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Midwives and Normalcy in Childbirth: A Phenomenologic Concept Development Study
FEATURES Midwives and Normalcy in Childbirth: A Phenomenologic Concept Development Study Jo Anne P. Davis, CNM, PhD Introduction: The purpose of this study was to explore midwives’ understanding of the concept of normalcy as experienced during the care of women during labor and birth. Methods: A two-tier, elite sampling strategy was used to identify and enroll participants who showed a strong commitment to normalcy in childbirth care. Thirteen participants completed all study procedures, including individual interviews. Iterative rounds of qualitative analyses were conducted to describe the concept, resulting in the defining aspects of the concept, contextual dynamics that influence its manifestation, and empiric referents. Results: Midwives experience normalcy in childbirth care as 1) a wide, individualized continuum of variations; 2) interactive with the woman’s unique nature, composed of her physiologic capacities and her specific life circumstances; and 3) sensitive and responsive to the contextual environment. Discussion: Midwives’ experience of normalcy in childbirth admits a broad continuum of healthy variations, differing from the narrow parameters held in the predominant maternity care culture. Midwives consider the woman’s nature and the context of childbirth to be interactive and significant in explaining variations in the woman’s childbirth experience. The contextual environment is considered to be the most influential dynamic affecting the normalcy of childbirth. J Midwifery Womens Health 2010;55:206–215 Ó 2010 by the American College of Nurse-Midwives. keywords: childbirth, concept development, midwives, normalcy, normal processes, phenomenologic
INTRODUCTION
HISTORICAL BACKGROUND
The concept of normalcy is a philosophical mainstay of the midwifery model of care, and provides rationale for care processes and a powerful explanation for favorable outcomes. The American College of Nurse-Midwives (ACNM) Philosophy positions normalcy as fundamental to US midwifery’s disciplinary identity.1 For midwifery, the concept of normalcy characterizes the essential nature of women’s life processes as healthy, particularly during pregnancy and childbirth. However, valuing normalcy does not provide descriptive or explanatory linkages between midwifery management of care and actual outcomes. An experienced midwife may assert that she/he ‘‘knows normal’’ when she/he sees it and can provide a rationale for specific care processes while caring for a woman in labor because ‘‘everything is proceeding normally.’’ Like-minded others will grasp immediately what she/he means, but would be hard-pressed to actually define what is normalcy. Exploration of this concept may contribute further understanding of linkages between how midwives practice and how midwifery care achieves favorable outcomes.
To consider the concept of normalcy in childbirth, it is useful to review historical perceptions of childbirth. Three noteworthy themes regarding the nature of childbirth emerge: 1) traditional midwives’ experiential knowledge for ‘‘waiting on nature,’’ an essentially conservative stance; 2) obstetric thinking favoring active intervention in the natural process of labor; and 3) van Deventer’s reliance on facilitative processes and restrained intervention (i.e., ‘‘facilitating nature’’). In the early 18th century, two important developments emerged to dramatically alter the customary childbirth care of midwives. The first was the obstetric forceps, which made possible active intervention to override obstructed or prolonged labors.2 The second was Henrick van Deventer’s therapeutic approach to facilitate expulsive forces in overcoming resistive forces during childbirth.3 van Deventer, an obstetric surgeon at The Hague, developed a scientific approach that combined knowledge of obstetric anatomy and physiology with extensive experience of normal labor. It is reasonable to conclude that contemporary midwifery practice is most consistent with van Deventer’s approach—using scientific knowledge to facilitate physiologic labor and birth, rather than overriding labor and birth processes unless indicated. A parallel development of the 19th century—demographic statistical analysis—added new perspective to
Address correspondence to Jo Anne P. Davis, CNM, PhD, Department of Nursing, School of Nursing and Health Studies, Georgetown University, 417 St. Mary’s Hall, 3700 Reservoir Rd. NW, Washington, DC 20057. E-mail: [email protected]
206 Ó 2010 by the American College of Nurse-Midwives Issued by Elsevier Inc.
Volume 55, No. 3, May/June 2010 1526-9523/$36.00 doi:10.1016/j.jmwh.2009.12.007
medical care, shifting the focus of therapeutics from individuals to populations. The notion of the ‘‘average man’’ emerged, was statistically defined, and was increasingly applied to social and then medical phenomena. In medical circles, there was intense debate about the value of population-based analyses in determining therapeutic efficacy.4 Proponents argued that statistical analysis was the foundation of ‘‘scientific observation’’ and the new hallmark of medical thinking. Conservative physicians insisted that the physician’s insight into the individual was more important in choosing therapeutics, a concept that has been incorporated into contemporary midwifery practice. Statistical caseload analyses set parameters for the average course of ‘‘natural’’ childbirth and the analytic terminology of ‘‘normal’’ and ‘‘abnormal’’ entered obstetric discourse.5 At the turn of the 20th century, population-based descriptors were well incorporated in medical practice and exercised occupational jurisdiction in defining the role of the ‘‘new midwife.’’6 This feature was the margin between normal and abnormal childbirth and defined midwifery’s boundaries of care.7 THEORETICAL BACKGROUND Theoretical descriptions of the midwifery model of care have appeared in the United States only in the last 20 years. The concept of normalcy is explicitly identified in the works of Lehrman,8 Thompson et al.,9 Kennedy,10,11 and Kennedy and MacDonald,12 Kennedy et al.,13 and Kennedy and Shannon.14 Gould15 reported a classic concept analysis of normal labor. Hunter reports that normalcy in childbirth is found in midwives’ ‘‘self-knowledge,’’ which she defined as ‘‘the midwife’s belief in what she knows, knowing what she believes and acting upon those beliefs.’’16 All are drawn on principles articulated in the ACNM Philosophy.1 Collectively, these studies have advanced descriptive concepts and frameworks for the midwifery model of care that are largely congruent and reflect the current theoretical development in midwifery. Lehrman8 defined ‘‘positive presence’’ in midwifery care as ‘‘the degree to which the nurse-midwife applies scientific processes of care in a manner promoting the normal and natural processes of labor and birth. This descriptor, as well as the humanistic art of caring, is observable in clinical decision-making.’’ Lehrman located the midwife’s belief in normalcy within positive presence; the concept of normalcy was minimally elaborated.8 Hunter17 elaborated on Lehrman’s work on positive presence in an analysis of ‘‘being with woman’’ and its beneficial effects on labor and birth physiologic outcomes. Jo Anne P. Davis, CNM, PhD, is Assistant Professor, Midwifery Tutor, and Assistant Chair for Education and Practice in the Department of Nursing, School of Nursing and Health Studies, Georgetown University, Washington, DC. Dr. Davis received her BS in Nursing at the University of Cincinnati, her MS in Midwifery at St. Louis University, and her PhD in Nursing Science at Vanderbilt University.
Journal of Midwifery & Women’s Health www.jmwh.org
Thompson et al.9 undertook a theoretical description of the process of nurse-midwifery care. Six descriptors derived from the ACNM Philosophy were identified, including ‘‘health promoting.’’18 The authors defined health promoting as ‘‘those actions that encourage behaviors conducive to the woman’s well-being throughout her life cycle and specifically promote the naturalness of pregnancy and birth.’’9 These descriptor concepts were further refined and clustered into the ethical concepts of competence, compassion, and covenant fidelity; the concept of normalcy is positioned within covenant fidelity.9 Kennedy developed a model of exemplary midwifery practice, and put forward three ‘‘dimensions’’: therapeutics, caring, and the profession. Kennedy’s dimension of therapeutics explores how the exemplary midwife chooses care processes that support normalcy; belief in normalcy and vigilance were the two critical concepts of exemplary midwifery care. Kennedy10,11 described how exemplary midwives actively model that childbirth is a normal process and tolerate wide variations in labor while simultaneously attending to the safety of the woman and baby. Kennedy summarized participants’ views of normalcy in childbirth as follows: ‘‘The midwives repeatedly articulated the process of supporting the normalcy of birth [emphasis added]. This included judicious and appropriate use of technology, intervening only if necessary, not hurrying the birth process, personalizing care, and using a wide array of options and resources (rather than one in particular) to assist the woman and/or her family. (The midwife) [sic] understands that birth can be trusted and is patient with, and positive about, the process.’’10 Cragin conducted a critical analysis of Lehrman,8 Thompson et al.,9 and Kennedy10,11 that also verified belief in normalcy as a primary aspect and process of midwifery care.19 Cragin19 states that the theoretical development in midwifery consistently identifies ‘‘protection and nurturance of the ‘normal’ in processes related to women’s health, implying a judicious use of technology and intervention.’’ In addition, Cragin concludes that theory development in midwifery must extend beyond physiologic processes and outcomes, to encompass women’s minds, bodies, and the context of their life experiences.19 In a concept analysis of normal labor, Gould15 rightly points out that theoretical parameters that define normal labor are problematic because midwives believe the woman’s perception of her experience must be taken into account. Providers’ interpretation of a woman’s childbirth may not agree with the woman’s own interpretation of her experience.15 Gould15 emphasizes that theorists have focused almost exclusively on the physiologic parameters of normalcy in childbirth valued by the obstetric perspective, to the general exclusion of other factors, such as 207
relationships, culture, and social contexts. Arguing for integration of nonphysiologic aspects, Gould characterized normal labor to include its sensitive, dynamic, and sequential pattern; its strenuous and productively painful nature; and the sequential movements that culminate in spontaneous birth of the baby and placenta.15 BACKGROUND The historical and theoretical reviews support the concept of midwives’ belief in normalcy as the core characteristic of the midwifery model of care. While significant theoretical work has developed descriptions of the midwifery model of care, normalcy as a scientific concept that helps to explain links between midwifery’s approach to care and associated outcomes has yet to be developed. The purpose of this study was to describe and define the concept of normalcy as the critical characteristic of the midwifery model of care, in a specified category of midwives. As a discrete clinical context for the study, care of women during labor and birth forms the context for exploration of midwives’ belief in normalcy. METHODS Description of the concept of normalcy indicates the study is a concept development project. Rodgers and Knafl20 state that the purpose of concept development is ‘‘to clarify the current use of a concept with attention to contextual and temporal aspects (and) provide a clear conceptual foundation as a (means) for further inquiry.’’ Concept development is indicated when a generally familiar concept requires fresh analysis because it has come to lack clear, conscious, and defined parameters, properties, or meanings.21 In midwifery, the concept of normalcy in its current form may be characterized in this way: ‘‘the only way to ‘define’ (the concept) is to point out instances of the concept and instances of ‘notthe-concept’ so that another can experience the sensory impressions [emphasis added] associated with the concept.’’ The most important feature of a concept is its intersubjective agreement (i.e., the degree of agreement about the concept among those who use the term).22 There are several strategies for concept development; the Schwartz-Barcott and Kim23 hybrid model of concept development was chosen because it relies heavily on insights generated from clinical practice. The hybrid model integrates historical and research literature with a fieldwork component (i.e., the current study). A phenomenologichermeneutic methodology was selected to explore midwives’ experience of normalcy and to hear what meanings midwives attach to the concept.23 This article reports the findings of the phenomenologic component of the study. Participants with lived experience of the phenomenon of interest (i.e., midwives’ belief in normalcy during childbirth) possess rich understanding essential to phenomenologic research.24 This qualitative approach is well-suited to answering questions about an experience 208
best understood by those who have lived it. As Gadamer26 asserts, reflection on the lived experience of a phenomenon is the attempt to make meaning of the world and to make linkages between meaning and actions that are driven by meaning. The link between midwives’ lived experience of normalcy and their ensuing choices in clinical care drives the choice of this phenomenologic strategy. A two-step elite sampling strategy was used to purposefully identify potential participants.27 Directors of midwifery practices in the Midwest United States were contacted and asked to nominate midwives whose clinical care of laboring women demonstrated a strong commitment to normalcy in childbirth. Additional criteria for nomination included certification as a certified nurse-midwife (CNM) or certified midwife (CM), current membership in ACNM, graduate level preparation in midwifery, and at least 5 years of clinical practice. These criteria were used to narrow the focus of findings to this category of US midwives. Participants were purposively sought by practice site—hospital, freestanding birth center, and home—to account for the midwife’s latitude to direct care in congruence with her philosophical values and beliefs in a given setting. Nominees were contacted by correspondence to their practice address, the study was described, and those who agreed to participate returned a self-screening inclusion criteria checklist, a signed informed consent form, and a demographic and professional background survey. All documents and the interview guide had been piloted with five participants, debriefed with research colleagues, and revised for this study. One-to-one interviews lasting 60 to 75 minutes were obtained, recorded, transcribed verbatim, cleaned, checked, and entered into Atlas.ti 5.0, a data management and analysis software package.28 Each transcript was read in its entirety and then iteratively analyzed to identify units of meaning, which were then coded, clustered, and synthesized into overarching themes. Two series of analysis were conducted: 1) analysis across all participants, and 2) analysis within each practice setting category. Development of the study, the interview and analytic processes, and the researcher’s assumptions (bracketed and documented in multiple memos, creating the audit trail) were debriefed with a nonmidwife nurse researcher and a midwife researcher at multiple steps in the process. Participants were invited to review and respond to transcripts and preliminary and final findings. The Institutional Review Board of Vanderbilt University reviewed and approved this study, which was conducted in 2006 and 2007. RESULTS Twenty midwives were nominated; 13 (12 CNMs and one CM) completed all study procedures: five practiced in hospital settings, five in freestanding birth centers, and three in home birth practices. When compared to national descriptions, midwives in freestanding birth centers and home birth practices were overrepresented, and as a group, Volume 55, No. 3, May/June 2010
Table 1. Summary of Participant’s Demographic and Professional Experience Participant Characteristics Age, mean (range), y Years of clinical experience, mean (range), y
Overall Sample (N = 13)
Hospital Setting Participants (n = 5)
Freestanding Birth Center Setting Participants (n = 5)
Home Birth Practice Setting Participants (n = 3)
50.5 (39–60) 17.2 (7.5–24)
49.2 (42–53) 14.8 (8–23)
52.8 (43–60) 17.4 (12–22)
48.7 (39–59) 16.2 (7.5–24)
participants had more clinical experience than the average number of years in practice of ACNM members as a whole (Personal communication, ACNM membership department, November 2, 2006). Specific characteristics of the participants are shown in Tables 1 and 2. The findings of this study resulted in description of the concept of normalcy in childbirth, observable clinical events and processes that signify normalcy, and contextual factors that influence normalcy in women’s experiences that are referred to in this study as ‘‘dynamics.’’ The Concept of Normalcy in Childbirth Collectively, the midwives described normalcy in childbirth as 1) an expression of a complex physiologic–psychologic process along a wide, interpretive continuum, and includes both process and outcome; 2) meaningful within the context of the individual woman’s ‘‘nature,’’ which includes both her physiologic capacity to give birth and her unique life circumstances; and 3) sensitive and responsive to environmental factors. The midwives stipulated unanimously that normalcy in childbirth is grounded unequivocally on the well-being of the woman and her baby. Life circumstances included the woman’s culture and relationships and her unique life history.29 The midwives believed that a woman’s physiologic capacities interact with her life circumstances, in ways not yet well understood, and are simultaneously indivisible and influential. A midwife in a freestanding birth center captured how the woman’s ‘‘nature’’ is expressed in labor and birth: ‘‘Women tend to do childbirth however they tend to do the rest of their lives. So screamers will scream, whiners will whine, and hiders will hide, and the baby will come out. If they’re tired, then they’re tired.the baby will still come out.’’ The midwives recognized that many variations in childbirth could be and are interpreted as abnormal when using a narrow understanding of normalcy based on physiologic evidence alone and measured against population norms. After carefully ruling out pathophysiology, the midwives considered variations reflective of woman’s unique nature and not inevitably abnormal. The midwives were explicit that the woman’s experience is highly sensitive to her environment for labor and birth. The midwives collectively described a multidimensional continuum of physical and attitudinal contexts, primarily by clinical setting, that impact the woman’s caJournal of Midwifery & Women’s Health www.jmwh.org
pacity to cope. One end of this continuum was the woman’s home, her own domain of familiar people and unencumbered privacy and freedom, and the other was a large hospital maternity unit, where her behavioral freedom and social support were likely to be limited. The midwives considered attitudinal environment highly influential because clinical practice reflects providers’ values and beliefs about childbirth and drives care decisions in a given setting. The midwives believed the woman’s physiologic processes, unique nature, and the environmental factors to be highly interactive, and were confident that these interactions held significant explanatory power for how women’s experiences unfold. Rather than narrowly interpreting all physiologic variations as abnormalities, the midwives were willing to consider that psychologic and environmental influences also influence the woman’s experience. Dynamics Shaping Normalcy in Childbirth The midwives identified three dynamics that powerfully shape normalcy in childbirth: 1) the environment of care, 2) the midwife’s ‘‘knowing,’’ and 3) midwifery’s therapeutic lens. The term ‘‘dynamics’’ captures the forces that influence activity and change in a given sphere of interest, as well as relationships of power between people in a given situation. Description and elaboration of the dynamics influencing normalcy in childbirth appear in Table 3. The Environment of Care The midwives unanimously agreed that the biomedical model dominates the environment in US maternity care practice and the midwifery model of care is marginalized Table 2. Comparison of Participants With ACNM Membership Characteristicsa Characteristics Location of midwife-attended births, % Hospitals Freestanding birth centers Home Master’s degree, % Age, mean, y Midwifery clinical experience, mean, y
Participants ACNM Membership (N = 13) (N = 6200) 38 38 23 100 50.5 17.2
97 1.833 1 68 47.0 8.0
a
Membership data were current at the time of this study (2006). Sources: ACNM membership department data (Personal communication, ACNM membership department, November 2, 2006) and Martin et al.33
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Table 3. Dynamics Influencing Normalcy in Childbirth Dynamic Environment
Midwife’s knowing
Midwifery’s therapeutic lens
Components Prevailing model of care
a. Beliefs, attitudes, and values regarding surveillance and care procedures
The midwife’s degree of role autonomy
a. Flexibility, authoritative rationales for care; ‘‘who is the boss?’’ b. Clinical judgment regarding assessment and care processes
Clinical knowledge
a. Formal foundation in knowledge of physiologic, psychologic, and relational aspects of childbirth b. Extensive skills in assessment (vigilance)
Intuitive knowing
a. Perception experienced as ‘‘gut feeling’’ that has meaning for managing care b. The midwife’s confidence in the reliability of intuitive knowing
The midwife–woman relationship
a. Comprehension of the woman’s unique ‘‘nature’’ b. Degree of relational trust
Cumulative clinical experience
a. Duration and scope of clinical experience b. Reflective practice c. Confidence in the reliability of childbearing
Midwifery philosophy and values
a. Respect for the woman’s autonomy and expectations b. Shared decision-making c. Individualization of care
Midwifery education
a. Formal education b. Professional socialization c. Collegial care teams
as a ‘‘minority opinion.’’ They believed the care environment to be the most powerful dynamic shaping normalcy in childbirth, for the woman and for the midwife. One midwife noted the difference in her role between the freestanding birth center and the hospital: ‘‘Being in the hospital affects my independent role. I am not able to protect the ‘normal’ as well as I could over [in the birth center].’’ The Midwife’s Knowing The midwives constructed midwife’s knowing as the midwife’s comprehensive understanding of the individual woman’s labor and birth within the context of the midwife–woman relationship. Along with knowing the woman, the midwife’s continuous, systematic, and intuitive assessments provide reliable rationale for choosing facilitative care processes. The midwives agreed that knowing is most powerful when it synthesizes clinical knowledge and intuitive awareness; both are valued midwifery perspectives. A midwife in home birth practice described this balance: ‘‘Well, it’s part intuition and it’s part analytical. You take into your intuitive process all the background on that woman, all of what your gut is telling you about her, and your own sense of how much you trust yourself and your experience.’’ The midwives had a range of opinions about how the midwife–woman relationship influences normalcy. One end of 210
Aspects and Signifiers
this range was characterized by valuing a deep midwife– woman connection, the middle by balancing the midwife– woman relationship with confidence in the labor and birth process, and the opposite end by the midwife’s relying on the normalcy of the childbirth process, particularly when the midwife–woman relationship is not well established. The following quotes exemplify this range of opinion: ‘‘You get a feel for what her life is like, how she handles things, how she deals with the normal, usual, and everyday life stressors. It gives you something to go on when she comes in, in labor.’’ ‘‘Maybe because I’ve been in practice for a while now, I don’t feel I necessarily have to have a deep connection to take care of somebody, although I enjoy it. It might be harder if I don’t, but I just have to trust labor and birth. Whether you know her that well is less important, because most of the time, it’s going to turn out normal.’’ Midwifery’s Therapeutic Lens The midwives represented midwifery’s therapeutic lens as the unique perspective of midwifery care, based on midwifery education, cumulative clinical experience, and commitment to midwifery’s philosophy and values. Education results in a solid, formalized knowledge of physiology and related sciences, and skills favoring facilitative Volume 55, No. 3, May/June 2010
processes. Clinical experience includes the midwife’s understanding of how women’s labors and births may unfold, sophisticated clinical judgment about facilitative physiologic and psychologic care processes, and finely honed vigilance during the woman’s labor and birth. They believed that midwives’ tolerance of wide variations in labor and birth sets a high threshold for unequivocal pathology, and comes only from extensive experience. Two midwives expressed their understanding as follows: ‘‘You have to prove [emphasis sic] it to me, beyond a shadow of a doubt, that something isn’t normal.’’
ence was a freaking disaster.the baby died. The final line in her birth story is, ‘you can do everything right, and normal can include death.’ So we say, no provider or setting can promise you any given outcome’’ [emphasis added].
Empiric Referents
The midwives agreed that normalcy in childbirth is affirmed in midwifery’s philosophical values. Explicit values included the perception of childbirth as an inherently healthy process best accomplished by women’s innate capacities, respect for the woman’s autonomy, shared decision-making, and the midwife’s coordination of a safe and sensitive environment of care. The midwives unanimously valued individualized care, characterizing it as safe, flexible, requiring specific indications for interventions, and respectful of the woman’s needs and expectations. A hospital-based midwife expressed the importance of individualized care in this way:
The midwives identified five observable processes significantly associated with normalcy in childbirth, termed ‘‘empiric referents.’’30 These included the following processes: 1) spontaneous onset of labor; 2) spontaneous progress in labor; 3) spontaneous birth; 4) the woman’s effective coping with labor and birth; and 5) the woman’s freedom and capacity to do whatever she needs to do to give birth to her baby. The first three are somewhat measurable; the woman’s coping and her freedom and capacity to birth are more appropriately judgment calls. Elaboration of the empiric referents for normalcy in childbirth appears in Table 4. The midwives asserted that spontaneous labor onset, spontaneous progress in labor, and spontaneous birth are all highly associated with normalcy in childbirth. The midwives who practiced in freestanding birth centers and home birth practices put robust emphasis on the importance of these innate physiologic processes. One participant offered these observations about spontaneous labor onset:
‘‘When we have to change the plan, I try to think of what would be best for this woman, and this baby, in this labor at this time [emphasis sic]. I want to give the woman all the options and help her sort out what would be best for her and her baby.’’
‘‘When spontaneous labor occurs at the right time, with a healthy mom and baby, you have the best chance of having a normal birth. I think that’s critical.it’s critical.’’
‘‘Bottom line, that baby’s okay until it isn’t, it’s going to come out until it doesn’t, and that labor is normal until it’s not.’’
A freestanding birth center midwife boldly characterized the philosophical valuing of individualized care: ‘‘The difference [in settings] is ‘who is your boss?’ The ‘boss’ for the midwife is the mom, not the institution, the obstetrician, the timeline or the protocol.’’ Within the dynamic of midwifery’s therapeutic lens, the midwives acknowledged the possibility of injury or death, a significant finding in a study of normalcy in childbirth. Death or injury occurs, even when all available capabilities are used in a timely and appropriate manner. They were clear that midwives are deeply concerned about poor outcomes and strive to avoid these possibilities, yet recognize that there are practical limitations of health care capabilities. A midwife in a freestanding birth center offered the following poignant scenario: ‘‘We really do believe that Nature loves her babies; we are also very aware of the fact that Nature doesn’t particularly care about the individual woman or baby, so we have to pay attention. The saddest story was of a mom whose whole experiJournal of Midwifery & Women’s Health www.jmwh.org
‘‘Every baby has its own little ‘pop-up timer’ for when it’s done. We just wait for that.’’ The midwives favored a broad interpretation of progress in labor, differing from the conventional criterion of progressive cervical dilatation. Any evidence of progress, such as effacement changes, firmer application of the vertex to the cervix, favorable adjustments of the fetal position, a bit of descent, or improved quality of contractions, was accepted. The midwives ‘‘uncoupled’’ labor progress from rigid timeframes; those in out-of-hospital settings were more likely to favor flexible timeframes and functional laboring and pushing efforts, rather than those ‘‘on the clock.’’ The midwives strongly supported spontaneous vaginal birth as an empiric referent for normalcy. They understood ‘‘spontaneous’’ as the birth of the baby accomplished solely under the woman’s own physiologic and psychologic powers. The midwives did not address vaginal birth under regional anesthesia or other medications, but were clear that forceps or vacuum extraction were not part of ‘‘spontaneous’’ vaginal birth. 211
Table 4. Empiric Referents for the Concept of Normalcy in Childbirth Empiric Referent
Characteristics
Observable Phenomena
Spontaneous onset of labor
Physiologic and psychologic readiness Intrinsic physiologic reliability
Spontaneous progress in labor
Functional progress in labor Absence of augmentation
Spontaneous vaginal birth
Intrinsic, adaptive, and expulsive power
The woman’s effective coping
Multidimensional and unique to the woman’s nature Coping strategies appear consistent with the woman’s unique nature The woman’s understanding of childbirth as a reliable and healthy process Willingness to ‘‘take on’’ the process
The woman’s freedom and capacity to give birth
The midwives endorsed the woman’s effective coping with childbirth and her freedom and capacity to give birth as important components of normalcy. They agreed that women’s effective coping strategies manifest along a wide continuum, include both physiologic and psychologic adaptations, and, again, are consistent with her unique nature. The midwives believed that effective coping is the woman’s adaptation to labor in ways that support progress. The midwives linked the woman’s remaining ‘‘in control’’ with her sense of safety, and not to any judgment about her personal coping behavior. A midwife in a home birth practice described it this way:
Signs and symptoms of labor onset Absence of intentional stimulation: sexual activity, castor oil or other substance ingestion, nipple stimulation, stripping membranes, prostaglandins, misopristol, oxytocin, or amniotomy Physiologic progression Adaptive behavioral signs and symptoms of progressive labor Any form of progressive anatomic/physiologic change that favors vaginal birth Vaginal birth of a healthy baby accomplished solely under the woman’s powers Absence of instrumental interventions Coping strategies are adaptive and promote progress in labor Adaptive coping manifests spontaneously (not directed by provider) Mobility, privacy, minimal encumbrances, supportive measures, and people Instinctive mammalian responses to childbirth (i.e., altered state and/or disinhibition)
‘‘The fact is, monitoring tends to restrict [the woman] not only to the bed, but also in her mind.’’ Three midwives in nonhospital settings linked the woman’s freedom and capacity to ‘‘unlearning’’ social and cognitive approaches to childbirth. The woman with capacity to experience this very mammalian process in an uninhibited, instinctual way greatly enhances her possibility of a normal childbirth. A midwife in a freestanding birth center described how she viewed the link between instinctual freedom and normal birth:
‘‘This is her artistry in labor, her variation on a scene. It’s appreciating the way each woman copes or doesn’t, and how to help her know her own strength, and feel the sense of her childbirth.’’
‘‘We tell them over and over again, ‘The baby is going to come out, just like all other mammals. And your mind, if it’s willing, will be able to help it instead of get in its way.’ Nature has a well-designed way, if the woman can get her head out of the process.’’
The midwives believed that the woman’s freedom and capacity to ‘‘do whatever she needs to do to give birth to her baby’’ benefited from physical freedom, an attitudinal environment that expresses confidence in the woman, and psychological capacities within the woman herself. The midwives in freestanding birth centers and home birth practices supported this more emphatically than those in hospital settings. Physical freedom included adequate space to move about, privacy, minimal physical encumbrances (such as intravenous lines and monitoring equipment), availability of supportive measures, and accommodation of the woman’s preferred social support. A hospital-based midwife commented:
The midwives also believed that freedom and capacity in childbirth are interdependent: a restrictive environment for labor and birth may correlate with the woman experiencing decreased freedom and capacity and less willingness to resort to instinctual behaviors in labor. The findings of this concept development study affirm that normalcy in childbirth is a valid and valued concept in midwifery practice, and plays a critical role in decision-making during labor and birth care. The concept of normalcy in childbirth possesses attributes that are discernible to assessment and clinical judgment and sensitive to clinical management. How the woman’s birth process expresses normalcy is highly individual to the woman,
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Figure 1. Midwives’ construction of the concept of normalcy in childbirth.
and her experience is sensitive and responsive to dynamics shaping her labor and birth. A graphic representation of the concept of normalcy in childbirth as experienced by midwives appears in Figure 1. DISCUSSION This study formally describes the concept of normalcy in childbirth as understood by experienced midwives with a demonstrably strong commitment to childbirth care that reflects their confidence and belief that childbearing is a healthy life process. Valuing normalcy in childbirth performs a critical role in midwives’ clinical assessment, decision-making, and care processes. It may be challenged, compromised, or supported in given practice environments. Its attributes are multidimensional yet discernible in clinical care. This concept development of normalcy in childbirth harmonizes more readily with van Deventer’s3 therapeutic approach of relying on and facilitating women’s physiologic capabilities in childbirth than it does with early modern midwives’ conservative stance of ‘‘waiting on nature.’’3 Contemporary midwifery practice benefits from a synthesis of formal knowledge and clinical experience. In practice, midwives base management decisions on the reliability Journal of Midwifery & Women’s Health www.jmwh.org
of childbearing as a healthy process, differing from the obstetric view that childbearing is an unpredictable and dangerous physiologic process. These midwives understand that childbearing is more complex than the physiology of muscles, bones, chemicals and ‘‘powers’’—it is a complex, holistic process that is highly sensitive to the woman’s life circumstances and the environment of care. These midwives viewed childbirth as widely variable in nonpathologic ways. They appreciated interactions between the woman’s physiology and her unique life circumstances—recognized but not well understood—that manifest across a broad continuum. Deep understanding of physiology and coping, extensive clinical experience, and commitment to midwifery’s philosophical values were identified as essential to discerning differences between healthy, individualized variations and real or potential pathological developments during labor and birth. These findings positioning normalcy as a core concept in midwifery theory development affirm and extend the theoretical work of Lehrman8 and Thompson et al.9 Lehrman’s concept of ‘‘positive presence’’ as belief in the normal processes of childbirth and extensive knowledge and experience in care of laboring women resonates with the dynamics of the midwife’s knowing and midwifery’s therapeutic lens articulated by the participants in this study. 213
Thompson et al.’s descriptor of ‘‘health promoting’’ links ‘‘naturalness’’ of childbearing with the inherent reliability of childbearing and aligns with the midwifery’s therapeutic lens dynamic found in this study. Confidence in normalcy in childbirth and recognition of a continuum of variations extend Kennedy’s10,11 dimension of therapeutics, linking belief in normalcy with processes of care that support normalcy in childbirth. The current study expands understanding of this linkage by making explicit midwives’ preferences for assessment, decision-making, and choice of care processes, identified as midwifery’s therapeutic lens. The dynamic of environment, particularly the attitudinal environment as a powerful influence in shaping women’s childbearing experiences, further supports Kennedy et al.’s31,32 work on the midwife’s role in shaping the landscape of care to promote normalcy in childbirth. Regarding Gould’s15 concept analysis of normal labor, the empiric referents found in the current study differ in substance yet are congruent in spirit. The current study concurs with Gould’s analysis that normalcy in childbirth is sensitive, dynamic and sequential, and culminates in spontaneous birth. Gould’s assertion that conceptual development has focused on physiologic parameters of childbirth is addressed in this study, by expanding beyond the physiologic focus to include the multidimensional and individualized nature of a woman’s experience as inherent to normalcy in childbirth.15 The empiric referents for normalcy in childbirth identified in this study are problematic at this early stage because there is no consensus regarding their precise definitions. Spontaneous onset and progress in labor and spontaneous birth are not yet operationally defined and therefore lack theoretical utility. The woman’s effective coping and her freedom and capacity to give birth are discernible but open to wide interpretation. Experienced midwives may conclude that the woman’s effective coping efforts support physiologic labor and birth and her instinctive responses may be adaptive, but these referents are not yet well understood or measurable. The midwives’ convictions about the concept’s importance to the profession have significant implications for professional midwifery. Practicing midwives may well recognize this description of normalcy in childbirth. For midwives in contested clinical environments, articulating concise conceptual descriptors may fortify the case for care processes that facilitate normalcy, and rationalize care management decisions that build support for a broader interpretation of labor variations. As a clarified concept, normalcy in childbirth reinforces the efficacy of flexible, individualized care. The midwives’ affirmation that nonphysiologic factors influence the course of a woman’s labor and birth opens the possibility of exploratory care processes rather than prescriptive ones. This study offers specific descriptors that clarify the concept of normalcy and supports midwifery education and socialization to that end. Specific descriptors move the ed214
ucational dialogue from ‘‘normalcy in childbirth is like.’’ to ‘‘normalcy is..’’ Educators may incorporate these findings to help learners grasp the concept of normalcy in midwifery practice. The midwives in this study emphasized the importance of extensive clinical experience to formation of belief in normalcy, reinforcing the importance of midwifery educators’ ongoing and often arduous efforts to acquire rich clinical experiences for their learners. This study has several limitations. The voices of the participant midwives may not be representative of the profession as a whole; trustworthiness must be determined by midwives and others who view these findings as authentic. Two categories of clinical sites were overrepresented in the selection of participants, and participants had on average more clinical experience than the average ACNM member. Membership in ACNM was selected as an inclusion criterion to focus on a particular category of midwives; the study would be strengthened by the inclusion of voices of other types of midwives and wider geographic participation. There are several potential research opportunities posed by the findings of this study. Promising research efforts may include elucidation of midwives’ decision-making processes when driven by strong commitment to normalcy, further development of empiric referents into a clinically applicable tool, and investigation of role autonomy in midwifery practice. Understanding how childbearing women view the nature of childbirth would contribute to continuous alignment of maternity care with women’s expectations. Exploration of other maternity care providers’ understanding of normalcy in childbirth may also improve interdisciplinary work environments, enhance approbation of the midwifery model of care, and affirm linkages between facilitative care processes and favorable outcomes. That these midwives perceived the woman being ‘‘in control’’ to be more about the woman’s sense of safety and not her personal coping behavior is another intriguing and potentially fruitful line of inquiry. As an exploratory study, this project establishes a more precise description of normalcy as these midwives experience the concept, but comparison to understandings of childbearing women and other maternity care providers remains, to fully clarify its importance and significance to society’s expectations of maternity care. CONCLUSION This study raises questions about how accurately the concept that midwives know as ‘‘normalcy’’ is determined. The concept of normalcy emerged from statistical science, and to assert that childbirth is normal is to generalize population-based parameters and descriptors to the experience of a unique laboring woman. This narrow construction may disadvantage the woman’s experience, should her unique labor and birth deviate from narrowly constructed parameters. In addition, a statistical understanding of Volume 55, No. 3, May/June 2010
normalcy may conflict with individualized care, the unique midwife–woman relationship, and the unique nature of the childbearing woman. Moreover, women require support for unlearning the medical discourse of childbearing and re-envisioning their life processes as healthy and reliable; this is a significant challenge, because the majority of women currently experience medically managed childbearing. Midwives will rightly continue to promote and protect broad interpretations of normalcy in childbirth, strive to enact it in clinical practice, and incorporate these findings to build women’s confidence and capacity to ‘‘do whatever they need to do to give birth.’’ This concept development of midwives’ belief in normalcy affirms and describes the defining value of the midwifery model of care and offers further opportunities for theory development linking the midwifery model of care to childbearing processes and outcomes. Supported in part by the L. Newton Long Award for the Advancement of Midwifery from the American College of Nurse-Midwives Foundation, Inc. The author would like to thank the midwives who participated in this study for their time, insights, and willingness to wrestle with this concept. The author also thanks Kathleen Dwyer, RN, PhD, and Holly Kennedy, CNM, PhD.
REFERENCES 1. American College of Nurse-Midwives. Philosophy of the American College of Nurse-Midwives. Washington, DC: American College of Nurse Midwives; 2004.
13. Kennedy HP, Shannon MT, Chuahorm U, Dravitz MK. The landscape of caring for women: A narrative study of midwifery care. J Midwifery Womens Health 2004;49:14–23. 14. Kennedy HP, Shannon MT. Keeping birth normal: Research findings on midwifery care during childbirth. J Obstet Gynecol Neonatal Nurs 2004;33:554–60. 15. Gould D. Normal labour: A concept analysis. J Adv Nurs 2000;31:418–27. 16. Hunter LP. A hermeneutic phenomenological analysis of midwives’ ways of knowing during childbirth. Midwifery 2008; 24:405–15. 17. Hunter LP. A descriptive study of ‘‘being with woman’’ during labor and birth. J Midwifery Womens Health 2009;54:111–8. 18. American College of Nurse-Midwives. Philosophy of the American College of Nurse-Midwives. Washington, DC: American College of Nurse-Midwives, 1983. 19. Cragin L. The theoretical basis for nurse-midwifery practice in the United States: A critical analysis of three theories. J Midwifery Womens Health 2004;49:381–9. 20. Rodgers BL, Knafl KA, editors. Concept development in nursing: Foundations, techniques, and applications, 2nd ed. Philadelphia: W.B. Saunders Company, 2000. 21. Meleis AI. Theoretical nursing: Development and progress, 3rd ed. Philadelphia: Lippincott-Raven Publishers, 1997. 22. Kim H. The nature of theoretical thinking in nursing, 2nd ed. New York: Springer Publishers, 2000.
2. Arney WR. Power and the profession of obstetrics. Chicago: University of Chicago Press, 1982.
23. Schwartz-Barcott D, Kim HS. An expansion and elaboration of the hybrid model of concept development. In: Rodgers BL, Knafl KA, editors. Concept development in nursing: foundations, techniques, and applications, 2nd ed. Philadelphia: W.B. Saunders Company, 2000.
3. van Deventer H. New improvements in the art of midwifery. Translated from Operationes chirurgicae, novum lumen exhibentes obstetricantibus (Leyden, 1701). London: T. Warner, 1724.
24. Cohen MZ, Kahn DL, Steeves RH. Hermeneutic phenomenological research: A practical guide for nurse researchers. Thousand Oaks, CA: Sage Publications, 2000.
4. Warner JH. The therapeutic perspective: Medical practice, knowledge, and identity in America, 1820–1885. Princeton, NJ: Princeton University Press, 1997.
25. Denzin NK, Lincoln YS, editors. Handbook of qualitative research, 2nd ed. Thousand Oaks, CA: Sage Publications, 2000.
5. Stigler SM. History of statistics: The measurement of uncertainty before 1900. Cambridge, MA: Harvard University Press, 1990. 6. Witz A. Professions and patriarchy. London: Routledge & Kegan Paul, 1992. 7. Ettinger LE. Nurse-midwifery: The birth of a new American profession. Columbus, OH: Ohio State University Press, 2006. 8. Lehrman EJ. A theoretical framework for nurse-midwifery practice [dissertation]. Tucson, AZ: University of Arizona, 1988. 9. Thompson JE, Oakley D, Burke M, Jay S, Conklin M. Theory building in nurse-midwifery. The care process. J Nurse Midwifery 1989;34:120–30. 10. Kennedy HP. Linking midwifery practice to outcomes: A Delphi study [dissertation]. Kingston, RI: University of Rhode Island, 1999.
26. Gadamer HG. Truth and method, 2nd ed. (Weinsheimer J, Marshall DG, trans). New York: Crossroads Press, 1989. 27. Patton MQ. Qualitative research and evaluation methods, 3rd ed. Thousand Oaks, CA: Sage Publications, 2002. 28. Atlas.ti Web site. Atlas.ti features overview. Available from: www.atlasti.com/features.html [Accessed July 26, 2009]. 29. Kaplan HB, editor. Psychosocial stress: Perspectives on structure, theory, life-course, and methods. San Diego: Academic Press, 1996. 30. Walker LO, Avant KC. Strategies for theory construction in nursing, 4th ed. Upper Saddle River, NJ: Prentice Hall Publishers, 2004. 31. Kennedy HP, MacDonald E. Altered consciousness in childbirth. J Midwifery Womens Health 2002;47:380–3.
11. Kennedy HP. A model of exemplary midwifery practice: Results of a Delphi study. J Nurse Midwifery 2000;45:4–19.
32. Kennedy HP, Shannon MT, Chuahorm U, Dravitz MK. The landscape of caring for women: A narrative study of midwifery care. J Midwifery Womens Health 2004;49:14–23.
12. Kennedy HP, MacDonald E. The midwife as an ‘‘instrument of care.’’ Am J Public Health 2002;92:1759–60.
33. Martin JA, Hamilton BE, Sutton PD. Births: Final data for 2003. Natl Vital Stat Rep 2005;54:2.
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INTRODUCTION
HISTORICAL BACKGROUND
The concept of normalcy is a philosophical mainstay of the midwifery model of care, and provides rationale for care processes and a powerful explanation for favorable outcomes. The American College of Nurse-Midwives (ACNM) Philosophy positions normalcy as fundamental to US midwifery’s disciplinary identity.1 For midwifery, the concept of normalcy characterizes the essential nature of women’s life processes as healthy, particularly during pregnancy and childbirth. However, valuing normalcy does not provide descriptive or explanatory linkages between midwifery management of care and actual outcomes. An experienced midwife may assert that she/he ‘‘knows normal’’ when she/he sees it and can provide a rationale for specific care processes while caring for a woman in labor because ‘‘everything is proceeding normally.’’ Like-minded others will grasp immediately what she/he means, but would be hard-pressed to actually define what is normalcy. Exploration of this concept may contribute further understanding of linkages between how midwives practice and how midwifery care achieves favorable outcomes.
To consider the concept of normalcy in childbirth, it is useful to review historical perceptions of childbirth. Three noteworthy themes regarding the nature of childbirth emerge: 1) traditional midwives’ experiential knowledge for ‘‘waiting on nature,’’ an essentially conservative stance; 2) obstetric thinking favoring active intervention in the natural process of labor; and 3) van Deventer’s reliance on facilitative processes and restrained intervention (i.e., ‘‘facilitating nature’’). In the early 18th century, two important developments emerged to dramatically alter the customary childbirth care of midwives. The first was the obstetric forceps, which made possible active intervention to override obstructed or prolonged labors.2 The second was Henrick van Deventer’s therapeutic approach to facilitate expulsive forces in overcoming resistive forces during childbirth.3 van Deventer, an obstetric surgeon at The Hague, developed a scientific approach that combined knowledge of obstetric anatomy and physiology with extensive experience of normal labor. It is reasonable to conclude that contemporary midwifery practice is most consistent with van Deventer’s approach—using scientific knowledge to facilitate physiologic labor and birth, rather than overriding labor and birth processes unless indicated. A parallel development of the 19th century—demographic statistical analysis—added new perspective to
Address correspondence to Jo Anne P. Davis, CNM, PhD, Department of Nursing, School of Nursing and Health Studies, Georgetown University, 417 St. Mary’s Hall, 3700 Reservoir Rd. NW, Washington, DC 20057. E-mail: [email protected]
206 Ó 2010 by the American College of Nurse-Midwives Issued by Elsevier Inc.
Volume 55, No. 3, May/June 2010 1526-9523/$36.00 doi:10.1016/j.jmwh.2009.12.007
medical care, shifting the focus of therapeutics from individuals to populations. The notion of the ‘‘average man’’ emerged, was statistically defined, and was increasingly applied to social and then medical phenomena. In medical circles, there was intense debate about the value of population-based analyses in determining therapeutic efficacy.4 Proponents argued that statistical analysis was the foundation of ‘‘scientific observation’’ and the new hallmark of medical thinking. Conservative physicians insisted that the physician’s insight into the individual was more important in choosing therapeutics, a concept that has been incorporated into contemporary midwifery practice. Statistical caseload analyses set parameters for the average course of ‘‘natural’’ childbirth and the analytic terminology of ‘‘normal’’ and ‘‘abnormal’’ entered obstetric discourse.5 At the turn of the 20th century, population-based descriptors were well incorporated in medical practice and exercised occupational jurisdiction in defining the role of the ‘‘new midwife.’’6 This feature was the margin between normal and abnormal childbirth and defined midwifery’s boundaries of care.7 THEORETICAL BACKGROUND Theoretical descriptions of the midwifery model of care have appeared in the United States only in the last 20 years. The concept of normalcy is explicitly identified in the works of Lehrman,8 Thompson et al.,9 Kennedy,10,11 and Kennedy and MacDonald,12 Kennedy et al.,13 and Kennedy and Shannon.14 Gould15 reported a classic concept analysis of normal labor. Hunter reports that normalcy in childbirth is found in midwives’ ‘‘self-knowledge,’’ which she defined as ‘‘the midwife’s belief in what she knows, knowing what she believes and acting upon those beliefs.’’16 All are drawn on principles articulated in the ACNM Philosophy.1 Collectively, these studies have advanced descriptive concepts and frameworks for the midwifery model of care that are largely congruent and reflect the current theoretical development in midwifery. Lehrman8 defined ‘‘positive presence’’ in midwifery care as ‘‘the degree to which the nurse-midwife applies scientific processes of care in a manner promoting the normal and natural processes of labor and birth. This descriptor, as well as the humanistic art of caring, is observable in clinical decision-making.’’ Lehrman located the midwife’s belief in normalcy within positive presence; the concept of normalcy was minimally elaborated.8 Hunter17 elaborated on Lehrman’s work on positive presence in an analysis of ‘‘being with woman’’ and its beneficial effects on labor and birth physiologic outcomes. Jo Anne P. Davis, CNM, PhD, is Assistant Professor, Midwifery Tutor, and Assistant Chair for Education and Practice in the Department of Nursing, School of Nursing and Health Studies, Georgetown University, Washington, DC. Dr. Davis received her BS in Nursing at the University of Cincinnati, her MS in Midwifery at St. Louis University, and her PhD in Nursing Science at Vanderbilt University.
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Thompson et al.9 undertook a theoretical description of the process of nurse-midwifery care. Six descriptors derived from the ACNM Philosophy were identified, including ‘‘health promoting.’’18 The authors defined health promoting as ‘‘those actions that encourage behaviors conducive to the woman’s well-being throughout her life cycle and specifically promote the naturalness of pregnancy and birth.’’9 These descriptor concepts were further refined and clustered into the ethical concepts of competence, compassion, and covenant fidelity; the concept of normalcy is positioned within covenant fidelity.9 Kennedy developed a model of exemplary midwifery practice, and put forward three ‘‘dimensions’’: therapeutics, caring, and the profession. Kennedy’s dimension of therapeutics explores how the exemplary midwife chooses care processes that support normalcy; belief in normalcy and vigilance were the two critical concepts of exemplary midwifery care. Kennedy10,11 described how exemplary midwives actively model that childbirth is a normal process and tolerate wide variations in labor while simultaneously attending to the safety of the woman and baby. Kennedy summarized participants’ views of normalcy in childbirth as follows: ‘‘The midwives repeatedly articulated the process of supporting the normalcy of birth [emphasis added]. This included judicious and appropriate use of technology, intervening only if necessary, not hurrying the birth process, personalizing care, and using a wide array of options and resources (rather than one in particular) to assist the woman and/or her family. (The midwife) [sic] understands that birth can be trusted and is patient with, and positive about, the process.’’10 Cragin conducted a critical analysis of Lehrman,8 Thompson et al.,9 and Kennedy10,11 that also verified belief in normalcy as a primary aspect and process of midwifery care.19 Cragin19 states that the theoretical development in midwifery consistently identifies ‘‘protection and nurturance of the ‘normal’ in processes related to women’s health, implying a judicious use of technology and intervention.’’ In addition, Cragin concludes that theory development in midwifery must extend beyond physiologic processes and outcomes, to encompass women’s minds, bodies, and the context of their life experiences.19 In a concept analysis of normal labor, Gould15 rightly points out that theoretical parameters that define normal labor are problematic because midwives believe the woman’s perception of her experience must be taken into account. Providers’ interpretation of a woman’s childbirth may not agree with the woman’s own interpretation of her experience.15 Gould15 emphasizes that theorists have focused almost exclusively on the physiologic parameters of normalcy in childbirth valued by the obstetric perspective, to the general exclusion of other factors, such as 207
relationships, culture, and social contexts. Arguing for integration of nonphysiologic aspects, Gould characterized normal labor to include its sensitive, dynamic, and sequential pattern; its strenuous and productively painful nature; and the sequential movements that culminate in spontaneous birth of the baby and placenta.15 BACKGROUND The historical and theoretical reviews support the concept of midwives’ belief in normalcy as the core characteristic of the midwifery model of care. While significant theoretical work has developed descriptions of the midwifery model of care, normalcy as a scientific concept that helps to explain links between midwifery’s approach to care and associated outcomes has yet to be developed. The purpose of this study was to describe and define the concept of normalcy as the critical characteristic of the midwifery model of care, in a specified category of midwives. As a discrete clinical context for the study, care of women during labor and birth forms the context for exploration of midwives’ belief in normalcy. METHODS Description of the concept of normalcy indicates the study is a concept development project. Rodgers and Knafl20 state that the purpose of concept development is ‘‘to clarify the current use of a concept with attention to contextual and temporal aspects (and) provide a clear conceptual foundation as a (means) for further inquiry.’’ Concept development is indicated when a generally familiar concept requires fresh analysis because it has come to lack clear, conscious, and defined parameters, properties, or meanings.21 In midwifery, the concept of normalcy in its current form may be characterized in this way: ‘‘the only way to ‘define’ (the concept) is to point out instances of the concept and instances of ‘notthe-concept’ so that another can experience the sensory impressions [emphasis added] associated with the concept.’’ The most important feature of a concept is its intersubjective agreement (i.e., the degree of agreement about the concept among those who use the term).22 There are several strategies for concept development; the Schwartz-Barcott and Kim23 hybrid model of concept development was chosen because it relies heavily on insights generated from clinical practice. The hybrid model integrates historical and research literature with a fieldwork component (i.e., the current study). A phenomenologichermeneutic methodology was selected to explore midwives’ experience of normalcy and to hear what meanings midwives attach to the concept.23 This article reports the findings of the phenomenologic component of the study. Participants with lived experience of the phenomenon of interest (i.e., midwives’ belief in normalcy during childbirth) possess rich understanding essential to phenomenologic research.24 This qualitative approach is well-suited to answering questions about an experience 208
best understood by those who have lived it. As Gadamer26 asserts, reflection on the lived experience of a phenomenon is the attempt to make meaning of the world and to make linkages between meaning and actions that are driven by meaning. The link between midwives’ lived experience of normalcy and their ensuing choices in clinical care drives the choice of this phenomenologic strategy. A two-step elite sampling strategy was used to purposefully identify potential participants.27 Directors of midwifery practices in the Midwest United States were contacted and asked to nominate midwives whose clinical care of laboring women demonstrated a strong commitment to normalcy in childbirth. Additional criteria for nomination included certification as a certified nurse-midwife (CNM) or certified midwife (CM), current membership in ACNM, graduate level preparation in midwifery, and at least 5 years of clinical practice. These criteria were used to narrow the focus of findings to this category of US midwives. Participants were purposively sought by practice site—hospital, freestanding birth center, and home—to account for the midwife’s latitude to direct care in congruence with her philosophical values and beliefs in a given setting. Nominees were contacted by correspondence to their practice address, the study was described, and those who agreed to participate returned a self-screening inclusion criteria checklist, a signed informed consent form, and a demographic and professional background survey. All documents and the interview guide had been piloted with five participants, debriefed with research colleagues, and revised for this study. One-to-one interviews lasting 60 to 75 minutes were obtained, recorded, transcribed verbatim, cleaned, checked, and entered into Atlas.ti 5.0, a data management and analysis software package.28 Each transcript was read in its entirety and then iteratively analyzed to identify units of meaning, which were then coded, clustered, and synthesized into overarching themes. Two series of analysis were conducted: 1) analysis across all participants, and 2) analysis within each practice setting category. Development of the study, the interview and analytic processes, and the researcher’s assumptions (bracketed and documented in multiple memos, creating the audit trail) were debriefed with a nonmidwife nurse researcher and a midwife researcher at multiple steps in the process. Participants were invited to review and respond to transcripts and preliminary and final findings. The Institutional Review Board of Vanderbilt University reviewed and approved this study, which was conducted in 2006 and 2007. RESULTS Twenty midwives were nominated; 13 (12 CNMs and one CM) completed all study procedures: five practiced in hospital settings, five in freestanding birth centers, and three in home birth practices. When compared to national descriptions, midwives in freestanding birth centers and home birth practices were overrepresented, and as a group, Volume 55, No. 3, May/June 2010
Table 1. Summary of Participant’s Demographic and Professional Experience Participant Characteristics Age, mean (range), y Years of clinical experience, mean (range), y
Overall Sample (N = 13)
Hospital Setting Participants (n = 5)
Freestanding Birth Center Setting Participants (n = 5)
Home Birth Practice Setting Participants (n = 3)
50.5 (39–60) 17.2 (7.5–24)
49.2 (42–53) 14.8 (8–23)
52.8 (43–60) 17.4 (12–22)
48.7 (39–59) 16.2 (7.5–24)
participants had more clinical experience than the average number of years in practice of ACNM members as a whole (Personal communication, ACNM membership department, November 2, 2006). Specific characteristics of the participants are shown in Tables 1 and 2. The findings of this study resulted in description of the concept of normalcy in childbirth, observable clinical events and processes that signify normalcy, and contextual factors that influence normalcy in women’s experiences that are referred to in this study as ‘‘dynamics.’’ The Concept of Normalcy in Childbirth Collectively, the midwives described normalcy in childbirth as 1) an expression of a complex physiologic–psychologic process along a wide, interpretive continuum, and includes both process and outcome; 2) meaningful within the context of the individual woman’s ‘‘nature,’’ which includes both her physiologic capacity to give birth and her unique life circumstances; and 3) sensitive and responsive to environmental factors. The midwives stipulated unanimously that normalcy in childbirth is grounded unequivocally on the well-being of the woman and her baby. Life circumstances included the woman’s culture and relationships and her unique life history.29 The midwives believed that a woman’s physiologic capacities interact with her life circumstances, in ways not yet well understood, and are simultaneously indivisible and influential. A midwife in a freestanding birth center captured how the woman’s ‘‘nature’’ is expressed in labor and birth: ‘‘Women tend to do childbirth however they tend to do the rest of their lives. So screamers will scream, whiners will whine, and hiders will hide, and the baby will come out. If they’re tired, then they’re tired.the baby will still come out.’’ The midwives recognized that many variations in childbirth could be and are interpreted as abnormal when using a narrow understanding of normalcy based on physiologic evidence alone and measured against population norms. After carefully ruling out pathophysiology, the midwives considered variations reflective of woman’s unique nature and not inevitably abnormal. The midwives were explicit that the woman’s experience is highly sensitive to her environment for labor and birth. The midwives collectively described a multidimensional continuum of physical and attitudinal contexts, primarily by clinical setting, that impact the woman’s caJournal of Midwifery & Women’s Health www.jmwh.org
pacity to cope. One end of this continuum was the woman’s home, her own domain of familiar people and unencumbered privacy and freedom, and the other was a large hospital maternity unit, where her behavioral freedom and social support were likely to be limited. The midwives considered attitudinal environment highly influential because clinical practice reflects providers’ values and beliefs about childbirth and drives care decisions in a given setting. The midwives believed the woman’s physiologic processes, unique nature, and the environmental factors to be highly interactive, and were confident that these interactions held significant explanatory power for how women’s experiences unfold. Rather than narrowly interpreting all physiologic variations as abnormalities, the midwives were willing to consider that psychologic and environmental influences also influence the woman’s experience. Dynamics Shaping Normalcy in Childbirth The midwives identified three dynamics that powerfully shape normalcy in childbirth: 1) the environment of care, 2) the midwife’s ‘‘knowing,’’ and 3) midwifery’s therapeutic lens. The term ‘‘dynamics’’ captures the forces that influence activity and change in a given sphere of interest, as well as relationships of power between people in a given situation. Description and elaboration of the dynamics influencing normalcy in childbirth appear in Table 3. The Environment of Care The midwives unanimously agreed that the biomedical model dominates the environment in US maternity care practice and the midwifery model of care is marginalized Table 2. Comparison of Participants With ACNM Membership Characteristicsa Characteristics Location of midwife-attended births, % Hospitals Freestanding birth centers Home Master’s degree, % Age, mean, y Midwifery clinical experience, mean, y
Participants ACNM Membership (N = 13) (N = 6200) 38 38 23 100 50.5 17.2
97 1.833 1 68 47.0 8.0
a
Membership data were current at the time of this study (2006). Sources: ACNM membership department data (Personal communication, ACNM membership department, November 2, 2006) and Martin et al.33
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Table 3. Dynamics Influencing Normalcy in Childbirth Dynamic Environment
Midwife’s knowing
Midwifery’s therapeutic lens
Components Prevailing model of care
a. Beliefs, attitudes, and values regarding surveillance and care procedures
The midwife’s degree of role autonomy
a. Flexibility, authoritative rationales for care; ‘‘who is the boss?’’ b. Clinical judgment regarding assessment and care processes
Clinical knowledge
a. Formal foundation in knowledge of physiologic, psychologic, and relational aspects of childbirth b. Extensive skills in assessment (vigilance)
Intuitive knowing
a. Perception experienced as ‘‘gut feeling’’ that has meaning for managing care b. The midwife’s confidence in the reliability of intuitive knowing
The midwife–woman relationship
a. Comprehension of the woman’s unique ‘‘nature’’ b. Degree of relational trust
Cumulative clinical experience
a. Duration and scope of clinical experience b. Reflective practice c. Confidence in the reliability of childbearing
Midwifery philosophy and values
a. Respect for the woman’s autonomy and expectations b. Shared decision-making c. Individualization of care
Midwifery education
a. Formal education b. Professional socialization c. Collegial care teams
as a ‘‘minority opinion.’’ They believed the care environment to be the most powerful dynamic shaping normalcy in childbirth, for the woman and for the midwife. One midwife noted the difference in her role between the freestanding birth center and the hospital: ‘‘Being in the hospital affects my independent role. I am not able to protect the ‘normal’ as well as I could over [in the birth center].’’ The Midwife’s Knowing The midwives constructed midwife’s knowing as the midwife’s comprehensive understanding of the individual woman’s labor and birth within the context of the midwife–woman relationship. Along with knowing the woman, the midwife’s continuous, systematic, and intuitive assessments provide reliable rationale for choosing facilitative care processes. The midwives agreed that knowing is most powerful when it synthesizes clinical knowledge and intuitive awareness; both are valued midwifery perspectives. A midwife in home birth practice described this balance: ‘‘Well, it’s part intuition and it’s part analytical. You take into your intuitive process all the background on that woman, all of what your gut is telling you about her, and your own sense of how much you trust yourself and your experience.’’ The midwives had a range of opinions about how the midwife–woman relationship influences normalcy. One end of 210
Aspects and Signifiers
this range was characterized by valuing a deep midwife– woman connection, the middle by balancing the midwife– woman relationship with confidence in the labor and birth process, and the opposite end by the midwife’s relying on the normalcy of the childbirth process, particularly when the midwife–woman relationship is not well established. The following quotes exemplify this range of opinion: ‘‘You get a feel for what her life is like, how she handles things, how she deals with the normal, usual, and everyday life stressors. It gives you something to go on when she comes in, in labor.’’ ‘‘Maybe because I’ve been in practice for a while now, I don’t feel I necessarily have to have a deep connection to take care of somebody, although I enjoy it. It might be harder if I don’t, but I just have to trust labor and birth. Whether you know her that well is less important, because most of the time, it’s going to turn out normal.’’ Midwifery’s Therapeutic Lens The midwives represented midwifery’s therapeutic lens as the unique perspective of midwifery care, based on midwifery education, cumulative clinical experience, and commitment to midwifery’s philosophy and values. Education results in a solid, formalized knowledge of physiology and related sciences, and skills favoring facilitative Volume 55, No. 3, May/June 2010
processes. Clinical experience includes the midwife’s understanding of how women’s labors and births may unfold, sophisticated clinical judgment about facilitative physiologic and psychologic care processes, and finely honed vigilance during the woman’s labor and birth. They believed that midwives’ tolerance of wide variations in labor and birth sets a high threshold for unequivocal pathology, and comes only from extensive experience. Two midwives expressed their understanding as follows: ‘‘You have to prove [emphasis sic] it to me, beyond a shadow of a doubt, that something isn’t normal.’’
ence was a freaking disaster.the baby died. The final line in her birth story is, ‘you can do everything right, and normal can include death.’ So we say, no provider or setting can promise you any given outcome’’ [emphasis added].
Empiric Referents
The midwives agreed that normalcy in childbirth is affirmed in midwifery’s philosophical values. Explicit values included the perception of childbirth as an inherently healthy process best accomplished by women’s innate capacities, respect for the woman’s autonomy, shared decision-making, and the midwife’s coordination of a safe and sensitive environment of care. The midwives unanimously valued individualized care, characterizing it as safe, flexible, requiring specific indications for interventions, and respectful of the woman’s needs and expectations. A hospital-based midwife expressed the importance of individualized care in this way:
The midwives identified five observable processes significantly associated with normalcy in childbirth, termed ‘‘empiric referents.’’30 These included the following processes: 1) spontaneous onset of labor; 2) spontaneous progress in labor; 3) spontaneous birth; 4) the woman’s effective coping with labor and birth; and 5) the woman’s freedom and capacity to do whatever she needs to do to give birth to her baby. The first three are somewhat measurable; the woman’s coping and her freedom and capacity to birth are more appropriately judgment calls. Elaboration of the empiric referents for normalcy in childbirth appears in Table 4. The midwives asserted that spontaneous labor onset, spontaneous progress in labor, and spontaneous birth are all highly associated with normalcy in childbirth. The midwives who practiced in freestanding birth centers and home birth practices put robust emphasis on the importance of these innate physiologic processes. One participant offered these observations about spontaneous labor onset:
‘‘When we have to change the plan, I try to think of what would be best for this woman, and this baby, in this labor at this time [emphasis sic]. I want to give the woman all the options and help her sort out what would be best for her and her baby.’’
‘‘When spontaneous labor occurs at the right time, with a healthy mom and baby, you have the best chance of having a normal birth. I think that’s critical.it’s critical.’’
‘‘Bottom line, that baby’s okay until it isn’t, it’s going to come out until it doesn’t, and that labor is normal until it’s not.’’
A freestanding birth center midwife boldly characterized the philosophical valuing of individualized care: ‘‘The difference [in settings] is ‘who is your boss?’ The ‘boss’ for the midwife is the mom, not the institution, the obstetrician, the timeline or the protocol.’’ Within the dynamic of midwifery’s therapeutic lens, the midwives acknowledged the possibility of injury or death, a significant finding in a study of normalcy in childbirth. Death or injury occurs, even when all available capabilities are used in a timely and appropriate manner. They were clear that midwives are deeply concerned about poor outcomes and strive to avoid these possibilities, yet recognize that there are practical limitations of health care capabilities. A midwife in a freestanding birth center offered the following poignant scenario: ‘‘We really do believe that Nature loves her babies; we are also very aware of the fact that Nature doesn’t particularly care about the individual woman or baby, so we have to pay attention. The saddest story was of a mom whose whole experiJournal of Midwifery & Women’s Health www.jmwh.org
‘‘Every baby has its own little ‘pop-up timer’ for when it’s done. We just wait for that.’’ The midwives favored a broad interpretation of progress in labor, differing from the conventional criterion of progressive cervical dilatation. Any evidence of progress, such as effacement changes, firmer application of the vertex to the cervix, favorable adjustments of the fetal position, a bit of descent, or improved quality of contractions, was accepted. The midwives ‘‘uncoupled’’ labor progress from rigid timeframes; those in out-of-hospital settings were more likely to favor flexible timeframes and functional laboring and pushing efforts, rather than those ‘‘on the clock.’’ The midwives strongly supported spontaneous vaginal birth as an empiric referent for normalcy. They understood ‘‘spontaneous’’ as the birth of the baby accomplished solely under the woman’s own physiologic and psychologic powers. The midwives did not address vaginal birth under regional anesthesia or other medications, but were clear that forceps or vacuum extraction were not part of ‘‘spontaneous’’ vaginal birth. 211
Table 4. Empiric Referents for the Concept of Normalcy in Childbirth Empiric Referent
Characteristics
Observable Phenomena
Spontaneous onset of labor
Physiologic and psychologic readiness Intrinsic physiologic reliability
Spontaneous progress in labor
Functional progress in labor Absence of augmentation
Spontaneous vaginal birth
Intrinsic, adaptive, and expulsive power
The woman’s effective coping
Multidimensional and unique to the woman’s nature Coping strategies appear consistent with the woman’s unique nature The woman’s understanding of childbirth as a reliable and healthy process Willingness to ‘‘take on’’ the process
The woman’s freedom and capacity to give birth
The midwives endorsed the woman’s effective coping with childbirth and her freedom and capacity to give birth as important components of normalcy. They agreed that women’s effective coping strategies manifest along a wide continuum, include both physiologic and psychologic adaptations, and, again, are consistent with her unique nature. The midwives believed that effective coping is the woman’s adaptation to labor in ways that support progress. The midwives linked the woman’s remaining ‘‘in control’’ with her sense of safety, and not to any judgment about her personal coping behavior. A midwife in a home birth practice described it this way:
Signs and symptoms of labor onset Absence of intentional stimulation: sexual activity, castor oil or other substance ingestion, nipple stimulation, stripping membranes, prostaglandins, misopristol, oxytocin, or amniotomy Physiologic progression Adaptive behavioral signs and symptoms of progressive labor Any form of progressive anatomic/physiologic change that favors vaginal birth Vaginal birth of a healthy baby accomplished solely under the woman’s powers Absence of instrumental interventions Coping strategies are adaptive and promote progress in labor Adaptive coping manifests spontaneously (not directed by provider) Mobility, privacy, minimal encumbrances, supportive measures, and people Instinctive mammalian responses to childbirth (i.e., altered state and/or disinhibition)
‘‘The fact is, monitoring tends to restrict [the woman] not only to the bed, but also in her mind.’’ Three midwives in nonhospital settings linked the woman’s freedom and capacity to ‘‘unlearning’’ social and cognitive approaches to childbirth. The woman with capacity to experience this very mammalian process in an uninhibited, instinctual way greatly enhances her possibility of a normal childbirth. A midwife in a freestanding birth center described how she viewed the link between instinctual freedom and normal birth:
‘‘This is her artistry in labor, her variation on a scene. It’s appreciating the way each woman copes or doesn’t, and how to help her know her own strength, and feel the sense of her childbirth.’’
‘‘We tell them over and over again, ‘The baby is going to come out, just like all other mammals. And your mind, if it’s willing, will be able to help it instead of get in its way.’ Nature has a well-designed way, if the woman can get her head out of the process.’’
The midwives believed that the woman’s freedom and capacity to ‘‘do whatever she needs to do to give birth to her baby’’ benefited from physical freedom, an attitudinal environment that expresses confidence in the woman, and psychological capacities within the woman herself. The midwives in freestanding birth centers and home birth practices supported this more emphatically than those in hospital settings. Physical freedom included adequate space to move about, privacy, minimal physical encumbrances (such as intravenous lines and monitoring equipment), availability of supportive measures, and accommodation of the woman’s preferred social support. A hospital-based midwife commented:
The midwives also believed that freedom and capacity in childbirth are interdependent: a restrictive environment for labor and birth may correlate with the woman experiencing decreased freedom and capacity and less willingness to resort to instinctual behaviors in labor. The findings of this concept development study affirm that normalcy in childbirth is a valid and valued concept in midwifery practice, and plays a critical role in decision-making during labor and birth care. The concept of normalcy in childbirth possesses attributes that are discernible to assessment and clinical judgment and sensitive to clinical management. How the woman’s birth process expresses normalcy is highly individual to the woman,
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Figure 1. Midwives’ construction of the concept of normalcy in childbirth.
and her experience is sensitive and responsive to dynamics shaping her labor and birth. A graphic representation of the concept of normalcy in childbirth as experienced by midwives appears in Figure 1. DISCUSSION This study formally describes the concept of normalcy in childbirth as understood by experienced midwives with a demonstrably strong commitment to childbirth care that reflects their confidence and belief that childbearing is a healthy life process. Valuing normalcy in childbirth performs a critical role in midwives’ clinical assessment, decision-making, and care processes. It may be challenged, compromised, or supported in given practice environments. Its attributes are multidimensional yet discernible in clinical care. This concept development of normalcy in childbirth harmonizes more readily with van Deventer’s3 therapeutic approach of relying on and facilitating women’s physiologic capabilities in childbirth than it does with early modern midwives’ conservative stance of ‘‘waiting on nature.’’3 Contemporary midwifery practice benefits from a synthesis of formal knowledge and clinical experience. In practice, midwives base management decisions on the reliability Journal of Midwifery & Women’s Health www.jmwh.org
of childbearing as a healthy process, differing from the obstetric view that childbearing is an unpredictable and dangerous physiologic process. These midwives understand that childbearing is more complex than the physiology of muscles, bones, chemicals and ‘‘powers’’—it is a complex, holistic process that is highly sensitive to the woman’s life circumstances and the environment of care. These midwives viewed childbirth as widely variable in nonpathologic ways. They appreciated interactions between the woman’s physiology and her unique life circumstances—recognized but not well understood—that manifest across a broad continuum. Deep understanding of physiology and coping, extensive clinical experience, and commitment to midwifery’s philosophical values were identified as essential to discerning differences between healthy, individualized variations and real or potential pathological developments during labor and birth. These findings positioning normalcy as a core concept in midwifery theory development affirm and extend the theoretical work of Lehrman8 and Thompson et al.9 Lehrman’s concept of ‘‘positive presence’’ as belief in the normal processes of childbirth and extensive knowledge and experience in care of laboring women resonates with the dynamics of the midwife’s knowing and midwifery’s therapeutic lens articulated by the participants in this study. 213
Thompson et al.’s descriptor of ‘‘health promoting’’ links ‘‘naturalness’’ of childbearing with the inherent reliability of childbearing and aligns with the midwifery’s therapeutic lens dynamic found in this study. Confidence in normalcy in childbirth and recognition of a continuum of variations extend Kennedy’s10,11 dimension of therapeutics, linking belief in normalcy with processes of care that support normalcy in childbirth. The current study expands understanding of this linkage by making explicit midwives’ preferences for assessment, decision-making, and choice of care processes, identified as midwifery’s therapeutic lens. The dynamic of environment, particularly the attitudinal environment as a powerful influence in shaping women’s childbearing experiences, further supports Kennedy et al.’s31,32 work on the midwife’s role in shaping the landscape of care to promote normalcy in childbirth. Regarding Gould’s15 concept analysis of normal labor, the empiric referents found in the current study differ in substance yet are congruent in spirit. The current study concurs with Gould’s analysis that normalcy in childbirth is sensitive, dynamic and sequential, and culminates in spontaneous birth. Gould’s assertion that conceptual development has focused on physiologic parameters of childbirth is addressed in this study, by expanding beyond the physiologic focus to include the multidimensional and individualized nature of a woman’s experience as inherent to normalcy in childbirth.15 The empiric referents for normalcy in childbirth identified in this study are problematic at this early stage because there is no consensus regarding their precise definitions. Spontaneous onset and progress in labor and spontaneous birth are not yet operationally defined and therefore lack theoretical utility. The woman’s effective coping and her freedom and capacity to give birth are discernible but open to wide interpretation. Experienced midwives may conclude that the woman’s effective coping efforts support physiologic labor and birth and her instinctive responses may be adaptive, but these referents are not yet well understood or measurable. The midwives’ convictions about the concept’s importance to the profession have significant implications for professional midwifery. Practicing midwives may well recognize this description of normalcy in childbirth. For midwives in contested clinical environments, articulating concise conceptual descriptors may fortify the case for care processes that facilitate normalcy, and rationalize care management decisions that build support for a broader interpretation of labor variations. As a clarified concept, normalcy in childbirth reinforces the efficacy of flexible, individualized care. The midwives’ affirmation that nonphysiologic factors influence the course of a woman’s labor and birth opens the possibility of exploratory care processes rather than prescriptive ones. This study offers specific descriptors that clarify the concept of normalcy and supports midwifery education and socialization to that end. Specific descriptors move the ed214
ucational dialogue from ‘‘normalcy in childbirth is like.’’ to ‘‘normalcy is..’’ Educators may incorporate these findings to help learners grasp the concept of normalcy in midwifery practice. The midwives in this study emphasized the importance of extensive clinical experience to formation of belief in normalcy, reinforcing the importance of midwifery educators’ ongoing and often arduous efforts to acquire rich clinical experiences for their learners. This study has several limitations. The voices of the participant midwives may not be representative of the profession as a whole; trustworthiness must be determined by midwives and others who view these findings as authentic. Two categories of clinical sites were overrepresented in the selection of participants, and participants had on average more clinical experience than the average ACNM member. Membership in ACNM was selected as an inclusion criterion to focus on a particular category of midwives; the study would be strengthened by the inclusion of voices of other types of midwives and wider geographic participation. There are several potential research opportunities posed by the findings of this study. Promising research efforts may include elucidation of midwives’ decision-making processes when driven by strong commitment to normalcy, further development of empiric referents into a clinically applicable tool, and investigation of role autonomy in midwifery practice. Understanding how childbearing women view the nature of childbirth would contribute to continuous alignment of maternity care with women’s expectations. Exploration of other maternity care providers’ understanding of normalcy in childbirth may also improve interdisciplinary work environments, enhance approbation of the midwifery model of care, and affirm linkages between facilitative care processes and favorable outcomes. That these midwives perceived the woman being ‘‘in control’’ to be more about the woman’s sense of safety and not her personal coping behavior is another intriguing and potentially fruitful line of inquiry. As an exploratory study, this project establishes a more precise description of normalcy as these midwives experience the concept, but comparison to understandings of childbearing women and other maternity care providers remains, to fully clarify its importance and significance to society’s expectations of maternity care. CONCLUSION This study raises questions about how accurately the concept that midwives know as ‘‘normalcy’’ is determined. The concept of normalcy emerged from statistical science, and to assert that childbirth is normal is to generalize population-based parameters and descriptors to the experience of a unique laboring woman. This narrow construction may disadvantage the woman’s experience, should her unique labor and birth deviate from narrowly constructed parameters. In addition, a statistical understanding of Volume 55, No. 3, May/June 2010
normalcy may conflict with individualized care, the unique midwife–woman relationship, and the unique nature of the childbearing woman. Moreover, women require support for unlearning the medical discourse of childbearing and re-envisioning their life processes as healthy and reliable; this is a significant challenge, because the majority of women currently experience medically managed childbearing. Midwives will rightly continue to promote and protect broad interpretations of normalcy in childbirth, strive to enact it in clinical practice, and incorporate these findings to build women’s confidence and capacity to ‘‘do whatever they need to do to give birth.’’ This concept development of midwives’ belief in normalcy affirms and describes the defining value of the midwifery model of care and offers further opportunities for theory development linking the midwifery model of care to childbearing processes and outcomes. Supported in part by the L. Newton Long Award for the Advancement of Midwifery from the American College of Nurse-Midwives Foundation, Inc. The author would like to thank the midwives who participated in this study for their time, insights, and willingness to wrestle with this concept. The author also thanks Kathleen Dwyer, RN, PhD, and Holly Kennedy, CNM, PhD.
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