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Essential elements of midwifery care
needs. The birth center provided low intervention care, such as intermittent auscultation, emotional support, and no epidural anesthesia. Physician care was provided in hospital clinics and private practices with births taking place in hospitals with routine use of electronic fetal monitoring and continuous availability of anesthesia services. Major maternal morbidity was similar in both groups throughout pregnancy, birth, and the postpartum period. More-technical interventions (e.g., oxytocin use and epidural anesthesia) were used in women cared for by physicians, while less-technical interventions (e.g., ambulation and hydrotherapy) were more common in women cared for by the CNM/obstetrician collaborative model. Women who received collaborative care had more spontaneous vaginal births (14.9% adjusted difference with 95% CI of 11.5%– 18.3%) and fewer episiotomies (⫺22.5% adjusted difference with 95% CI of ⫺26.4% to ⫺18.5%) than those who had physician care. Duration of stay in the birth facility was shorter in the group who had collaborative care with 28% more women discharged before 24 hours. Both groups had similar neonatal outcomes and readmissions. These results clearly support the comparable outcomes and safety of the two types of care and demonstrate reduced use of resources and procedures with collaborative care. The findings of this study regarding differences in and outcomes with the diagnosis of fetal heart rate (FHR) abnormalities are very interesting. This diagnosis was more common among the physician care group than the collaborative care group (19% vs. 11%); however, rates of cesarean birth among the women with FHR abnormalities were similar (31% in the collaborative care group and 30% in the physician care group). This is inconsistent with previous studies showing increased cesarean rates in women who have continuous electronic fetal monitoring, but it raises the question of what other interventions may have ensued due to the increased diagnoses. Research regarding resource utilization and costs associated with a diagnosis of FHR abnormalities could further support the use of intermittent auscultation, which has been established as safe and effective.
Journal of Midwifery & Women’s Health • www.jmwh.org
ESSENTIAL ELEMENTS OF MIDWIFERY CARE Kennedy HP, Rousseau AL, Low LK. An exploratory metasynthesis of midwifery practice in the United States. Midwifery 2003;19:203–14. The effectiveness of midwifery care has been established by numerous studies, but the processes through which midwives accomplish successful outcomes are not well understood. Kennedy et al. conducted a metasynthesis to address this question and provide a benchmark for further research. The article begins with a succinct but thoughtprovoking discussion of the complexities of midwifery practice in the United States, including the distinctions between the types of preparation for the midwifery profession, the increasing intervention in maternity care, and the complexities of a health system in which reimbursement significantly dictates the provider and type of care for women. Six qualitative studies of midwifery practice were identified and subjected to a rigorous process that allowed new ideas to emerge from the evaluation of the collective findings. Four themes emerged from the metasynthesis. The first theme is the midwife as an “instrument” of care using attributes—such as being non-judgmental, clinically competent, and experiencing joy in one’s work—to affect the process of care. The second theme is the woman as a partner in care that is individualized and includes respect and self-determination. The third theme is an “alliance” in midwifery care demonstrated by a relationship with trust, mutual control, and shared decision making. The final theme is the “environment” in the process of midwifery care with emphasis on the midwife protecting normalcy and being present. The authors of this metasynthesis are pre-eminent researchers in the qualitative analysis of midwifery care processes. This work integrates the commonalities of their previous studies to further develop a description of midwifery practice. Defining the essence of midwifery care is a complex undertaking, and this study is an important contribution to that process.
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Journal of Midwifery & Women’s Health • www.jmwh.org
ESSENTIAL ELEMENTS OF MIDWIFERY CARE Kennedy HP, Rousseau AL, Low LK. An exploratory metasynthesis of midwifery practice in the United States. Midwifery 2003;19:203–14. The effectiveness of midwifery care has been established by numerous studies, but the processes through which midwives accomplish successful outcomes are not well understood. Kennedy et al. conducted a metasynthesis to address this question and provide a benchmark for further research. The article begins with a succinct but thoughtprovoking discussion of the complexities of midwifery practice in the United States, including the distinctions between the types of preparation for the midwifery profession, the increasing intervention in maternity care, and the complexities of a health system in which reimbursement significantly dictates the provider and type of care for women. Six qualitative studies of midwifery practice were identified and subjected to a rigorous process that allowed new ideas to emerge from the evaluation of the collective findings. Four themes emerged from the metasynthesis. The first theme is the midwife as an “instrument” of care using attributes—such as being non-judgmental, clinically competent, and experiencing joy in one’s work—to affect the process of care. The second theme is the woman as a partner in care that is individualized and includes respect and self-determination. The third theme is an “alliance” in midwifery care demonstrated by a relationship with trust, mutual control, and shared decision making. The final theme is the “environment” in the process of midwifery care with emphasis on the midwife protecting normalcy and being present. The authors of this metasynthesis are pre-eminent researchers in the qualitative analysis of midwifery care processes. This work integrates the commonalities of their previous studies to further develop a description of midwifery practice. Defining the essence of midwifery care is a complex undertaking, and this study is an important contribution to that process.
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