As we enter the season of Advent we pray that indeed justice will reign in this land. We pray that a culture of violence and impunity will be replaced by a culture of peace. We pray that those who experience an environment of fear will, as Jeremiah pronounced, �experience salvation and will live in safety.�
This paper describes the re-emergence of direct-entry midwifery in the United States, and focuses specifically on the over 1,000 midwives nationwide who are licensed in the 16 states where direct-entry midwifery is legal and regulated, and/or certified by the North American Registry of Midwives; it does not focus on direct-entry midwives or nurse-midwives who are certified by the American College of Nurse-Midwives Certification Council, Inc. Professional developments of direct-entry midwives are highlighted, including the establishment of core competencies and articulation of values, the creation of a certification process, and development of education program accreditation. The current status of licensed midwives in Washington State, where state policies have supported the development of direct-entry midwifery and the integration of direct-entry midwives into managed care systems, is presented as one example of the evolution of professional direct-entry midwifery in this country. Additionally, recommendations from the UCSF Center for the Health Professions Taskforce on Midwifery, which address particular areas of concern for direct-entry midwives, are discussed.
Vaginal birth is a recognized factor in perineal tissue damage and postpartum perineal pain. This study examined outcomes of 39 primiparous women who had spontaneous vaginal births. In a retrospective survey, women were asked to describe the type of pushing used to give birth and what the level of pain had been in the perineal (or vaginal) area during the first week postpartum. Labor and delivery chart data documented extent of episiotomy and/or laceration sustained. Eleven (28%) women reported using spontaneous bearing down efforts, and the remaining 28 (72%) were directed. Women who used spontaneous pushing were more likely to have intact perineums postpartum and less likely to have episiotomies, and second or third degree lacerations (χ2 [3, N = 39] = 8.1, P = .043). Other variables, such as maternal age, infant birth weight, length of second stage, provider type, and use of epidural, did not demonstrate a significant difference in perineal outcome. Further analysis showed a significant relationship between the extent of perineal disruption and pain (F [3,30] = 5.08, P = .005).
Approximately one of five pregnant women will experience bleeding during the first trimester of pregnancy. Of these women, about half will go on to have a spontaneous abortion. Comfort with triaging this common problem assists the midwife in providing quality, cost-effective care without eliminating continuity. This article reviews the causes of early pregnancy bleeding, offers strategies to differentiate between these causes, and identifies emergent from nonemergent presentations. Triage and management strategies for women with an impending or threatened spontaneous abortion are reviewed, exploring the alternative of expectant management.
Quality management is the umbrella under which quality assurance, quality improvement, and peer review reside. Although quality assurance monitors structure, process, and outcomes, quality improvement strives to continually improve care. Ongoing communication among team members and utilization of ancillary resources facilitates an effective quality management program in obstetric (OB) triage. This article describes the components of an OB triage quality management program and its relationship to risk management.
Smoking is the leading preventable cause of cancer, cardiovascular disease, and other premature deaths among women in the United States. Tobacco use accounts for 10% of perinatal mortality and is 100% preventable. Smoking is now more common among adolescent girls than among boys. Women’s health care providers are in an excellent position to intervene in this growing epidemic. This article addresses the health consequences of smoking as well as the social, economic, and emotional toll of cigarette smoking on the woman and her family. The reasons women begin and continue smoking in spite of known risks are examined. The role of the midwife in treating nicotine addiction in women throughout the life span is examined. A theoretical model based on the woman’s stage of change is presented as a framework for intervention. Behavioral and pharmacologic treatment recommendations are included. Opportunities for professional activities for community education and advocacy for a tobacco-free society are presented.
An introduction to the therapeutic applications, history, and theory of acupuncture and acupressure is presented. The traditional concepts that underlie treatment of imbalances of ch’i, or vital energy, are presented, along with the theories of yin and yang, meridians, vital substances, pathogenic factors, five phases, and the eight principle patterns. Contemporary Western research findings on the biochemical mediaries and effects of acupuncture are reviewed. Clinical applications to women’s reproductive care that are presented include treatment for dysmenorrhea, infertility, and childbearing. Data on clinical trials are reviewed, and licensure and educational preparation for practice of these modalities are discussed.
The aim of this study was to explore the lived experiences of postpartum depression among the Middle Eastern women living in Sydney, Australia. A phenomenologic research design was used to conduct in-depth, unstructured interviews with a purposive sample of 45 mothers who had experienced postpartum depression. The interviews were conducted in the mothers’ homes. Transcriptions of these interviews were analyzed using Colaizzi’s (1978) phenomenologic method. Five themes emerged that illustrated the Middle Eastern woman’s experiences of postpartum depression: 1) loneliness due to feelings of isolation and lack of social support, 2) helplessness due to inability to cope with the overwhelming task of fulfilling her traditional role as mother and wife, 3) fear of failure and being labeled a “bad mother” by in-laws, 4) insufficient knowledge about postpartum depression and available support services, and 5) coming to terms with postpartum depression by undertaking diversional activities and learning new skills. The exhaustive description of postpartum depression as experienced by the women that emerged from this phenomenologic study will help midwives and other health care professionals to be more sensitive to and understanding of women from different cultural backgrounds so that appropriate interventions can be designed that meet their specific needs and beliefs.
This Clinical Practice Exchange focuses on alternative healing in nurse-midwifery practice. It features interviews with six certified nurse-midwives (CNMs) who practice complementary therapies (CTs). The healing modalities they use include homeopathy, Healing Touch, hypnosis, herbal healing, mindfulness meditation, and water healing. The CNMs discuss their training to practice CTs, how they use alternative healing with clients, and how they integrate this with midwifery practice. The interviews are followed by an Alternative Healing Directory composed of 37 CNMs who responded to a Call, which appeared several times in Quickening and JNM. Each midwife's listing includes contact information, CTs practices, and special interests in networking with other CNMs about alternative healing. The JNM hopes that this Directory will be a catalyst for networking and communication that will move forward the discussion, practice, and research of alternative healing within the midwifery community.
Recent studies suggest that few maternity care providers are offering the assistance that women need to reduce or stop smoking during pregnancy. This is probably because of a lack of conviction among providers that they can be effective, a perception that they lack counseling skills, and the absence of reimbursement for counseling and self-help materials. Midwives have strong counseling skills and materials will soon be available that can help them and others become trained smoking counselors. Thus, midwives can easily adopt the techniques that have been shown effective in reducing or stopping smoking during pregnancy. These are a 5- to 10-minute counseling session at the first prenatal visit by a trained provider plus appropriate print materials (pregnancy-specific and culturally- and reading-level-appropriate). Guiding the smoker to select a date for quitting and checking on smoking status at each visit increase the likelihood of behavior change. These techniques should increase the quit rate, over spontaneous quitting, by 10%–20%. Managed care organizations looking for ways to reduce costly hospitalizations for low birth weight infants or ambulatory care visits for smoking-related illnesses in infants and children should support this intervention. Medicaid and tobacco settlement funds are potential sources of reimbursement for counseling and educational materials.
Service-learning entwines community work/volunteerism with midwifery academic instruction, taking the student outside the traditional clinical realm and placing the experience into community-based projects. These projects draw on academic principles, public/community health, liberal arts, and hands on delivery, enticing the student to delve deeper into the lives of the women and families they will be serving. Service-learning directs the student to fully embrace the midwifery philosophy as espoused by the American College of Nurse-Midwives. The experiences of the nurse-midwifery students at the University of Missouri-Columbia are described to show the depth and variety of service-learning as it reflects the scope of well woman care.
This article focuses on midwifery as one solution to many of the problems that confront contemporary American obstetrics. Documented evidence with historic perspective that supports the view that midwifery should become the mainstream in maternity care in the United States, not an alternative, is presented. The role differences and conflicts that tend to arise between doctors and midwives are discussed and collaboration between the two professional groups is suggested as yet another solution to the problem.
The midwifery and medical models for the care of pregnant women are based on particular perspectives on pregnancy and birth. The approaches resulting from these perspectives are complementary and, as a result of midwives and physicians working together, there has been significant merging of the models. Instead of two mutually exclusive ways of managing birth, there is wide variation. Nevertheless, there are important differences between the two models, including differences in philosophy and focus, in the relationship between the care provider and the pregnant woman, in the main focus of prenatal care, in use of obstetric interventions and other aspects of care during labor, and in the goals and objectives of care. The midwifery model has advantages for many women because it avoids unnecessary interventions during labor, thus helping the process remain normal, and because it addresses needs that are often not adequately met by the medical management model.
Preterm birth is one of the most devastating problems facing obstetrics today. Despite all of the available sophisticated research and therapeutic technology, the preterm birth rate has remained the same for the last 40 years. One birth in 10 occurs prematurely. Preterm labor manifests itself in a variety of ways. It is essential to promptly differentiate true preterm labor from preterm contractions or other conditions that present with similar symptoms. True preterm labor requires prompt clinical intervention in the obstetric triage setting.
