Pregnancy & Birth
The Midwifery Model of Care
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.
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.
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Written by: Judith Rooks
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