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Communicating public health to midwives
COMMUNICATING PUBLIC HEALTH TO MIDWIVES Promoting a Population-Based Approach to Primary Care for Women
Midwifery and public health are so intrinsically intertwined that practitioners of either group often are unaware of the professional ties that they share. It was this realization, and an understanding of the increasing importance of interdisciplinary collaboration, that prompted the Journal of Nurse-Midwifery (JNM), in collaboration with the Boston University School of Public Health, to dedicate this home study program (HSP) to a public health perspective on Primary Care for Women. In the first editorial of this three-part series on Primary Care for Women, Williams pointed out that midwives have inherited a rich legacy with roots closely bound to a public health agenda, and she urged that they not abandon that inheritance (1). In the same issue, Paine et al (2) cited the midwifery services at the Frontier Nursing Service in Kentucky, the Maternity Center Association in New York, and La Casita in New Mexico as just three historical examples of settings in which primary care and public health services were integral to the practice of midwifery. After reading the 1995 HSP on Primary Care for Women, midwives may have questioned the significance of Williams' statements and Paine's examples and asked themselves "What is a public health agenda?" or " H o w do I apply these historical examples of a public health legacy to my current practice?" As one means of answering these important questions, JNM has focused this HSP on the public health perspective inherent in the provision of primary care for women and the importance of working with public health colleagues to improve the health and well-being of the population. Nineteen ninety-seven marks the 125th anniversary of the American Public Health Association (APHA), the oldest and largest organization of public health profes-
Address correspondence to Lisa L. Paine, CNM, DrPH, FACNM,Chair, Department of Maternal and Child Health, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118.
sionals in the world, representing more than 50,000 members from more than 50 public health occupations (including midwifery). The theme of the 1997 annual meeting was "Communicating Public Health." Earlier this year, APHA President, Dr. Barry Levy, challenged APHA members to communicate public health, citing the following 10 means of doing so (3): 1. 2. 3. 4. 5. 6. 7. 8.
Listen Capture attention Prepare well Communicate with passion Give it a human face Think globally, communicate locally Communicate in multiple ways Communicate with groups you don't normally communicate with 9. Empower individuals and communities 10. Evaluate the impact In keeping with this charge to communicate public health, the faculty of the Boston University School of Public Health Department of Maternal and Child Health, guest editors of this issue, have selected midwives as the first professional group with whom they will "communicate public health," especially in the area of populationbased primary care services for women. It has been 5 years since the American College of Nurse-Midwives (ACNM) took the position that certified nurse-midwives "are providers of primary health care for women and infants (4)." Since that time, ACNM-sponsored activities, such as JNM-sponsored HSPs (5,6) and regional workshops conducted by the Continuing Education Committee, have guided and supported midwives both individually and collectively in this role. However, as this nation continues its shift toward a system of managed care, the demographic trends in populations of women and their families will change, as will the needs of its most vulnerable populations. Therefore, it is not enough for midwives to provide primary care that focuses solely on the individual woman; rather, midwifery
Journal of Nurse-Midwifery • Voi. 42, No. 6, November/December 1997 © 1997 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.
457 0091-2182/97/$17.00 . PII S0091-2182(97)00094-3
and primary care must now be practiced from a population-based, public health perspective. Matemal and child health professionals describe their public health activities in several distinct categories, including graduate and continuing education, service, research, policy, and advocacy. Recent examples of public healthrelated activities sponsored by the ACNM include the Maternal and Child Health Providers Partnership Cooperative Agreement and the Special Projects Section Domestic Violence Education Project (both funded by the Maternal and Child Health Bureau); the Domestic Women's Health Policy Forum; the Safe Motherhood Initiative USA Task Force; the ACNM Web site, which includes resources for members, policy makers, and consumers; the A.C.N.M. Foundation-sponsored and Robert Wood Johnson-funded study entitled Nurse-Midwifery Care for Vulnerable Populations in the United States; and the three-part JNM HSP Primary Care for Women. Several documents were used by the guest editors in the development of this JNM issue. However, two were particularly useful: 1) Ten Essential Public Health Services to Promote Maternal and Child Health, identifled by Grayson and Guyer (7) in collaboration with the Maternal and Child Health Bureau and several MCH service organizations, and 2) ATMCH Competencies for Education and Practice in Maternal and Child Health (8), developed and disseminated by the Association of Teachers of Maternal and Child Health (ATMCH) in collaboration with the MCH Council of the Association of Schools of Public Health. These competencies are used by students of MCH to prepare for future leadership careers and by MCH practitioners to guide their own professional development in five distinct areas: scientifically-based skills, methodological and analytical skills, management and communication skills, policy and advocacy skills, and cross-cutting issues and skills. Both documents are presented immediately following this editorial with the hope that they may offer the midwife a framework for understanding public health practice in MCH. In addition, a glossary of public health-related terms used herein is provided at the outset of this HSP. Although this HSP does not include all facets of public health, it highlights critical elements needed for the attainment of competencies in MCH, the multidisciplinary public health field in which midwives have been valued members for many decades. The articles presented in this issue offer the midwife a unique perspective on the primary care role. In Population-Based Primary Health Care for Women: An Overview for Midwives, Garceau et al (pp 465-477) propose that public health and primary care be viewed as two interacting and mutually supportive elements of a complex health care system, which has as its single goal the improvement of the health status of a community and its members. Garceau also supports the prediction that the public health of the past will become the population-based
458
health care of the future, whereas the primary care of the past will become the clinical and preventive primary care and community-based health care of the future. She summarizes that, simply put, midwives must prepare themselves to practice population-based health care and community-based preventive primary care, explaining these concepts in a clear, comprehensive way. The importance of population-based needs assessments is well established throughout this HSP. In Population-Based Needs Assessment: Bringing Public Health to Midwifery Practice, Declercq et al (pp 4 7 8 488) offer the midwife an instructional approach to the development of a community-based needs assessment. Relevant clinical practice examples are presented throughout the paper that reinforce the merger of clinical practice and public health as mentioned by Garceau. An excellent example of how broad, policyoriented plans that emerge from a population-based needs assessment and city-wide public health agenda can support midwifery is offered by Rorie et al (pp 527-535) in their paper entitled Public Health Approaches to Community-Based Needs: Boston's Infant Mortality Crisis as a Case Study. In Home Birth and Short-Stay Delivery: Lessons in Health Care Financing for Providers of Health Care for Women, Germano and Bernstein (pp 4 8 9 - 4 9 9 ) use a historical approach to address how shifts in health care financing can influence health delivery and health care options. The importance of health promotion as one aspect of the public health perspective is first proposed by Garceau, then further demonstrated in Morris and Rorie's (pp 5 0 9 - 5 2 0 ) article, Nutritional Aspects of Health Promotion in Women's Primary Care. The two articles, Providing Culturally Competent Primary Care for Immigrant and Refugee Women: A Cambodian Case Study by Downs et al (pp 4 9 9 - 5 0 8 ) and Women's Health and Low-lncome Housing by Welch (pp 521-526) stress advocacy and cultural competence issues at the client and community levels. Failure to recognize a population-based approach to health care delivery places the profession of midwifery at risk of losing its strong and historic legacy; in addition, important opportunities to provide leadership in maternal and child health will be missed if midwives fail to extend their own professional boundaries to include public health. As Levy (3) urged in his 10 points to communicating public health, midwives must communicate with groups they don't normally communicate with. Midwives should start by communicating and collaborating with their 50,000 public health colleagues, with whom they have a shared vision. Recently, APHA has both supported midwifery and benefited from the leadership of midwives. In 1994, APHA issued a policy statement recommending increased support for education and practice opportunities for nurse-midwives (9); last year, four of the eight elected
Journal of Nurse-Midwifery • Vol. 42, No. 6, November/December 1997
delegates to the Governing Council from the MCH Section were certified nurse-midwives. In 1996, A P H A embraced a seven-point public health agenda calling on Congress to protect the health of our nation's children (10). The agenda began with the statement "Every child should come into the world as healthy as possible" and ended with the statement "Every child should be assured the opportunity for reproductive health" (I I). In effect, if midwives collaborate with their public health colleagues, they will have the opportunity to both participate and provide leadership in this important public health agenda. Strengthening the professional relationship between midwifery and public health offers great hope for improved health and well-being for the members of our society who could most benefit, namely women, mothers, children, and families. Lisa L. Paine, CNM, DrPH, FACNM Guest Editor Chair, Department of Maternal and Child Health Boston University School of Public Health
REFERENCES 1. Williams DR. Primary care for women: the nurse-midwifery legacy. J Nurse Midwifery 1995;40:57-8.
2. Paine LL, Barger MK, Marchese TM, Rorie JL. Primarycare for women: an overview of the role of the nurse-midwife. J Nurse Midwifery 1995;40:65-73. 3. LevyBS. Communicatingpublic health: a 'top 10' list. Nations Health 1997;27:2. 4. American College of Nurse-Midwives. Certified nurse-midwives as primary care providers. Washington (DC): ACNM, 1992. 5. AmericanCollege of Nurse-Midwives. Primary care for women: part 1. Comprehensive health assessment. J Nurse Midwifery 1995: 40:57-245. 6. AmericanCollege of Nurse-Midwives. Primary care for women: part 2. Management of common health problems. J Nurse Midwifery 1996;41:75-187. 7. GraysonHA, Guyer B. MCH program functions framework: essential public health services to promote maternal and child health in America. McLean (VA): The National MCH Clearinghouse; 1995. 8. Associationof Teachers of Maternal and Child Health. Competencies for education and practice in maternal & child health. Washington (DC): Associationof Schools of Public Health (MCH Council), 1993. 9. American Public Health Association. Public policy statement #9403: increase support for education and practice opportunities for nurse-midwives. Washington (DC): APHA, 1994. 10. Brown ER. A public health agenda for children. Nations Health 1996;26:2. 11. AmericanPublic Health Association. A call to action, protecting the health of children: a public health agenda. Washington (DC): American Public Health Association, 1996.
AMERJCAN PUBLIC HEALTH ASSOCIATION
American Public Health Association, 1015 15th Street, NW, Washington, DC 20005. Telephone: (202) 789-5600. Internet: http://www, apha.org/
Journal of Nurse-Midwifery • Vol. 42, No. 6, November/December 1997
459
Midwifery and public health are so intrinsically intertwined that practitioners of either group often are unaware of the professional ties that they share. It was this realization, and an understanding of the increasing importance of interdisciplinary collaboration, that prompted the Journal of Nurse-Midwifery (JNM), in collaboration with the Boston University School of Public Health, to dedicate this home study program (HSP) to a public health perspective on Primary Care for Women. In the first editorial of this three-part series on Primary Care for Women, Williams pointed out that midwives have inherited a rich legacy with roots closely bound to a public health agenda, and she urged that they not abandon that inheritance (1). In the same issue, Paine et al (2) cited the midwifery services at the Frontier Nursing Service in Kentucky, the Maternity Center Association in New York, and La Casita in New Mexico as just three historical examples of settings in which primary care and public health services were integral to the practice of midwifery. After reading the 1995 HSP on Primary Care for Women, midwives may have questioned the significance of Williams' statements and Paine's examples and asked themselves "What is a public health agenda?" or " H o w do I apply these historical examples of a public health legacy to my current practice?" As one means of answering these important questions, JNM has focused this HSP on the public health perspective inherent in the provision of primary care for women and the importance of working with public health colleagues to improve the health and well-being of the population. Nineteen ninety-seven marks the 125th anniversary of the American Public Health Association (APHA), the oldest and largest organization of public health profes-
Address correspondence to Lisa L. Paine, CNM, DrPH, FACNM,Chair, Department of Maternal and Child Health, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118.
sionals in the world, representing more than 50,000 members from more than 50 public health occupations (including midwifery). The theme of the 1997 annual meeting was "Communicating Public Health." Earlier this year, APHA President, Dr. Barry Levy, challenged APHA members to communicate public health, citing the following 10 means of doing so (3): 1. 2. 3. 4. 5. 6. 7. 8.
Listen Capture attention Prepare well Communicate with passion Give it a human face Think globally, communicate locally Communicate in multiple ways Communicate with groups you don't normally communicate with 9. Empower individuals and communities 10. Evaluate the impact In keeping with this charge to communicate public health, the faculty of the Boston University School of Public Health Department of Maternal and Child Health, guest editors of this issue, have selected midwives as the first professional group with whom they will "communicate public health," especially in the area of populationbased primary care services for women. It has been 5 years since the American College of Nurse-Midwives (ACNM) took the position that certified nurse-midwives "are providers of primary health care for women and infants (4)." Since that time, ACNM-sponsored activities, such as JNM-sponsored HSPs (5,6) and regional workshops conducted by the Continuing Education Committee, have guided and supported midwives both individually and collectively in this role. However, as this nation continues its shift toward a system of managed care, the demographic trends in populations of women and their families will change, as will the needs of its most vulnerable populations. Therefore, it is not enough for midwives to provide primary care that focuses solely on the individual woman; rather, midwifery
Journal of Nurse-Midwifery • Voi. 42, No. 6, November/December 1997 © 1997 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.
457 0091-2182/97/$17.00 . PII S0091-2182(97)00094-3
and primary care must now be practiced from a population-based, public health perspective. Matemal and child health professionals describe their public health activities in several distinct categories, including graduate and continuing education, service, research, policy, and advocacy. Recent examples of public healthrelated activities sponsored by the ACNM include the Maternal and Child Health Providers Partnership Cooperative Agreement and the Special Projects Section Domestic Violence Education Project (both funded by the Maternal and Child Health Bureau); the Domestic Women's Health Policy Forum; the Safe Motherhood Initiative USA Task Force; the ACNM Web site, which includes resources for members, policy makers, and consumers; the A.C.N.M. Foundation-sponsored and Robert Wood Johnson-funded study entitled Nurse-Midwifery Care for Vulnerable Populations in the United States; and the three-part JNM HSP Primary Care for Women. Several documents were used by the guest editors in the development of this JNM issue. However, two were particularly useful: 1) Ten Essential Public Health Services to Promote Maternal and Child Health, identifled by Grayson and Guyer (7) in collaboration with the Maternal and Child Health Bureau and several MCH service organizations, and 2) ATMCH Competencies for Education and Practice in Maternal and Child Health (8), developed and disseminated by the Association of Teachers of Maternal and Child Health (ATMCH) in collaboration with the MCH Council of the Association of Schools of Public Health. These competencies are used by students of MCH to prepare for future leadership careers and by MCH practitioners to guide their own professional development in five distinct areas: scientifically-based skills, methodological and analytical skills, management and communication skills, policy and advocacy skills, and cross-cutting issues and skills. Both documents are presented immediately following this editorial with the hope that they may offer the midwife a framework for understanding public health practice in MCH. In addition, a glossary of public health-related terms used herein is provided at the outset of this HSP. Although this HSP does not include all facets of public health, it highlights critical elements needed for the attainment of competencies in MCH, the multidisciplinary public health field in which midwives have been valued members for many decades. The articles presented in this issue offer the midwife a unique perspective on the primary care role. In Population-Based Primary Health Care for Women: An Overview for Midwives, Garceau et al (pp 465-477) propose that public health and primary care be viewed as two interacting and mutually supportive elements of a complex health care system, which has as its single goal the improvement of the health status of a community and its members. Garceau also supports the prediction that the public health of the past will become the population-based
458
health care of the future, whereas the primary care of the past will become the clinical and preventive primary care and community-based health care of the future. She summarizes that, simply put, midwives must prepare themselves to practice population-based health care and community-based preventive primary care, explaining these concepts in a clear, comprehensive way. The importance of population-based needs assessments is well established throughout this HSP. In Population-Based Needs Assessment: Bringing Public Health to Midwifery Practice, Declercq et al (pp 4 7 8 488) offer the midwife an instructional approach to the development of a community-based needs assessment. Relevant clinical practice examples are presented throughout the paper that reinforce the merger of clinical practice and public health as mentioned by Garceau. An excellent example of how broad, policyoriented plans that emerge from a population-based needs assessment and city-wide public health agenda can support midwifery is offered by Rorie et al (pp 527-535) in their paper entitled Public Health Approaches to Community-Based Needs: Boston's Infant Mortality Crisis as a Case Study. In Home Birth and Short-Stay Delivery: Lessons in Health Care Financing for Providers of Health Care for Women, Germano and Bernstein (pp 4 8 9 - 4 9 9 ) use a historical approach to address how shifts in health care financing can influence health delivery and health care options. The importance of health promotion as one aspect of the public health perspective is first proposed by Garceau, then further demonstrated in Morris and Rorie's (pp 5 0 9 - 5 2 0 ) article, Nutritional Aspects of Health Promotion in Women's Primary Care. The two articles, Providing Culturally Competent Primary Care for Immigrant and Refugee Women: A Cambodian Case Study by Downs et al (pp 4 9 9 - 5 0 8 ) and Women's Health and Low-lncome Housing by Welch (pp 521-526) stress advocacy and cultural competence issues at the client and community levels. Failure to recognize a population-based approach to health care delivery places the profession of midwifery at risk of losing its strong and historic legacy; in addition, important opportunities to provide leadership in maternal and child health will be missed if midwives fail to extend their own professional boundaries to include public health. As Levy (3) urged in his 10 points to communicating public health, midwives must communicate with groups they don't normally communicate with. Midwives should start by communicating and collaborating with their 50,000 public health colleagues, with whom they have a shared vision. Recently, APHA has both supported midwifery and benefited from the leadership of midwives. In 1994, APHA issued a policy statement recommending increased support for education and practice opportunities for nurse-midwives (9); last year, four of the eight elected
Journal of Nurse-Midwifery • Vol. 42, No. 6, November/December 1997
delegates to the Governing Council from the MCH Section were certified nurse-midwives. In 1996, A P H A embraced a seven-point public health agenda calling on Congress to protect the health of our nation's children (10). The agenda began with the statement "Every child should come into the world as healthy as possible" and ended with the statement "Every child should be assured the opportunity for reproductive health" (I I). In effect, if midwives collaborate with their public health colleagues, they will have the opportunity to both participate and provide leadership in this important public health agenda. Strengthening the professional relationship between midwifery and public health offers great hope for improved health and well-being for the members of our society who could most benefit, namely women, mothers, children, and families. Lisa L. Paine, CNM, DrPH, FACNM Guest Editor Chair, Department of Maternal and Child Health Boston University School of Public Health
REFERENCES 1. Williams DR. Primary care for women: the nurse-midwifery legacy. J Nurse Midwifery 1995;40:57-8.
2. Paine LL, Barger MK, Marchese TM, Rorie JL. Primarycare for women: an overview of the role of the nurse-midwife. J Nurse Midwifery 1995;40:65-73. 3. LevyBS. Communicatingpublic health: a 'top 10' list. Nations Health 1997;27:2. 4. American College of Nurse-Midwives. Certified nurse-midwives as primary care providers. Washington (DC): ACNM, 1992. 5. AmericanCollege of Nurse-Midwives. Primary care for women: part 1. Comprehensive health assessment. J Nurse Midwifery 1995: 40:57-245. 6. AmericanCollege of Nurse-Midwives. Primary care for women: part 2. Management of common health problems. J Nurse Midwifery 1996;41:75-187. 7. GraysonHA, Guyer B. MCH program functions framework: essential public health services to promote maternal and child health in America. McLean (VA): The National MCH Clearinghouse; 1995. 8. Associationof Teachers of Maternal and Child Health. Competencies for education and practice in maternal & child health. Washington (DC): Associationof Schools of Public Health (MCH Council), 1993. 9. American Public Health Association. Public policy statement #9403: increase support for education and practice opportunities for nurse-midwives. Washington (DC): APHA, 1994. 10. Brown ER. A public health agenda for children. Nations Health 1996;26:2. 11. AmericanPublic Health Association. A call to action, protecting the health of children: a public health agenda. Washington (DC): American Public Health Association, 1996.
AMERJCAN PUBLIC HEALTH ASSOCIATION
American Public Health Association, 1015 15th Street, NW, Washington, DC 20005. Telephone: (202) 789-5600. Internet: http://www, apha.org/
Journal of Nurse-Midwifery • Vol. 42, No. 6, November/December 1997
459