A COMPARISON OF TWO TIME INTERVALS FOR THE AUSCULTATED ACCELERATION TEST

OBJECTIVE

Interest in an inexpensive, easy-to-administer antenatal screening test that did not rely on the use of electronic fetal monitoring led to development of the fetoscope administered auscultated acceleration test (AAT) in the late 1980s. More recent efforts have been directed toward providing those who may use the AAT with important information about the most effective and clinically appropriate AAT procedures. The purpose of this study was to determine the screening test validity performance of two AAT time intervals--6 minutes and 10 minutes.

METHODS

Two auscultated acceleration tests (AAT6 and AAT10) were simultaneously performed using different time intervals on 205 women with high-risk pregnancies undergoing simultaneous nonstress tests (NSTS) who were referred to a tertiary care unit for antepartum testing. Standard measurements of screening test validity were calculated for each test in the prediction of selected perinatal outcomes. NST findings were included for comparative purposes.

RESULTS

The AAT6 yielded an overall higher specificity as compared with the AAT10 at the expense of a slightly lower sensitivity for most perinatal outcomes; these differences were not significant at the .05 level. Relative risk ratios were similar for the AAT6 and AAT10 for both fetal distress and neonatal morbidity, with both AAT being a more effective predictor of neonatal morbidity than for fetal distress. Both tests yielded better sensitivity when compared with NST.

CONCLUSIONS

Even though there was a nonsignificant trend toward higher sensitivities and lower specificities for the 10-minute AAT, this study showed that the differences in prediction of perinatal outcomes between the 6-minute and 10-minute AAT were minimal. In view of the added labor required for the 10-minute AAT in the absence of enhanced screening test validity, the 6-minute AAT is clinically preferred. This study has prompted new research questions for the continued development of the AAT as a low-technology fetal assessment technique with potential usefulness by midwives and their colleagues in a variety of settings worldwide.

The MCH Certificate Program: a new path to graduate education in public health

OBJECTIVE

The purpose of the MCH Certificate Program was threefold: to develop a new educational initiative in response to national and local demands for increased MCH workforce capacity, to eliminate key financial and nonfinancial barriers to advanced MCH academic preparation, and to improve rates of recruitment and retention of students from minority communities, thus enhancing the quality of MCH services available to the region.

METHODS

An MCH Certificate Program, designed for clinicians (e.g., nurses, occupational therapists and nutritionists) and public health practitioners as a bridge to graduate programs in public health, combined a competency based curriculum with skills workshops, leadership seminars, mentoring, small group activities, and an interactive teaching format. RESULSTS: Students from the first two cohorts (n = 45) report an expansion of core public health knowledge (issues, policies, and strategies), enhanced self-confidence, and efficacy. Half have experienced job changes that represent increased responsibility, leadership, and professional advancement. A third are enrolled in or have completed a formal program of graduate study in MCH.

CONCLUSIONS

This innovative MCH Certificate Program, now in its fourth year, is a new approach to increasing workforce capacity and a successful model of instruction for adult learners. It has the potential for adaptation to a variety of educational settings and MCH populations, and helps to expand the continuum of MCH training experiences in schools of public health.

Serving women in need: nurse-midwifery practice in the United States

OBJECTIVE

Nurse-midwifery practices in the United States were examined to study the relationship between certified nurse-midwives' (CNMs) demographic, work setting, and practice characteristics in terms of clientele, practice size, and practice type. Factors that might influence the ability of CNMs to serve populations at risk for poor outcomes were given particular attention.

METHODOLOGY

A total of 2,405 responses to a 1998 mailed survey of 6,365 nurse-midwives ever-certified by the American College of Nurse-Midwives were analyzed.

RESULTS

Study results indicated that CNMs continue to serve a population who are, based on a social risk profile, disproportionately at risk for poor pregnancy outcomes, including women who are uninsured (16%), immigrant (27%), adolescent (29%), and women of color (50%). It was also found that clientele varied according to practice settings: CNMs working in non-hospital, nonprofit settings served a clientele that was 65% nonwhite, 44% immigrant, 40% adolescent, and 29% uninsured; these CNMs received 61% of their client payments from Medicaid. CNMs working in private offices or for managed care organizations were less likely to serve women with these characteristics.

CONCLUSION

Study results, taken in conjunction with research that documents the safety of nurse-midwifery practice, reinforce policy recommendations that support expanded access to nurse-midwifery services. Findings also indicate a need for further research in the areas of CNM workload and productivity in managed care settings and the association between CNM race and ethnicity and the race and ethnicity of their clients.

A comparison of visits and practices of nurse-midwives and obstetrician-gynecologists in ambulatory care settings

With more than 5 million patient visits annually, certified nurse-midwives (CNMs) substantially contribute to women's health care in the United States. The objective of this study was to describe ambulatory visits and practices of CNMs, and compare them with those of obstetrician-gynecologists (OB/GYNs). Sources of population-based data used to compare characteristics of provider visits were three national surveys of CNMs and two National Ambulatory Medical Care Surveys of physicians. When a subset of 4,305 visits to CNMs in 1991 and 1992 were compared to 5,473 visits to OB/GYNs in similar office-based ambulatory care settings in 1989 and 1990, it was found that a larger proportion of CNM visits were made by women who were publicly insured and below age 25. The majority of visits to CNMs were for maternity care; the majority of visits to OB/GYNs were for gynecologic and/or family planning concerns. Face-to-face visit time was longer for CNMs, and involved more client education or counseling. This population-based comparison suggests that CNMs and OB/GYNs provide ambulatory care for women with diverse demographic characteristics and differing clinical service needs. Enhancing collaborative practice could improve health care access for women, which would be especially beneficial for those who are underserved and vulnerable.

The association of childhood sexual abuse with depressive symptoms during pregnancy, and selected pregnancy outcomes

OBJECTIVES

The objectives were: (1) to investigate the association during pregnancy of sexual abuse before the age of 18 on depressive symptomatology in pregnancy, controlling for the presence of negative life events and challenges; and (2) to investigate the association of selected pregnancy outcomes (maternal labor and delivery factors, infant birth weight and gestational age) with sexual abuse before age 18.

METHODS

Three hundred fifty-seven primiparous women aged 18 years and older were interviewed between 28-32 weeks gestation with reference to current functioning and past history (Objective 1). Medical record information was abstracted after delivery for pregnancy, labor and delivery factors, and pregnancy outcomes (Objective 2).

RESULTS

Thirty-seven percent of the women reported past sexual abuse. Prevalence was not associated with ethnic background, educational level, or hospital payment source. Previously sexually-abused pregnant women reported significantly higher levels of depressive symptomatology, negative life events, and physical and verbal abuse before and during pregnancy. There were no significant associations found between past sexual abuse and labor or delivery variables or newborn outcomes.

CONCLUSIONS

Previously sexually-abused pregnant women reported a wider constellation of past and current functioning problems than nonabused women although past sexual abuse was not associated with pregnancy outcome. Prenatal care provides a unique opportunity to evaluate the impact of life history and current life events during pregnancy, and to develop a coordinated intervention plan.

Midwifery in the 21st century. Recommendations from the Pew Health Professions Commission/UCSF Center for the Health Professions 1998 Taskforce on Midwifery

Unprecedented changes in the delivery and financing of health care have produced angst and opportunity, criticism, and innovation. To explore the effects of these market-driven changes on midwifery, the University of California at San Francisco Center for the Health Professions convened a Taskforce on Midwifery in 1998. Consisting of eight experts from across the country, the Taskforce was charged with exploring the impact of health care system developments on midwifery, and identifying issues facing the profession and the roles midwives play in women's health care. The Taskforce answered its charge by offering 14 recommendations related to midwifery practice, regulation, education, research, and policy. The recommendations incorporate the Taskforce vision that the midwifery model of care should be embraced by, and incorporated into, the health care system in order to make it available to all women and their families. Midwives, educators, collaborators, and policymakers can use the recommendations to develop curricula, practice sites, and laws for an improved health care system that fully includes midwives and encompasses the midwifery model of care.

Characteristics of nurse-midwife patients and visits, 1991

OBJECTIVES

This study describes the patient populations served by and visits made to certified nurse-midwives (CNMs) in the United States.

METHODS

Prospective data on 16,729 visits were collected from 369 CNMs randomly selected from a 1991 population survey. Population estimates were derived from a multistage survey design with probability sampling.

RESULTS

We estimated that approximately 5.4 million visits were made to nearly 3000 CNMs nationwide in 1991. Most visits involved maternity care, although fully 20% were for care outside the maternity cycle. Patients considered vulnerable to poor access or outcomes made 7 of every 10 visits.

CONCLUSIONS

Nurse-midwives substantially contribute to the health care of women nationwide, especially for vulnerable populations.

Population differences affect the interpretation of fetal nonstress test results

OBJECTIVE

The object of the study was to determine whether population differences exist with respect to outcomes of women with reactive and nonreactive nonstress test results.

STUDY DESIGN

An epidemiologic evaluation was conducted on 2579 women who underwent nonstress tests in the Fetal Assessment Center of the Johns Hopkins Hospital within a week of delivery. Risk factors such as hypertension, diabetes, and postterm pregnancy were used in a logistic regression model to evaluate the ability of the nonstress test to predict outcomes including proxies of fetal distress and fetal and neonatal death. The sensitivities, specificities, and predictive values of the nonstress test for predicting these outcomes in cohorts of black and white women were also determined.

RESULTS

The nonstress test was consistently more sensitive for black women than for white women in predicting several perinatal outcomes, but specificity and negative predictive value were consistently lower for black women. The positive predictive value for fetal and neonatal death was higher for white women than for black women. Although the nonreactive nonstress test result seemed to be predictive of certain perinatal events, the odds ratio for predicting perinatal mortality in any study population was no greater than when the nonstress test result was reassuring.

CONCLUSIONS

Epidemiologic characteristics affecting test results, such as disease prevalence and population differences, may lead to clinically significant differences in outcome prediction when these tests' results are used. These differences should be considered in the implementation of antepartum fetal testing programs.

State regulation, payment policies, and nurse-midwife services

State regulatory and reimbursement policies continue to exert a strong influence on health workforce policy. Surveys conducted in 1991 and 1995 for the purpose of examining the impact of state regulation on the supply and practice of certified nurse-midwives (CNMs) showed that the single best predictor of the distribution and practice activities of CNMs was the degree to which state policies facilitated or restricted CNM practice.

Population-based primary health care for women. An overview for midwives

This home study program has as its focus population-based care for women. Although clearly significant, concentrating effort solely on the individual does not ensure that the population as a whole is healthier. Experts are encouraging health care providers to consider the population as their "patient" and to begin documenting the incidence and prevalence of its disease. This article addresses the following issues: the definition of population-based health care; the relationship between primary care, women's health care, and population-based health care; the importance of a population-based approach or perspective for midwives; the use of population-based care in the provision of prenatal care; the definition of the populations to whom midwives have historically provided care and the documentation of how those populations are changing; and the research and policy issues for midwives related to population-based health care.

Psychopharmacologic management of women with common mental health problems

This article reviews the essential aspects of the psychopharmacologic management of women with mental health problems, with particular emphasis on the role of the nurse-midwife as a primary care provider. The article also addresses the neurobiology of psychopharmacology, pharmacokinetics, and the selection of pharmacologic treatments used for depression, bipolar disorders, anxiety disorders, eating disorders, and psychosis. Considerations for the timely and appropriate referral for psychiatric intervention for women with psychiatric or pharmacologic emergencies are discussed, and issues relating to pregnancy, lactation, and reproductive health are included. The importance of the nurse-midwife's role in ensuring women's access to and compliance with psychopharmacologic therapy is emphasized.

Primary care for women. Comprehensive assessment and management of common mental health problems

This article emphasizes the importance of the role of the certified nurse-midwife (CNM) in the primary care assessment of, and appropriate referral for women with mental health problems, especially in cases of psychiatric emergencies. Essential aspects of assessment, diagnosis, and treatment of the more common psychiatric problems are included, and the treatment modalities that are considered when referral results in psychiatric intervention are reviewed. In addition, the overall prevalence of mental health problems in women, the frequency with which primary care providers may encounter mental health problems, and issues of mental health care utilization are discussed.

Primary care for women. Cultural competence in primary care services

The assessment of cultural competence in providing primary care services for women is addressed. Emphasis is placed on the ways in which cultural competency attainment can ensure the availability of key primary care components to all women, especially those from certain vulnerable populations and those who have specific primary health care needs. A cultural competence continuum is described that will assist providers in an assessment of their own cultural competency levels, as well as those of the service settings in which they practice. Six scenarios are provided, describing experience at each level of the continuum that may hinder the development and delivery of effective primary care service interventions. Examples of ways in which nurse-midwives can provide leadership in the area of cultural competence in women's primary care are also included.

Home birth in the United States, 1989-1992. A longitudinal descriptive report of national birth certificate data

This study was conducted to profile home birth in the United States from 1989 to 1992 using two birth certificate data sources from the Natality Branch of the National Center for Health Statistics (NCHS). Analysis included published and unpublished descriptive tables about all U.S. home births from 1989 to 1992, and a subset of the 82,210 U.S. home births from 1989 to 1991 that were drawn from NCHS national birth certificate data tapes. Results indicated that less than one-third of reported home births were attended by nurse-midwives or physicians. Distinct regional patterns in the frequency of home births were observed, with higher concentrations in the southwestern and western states. When compared with the average childbearing woman in the United States, mothers who gave birth at home were more likely to be older, have fewer years of education, be married, and be white; they were also more likely to be of higher parity and to receive less prenatal care. Home birth mothers were less likely than average to smoke or drink alcohol prenatally, to have a prenatal medical risk condition or an obstetric complication, or to receive certain prenatal tests. The outcomes of newborns born at home compared favorably to the national average during the same period. Several findings varied considerably by race or ethnicity of the mother.

Primary care for women. Comprehensive dermatologic assessment

This article identifies the components necessary for comprehensive dermatologic assessment, including the pertinent anatomy and physiology, appropriate health history, and physical examination strategies. An overview of common dermatologic conditions in women is presented, and the identification of and action needed for life-threatening dermatologic conditions are reviewed. This article is the first of two articles on primary care for women with dermatological complaints; the subsequent article will address primary care management of common dermatologic conditions.

Primary care for women. An overview of the role of the nurse-midwife

The nurse-midwife's past, present, and future roles in the primary care of women are explored using a recent Institute of Medicine report on primary care as a framework for discussion. Primary care, the scope of services, and the role of the primary care clinician are described, and specific strategies for a primary care emphasis in basic nurse-midwifery education are addressed. The nurse-midwife's future roles in collaborative practice for the primary care of women and the need for continuing education opportunities in primary care are also discussed.

Twelve years and more than 30,000 nurse-midwife-attended births: the Los Angeles County + University of Southern California women's hospital birth center experience

This article describes the setting, policies, practices, and outcomes of the nurse-managed in-hospital birth center at Los Angeles County + University of Southern California Women's Hospital, where women are selected upon admission for birth center care. A retrospective review of available data was made; when compared with hospital records, the primary data source was found to be 96% accurate. Results of the review indicated that from 1981 to 1992, there were 36,410 birth center admissions and 30,311 births, all attended by nurse-midwives; no intrapartum maternal or fetal deaths occurred among all admissions. The intrapartum transfer rate averaged 17%, and declined steadily from a high of 28% in 1982 to a low of 7% in 1990. More in-depth review showed an overall primary cesarean birthrate of 1.8% and an operative birthrate of 4% among the 25,890 admissions and 22,490 births from 1985 to 1992. Detailed postpartum and newborn outcomes from 1982 to 1986 showed a neonatal intensive care unit admission rate of 1.5% and a one-week newborn readmission rate of 1.3% among newborns discharged within 12 to 24 hours; 85% of all newborns returned for follow-up care. This large longitudinal experience demonstrates excellent outcomes that can be achieved when nurse-midwives, working cooperatively with a multidisciplinary health care team, provide in-hospital birth center care to a predominately low-income Hispanic population using a variety of less-traditional intrapartum management techniques. Broader implications for making alternative maternity care services available for low-income women with nurse-midwives and nurses playing a central role are discussed.

Interpretation of biophysical profiles by nurses and physicians

OBJECTIVE

To determine the agreement between nurse and physician interpretation of biophysical profile scores.

DESIGN

A prospective evaluation of videotaped biophysical profiles was independently scored by four nurse and four physician interpreters and compared to that of an expert physician.

SETTING

The fetal assessment center of a large tertiary-care center; study included women from public and private practices.

PATIENTS

Twenty-three women with high-risk pregnancies who were regularly scheduled for a biophysical profile. Women pregnant with multiple fetuses or whose fetuses were less than 28 weeks' gestational age or had severe fetal anomalies were excluded.

MAIN OUTCOME MEASURE

The proportion of agreement between the physicians and nurses and the physician expert was calculated for each biophysical profile criterion.

RESULTS

The kappa statistic was used to evaluate the proportion of agreement with the "gold standard." When compared with the expert, physicians showed 60% moderate or substantial agreement, and the nurses showed 80% moderate or substantial agreement.

CONCLUSIONS

Nurses' interpretations of biophysical profiles were at least as reliable as physicians' when compared with an expert reviewer.

Time associated with components of clinical services rendered by nurse-midwives. Sample data from phase II of nurse-midwifery care to vulnerable populations in the United States

The purpose of this article is to present prospective data from phase II of "Nurse-Midwifery Care to Vulnerable Populations in the United States" about the components of clinical services provided to women and infants by CNMs, and the amount of time spent providing services in a variety of settings. Three hundred sixty nine CNMs collected data on 16,729 client visits. The results indicate that the amount of time taken by a CNM to conduct an ambulatory client visit is similar, regardless of site. There were slight differences in the length of time taken for major components of a visit between sites but, in general, there was a remarkable similarity. The amounts of time spent in intrapartum care and inpatient visits is also reviewed.

Midwifery care for women with human immunodeficiency virus disease in pregnancy. A demonstration project at the Johns Hopkins Hospital

Nurse-midwives at the Johns Hopkins Hospital, in conjunction with their colleagues in obstetrics, pediatrics, and infectious disease, are participating in a demonstration project designed to provide continuity of care for women with HIV disease in pregnancy. In the past 19 months, 73 women have been enrolled in the project. This article describes how the midwifery model of care has been integrated into the existing system of routine obstetric care and specialized HIV-related care at the institution. This project could serve as a model for others who are redesigning health care delivery systems to include more nurse-midwives, especially those who are trying to adapt to an ever-increasing number of women experiencing some phase of HIV disease during their pregnancy. A companion article explains the midwifery and medical protocols used in the project and discusses other clinically relevant issues.

Nurse-midwifery management of women with human immunodeficiency virus disease

Primary care for women with human immunodeficiency virus (HIV) disease is appropriately provided by nurse-midwives within a well-coordinated system of medical consultation and referral. The issues of access to care, partner notification, reproductive choice, and breast-feeding are discussed. The nature of the collaborative management of HIV in pregnancy is explained. Management issues include the effects of HIV infection and pregnancy upon each other, perinatal transmission risks and postpartum needs, family planning, and gynecologic needs. Clinical care guidelines are included.

Nurse-midwifery care to vulnerable populations. Phase I: Demographic characteristics of the National CNM Sample

The purpose of this article is to describe the extent to which certified nurse-midwives (CNMs) provide care to vulnerable populations in the United States and the source of reimbursement for this care. The data were obtained from the first phase of a national study to address the characteristics of women served and cost of care provided by CNMs. Results were analyzed nationally and by American College of Nurse-Midwives regions. Certified nurse-midwives in all types of practices are providing care to women from populations that are vulnerable to poorer than average outcomes of childbirth because of age, socioeconomic status, refugee status, and ethnicity. Ninety-nine percent of CNMs report serving at least one group of vulnerable women, and CNMs in the inner city and rural practices serve several groups. The vast majority of CNMs are salaried; only 11% receive their primary income from fee-for-service. Fifty percent of the payment for CNM services is from Medicaid and government-subsidized sources whereas less than 20% comes from private insurance. Source of income varies by type of setting in which the CNM attends births. The results suggest that CNMs, as a group, make a major contribution to the care of vulnerable populations.

Coupling of fetal movement and fetal heart rate accelerations as an indicator of fetal health

OBJECTIVE

The purpose of this study was to determine the clinical value of identified coupling of fetal heart rate (FHR) accelerations (more than five beats per minute for any duration) with objectively detected fetal movements.

METHODS

One hundred sixty-six patients underwent routine fetal testing using a Doppler device that recognized both FHR and fetal movements. The coupling index was determined to be the percentage of fetal movements associated with FHR accelerations, and various coupling indices were compared with nonstress test (NST) results.

RESULTS

A coupling index above 25% and below 75% compared well with the traditional NST by standard epidemiologic criteria and by the kappa statistic.

CONCLUSION

Coupling of even small FHR accelerations and fetal movements could substitute for or replace the NST in antenatal screening.

A comparison of the auscultated acceleration test and the nonstress test as predictors of perinatal outcomes

In this prospective study, the predictive ability of the nonstress test (NST), the most widely used antepartum screening test to assess fetal well-being, was compared with that of the auscultated acceleration test (AAT) in predicting perinatal outcomes. The AAT is a more easily administered test than the NST, and, unlike the NST, does not use electronic fetal monitors. Study subjects were 205 women with singleton pregnancies greater than 34 weeks' gestation, whose delivery occurred within 7 days of receiving antepartum testing by NST at Johns Hopkins Hospital. The AAT yielded better prediction of poor perinatal outcomes than the NST. The NST, however, was a significantly better predictor of favorable outcomes than the AAT. The AAT has the potential to affect perinatal care if false positive results can be decreased through further research.

The effect of maternal bearing-down efforts on arterial umbilical cord pH and length of the second stage of labor

This study was conducted to compare two types of maternal bearing-down techniques as they relate to the fetal and maternal outcomes of arterial umbilical cord blood pH and length of the second stage of labor. A convenience sample was drawn from the laboring women at a 305-bed medical center who met specific inclusion criteria. Women self-selected to one of two bearing-down groups: spontaneous or Valsalva. Subjects were given specific instructions for the chosen method. The Valsalva group was comprised of 14 subjects, and the spontaneous group was comprised of 16 subjects. The groups were found to be comparable after analysis of several variables. Results of statistical analysis using t-test indicated that, in this small sample, there is no relationship between the second stage bearing-down method and arterial umbilical cord blood pH or length of the second stage of labor. These findings support the conclusions of several studies: using the spontaneous bearing-down method does not have a deleterious effect upon the mother or the fetus. Several recommendations are made for future research based on methodological issues raised during this study.

Population differences of fetal biophysical and behavioral characteristics

Population differences in nonstress test reactivity have been reported with a threefold increase in the likelihood of nonreactive nonstress tests observed in black fetuses as compared with white fetuses. We analyzed fetal behavioral states and fetal heart rates in 14 black and 15 white fetuses at term to explain this observed difference in nonstress test reactivity. Two-hour Doppler and real-time ultrasonographic examination of each patient revealed no differences in percent time spent in the four behavioral states between the two populations. A 9.5 beats/min difference between black and white fetuses was found. The higher baseline heart rate of the black fetuses persisted in each behavioral state and may affect nonstress test reactivity because of rate-dependent decreases in short-term variability and rate-dependent limitations of maximal acceleration amplitude.

Fetal movement during labor

The prognostic significance of antepartum fetal movement is well known; therefore it may be a variable in intrapartum fetal well-being. We report the simultaneous observation of fetal movement with fetal heart rate and uterine contractions by processed Doppler actograph signals during spontaneous labor of 22 normal women with normal fetal outcome. The mean percent incidence of fetal movement during labor was 17.3%. The percentage occurring during uterine contractions was 65.9%. Of all uterine contractions, 89.8% were associated with fetal movement. The proportion of time the fetus spent moving during uterine contractions (21.4%) was higher than between uterine contractions (12.9%). Uterine contractions associated with fetal movement were significantly longer than those not associated with fetal movement (p less than 0.0001). Mean percent incidence of fetal movement did not differ significantly between latent and active-phase labor. This study demonstrates a clear relationship between fetal movement and uterine contractions in labor.

Antepartum fetal assessment. A nurse-midwifery perspective

This article provides an in-depth review of the most current antepartum fetal assessment techniques. Included in this review are both low- and high-technology methods, such as fetal movement counting, nonstress tests, vibroacoustic stimulation, auscultated acceleration tests, contraction stress tests, amniotic fluid index, biophysical profiles, and Doppler velocimetry. The interpretation of antepartum testing using screening test validity concepts is addressed, as is the current and emerging role of the nurse-midwife in fetal assessment. By integrating content on maternal and fetal physiology, including a critical review of current literature, together with relevant clinical information, including protocols, this article provides a useful guide to fetal assessment for nurse-midwives.

Midwifery education and research in the future

This paper is adapted from a plenary lecture presented at the 22nd International Congress, International Confederation of Midwives, Kobe, Japan, October 11, 1990. Midwifery education and research in the past, present, and future are discussed. Special emphasis is placed on innovation in midwifery education to address more adequately the worldwide concern about safe motherhood. Midwifery research and the integral components of information and inquiry are also discussed, with emphasis on five major areas in need of further research. Collaborative education and research are explored from both an interdisciplinary and an international perspective.

Trends in selected obstetric complications from University Hospital, Kuala Lumpur, Malaysia

Trends in selected pregnancy complications from 1969 to 1987 in a tertiary hospital in Malaysia are presented. Complications reviewed were abortion, ectopic pregnancy, anemia, hypertension, hyperemesis, antepartum and postpartum hemorrhage. Possible explanations for the observed trends were discussed, including the role of improved obstetric care and changes in the characteristics of the childbearing population. The data presented give some indication of maternal morbidity in the childbearing population served by this tertiary center and should lead to improvements in provision of services as well as in health data collection in the future.

Population differences affect nonstress test reactivity

The nonstress test (NST) is the most widely used test of fetal well-being. Recently it has been suggested that race may play a role in NST reactivity. The objective of this research was to explore population variables in addition to race that may influence NST reactivity. Study subjects were 1263 black and 658 white women who underwent NST in the week preceding delivery at a tertiary facility. Retrospective analysis of data from a comprehensive database was conducted. It was found that the percentage of black women with a nonreactive NST was more than three times the percentage of white women, and that from 35 weeks' to 42 weeks' gestation there were significantly fewer reactive NSTs for blacks than for whites (P less than .05). Racial differences in NST results persisted in a logistic regression analysis controlling for several population variables including pregnancy complications and demographic and behavioral factors (odds ratio 3.81; 95% CI 3.03 to 4.78). Regression analysis also confirmed that gestational age, maternal education, epilepsy, and smoking significantly influenced NST reactivity. These results indicate that population differences in NST reactivity exist at our facility. Further prospective study of population determinants of NST reactivity is needed to determine how race, test indication, and other clinical, demographic, and behavioral variables should be used in interpretation of tests of fetal well-being. Standard criteria for NST testing may not be useful in all obstetrical populations.

Investigation of institutional differences in primary cesarean birth rates

Differences in primary cesarean birth rates between a maternity center staffed by certified nurse-midwives (CNM) with physician backup on the premises and a university teaching hospital staffed by resident and attending physicians were studied. The study sample included 796 and 804 women, similar in demographics, who received their prenatal and intrapartum care in the respective sites in 1977 and 1978. Study results indicate a significantly lower rate of primary cesarean birth at the maternity center than at the university hospital that was independent of institutional differences in the indications for abdominal delivery. Although cesarean birth was related to contracted pelvis (at labor), fetal malpresentation, and placental bleeding at both institutions, it was significantly associated with preeclampsia, primiparity, fetal distress, and maternal age only at the university hospital. There were no noteworthy differences in pregnancy outcomes for women delivered vaginally or by cesarean, except for more newborns with low Apgar scores among primary cesarean births at the university hospital. A likely explanation for these findings is differing labor and delivery management styles between the providers of care at the two institutions.

Doppler recordings of fetal movement: II. Comparison with maternal perception

Twenty-seven women were studied to assess the relationship between maternally perceived fetal movement and that recorded by a Doppler device. Eighty-eight percent (433 of 492) of maternally perceived movements were detected by Doppler, but only 16% of movements detected by Doppler were maternally perceived (433 of 2196). When complex movements were classified by duration, those movements lasting between 20-60 seconds were most likely (correlation greater than 0.9) to be perceived by the mother. This Doppler method has the potential to replace maternal event marking and other techniques in the recording of fetal movement.

A prospective comparison of hourly and quarter-hourly oxytocin dose increase intervals for the induction of labor at term

Fifty-two women undergoing labor induction and vaginal delivery at term were randomized between two oxytocin infusion protocols, involving hourly versus quarter-hourly increases in dose. Potential differences were sought of duration of labor, amount of uterine activity generated, and amount of oxytocin required. Starting at 0.5 mU/minute, oxytocin infusion was increased regularly in small increments every hour or every 15 minutes, according to group assignment. No differences were observed in potentially confounding clinical and demographic factors between the groups, including time to ruptured membranes. There were no clinically or statistically significant differences found for the duration of any phase or stage of labor, quantitative assessment of uterine activity, incidence of hyperstimulation, or neonatal outcome. The average dose of oxytocin used was lower in the hourly than in the quarter-hourly, protocol (4.4 versus 6.7 mU/minute; P less than .005). Significantly fewer patients on the hourly protocol required a maximum infusion rate exceeding 8 mU/minute (P less than .05). More patients on the hourly protocol either had oxytocin discontinued completely or were maintained at 4 mU/minute or less during the active phase of labor (P less than .05 and P less than .001, respectively). We conclude that a slower rate of increase in oxytocin administration via continuous infusion results in no prolongation of any phase of induced labor, while permitting lower infusion rates of the drug.

Nurse-midwives speak out on research. Results of the 1987-88 needs assessment survey, Part 2

Part 1 of this 2 part article appeared in the preceding (January/February) issue of this journal. Results from the 1987-88 ACNM Needs Assessment Survey pertaining to research are presented. As with other topics addressed in Part 1 of the Needs Assessment Survey, subgroup analysis was conducted to determine if certain groups of CNMs had differing views and perceived needs regarding research. Survey responses were categorized to include: 1) CNM attitudes about research, 2) importance of ACNM research related services and activities, 3) use of a uniform data collection instrument, 4) CNM access to research resources, and 5) views on funding for ACNM research activities. Discussion of the implications of the results as they relate to development of the goals and objectives of the newly formed ACNM Division of Research is included.

Nurse-midwives speak out on the ACNM. Results of the 1987-88 Needs Assessment Survey, Part 1

This article presents the purposes and methods of the first Needs Assessment Survey of all nurse-midwives who have been certified by the ACNM. A detailed summary of the general results of the survey is provided, and includes the perceptions of respondents about the ACNM organizational structure, goals, leadership, and services. Analyses of differences in response based on such variables as membership status, minority status, years since certification, level of educational preparation, work setting, and region of residence are also presented. The article concludes with a discussion of the implications for the nurse-midwifery profession. Part 2 will appear in JNM 34:2.

Auscultated fetal heart rate accelerations. III. Use of vibratory acoustic stimulation

The auscultated acceleration test has been proposed as a simple, inexpensive screening test for fetal health; previous studies of the auscultated acceleration test used external stimulation to elicit fetal movement. This study was conducted to explore the ability of the auscultated acceleration test to predict nonstress test results when vibratory acoustic stimulation is used to elicit fetal reactivity. After antepartum nonstress testing on 100 gravid women between 28 and 43 weeks' gestation, a 6-minute auscultated acceleration test protocol was performed with two vibratory acoustic stimulations to the maternal abdomen if no spontaneous fetal heart rate acceleration occurred. The ability of the auscultated acceleration test to predict nonstress test results after selected variables were controlled for was as follows: sensitivity, 75%; specificity, 97.6%; false-positive results, 14.3%; and false-negative results, 4.7%. Logistic regression analysis indicated that, in addition to the auscultated acceleration test, gestational age and race contributed significantly to the prediction of nonstress test results. Although specificity and the false-positive rate were improved, the use of vibratory acoustic stimulations to elicit fetal movement did not improve the validity of the auscultated acceleration test in terms of sensitivity and false-negative results over previous studies. However, the auscultated acceleration test continues to show potential as an initial screening test for fetal assessment. In addition to recommendations for further research, methodologic issues related to sampling techniques are identified.