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Pregnancy & Birth

The Midwifery Model of Care

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Continuous Presence and Hands-On Assistance During Labor

The midwifery model of care is time-intensive and relationship-intensive. Midwives use their own physical and emotional energy to encourage, support, and comfort women during birth; the medical management model, in contrast, tends to substitute more use of medical technology for more use of professional time. Researchers studying the impact of caregiver support for women during childbirth have noted that nurses who work in obstetric units with a high use of technical obstetric interventions may have little time to provide support to women in labor (29). That description seems to fit American obstetric care in general. More than 80% of women who gave birth in the United States in 1997 had EFM during labor (whether internal or external, continuous or intermittent), more than a third had their labors either induced and/or stimulated by oxytocin (18), and more than 40% had epidurals (30). Use of both oxytocin and epidurals is increasing rapidly. Recent studies have reported a doubling in use of both interventions during the previous 10 years (18,30), and there are anecdotal reports of epidural rates of 90% or higher in specific hospitals (31,32). Nurses in many hospitals watch fetal monitor tracings from several patients at a central nursing station. Careful observational studies conducted at some hospitals have found that labor-and-delivery-unit nurses spend only about one-fourth of their time in a room in which there is a patient (33,34).

Use of Obstetric Interventions

The midwifery model of care is based on respect for the intricacy of the natural physiology of childbirth and belief that women’s bodies are well designed for birth. Midwives try to protect, support, and avoid interfering with the normal processes; thus they try to avoid unnecessary use of obstetric interventions. The medical management model, in contrast, views women’s bodies as very imperfect at giving birth and calls for close monitoring and control of the process.

Physicians tend to manage labor using relatively narrow criteria for what is normal and intervene when a woman’s labor falls outside those criteria. Midwives may accept greater variation as within the range of normal, so long as both the woman and fetus tolerate labor well. Labors that deviate from these norms are cause for increased vigilance for early signs of actual complications, but not for automatic use of interventions.

Medical management often calls for applying treatments as preventive measures. The midwifery model recommends waiting until there is evidence that the intervention is needed. Treating more labors as normal may help them stay normal; some of the interventions applied because a woman is high-risk cause actual complications. For example, using oxytocin to increase the frequency and strength of contractions can interfere with the supply of blood going to the placenta and thus cause fetal distress (35). Oxytocin also tends to increase the pain of labor (36), sometimes making it necessary to give an epidural to a woman who would not have needed it if she had not had the oxytocin. Epidurals, in turn, tend to increase the need for either a cesarean section or use of forceps or vacuum extraction to actually deliver the baby (37).

Most CNMs and CMs use some obstetric procedures, including electronic fetal monitoring (EFM), and some of their clients have episiotomies or receive oxytocin, epidural analgesia, or anesthesia, and other procedures that are needed sometimes (18). But, except for EFM, midwives’ clients are less likely to have these procedures, in part because midwives specialize in the care of women without serious complications, in part because women who want to avoid unnecessary procedures seek the care of midwives (38), and in part because midwives have other, less invasive methods to assist women, such as warm water baths and counter-pressure as measures to relieve and help women cope with pain.

Goals and Objectives of Care

The health and safety of the mother and baby are of paramount importance in both the midwifery and medical models. But, they are not the midwife’s only goals. Midwives value childbirth as an emotionally, socially, culturally, and often spiritually meaningful life experience—something to be experienced positively, with potential for making women feel stronger, and be stronger, and for strengthening bonds between the mother and father, as well as the other siblings and the newborn.

In addition, the baby is not the only important outcome of the pregnancy. Pregnancy, especially every first pregnancy, is a critical developmental process for a woman. Pregnancy results in a mother as well as a baby. It is important that the woman’s transition into motherhood is a positive experience, that she and all members of her family make emotionally healthy adjustments to each pregnancy and birth, and that she has the means to acquire the necessary information, skills, support, and self-confidence needed to successfully assume the roles and responsibilities of motherhood. Breastfeeding and mothercraft are part of the focus of midwifery.

Summary

The midwifery and medical models are based on particular perspectives of pregnancy and birth. Both of these perspectives are valid and important; the extent to which one or the other should be given priority varies with different women. Conceptually, the two approaches are complementary rather than competitive, and the experience of midwives and physicians working together in hospitals and practices throughout the United States and Europe shows that they are compatible. Although these perspectives have sometimes competed, midwives and physicians work together and share information, and the two models have merged, to some extent. Most midwives acknowledge the importance of medical treatment for women with pregnancy complications, and most physicians acknowledge the importance of the social and emotional aspects of pregnancy and childbirth. Hospitals and physicians who at first resisted women’s requests to have their husband or another support person with them during labor now “allow” it, and the practice is widespread. Instead of two mutually exclusive ways of managing birth, there is a wide continuum, with some examples of more extreme or pure renditions of each model at the ends of the continuum, but most practices falling towards the middle. If childbirth practitioners were placed on this continuum and plotted on a frequency curve, the curve might be bimodal—with relatively few examples of the pure expression of each model, most practices incorporating some elements of both, and two distinct peaks in the curve, one reflecting practices that adhere more to the midwifery model and one reflecting practices that adhere more to the medical model.

Nevertheless, there are two models, and important differences between them. The midwifery model has advantages for many women because it avoids unnecessary obstetric interventions during labor, thus helping the process remain normal, and because it addresses needs that are not adequately met by the medical management model when it is practiced without its complement—midwifery.

This article was written by Judith Rooks and originally published in the July/August 1999 edition of the Journal of Nurse-Midwifery (now the Journal of Midwifery and Women's Health).  It is posted here with permission from the author and the publisher.

REFERENCES

1. Rooks J. Midwifery and childbirth in America. Philadelphia: Temple University Press, pp. 1–3, 125–132, 1997.  Back to text.

2. Kaunitz AM, Spence C, Danielson TS, Rochat RW, Grimes DA. Perinatal and maternal mortality in a religious group avoiding obstetric care. Am J Obstet Gynecol 1984;150:826–31.  Back to text.

3. American College of Nurse-Midwives. Standards for the practice of nurse-midwifery. Washington, DC: ACNM, 1993. Back to text.

4. Nelson KB, Dambrosia JM, Ting TY, Grether JK. Uncertain value of electronic fetal monitoring in predicting cerebral palsy. N Engl J Med 1996;334:613–8. Back to text.

5. Goer H. Obstetric myths versus research realities: a guide to the medical literature. Westport, Connecticut: Bergin & Garvey, pp. 131– 153, 1995. Back to text.

6. Curzen P, Bekir JS, McLintock DG, Patel M. Reliability of cardiotocography in predicting baby’s condition at birth. Br Med J 1984;289:1345–7.  Back to text.

7. Keegan KA, Waffarn F, Quilligan EJ. Obstetric characteristics and fetal heart rate patterns of infants who convulse during the newborn period. Am J Obstet Gynecol 1985;153:732–7.  Back to text.

8. Stewart PJ, Dulberg C, Arnill AC, Elmslie T, Hall PF. Diagnosis of dystocia and management with cesarean section among primiparous women in Ottawa-Carleton. Can Med Assoc J 1990;142:459–463.  Back to text.

9. Sheehan KH. Caesarean section for dystocia: a comparison of practices in two countries. Lancet 1987;1(8532):548–551.  Back to text.

10. Bottoms SF, Hirsch VJ, Sokal RJ. Medical management of arrest disorders of labor: a current overview. Am J Obstet Gynecol 1987;156:935–9.  Back to text.

11. Rooks J. Midwifery and childbirth in America,1 pp. 56–60.  Back to text.

12. Rooks J, Winikoff B. A reassessment of the concept of reproductive risk in maternity care and family planning services. New York: The Population Council, 1992.  Back to text.

13. Enkin M, Keirse MJNC, Renfrew MJ, Neilson JP. A guide to effective care in pregnancy and childbirth, 2nd ed. New York: Oxford University Press, 1995.  Back to text.

14. Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gil-strap III LC. Williams Obstetrics, 19th ed. Norwalk, Connecticut: Appleton & Lange, p. 377, 1993.  Back to text.

15. Rooks JP, Weatherby NL, Ernst EKM. The National Birth Center Study Part II: intrapartum and immediate postpartum and neonatal care. J Nurse Midwifery 1992;37:301–30.  Back to text.

16. Bennetts AB, Lubic RW. The free-standing birth centre. Lancet 1982;1:378–80.  Back to text.

17. Harman PJ, Summers L, King T, Harman TF. Interdisciplinary teaching: a survey of CNM participation in medical education in the United States. J Nurse Midwifery 1998;43:27–37.  Back to text.

18. Curtin S. Recent changes in birth attendant, place of birth, and the use of obstetric interventions, United States, 1989 to 1997. J Nurse Midwifery 1999;44:349–54.  (Click your browser's "back" button to continue reading the article.)

19. Frye A. Holistic midwifery: A comprehensive textbook for midwives in homebirth practice, volume I, care during pregnancy. Portland, Oregon: Labrys Press, 1995.  Back to text.

20. Kleinman JC, Madans JH. The effects of maternal smoking, physical stature and educational attainment of the incidence of low birth weight. Am J Epidemiol 1985;121:843–55.  Back to text.

21. Thorndike AN, Rigotte NA, Stafford RX, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998;279: 604–8.  Back to text.

22. Kogan MD, Kotelchuck M, Alexander GR, Johnson WE. Racial disparities in preported prenatal care advice from health care providers. Am J Public Health 1995;84:82–8.  Back to text.

23. Mullen PD, Pollak KI, Titus JP, Sockrider MM, Moy JG. Prenatal smoking cessation counseling by Texas obstetricians. Birth 1998; 25:25–31.  Back to text.

24. Murphy PA. Primary care for women: health assessment, health promotion, and disease prevention services. J Nurse Midwifery 1996;41:83–91.  Back to text.

25. Baldwin L-M, Raine T, Jenkins LD, Hart LG, Rosenblatt R. Do providers adhere to ACOG standards? The case of prenatal care. Obstet Gynecol 1994;84:549–56.  Back to text.

26. Aaronson LS. Nurse midwives and obstetricians: alternative models of care and client “fit.” Res Nurs Health 1987;10:217–26.  Back to text.

27. Petersen R, Gazmararian JA, Spitz AM, Rowley D, Goodwin MM, Saltzman LE, Marks JS. Violence and adverse pregnancy outcomes: a review of the literature and directions for future research. Am J Prev Med 1997;13:366–73.  Back to text.

28. Nursing progress. Anonymously authored article reporting an interview with Mary Ann Curry, a professor at the Oregon Health Sciences University. Spring 1996;7(3):6–7. (Nursing Progress is published by the Oregon Health Sciences University School of Nursing, Portland, OR.)  Back to text.

29. Hodnett ED. Caregiver support for women during childbirth (Cochrane Review). In: The Cochrane Library, Issue 1, 1999. Oxford: Update Software.  Back to text.

30. Hawkins JL, Gibbs CP, Orleans M, Martin-Salvag G, Beaty B. Obstetric work force survey, 1981 versus 1992. Anesthesiology 1997; 87:135–43.  Back to text.

31. Biasella S. Epidural anesthesia. J Perinatal Ed 1994;3(4):67–9.  Back to text.

32. Lothian J. Why do women choose epidural? J Perinatal Ed 1993;2(2):ix–x.  Back to text.

33. McNiven P, Hodnett E, O’Brien-Pallas LL. Supporting women in labor: a work sampling study of the activities of labor and delivery nurses. Birth 1992;19:3–8.  Back to text.

34. Gagnon AJ, Waghorn K. Supportive care by maternity nurses: a work sampling study in an intrapartum unit. Birth 1996;23:1–6.  Back to text.

35. Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap III LC. Williams Obstetrics, 19th ed,14 487.  Back to text.

36. Simkin P. Stress, pain and catecholamines in labor: part 2. Stress associated with childbirth events: a pilot survey of new mothers. Birth 1986;13(4):234–40.  Back to text.

37. Lieberman E. No free lunch on labor day: the risks and benefits of epidural analgesia during labor. J Nurse Midwifery 1999;44: 394–8.  Back to text.

38. Oakley D, Murray ME, Murtland T, Hayashi R, Andersen F, Mayes F, Rooks J. Comparisons of outcomes of maternity care by obstetricians and certified nurse-midwives. Obstet Gynecol 1996;88:823–9. Back to text.

Companion Pages:  1  2 

Written by: Judith Rooks

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