Professional Midwifery Today

Transcription

1 style_ttt/shutterstock, Inc. C H A Jones P T E& Bartlett R Learning, 2 Professional Midwifery Today Deanne R. Williams Susanna R. Cohen Celeste Thomas Jones & Bartlett Introduction Learning, Jones with a & commitment Bartlett Learning, to serve (professional membership FOR organizations); SALE OR DISTRIBUTION (4) standards of competency NOT Midwifery in the twenty-first century is a profession (e.g., certification by a nationally recognized certification agency); (5) established standards of practice; that is deeply rooted in service to both women who are vulnerable to poor pregnancy outcomes and the and (6) adheres to ethical standards. preservation of a childbirth experience that honors Although this chapter will not contribute directly to the clinical competence Jones that students & Bartlett and Learning, LL the normal process of Jones birth as & well Bartlett as the transformational power of the NOT childbearing FOR SALE experience. OR DISTRIBUTION While midwives seek early in their NOT careers, FOR it does SALE put mid- OR DISTRIBUT Learning, midwives maintain their commitment to provide wifery practice into a societal context via a review of individualized care responsive to the needs of the these essential characteristics that make midwifery woman, they are also increasingly recognized as key a profession. This is the environment that graduates players in a global community of healthcare professionals Jones who improve & Bartlett the lives Learning, of mothers and babies. legal, independent, Jones and & successful Bartlett midwife Learning, requires enter as they come to understand that being a safe, This NOT expanded FOR SALE allegiance from OR DISTRIBUTION the individual, to more than NOT clinical FOR competence. SALE OR DISTRIBUTION the profession, to women wherever they need care is reflected throughout this text and is the primary focus of this chapter. The Professional Paradigm: Midwifery in Midwifery in the United States, as represented Jones & Bartlett by certified Learning, nurse-midwives, certified midwives, and Jones the & Twenty-First Bartlett Learning, Century NOT FOR SALE certified OR professional DISTRIBUTION midwives, is a dynamic profes-nosion. The scope of midwifery practice has expanded, Along FOR with SALE the OR more DISTRIBUTION detailed information about the as has the core knowledge needed to provide safe care history of midwifery that was presented in the introductory chapter, Box 2-1 provides a list of some of and to participate as members of an interdisciplinary team. Likewise, civil society has expanded its expectations for healthcare professionals, and midwives the seminal events in the development of modern midwifery in the United States and acknowledges a few have responded by adopting new standards for their of the key individuals, groups, and events that have profession. helped develop midwifery into NOT a profession FOR SALE today. OR 1,2 DISTRIBUT The essential characteristics of a profession are measurable, interconnected, and commonly recognized. A profession has the following properties: Most midwives have been asked the following Types of Professional Midwives (1) Jones specialized & Bartlett knowledge Learning, typically obtained at the questions about Jones their & profession: Bartlett What Learning, is the difference among NOT a FOR certified SALE nurse-midwife OR DISTRIBUTION (CNM), college NOT FOR level (graduation SALE OR from DISTRIBUTION a nationally accredited education program and earning a degree); (2) legal a certified midwife (CM), and a certified professional midwife (CPM)? What is a lay recognition (federal and state laws); (3) self-organized midwife?

2 36 PART I Midwifery Box 2-1 Evolution of the Profession of Midwifery in the United States 1925: Mary Breckinridge opens the Frontier Nursing Service (FNS) in Hyden, Kentucky the first nurse-midwifery service. 1929: FNS nurse-midwives NOT FOR organize SALE the OR American DISTRIBUTION Association of Nurse-Midwives. 1931: Lobenstine Midwifery School opens the first nurse-midwifery education program. 1955: ACNM incorporated. 1956: Yale University School of Nursing opens a nurse-midwifery program. 1965: ACNM accredits education programs. 1960s Counterculture, feminism, and grassroots rejection of over-medicalization of birth and increased 1970s: conversation about home birth; childbearing women share their very personal experiences comparing traditional medical care with midwifery care. 1970: First edition of Our Bodies, Ourselves published. The ninth edition was published in This book has been a strong supporter of midwifery since its beginnings and includes many midwives as contributing authors. 1971: First CNM credential issued based on national examination. Jones & Bartlett Learning, 1975: Publication of Spiritual Midwifery by Ina May Gaskin. NOT This FOR book SALE introduced OR a generation DISTRIBUTION of women to natural childbirth while giving voice to childbirth s spiritual components. 1977: The Maternity Center of El Paso opens the first direct-entry education program for lay midwives. 1977: The first gathering of lay midwives in El Paso, Texas. 1978: ACNM s Core Jones Competencies & Bartlett for Basic Nurse-Midwifery Learning, Practice published. 1982: Founding NOT of MANA. FOR SALE OR DISTRIBUTION 1989: MANA establishes the Interim Registry Board to explore a national registry exam; this later becomes NARM. 1990: ACNM s first Code of Ethics published. 1993: ICM s first Code of Ethics published. 1994: MANA s Core Competencies for Basic Midwifery Practice published. 1994: First CPM credential issued. 1994: ACNM endorses development of the CM credential. 1998: First CM credential issued. 1999: Baccalaureate degree required for CNM. 2000: NACPM founded. 2010: Graduate degree required for CNM/CM. Over time these efforts have been supported by the following parties: Community activists who set out to improve the quality of care for special populations, especially those composed of those individuals who because of age, race, ethnicity, or socioeconomic status are considered vulnerable Military leaders Jones who identified & Bartlett nurse-midwives Learning, as qualified providers who could help make up for difficulty in recruiting physicians Birth collectives that wanted to train their own midwives Epidemiologists who looked beyond care provided by physicians, discovered midwifery, and published research on midwifery outcomes Elected public officials who pushed motivated midwives to get their policies in order, codified those policies, and then resisted attempts by organized medicine to make midwifery illegal ACNM = American College of Nurse-Midwives; CM = certified midwife; CNM = certified nurse-midwife; CPM = certified professional midwife; ICM = International Confederation of Midwives; MANA = Midwives Alliance of North America; NACPM = National Association of Certified Professional Midwives; NARM = North American Registry of Midwives

3 CHAPTER 2 Professional Midwifery Today 37 NOT FOR SALE A direct-entry OR DISTRIBUTION midwife? A licensed midwife? An in-nodigenous midwife? While the answers to these ques- first becoming a nurse. In some states, direct-entry midwife FOR SALE who has OR entered DISTRIBUTION the profession without tions are evolving, and they can be both confusing and licensed midwife are categories of licensure that and controversial, an exploration of the similarities are separate from the licensure of CNMs. The terms and differences between midwives is important to traditional midwife, community midwife, and the profession (Table Jones 2-1). & Bartlett Learning, indigenous midwife acknowledge Jones the & women Bartlett or Learning, LL Terms such as NOT lay midwife FOR SALE and direct-entry OR DISTRIBUTION men who follow traditional NOT customs FOR as they SALE attend OR DISTRIBUT midwife do not have a common definition. For births in their community. These midwives work some, the term lay midwife describes an individual who has no formal education as a midwife, cation and well-staffed hospitals found in larger in areas that have limited access to the formal edu- while others use this term to refer to a midwife cities. Traditional midwives often are elders who who Jones is not recognized & Bartlett by Learning, a government entity. The are influential Jones and trusted & Bartlett because Learning, they practice in term NOT direct-entry FOR SALE midwife OR DISTRIBUTION typically refers to a concert with NOT local FOR belief SALE systems. OR Examples DISTRIBUTION include Table 2-1 Education Certification Scope of practice Types of Midwives in the United States Certified Midwife Certified Nurse-Midwife (CM does not have to be an RN) Nationally accredited education programs Graduate degree Increase in number of programs that require doctoral degree Nationally recognized certification exam Must graduate from accredited program Graduate degree required Obstetrics (hospital and out-of-hospital births), well-woman gynecology, newborn, prescriptive authority Nationally accredited education programs Graduate degree Nationally recognized certification exam Must graduate from accredited program Graduate degree required Obstetrics (hospital and out-of-hospital births), well-woman gynecology, newborn, prescriptive authority Certified Professional Midwife Nationally accredited education programs Nationally recognized certification exam Minimum requirement: high school diploma or equivalent CNMs and CMs may qualify to take the certification exam Primary maternity care of healthy women experiencing normal pregnancies Specialize in home and out-of-hospital births Licensure 50 states and 3 territories 3 states Recognized by licensure in 16 states and by permit or certification in 3 additional states Challenges Standard-setting professional organizations Licensure and scope of practice vary from state to state Some states do not recognize independent practice ACNM AMCB ACME Licensure and scope of practice vary from state to state Some states do not recognize independent practice Not recognized in Medicare rules ACNM ACMB ACME Illegal in 12 states Licensure and scope of practice vary from state to state Not recognized in Medicare rules NACPM NARM MEAC MANA ACNM = American College of Nurse-Midwives; AMCB = American Midwifery Certification Board; ACME = Accreditation Commission on Midwifery Education; NACPM = National Association of Certified Professional Midwives; NARM = North American Registry of Midwives; MEAC = Midwifery Education Accreditation Council;MANA = Midwives Alliance of North America ; RN = registered nurse

4 38 PART I Midwifery NOT FOR SALE aboriginal OR DISTRIBUTION midwives in Canada and comodronas NOT Professional FOR SALE Midwives OR DISTRIBUTION (NACPM) now focuses in Guatemala. more on common values and goals than on differences. It is increasingly clear that in the United In the United States, the midwifery community was divided for many years between nurse-midwives States, where the consumer is unlikely to understand and lay midwives. Prior to the 1990s, many midwives the difference between midwives with different credentials, each individual who Jones uses the & title Bartlett mid- Learning, LL who were not CNMs Jones resisted & becoming Bartlett nurses Learning, to be eligible for midwifery NOT FOR education SALE programs OR DISTRIBUTION and wife assumes responsibility NOT for FOR the image SALE of the OR DISTRIBUT were opposed to adopting national standards for entire profession. education and certification. This resistance partially stemmed from concern that the next steps would be a formal education requirement that did not recognize Jones apprenticeship & Bartlett education Learning, and state licensure. Evolution of Jones the Profession & Bartlett of Learning, Midwifery Concern NOT FOR also SALE arose that OR national DISTRIBUTION standards would permit non-midwives to define the midwife s scope of I found that NOT FOR wherever SALE a city, OR a DISTRIBUTION country, a practice. Being a lay midwife and attending home region, or a nation had developed a system births was seen by some as the ultimate in independent practice and a source of pride. of maternal care which was firmly based on a body of trained, licensed, regulated The CPM credential, first issued in 1994, was and respected midwives (especially when originally developed to provide competency-based the midwives worked in close and cordial NOT FOR certification for midwives who were primarily apprentice trained in out-of-hospital birth. The natural co-operation SALE OR with DISTRIBUTION doctors), the standard of maternal care was at its highest and consequences of creating the CPM certification examination were the obligation to ensure that those maternal mortality was at its lowest. I cannot think of an exception to that rule 3 who take the exam meet Jones common & Bartlett standards Learning, for education and practice NOT and FOR the creation SALE of OR a structure DISTRIBUTION The Early Years: The Trailblazers within which to discipline those who do not perform The scope of practice of CNMs and CMs as defined in a manner consistent with the standards. CPMs by the ACNM and recognized in federal and state now have national standards for education, certification, and practice; are seeking licensure in all states; laws has changed over the years. The early nursemidwifery trailblazers (1930s to 1950s) 2 who and Jones are pursuing & Bartlett reimbursement Learning, from both govern- ment NOT and FOR nongovernment SALE OR insurance DISTRIBUTION companies. predated the 1955 incorporation of the American College of NOT Nurse-Midwifery FOR SALE (changed OR DISTRIBUTION to Midwives When all nurse-midwives were required to be in 1969) would probably be surprised to learn that experienced nurses prior to entering midwifery education, it was difficult for CNMs to consider other today s CNMs and CMs provide more than just maternity care to women and are working in very routes to midwifery as equivalent to their own. In specialized women s healthcare clinics. The small Jones & Bartlett 1991, the Learning, board of directors of the American College Jones number & Bartlett of home births Learning, attended by CNMs/CMs NOT FOR SALE of Nurse-Midwives OR DISTRIBUTION (ACNM) endorsed the develop-noment of an alternative educational path to midwifery might FOR also SALE surprise OR the DISTRIBUTION trailblazers. They might also wonder why today s CNMs/CMs sometimes have that did not require a nursing degree, leading to the to fight to be recognized as primary care providers, given that primary care was an essential com- CM credential. Over the next 7 years, the requirements to accredit education programs and certify ponent of the public health nursing practiced by graduates who were Jones not registered & Bartlett nurses Learning, were designed and tested to NOT ensure FOR that SALE after graduation OR DISTRIBUTION and those who added midwifery Jones training & to Bartlett become Learning, LL nurse-midwives. certification, one could not distinguish between the knowledge and skills of a CNM and a CM. The first CM credential, which required passing the same certification examination that is offered to nurse-mid- Lessons learned from the successes and failures of the Building the Profession: The Fence Builders wives, Jones was issued & Bartlett in Learning, CNM trailblazers Jones served & Bartlett as guideposts Learning, for the fence NOT Although FOR SALE significant OR variations DISTRIBUTION between CPMs, builders. NOT 4 The fence FOR builders SALE wrote OR DISTRIBUTION ACNM standards for the education, certification, and practice of CNMs, and CMs still exist (as summarized in Table 2-1), the interaction between the three professional midwives, launched a peer-reviewed journal (Journal membership organizations for midwives the of Midwifery, whose name was changed to Journal of ACNM, the Midwives Alliance of North America Midwifery & Women s Health in 1999), created a Jones & Bartlett (MANA), Learning, and the National Association of Certified Jones network & Bartlett of midwives Learning, supporting midwifery-owned

5 CHAPTER 2 Professional Midwifery Today 39 NOT FOR SALE businesses OR DISTRIBUTION and offered their services to help save NOT midwives FOR SALE will OR carry DISTRIBUTION the profession, and its lowtechnology, high-touch roots into a high-technology women s lives and educate midwives in low- resource countries. More recent accomplishments that depended upon the work of the early fence builders delivery systems. Like the midwifery trailblazers and world characterized by more integrated healthcare include legislation that (1) protects the right of fence builders, today s midwives must also be protectors. They must continue to Jones distinguish & Bartlett the mid- Learning, LL women to choose midwifery Jones care & Bartlett (1997); (2) Learning, ensures Medicare payment NOT for maternity FOR SALE care OR provided DISTRIBUTION by wifery profession from the professions NOT FOR of nursing SALE and OR DISTRIBUT nurse-midwives (1988); (3) expands this coverage to medicine and expand the evidence base that defines full-scope nurse-midwifery care (1993); and (4) now the best practices in midwifery. provides for Medicare payments to CNMs that are Few of these labor-intensive accomplishments equal to payments made to physicians (2011). would have ever moved from internal ideals to Jones CPMs have & Bartlett also evolved Learning, over time. There are cultural norms Jones without & Bartlett consumer Learning, support. From now NOT three FOR standard-setting SALE OR DISTRIBUTION professional organizations that work to move the CPM profession for- Connection) to Citizens for Midwifery, consumers the Maternity NOT Center FOR Association SALE OR (now DISTRIBUTION Childbirth ward: MANA, founded in 1982; the North American have provided inspiration, influence, and financial Registry of Midwives (NARM), founded in 1994; resources to promote and protect access to midwifery and NACPM, founded in One unique aspect care. 5,6 The list of individuals who created a public Jones & Bartlett of these organizations Learning, is that they represent midwives Jones demand & Bartlett and stood Learning, beside midwifery during some NOT FOR SALE from OR very DISTRIBUTION diverse clinical and educational experi-noences and, therefore, it is not easy to summarize their very FOR difficult SALE times OR is DISTRIBUTION long. evolution over time. Judith P. Rooks, in her landmark book, Midwifery and Childbirth in America, stated that these midwives developed as part of the Characteristics of the Midwifery Profession social and cultural ferment Jones of & the Bartlett late 1960s Learning, and invented themselves in rural communes, religious To protect the profession from those who resist increasing access to midwifery communities, and the nooks and crannies of urban NOT care by FOR suggesting SALE that OR DISTRIBUT counterculture enclaves. 2 midwives are undereducated, outdated, or unprofessional, it is important for midwives to be able to After the late 1960s, these midwives faced a number of challenges: (1) their lack of credentials answer a critical question: What makes one a professional? According Jones to Ament, & Bartlett in the Learning, United States, and Jones illegal status & Bartlett in some states; Learning, (2) different educational processes, which range from pure apprenticeship to private 3-year schools; (3) negative publicity the overall objective of protecting the public welfare is accomplished NOT FOR through SALE three OR interdependent DISTRIBUTION accompanying bad outcomes at home births that mechanisms: 1) a prescribed, accredited course of may have been attended by midwives with insufficient training who have not undergone recognized study; 2) national certification; and 3) governmental, usually state or other jurisdiction, licensure. 7 Thus educational processes for direct-entry midwives; and a professional must show evidence of attending an (4) the negative stereotype that midwives in general accredited education program, attaining national NOT are less competent than physicians. 1 certification, FOR SALE and OR becoming DISTRIBUTION licensed by all the appropriate legal jurisdictions. Midwifery leaders and Members of MANA realized that the only way to convince the public and the government of their healthcare researchers have also described additional professionalism and avoid legal persecution was to characteristics of professionalism that are less easily measured, but considered to be integral to the create a standardized national certification process. In response, the NARM certification exam and CPM specific profession of midwifery. credential were created. The CPM credential is open to midwives educated through all possible routes, including apprenticeship, self-study, formal vocational Core competencies delineate the fundamental knowl- Core Competencies programs, university training, and all combinations edge, skills, and behaviors expected of members of thereof. Jones 1 & Bartlett Learning, the profession. Jones They serve & Bartlett as the reference Learning, point for standardization NOT of FOR the curricula SALE for OR otherwise DISTRIBUTION diverse Midwifery Now: The Tower Builders education programs, the criteria for accrediting education programs that are not all within colleges of Midwives in the twenty-first century must fill the role of tower builders 4 by continuing to help the nursing, and the development of the certification profession, in all of its diversity, meet the growing examination. These competencies inform regulatory Jones & Bartlett demand for Learning, midwifery care in a digital world. These Jones agencies, & Bartlett consumers, Learning, and employers of what, at a

6 40 PART I Midwifery NOT FOR SALE minimum, OR DISTRIBUTION can be expected from those who meet the NOT accrediting FOR SALE agency OR for DISTRIBUTION direct-entry midwifery education programs. MEAC-accredited programs, which criteria to use the professional credential. The first ACNM Core Competencies for Basic may or may not be affiliated with an institution of Midwifery Practice were published in 1978, although higher education, prepare students to take the CPM some concepts could be found in earlier midwifery examination. documents. 8 The core Jones competencies & Bartlett have Learning, been updated regularly to NOT reflect FOR changes SALE in the OR profession, DISTRIBUTION Certification including the decision to educate and certify midwives who do not have a nursing education, previously mentioned as the CM. For CNMs and CMs, certification passing an examination that measures mastery of fundamental First published in 1994, the MANA Core Competencies for Basic Midwifery Practice are referenced knowledge needed for safe practice that is obtained through a recognized program of study is required for the CPM certification exam and the Midwifery to obtain a state license to practice, to obtain hospital staff NOT privileges, FOR and SALE to qualify OR DISTRIBUTION for reimburse- Education Accreditation Council (MEAC) accreditation process. 9 ment from government and private health insurance Using core competencies as a measurement of plans. The criteria for taking the exam, the content a student s success enables education programs to of the exam, and the requirements for maintaining recognize that many individuals enter midwifery certification are developed under the auspices of organizations that do not serve as advocates for the programs with preexisting skills and enables the students to focus their studies on new areas, rather than NOT profession. FOR SALE While OR members DISTRIBUTION of the profession can repeating already learned information. serve as expert advisors, certification organizations In addition, work to protect the recipients of care and follow the clear, meaningful competencies reassure the public as standards established by the National Commission well as the midwifery community that all accredited programs graduate well-prepared Jones & Bartlett individuals. Learning, for Certifying Agencies. CNMs Jones have been & Bartlett certified Learning, LL by examination since 1971, CPMs since 1994, and CMs since Accreditation Earning a college degree is a significant measure of success in the United States. It represents knowledge State Regulation obtained in an institution that adheres to national The assumption of responsibility for the life and standards Jones that & are Bartlett established Learning, to ensure preparation health of another Jones individual or & Bartlett individuals, Learning, the of NOT students FOR who SALE are well OR educated, DISTRIBUTION by qualified faculty in their chosen field. Students, employers, and gal and social contract with multiple contingency case of the NOT maternal fetal FOR SALE dyad comprises OR DISTRIBUTION a le- consumers want to know that a degree reflects mastery of a prescribed set of knowledge and skills. tecting citizens from unsafe healthcare practitioners clauses. State legislators have responsibility for pro- To increase the value of formal education and and do so by establishing, via state laws, the rules Jones & Bartlett to protect Learning, students from fraud, the federal govern-ment OR and DISTRIBUTION professional organizations have estab-not adopting FOR SALE regulations OR DISTRIBUTION that further clarify the rules. Jones that govern & Bartlett practice. Learning, State agencies are charged with NOT FOR SALE lished standards for institutions of higher education A typical state midwifery practice act will establish that address the learning environment, content of (1) qualifications for initial and renewed licensure, the curriculum, and qualifications of faculty. In the (2) scope of practice, (3) relationship with physicians, case of midwifery, the Accreditation Commission (4) prescriptive authority with special requirements for Midwifery Education Jones (ACME) & Bartlett has been Learning, recognized by the U.S. NOT Department FOR SALE of Education OR DISTRIBUTION as a (5) definitions of unlawful or NOT unprofessional FOR SALE conduct. OR DISTRIBUT related to prescribing controlled Jones substances, & Bartlett and Learning, LL programmatic accrediting agency since 1982 for Because the laws governing licensure must be handled nurse-midwifery education programs and since 1994 through the legislative process, they are subject to the for direct-entry midwifery programs. Maintaining influence of multiple stakeholders; moreover, the process of getting a bill passed can be unpredictable. As a midwifery accreditation standards that are separate from Jones those required & Bartlett for nursing Learning, education has allowed NOT FOR the CNM/CM SALE OR profession DISTRIBUTION to self-regulate, tice and requirements NOT FOR for SALE licensure OR or DISTRIBUTION authorization result, there is Jones variation & in Bartlett midwifery Learning, scopes of prac- maintain a strong public voice for improving access to practice from state to state. Some state practice to midwifery care, and influence public policy that acts are not entirely consistent with the standards of affects the health of women and families. practice endorsed by professional midwifery organizations and taught in accredited midwifery educa- The U.S. Secretary of Education recognizes Jones & Bartlett the MEAC, Learning, established in 1991, as a national Jones tion programs. & Bartlett Despite Learning, this discrepancy, the licensed

7 the healthcare facility, define the requirements for obtaining privileges, the responsibilities of those who are granted privileges, specific procedures that may be performed by the individual providers, protections offered to those who are privileged, and grounds for removal of privileges. These bylaws may also specify CHAPTER 2 Professional Midwifery Today 41 NOT FOR SALE midwife OR is DISTRIBUTION expected to follow the rules and regula-notions for whatever method of authorization he or wifery professionalism: FOR Kennedy SALE identified OR DISTRIBUTION three dimensions of mid- she is granted by the state. The practice of midwifery can also be subject to state and federal laws governing Medicare and Medicaid payment, prescriptive trates how and why the midwife chooses and 1. The dimension of therapeutics, which illus- authority, controlled Jones substances, & Bartlett and licensing Learning, of uses specific therapies when Jones providing & Bartlett care Learning, LL freestanding birth NOT centers. FOR SALE OR DISTRIBUTION 2. The dimension of caring, NOT which FOR reflects SALE how OR DISTRIBUT the midwife demonstrates that she cares for, Midwifery Scope of Practice and about, the woman An individual s scope of practice is determined by several factors, including legal jurisdictions, institutional amines how midwifery might be enhanced 3. The dimension of the profession, which ex- policy, and individual education and training. Most and accepted by exemplary practice 11 laws NOT governing FOR SALE midwifery OR practice DISTRIBUTION define the clinical or professional relationship between midwives and Kennedy divided the dimension of therapeutics into consulting physicians. At their best, the laws support midwifery independent practice and collabora- two qualities that must be held in balance: supporting the normalcy of birth, while simultaneously maintaining vigilance and attention to detail, intervening tive management; at their worst, they require direct Jones physician supervision of midwives. The rules and only when & Bartlett necessary. Learning, This process of supporting NOT FOR SALE regulations OR DISTRIBUTION governing midwifery practice usually are NOT normalcy FOR SALE could OR aptly DISTRIBUTION be described as the art of doing available on state-sponsored websites. Professional nothing well. 11 organizations such as ACNM and MANA provide The dimension of caring is demonstrated by online summaries of all the state midwifery laws. 1) respecting the uniqueness of the woman and A recent review by Osborne summarized current family; and 2) creation of a setting that is respectful state regulations regarding prescriptive authority and reflects the woman s needs. Jones 11 Midwives & Bartlett explore Learning, LL for midwives. 10 and honor each individual woman s NOT FOR personal SALE history OR DISTRIBUT Midwives who attend births in a hospital and and cultural context. They work in partnership with some birth centers are required to be credentialed and women with the goal of providing emotional support privileged by the healthcare facility prior to caring and strengthening self-confidence. for women in that setting. Bylaws, as established by Some qualities identified by Kennedy as linked to the dimension Jones of caring & include Bartlett an Learning, unwavering integrity and NOT honesty, FOR compassion SALE OR and understanding, DISTRIBUTION the ability to communicate effectively, and flexibility. 11 Midwives are emotion-workers. They support the emotional journey of women through health care. For example, midwives support the birthing woman Jones the role and responsibilities of the midwife in relation while & also Bartlett identifying Learning, and managing their own emotions FOR in SALE order to OR best DISTRIBUTION meet the needs of the woman, NOT FOR SALE to consulting OR DISTRIBUTION physician(s) and the responsibilities of NOT the physician in relationship to collaborating midwives. All privileged providers are expected to ad- including situations in which the woman may be fearful. The professional midwife then works to minimize here to institution bylaws, even when they are more her fear. In addition to creating an emotional setting that meets the woman s needs, exemplary restrictive than the state law. mid- wives are experts at creating safe Jones emotional & Bartlett settings. Learning, LL Midwives who care for women NOT in FOR labor SALE are experts OR DISTRIBUT in protecting the sacred physical birth space. Using The Professional: The Exemplary Midwife skills that make midwifery a unique profession, they help to create a peaceful environment that is the most Professions also assume responsibility for setting their conducive to the birth process, maternal satisfaction, own Jones standards & Bartlett of performance. Learning, As is often noted, and mother child Jones bonding & Bartlett in the immediate Learning, postpartum period. there NOT is FOR a difference SALE between OR DISTRIBUTION being a member of a profession and being a professional. As Kennedy The dimension of the profession focuses on the has stated, the midwife s professionalism is a key delineation, promotion, and sustenance of midwifery factor in empowering women during the childbearing process. 11 Thus, to be a professional, one must dimension through evidence-based practice, quality as a professional role. 11 Midwives demonstrate this Jones & Bartlett know how Learning, professionalism is defined and measured. Jones and peer & Bartlett review, continuing Learning, education, commitment

8 42 PART I Midwifery NOT FOR SALE to and OR passion DISTRIBUTION for the profession, and nurturing and NOT in FOR small SALE private OR practices DISTRIBUTION in rural communities, and caring for themselves. The exemplary midwife s focus anywhere in between. Midwives may attend births in is not just on the individual woman or birth; in addition, the midwife is driven to foster the profession and may be self-employed in a private business, or they homes, freestanding birth centers, or hospitals. They advocate for improving women s health care locally may be employees of physicians or healthcare organizations. They may provide Jones care to women & Bartlett from Learning, LL and globally. vulnerable populations or to NOT women FOR with SALE extensive OR DISTRIBUT social and financial resources. Midwives can limit their practice to women with needs that are age or Midwifery Within the U.S. disease specific, such as family planning, infertility, Healthcare System obstetric triage, menopause, incontinence, or pelvic pain, or they can Jones provide & Bartlett a general range Learning, of services. The NOT quintessential FOR SALE midwifery OR DISTRIBUTION role is provider of direct Since the NOT 1960s, FOR the SALE majority OR of CNMs, DISTRIBUTION and now care to women. The other chapters in this text detail CMs, who attend births have done so in hospitals and how that role is fulfilled. Additional roles inherent in freestanding birth centers, whereas the vast majority of CPMs attend births in homes or freestanding midwifery include researcher, educator, policymaker, and business manager, among others. Thus the practice of midwifery Learning, is not solely devoted to direct pa- Jones for a & while, Bartlett the future Learning, may present more birth centers. Although these trends may continue Jones & Bartlett workplace NOT FOR SALE tient care, OR but DISTRIBUTION rather encompasses a variety of other NOT opportunities FOR SALE for OR all DISTRIBUTION midwives. activities. Improving the health of women is a personal, communal, and political responsibility, and midwives work wherever women need them. While many In 1989, the Centers for Disease Control and Prevention (CDC) began collecting data on nursemidwife attended births. Since then, there has been a steady increase in the number of women having vaginal births attended by CNMs Jones and CMs, & Bartlett and in 39 Learning, LL midwives attend births Jones and provide & Bartlett women s Learning, health services, they may NOT also work FOR as SALE entrepreneurs, OR DISTRIBUTION educators, and researchers. In all of these settings, mid- attended by midwives (Figure 2-1). 12,13 states an overall increase in NOT the proportion FOR SALE of births OR DISTRIBUT wives collaborate with a variety of team members. Historically, the percentage of out-of-hospital births (including birth center and home births) In clinical practice, midwives may work for large hospitals or healthcare systems in metropolitan areas, declined from 44% in 1940 to 1% in 1969, and 12% Jones & Bartlett Learning, 10% 8% % Jones vaginal births & Bartlett Learning, 6% 4% % all births 2% All 3.3 Vaginal 4.8 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 ' Figure 2-1 Percentage of live births attended by certified nurse-midwives, Source: Martin JA, Hamilton BE, Ventura SJ, et al. Births: Final Data for National Vital Statistics Reports, Vol. 61, No. 1. Hyattsville, MD: National Center for Health Statistics;

9 NOT FOR SALE remained OR stable DISTRIBUTION until recently. The majority of out-noof-hospital births occur at home. According to the FOR Table SALE 2-2 OR Postinterview DISTRIBUTION Evaluation for a Midwife National Center for Health Statistics (NCHS), from 2004 to 2009, U.S. home births increased from Rate your responses to the following questions: 1 = acceptable 2 = unsure 3 = unacceptable 0.56% to 0.72% a 29% increase. 14 Practice philosophy The Employee Patient volume With so many opportunities, the typical midwife Patient demographics seeking a job searches for a position that is a good match to his or her experience, personality, skill set, and lifestyle. When evaluating the positives and negatives Patient outcomes Productivity requirements Jones of any job, & Bartlett it is important Learning, to review several other Clinical hours Jones & Bartlett 1 Learning, 2 3 aspects NOT of FOR the business SALE that OR may DISTRIBUTION contribute to success or frustration. These aspects may include availability Practice partners of and relationship with collaborative physicians, ancillary support (e.g., billing, patient flow), retirement benefits, reimbursement for professional expenses Support staff Practice facilities Jones & Bartlett (e.g., licenses, Learning, certification, continuing education), Jones Birth & facilities Bartlett Learning, NOT FOR SALE and payment OR DISTRIBUTION for malpractice premiums. It is impor-notant to determine whether the malpractice coverage FOR Nonclinical SALE responsibilities OR DISTRIBUTION is an occurrence policy or a claims-made policy. An Availability of resources occurrence policy covers claims that occur during the life of the policy, whereas a claims-made policy Orientation covers only claims that Jones are made & Bartlett during the Learning, life of the policy. A claims-made NOT policy FOR requires SALE the OR insured DISTRIBUTION to purchase extended coverage, termed a tail or prior avoid the limitations imposed by the business model acts policy, if employment changes. Who pays the or clinical guidelines developed by others, such as cost of the extension which may be 1.5 times the physicians, hospitals, and community clinics, can be annual premium is an important consideration, very tempting, and in some cases, it may be a necessity. While many Jones midwifery-owned & Bartlett Learning, businesses have especially Jones when & Bartlett the midwife Learning, is an employee. Ament provides NOT FOR a post-job-interview SALE OR DISTRIBUTION rating tool that facilitates an objective measure of the match between the midwife s expectations and the practice characteristics (Table 2-2). 7 Whether or not a prospective employer offers a formal contract, asking for confirmation in writing data. Each of these aspects of running an independent Jones midwifery & Bartlett practice Learning, is an important factor that can NOT FOR SALE of offered OR DISTRIBUTION remuneration and job specifics is a wise NOT facilitate FOR SALE long-term OR success. DISTRIBUTION request. If asked to sign a contract, it may be important for the professional to consult with an attorney. Even if a contract is considered non-negotiable, the Business Advice from Experts midwife should thoroughly understand the content It is unwise to open a business without seeking the The Entrepreneur Most midwives consider midwifery to be a vocation. Thus it can be challenging to think of midwifery as a business yet Jones & Bartlett all midwives Learning, need to understand the NOT basic FOR principles SALE of OR running DISTRIBUTION a successful business. There is a growing need for midwives to become accomplished administrators and business managers. Even job hunting is a business skill. Many midwives have, either independently or in Jones & Bartlett groups, become Learning, business owners. The opportunity to CHAPTER 2 Professional Midwifery Today 43 succeeded NOT in spite FOR of inadequate SALE OR planning DISTRIBUTION or limited resources, the advice offered by successful entrepreneurs is consistent namely, consult experts, invest in marketing, develop competence in billing, and collect prior to signing. Box Jones 2-2 provides & Bartlett a list of topics Learning, that expertise of, at a minimum, Jones an attorney & Bartlett and an Learning, LL should be discussed NOT prior FOR to accepting SALE a OR position. DISTRIBUTION accountant. The legal structure NOT of FOR a midwifery SALE business (e.g., sole proprietorship, partnership, or limited OR DISTRIBUT liability company) will have short- and long-term personal and financial consequences. Midwife business owners should be experts on the laws and regulations that govern midwifery Jones & practice, Bartlett but Learning, must also know how the laws NOT governing FOR SALE medical OR practice, DISTRIBUTION the corporate practice of medicine, and pharmacy regulations impact their plans. Midwives providing care during out-of-hospital births must comply with health department regulations, birth center requirements, Jones building & Bartlett codes, and Learning, a variety of business regulations

10 44 PART I Midwifery NOT Midwives FOR SALE who OR employ DISTRIBUTION others must determine how they will compensate those employees and follow the Box 2-2 Contract Negotiations relevant employment tax codes and antidiscrimination policies. Beyond malpractice coverage, new business owners are often surprised to learn how many 1. Type of Position: salary, hourly? 2. Benefits insurance policies need to be Jones purchased & Bartlett and how Learning, LL a. Salary many business contracts need NOT to be FOR finalized. SALE In OR all DISTRIBUT b. Health, dental, optical insurance of these areas, good advice can save money, protect c. Paid vacation (#) investments, and enable midwives to provide care for women. d. Paid sick leave (#) Preparing a business plan and seeking guidance e. Paid holidays (#) from an accountant Jones on & the Bartlett costs of Learning, doing business f. Life insurance, retirement annuity NOT provide clarity for all involved and are requirements 3. Other FOR Professional SALE Benefits OR DISTRIBUTION when seeking loans to help establish a business. a. Tuition reimbursement Elements in a business plan are listed in Box 2-3. b. Expense account/continuing education costs The time spent attending to details and establishing and paid time off a reporting system that provides regular feedback on c. Professional membership dues Jones revenues & Bartlett versus expenses Learning, provides a way to measure d. Professional journal subscriptions NOT success FOR SALE for the entire OR DISTRIBUTION team and relieves pressure when e. Professional licenses the unexpected happens. f. Pager/cell phone In a country that places a high value on independent business ownership, many types of support exist g. Mileage h. Bonuses i. Productivity Jones by volume & Bartlett or Learning, ii. Productivity NOT by FOR effectiveness SALE OR DISTRIBUTION i. Malpractice insurance i. Amount of coverage Box 2-3 Business Planning ii. Personal policy or rider iii. Tail Benefits of a Business Plan Jones 4. Other & Bartlett Learning, a. Work hours: office, call, administrative time, Makes you think about many aspects you committee or other responsibilities might not have considered Helps to solidify ideas into an organized b. Paid for overtime? format c. Scheduling of appointments: how many per Clarifies the role of others: collaborating day, time per visit physicians, other health professionals Jones & Bartlett d. Learning, Productivity data Jones & Bartlett Serves as a benchmark Learning, for actual performance NOT FOR SALE OR e. Length DISTRIBUTION of orientation NOT FOR Business SALE Plans OR Help DISTRIBUTION You To f. Employee handbook Quantify resources Contract 1. Position description Evaluate finances Prioritize objectives 2. Work hours/expectations Elements of a Business Plan 3. How evaluated? When? By whom? Cover page 4. Salary (and benefits) 5. Duration of contract 6. Amendment and modification agreement 7. Restrictive clause? 8. Termination of contract conditions a. Of the person b. Of the position c. Length of notice d. Compensation Executive summary Practice organization Market analysis Market plan Regulatory issues Facility and space requirements Equipment requirements Accounting, taxes Financial data Time lines

11 CHAPTER 2 Professional Midwifery Today 45 NOT FOR SALE for small OR business DISTRIBUTION owners, including information on NOT involved FOR SALE in national OR marketing DISTRIBUTION campaigns that can be how to formulate business plans and where to apply adapted to local settings. Both ACNM and MANA, for small business loans. Midwives who are business for example, have marketing campaigns that can be owners often agree to mentor the next entrepreneur. adapted for local audiences. The Midwifery Business Network is an organization of midwives who are Jones committed & Bartlett to sharing Learning, information, providing support NOT to FOR midwives SALE interested OR DISTRIBUTION in the Billing for Services No matter what size the business, NOT FOR every SALE employee OR DISTRIBUT business aspects of midwifery practice, and increasing the number of midwife-owned services. 15 should be able to describe the source of revenue that The covers employee salaries and know how to support Midwifery Business Network sponsors an annual that revenue stream. When the services provided by fall conference and has published an Administrative Manual for Midwifery Practices. 16 a midwife are billable, then the midwife must clearly Jones & Bartlett Learning, Other business document the services provided and complete a form guides NOT also FOR exist SALE in areas OR outside DISTRIBUTION of midwifery, which may provide additional useful information. 17 to initiate the NOT billing FOR process. SALE The OR midwife DISTRIBUTION also is responsible for fulfilling the requirements for documentation that support the billing codes. For example, Midwifery services that are not independent businesses still have business or administrative aspects of importance. Even a two-person service has the amount paid for an exam will vary based on the intensity of the exam as measured by the number of Jones & Bartlett to reach an Learning, agreement on scheduling, compensation, systems included in the physical assessment, the types NOT FOR SALE records OR management, DISTRIBUTION monitoring of financial state-noments, negotiation of collaborative agreements with of FOR problems SALE identified, OR DISTRIBUTION and the amount of time spent providing and coordinating care. If this content is physicians, peer review, and strategies to handle personal and professional adversity. Services that reside not thoroughly documented in the healthcare record, payment may be reduced or even denied. in large corporations may inherit many of these decisions and struggle to Jones have a voice & Bartlett in changes Learning, that di- However the billing gets done, service directors are usually responsible for establishing a system of rectly influence their NOT practices. FOR While SALE responsibilities OR DISTRIBUTION checks and balances that monitors NOT FOR the accuracy SALE and OR DISTRIBUT for the success of the service are shared, there must timeliness of the billing process and limits the opportunity for embezzlement or insurance fraud. The time be a designated leader or service director who serves as the primary contact with the corporation, assumes and money spent establishing a viable medical record responsibility for participating on department- or and billing system are necessary outlays to ensure the corporate-level Jones & Bartlett committees, Learning, is able to describe the ongoing success of the business. success NOT FOR of the service SALE in OR corporate DISTRIBUTION terms, and knows how to move an agenda within the organization. Midwives place a high value on building relationships with women and on positive feedback from the Lessons learned from Mary Breckenridge, who gath- Data Collection individuals for whom they provide care. Those skills ered local data prior to opening the Frontier Nursing Jones & Bartlett can be extrapolated Learning, into the business arena and will Jones Service, & Bartlett continue to Learning, serve the midwifery profession NOT FOR SALE serve the OR midwives DISTRIBUTION well. NOT well. FOR These SALE lessons OR include DISTRIBUTION the power of local data, including baseline descriptive data before opening a service, descriptive and outcome data from the first Marketing day of operation, assistance from researchers, and Many advisors encourage early attention to a marketing plan. Without Jones a coherent, & Bartlett consumer-friendly Learning, ily accessible mechanisms for Jones collecting & Bartlett and col- Learning, LL dissemination of the findings. A number of read- message about the NOT services FOR offered SALE and OR an DISTRIBUTION identified medium for reaching the target population, the describe the care provided by midwives. Members lating practice-specific and NOT national FOR data SALE exist that OR DISTRIBUT business may not be able to sustain itself. Not every of ACNM can join in the ACNM Benchmarking service can cover the cost of a logo and four-color Project, 18 which allows participants to examine their brochures, but all midwives can develop marketing practices and compare them to other like practices skills. Jones For example, & Bartlett the organized, Learning, scientific, lecture across the United Jones States. & Bartlett The MANA Learning, Division of approach NOT FOR may SALE intimidate OR some DISTRIBUTION women, while others Research, NOT with FOR its MANAStats SALE OR system, DISTRIBUTION and the may look for messages that midwifery practice is evidence based and provides adequate safeguards in the Uniform Data Set, both have developed web-based American Association of Birth Centers, with its event of major complications. data collection tools that can be used by individuals Professional organizations may be a ready source and contribute to a national database on the outcomes & of Bartlett midwifery Learning, care. 19,20 Jones & Bartlett of marketing Learning, advice and materials. Indeed, many are Jones

12 46 PART I Midwifery NOT FOR SALE The Educator OR DISTRIBUTION NOT include FOR SALE PubMed, OR the DISTRIBUTION Up-to-Date Database, and All midwives are educators. Policymakers, potential DynaMed. Anderson and Stone, in their textbook, employers, and consumers all need to learn what is outlined the steps for locating the evidence for a particular clinical scenario (Box 2-4). 24 It is of note that unique and valuable about the midwifery approach to care. Women need to learn how to care for their these steps are similar to the midwifery management own bodies and how Jones to safely & prepare Bartlett for Learning, puberty, process as discussed in the Introduction Jones & to Bartlett the Care Learning, LL pregnancy, menopause, NOT and FOR all the SALE points OR in between. DISTRIBUTION of Women chapter. Consumer-oriented materials often are used for this When gathering information, it is important to purpose, and may be written by midwives. For example, the Journal of Midwifery & Women s Health Once all the research data have been gathered, remember that not all evidence is created equal. regularly publishes a patient education handout the findings need to be compared and contrasted. titled Jones Share with & Bartlett Women. Learning, This series of copyrightfree NOT handouts FOR SALE targeted OR to women DISTRIBUTION reviews important clinically applicability NOT FOR of SALE the recommendations OR DISTRIBUTION are Evidence then Jones is evaluated & Bartlett as to its Learning, strength. The clinical topics using appropriate language and illustrations for lower health literacy. (Figure 2-2). 25 ultimately based on the strength of the evidence Some midwives educate others to be midwives. All midwives in practice are encouraged to clinically The Collaborator: Member of an Interprofessional Jones & Bartlett teach and Learning, precept students. There are approximately Jones Healthcare & Bartlett Team Learning, NOT FOR SALE 40 midwifery OR DISTRIBUTION education programs accredited by NOT All FOR healthcare SALE providers OR DISTRIBUTION work within a healthcare ACME with numerous midwives on faculty. Directors system that includes professionals who have different scopes of practice, different professional cul- of these programs meet twice a year through their association, known as Directors of Midwifery tures, and different professional roles. The factors Education (DOME). It is by midwifing individuals to develop skills Jones in the cognitive, & Bartlett affective, Learning, and become especially pertinent for Jones midwives & Bartlett when a Learning, LL that make interprofessional relationships work well psychomotor domains NOT that FOR the midwifery SALE OR profession DISTRIBUTION woman develops complications NOT or FOR conditions SALE that OR lie DISTRIBUT continues to flourish. The legacy of midwifery also beyond the scope of midwifery practice. Although it depends on socialization of midwifery students into has long been recognized that interprofessional teams the role and responsibilities of the midwife. provide better care than single-disciplinary groups for patients with complex medical needs, 26 interprofessional collaboration Jones & Bartlett and communication Learning, have The Researcher and User of Research only recently NOT been FOR the focus SALE of education, OR DISTRIBUTION research, Sackett et al. concisely defined evidence-based practice (EBP) in 2000 as the integration of the best re- and clinical initiatives. 27,28 search evidence with clinical expertise and patient values. 21 Not all midwives need to actively conduct Jones & Bartlett research, Learning, but all need to understand relevant research NOT FOR SALE and implement OR DISTRIBUTION evidence-based care. The systematic use of evidence in the field of obstetrics usually is Box 2-4 Methodology for dated to the 1989 publication of the two-volume Finding the Evidence book, Effective Care in Pregnancy and Childbirth (1989). 22 In this ground-breaking treatise, the authors combed through Jones existing & Bartlett obstetric Learning, research 2. Formulate a focused, answerable Jones question & Bartlett Learning, 1. Identify the clinical problem. LL articles and identified NOT those FOR clinical SALE practices OR DISTRIBUTION supported by research as well as those practices that the evidence did not support. Several databases that summarize the most recent evidence on a multitude of clinical topics are following the PICO format (problem, intervention, comparison, outcomes). 3. Locate relevant and appropriate resources. 4. Critically appraise the information. 5. Implement and integrate the evidence into available Jones to & women s Bartlett healthcare Learning, providers. One important NOT FOR evidence-based SALE OR database DISTRIBUTION is the Cochrane clinical Jones practice. & Bartlett Learning, 6. Communicate NOT FOR the SALE information OR (to DISTRIBUTION the Library (named for Archie Cochrane a physician and woman, her family, and to other providers). pioneer in the area of evidence-based medicine). The Cochrane Library contains several databases, including the Cochrane Database of Systematic Reviews. 23 in Midwifery. New York: Springer; Source: Adapted from Anderson BA, Stone SE. Best Practices Jones & Bartlett Other sources Learning, of research that midwives often use

13 Is this a key recommendation for clinicians regarding diagnosis or treatment that ments a label? Yes Is the recommendation based on No Strength of recommendation not needed CHAPTER 2 Professional Midwifery Today 47 NOT interprofessional FOR SALE OR collaboration DISTRIBUTION in obstetrics, for example, has been associated with improved patient outcomes, a high degree of patient satisfaction, fewer cesarean sections, and lower costs. 31 patient-oriented evidence (i.e. Jones & No Bartlett Strength Learning, of The Definitions of Collaborative Jones Care & Bartlett Learning, LL an improvement in morbodity, recommendation = C mortality, symptoms, quality of life or cost)? According to the International NOT Confederation FOR SALE OR of DISTRIBUT Midwives (ICM) Essential Competencies for Basic Yes Midwifery Practice, The midwife works collaboratively (teamwork) with other health workers to Is the recommendation based on opinion, bench research, a Yes consensus guideline, usual improve the delivery of services to women and families. 32 a case series study? Jones practice, clinical & Bartlett experience, orlearning, Moreover, [t]he midwife has the skill and/ or ability to identify NOT FOR deviations SALE OR from DISTRIBUTION normal during the course of pregnancy and initiate the referral No Is the recommendation based on one of the following: process for conditions that require higher levels of Cochrance review with a clear recommendation Yes Strength of intervention. 32 USPSTF Grade A recommendation recommendation = A Clinical Evidence rating of Beneficial ACNM recognizes that midwives are independent practitioners who function within a complex Jones & Bartlett Consistent Learning, findings from at least two good quality randomized controlled trials or a systematic Strength of NOT FOR SALE review/meta-analysis OR DISTRIBUTION of same recommendation = B Validated clinical decision rule in a referral No NOT medical FOR SALE system, OR which DISTRIBUTION includes collaboration with population multiple healthcare professionals, to ensure the Consistent findings from at least two good quality diagnostic cohort studies or systematic review/ health and safety of women and their newborns. 33 meta-analysis of same The levels of collaborative management as defined by ACNM include consultation, collaboration, and Figure 2-2 Algorithm for Jones evaluation & of Bartlett strength of Learning, evidence referral, and the definitions for each of these levels and determination of NOT recommendation. FOR SALE OR DISTRIBUTION often serve as guidelines for NOT similar FOR language SALE within OR DISTRIBUT Source: Reprinted with permission from Ebell MH, Siwek J, Weiss BD, et state laws and hospital bylaws (Table 2-3). 34 al. Strength of recommendation taxonomy (SORT): a patient-centered The 2011 ACNM and American College of approach to grading evidence in the medical literature. J Am Board Fam Pract. 2004;17(1): Obstetricians and Gynecologists (ACOG) Joint Statement of Practice Relations Between Obstetrician- Gynecologists and Certified Nurse-Midwives/ NOT The FOR patient SALE safety OR movement DISTRIBUTION has shined a light Certified Midwives NOT FOR declares SALE that OR health DISTRIBUTION care is most on the most recent focus on interprofessional collaboration and the need to improve communication effective when it occurs in a system that facilitates communication across care settings an among providers. 35 MANA, NARM, and NACPM have all between healthcare providers. In the 1999 groundbreaking Institute of Medicine (IOM) report To Err published documents that address the relationship Jones & Bartlett Is Human, Learning, it was estimated that 45,000 to 98,000 Jones between & Bartlett CPMs and Learning, physicians. 36 In these documents, NOT FOR SALE patients OR die DISTRIBUTION each year in U.S. hospitals due to medi-nocal errors. 29 midwifery FOR SALE practice OR is DISTRIBUTION described as autonomous and Subsequent medical error and patient CPMs are expected to collaborate, refer, and transfer safety reports have highlighted poor communication care in critical situations. and inadequate team coordination as the source of many of these medical errors. For example, a Joint Commission sentinel Jones event analysis & Bartlett on preventing Learning, Essential Components of Collaboration infant death and injury NOT during FOR SALE birth identified OR DISTRIBUTION communication problems as the root cause of the health- endeavor. In 2011, a group of experts from several Interprofessional collaboration NOT can FOR be a challenging SALE OR DISTRIBUT care delivery error in 72% of the cases analyzed. 30 professional associations published a white paper Fifty-five percent of the organizations studied cited that itemized recommended core competencies for interprofessional collaboration within four competency organizational culture, including hierarchy and intimidation, Jones failure & Bartlett to function Learning, as a team, and failure domains: (1) Jones roles and & responsibilities Bartlett Learning, for collaborative practice, NOT (2) FOR values SALE and ethics OR for DISTRIBUTION interprofes- to NOT follow FOR the SALE chain-of-communication, OR DISTRIBUTION as commonly encountered barriers to effective communication and teamwork. 30 and (4) interprofessional teamwork and team-based sional practice, (3) interprofessional communication, In the years following these publications, much care. 27, 28,37 In addition, several authors have identified essential components of successful collaboration, work has been done on identifying ways to foster and Jones & Bartlett support teamwork Learning, healthcare delivery. Successful Jones which & are Bartlett summarized Learning, Box ,28,

14 48 PART I Midwifery Table 2-3 The Continuum of Collaborative Management in Midwifery Care Primary Responsibility for Patient Midwife s Role Collaborator s Role Comments Level of Collaborative Management Definition Midwife Primary provider Advisor/consultant Prepare for the consultation Know the woman s medical history The process whereby a CNM or CM seeks the advice or opinion of a physician or another member of the health care team. Consultation (With a provider of any specialty ) Review the basics of management of the diagnosis or problem Understand the social and psychosocial factors underlying her health Understand your practice setting and scope of practice Remember the Midwifery Management Process Use interprofessional communication techniques such as SBAR and closed-loop communication Care for the obstetric, gynecologic, or neonatal complications Normal processes, coordination of care, continuity with patient Clearly delineate roles to ensure all aspects of the plan of care (POC) are considered Co-management (depending on the severity of the complication, the midwife may remain the primary care provider) Communicate with the woman and her family about the relationship Collaboration The process whereby a CNM or CM and physician jointly manage the care of a woman or newborn who has become medically, gynecologically or obstetrically complicated. Ensure that referral/transfer is the best POC for the patient Assumes the primary responsibility for care of the patient Coordination of care, ensure timely and full transfer of care, continuity of services Physician or other referral provider Ensure that the woman understands that she has been transferred to another provider s care and that she has access to appointment and contact information Consider potential problem of patient abandonment and/or punting of difficult-to-care-for women Referral a The process by which the CNM or CM directs the client to a physician or another health care professional for management of a particular problem or aspect of the client s care. Use interprofessional communication techniques like the handoff SBAR = situation, background, assessment, recommendation. Referral in this continuum refers to transfer of care. Referral in the context of insurance is providing a patient with a reference to a specialty provider. a Source: Definitions adapted from American College of Nurse-Midwives. Collaborative Management in Midwifery Practice for Medical, Gynecological and Obstetrical Conditions. Silver Spring, MD: American College of Nurse-Midwives;

15 NOT FOR The SALE U.S. Agency OR DISTRIBUTION for Healthcare Research and Quality (AHRQ) has developed a series of materials and training curricula, collectively titled Box 2-5 Essential Components of Successful Collaboration and Teamwork a TeamSTEPPS, which can be used in healthcare settings to help foster successful teamwork. 39,44,45 The 1. Professional competence Jones & in Bartlett each member Learning, TeamSTEPPs curricula emphasize Jones the & development Bartlett Learning, LL of the team NOT (common FOR body SALE of knowledge, OR DISTRIBUTION of four core competencies: NOT communication, FOR SALE mutual OR DISTRIBUT shared language, similarities in treatment support, situation monitoring, and leadership. modalities) 2. Common orientation to the patient as the primary unit of attention 3. Shared mental model: every member of the team can anticipate and predict the needs of the others 4. Recognition and acknowledgment of interdependence among all members of the team 5. Interprofessional respect and mutual trust 6. Formal system of communication between providers 7. Effective communication based on the goal of reaching consensus (an interest in solutions that maximize the contributions of all parties) 8. Mutual performance monitoring (identifica- Communication Techniques for Successful Collaboration Direct and deliberate Jones communication & Bartlett Learning, techniques include the SBAR, NOT FOR closed-loop SALE communication, OR DISTRIBUTION and the handoff. The SBAR an acronym for Situation, Background, Assessment, and Recommendation is structured communication tool that has been shown to Jones significantly & Bartlett improve Learning, the quality of communication NOT between FOR SALE healthcare OR providers DISTRIBUTION and to reduce medical errors. 46 The SBAR approach omits the nonessential elements of a woman s history, distills the most pertinent information, and clarifies what is needed. The midwife can use the SBAR approach to obtain a consultation from a specialist Jones (Box 2-6) & or Bartlett to com- Learning, LL tion of mistakes and provision of feedback within team to facilitate self-correction) municate during an emergency (Box 2-7). 9. Identified NOT team leader FOR for SALE each situation OR DISTRIBUTION In closed-loop communication, the midwife directs the message to a particular team member, the 10. Situation monitoring and adaptability as the situation changes 11. Ability to shift work responsibilities as team member repeats the order or request aloud, and needed to under-utilized team members the midwife confirms that the team member heard a This list is compiled from different analyses of essential characteristics for teams in general and teams in specific urgent or emergency situations. It is not designed to be complete or placed in rank order, but rather to give the reader a description of some characteristics that are essential for successful interprofessional team function. Midwives are always members of interprofessional teams. Sources: Adapted from Interprofessional Education CHAPTER 2 Professional Midwifery Today 49 correctly. This Jones communication & Bartlett allows Learning, the whole team to hear the NOT orders FOR and correct SALE any OR errors DISTRIBUTION before the orders are executed. Closed-loop communication tools such as the call-out and the check-back can be used to communicate critical information to all members of the team, thereby allowing them to anticipate Jones what & will Bartlett be needed Learning, next, but use of such tools also NOT FOR SALE Collaborative OR DISTRIBUTION Expert Panel. Core Competencies for NOT requires FOR SALE that team OR members DISTRIBUTION communicate what they Interprofessional Collaborative Practice: Report of an intend to do with the information. Expert Panel. Washington, DC: Interprofessional Education When transferring care from one provider to Collaborative; 2011; Ivey S. A model for teaching about another, an official handoff includes the transfer of interdisciplinary practice. J Allied Health. 1988;17: ; King TL, Laros RK, Parer JT. Interprofessional collaborative information along with primary care responsibility; practice in obstetrics and Jones midwifery. & Obstet Bartlett Gynecol N Learning, Amer. this step provides an opportunity Jones to clarify & Bartlett information, confirm understanding, NOT and FOR discuss SALE the man- OR DISTRIBUT Learning, LL 2012;39: agement plan. The handoff can occur between two midwives or between the midwife and the referral physician when a transfer of care is indicated. The goal of the handoff is to give the new primary provider all of the Jones information & Bartlett needed to Learning, safely care for Teamwork Teamwork NOT FOR and SALE communication OR DISTRIBUTION are skills that can the woman NOT and FOR her family. SALE Figure OR 2-3 DISTRIBUTION provides an be learned Although patient outcomes following simulation training have not yet fully been deter- Communication skills such as the SBAR, closed- example of a handoff form. mined, it appears that simulation training improves loop communication, and the handoff are like any teamwork, team coordination, and interprofessional clinical skill they must be practiced and adapted to Jones & Bartlett communication. Learning, 41,43 Jones individual & Bartlett settings. Learning,

16 50 PART I Midwifery Box 2-6 SBAR Used for a Consultation The midwife at a clinic is caring for a woman at 33 weeks gestation who was previously diagnosed with gestational diabetes type 1A. When reading the woman s blood glucose log, the midwife observes that more than 20% of her values are high. She calls the consulting maternal fetal medicine physician and gives this consult SBAR. S: I want to consult with you about a woman with uncontrolled gestational diabetes. B: Maria Gonzalez is a 24-year-old G1P0 at 33 weeks by LMP consistent by 19-week ultrasound. Her 1-hour GTT was 150 and her 3-hour GLT had 2 elevated values. She was sent to the diabetes education center and received diet and glucose monitoring education. Over the last 2 weeks, 20% of her values are out of range, with five fasting levels between 100 and 110 and five 2-hour postprandial levels higher than 150, the highest being 180. She had a reactive NST today, the fetus is size equal to dates, and her urinalysis was negative for glucose. A: Diabetes diet is inadequate to control glucose levels and I believe she needs medication. R: I would like your recommendation for medication therapy and schedule her to see you for a consultation in the next few days. Box 2-7 SBAR Used in an Emergency Situation The midwife at a small community hospital is caring for a woman who is bleeding heavily immediately after giving birth. She has called for physician assistance from a provider in the next room. When the physician arrives, the midwife says: S: This woman is having a postpartum hemorrhage. B: Marta gave birth to her fifth child 15 minutes ago over an intact perineum. Her total EBL is 800 ml. She has received 40 IU of oxytocin (Pitocin), 0.2 mg of ergonovine (Methergine), and 800 mcg of misoprostol per rectum (Cytotec). The placenta appeared intact, and there are no clots in the lower uterine segment. A: She has severe uterine atony, and I think I feel some placental tissue in the anterior portion of the fundus. R: Can you please put on some gloves and assist me? majority of the original policies that define the profession of midwifery. Even today, professional organizations remain dependent upon a high level of volunteer effort to keep these policies relevant. Meeting the Jones policy & needs Bartlett of the Learning, profession primarily represents a NOT labor FOR of SALE love and OR a dogged DISTRIBUTION determination to turn a The Policymaker vision into reality. The building blocks of the midwifery profession Many of the successful midwifery policymakers will confess to initially not seeing the need for (standards for education, certification, and practice) open many doors for midwives to contribute to the this work, doubting their own abilities, or hoping development of public and private policy. For the someone else would do it. 47 It was discovered that profession as a whole NOT to FOR thrive, SALE each midwife OR DISTRIBUTION must becoming a policymaker is NOT a learned FOR behavior; SALE thus OR DISTRIBUT walk through these doors. Federal, state, and institutional policies determine which healthcare services midwife role models, and guidance on how to make the midwifery profession is now filled with successful and birth settings are available to women as well as this transition is readily available (Box 2-8). who will be reimbursed and at what rate. Which education programs receive government funding to sup- work remains to be done. Some physician associa- In spite of many past successes, much policy port NOT faculty FOR and SALE students OR is DISTRIBUTION also a matter of policy. tions are opposed NOT FOR to laws SALE that OR recognize DISTRIBUTION advanced Hospitals, clinics, and employers all write policies practice clinicians as independent providers, instead that influence access to midwifery care. advocating for required physician supervision. Many Members of the midwifery profession, primarily serving in a volunteer capacity, wrote the vast need to be changed to permit independent state laws governing the practice of nurse-midwifery practice

17 Box 2-8 How to Become a Midwife-Policymaker NOT FOR Professional SALE OR Ethics DISTRIBUTION in Midwifery Midwives must be well versed in the ethics involved in all healthcare interactions. 48,49 The subject of professional ethics in health care is complex, and the introduction presented here is Jones not a comprehensive & Bartlett Learning, LL Write policies Jones for your midwifery & Bartlett practice Learning, or local midwifery NOT group. FOR SALE OR DISTRIBUTION review of this important topic. NOT Additional FOR SALE resources OR DISTRIBUT What do you need to write good policy? that address health literacy, health numeracy, values clarification, options counseling, the interface Volunteer to observe legislative policy in between legal and ethical issues, and ways to communicate risk are listed at the end of this action. chapter. Who seems most effective and why? What is common etiquette and the standard for appearance? Was the speaker effective? How did you know? Identify a mentor. Know your strengths. Offer a lived experience. Be the voice of a midwife or support a client who agrees to speak. If you can t do policy, support your colleagues who can. An ethical Jones framework & Bartlett for practice, Learning, beginning with the concept NOT FOR of accountability, SALE OR is DISTRIBUTION critical to the continuation of midwifery as an independent and respected profession. 7,50 Ethical guidelines encourage self-regulation, foster professional identity, protect midwives and clients, and serve as a measure of pro- Jones fessional & Bartlett maturity. 51 Learning, NOT FOR Ethics SALE is defined OR as DISTRIBUTION a guiding set of principles that inform actions. 51 The ACNM Code of Ethics was first published in 1990, and the ICM ethical code was introduced in These documents, as well as the MANA Statement of Values, provide guidance for the Come prepared Jones and speak & a language Bartlett the Learning, ethical behavior of midwives in Jones various & roles, Bartlett including caring for women and their NOT families, FOR SALE education, OR DISTRIBUT Learning, LL audience can understand. No bluffing. research, public policy, business management, and financial organization of health services. 52,53 A number Know your opposition. of other organizations have published statements on Never go alone. the rights of individuals who receive health care a Get help preparing statements. Make friends in the room. Defer to other experts. NOT FOR SALE OR DISTRIBUTION Learn a new language. Source: Adapted from Williams DR. We need to say in unison: We are midwives and we do policy! Editorial. J Midwifery Women s Health. 2008;53(2): CHAPTER 2 Professional Midwifery Today 51 concept that Jones is inherent & in Bartlett most statements Learning, on ethical principles. NOT In FOR 2004, SALE the Childbirth OR DISTRIBUTION Connection (formerly the Maternity Association) revised The Rights of Childbearing Women; this document applies widely accepted principles of human rights to maternity care. 54 NOT Bioethical FOR SALE Principles OR DISTRIBUTION Four broad ethical principles define modern bioethics the ethics of working with or caring for human beings. They include respect for autonomy, As of 2012, CPMs could not be licensed to practice nonmaleficence (do no harm), beneficence (do good), 55, 56 in more than 30 states, and CMs could not be licensed in 47 states. NOT Major FOR decisions SALE are also OR looming: DISTRIBUTION Respecting an individual s NOT privacy, FOR SALE ensuring OR DISTRIBUT and justice (Table 2-4). should CNMs seek more midwifery practice acts that confidentiality, encouraging shared decision making, and providing for informed decision making are are separate from nursing and include their CM colleagues or stay under the advanced practice registered all extensions of these bioethical principles. Research nurse (APRN) umbrella; can CNMs/CMs and CPMs has shown that when healthcare providers do not be licensed under the same practice act; should CPMs respect these rights, their behavior may be seen as be NOT required FOR to SALE earn a college OR DISTRIBUTION degree; should CNMs/ a form of NOT abuse FOR and could SALE lead OR to DISTRIBUTION psychological CMs be required to earn a doctoral degree; and will trauma for the woman. 57 Healthcare professionals the U.S. Congress pass healthcare legislation that can also experience ethical dilemmas when the application of one ethical principle appears to contradict moves the profession forward or backward either outcome is always a possibility. a second principle

18 52 PART I Midwifery Table 2-4 Bioethical Principles Bioethical Principle Definition Midwifery Application Autonomy Self-determination The midwife respects the right of the woman to make decisions regarding her care. Beneficence Do good The midwife acts in a way that promotes the woman s best interests and well-being. Nonmaleficence Do no harm The midwife avoids any actions that cause harm to the woman or her infant. Justice Fairness The midwife accords the woman her due rights and treats all women equally. Source: Adapted from Mighty HE, Fahey J. Clinical ethics in obstetrics and gynecology. In Obstetrics and Gynecology: The Essentials of Clinical Care. Stuttgart, Germany: Thieme Publishers; 2010: NOT FOR SALE Privacy OR and DISTRIBUTION Confidentiality NOT treatment FOR SALE and her OR free DISTRIBUTION consent to that treatment. 59 Protection of a woman s privacy is not simply ethical; The minimum required components of informed in most cases it is mandated by the Health Insurance consent are sixfold: (1) diagnosis or assessment, Portability and Accountability Act of 1996 (HIPAA). (2) purpose of the proposed treatment or procedure, (3) possible risks of the treatment, (4) possible When working in collaboration with other healthcare providers, only those Jones parts of & the Bartlett health Learning, information that are immediately NOT FOR pertinent SALE to the OR individual s DISTRIBUTION and the risks and benefits of NOT those FOR alternatives, SALE and OR DISTRIBUT benefits of the treatment, (5) alternative Jones & treatments Bartlett Learning, LL care should be disclosed, and the woman should be (6) possible benefits and risks of not receiving the personally notified if the midwife desires to contact treatment or procedure. The assumption underlying a consultant about the woman s health. informed consent is that the individual is capable of Family members, partners, or friends are often understanding the content of the discussion so that present Jones during & Bartlett office visits Learning, or a birthing site. It self-determination Jones may & be Bartlett protected Learning, and supported. is NOT important FOR to SALE confirm OR that DISTRIBUTION the woman has given The legal NOT interpretation FOR SALE of informed OR DISTRIBUTION consent centers on disclosure and liability did the individual permission before information is shared when others are present. A midwife must also be careful to not receive enough information to consent to a procedure discuss client information in places where third parties might overhear. s, faxes, digital records, the interpretation has been the cited as one reason for the to protect the provider from being sued? This legal Jones & Bartlett Internet, and Learning, social media can all be sources that lead Jones creation & Bartlett of consent Learning, forms. NOT FOR SALE to inadvertent OR DISTRIBUTION but serious breaches in confidentiality. NOT FOR Some SALE midwives OR and DISTRIBUTION others prefer to use the term Family members should not automatically be used as informed decision making for this process, as it translators when a woman does not speak the same encompasses both informed consent and informed language as the midwife. refusal. Foster identified three essential components of informed decision making: (1) knowing or understanding, (2) competency, and Jones (3) voluntary & Bartlett permis- Learning, LL Informed Consent and Informed Decision Making sion. 51 The ethical/moral interpretation NOT FOR of SALE informed OR DISTRIBUT The concept of informed decision making or informed consent (as it is often referred to legally) the woman able to exercise her right to decide what decision making centers on autonomous choice was evolved through a number of court decisions and happens to her body? The ethical obligation is often government regulations. In the 1950s and 1960s, U.S. a higher standard than what is mandated by the law. courts Jones began & to Bartlett mandate Learning, that consent be obtained Facilitating Jones informed & Bartlett or shared Learning, decision making before NOT surgery. FOR SALE The 1970s OR saw DISTRIBUTION an explosion of court rulings provided legal guidance regarding informed decision making. 58 The ethical concept underlying informed consent includes client understanding of the recommended is a process NOT that may FOR take SALE place over OR several DISTRIBUTION visits and conversations. Women need time to process information and ask questions. Healthcare consumers may not always be familiar with complicated language and may need concrete explanations to understand

19 NOT FOR SALE the information OR DISTRIBUTION well enough to make a decision. NOT be FOR interpreted SALE OR by the DISTRIBUTION recipient of care as doing A woman s cognitive ability or the presence of physical, medical, intellectual, or developmental disabili- adequate time waiting for a vaginal birth. Equally harm in this case, performing surgery without ties must be taken into consideration as well. If a challenging is the fact that obstetrics is a field in woman is deemed incapable or incompetent, then a which the professional attending birth has two patients, the mother and the fetus, Jones whose interests & Bartlett may Learning, LL responsible individual Jones must decide & Bartlett for her. Learning, Women may NOT also experience FOR SALE personal OR circumstances that curtail their ability to make a decision autonomy does not change because she is pregnant. DISTRIBUTION not be in equipoise. 56 However, NOT a FOR woman s SALE right OR to DISTRIBUT voluntarily. The ACNM Code of Ethics identifies The consensus of modern medical ethics is that the some of these circumstances: pressure from family members, the midwife, or other care providers; owed to the mother, and the duty to both change duty owed to the fetus may be different from that aspects Jones of the & environment Bartlett Learning, such as lack of privacy; depending on Jones the gestational & Bartlett age Learning, and maternal lack NOT of FOR funding; SALE restriction OR DISTRIBUTION of healthcare access; or condition(s). NOT 61 A FOR few example SALE ethical OR DISTRIBUTION scenarios are an abusive relationship. 57 The midwife must assess presented in Box these factors and also take into account the cultural context when determining whether the woman is able to make a decision on her own volition at any given Jones & Bartlett time. 58,60 Learning, Box 2-9 identifies some practical consider-ations OR for addressing DISTRIBUTION a potential ethical issue. Jones & Bartlett Learning, NOT FOR SALE Box 2-10 Ethical Scenarios Ethical Dilemmas Ethical Scenario 1 The ACNM Code of Ethics states: A woman with a low-risk pregnancy Jones is miserable & Bartlett and Learning, LL requests an induction at 37 weeks gestation. She and The conflict of NOT two FOR or more SALE moral OR obligations in a particular situation necessitates de- DISTRIBUTION is adamant that she will go NOT elsewhere FOR for her SALE care if OR DISTRIBUT the midwife will not induce her. The midwife validates liberate ethical analysis and decision making, the woman s feelings and explains the risks of elective including weighing and balancing principles induction but supports the position that induction at and preferably involving and achieving consensus among & Bartlett all affected Learning, parties. 52 The midwife Jones knows & Bartlett that the benefits Learning, to the 37 weeks is not recommended. Jones For NOT example, FOR SALE one healthcare OR DISTRIBUTION provider s attempt to do good, such as performing a cesarean section birth for a diagnosis of failure to progress, might Box 2-9 Ethics: A Midwife s Quick Checklist Are the woman s wishes clear? Does the woman have the capacity to consent to, or refuse, treatment? Are there disagreements involving family members or partners? Is the woman s current plan of care appropriate? Is her health information being protected? Can you identify resource or fairness issues? Source: Adapted from Sokol DK. Ethics man: rethinking ward rounds. BMJ. 2009;338:571. CHAPTER 2 Professional Midwifery Today 53 woman and fetus are maximized (beneficence) and harm is minimized (nonmaleficence) when labor begins on its own. This professional must weigh this information with the principle of autonomy, the woman s right to make an informed decision about her body and fetus. Ethical Scenario 2 A woman presents for her first visit of the pregnancy and tells the midwife that she is uninsured and does not have many financial resources. Normally the midwife counsels women extensively about their genetic options in pregnancy at the first visit. It becomes clear to the midwife in the course of their conversation that the woman would never be able to afford any of the costly genetic testing and wonders if counseling should be performed. The midwife decides to counsel this woman in the same manner as any other woman. The midwife s decision to counsel this woman regardless of her ability to afford genetic testing illustrates the principle of justice

20 54 PART I Midwifery NOT FOR SALE Evidence OR DISTRIBUTION for Midwifery Care Recent systematic reviews have demonstrated that not only is midwifery-led care (care in which the primary provider is the midwife) equivalent to the care provided by physicians, but on many outcome mea- were cared for in a system of midwife-led care were more likely to experience no intrapartum Jones & Bartlett analgesia/ Learning, LL sures it has proved NOT to be FOR superior. SALE A 2008 OR Cochrane DISTRIBUTION anaesthesia, a spontaneous NOT vaginal FOR birth, SALE feeling OR in DISTRIBUT meta-analysis reviewed 11 trials including 12,276 control during childbirth, attendance at birth by women, and found several statistically significant differences in outcomes for those women who received Finally, the newborns of women who had midwife- a known midwife, and initiation of breastfeeding. midwife-led care (Table 2-5). 62 All of the studies led care were more likely to have a shorter length included Jones in & this Bartlett systematic Learning, review were random- ized, NOT controlled FOR SALE trials; OR in addition, DISTRIBUTION the studies were NOT not FOR limited SALE to one OR country. DISTRIBUTION The findings noted that midwife-led care included less prenatal hospitalization, less regional analgesia, fewer episiotomies, and fewer instrument deliveries. In addition, women who of hospital stay. Jones The authors & Bartlett concluded Learning, that most women should NOT be FOR offered SALE midwife-led OR DISTRIBUTION models of care Table 2-5 Systematic Review of Midwife-Led Care, 2008 Outcome or Number Number of Subgroup Title of Studies Participants Statistical Measure with 95% Confidence Interval Significant Risk Reductions Found Duration of postnatal hospital stay (days) Mean difference = 0.14 [ 0.33, 0.04] Mean labor length (hours) Jones & Bartlett Learning, Mean difference = 0.27 [ 0.18, 0.72] Mean length of neonatal NOT hospital FOR stay SALE (days) OR DISTRIBUTION Mean difference = 2.00 [ 2.15, 1.85] Antenatal hospitalization RR = 0.90 [0.81, 0.99] Fetal loss/neonatal death before 24 weeks RR = 0.79 [0.65, 0.97] Overall fetal loss and neonatal death RR = 0.83 [0.70, 1.00] Instrumental vaginal birth (forceps/vacuum) RR = 0.86 [0.78, 0.96] Episiotomy RR = 0.82 [0.77, 0.88] Admission to special care nursery/neonatal intensive care unit RR = 0.92 [0.81, 1.05] Neonatal convulsions (as defined by trial authors) RR = 0.33 [0.01, 8.03] Regional analgesia (epidural/spinal) RR = 0.81 [0.73, 0.91] Opiate analgesia RR = 0.88 [0.78, 1.00] Significant Increases Found Attendance at birth by known midwife RR = 7.84 [4.15, 14.81] High perceptions of control during labor RR = 1.74 [1.32, 2.30] and childbirth No intrapartum analgesia/anaesthesia RR = 1.16 [1.05, 1.29] Breastfeeding initiation RR = 1.35 [1.03, 1.76] RR = relative risk. Source: Adapted from Hatem M, Sandall J, Devane D, et al. Midwife-led versus other models of care for childbearing women. Cochrane Database Syst Rev. 2008;4(CD004667). doi: / CD pub