Midwifery care during labor and birth in the United States.

The intrapartum period is a crucial time in the continuum of pregnancy and parenting. Events during this time are shaped by individuals' unique sociocultural and health characteristics and by their healthcare providers, practice protocols, and the physical environment in which care is delivered. Childbearing people in the United States have less opportunity for midwifery care than in other high-income countries. In the United States, there are 4 midwives for every 1000 live births, whereas, in most other high-income countries, there are between 30 and 70 midwives. Furthermore, these countries have lower maternal and neonatal mortality rates and have consistently lower costs of care. National and international evidences consistently report that births attended by midwives have fewer interventions, cesarean deliveries, preterm births, inductions of labor, and more vaginal births after cesarean delivery. In addition, midwifery care is consistently associated with respectful care and high patient satisfaction. Midwife-physician collaboration exists along a continuum, including births attended independently by midwives, births managed in consultation with a physician, and births attended primarily by a physician with a midwife acting as consultant on the normal aspects of care. This expert review defined midwifery care and provided an overview of midwifery in the United States with an emphasis on the intrapartum setting. Health outcomes associated with midwifery care, specific models of intrapartum care, and workforce issues have been presented within national and international contexts. Recommendations that align with the integration of midwifery have been suggested to improve national outcomes and reduce pregnancy-related disparities.

Asking different questions: A call to action for research to improve the quality of care for every woman, every child.

Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal care, and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents "different research questions" drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on "right care," which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of care, advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.

Perspectives on Promoting Hospital Primary Vaginal Birth: A Qualitative Study.

BACKGROUND: One in three women will deliver by cesarean, a procedure that can be life saving, but which also carries short- and long-term risks. There is growing interest in preventing primary cesarean deliveries, while optimizing the health of the mother and infant. The primary aim of this study was to use participatory action strategies and ethnographic interview data collected from diverse stakeholders in birth (caregivers, women, policymakers) about facilitators and barriers to the achievement of primary vaginal birth in first-time mothers in hospital settings. The secondary aim was to use the findings to identify strategies to promote primary vaginal birth and future areas of research. METHODS: Individual and small group interviews were conducted with caregivers and policymakers (N = 79) and first-time mothers (N = 24) at a northeastern hospital. All interviews were audio-recorded, transcribed, and analyzed using Atlas.ti. RESULTS: Four broad themes were identified: 1) preparation for childbirth, 2) early labor management, 3) caregiver knowledge and practice style, and 4) birth environment (physical, cultural/emotional). The first two were closely linked from caregivers' perspectives. If the woman was not prepared for childbirth, it was perceived she would be more likely to present to the hospital in early labor. Once there, it was hard to prevent admission and interventions. A woman's knowledge and confidence were perceived as powerful mediators for vaginal birth. CONCLUSION: Caregivers and first-time mothers identified early labor management and childbirth preparation as important factors to promote primary vaginal birth in hospital settings. Both deserve further inquiry as potential strategies to decrease rising cesarean delivery rates.

Integrative Literature Review: U.S. Military Women's Genitourinary and Reproductive Health.

OBJECTIVES: This integrated literature review evaluated research on genitourinary and reproductive health care needs and gender-specific health care delivery for active duty U.S. military women, a growing population in the armed forces. METHODS: A literature search was conducted for publications on genitourinary and reproductive health published between 2008 and 2014 using keywords and terms utilized in previous systematic literature reviews in similar military populations. RESULTS: Previous literature reviews concentrated on broader health care issues of military women. This review updates and expands the literature identified in three previous reviews. Publications were evaluated for relevancy to U.S. military women's health and a sample of 82 publications was included. Five broad categories were addressed across the literature: (1) pregnancy health, (2) deployment and preventive health, (3) sexually transmitted infections, (4) family planning and contraceptive services, and (5) sexual violations. DISCUSSION: Health care challenges are evolving within a changing military environment that includes a greater integration of women. Contraceptive, genitourinary-reproductive health care access, and self-diagnostic tools for easily treatable vulvovaginal conditions can empower military women and improve quality of life. CONCLUSIONS: Studies examining military gender-specific health care delivery are limited. Research to understand factors important for women in a changing military environment can improve health care delivery and outcomes, and military readiness.

Research on U.S. Military Women: Recruitment and Retention Challenges and Strategies.

OBJECTIVES: To examine literature on recruitment and retention of military women in research studies as an underrepresented, and potentially marginalized, population. METHODS: A literature search was conducted to examine challenges, identify potential barriers and facilitators, and to inform strategies for recruitment and retention of military women in research studies. This search was supplemented by findings in military-specific databases and discussions with Military Women's Health Research Interest Group subject matter experts. RESULTS: Ten articles addressed research recruitment and retention challenges and strategies in marginalized/underrepresented populations, providing an effective context to inform research recruitment and retention in military settings. Research with military women is often challenged by logistical, cultural, social, ethical, and methodological issues, which may hinder exploration of potentially sensitive issues. DISCUSSION: Researchers must consider military-specific challenges to conducting research that include lengthy deployments, unpredictable military exercises, and foreign assignments, in accessing research participants. A case example shows strategies used in a military cervical cancer screening study. CONCLUSION: There are few published articles specific to research recruitment and retention in female military populations. Available resources broadly address recruitment challenges for Veterans, marginalized, hard-to-access, and transient research participants, which may provide guidance and strategies for success when applied to military populations.

Developing an Internet-Based Decision Aid for Women Choosing Between Vaginal Birth After Cesarean and Planned Repeat Cesarean.

INTRODUCTION: In response to the call to develop strategies to engage women and providers in shared decision making, this article outlines a framework and process used to create an Internet-based decision aid about birth choices after previous cesarean. Recognizing the potential benefits of mobile health information technology, a paper-based decision aid was transformed into a secure, interactive Web site to meet the diverse needs of women and providers in this often challenging health care decision. METHODS: An iterative and participatory research approach was used, engaging targeted users (pregnant women and pregnancy care providers) in the design and development process. RESULTS: Women recommended that features and functions of the decision aid should include individualized information, trustworthy evidence, a secure and private site, quizzes to check knowledge, and a way to share values and preferences with their providers. Providers recommended individualized information for women, a process for women to share and document values and preferences with providers, and balanced, straightforward and complete information about the risks and benefits of each option. DISCUSSION: There is great potential for direct linkage between Internet-based decision aids and the electronic medical record. Work is currently underway to integrate and evaluate the Internet-based decision aid within busy practice settings to support shared decision making. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Nighttime breastfeeding behavior is associated with more nocturnal sleep among first-time mothers at one month postpartum.

STUDY OBJECTIVE: To describe sleep duration and quality in the first month postpartum and compare the sleep of women who exclusively breastfed at night to those who used formula. METHODS: We conducted a longitudinal study in a predominantly low-income and ethnically diverse sample of 120 first-time mothers. Both objective and subjective measures of sleep were obtained using actigraphy, diary, and self-report data. Measures were collected in the last month of pregnancy and at one month postpartum. Infant feeding diaries were used to group mothers by nighttime breastfeeding behavior. RESULTS: Mothers who used at least some formula at night (n = 54) and those who breastfed exclusively (n = 66) had similar sleep patterns in late pregnancy. However, there was a significant group difference in nocturnal sleep at one month postpartum as measured by actigraphy. Total nighttime sleep was 386 ± 66 minutes for the exclusive breastfeeding group and 356 ± 67 minutes for the formula group. The groups did not differ with respect to daytime sleep, wake after sleep onset (sleep fragmentation), or subjective sleep disturbance at one month postpartum. CONCLUSION: Women who breastfed exclusively averaged 30 minutes more nocturnal sleep than women who used formula at night, but measures of sleep fragmentation did not differ. New mothers should be encouraged to breastfeed exclusively since breastfeeding may promote sleep during postpartum recovery. Further research is needed to better understand how infant feeding method affects maternal sleep duration and fragmentation. CITATION: Doan T; Gay CL; Kennedy HP; Newman J; Lee KA. Nighttime breastfeeding behavior is associated with more nocturnal sleep among first-time mothers at one month postpartum.

Weaving dreamcatchers: mothering among American Indian women who were teen mothers.

AIMS: The aim of this study was to explore the mothering experience and practice among reservation-based adult American Indian women who had been adolescent mothers. BACKGROUND: Adolescent American Indian women are at an elevated risk for teen pregnancy and poor maternal/child outcomes. Identifying mothering practices among this population may help guide intervention development that will improve health outcomes. DESIGN: A collaborative orientation to community-based participatory research approach. METHODS: Employing interpretive phenomenology, 30 adult American Indian women who resided on a Northwestern reservation were recruited. In-depth, face-to-face and telephone interviews were conducted between 2007-2008. FINDINGS: Women shared their mothering experience and practice, which encompassed a lifespan perspective grounded in their American Indian cultural tradition. Four themes were identified as follows: mother hen, interrupted mothering and second chances, breaking cycles and mothering a community. Mothering originated in childhood, extended across their lifespan and moved beyond mothering their biological offspring. CONCLUSION: These findings challenge the Western construct of mothering and charge nurses to seek culturally sensitive interventions that reinforce positive mothering practices and identify when additional mothering support is needed across a woman's lifespan.

Crying babies, tired mothers - challenges of the postnatal hospital stay: an interpretive phenomenological study.

BACKGROUND: According to an old Swiss proverb, "a new mother lazing in childbed is a blessing to her family". Today mothers rarely enjoy restful days after birth, but enter directly into the challenge of combining baby- and self-care. They often face a combination of infant crying and personal tiredness. Yet, routine postnatal care often lacks effective strategies to alleviate these challenges which can adversely affect family health. We explored how new mothers experience and handle postnatal infant crying and their own tiredness in the context of changing hospital care practices in Switzerland. METHODS: Purposeful sampling was used to enroll 15 mothers of diverse parity and educational backgrounds, all of who had given birth to a full term healthy neonate. Using interpretive phenomenology, we analyzed interview and participant observation data collected during the postnatal hospital stay and at 6 and 12 weeks post birth. This paper reports on the postnatal hospital experience. RESULTS: Women's personal beliefs about beneficial childcare practices shaped how they cared for their newborn's and their own needs during the early postnatal period in the hospital. These beliefs ranged from an infant-centered approach focused on the infant's development of a basic sense of trust to an approach that balanced the infants' demands with the mother's personal needs. Getting adequate rest was particularly difficult for mothers striving to provide infant-centered care for an unsettled neonate. These mothers suffered from sleep deprivation and severe tiredness unless they were able to leave the baby with health professionals for several hours during the night. CONCLUSION: New mothers often need permission to attend to their own needs, as well as practical support with childcare to recover from birth especially when neonates are fussy. To strengthen family health from the earliest stage, postnatal care should establish conditions which enable new mothers to balance the care of their infant with their own needs.

The conduct of ethical research collaboration across international and culturally diverse communities.

OBJECTIVE: to present recently developed guidelines by the International Confederation of Midwives (ICM) to guide the ethical conduct of research by midwives across international and culturally diverse communities. To illustrate the complexities of conducting collaborative research across diverse communities, a case study is provided highlighting unequal power balances, legal, ethical and cultural constraints. BACKGROUND: the research guidelines are structured using a human rights framework. The document was developed with input and consideration by the ICM Research Standing Committee and comments of 35 delegates who participated in a workshop to evaluate the guidelines from the perspectives of frontline midwifery clinicians, leaders and researchers. It is intended to serve as a blueprint for midwives aiming to enter into a collaborative research partnership with ethnic and culturally diverse groups. CONCLUSIONS: although the document was developed with the international midwifery community in mind, it will guide any researcher seeking to conduct research in the best interest of women, their newborn babies, their families, and their wider communities.

An exploratory metasynthesis of midwifery practice in the United States.

OBJECTIVES: To conduct a metasynthesis of six qualitative studies of midwifery care and process; identify common themes and metaphors among the six studies for further exploration and theory development; and create a framework for further metasynthesis of qualitative studies of midwifery practice in the USA. DESIGN: A qualitative metasynthesis to analyse, synthesise, and interpret six qualitative studies on the process and practice of midwifery care. SAMPLE AND SETTING: Hospital, birth centre, and home birth settings were represented across all of the studies. Participants included nurse- and direct-entry midwives who provided both childbearing and gynaecological care. Recipients of midwifery care also received both childbearing and gynaecological care. FINDINGS: Four overarching themes were identified: the midwife as an 'instrument' of care; the woman as a 'partner' in care; an 'alliance' between the woman and midwife; and the 'environment' of care. These were interpretively and conceptually arrayed into a helix model of midwifery care. KEY CONCLUSIONS: The findings from this exploratory metasynthesis clearly indicate that the practice of midwifery is a dynamic partnership between the midwife and the woman, and reflects an environmental perspective. In a country that has a standard of highly technical childbirth care, perhaps the most outstanding concept of this model is that of the midwife as an 'instrument' of care. The significance of the findings will be determined by their ability to guide further research efforts to support a standard of midwifery care for all women in the USA. IMPLICATIONS FOR PRACTICE: This model offers a benchmark and a structure for considering the dynamic elements of midwifery practice and key roles that the midwife plays in the health care of women and babies.

The practice of nurse-midwifery in the era of managed care: reports from the field.

OBJECTIVE: The purpose of this paper is to describe the reports of certified nurse-midwives (CNMs) about how changes in the financing and organization of health care in the late 1990s influenced their ability to serve vulnerable populations and provide a woman-centered, prevention-oriented midwifery model of care. METHODS: A 13-page survey was mailed to all CNMs ever certified by the American College of Nurse-Midwives (N = 6365) in July 1998. The survey included closed- and open-ended questions. A total of 2405 CNMs responded: of these, 2089 were in clinical practice during the study period (1997-98) and 82% of the 2089 (N = 1704) wrote responses to the open-ended questions and were included in the qualitative database. We present responses to the closed-ended questions about seven domains of practice and elaborate on three major themes identified through content analysis of the qualitative data. RESULTS: The majority (57%) reported that the changes in the larger health care environment had influenced their practices during 1997-98. The effects most frequently reported were 1) increased client loads (31%); 2) altered style of practice (30%): 3) inability to serve the same populations; (20%); 4) decreased client loads (20%); and 5) increased administrative duties (17%). Three major themes were identified and elaborated upon in the qualitative data: 1) challenges to the style of midwifery practice related to the managed care environment; 2) the loss of socially and economically at-risk women from CNMs' client base; and 3) barriers to high quality and comprehensive services for women. CONCLUSIONS: During the late 1990s as managed care was expanding and health systems were merging, a significant number of CNMs in the field described threats to their ability to sustain economically viable practices and a style of care consistent with the woman-centered, prevention-oriented midwifery model.