Methodological problems in the assessment of nurse-midwifery practice

Challenges and opportunities for nurse-midwives

This article reviews the major indicators of the growth in nurse-midwifery practice and education over the past 10 years. The major issues the profession has addressed are identified, as well as future challenges and opportunities. These challenges and opportunities are identified within the major dimensions of nurse-midwifery, that is, in practice, education, research, and within the public sector. The two major issues facing nurse-midwives are legislative initiatives related to the practice of nurse-midwives, such as reimbursement, and the mixed societal image of midwifery as a contemporary, cost-effective practice versus a peripheral activity by "old fashioned," informally educated individuals. The professional organization of nurse-midwives, the American College of Nurse-Midwives (ACNM), is addressing these issues through interdisciplinary and interorganizational legislative and marketing initiatives.

Midwifery care research: what questions are being asked? What lessons have been learned?

PURPOSE

To create and critically evaluate a research database about midwifery care that identifies topics studied, research methods, results, funding, publication data, and implications for a future midwifery research agenda.

METHODS

Systematic literature review. Studies included were 1) data-based research; 2) about midwifery care or practice; 3) in the United States; and 4) published between 1984-1998. The CINAHL and MEDLINE electronic databases were searched using a defined strategy, and relevant journals and bibliographies were searched by hand.

RESULTS

This 15-year review identified 140 studies of midwifery care published in 161 papers. A midwife was the lead author on 60%. Sixty percent were published in the Journal of Nurse-Midwifery. Six to 15 studies were published each year, and both the number of publications and funding increased over the time period. The six major areas of focus were: 1) midwifery management, 2) structure of care, 3) midwifery practice, 4) midwife-physician comparisons, 5) place of birth, and 6) care of vulnerable populations.

DISCUSSION

Although retrospective descriptive studies still predominate, more prospective studies, randomized controlled trials, multi-site studies, and quasi-experimental designs are being conducted. Qualitative methods are helping to measure nontraditional outcomes. A research agenda should be established based on discussion and debate within the profession. Midwife investigators need to build research teams and collaborate with other disciplines. Key areas for future research include alternative therapies, breastfeeding, cost-effectiveness, cultural studies, gynecology, health policy, menopause, postpartum care, substance abuse interventions, and the woman's experience of birth and midwifery care.

A randomized, controlled trial of nurse-midwifery care

BACKGROUND

In 1990 a pilot nurse-midwifery program was implemented in a tertiary care hospital in a major western Canadian city. a randomized, controlled trial was conducted to determine if, when maternal and newborn patient outcomes were compared, the midwifery program was as effective as traditional, low-risk health care available in the city.

METHODS

All low-risk women who requested and qualified for nurse-midwifery care were randomly assigned to an experimental or control group.

RESULTS

One hundred one women received care from nurse-midwives and 93 received standard care from either an obstetrician or family physician. The rate of cesarean delivery in the nurse-midwife group was 4 percent compared with 15.1 percent in the physician group. The episiotomy rate, excluding cesarean deliveries, for the nurse-midwife group was 15.5 percent compared with 32.9 percent in the physician group. The rates of epidural anesthesia for pain relief in labor were 12.9 percent and 23.7 percent, respectively. Statistically significant differences were found ultrasound examinations, amniotomy, intravenous drug administration during labor, dietary supplements, length of hospital stay, and admission of infants to the neonatal intensive care unit.

CONCLUSIONS

The results clearly support the effectiveness of the pilot nurse-midwifery program and suggest that more extensive participation of midwives in the Canadian health care system is an appropriate use of health care dollars.