Project 20: Midwives' insight into continuity of care models for women with social risk factors: what works, for whom, in what circumstances, and how.

INTRODUCTION: Continuity of care models are known to improve clinical outcomes for women and their babies, but it is not understood how. A realist synthesis of how women with social risk factors experience UK maternity care reported mechanisms thought to improve clinical outcomes and experiences. As part of a broader programme of work to test those theories and fill gaps in the literature base we conducted focus groups with midwives working within continuity of care models of care for women with social factors that put them at a higher chance of having poor birth outcomes. These risk factors can include poverty and social isolation, asylum or refugee status, domestic abuse, mental illness, learning difficulties, and substance abuse problems. OBJECTIVE: To explore the insights of midwives working in continuity models of care for women with social risk factors in order to understand the resources they provide, and how the model of care can improve women's outcomes. DESIGN: Realist methodology was used to gain a deeper understanding of how women react to specific resources that the models of care offer and how these resources are thought to lead to particular outcomes for women. Twelve midwives participated, six from a continuity of care model implemented in a community setting serving an area of deprivation in London, and six from a continuity of care model for women with social risk factors, based within a large teaching hospital in London. FINDINGS: Three main themes were identified: 'Perceptions of the model of care, 'Tailoring the service to meet women's needs', 'Going above and beyond'. Each theme is broken down into three subthemes to reveal specific resources or mechanisms which midwives felt might have an impact on women's outcomes, and how women with different social risk factors respond to these mechanisms. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Overall the midwives in both models of care felt the service was beneficial to women and had a positive impact on their outcomes. It was thought the trusting relationships they had built with women enabled midwives to guide women through a fragmented, unfamiliar system and respond to their individual physical, emotional, and social needs, whilst ensuring follow-up of appointments and test results. Midwives felt that for these women the impact of a trusting relationship affected how much information women disclosed, allowing for enhanced, needs led, holistic care. Interesting mechanisms were identified when discussing women who had social care involvement with midwives revealing techniques they used to advocate for women and help them to regain trust in the system and demonstrate their parenting abilities. Differences in how each team provided care and its impact on women's outcomes were considered with the midwives in the community-based model reporting how their location enabled them to help women integrate into their local community and make use of specialist services. The study demonstrates the complexity of these models of care, with midwives using innovative and compassionate ways of working to meet the multifaceted needs of this population.

Knowledge of US Midwifery Credentials Among Members of the American College of Nurse-Midwives.

INTRODUCTION: Three midwifery credentials are granted in the United States: certified nurse-midwife (CNM), certified midwife (CM), and certified professional midwife (CPM). Confusion about US midwifery credentials may restrict growth of the midwifery profession. This survey assessed American College of Nurse-Midwives (ACNM) members' knowledge of US midwifery credentials. METHODS: ACNM members (N = 7551) were surveyed via email in 2017. The survey asked respondents to report demographic information and to identify correct statements about the education, certification, and scope of practice of CNMs, CMs, and CPMs. Responses to 17 items about all midwives certified in the United States, a 5-item subset specific to CNMs/CMs, and one item related to location of midwifery practice by credential were analyzed. RESULTS: Nearly a quarter of the membership (22.1%) responded to the survey. Higher scores on the survey indicated greater identification of correct statements about the education, certification, scope, and location of practice of CNMs, CMs, and CPMs. Significant differences in scores were found among ACNM members based on their level of education, degree of professional involvement in midwifery, and prior practice as a nurse. ACNM members with higher scores on the survey held a doctorate, worked in Region I, and had greater professional leadership involvement in midwifery organizations. Participants with less nursing experience prior to their midwifery education also scored significantly higher on the survey. DISCUSSION: Although two-thirds of respondents correctly answered items on the preparation, credentialing, and scope of practice of CNMs, CMs, and CPMs, a significant minority had gaps in knowledge. Results of this survey suggest the need for outreach about US midwifery credentials. Future research to replicate and expand upon this survey may benefit the profession of midwifery in the United States.

Nurse and midwifery prescribing in Ireland: A scope-of-practice development for worldwide consideration.

For 10 years, select Irish nurses and midwives who pass a rigorous 6 month theory and practical program can prescribe medications and other medicinal products. Given the need for timely, accessible, and affordable health-care services in all countries, this nursing/midwifery education and practice development is worthy of examination. Irish nurse/midwife prescribing occurred following long-term deliberative nursing profession advocacy, nursing education planning, nursing administration and practice planning, interdisciplinary health-care team support and complementary efforts, and government action. A review of documents, research, and other articles was undertaken to examine this development process and report evaluative information for consideration by other countries seeking to improve their health-care systems. Nurse/midwife prescribing was accomplished successfully in Ireland, with the steps taken there to initiate and establish nurse/midwife prescribing of value internationally.

Regulation of Certified Nurse-Midwife Scope of Practice: Change in the Professional Practice Index, 2000 to 2015.

INTRODUCTION: Certified nurse-midwives (CNMs) across the United States are educated in the same core competencies, yet scope of practice varies with state regulation. The Health Resources and Services Administration (HRSA) funded studies published in 1994 and 2004 on the professional practice environment of CNMs, nurse practitioners, and physician assistants, and developed the Certified Nurse-Midwife Professional Practice Index (CNMPPI), a 100-point scoring system of state regulation focusing on 3 domains: legal status, reimbursement, and prescriptive authority. The purpose of this study was to examine changes to CNM regulation between 2000 and 2015 by updating scores to the CNMPPI. METHODS: Individual state CNMPPI scores from 2000 were updated for every year through 2015 by reviewing data published in the American College of Nurse-Midwives (ACNM) quarterly publication Quickening, the annual advanced practice registered nurse legislative updates in the journal Nurse Practitioner, and the ACNM State Legislative and Regulatory Guidance. RESULTS: Mean state scores increased 18%, from 69.7 in 2000 to 79.8 in 2015, and variation between state scores fell. Increases were seen in all 3 domains, with the greatest increase in the domain of prescriptive authority and the smallest in the legal domain. Individual state CNMPPI scores tend to be correlated with scores of adjacent states. DISCUSSION: The CNMPPI can be used to document changes in practice authority of CNMs. The increase in state CNMPPI scores and decrease in variance across states can be interpreted as indicating growth of professional authority and increasing consensus regarding the CNM role. The scoring system needs to be updated to reflect the current health systems environment and to include certified midwives and other midwives meeting the International Confederation of Midwives definition of a midwife. Applications of the CNMPPI to future research are discussed.

Australian primary maternity units: past, present and future.

Primary maternity units are commonly those run by midwives who provide care to women with low-risk pregnancies with no obstetric, anaesthetic, laboratory or paediatric support available on-site. In some other countries, primary level maternity units play an important role in offering equitable and accessible maternity care to women with low-risk pregnancies, particularly in rural and remote areas. However there are very few primary maternity units in Australia, largely due to the fact that over the past 200 years, the concept of safety has become inherently linked with the immediate on-site availability of specialist medical support. The purpose if this paper is to explore the various drivers and barriers to the sustainability of primary maternity units in Australia. It firstly looks at the historical antecedents that shaped primary level maternity services in Australia, from the time of colonisation to now. During this period the space and management of childbirth moved from home and midwifery-led settings to obstetric-led hospitals. Following on from this an analysis of recent political events shows how Australian government policy both supports and undermines the potential of primary maternity units. It is important that researchers, clinicians and policy makers understand the past in order to manage the challenges facing the development and maintenance of midwifery-led maternity services, in particular primary maternity units, in Australia today.

Nurse practitioners, certified nurse midwives, and physician assistants in physician offices.

The expansion of health insurance coverage through health care reform, along with the aging of the population, are expected to strain the capacity for providing health care. Projections of the future physician workforce predict declines in the supply of physicians and decreasing physician work hours for primary care. An expansion of care delivered by nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) is often cited as a solution to the predicted surge in demand for health care services and calls for an examination of current reliance on these providers. Using a nationally based physician survey, we have described the employment of NPs, CNMs, and PAs among office-based physicians by selected physician and practice characteristics.

Toward developing a training pathway for fertility nurses: report of the 2010 training and educational survey.

Fertility nursing and its role extension has increasingly been referred to as 'specialist' or 'advanced nursing practice'. Nevertheless, Government initiatives have prompted a review of 'Advanced Nursing Practice' and the Nursing & Midwifery Council (NMC) has taken steps to address the disparity of roles, job titles, training and competence of nurse practitioners, concluding that advanced nursing practice should be subject to revalidation in the same way as professional registration. Fertility nurses form an integral part of the multidisciplinary team. Yet no formal or nationally recognised framework or training pathway exists. In this paper, we present the findings of a recent online survey of training and educational needs of fertility nurses; its aim being to work toward developing a national training pathway. Our findings identify the relationship between fertility nurse competencies, advanced nursing practice and medical sub-specialist training, at the same time, highlighting the difference in accessibility, funding and levels of training, as well as assessment and expertise within clinical practice. We conclude that it is essential to protect role extension through regonised Higher Educational Institution (HEI) accreditation, by appropriate, role-focussed training. Notwithstanding a national review, the diverse list of job titles also needs to be addressed adequately to encompass and respect role extension.

Rekindling of nurse-midwifery in Brazil: public policy and childbirth trends.

In the last decade, nurse-midwifery in Brazil has experienced many changes both professionally and politically. In the 1990s, Brazil's Ministry of Health generated policies to improve childbirth services. Included in these policy initiatives was legislation for the reimbursement of nurse-midwifery services and a substantial increase in financing of nurse-midwifery schools throughout the country. It was during this period that the Brazilian National Nurse-Midwifery Organization was formed to provide professional leadership and an alternative model of childbirth care. The future is hopeful, but the nurse-midwifery profession will need collective determination to succeed in changing practices and improving services to women and families.

Factors influencing cessation of pregnancy care in Oregon.

BACKGROUND AND OBJECTIVES: Anecdotal evidence suggests that many providers who previously delivered babies are no longer doing so, both in Oregon and nationally. This study determined the proportion of pregnancy care providers who have stopped or are planning to stop providing this care in Oregon and identified the important factors influencing such practice changes. METHODS: We mailed a survey in October and November 2002 to all obstetrician-gynecologists, family physicians, general practitioners, and certified nurse midwives practicing in Oregon. The survey inquired about whether they currently perform deliveries. If they did not do so, or if they did so but planned to stop, further questions were asked about reasons for not providing this care. RESULTS: A total of 2,158 surveys were mailed; 1,232 were returned (58% adjusted response rate), and 1,069 had sufficient information to be included in our analysis. Of respondents, 511 (47.8%) currently perform deliveries. Of these, 157 (30.7%) indicated that they planned to stop doing so in 1 to 5 years, with cost of professional liability insurance (59%) and fear of lawsuits (43%) most frequently cited as major reasons. A total of 367 (34%) respondents had previously stopped performing deliveries. Providers who stopped providing this care since 1999 were significantly more likely to cite cost of medical liability insurance and low reimbursement as major reasons, compared to providers who stopped earlier. CONCLUSIONS: Our study suggests that as many as half of clinicians who previously performed or currently perform deliveries in Oregon are planning to stop or have already stopped providing this service, raising concern about access to pregnancy care services for women in the state.

A challenge for nurse-midwifery.

This article suggests that nurse-midwifery today has an exceptional opportunity to play a leadership role in the restructuring of health care policy in the United States. A case is made for the profession to initiate the actions necessary to meet the need for at least 50,000 and possible as many as 100,000 practicing nurse-midwives in this country within the next three decades. The choice for action is in the hands of today's 4,000 nurse-midwives.

Annual student report to the American College of Nurse-Midwives.

This article profiles current areas of concern identified by the student membership at the 38th annual American College of Nurse-Midwives convention in June. Communication, financial aid, education, and practice are identified as topics affecting past, present, and future students, as well as the current membership of certified nurse-midwives. Recommendations are offered and the College is petitioned to address these substantial issues that directly impact the membership.

Birth places: a geographical perspective on planned home birth in New Zealand.

In New Zealand until the 1920s, most births occurred at home or in small maternity hospitals under the care of a midwife. Births subsequently came under the control of the medical profession and the prevalent medical ideology continues to support hospitalised birth in the interests of safety for mother and child. Despite resistance from the medical profession, recent (1990) legislation has reinstated the autonomy of midwives and this has come at a time when the demand for home births is increasing. This paper locates these changes within the geographical context of home as a primary place within human experience. It is argued that the medical profession has been an agent of an essentially patriarchal society in engendering particular experiences of time and place for women in labour. Narrative data indicate that the choice of home as a birth place is related to three dimensions of experience unavailable in a hospital context: control, continuity and the familiarity of home.

Trends in nurse-midwifery. Results of the 1988 ACNM Division of Research Mini-Survey.

The purpose of the 1988 Mini-Survey was the collection of up-to-date data from the ACNM membership, focusing on nurse-midwifery income. These were the last data collected about CNMs for the 1980 decade. The final survey sample included 1,735 CNMs and 67 SNMs; 70.6% of the CNMs were in clinical practice. The demographic, employment, and income findings are presented for all CNM respondents by ACNM region of residence and for CNMs in full-scope clinical nurse-midwifery practice. Additional income findings for CNMs working full time and part time are also presented by ACNM region of residence, as well as by selected individual states. Nurse-midwifery income is compared with nursing income during the same time period. Demographic and/or employment characteristics are presented for CNMs doing home births, for student nurse-midwives, for nurse-midwifery faculty, and for nurse-midwives with doctorates. In surveys done from 1984 to 1988, the mean full-time CNM annual income increased by +10,000. The 1988 Survey data are now approximately two years old and the impact of the recent nursing shortage on both nursing and nurse-midwifery salaries was not necessarily reflected in these data.