Midwifery care research: what questions are being asked? What lessons have been learned?

The experience of perinatal care at a birthing center: a qualitative pilot study

The purpose of this qualitative descriptive pilot study was to describe women's experiences of care and satisfaction at a freestanding birth center. Data were collected through semistructured interviews with seven women who had given birth within 12 months of participant selection. Using qualitative content analysis, three themes emerged: (1) Empowerment, (2) Sense of Motherhood, and (3) Establishing and Strengthening Relationships. Data revealed that women value caring providers, that caring providers may affect positive outcomes, and that those outcomes may lead to a satisfactory experience.

SCIENCE AND MIDWIFERY: PARADIGMS AND PARADOXES

The everyday world of clinical practice is filled with paradigms and paradoxes that stem from the issues of who defines knowledge, how it is generated, and how the individual midwife applies it when providing care for women and families. Research useful for clinical practice should provide evidence to support scientific approaches (models) or strategies (interventions) in caring for women. In a clinical discipline, the answers to research questions should eventually inform clinical decision-making by providing practical clinical knowledge. This article presents an application of Stevenson's research steps for the development of clinically applicable knowledge that the midwife can use to analyze and evaluate research findings as a basis for practice decisions. Specific examples of midwifery research are used to illustrate each stage in the process and the circular nature of knowledge development. The challenge is to prepare midwives who can apply research findings skillfully using the best evidence to support clinical practice, as well as to groom midwife researchers who will develop systematic programs of relevant research about midwifery practice and outcomes.

Midwifery Care of Poor and Vulnerable Women, 1925-2003

A systematic literature review of research on midwifery care of poor and vulnerable women from 1925 to 2003, which included topics studied, research methods used, and special issues and implications for future research, was performed; 44 studies published between 1955 and 2003 were identified. The majority were retrospective, descriptive studies. Outcomes examined included prenatal care visits, vaginal versus operative births, labor interventions, maternal and neonatal mortality and morbidity, birth weight, and cost-effectiveness. Studies showed that midwives predominantly serve vulnerable women who are young, poor, immigrants, or members of racial and ethnic minorities. Preterm birth prevention is emerging as a midwifery research focus. Health system changes are making it more difficult to provide effective care and counseling to disadvantaged women, especially in managed care settings. Extensive evidence documents excellent outcomes of midwifery care for the poor in urban and rural settings over the past three quarters of a century. Future research should include more intervention studies and use both qualitative and quantitative methods to investigate midwifery processes of care and the process-outcome connection. The research focus should broaden beyond childbirth to include gynecology, family planning, and primary care issues. Health disparities, cultural studies, obstetric interventions, and poor women's experiences of childbirth and midwifery care are important topics for future research.

Identifying research priorities for midwifery in Ireland

OBJECTIVE

to identify research priorities for midwifery in Ireland in the short, medium and long term.

METHOD

a three-round Delphi survey design was used to identify midwifery research topics. Issues identified through content analysis formed Questionnaires 2 and 3. Participants rated the importance of each topic (1=low importance to 7=high importance), and a mean score of 6.0 or more was considered a priority issue. A final discussion group set short-, medium- or long-term timeframes for the research topics.

PARTICIPANTS

334 midwives were recruited from a national invitation to all midwives. Response rates were 43% (Round 1; 142/334), 85% (Round 2; 121/142) and 81% (Round 3; 98/121). Nine consumers of maternity services were included in the discussion group workshop.

FINDINGS

participants identified 11 clinical, eight management, and seven education midwifery research topics with six high-priority issues: promoting woman-centred care (management), promoting the distinctiveness of midwifery (education), satisfaction with care (clinical), care in labour (clinical), preparation for practice (clinical), and promoting research/evidence-based practice (education).

KEY CONCLUSIONS

this research sought to achieve consensus amongst a representative sample of midwives on the priorities for midwifery research in Ireland. Midwives can now select topics for graduate or other research studies of importance to practice, management and education. Funding agencies can confidently direct the allocation of national and local funding for priority areas of midwifery research within Ireland.

A hermeneutic phenomenological analysis of midwives’ ways of knowing during childbirth

OBJECTIVE

to explore the ways of knowing used by the midwife while attending women during childbirth through textual analysis of poems written by American midwives.

DESIGN

a hermeneutic phenomenology and human science research method inspired by van Manen was used. Midwifery ways of knowing during childbirth were thematically derived from 10 poems written by midwives about attending childbirth or the experience of being a midwife. Textual analysis included examination of the poems as a whole, via verse and metaphor, and via individual lines of prose.

PARTICIPANTS

10 American midwives wrote the poems used in this study. The poems were discovered through online searches of many databases using the key words 'poetry, poems, midwifery and childbirth' and through a national call for poetry by the researcher over a period of 4 years (1996-2000), undertaken in order to publish an anthology of poetry written by midwives.

FINDINGS

three authoritative ways of knowing that guided the care given by the midwife to women during childbirth were discovered. They were self-knowledge from the belief system of the individual midwife, grounded knowledge from the midwife's personal lived experience with childbirth, and informed knowledge from objective and scholarly sources.

KEY CONCLUSIONS

midwives must continue to develop their own body of knowledge in order to move the profession forward. Multiple ways of knowing including the use of experiential/contextual and intuitive knowledge is legitimate and humane, if provision of care is holistic. Care of women during childbirth can be enhanced with the use of multiple knowers and multiple ways of knowing. This study captured a unique and fresh interpretation of the lived experience of midwifery knowledge. Midwifery educational programmes should offer opportunities for students to explore the artistry as well as the science of midwifery practice.

Critical views on postpartum care expressed by new mothers

BACKGROUND

Women's evaluation of hospital postpartum care has consistently been more negative than their assessment of other types of maternity care. The need to further explore what is wrong with postpartum care, in order to stimulate changes and improvements, has been stressed. The principal aim of this study was to describe women's negative experiences of hospital postpartum care, expressed in their own words. Characteristics of the women who spontaneously gave negative comments about postpartum care were compared with those who did not.

METHODS

Data were taken from a population-based prospective longitudinal study of 2783 Swedish-speaking women surveyed at three time points: in early pregnancy, at two months, and at one year postpartum. At the end of the two follow-up questionnaires, women were asked to add any comment they wished. Content analysis of their statements was performed.

RESULTS

Altogether 150 women gave negative comments about postpartum care, and this sample was largely representative of the total population-based cohort. The women gave a diverse and detailed description of their experiences, for instance about lack of opportunity to rest and recover, difficulty in getting individualised information and breastfeeding support, and appropriate symptom management. The different statements were summarised in six categories: organisation and environment, staff attitudes and behaviour, breastfeeding support, information, the role of the father and attention to the mother.

CONCLUSION

The findings of this study underline the need to further discuss and specify the aims of postpartum care. The challenge of providing high-quality follow-up after childbirth is discussed in the light of a development characterised by a continuous reduction in the length of hospital stay, in combination with increasing public demands for information and individualised care.

Evaluating multi-dimensional aspects of postnatal hospital care

OBJECTIVES

to investigate women's experiences of postnatal hospital care in relation to four different aspects: (1) interpersonal care; (2) time spent on physical check-ups; (3) time spent on information and support; and (4) time spent on assistance with breast feeding. More specifically, we aimed to establish whether typical clusters of women could be identified, and if so, whether these clusters could be related to specific outcomes of care, to the way in which care is organised, and to the individual's psychological health and socio-demographic background.

DESIGN

longitudinal population-based survey, including three questionnaires completed in early pregnancy, at 2 months and 1 year after birth.

SETTING

all postnatal wards in Sweden.

PARTICIPANTS

women (n=2338) recruited at their first booking visit at 593 antenatal clinics, who responded to questions relating to postnatal hospital care 2 months after birth.

FINDINGS

eight cluster profiles defined by the four aspects of postnatal care were identified. About half of the women were found in clusters that were satisfied with most aspects of care, and half in clusters that were dissatisfied with one aspect or more. Only 32% were very satisfied with all four dimensions. Specific groups of women, such as first-time mothers, migrants, young mothers and those with a short length of stay, were dissatisfied with different assessments of postnatal care. Psychological health in early pregnancy was associated with high ratings of all aspects of care, whereas emergency caesarean section and instrumental vaginal delivery was associated with dissatisfaction with breast feeding support and time spent on health check-ups.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

women's individual appraisal of specific aspects of hospital postnatal care could be grouped into response patterns that were shared by smaller or larger groups. These patterns were related to maternal characteristics, labour outcomes and the way in which care was organised. The multi-faceted approach used in this study provided details about who was dissatisfied with what, and showed that women are not necessarily either satisfied or dissatisfied with care in a general sense. In order to provide individualised care, the carer needs to be aware of these differences.

Piercing the veil: The marginalization of midwives in the United States

This paper investigates the marginalization of certified nurse-midwives (CNMs) in the US. This marginalization occurs despite ample evidence demonstrating that a midwifery model delivers high-quality cost-effective care. Currently midwives attend only 7% of births, compared to 50-75% of births in other developed countries. Given the escalating costs of health care and relatively poor maternal and child health indicators in comparison with other developed countries, these findings are disturbing. This paper investigates this paradox through a qualitative case study of two prestigious but declining midwifery services in a large US city. Fifty-two multi-sited in-depth interviews were conducted along with an analysis of relevant archival sources. It was found that institutions successfully altered maternity care and diminished midwifery services without accountability for their actions. These findings illuminate the larger political-economic forces that shape the marginalization of midwifery in the US.

Disparity in prenatal care among women of colour in the USA

OBJECTIVE

To describe the disparity in prenatal care among women of colour in timing of initiation of prenatal care and total number of prenatal visits.

DESIGN

A retrospective, descriptive design.

SETTING

A large, urban university midwifery faculty practice.

PARTICIPANTS

439 healthy women at term (37-42 weeks gestation) with a vertex singleton pregnancy, and an essentially uncomplicated prenatal course. One clinic, the university facility, provided full-scope services. The other four community clinics, all outside the university in the larger metropolitan area, were designed to provide care to low-, under-, and uninsured pregnant women.

MEASUREMENTS

Timing of initiation of prenatal care and total number of prenatal visits were examined in relation to demographic variables, including race, education, age, marital status, method of payment and clinic sites.

FINDINGS

Significant differences in initiation of prenatal care and total number of prenatal visits were documented. The non-Hispanic white women at the university hospital clinic, with high school or college degrees and insurance or Medicaid, were more likely to visit prenatal clinics. Examination of association between timing of initiation of prenatal care and demographic variables showed significant differences in race and education.

KEY CONCLUSIONS

This study reflects the difficulty in access to care faced by women of colour. When comparing 1997 national survey findings with those of a 2001 study, about 40% of the 50 States and the District of Columbia showed an increase in the frequency of women receiving late care or no care; additionally, a disparity in access to prenatal care between non-Hispanic white and non-white women was noted in most of these areas.

IMPLICATIONS FOR PRACTICE

The number of births to women of colour delivered by midwives has rapidly increased in recent years. Also, the numbers of babies born to women of colour is anticipated to surpass 50% in the next few decades. Considering the increased proportion of births to women of colour, special attention to promote early prenatal care for these populations is needed. Recruitment and retention efforts for non-white midwives, regular education for cultural competence of midwives, and provision of culturally and linguistically appropriate care for women of colour should be considered.

Actions speak louder than words: mainstream health providers' definitions and behaviour regarding complementary and alternative medicine

The purpose of this paper is to explore how mainstream practitioners define and categorize complementary and alternative medicine (CAM) as one component of assessing their views. The following themes emerged from interviews with Canadian physicians, midwives and nurses: epistemological, evidence-based, medical domain, political-regulatory, funding-based, and role-based definitions of CAM. We also assess any possible links to their behaviour vis-à-vis CAM. We found that classifying something as CAM does not appear to inhibit most providers from recommending, referring for, or supporting their patients' use of these treatments. In conclusion, we highlight that despite their clear definitional boundaries around CAM, providers tend to evaluate each individual therapy on its own merits, taking other situational factors into consideration.

Midwifery's research heritage: A Delphi survey of midwife scholars

A Delphi survey was conducted with midwife scholars to determine the top 10 midwifery studies worthy of recognition in 2005, the 50th anniversary of the American College of Nurse-Midwives (ACNM). This survey was undertaken by students of Philadelphia University's Graduate Midwifery Program as a service-learning project on behalf of the ACNM Division of Research. Selected midwife scholars participated in 2 or 3 rounds of response and feedback to achieve consensus about research deemed historically or currently important to midwifery practice. The top 10 studies, as determined by the 19 participating midwife scholars, are presented here. These results are offered as reflection on research that has helped to shape and define the discipline of midwifery in the United States.

Keeping Birth Normal: Research Findings on Midwifery Care During Childbirth

OBJECTIVE

This study describes processes and outcomes of midwifery care through narratives told by exemplary midwives.

DESIGN

Narrative analysis.

SETTING

Midwifery practices in hospital, birth center, and home settings.

PARTICIPANTS

Purposive sample of 14 midwives drawn from a large national Delphi panel on exemplary midwifery practice.

DATA ANALYSIS

Systematic analysis of interview data was conducted until interpretive consensus was achieved across all text and codes. Results were compared with two prior qualitative studies conducted by the first author on midwifery practice for congruence and emergence of new findings.

RESULTS

The support of normalcy was identified as a significant process of midwifery care during labor and birth.

CONCLUSIONS

The midwives believed that birth is normal, and many of their actions were specifically aimed toward the support of it as a physiologic, rather than pathologic, process. Through their words, we see subtle care processes focused on meeting a woman's individual needs and tapping into her personal strength. Implications for practice and further research to link their approach to caring for women with perinatal outcomes are reviewed.

An exploratory metasynthesis of midwifery practice in the United States

OBJECTIVES

To conduct a metasynthesis of six qualitative studies of midwifery care and process; identify common themes and metaphors among the six studies for further exploration and theory development; and create a framework for further metasynthesis of qualitative studies of midwifery practice in the USA.

DESIGN

A qualitative metasynthesis to analyse, synthesise, and interpret six qualitative studies on the process and practice of midwifery care.

SAMPLE AND SETTING

Hospital, birth centre, and home birth settings were represented across all of the studies. Participants included nurse- and direct-entry midwives who provided both childbearing and gynaecological care. Recipients of midwifery care also received both childbearing and gynaecological care.

FINDINGS

Four overarching themes were identified: the midwife as an 'instrument' of care; the woman as a 'partner' in care; an 'alliance' between the woman and midwife; and the 'environment' of care. These were interpretively and conceptually arrayed into a helix model of midwifery care.

KEY CONCLUSIONS

The findings from this exploratory metasynthesis clearly indicate that the practice of midwifery is a dynamic partnership between the midwife and the woman, and reflects an environmental perspective. In a country that has a standard of highly technical childbirth care, perhaps the most outstanding concept of this model is that of the midwife as an 'instrument' of care. The significance of the findings will be determined by their ability to guide further research efforts to support a standard of midwifery care for all women in the USA.

IMPLICATIONS FOR PRACTICE

This model offers a benchmark and a structure for considering the dynamic elements of midwifery practice and key roles that the midwife plays in the health care of women and babies.

Reducing genital tract trauma at birth: launching a clinical trial in midwifery

Genital tract trauma is a common outcome of vaginal birth, and can cause short-term and long-term problems for new mothers. Preventive measures have not been fully explicated. Midwives use a variety of hand maneuvers late in the second stage of labor, in the belief that genital trauma can be reduced. However, none of these care measures have been rigorously tested to determine if they are effective. A midwifery practice offers an ideal setting to study the relationship of hand techniques by the birth attendant to reduction of genital tract trauma.

New directions in midwifery education: the master's of science in midwifery degree

Midwifery is reclaiming its perspective as a discipline separate from, yet integrally related to nursing and medicine. Emerging trends in health care place increased demands on the knowledge base and clinical practice of midwifery, stimulating a need for new directions in midwifery education. The master's of science with a major in midwifery is a new degree option available to midwifery students in the United States. This article presents the argument that midwifery is a distinct discipline and describes the importance of a master's of science in midwifery degree toward furthering the work of the discipline of midwifery. Descriptions of the current master's of science in midwifery degree programs are included.

Challenges and opportunities for nurse-midwives

This article reviews the major indicators of the growth in nurse-midwifery practice and education over the past 10 years. The major issues the profession has addressed are identified, as well as future challenges and opportunities. These challenges and opportunities are identified within the major dimensions of nurse-midwifery, that is, in practice, education, research, and within the public sector. The two major issues facing nurse-midwives are legislative initiatives related to the practice of nurse-midwives, such as reimbursement, and the mixed societal image of midwifery as a contemporary, cost-effective practice versus a peripheral activity by "old fashioned," informally educated individuals. The professional organization of nurse-midwives, the American College of Nurse-Midwives (ACNM), is addressing these issues through interdisciplinary and interorganizational legislative and marketing initiatives.

Fostering evidence-based care in clinical teaching

Understanding scientific research evidence and applying it to clinical practice is a focus in today's health care arena. Fostering evidence-based care (EBC) in clinical teaching is an effective way to help students learn to think critically, search for, evaluate, and incorporate the best research evidence into their clinical practice. For example, helping a student plan care for a woman creates a "teaching moment" for the application of scientific evidence to clinical practice. Essentially, EBC is a learned skill for both the student and the clinical teacher. It requires intellectual curiosity and a willingness to explore beyond "the way it has always been done." This article presents a review of the goals of clinical teaching, strategies to foster EBC, and tools to assess the readiness of the teacher, the student, and the clinical setting for EBC. By aligning the goals of clinical teaching with evidence-based strategies, both the educator and student strive together to provide midwifery care that is supported by available research.

Perinatal nursing research: a 25-year review--1976-2000

Parent-infant nursing research from 1976-2000 is reviewed through four groups of studies: development of research instruments, studies of mothers and fathers through the childbearing years, studies of newborns (both healthy and at risk), and studies of special populations. Potential directions for maternal/parent/newborn nursing research in the 21st century are suggested.