go’ between midwife and woman Fig. 1 Conceptual representation of the metasynthesis of midwifery care. These two concentric Celtic helices represent the midwife as an instrument of care on one side in alliance with the woman as her partner on the other side. Midwifery care takes place in the context of the environment represented by the open spaces within the circles.There is a continual flow between the woman and the midwife, which represents the ‘taking control and letting go’ as both the midwife and the woman work toward shared goals.

strong and I think that that’s an important factor in listening (Levi 2000, p. 34). Midwives and women in these six studies noted the use of presence, both physical and emotional, as a unique feature of midwifery care: Much of what midwives do during early labor doesn’t even look like ‘doing’ . . . I speak for myself and the long honorable tradition of midwifery when I describe this work as the mastery of doing ‘nothing.’ It is a specific skill that must be learned and developed, no less so than any of those busy medical skills associated with the ‘doing-ness’ of hospital-based obstetrics. As a community midwife, I sit for many long hours doing this ‘nothing’ silently observing while listening to the parents talk about their hopes and dreams, fears and frustrations’ (Kennedy 2000, p. 12). The following two women reflect the need and importance of that presence: I was a coach for a friend of mine, she’s a single mom and it was her first baby. The doctors were in and out in five minutes and then they’d leave for hours, and then come back again. And that was, I think, one of the things that inspired me to have the midwives because I did not want that. I wanted somebody that was going to be there and listen and take the time. I think that made a difference to [my labor] (Powers & Kane Low 2002, p. 8). She was right there and it was as if she was going to have this baby right along with me and I found a great deal of comfort physically and emotionally in that (Kennedy 1995, p. 415). Women were also expressive about some of the more elusive attributes of their midwives. The

ability to be non-judgemental was evident in one woman’s description of her midwife’s gentle advice: The midwife’s encouragement during pushing was just right. What she said was ‘this is how some people find it most effective’ which I thought was really nice because it wasn’t this is how you should do it (Powers & Kane Low 2002, p. 9). The following woman perceived a concern by the midwife, but observed her ability to remain calm: She did it in a nice way, but at the same time you knew she was watching the monitor and was concerned. She wasn’t nervous and didn’t panic about it (Kennedy 1995, p. 414). Feeling a continual support was seen as special and important: The midwife just took so much time. And every time I had a question, I would call the number. And I mean 24 hours a day there was an answer for me and just the support and the understanding. It was just fabulous (Powers & Kane Low 2002, p. 8). The midwife’s demonstration of clinical competence varied from specific skills to her general professional demeanor. One midwife viewed her clinical skill as the foundation of her work: Certainly assessment is important in the entire process of what I do. I am always assessing what the woman is saying—watching nonverbal language, listening acutely to what she is saying and what she isn’t saying (Kennedy 2000, p. 9).

Metasynthesis of midwifery practice in the US

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This careful attention to physical care was echoed by one woman:

thinking—it’s okay, I’m here now; I’m safe (Levi 1996, p. 16--17).

One thing that stood out was the excellence of the medical care, from a purely medical standpoint—I don’t think I have ever had anyone check my thyroid before (Kennedy 2000, p. 9).

Respect for the woman’s self-determination was often discussed by the women as a unique and valued feature of their care:

The midwives believed in providing information to women and the women saw that as a valuable part of their care: Oh gosh [the midwife] was great. She was telling me to relax and breathe through contractions. Before that she told me what to eat, how far along I was, what did it look like. She gave me packets to read—to learn about stuff that helped me a lot too (Kane Low 2001, p. 88). Finally, many of the midwives expressed joy in their work and believed this was essential to their own continuance in a demanding profession: I just enjoy people who are pregnant. Pregnancy is joyful and needs to be a part of everything I do (Levi 2000, p. 42). This particular theme centred on the midwife as a unique individual and an ‘instrument’ in care. The following theme adds the other part of the equation—the woman as a ‘partner’ in care.

The woman as a ‘PARTNER’ in care Attributes of this theme include the recognition of the woman [and her family] as uniquely individual with the midwife tailoring care to meet her needs. Respect for the woman and her self-determination was paramount. There was a goal of helping the woman feel both safe and satisfied with her care, partially through shared decision-making between the midwife and the woman and/or her family. One woman describes her partnership in the following way: It was a dialogue and relationship with people I was interested in getting to know each other as partnersythey felt honestly, genuinely, sincerely [and] professionally interested in getting to know me in all the ways that would help them, help me (Levi 1996, p. 7). Women described their sense of feeling safe in a variety of ways. In this description the woman connected feeling safe with the midwife to a prior life experience: The only comparable experience to the first time being touched by the nurse-midwife was being shepherded across a crowded street as a 17-year old, newly arrived foreign exchange student in Brazil. I remembered my world turned upside down—and then I felt so taken care of, I felt so at home, I remember

They weren’t making decisions about me but with me. It was shared informationy. (Levi 1996, p. 8). Knowing that I had options. Even though it didn’t seem totally like I had options, but they always gave me a choice. Even at the point of the C-section. It was well, we could do the Csection, or we have the option to continue. I mean it was always . . . I always had options and choices (Powers & Kane Low 2002, p. 11). Tailoring care to their unique needs was also considered fundamental: They offered suggestions to me and to my partner. Why don’t you help her do this or why don’t you do this a different way. And I think that helped her a lot too, because I know there were points where she probably felt like she didn’t know how to help me, so I think that was really helpful (Powers & Kane Low 2002, p. 10). The focus of this theme was on the woman as a unique person and ‘partner’ with the midwife. The following theme describes how the midwife and the woman form an alliance to navigate the health-care situation together.

‘ALLIANCE’ in midwifery care Within the context of midwifery practice, a relationship was described between the midwife and the woman that took the form of an alliance. This relationship was founded upon trust and mutual respect, with shared control and decisionmaking. These attributes contributed to the achievement of shared or common goals between the midwife and the woman. The alliance was dynamic and changing, based on social, emotional, or physical needs. It was influenced by the uniqueness of the individuals involved, and the environment in which the care or practice occurs. Finally, the expression of the alliance allowed an interplay between the midwife and the woman in which each was able to ‘take control and let go’ as needed in the current situation. The dynamic nature of the alliance was unmistakable as women described a relationship in which there was trust, both in each other and in the process as is articulated by the following quotes: y she [the midwife] basically told me that when I felt comfortable pushing to go ahead and push. Whenever I felt comfortable doing

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something, she just told me to go ahead and do it. That made me feel easier too, because that made me feel that when I was comfortable to do something then I did’ (Kane Low 2001, p. 94). I think just keeping the care on the human scale, and in keeping with trying to educate people about the process, and at the same time hear and respond to what they want out of the process—that’s really important—and that’s why we were really happy with the midwives (Powers & Kane Low 2002, p. 9).

oriented toward preparing [the woman] for the worst and expecting and cultivating a sense of the best (Levi 2000, p. 34). Yet another midwife asserted the importance of actively working to keep normalcy at the forefront: Remind yourself, your colleagues, your support workers, and especially the woman, of the power of normal pregnancy, labor, birth, postpartum and breastfeeding when no intervention occurs (Kennedy 2000, p. 9).

Some of the midwives described themselves as similar to a partner or guide with the woman, listening carefully to her and helping her to draw upon her inner strength without taking over:

Although the midwives worked to promote an environment of normalcy, it was the women’s experience of this that was emblematic of her care and that experience:

I see myself as a guide on a canoe trip, ready to grab the paddle if we hit a snag, but otherwise watching the water and the paddler’s ability to navigate, giving encouragement and suggestions as needed. One woman echoed this when describing her birth: It was a searing, forever-to-be-etched experience, and my midwife stands out as someone who rode the river with me (Kennedy 2000, p. 10).

The midwives were wonderful. That’s why I picked them. It’s natural you know. I didn’t have to get an IV and be strapped down. I never heard of pushing on my side before and that was the best. I just wish that the regular doctors would appreciate that. It is a natural experience (Powers & Kane Low 2002, p. 11).

Finally one woman sums up this unique ability to work as a team with the midwife so that both could ‘take control and let go’ as needed: They practiced with skill, experience and an uncanny knowing of when to step in and when to let me be (Kennedy 2000, p. 9). The alliance speaks to the dynamic relationship between the woman and the midwife. The final theme identified in the metasynthesis was an environment that reflects the contributions of the woman and her family, the midwife, and the alliance between them.

The ‘ENVIRONMENT’ in the process of midwifery care The environment created by the midwife reinforced the normalcy of pregnancy and birth. It was one in which the midwife uses interventions only when necessary and then individualises them to the woman’s needs. The ‘presence’ of the midwife was integral to the environment and contributed to the woman’s sense of feeling respected through the time and attention provided. Additional attributes include family centred care and supporting the spirituality of the woman in the context of her experience. To promote an environment of normalcy and respect, several midwives described their process and relationship with the woman this way: Hey, we’re all in this together, and [I] try to create a sense that this is an okay thing. A lot of my activities in this first part of the visit are

Within the environment, the midwife had a sense of when to be present, and when not to be present: She stepped into the background and let the three of us be a family (Kennedy 1995, p. 415). I just remember being with my girlfriend when she was in labor and the doctors coming in just like the last possible moment and then leaving and you never see them again. It was really nice because they [the midwives] were thereyI don’t even think they ever left (Powers & Kane Low 2002, p. 8). The midwives used both time and respect to create an environment in which the woman could take control and feel as if she could accomplish her goals. One midwife called it: ycreating a setting in which the woman comes first, in which she is taken seriously (Kennedy 2000, p. 10). The structure of a prenatal visit contributed to this woman’s awareness of the setting and her own sense of dignity: [The physician] was not helping me to take responsibility; I felt like a patient. This was odd, unnecessary, and infantilizing. There was no dignity in a five minute visit where I was wearing only a [patient] gown, compared to the midwife visit where I would be dressed while we talked (Levi 1996, p. 11). One woman described the sense of respect for her time: I never waited 10 minutes for an appointment. I just think that there’s a different level of

Metasynthesis of midwifery practice in the US

understanding as far as that my schedule is as important as hers (Kennedy 1995, p. 414). Finally, one of the midwives spoke of the need to understand the context and resources of the family’s environment as she described working with a young couple with no food or money to achieve a healthy pregnancy: The ups and downs, struggles and accomplishments that came like the unfolding of the skin of an onion, as I learned slowly what their needs were and how to help them y (Kennedy 2000, p. 12). This final theme of the environment of care reflects an awareness of the midwife’s ability to create a sense of normalcy and atmosphere for caring, respect, and success. Although the four overarching themes interpretively fit and make conceptual sense, there were several codes that we had to examine very carefully to understand their placement and alignment across all of the studies. This included an understanding of the midwife as a person and what she brought to the relationship. This was particularly strong in some of the studies and more implied in others. A decision was made that because her actions often conveyed her sense of self (and use of self) that it should be included in the theme of ‘instrument of care’ supporting that the midwife is a person first and clinician second. Another issue related to the midwife was the lack of discussion about her professional role across all studies. This is likely because most of the studies did not query for this aspect of practice and it is less likely to come up in discussion as women describe their care experience. Although some of the studies provided us with the complexities of working with other colleagues and health-care challenges in the professional life of a midwife, it was not a strong enough theme to retain. We also had to grapple with some negative examples of when the processes of care did not take place. For example, the significance of partnering with the midwife was demonstrated by the contrast of when that role of ‘partner’ was absent. In the following instance, an adolescent mother was not included in the decision-making regarding her plan of care because the midwife only listened to the father of the baby and not to the adolescent herself: Well y she [the midwife] talked to me and told me that she’d be back. I’m thinking something is wrong. She brings him [the father of the baby] in there and she is like ‘Do you want to have this baby today?’ I was like WHAT? He said ‘Yes she does, yes she does!’ So that is what happened—I wasn’t ready at all’ (Kane Low 2001, p. 66). We believed that this negative example was important to consider, and include because it told

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us from the woman’s point of view what was important and how she felt when not included in the development of the plan of care. It became an interpretive contrary case for the process of alliance. The four themes together represent the authors’ interpretations of the collective findings of the six studies. Each of the themes identified—the woman, the midwife, the alliance between them, and the environment of care—overlap and contribute to the dynamic nature of midwifery practice. The helix (Fig. 1) is used to represent this dynamic, ever changing process. It symbolises the midwife’s ongoing assessment of the woman’s needs and desires, juxtaposed with the cultural, sociopolitical, and health-care environment in which it occurs. These tensions metaphorically create a give and take, back and forth dance reflecting a philosophical stance of the midwife to support, and be with women, but also having to manage meeting the woman’s needs within healthcare settings that may not be aligned with her desires. Through their alliance, they continue to work together to accomplish their common goals. The dance of being able to ‘take control and let go’ responsively in a given situation by both the woman and the midwife is captured by the helix, which encompasses the four themes.

DISCUSSION This metasynthesis used six studies to interpret the multidimensional aspects of midwifery practice in the USA. The collective interpretation revealed a complex and dynamic interaction between the woman and the midwife within a contextual environment of care. Although an articulation of the ‘art’ of midwifery practice continues to be subtle, this metasynthesis may have brought us one step closer to clarity. As Carper (1978) notes in her identification of the four fundamental patterns of knowing, ‘each of the patterns may be conceived as necessary for achieving mastery in the discipline, but none of them alone should be considered sufficient. Neither are they mutually exclusive’ (p. 253). Clearly the model that resulted from this metasynthesis demonstrates multiple patterns of knowing that are integral to the practice of midwifery. For example, being clinically competent, calm, and present to the woman were all important attributes of the midwife. The personal knowledge of how to use one’s self as an ‘instrument’ of care in relationship with the woman is most likely learned and influenced in many ways. It may come partially from observing others, but is likely to be swayed by personal beliefs about pregnancy and birth. Staying calm so the mother can be reassured is difficult if one possesses a basic fear about birth. Being ‘present’ with women implies a level of

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comfort with intimacy and quiet. A classic study by Balint (1964) on physician, patient and illness relationships reflects the ever evolving nature of this process. ‘The important thing is that education is not one-sided only. Both patient and doctor grow together into a better knowledge of one another’ (Balint 1964, p. 249). A study conducted about nurse practitioners 30 years later describes an alliance similar to what we have seen with these midwives. The nurse practitioner, without making distinctions between medical and social issues, listens to her patient describe her life and concerns; they mutually come to a diagnosis after considering all of the findings (Fisher 1995). Moral knowledge or agency is also important to consider. Is there an ethical contract to work with a woman to help her achieve her goals during a life-altering event such as birth? An implied contract assumed by the midwife in caring for the woman is to see her safely through the pregnancy, labour, birth, or gynaecological care. But, is providing safety the only important factor? Several of the study findings included in this metasynthesis suggested that the effect of midwifery care persisted far beyond the actual event of birth. Although there was not enough evidence to cluster these into a separate theme, the words of several women were exceptionally powerful. When a 15-year old was asked what she felt good about during her labour and birth she replied: Ya, that I can actually be able to do it. I know it hurts, but I can do it. So I knew in my mind that I was able to do it . . . when I’m stuck on a problem, or when I need help with something, I think—I can do this—I did it through labor, and this is not as bad as labor, so I can do this here! I think I am able to do what I put my mind up to do (Kane Low 2000, p. 118). Another woman described how her midwife validated her as a person and helped her to find strength to travel a difficult road ahead after giving birth to a child with Down’s syndrome: My midwife walked a fine line flawlessly. On the one hand, when I sobbing, told her I didn’t want to raise a retarded child, she sympathetically agreed, neither would she. She thus shared in our common humanity without making me feel less a person. On the other hand, she held and treated my baby as a precious, beautiful gift. That too, helped me overcome my own fears of being rejected and stigmatized since my baby was retarded. She helped me rise to the occasion (Kennedy 2000, p. 11). The lifelong effects of care during birth have been commented upon in other qualitative studies. Simkin (1991) found that 15--20 years

after birth many women felt that they had achieved something significant and believed that their self-confidence and esteem were enhanced. Yet, others did not have this experience. What is not known are the key factors for those longterm memories and effects—could it have anything to do with how they were assisted or guided in the process, or the sense of control they felt during a challenging time like labour and birth? Another perspective on knowing is proposed by Benner and Wrubel (1989) as ‘embodied knowledge,’ seen in the performance of complex skills and pattern recognition by expert nurses. Benner and her colleagues (Benner 1984; Benner & Wrubel 1989; Tanner et al. 1993, Benner et al. 1996) have investigated expert knowledge of nurses in highly skilled settings such as intensive care units or emergency rooms. The skill sets and pattern recognition we have identified in the midwives from these six studies may, or may not, be quite different from those used with complexly ill clients. They may also represent a unique skill set and the substantive difference between obstetrics and midwifery. The ability to ‘take control and let go’ in response to each woman and each labour represents an expertise and knowledge that there are many ways to give birth and that flexibility, rather than rigidity, is more likely to achieve success. This kind of skill has been noted in other studies in which the midwife was likened to a ‘head coach’ or guide for the journey (Seibold et al. 1999). When placing this model against the current landscape of pregnancy and birth care in the USA, perhaps the most outstanding feature is that of the concept of the midwife as an ‘instrument’ of care. DeVries (1993) provides a compelling argument for the decline of midwifery with the increase of technology, noting that power lies with professions that emphasise risk, and then are able to step in to control that risk. Even though the use of technology and interventive birth practices have soared in the USA, there is little to show for it; we remain 27th in infant mortality—the lowest of developed countries in the world with the highest per capita expenditure (CDC 2001, Healthy People 2010, 2000). An intriguing notion is that of the midwife as a technological advancement. If the midwife’s use of self, belief in normalcy, presence and alliance could be clearly linked to positive outcomes at birth and beyond, would implementation of midwifery as a standard of care improve the entire maternal-child health-care system? And would this stand up against many of the ‘routine’ technologies used in USA labour and birth practices today? One limitation of this study is that the work represents only studies conducted by the authors. As previously noted, the impetus for the collaboration between the researchers was

Metasynthesis of midwifery practice in the US

recognition that their works held a common focus on midwifery practice, despite varied methods, sample populations, and findings. Potential methodological limitations within each of the individual studies are inherited in the process of conducting a metasynthesis. However, as noted by Sandelowski et al. (1997), despite potential limitations in the initial works, the rigour with which the metasynthesis process is conducted becomes the standard for the new analysis. The rigour in this study was congruent with the guidelines described by Noblit and Hare (1988). Jensen and Allen (1996) assert that ‘the meta-synthesis is rooted in the original data and is credible when it re-presents such faithful descriptions or interpretations of a human experience that the people having that experience would immediately recognize it from those descriptions or interpretations as their own’ (p. 556). By initially combining work that was familiar to the three authors, the emphasis was on developing expertise in the process of metasynthesis, rather than on concluding with a final theory. Nevertheless, the resulting model of this metasynthesis provides a more cogent description of midwifery practice than any of the individual studies included had previously offered. This metasynthesis represents a small sample of six qualitative studies regarding midwifery practice. There are more studies on midwifery practice that need to be included in a larger metasynthesis before a complete and comprehensive model can be advanced for theory development. The authors have moved forward with this next daunting step and are currently conducting an extensive search of the literature to identify qualitative studies on midwifery practice that incorporate the midwife’s perspective, the woman’s perspective, and structural issues such as legislative and reimbursement mandates. The search is encompassing many databases and experts in research on midwifery and women’s health care from nursing, anthropology, medical, literary, education, psychological, and social perspectives. The resulting model presented from this study moves the state of science regarding midwifery practice in the USA forward by offering a benchmark against which other studies might be compared. Clearly the practice of midwifery is dynamic and needs to be considered within the environment that it occurs. The significance of these findings will be determined by their ability to guide further research efforts designed to (1) evaluate outcomes that address both process and measurement in perinatal and women’s health; (2) compare differences in outcomes related to the midwifery process of care as an intervention; (3) compare the effects of beliefs about pregnancy, birth, and practice on outcomes; (4)

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compare processes of care between various health-care providers; and (5) describe the similarities and differences among various types of midwifery models. A number of questions arise from this step in theory development for midwifery practice in the USA. The issue of changing midwifery practice, including institutional or environmental changes precipitated by economic forces, needs to be addressed. If midwifery practice is shifting, a theory of midwifery practice must be responsive to change, and at the same time not lose the essence of midwifery care that might be critical to promoting positive outcomes. While these issues are not answered here, they should continue to be part of future debate and research. Continued theory development in midwifery practice will aid in this debate.

ACKNOWLEDGMENTS The author’s acknowledge the ACNM Foundation/ Ortho-McNeil Graduate Fellowship (all three authors were recipients), the ACNM-RI Chapter, Joyce Thompson, CNM, DrPH, FACNM, FAAN, Joyce Roberts, CNM, PhD, FACNM, FAAN, Holly Powers, MS, CNM, FNP, and all the women and midwives who have participated in the research.

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