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Midwifery Practice: Where Have We Been and Where Are We Going?

2005; Wiley; Volume: 50; Issue: 2 Linguagem: Inglês

10.1016/j.jmwh.2004.12.013

1542-2011

Mary K. Barger,

Organizational Change and Leadership

As the photographs in this issue and the historical time line of the American College of Nurse-Midwives (ACNM) published in January 2005 attest,1 midwifery practice has undergone remarkable changes over the last 75 years. In the early part of the 20th century, the only place midwives could attend births was at home. Later, the hospital became virtually the only place in which midwives could attend births, and there was a great debate among the midwifery community in the 1970s about the safety of homebirth. Then, with a push from the consumer and women's movements, midwives created the freestanding birth center, but this too was not entirely a new practice setting for midwives, because Catholic Maternity Institute had opened a maternity home in 1945 based on the concept of "maternity shelters" pioneered by 2 nurse-midwives in Georgia in 1942.1 The characteristics of the women served by midwives have also changed. When the first nurse-midwifery programs and schools started in the 20th century, the only births midwives were allowed to attend were those of poor women. Now midwives care for women from all socioeconomic strata and from many different ethnicities. Of course, clinical practice has also changed over the years, sometimes in ironic ways. At first, even at home, midwives treated birth as a sterile procedure: scrubbing and shaving women and draping them and ourselves completely during the birth. Then midwives realized that these procedures not only medicalized birth but could actually be harmful, so midwives slowly abandoned most of them. Homebirths were done anywhere, and the midwife might not even have worn gloves; instead, she oiled her hands with a lubricant to help stretch the perineum. With the advent of HIV, midwives are back to gowning and gloving themselves. Although the changes in midwifery practice around birth may seem dramatic, the changes in the scope of practice have been even more so. Earliest midwifery education centered on childbirth, parenting, and infant care. American nurse-midwives, for the most part, did not care for women outside of the maternity cycle. The exceptions were the midwives from the Frontier Nursing Service and those working independently, such as Maude Callen, who provided basic primary care for all members of a family. These midwives worked in areas where they were the sole health care provider. They understood that women and their children lived within the context of their families and that the women would not be healthy if other family members were not healthy and able to contribute to the family. In addition, in the earliest days, no contraceptive methods were offered. Papanicolaou smears for cervical cancer screening did not become a standard of practice until the 1950s. However, by the 1960s, with new breakthroughs in birth control methods, it became clear that nurse-midwives who were skilled in interpersonal communication could easily acquire the skills to provide sensitive contraceptive services to women during their childbearing years. The Journal, in a role that continues today, became the means to update midwives'knowledge in new areas of practice, starting in 1968 with the first issue of this journal devoted to 1 clinical topic. The third issue of volume 12 included an article on the standards for family-planning services by Okrent.2–7 Seeing women for contraceptive services also facilitated the provision of preventive health screening, which included screening for breast masses, cervical cancer, and sexually transmitted infections. Hence, midwifery health assessment skills had to be comprehensive. This kind of care also required that midwives have an ability to prescribe contraceptive pills, as well as antivirals and antibiotics to treat reproductive tract infections. Thus, nurse-midwives had to learn fundamentals of pharmacology and details about the newest relevant drugs. The growth of prescriptive privileges by midwives is detailed in an accompanying article by Fullerton et al.8 It became clear that nurse-midwives were both logical and de facto primary care providers for women. Considering nurse-midwives'focus on health screening and promotion, disease prevention, and health education to change unhealthy behaviors such as smoking, poor eating, and lack of exercise (the three leading actual causes of death), we are well suited to effectively improve women's health. Two surveys in 1991 and 1994 showed that this was not a new role for CNMs/CMs, although midwives customarily cared for common health problems within the context of gynecologic and antepartum visits and less often saw women solely for primary care visits.9,10 The official acknowledgment of the role of primary care provider by ACNM11 required changes in the core competencies for CNMs/CMs and updating the knowledge of those already certified, which occurred through 2 home study issues in the Journal of Nurse-Midwifery and is described in this issue by Avery.12 As the women whose babies midwives delivered and provided with preventive gynecology care continued their lives, they wanted to keep on seeing midwives. Accordingly, midwives increased their scope to care for women during perimenopause and into menopause. In addition, midwives have typically provided excellent care to adolescents, not only during pregnancy but also with gynecologic care. The midwifery model of care is not only well suited to providing adolescents with both high-level medical care but also meets the unique psychosocial needs of this special population. Some midwives are adding to their skill sets, bringing the "midwifery model of care" to specialties such as ultrasound, care of the high-risk pregnant woman, expanded delivery skills, and care of women with vulvar disorders, as a few examples. So what is the midwifery model of care and how did it develop? The basis of the midwifery model of care is best articulated by Ruth Lubic's first principle for a successful professional life, "Begin with the needs of the people you serve."13 That is what the founding women of ACNM did. Mary Brenkenridge's midwives provided primary care to the families they served because that was the need for families in eastern Kentucky in the first half of the 20th century. Nurse-midwives expanded their scope of practice into well-woman gynecology and primary care, not to enlarge their turf, but because that was what the women they cared for needed. A second tenet of the midwifery model of care, which is inherent in Dr. Lubic's first principle, is that midwives must listen attentively to what women are saying. Joyce Thompson was one of those who originated and emphasized the phrase, "Listen to Women," which now serves as a motto for ACNM. ACNM's earliest philosophy statement (1972) articulated this point: "Every childbearing family has a right to a safe, satisfying maternity experience with respect for human dignity and worth; for variety in cultural forms; and for the parents'right to self-determination."14 In today's language, it means that midwives must provide families with culturally competent and respectful care that provides them with the knowledge they need to make health care decisions for themselves. History demonstrates that this belief in human dignity is central to nurse-midwifery. A key rationale for the creation the American College of Nurse-Midwives was to ensure that women of all races could become nurse-midwives and that every graduate of a nurse-midwifery school could be a member of the profession, no matter what her race.15 Furthermore, over 30 years ago, long before the term "cultural competence" came into general usage, nurse-midwives were publishing articles about the need to understand the background and culture of their clients.16,17 The midwifery model of care emanates from the belief that pregnancy, birth, and menopause are normal processes of life and that it is, therefore, part of the role of the midwife to help protect the normalcy of these events from a culture or society that might believe otherwise.18 Holly Kennedy's qualitative work on exemplary midwifery care vividly portrays how CNMs/CMs are not just guardians of birth through the watchful expectancy they practice, but that midwives should be seen as "instruments" of care as valuable or more valuable than instruments of technology.19 In addition to these "softer" characteristics of care, the midwifery model is built on the scientific method. Embedded into the entirety of the educational system for CNMs/CMs is an organized approach to problem solving (data collection, interpretation of data, planning based on scientific rationale, and evaluation of care) that keeps care objective, safe, and professional. The section of this issue on midwifery research highlights the maturation of the research basis of our care. Finally, the midwifery model of care acknowledges that the midwife cannot provide health care by herself. The care midwives provide for women and their families can only take place within a framework of collaborative relationships with other health care professionals, but most especially with obstetrician-gynecologists, with whom CNMs/CMs consult and refer. Midwives view their task as keeping women healthy throughout the normal stages of reproductive life, including pregnancy, but when women develop serious disorders, there are others whose training and education make them better providers of care. How does the midwifery model of care and the midwifery scope of practice get communicated to new nurse-midwives and others outside the profession? Informally, it is through midwifery educators and the masterful clinical teachers who serve as role models for students. Formally, ACNM had a long history of articulating the Core Competencies for Basic Midwifery Practice, which every midwifery graduate should possess. These have given midwives credibility both professionally and with consumers. Early on it was recognized that midwives would develop their clinical skills beyond the basics once they graduated. The original guidelines for assisting midwives in adding new skills to their practice were first promulgated in 1972 and have remained virtually unchanged since then.20 Today, they have become incorporated as the eighth standard in the Standards for the Practice of Midwifery. Most recently, midwives have used the guidelines to expand their practice to perform colposcopy, use vacuum extractors, or first assist at cesarean birth. Documentation that a midwife has followed the guidelines ensures adequate training and monitoring of the newly acquired skills, fulfilling not only Standard VIII, but also "Standard I: midwifery care is provided by qualified practitioners."21 In many respects, future challenges bear a striking resemblance to the challenges midwives have faced since the beginning of professional practice in this country. Today, the profession faces a renewed challenge to their control of how midwifery is to be defined and practiced and to how midwives will be educated. This concern has already been clearly identified elsewhere in this issue.8,22 But midwives today also confront a challenge to the normalcy of birth, and this challenge, too, requires the kind of energy, creativity, and determination that saw midwives through many similar crises in the past. The current challenge to the basic precepts of the midwifery philosophy of birth is fundamental, and it is growing in strength, although its extent may be somewhat obscured by the remarkable growth and development of the College and its membership. When Hattie Hemschmeyer conveyed her first presidential address to the members of the American College of Nurse-Midwifery in 1955, there were 124 active members. Now, there are nearly 4000 midwifery practices available to consumers through the ACNM Web site. Fullerton et al8 describe both the growth in membership and the growth in the number of births attended by nurse-midwives. As exciting as this increase is, midwives also need to view these statistics within a broader context. Although it is true that midwives attended 10% of vaginal births in 2002, the increasing cesarean birth rate (27.6% for 200323) means that the midwifery contribution to total births has plateaued in recent years, given the high surgical birth rate. Reasons for the increase in cesarean births are complex, but there is evidence that it is occurring among all American women, including those with no indicated medical or obstetric health reasons for surgical birth.24 This is a cause of deep concern for childbearing women today as well as the midwives who serve them. First, this challenges midwives to live midwifery's own principles and philosophy in their practice. Are midwives really meeting one of the basic tenets of the midwifery model of care: that pregnancy and birth are normal processes and that midwives should intervene in that normal process only when medically necessary? Not all the answers to that question are reassuring. The "Listening to Mothers" survey showed that among the nearly 1600 American women participating, virtually all had some medical/technologic intervention during labor (e.g., intravenous drips, electronic monitoring, and use of oxytocin).25 Second, it challenges midwives to be at least as proactive, creative, and determined as previous generations were to guard the normalcy of birth from all the forces that may try to distort or even to eliminate that normalcy. Again, in the "Listening to Mothers" survey, only 45% responded affirmatively that "giving birth is a natural process that should not be interfered with unless absolutely medically necessary" and another 24% were undecided.25 If there is one thing that shines like a light through the College's history, it is the record of generation after generation of American nurse-midwives who used all their energy in refusing to acquiesce to those forces that would take the personal, intimate, life-altering process and experience of birth away from women and would instead turn birth into a mere technologic process—a technology that would, of course, be controlled by others. The midwives of previous generations were determined not to let that happen to the women they served, and their guardianship of birth on behalf of those women was a guardianship that they exercised not complacently, not sporadically, but consistently, at times through personal sacrifice, and with all their hearts. This generation of the membership of the College can do no less. Interview With Joyce Thompson, CNM, DrPH, FAAN, FACNM ACNM President 1989–1993 What should be the goals for the profession in the next 50 years? Midwifery care should become the norm for childbearing families, with obstetrician care reserved for those in need of physician care. We need to strive toward enhanced teamwork based on mutual respect among all who provide services to women, recognizing the unique and valuable contribution that each type of care provider can make. ACNM needs to have a global perspective on the health of women, and work to ensure that basic human rights are accorded every one. (Interview August 22, 2004) Interview With Sr. Angela Murdaugh, CNM, FACNM ACNM President 1981–1983 The next 50 years of midwifery in the US, I believe, hinges on one very major direction that midwifery takes and that is: how much are midwives going to allow technology and the medicalization of birth to influence midwifery care? Are midwives strong enough to be independent; and will women want the personalized, patient and low technology care that midwives are so good at providing? (Interview January 16, 2005)