The midwifery model of care.

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.

Evidence-based practice and its application to childbirth care for low-risk women.

"Evidence-based medicine" has been hailed as the "new paradigm" for health care. This paper defines evidence-based practice, describes its development and growing importance, explains why randomized controlled trials are the "gold standard" for evidence about the effectiveness of specific therapeutic methods, warns about reaching conclusions based on any single study, and points the reader towards good sources of information on how to assess the relevance of findings from published studies and systematic reviews of the most reliable evidence regarding particular components of the care of pregnant women. As a result of those reviews, specific elements of perinatal care have been classified into categories based on their usefulness or harmfulness when applied to low-risk women. The paper goes on to summarize the evidence regarding three intrapartum practices that are demonstrably safe and useful and "should be encouraged" and four intrapartum practices that have trade-offs between beneficial and adverse effects and are "frequently used inappropriately." Some of the most beneficial elements of intrapartum care are not available to most women who give birth in American hospitals, and some practices that are useful but have adverse effects are being provided to an ever-expanding proportion of women.

A simple, effective method that midwives can use to help pregnant women stop smoking.

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.

Public education: promoting the midwifery model of care in partnership with the Maternity Center Association.

Most people who are ignorant or misinformed about midwifery are also misinformed about birth, the needs of pregnant women, and problems related to the care provided to most pregnant women in this country. An understanding of these issues is the conceptual substrate that makes it possible to understand and value midwifery. Although midwives need to educate people about midwives and midwifery, it is also necessary for them to educate people about the nature of childbirth, the needs of pregnant women in general, and appropriate (and inappropriate) maternity care. Midwives are experts in these subjects, but they have to go beyond talking about midwifery--beyond talking about themselves. To maximize their effectiveness, midwives should work in partnership with individuals and organizations that support the midwifery model of care--regardless of the professional background of the person who practices this model. Midwives can advance public education by collaborating with organizations, such as the Maternity Center Association (MCA), which supports family-centered maternity care, based on the midwifery model. MCA's current public education activities are described and two new MCA brochures are presented. Information that supports midwifery care may be particularly effective when it is presented by an organization with broader objectives.

Criteria for accreditation of direct-entry midwifery education.

The American College of Nurse-Midwives' Division of Accreditation criteria for accreditating direct-entry midwifery education call for programs to require baccalaureate degrees for entry or award them at conclusion of the program and require faculty to be midwives certified by the ACNM Certification Council. Neither criteria can be met by any existing direct-entry program. The authors argue against these criteria, based in part on familiarity with the Seattle Midwifery School. The paper describes the development of the Seattle Midwifery School, summarizes reasons for and against requiring degrees for midwifery education, argues against excluding faculty of existing direct-entry schools who are not certified by the ACNM Certification Council, notes other efforts to develop credentials for direct-entry midwives, and concludes that professional direct-entry midwifery must be based on widely respected, rigorous national standards.

The National Birth Center Study. Part III--Intrapartum and immediate postpartum and neonatal complications and transfers, postpartum and neonatal care, outcomes, and client satisfaction.

This is the final article of the three-part report of the National Birth Center Study. Eight percent of the mothers or infants had serious complications; 16% were transferred, 12% before and 4% after the deliveries. Fifteen percent of transfers were emergencies. Nulliparous women were much more likely than parous women to experience dystocia, be transferred, or have cesarean sections. Seventy-five percent of the nulliparous women gave birth in the centers, compared with 95% of the parous women. Eighty-four percent of the women had at least one postpartum home or office visit. There were 11,814 mothers, no maternal deaths, and 15 intrapartum/neonatal deaths (1.3/1,000 births, 0.7 excluding congenital anomalies). Postterm deliveries with macrosomic infants, placental abruption, sustained fetal distress, and thick meconium were associated with high mortality. Mortality was very low for those not transferred and much lower for transfers during labor as compared with those after the delivery. Women with no medical/obstetric risk factors had the lowest rates of transfers and serious complications. Except for postterm pregnancies, the intrapartum/neonatal mortality rate for birth center clients was not higher than rates from studies of low-risk hospital births, and the cesarean section rate was lower. There is no evidence that hospitals are a safer place for low-risk births.

The National Birth Center Study. Part II--Intrapartum and immediate postpartum and neonatal care.

Part II of a three-part report of the National Birth Center Study describes care provided to 11,814 women and their newborns during and after labor and delivery until they were transferred or discharged from the birth centers. There were few low birth weight or preterm or postterm births, but more macrosomic babies than among all U.S. births during the same time period. Certified nurse-midwives provided most of the intrapartum care, which is described in the context of medically recommended standards and data that describe care provided to low-risk women giving birth in U.S. hospitals. Birth center care deviated from typical hospital care in several ways. Birth center clients were much less likely to receive central nervous system depressants, anesthesia, continuous electronic fetal monitoring, induction and/or augmentation of labor, intravenous infusions, amniotomies, or episiotomies, and they had relatively few vaginal examinations. They were more likely to eat solid food during labor and to take showers and/or baths. Nulliparity was strongly associated with longer first stage labors and longer labor was associated with more frequent use of many kinds of interventions. Infant birth weight, mother's position during delivery, and forceps- or vacuum-assisted deliveries are examined in relation to episiotomies and lacerations and tears.

The National Birth Center Study. Part I--Methodology and prenatal care and referrals.

This is the first of three articles that will report on the complete findings from the National Birth Center Study (NBCS). This article describes the study methodology, compares the entire group of NBCS subjects with all women who gave birth in the United States in 1986, describes the prenatal care and prenatal referral practices of birth centers in the study, and describes the women who were admitted to the birth centers for intrapartum care with regard to characteristics known or thought to be associated with perinatal risk. Nearly 18,000 women were included in the study; two-thirds of them (n = 11,814) were admitted to the birth centers for intrapartum care. Although medical and obstetric complications were the most common reason for discontinuing birth center care, they accounted for less than half of the women who were not admitted to the birth centers for labor and delivery; many women left for a variety of other reasons. In addition to describing birth center clients, birth center care providers, and birth center care, the NBCS provides detailed information about the characteristics and experiences during pregnancy of a large population of essentially low-risk women receiving a low-intervention style of maternity care.

Outcomes of care in birth centers. The National Birth Center Study.

We studied 11,814 women admitted for labor and delivery to 84 free-standing birth centers in the United States and followed their course and that of their infants through delivery or transfer to a hospital and for at least four weeks thereafter. The women were at lower-than-average risk of a poor outcome of pregnancy, according to many but not all of the recognized demographic and behavioral risk factors. Among the women, 70.7 percent had only minor complications or none; 7.9 percent had serious emergency complications during labor and delivery or soon thereafter, such as thick meconium or severe shoulder dystocia. One woman in six (15.8 percent) was transferred to a hospital; 2.4 percent had emergency transfers. Twenty-nine percent of nulliparous women and only 7 percent of parous women were transferred, but the frequency of emergency transfers was the same. The rate of cesarean section was 4.4 percent. There were no maternal deaths. The overall intrapartum and neonatal mortality rate was 1.3 per 1000 births. The rates of infant mortality and low Apgar scores were similar to those reported in large studies of low-risk hospital births. We conclude that birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women, particularly those who have previously had children, and that such care leads to relatively few cesarean sections.