More From NYT’s blog “Fixes” – Previous contributions to this series on the topic of reducing the rate of unnecessary Cesareans and other unproductive obstetrical interventions in normal childbirth in healthy women.
- How a new trend for hospitals to employ obstetricians as “hospitalists” is reducing the use of interventions speed up labor and Cesarean section rate in those institutions.
- How other hospitals are making a concerted effort to reduce the routine medicalization ofnormal childbirth by promoting the midwifery model of care — physiological management of labor and birth healthy women with normal pregnancies — a strategy described by one hospital official as “the art of doing nothing well”.
Since OB hospitalists spend all their time delivering babies, they are also expert in vaginal operative deliveries with forceps or vacuum — skills that can prevent C-sections. “If the baby’s shoulders are stuck, they call me and I stand by the door while the delivery goes on,” said Rob Olson, an OB hospitalist in Bellingham, Wash. “If I hear the baby cry I can leave. If I hear the doctor cry, I go deliver the baby.”
Brian Iriye, an OB who is managing partner of the Las Vegas High Risk Pregnancy Center, led a study of another Las Vegas hospital that found that when it hired hospitalists, the C-section rate decreased by 27 percent. The hospital had first tried having its private practice doctors take rotating shifts. Even though that model, too, guaranteed that a physician was always present, it had no effect on C-section rates. Iriye speculated that doctors didn’t want to let their competitors deliver their patients’ babies. Hospitalists, by contrast, have no patients of their own and are not seen as competitors. “It makes V.B.A.C. possible,” said Iriye.
Hospitalists are a fairly new phenomenon. Olson, who is founder of the Society of OB/Gyn Hospitalists, said that eight years ago he knew of only 15 hospitals that employed OB hospitalists, and now 212 do. But that’s still a tiny percentage of American hospitals.
This article (free registration required) discusses Iriye’s study, and other studies showing that hospitalists are associated with reductions in “adverse events” — hospital-speak for maternal deaths and babies’ severe neurodevelopment impairment. Also —— a point that gets hospitals’ attention — hospitalists in one study were associated with a 90 percent reduction in malpractice payouts.
If you are a patient at General in a normal pregnancy, you can choose a nurse-midwife as your primary caregiver — you’ll see a doctor only if there are complications. Nationally, nurse-midwives are rare; Morton says they attend 7 percent of all births. Even rarer is General’s model of an autonomous nurse-midwife service with its own caseloads.
The clout of nurses at General is another way the hospital encourages labor to take its course. The hospital’s chief executive officer is a nurse, as was her immediate predecessor. Nurse-midwives teach in the medical school in addition to the school of nursing. In the labor and delivery ward, nurse-midwives led a successful effort to greatly decrease the use of episiotomies and were co-leaders in developing new guidelines for V.B.A.C.s. The nurse-midwife service implemented CenteringPregnancy group medical appointments for prenatal care — the groups meet not in the hospital, but in community centers in the neighborhoods where General’s patients live.
Patients at General learn early in their pregnancies about the risks of C-sections. Ana Delgado, a certified nurse-midwife who is assistant director of inpatient obstetrics, said that midwives are trained in “the art of doing nothing, well {see Faith’s note below} Patients get the message from the beginning: We will intervene when needed, but if you don’t need it, we don’t.”
“A lot of us recognize that midwives are the real experts in labor,” said Vargas, the OB chief at General. “I trained as a high-risk obstetrician. I’m best at dealing with complications. So I stand by and try to be patient.” San Francisco General encourages and rewards patience. Any hospital wishing to bring down its C-section rates might start there.
NOTE from Editor about the expression “The art of doing nothing, well” quoted by Ana Delgado, CNM, assistant director of inpatient obstetrics at San Francisco General Hospital CNM, in the above article.
This elemental characterization of midwifery as ‘the art of doing nothing, well, was an original statement by me in a 1998 as a participant in a Delphi study by Holly Kennedy, CNM, PhD based on the perspectives of “exemplary midwives” identified by leadership circles in the midwifery profession.
As director of the nurse midwifery program at the University of Rhode Island) at the time, she was conducting qualitative research to identify the practice characteristics and processes of exemplary midwives.
It was a great honor to discover that I had been identified as an exemplary midwife.
Holly invited all of us to participate in her research by providing written answers a long series of questions about the most fundamental issues of midwifery — the basic needs of childbearing women and how we, as midwives, identified and met those challenges.
My answers to her questionnaire identified the essence of midwifery as a supportive process whose goal was to support the normal biology and physiology of labor and birth. Of necessity, this also include both psychological and sociological needs experienced by laboring women. When such needs go unrecognized and/or unmet, the likelihood
As provider of physiologically-based (as contrasted with medially-based) care, it was vitally important that this be done without unnecessarily disturbing these functions unless they became abnormal or dysfunctional.
I defined the role of the midwife as that of an “educated observer with emergency response capacity”. I further characterized the process of providing this responsive care as “the art of doing nothing, well”.
Prior to publishing the study, Holly contacted me and asked permission to the use the terminology coined by me to characterize the essence of midwifery care to be “the art of doing ‘nothing’ well” as the a core premise of the finding of her research.
I was happy to say yes, feel very gratified to see my expression — the art of doing nothing well be identified as the foundational essence of the midwifery model of care — physiologically- based care.
However, as exemplary midwife contributors, none of us were identified in the final publication of her work. I also was surprised and disappointed by the footnote that identified the word “midwife” to only apply to CNMs.
Nonetheless, I’m very happy to see that my expression has grown legs and is now showing up in the national media.
_________________________________________________________________
A Model Of Exemplary Midwifery Practice: Results Of A Delphi Study
Holly Powell Kennedy CNM, PhD, FACNM
DOI: 10.1016/S1526-9523(99)00018-5
2000 American College of Nurse Midwives
Journal of Midwifery & Women’s Health
Volume 45, Issue 1, pages 4–19, January-February 2000
Article first published online: 26 JAN 2011
ABSTRACT
What is unique and exemplary about the midwifery model of care? Does exemplary midwifery care result in improved outcomes for the recipient(s) of that care? These are the questions that the profession of midwifery grapples with today within the context of a changing health care arena. Exemplary midwives, and women who had received their care, came to consensus about these issues in a Delphi study.
A model of exemplary midwifery care is presented based on the identification of essential elements aligned within three dimensions: therapeutics, caring, and the profession of midwifery. Supporting the normalcy of pregnancy and birth, vigilance and attention to detail, and respecting the uniqueness of the woman, were several of many processes of care identified.
The critical difference that emerged was the art of doing “nothing” well.
By ensuring that normalcy continued through vigilant and attentive care, the midwives were content to foster the normal processes of labor and birth, intervening and using technology only when the individual situation required.
Health care, whether in the gynecologic setting or during pregnancy, was geared to help the woman achieve a level of control of the process and outcome. The ultimate outcomes were optimal health in the given situation, and the experience of health care that is both respectful and empowering. The model provides structure for future research on the unique aspects of midwifery care to support its correlation with excellent outcomes and value in health care economics.
________________________________________________________________
Am J Public Health. 2002 November; 92(11): 1759–1760.
PMCID: PMC1447324
The Midwife as an “Instrument” of Care
Holly Powell Kennedy, PhD, CNM
Author information ► Article notes ► Copyright and License information ►
This article has been cited by other articles in PMC.
A qualitative study was conducted with midwives from across the United States during 2000–2001 that suggests alternative approaches to caring for women and infants during pregnancy and birth. This study was a follow-up of a Delphi study in which 64 expert midwives and 71 recipients of midwife care sought to achieve consensus on dimensions of exemplary care.1 (Delphi studies involve the use of a panel of identified experts to come to consensus, by means of an anonymous survey, about a complex problem or issue.)
The dimensions identified were as follows:
- (1) therapeutics (how the midwife decided to use specific therapies in practice),
- (2) caring (the midwife’s relationship with the woman and her family), and
- (3) profession (how the profession of midwifery was enhanced by exemplary practice).
As a means of corroborating these findings, 11 midwives who took part in the original study were interviewed on videotape providing narratives about their practice. This report presents the results of this follow-up study. The mean age of the sample was 54 years (range: 49–62 years), and the median number of years in practice was 20 (range: 6–29). All of the participants practiced full-scope midwifery, providing both childbearing and gynecologic care. Hospitals served as the birth setting for 64% of the midwives; 18% attended births at homes, and 18% did so in birth centers. Most of the participants (64%) had master’s-level educations.
Videotapes were transcribed and analyzed via constant comparative methods used in grounded theory. Findings showed that several processes of care dominated, and these results supported and extended those of the earlier study. For example, many of the midwives used the phrase “the art of doing nothing well” to describe a process of care centered on the midwife’s presence with the laboring woman and the creation of an environment supporting pregnancy and birth as normal processes.
This process included selective use of interventions based on clinical judgment and the woman’s wishes.
The midwives described an intricate, attentive, and even vigilant stance in regard to assessment and guardianship of the birth process.
They expressed a belief that, unless proven otherwise, the mother and fetus are almost always physiologically able to complete the process, with the midwife as a present but nondominant force. One specific approach included the creation of an environment that was safe and that inspired a sense of normalcy.
According to one midwife:
What I have found that I need to continue to do is [to continue to] articulate how well mom is doing in a really low-intervention process. Otherwise, if I slip and stay silent, things get done [that don’t need to be done]. . . .
I want everyone in the room to continuously hear that this [maternal and fetal assessment during labor] is normal; the silence, that road, gives residents, interns, nurses the . . . [opportunity] to fill it with their fears and anxiety.
Care was, above all, respectful and the midwife was considered an invited guest, worked with the woman and her family as a partner, and was ready to take charge, but only if necessary:
I was a guest and I was invited to be an expert, but only if they needed me to be one. . . . I would talk about how, “Here’s the circle of safety, and as long as you give me normal [signs of continued normalcy for mother and baby] within it, my job is to just stay outside the boundaries. When you bump the boundaries, my job is to gently guide you back.”
Pregnancy and birth were thought to have important physical and emotional effects. Assisting the woman to achieve her goals during the birth was considered a way of helping her to assimilate a new motherhood role, one that would require strength.
In the words of one of the midwives:
That is to me what I think a midwife should be able to do: to somehow find that part of a woman, whatever that part is—and it can be in many different ways—that enables her to reach that strength and retain that strength.
The midwives were not opposed to technology or interventions in general and, in fact, used them creatively and expediently when needed. Optimal health of the mother and infant was paramount, and sometimes an epidural or an operative delivery was required. However, they noted that the low-technology use of their presence was vitally important and that it became an instrument in the care process.
For example:
The piece [element] that I have found that is most critical to me to reflect midwives, and me as a midwife, is quiet and spaciousness within a very, very busy frenetic environment.
So, each time that I present myself to a client, that’s where I go. I go to a place of introducing myself, sitting down and asking the client what she needs. Just giving them the opportunity to know that this is their special time.
What I have seen happen is that all of a sudden there is this sigh of “Okay, everything is fine, nothing is going to happen to me, I’m safe and I’m being attended to.”
A model of care in which providers themselves are the “instrument” of care seems counter to the growing emphasis on technology in the treatment of women during pregnancy. Working to create an environment of calm, trusting in the normal birth process, and being present during labor may appear to be “nothing” or inconsequential, but in reality it is likely to be very significant.
The United States spends more per capita than any other industrialized nation on health care, yet the country ranks only 27th in terms of infant mortality.2 Much of that expenditure is aimed toward technological advances rather than personalized care during pregnancy and birth.
In fact, the majority of countries with the best birth outcomes have midwives as frontline providers of maternity services.3
While midwifery has been shown to produce excellent outcomes,4–7 and while the practice has grown markedly,8 it is still seen as an alternative maternity care model in the United States. To date, there has been little research on how midwives achieve their remarkable results, although a recent review indicated that birth outcomes are improved when the mother has a supportive caregiver present during labor.9
The findings of this qualitative study suggest that midwives’ processes of caring for women may have significant health effects. Future investigation is essential to identify these processes more definitively and to correlate the midwifery model of care with both short-and long-term maternal, infant, and women’s-health outcomes.
Acknowledgments
This program of research was supported by an American College of Nurse-Midwives (ACNM) Foundation/Ortho-McNeil pharmaceutical fellowship for graduate education, the University of Rhode Island Foundation, and the Rhode Island Chapter of ACNM.
Human Participant Protection
This research was approved by the institutional review board of the University of Rhode Island, and written informed consent was obtained from all participants.
References
1. Kennedy HP. A model of exemplary midwifery practice: results of a Delphi study. J Midwifery Womens Health. 2000;45:4–19. [PubMed]
2. Centers for Disease Control and Prevention. Health, United States, 2001. Available at: http://www.cdc.gov/nchs/data/hus/hus01.pdf. Accessed January 16, 2002.
3. Dower CM, Miller JE, O’Neil EH, Task Force for Midwifery. Charting a Course for the 21st Century: The Future of Midwifery.San Francisco, Calif: Pew Health Professions Commission, University of California, San Francisco, Center for the Health Professions; 1999.
4. MacDorman MF, Singh GK. Midwifery care, social and medical risk factors, and birth outcomes in the USA. J Epidemiol Community Health. 1998;52:310–317. [PMC free article] [PubMed]
5. Murphy PA, Fullerton J. Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol. 1998;92:461–470. [PubMed]
6. Gabay M, Wolfe SM. Nurse-midwifery: the beneficial alternative. Public Health Rep. 1997;112:386–395. [PMC free article] [PubMed]
7. Rosenblatt RA, Dobie S, Hart LG, et al. Interspecialty differences in the obstetric care of low-risk women. Am J Public Health. 1997;87:344–351. [PMC free article] [PubMed]
8. American College of Nurse-Midwives. A sightseer’s guide to nurse-midwifery, 2001. Available at: http://www.midwife.org/week/day.cfm?id=tue. Accessed January 16, 2002.
9. Hodnett ED. Caregiver Support for Women During Childbirth (Cochrane Review).Oxford, England: Update Software; 2001.
___________________________________________________________
http://midwifeinsight.com/articles/what-makes-midwives-different/
What Makes Midwives Different ~ Nancy Sullivan, CNM
March 24, 2008 Midwifery Practice
The Art of Doing “Nothing” Well: What Makes Midwives Different.
Results of a Delphi study by Holly Powell Kennedy, CNM, PhD, FACNM
In the January/February 2000 Journal of Midwifery and Women’s Health, Holly Powell Kennedy reports on the results of her study of “exemplary” midwives and their patients to try and learn what is unique and exemplary about the midwifery model of care. That is, what is different about the way that midwives provide care from the way that physicians provide care?
The critical difference that emerged from this study was the midwives’ art of doing “nothing” well; that is, being there with the woman, being vigilant to assure that things were going well, but not intervening or using technology unless it was necessary.
One woman summed it up by saying,
“A large part of her providing the kind of care we wanted is what she didn’t do… she didn’t rush anything … she said to me your body knows what to do so just let it do it.”
Some of the qualities that were strongly identified by women with midwifery care were belief in the normalcy of birth, exceptional clinical skills and judgment, and commitment to the health of women and families. The following terms were also strongly identified by women with the midwives who cared for them:
calm, patient, confident, decisive, intelligent, mature, persistent, honest, compassionate, trustworthy, flexible, understanding and supportive, warm, nonjudgmental, gentle, nurturing, not focused on self, realistic, reassuring and soothing, possessing a generous and loving spirit, possessing a sense of homor, and being personable
Why is it important to try to identify what it is that midwives do differently and do well? Midwifery care has been shown to be safe, effective, and satisfying for women, but there has been little research on why this is so, that is, on the process of midwifery care.
If women are to continue to have access to midwifery care in the future, midwives must be able to describe our philosophy and process of care and link these attributes to our outcomes.
Holly Kennedy’s landmark study is a significant contribution to this effort.
(Kennedy HP (2000). A model of exemplary midwifery practice: results of a Delphi study. J Midwifery & Women’s Health, Volume 45, No. 1, pp. 4-19.)
___________________________________________________________
http://midwifeinsight.com/articles/about-midwives/
About Midwives, Midwifery Practice, Pregnancy
Nancy Sullivan, CNM ~ May 4, 2008
Congratulations!
If you have found your way to this page, you have already started to think about a midwife as a possible attendant at the birth of your baby.
Now you want to find out more about midwives, who we are, what we believe and practice, where we do what we do, how we are different from physicians.
Holly Powell Kennedy, a certified nurse-midwife, studied “exemplary” midwives and their patients to try and learn what is unique and exemplary about the midwifery model of care. That is, what is different about the way that midwives provide care from the way that physicians provide care?
The critical difference that emerged from Holly’s study was the midwives’ art of doing “nothing” well; that is, being there with the woman, being vigilant to assure that things were going well, but not intervening or using technology unless it was necessary.
One woman summed it up by saying,
“A large part of her providing the kind of care we wanted is what she didn’t do… she didn’t rush anything … she said to me your body knows what to do so just let it do it.”
Some of the qualities that were strongly identified by women with midwifery care were belief in the normalcy of birth, exceptional clinical skills and judgment, and commitment to the health of women and families.
The following terms were also strongly identified by women with the midwives who cared for them: calm, patient, confident, decisive, intelligent, mature, persistent, honest, compassionate, trustworthy, flexible, understanding and supportive, warm, nonjudgmental, gentle, nurturing, not focused on self, realistic, reassuring and soothing, possessing a generous and loving spirit, possessing a sense of homor, and being personable.
Why is it important to try to identify what it is that midwives do differently and do well?
Midwifery care has been shown to be safe, effective, and satisfying for women, but there has been little research on why this is so, that is, on the process of midwifery care. If women are to continue to have access to midwifery care in the future, midwives must be able to describe our philosophy and process of care and link these attributes to our outcomes. Holly Kennedy’s landmark study is a significant contribution to this effort. (Kennedy HP (2000). A model of exemplary midwifery practice: results of a Delphi study. J Midwifery & Women’s Health, Volume 45, No. 1, pp. 4-19.)
You may need some ammunition to convince your family or your friends that you are doing the right thing by deciding to have a midwife attend your birth. You will also want to find out about other professionals who work with midwives and enhance the experiences of pregnancy, labor and birth, and early parenthood. The following resources should be helpful to you.
The official source of information about certified nurse-midwives and certified midwives is the American College of Nurse-Midwives. The Midwives Alliance of North America has information about direct-entry midwives. Other sources of information about direct-entry midwives are Citizens for Midwifery (CfM), a consumer organization allied with MANA, a resource for midwives, birth professionals, parents, and others to find information about birth and parenting alternatives. Check the glossary and the history pages to find out more about the official midwifery organizations and types of midwives.
The Childbirth Connection has written an excellent pamphlet which you can download on their website entitled “Statement of the Rights of Childbearing Women”. It will give you some points to consider before or during your search for a midwife or other provider. Remember, first of all, you have the right to ask a prospective provider about her/his philosophy and practice! The best time to ask is before you make a decision.
The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and well-being of mothers, babies, and families. Their mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs. Their website will get you started thinking about your choices for childbirth. The information in this document is based on research evidence about the kinds of care that result in optimal outcomes for mother and baby. The CIMS website also provides more information about evidence-based maternity care for providers.
Midwifery care is supported by research. The Cochrane Collaboration is a systematic review of the research evidence about the effects of care given to women during pregnancy and childbirth. It classifies elements of care as effective, promising, not proven either way, or not worth using. The database is available in printed format as well as in a regularly updated electronic format. Now twenty years old, the Cochrane Database of Systematic Reviews continues to validate the midwifery model of care. For data on specific aspects of care, go to the Cochrane Pregnancy and Childbirth Group Abstracts.
______________________________________________
Linking midwifery practice to outcomes
Holly Powell Kennedy, University of Rhode Island
http://digitalcommons.uri.edu/dissertations/AAI9945209/
Abstract
How is excellence in the profession of midwifery defined? Does excellence result in improved outcomes for the recipient(s) of midwifery care. These are the questions that the profession of midwifery grapples with today within the context of a changing health care arena. The purpose of this research was to
- (a) describe exemplary midwifery practice,
- (b) link specific aspects of the process of exemplary practice to specific outcomes
- (c) initiate the development of an exemplary midwifery model of care
A Delphi study was conducted in 1998 using the perspectives of “exemplary midwives” identified by leadership circles in the midwifery profession. Women who had received care from these midwives were invited to participate in a parallel investigation. By using a variety of knowledgeable experts in the profession, and those with first hand knowledge of their care, the method allowed for consensus to emerge about the issues the research questions posed. ^
A model of exemplary midwifery care emerged from the responses of the midwives in the study that was well supported by the recipients of care. Three dimensions of care were identified, each with key processes which were supported by qualities and traits of the midwife. The first dimension of therapeutics reflected the philosophy supporting the choice and use of therapies by the exemplary midwife.
The second dimension of caring reflected the philosophy of care by the exemplary midwife. The final dimension was the profession of midwifery, which is supported by the exemplary practice of midwives. ^ There is little research that links specific processes of care used by midwives to specific outcomes for the woman, her newborn, or her family. This is a critical deficit; therefore research is essential to gain knowledge about how those processes of care are linked to outcomes. This study attempted to bridge that gap. Further research is crucial to test the model in actual practice settings to support the midwifery model as a national standard of care. ^
Subject Area
Anthropology, Cultural|Health Sciences, Obstetrics and Gynecology|Health Sciences, Nursing|Health Sciences, Public Health
Recommended Citation
Holly Powell Kennedy, “Linking midwifery practice to outcomes” (1999). Dissertations and Master’s Theses (Campus Access). Paper AAI9945209.
http://digitalcommons.uri.edu/dissertations/AAI9945209
{ 0 comments… add one now }