Pregnancy & Birth
The Midwifery Model of Care
This article describes the midwifery model of care and how it relates to and differs from the medical management model for the care of pregnant women. Although the model presented here is the opinion of a single author, it is based on diverse experience and relationships in midwifery, extensive study of a wide variety of midwives’ writings on this subject, and ﬁndings from research comparing the care provided by midwives and physicians. This article does not address the midwifery model as it applies to the care of women who are not pregnant. However, many of the differences between the midwifery and medical models for the care of pregnant women carry through to other aspects of the primary care of women.
The existence of two separate approaches to the care of pregnant women began in ancient history; ultimately it led to the development of the two professions of midwifery and medical obstetrics. Each of these disciplines is based on a different understanding of the nature and signiﬁcance of pregnancy and childbirth. Midwifery developed out of the social, informational, physical, and material support women have traditionally provided to one another in times of need. Midwives view pregnancy as a critical, vulnerable, but normal part of women’s lives. Obstetrics developed from within medicine for the purpose of dealing with the pathologies of pregnancy and childbirth. Each of these perspectives calls forth a different approach to the care of pregnant women—the midwifery model and the medical model (1).
The underlying purpose of this paper is to describe how midwifery care differs from the care provided by and under the authority of physicians. However, it is impossible to do that accurately, as there are many midwives and many physicians and much variation within each group. To make it easier to identify and discuss the differences, this paper focuses on models. Focusing on models allows the writer—and reader—to ignore the variety that exists in reality and refer to theoretical abstractions as though they were real. But, discussing any subject in terms of models tends to accentuate differences. In this case, it is essential for all readers to understand that the differences are relative.
Difference In Philosophy and Focus
Midwifery and medical obstetrics are separate but complementary professions with different philosophies and overlapping but distinct purposes and bodies of knowledge. Physicians are experts in pathology and should have primary responsibility for the care of pregnant women who have recognized diseases or serious complications. Midwives are experts in normal pregnancy and in meeting the other needs of pregnant women— the needs that are not related to pathology. In most countries, midwives have primary responsibility for the care of women with uncomplicated pregnancies.
Midwifery focuses on the normalcy of pregnancy, and its potential for health. Birth is viewed as a natural process that has profound meaning to many people and should be treated as normal until there is evidence of a problem. The possibility of complications is not allowed to preempt all other values associated with the woman’s experience of bearing and giving birth to a child. Midwives are experts in protecting, supporting, and enhancing the normal physiology of labor, delivery, and breast-feeding.
The medical management model focuses on the pathologic potential of pregnancy and birth. As a specialty of medicine, the main focus of obstetrics is diagnosis and treatment of pregnancy complications and management of diseases that affect pregnant women and the fetuses they carry. Attention to the pathologic potential of pregnancy is vital because, although most pregnancies would proceed healthfully without any medical intervention, serious complications and diseases are not uncommon and can be deadly. The importance of medical care for pregnant women with serious complications was dramatically shown by a study that documented extremely high mortality among well-nourished American women who belong to a religious sect that does not allow any kind of medical treatment (eg, deaths equaling a maternal mortality rate of 872/100,000 births among members of the Faith Assembly in 1983) (2). Acknowledging the essentialness of medical care for women and newborns with serious complications, the American College of Nurse-Midwives (ACNM) requires all certiﬁed nurse-midwives (CNMs) and certiﬁed midwives (CMs) to maintain a safe mechanism to obtain medical consultation, collaboration, and referral (3). But, physicians have expanded the proportion of pregnancies considered abnormal or pathologic by using monitoring devices that over-diagnose complications (4–7), basing diagnoses on overly narrow deﬁnitions of normal, and treating variation from those deﬁnitions as evidence of pathology (5,8–10). The desire to identify complications early has led to use of a sequence of preemptive interventions (to prevent complications or to treat them before there is evidence that they exist) and a focus on “risk factors” (conditions that are not pathologic but are associated with an increased incidence of complications). In many instances, the distinction between risk factors and actual pathology has been lost, and women with “high-risk factors” are treated as though they have actual complications (11,12).
Since an unexpected complication can happen to any woman at any time, the medical management model prepares for the worst. For example, an intravenous infusion (IV) or “hep-lock” (placement of an IV cannula to ensure rapid access to a vein) are often provided just in case the woman needs blood or drugs in an emergency. And, substantial oral intake is discouraged or not allowed just in case she needs anesthesia for an emergency cesarean section. Although an IV is not necessary for a woman having a normal birth (13), establishing an IV early in labor is a routine practice in many United States hospitals (14). In contrast, IVs are used relatively rarely in birth centers (15), which were speciﬁcally designed for the midwifery model of care (16).
Common Ground Between Midwifery and Medical Obstetric Practice
Although there are important differences between these models, there is also much common ground. The knowledge and skills of midwives and obstetricians overlap. Midwives read books and articles written by obstetricians and use information based on their research. Midwives do their own research and write their own articles and books, which are available to obstetricians. In addition, nurse-midwives teach management of normal childbirth to medical students and residents in many academic medical centers (17). Many important improvements in obstetric practice during the past 15 years have resulted from obstetricians adopting some of the beliefs and methods associated with midwifery. When a physician practices them, they become part of his or her medical practice. CNMs and CMs have also incorporated some aspects of the medical management of pregnancy into their practices—as demonstrated by data showing that women whose births were attended by CNMs were as likely as women whose births were attended by physicians to have had some kind of electronic fetal monitoring (EFM) in 1997, based on birth certiﬁcate data (18). The birth certiﬁcate item used to collect this information provides for only a “yes” or “no” response. Thus, the National Center for Health Statistics (NCHS) natality data cannot distinguish between internal versus external placement of the monitoring equipment or between continuous versus intermittent use of EFM (18).
The midwifery model is consistent with the purposes, philosophy, and knowledge base of midwives, but it is practiced, to varying degrees, by others, including some obstetricians and family physicians. Yet, an important part of the practice of both obstetricians and midwives is not fully accessible to the other. Even though no deﬁnitive line can be drawn between the care provided by midwives and physicians, there are important general differences between the midwifery model and medical management.
Differences in the Relationship Between the Care Provider and the Woman
The midwifery model establishes the pregnant woman as an active partner in her own care and recognizes her as the primary actor and decision-maker. A major part of the midwife’s role is providing the information and support the woman needs to make her own decisions. A midwife helps the woman identify problems and gives her information, options, and the authority to make her own choices (19). Many midwives avoid saying that they “deliver babies”; rather they “attend” the laboring woman and “catch” the baby, recognizing that the woman herself, through her labor, delivers her own child into the world. Physicians are more likely to see themselves as the key decision-makers, and most say that they “deliver” babies.
The Main Focus of Prenatal Care
The midwifery model of care makes the woman and her life the central focus of prenatal care. A large part of the midwife’s attention focuses on the pregnant woman as a unique person, in the context of her family and her life. The midwife is interested in the woman’s expectations and experience of her pregnancy—her perceptions and beliefs; her knowledge and opinions; her questions and worries; her satisfactions and dissatisfactions; her comforts and discomforts; her desires, decisions, and actions; and the effect of all these on her pregnancy, fetus, labor, delivery, breastfeeding, postpartum recovery, and development as a mother.
Pregnant women need a lot of information, and some need help and support to recognize and change aspects of their lifestyles or circumstances that put them or their babies at increased risk. Midwives emphasize helping women make changes conducive to a healthy pregnancy, baby, and family.
Prenatal care within the medical management model focuses primarily on the fetus and screening for pathology. Medically oriented prenatal care often fails to give enough attention to the problems embedded in the lives of pregnant women, such as smoking and domestic abuse. Nearly 20% of low birth weight has been attributed to smoking (20), and the National Ambulatory Medical Care Study (NAMCS) found that more than 80% of ofﬁce-based physicians determine whether their pregnant patients smoke (21); however, the doctors provided counseling to help women who smoke quit or cut down on their smoking during only 22% of the pregnant smokers’ visits. In another study based on a nationally representative sample, only 71% of white women and 64% of black women said that they had received advice about smoking during prenatal care (22). A survey based on a random sample of obstetricians in Texas found that most do not understand the seriousness of maternal smoking. Although most asked their patients if they smoked, one third of the doctors did not counsel the women who said they smoked (23).
In contrast, a 1994 study that queried a stratiﬁed random sample of active ACNM members about their practices reported that 93% of the CNMs indicated that they assessed the smoking habits of “most to all” of their prenatal patients (81%–100%), and 86% of the CNMs indicated that they provided smoking cessation counseling to “most to all” of the pregnant women who smoked (24). A study of care provided to low-risk pregnant women in Washington State found that CNMs were more likely than either obstetricians or family physicians to record information on smoking at the ﬁrst prenatal visit (25). In a study of women who had obtained prenatal care at a facility that offered care by either CNMs or obstetricians, the nurse-midwives’ clients believed that their care providers held signiﬁcantly stronger opinions about the importance of health-promotion behaviors, including abstinence from smoking, and offered more support to help the women conform to those behaviors, as compared to the women who obtained their prenatal care from obstetricians (26).
Domestic violence is another example of the need for prenatal care to focus on the lives of pregnant women. Approximately one of every 20 pregnant women is physically hurt by her husband or another man at some time during her pregnancy (27). When the Oregon Medicaid program converted to managed care, many high-risk women left special maternity-care programs to enter the care of private physicians. In order to facilitate this change, the health department developed a guide to help private doctors identify women with problems such as drug abuse and domestic violence. Although some physicians welcomed this help, many refused, saying they did not have time to ask women these questions, they were not willing to pay a nurse to do it, and they did not consider these problems to be any part of their business (28).
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