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.

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.

Home-based services by nurse-midwives. Sample data from phase II of nurse-midwifery care to vulnerable populations in the United States.

This article presents prospective data from Phase II of Nurse-Midwifery Care to Vulnerable Populations in the United States, about home-based health care, including home birth, provided to women and infants by CNMs and the type of practice in which these services are provided. Forty-one certified nurse-midwives collected data on 1,739 client visits, of which 234 occurred in the home. The results indicate that the majority of home visits occur within a practice setting that includes more traditional modes of service and that a proportion of women choose home as the place for health care.

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.

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.

Barriers to prenatal care in a multiethnic, urban sample.

The barriers that prevent women from obtaining prenatal care were studied in a multiethnic, primarily indigent urban population. Two thousand nine hundred eighty-seven women were delivered at the University of Miami/Jackson Memorial Medical Center from January 15 to April 10, 1988. Of these women, 227 (7.6%) did not access any prenatal care. These women formed the study group. The results indicated that the main barriers were systematic (35.5%), patient-related (35.5%), and financial (29%). Ethnic group, marital status, and education influenced access to prenatal care, whereas age did not appear to do so. Although low birth weight rates were higher in the study group, it was apparent that cultural behavior influenced birth weight, whether or not prenatal care was obtained.

A birth center affiliated with the tertiary care center: comparison of outcome.

A matched pair study compares 250 low risk women delivered in a tertiary care center with a similar group cared for and delivered in an affiliated birth center. The patients could be matched in every respect with the exception of educational background. Twenty-one percent of the birth center patients required transfer to the hospital during the intrapartum period. Differences were found in cervical dilatation upon admission and length of labor. Intermittent fetal heart auscultation was used exclusively in birth center mothers, oral fluids and light diet were allowed. The hospital group received intravenous fluids. Oxytocin augmentation was used twice as often, and the incidence of shoulder dystocia appeared significantly higher in the control group. The reasons for transfer are described. The one neonatal death was due to persistent fetal circulation.

Who helps? coping with the unexpected outcomes of pregnancy.

Death in our obstetric and neonatal units causes grief, not only to the families of the patient, but to the nursing and medical staff. It is a primary duty of hospital administrators and nursing leaders to assist the staff to resolve their grief processes in order that they can more effectively support the bereaved. This article explores some effective means of providing such support to staff members through self-awareness and group sessions.