Tuesday, May 09, 2006

Metromidwife submitted this article about newborn mortality

Thank you to Metromidwife who submitted the following article from CNN for discussion:

US Has Second Worst Newborn Death Rate in the Modern World

Here are the first two paragraphs of the article:

"An estimated 2 million babies die within their first 24 hours each year worldwide and the United States has the second worst newborn mortality rate in the developed world, according to a new report.

American babies are three times more likely to die in their first month as children born in Japan, and newborn mortality is 2.5 times higher in the United States than in Finland, Iceland or Norway, Save the Children researchers found. "

21 Old Comments:

I'm not sure that this article tells us much about modern obstetrical care. The primary cause of the poor standing of the US is prematurity often associated with social issues: race, drug use, triplets and higher from IVF, and poor access to health care.

It tells us something about our society and it is a real wake up call, but I'm not sure it has any implications for the practice of obstetrics.

By Blogger Amy Tuteur, MD, at 6:57 PM  

Midwife-led births seen as safe and cheap

By Anonymous Anonymous, at 7:05 PM  

Yeah... too bad the article neglects to mention the fact the birth in the US is also the most medicalized which is probably the reason there are so many deaths...
Especially when you compare it to the countries with the lowest death rates which have highest amount of midwife attended homebirths...

By Anonymous Anonymous, at 8:09 PM  

"too bad the article neglects to mention the fact the birth in the US is also the most medicalized which is probably the reason there are so many deaths"

The article doesn't "neglect" to mention it; it doesn't mention it because there is no proof for that claim.

For example, how would "de-medicalizing" prevent premature births to women who abuse drugs or to women who have no health care at all?

By Blogger Amy Tuteur, MD, at 8:44 PM  

So are you claiming that all of the countries with better results don't have preemies, don't have drugs or don't have women with no care or self-care?

If that is your claim then I stick to the first comment but will change it a bit... maybe the fact is so many babies die because pregnancy is automatically seen as a medical condition instead of being a natural state and is overmedicalized...
I knew that going to a doctor for pre-natal care is putting my baby at risk...

By Anonymous Anonymous, at 7:41 AM  

"So are you claiming that all of the countries with better results don't have preemies, don't have drugs or don't have women with no care or self-care?"

It's not that they don't have these things, it is that they have them much less. For example, in a country with universal healthcare, prenatal care is understood to be a right both for mother and baby. Every mother has access to prenatal care.

Unfortunately, race is a risk factor for prematurity and other obstetrical complications. Most of the countries that rank higher have very small black populations. That changes their statistics.

This is not my opinion about the situation; it is the reality of the situation. If you don't believe me, you can check into it yourself. You will find, for example, that the newborn mortality rates for white women with access to healthcare rival those of any other country.

By Blogger Amy Tuteur, MD, at 8:13 AM  

>>"For example, how would "de-medicalizing" prevent premature births to women who abuse drugs or to women who have no health care at all?"<<

There is documentation that community based midwifery is more effective at reaching out to women like that, helping them be successful at healthy lifestyle improvements and, if need be, easing them into the "system" via a referral. No, I'm not going to dig up a reference. Try google.

By Anonymous queen of Run On Sentences, at 8:22 PM  


"There is documentation that community based midwifery is more effective at reaching out to women like that, helping them be successful at healthy lifestyle improvements and, if need be, easing them into the "system" via a referral. No, I'm not going to dig up a reference. Try google."

If you "know" that there is documentation, then you can find it. I'm not going to spend my time looking for something that does not exist. The fact that you are unwilling to look for it suggests that you're also pretty sure that it doesn't exist.

By Blogger Amy Tuteur, MD, at 11:16 PM  

I'm an aspiring midwife and I support homebirth. I plan on having one eventually (assuming I am healthy and low risk of course). But I have to agree with amy on this one. The MAIN reason we have such a poor infant mortality rate is because social and political issues. We are the only industrialized nation not to have universalized health care. 40-50 million Americans don't have health care, thus many low income women, and disproportionately minority women don't get any or adequate prenatal care.

By Anonymous Anonymous, at 9:34 PM  

Midwifery care of poor and vulnerable women, 1925–2003

I'm not sure if this exactly address midwifery "community based midwifery is more effective at reaching out to women like that, helping them be successful at healthy lifestyle improvements and, if need be, easing them into the "system" via a referral." But it is a very good form of care for vulnerable populations. And on that note, most populations.

By Anonymous Anonymous, at 9:40 PM  

Sorry, I dont' know if that link worked, hopefully this does.

Journal of Midwifery & Women's Health
Volume 50, Issue 2 , March-April 2005, Pages 113-121

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Copyright © 2005 American College of Nurse-Midwives Published by Elsevier Inc.
The history of nurse-midwifery/midwifery research

Midwifery care of poor and vulnerable women, 1925–2003

Jeanne Raisler CNM, DrPH, and Holly Kennedy CNM, PhD

Available online 2 March 2005.

A systematic literature review of research on midwifery care of poor and vulnerable women from 1925 to 2003, which included topics studied, research methods used, and special issues and implications for future research, was performed; 44 studies published between 1955 and 2003 were identified. The majority were retrospective, descriptive studies. Outcomes examined included prenatal care visits, vaginal versus operative births, labor interventions, maternal and neonatal mortality and morbidity, birth weight, and cost-effectiveness. Studies showed that midwives predominantly serve vulnerable women who are young, poor, immigrants, or members of racial and ethnic minorities. Preterm birth prevention is emerging as a midwifery research focus. Health system changes are making it more difficult to provide effective care and counseling to disadvantaged women, especially in managed care settings. Extensive evidence documents excellent outcomes of midwifery care for the poor in urban and rural settings over the past three quarters of a century. Future research should include more intervention studies and use both qualitative and quantitative methods to investigate midwifery processes of care and the process-outcome connection. The research focus should broaden beyond childbirth to include gynecology, family planning, and primary care issues. Health disparities, cultural studies, obstetric interventions, and poor women’s experiences of childbirth and midwifery care are important topics for future research.

Keywords: vulnerable populations; racial disparities; outcomes of midwifery care; midwifery research

Article Outline
Selection criteria, literature retrieval, and analysis
Historical studies
Poverty, risk status, and midwifery care
Race and ethnicity of the woman and her midwife
Choice of midwifery care
How does midwifery care make a difference? Focusing on the process
Birth center care
Prevention of preterm birth and low birth weight
Predicting and reducing low birth weight
Health system factors affecting midwifery care of the poor
Recommendations for future research
Data collection
Structure, processes, and outcomes of care
Intervention studies and clinical trials
Poverty and risk
Research partnership with women
Content areas

Modern professional midwifery practice in the United States was established to serve poor and vulnerable women and their families. From the founding of Frontier Nursing Service (FNS) in the mountains of Kentucky in 1925 through the 1960s, most nurse-midwives worked in underserved communities with high infant and maternal mortality, including Indian reservations, rural southern health departments, and inner-city hospitals. The women they served were vulnerable to poor health and inadequate health care due to low income, lack of access to care, minority race, or immigrant status. Most of the early nurse-midwives followed a mission to serve the poor, and that commitment was reinforced by restrictive state laws, which allowed them to practice only in areas where physicians were in short supply and women could not afford to pay for maternity care.1

Midwives today care for women from all socioeconomic backgrounds, and practice in a wide variety of settings, including private offices, managed care organizations, birth centers, and public clinics. But care of the poor remains a major focus for many midwifery practices, despite health system changes that make it increasingly difficult to provide. This article reviews published research on midwifery care of poor and vulnerable women in the United States from 1925 through 2003. It builds on previous reviews of nurse-midwifery care research conducted by Thompson,2 Raisler,3 and Rooks.1 Important studies, accumulated evidence, and current trends are highlighted.

Selection criteria, literature retrieval, and analysis
Studies reviewed were 1) data-based research, 2) about midwifery care of poor and vulnerable women, 3) in the United States, and 4) published between 1925 and 2003. Unpublished research, literature reviews, meta-analyses, and studies in which the contribution of midwives could not be distinguished from other providers were excluded. Literature searches of the MEDLINE (1966–2003) and CINAHL (1982–2003) databases were performed by using the keywords “midwifery” and “nurse-midwives,” and limited to the English language. The Journal of Nurse-Midwifery/Journal of Midwifery & Women’s Health and several other journals known to publish midwifery care research were searched by hand. Historical texts on American midwifery, annotated bibliographies of nurse-midwifery research, and reference lists from meta-analyses, literature reviews, methodological studies, and health policy articles were also searched for relevant studies. Studies meeting the inclusion criteria were reviewed using a critique form developed for the project, organized into a bibliographic software database (ProCite), and tagged with keywords identifying their topics, methods, strengths and limitations, and special features.

The process identified 44 studies published between 1955 and 2003, which focused on the characteristics, problems, and risk factors of poor and vulnerable women cared for by certified nurse-midwives (CNMs). Study designs, methods, and data sources are summarized in Table 1. A CNM was the sole or lead author on 20 articles (45%) and a contributing author on 13, whereas 14 had no midwife author. Although space limitations preclude discussion of each individual study, selected studies that influenced health policy, broke new ground in research, or provided significant evidence about midwifery practice are highlighted.

Table 1.

Methods of Selected Studies of Midwifery Care of Poor and Vulnerable Women Study Designs, Data Sources, and Methods No. of Studies*
Birth certificate data18, 19, 24, 43 and 44 5
National midwifery data18, 19, 20, 21, 22, 44 and 49 7
Before and after study6, 7, 8 and 9 4†
Cohort study37, 41, 42, 45 and 46 5‡
Controlled comparison10, 24, 32, 33, 37, 43, 44 and 45 8§
Uncontrolled comparison4, 5, 6, 8, 13, 16, 17, 36, 41 and 42 10
Descriptive study4, 5, 11, 12, 13, 14, 15, 17 and 30 9
Prospective study10, 17, 27, 28, 32, 33, 34, 35, 37, 40, 43, 45, 46 and 48 14
Randomized controlled trial40 1
Medical record review4, 5, 7, 8, 9, 11, 12, 13, 15, 16, 17, 30, 34, 37, 41 and 42 16
Intervention delivered by midwives29, 40, 41, 42, 43, 45 and 46 7¶
Midwifery care is the intervention4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 17 and 37 13#
* Studies can appear in more than one group.
† Compares outcomes before and after introduction of midwifery care.
‡ Divides study participants on the basis of their exposure (to midwifery care); follows them to compare outcomes.
§ Compares midwife patients with a comparable group, such as low-risk physician patients selected according to the same criteria.
Compares midwife patients with local, state, or national statistics, which may or may not be comparable.
¶ Midwives conduct a specific intervention (e.g., pre-term birth prevention featuring patient education, cervical checks, and stress reduction techniques).
# No specific interventions described; midwifery care itself is the intervention.

Historical studies
The first studies of nurse-midwifery practice provided statistical summaries documenting dramatically improved access to care and improved maternal and infant outcomes for poor women, compared with regional and national infant and maternal mortality rates. The first study was Laird’s review of the Maternity Center Association’s (MCA) domiciliary midwifery service, which served poor women in New York from 1932 to 1951.4 There were 4988 homebirths, and an additional 16.5% of patients were transferred to a hospital because of medical problems or poor social or economic status. Midwives attended 99% of the homebirths, including 86 breech births and 56 multiple gestation births. Labors were short, averaging less than 7 hours, which the author speculated could have been due to “the confidence engendered in the patient and her family by the satisfying personal contact in this small service.” Neonatal mortality was 15 per 1000, maternal mortality was 8.6 per 10,000, and the maternal morbidity rate was 2.5%. Despite the high incidence of inadequate nutrition, poor home conditions, low income, unmarried mothers, and high parity, morbidity and mortality rates were much lower than those in the rest of the hospital’s catchment area.

Outcomes of 1000 births at FNS (the tenth 1000 births from the database of 10,000 births attended by FNS nurse-midwives from 1925 to 1954) were similarly excellent, despite extreme poverty and large numbers of women of high parity and very young or old age for childbearing. The overall maternal mortality rate was 9 per 10,000, compared to 34 per 10,000 in the United States as a whole, and low birth weight was half the national average (3.8% versus 7.6%). Perinatal and neonatal mortality in this medically underserved county, which had been among the highest in the country, declined dramatically, resulting in better outcomes than the national averages. FNS founder Mary Breckenridge showed great foresight in recruiting the chief statistician of the Metropolitan Life Insurance Company to analyze and publish these data documenting the contribution of midwives to improving access and outcomes for an isolated, rural population.5

These early positive examples stimulated the development of new midwifery services for the poor. One of the best known was a demonstration project of nurse-midwifery care in Madera County, California in 1960 to 1963. Because midwifery was illegal in California at the time, a special law was passed, which authorized employment of 2 CNMs to provide care to the county’s medically indigent agricultural workers, half of whom were receiving late or no prenatal care. By the end of the project, CNMs were attending 78% of hospital births, and prenatal care, hospital births, and postpartum visits increased substantially. Prematurity declined from 11% immediately before, to 6.4% during the project, and neonatal mortality declined from 24 per 1000 to 10.3 per 1000. The researcher said, “Mothers were attended throughout labor; the course of labor was observed more carefully with better recording; consultation was prompt and easily obtainable; delivery by unprepared attendants was reduced markedly.”6 A follow-up study after the CNM program closed documented a rise in prematurity to 9.8%, a tripling of neonatal mortality to 32.1%, and a doubling of the percentage of women receiving no prenatal care. No similar changes were observed in the neighboring hospitals, suggesting that the CNM program had been responsible for the improvement in access and outcomes.7

Another early “before-and-after study” retrospectively assessed outcomes and cost-effectiveness of a nurse-midwife program in rural Georgia.8 Mothers received more prenatal care, babies had less morbidity and higher birth weights, and costs of care declined. However, the study did not control for self-selection to midwifery care or other health system factors (e.g., the declining birth rate), so it was difficult to establish that the positive changes resulted from the nurse-midwife program.

When CNMs were incorporated into the Indian Health Service in the 1970s, a before and after study was performed by using medical records to document the impact of midwifery services on the health of Navajo women in Fort Defiance, Arizona.9 The Navajos were deemed vulnerable because of high rates of unemployment and inadequate housing, transportation, sanitation, health care, and nutrition. During the first 5 years of the program, prenatal care, postpartum visits, and health and nutrition counseling increased, and infant morbidity and length of hospital stay decreased, contributing to an overall improvement in maternal and infant health.

Slome and colleagues conducted the first prospective, randomized study comparing midwife and physician care at the University of Mississippi Medical Center in 1972 to 1973.10 Midwife patients kept more prenatal appointments (94% versus 80%) and had more spontaneous vaginal births (83% versus 62%). Forceps births were 3 times more common in the physician group, which the authors suggested was probably due to routine or training needs. Otherwise, there were no significant differences in outcomes. The authors proposed expanding CNM services for low-risk women to provide them with more family-centered care while freeing physicians to concentrate on high-risk cases.

In the 1980s and 1990s, descriptive studies based on service statistics of midwifery practices in Georgia,11 New York,12 Washington, DC,13 rural Kentucky,14 and California15, 16 and 17 continued to document safe and effective CNM care for large numbers of mixed-risk, low-income women, including inner-city, rural, and ethnic minority mothers. For example, Sharp and Lewis11 analyzed CNM service data covering 10 years and 10,766 births at a Georgia hospital serving mostly poor, African American women. The researchers described trends and changes in midwifery care over time and showed that CNMs could safely provide both caseload and episodic (CNM for labor only) care. Greulich and colleagues15 reviewed records from another high-volume midwifery practice that served low-income, primarily Hispanic women in California. The data covered 12 years and 30,000 births, and demonstrated that midwifery management, including ambulation, showers, eating and drinking, and emotional support, resulted in excellent outcomes and very low rates of primary cesarean births and operative birth, with no intrapartum mortality.

Outcomes of these and many other studies of midwifery care of the poor have documented increased access to prenatal care, low rates of cesarean births and obstetric interventions, higher birth weights, and better adolescent outcomes, compared to local, state, or national reference statistics. Evidence about the positive impact of midwifery care on vulnerable women will become even stronger if future studies focus on the processes as well as outcomes of care, and take care to choose reference groups that are as similar as possible to the midwives’ patients.

Poverty, risk status, and midwifery care
Although it is often assumed that midwives only care for low-risk women, in reality, midwives primarily serve “mixed-risk” women who are disproportionately young, poor, immigrants, or members of racial or ethnic minority groups.

Declercq pioneered the use of vital records data to document the number and place of midwife-attended births and the risk profiles of midwifery clients. His analysis of 1989 national birth certificate data showed that, compared with physician patients, mothers attended by midwives in hospitals were younger, less educated, and more likely to be nonwhite and unmarried.18 Despite having similar or more risk factors than the national average, their infants were less likely to be low birth weight or to suffer neonatal mortality. Clarke et al. reported similar findings from 1994 national birth certificate data; babies whose births were attended by midwives in hospitals were less likely to be preterm or low birth weight, even though their mothers began prenatal care later and had fewer visits than physician patients.19

In 1992, Scupholme and colleagues conducted a national, mail survey, showing that CNMs in all types of practices provided care to women who were at higher risk for poorer-than-average outcomes because of youth, poverty, refugee status, or ethnicity.20 Fifty-five percent of payment for midwifery services came from Medicaid and other government-subsidized sources, and less than 20% came from private insurance. In a later analysis of these data, Paine and colleagues reported that patients vulnerable to poor access or outcomes made 7 of every 10 ambulatory visits to nurse-midwives.21 These findings were confirmed again in a 1998 mail survey by Declercq and colleagues.22

Researchers have also examined midwifery care of vulnerable women in state populations. For example, a recent study based on survey and administrative data examined care for the poor by CNMs, family physicians, and physician assistants (PAs) in Washington and California.23 In both states, CNMs and PAs constituted a greater proportion of providers in rural and health professions shortage areas than physicians, and they cared for more Medicaid, uninsured, and ethnic minority patients. In fact, California CNMs cared for more Medicaid patients than any other provider group in the state. A study based on Michigan birth certificate data showed that compared with physicians, CNMs cared for twice as many patients who were nonwhite or receiving Medicaid, as well as larger proportions of mothers who were adolescents or had not completed high school.24

Race and ethnicity of the woman and her midwife
Although midwives serve large numbers of ethnic minority clients, the profession remains mostly white (92%).25 The national survey by Declercq et al.22 found that midwives were more than twice as likely as physicians to care for minority clients, and midwives of color were half again as likely as white midwives to care for women who were African American, Hispanic, or receiving Medicaid. More than 75% of African American CNMs’ clients were nonwhite, compared to 48% of white CNMs’ clients. The Michigan study discussed above25 reported that Medicaid recipients and white, college-educated women were more likely to use a nurse-midwife, whereas African American mothers were less likely to do so the more education they had. The researchers wondered whether “the use of midwives may not be part of an ideology of childbirth for educated, middle-class, non-whites.”26 Rooks also reported that in the early days of CNM practice, southern African American women were wary of being assigned to midwives in practice with physicians, perhaps fearing they were being assigned a less qualified care provider.1 All these findings suggest that the issue of midwife-client race and ethnicity should be investigated in the future, and may have implications for recruiting minority CNMs and training all CNMs in cultural competence.

Choice of midwifery care
The early nurse-midwifery services were often the only source of care in underserved areas where women had little choice of provider. Even today, the choice of a birth attendant may be determined more by practicalities such as lack of money, transport, health insurance, or information, than by obstetric risk factors or expectations about the birth experience.

Many women lack accurate information about midwifery care,17 and 27 and poor women may not know that CNMs are certified, clinically competent, and credentialed to attend births in hospitals. They may be unaware that midwifery services in health departments are often more comprehensive than those offered by managed care networks. This problem was illustrated by a focus group study of barriers to care for poor women in South Carolina. Few participants knew about federally supported health centers in their communities, and they did not understand the roles and qualifications of the midwives and nurse practitioners who staffed them. Most thought that midwives only attended homebirths. The few participants who had used the nurse-midwife-managed clinics were very satisfied, pronouncing them “the best kept secret of affordable health care.”26

Studies of women’s choice of a midwife or physician care provider have mostly focused on white, married, middle-class women receiving care from health maintenance organizations or physician-midwife private practices. Little is known about how poor women choose their birth attendants or how much choice they really have. Care choices of disadvantaged and ethnically diverse women should be studied, with a focus on informed choice.

How does midwifery care make a difference? Focusing on the process
A growing number of studies have used qualitative methods to focus on the process of midwifery care, including care for vulnerable women. For example, Morrow conducted a qualitative study using participant observation and interviews of immigrant Hmong (Laotian) women and men about their birthing beliefs and practices, in order to incorporate their customs into a California birth center.28 Her study combined birth stories and quotations with descriptions of how the birth center successfully adapted to their traditions and needs.

A midwife-staffed prenatal clinic in Philadelphia conducted a demonstration project to reduce substance abuse, which included a qualitative research component.29 The intervention featured substance abuse counselors, staff training, and longer and more frequent prenatal visits for drug-using women. During the project, the midwives gained a deeper understanding of addiction, learned how to ask less threatening questions, and became less judgmental toward their clients, who in turn, became more trusting of them. This study was notable for focusing on how the midwives’ care and thinking changed during the intervention as they learned how to promote behavior change more effectively among their clients.

The process of midwifery care has also been studied by using quantitative methods. For example, a retrospective evaluation of midwifery care in the Michigan prison system compared outcomes of a residential program with “usual care” for a matched group of incarcerated pregnant women, most of whom had been arrested on drug charges.30 Midwives provided care in both settings, but in the residential program, they had time for longer visits and coordinated the woman’s care. The residential program also featured substance abuse treatment, job skills training, educational and support groups. Infants lived with their mothers and attended an on-site nursery, whereas infants were removed from the prison a few days after birth in the “usual care” group. Program evaluation, based on chart review, found equally good birth and neonatal outcomes in both groups, which were better than those previously reported in the literature. Reported outcomes included Apgar scores, birth weight, and hemoglobin levels. If longer-term “soft” outcomes, such as attachment, parenting, and successful reintegration into the community could have been measured, it is likely that other differences would have also emerged.

Birth center care
Since the opening of the MCA’s Childbearing Center in 1975, most birth center clients have been white, married, and well educated.31 However, birth centers have also flourished in poor areas.

Scupholme and colleagues published several studies documenting the safety and effectiveness of birth center care for low-risk, predominantly African American women in Florida. Their first matched-pair study found that women who chose birth center care were admitted earlier; had longer labors; were more likely to walk, eat, and drink; and less likely to have continuous electronic fetal monitoring, IVs, or oxytocin augmentation, compared with low-risk women in the affiliated hospital. Despite dramatically different levels of intervention and technology, outcomes were equally good in both groups.32 When hospital overcrowding made birth center care standard for low-risk patients, a second matched-pair study was conducted to determine whether outcomes would suffer when women were assigned to birth center care rather than selecting it.33 Again, no significant differences in birth or newborn outcomes were noted.

A birth center that served poor Hispanic women in Texas conducted 3 studies to determine whether women with selected moderate-risk conditions could be safely managed there. The first study described and evaluated their program to manage gestational diabetes mellitus (GDM), which affected 10% of their clients.34 The second described their protocol and outcomes for expectant management of prelabor rupture of membranes (PROM) at term.35 The third evaluated their antepartum surveillance and management of postdates pregnancy and proposed the use of a modified biophysical profile to determine which mothers could safely continue birth center care.36 It is difficult to draw conclusions about the safety and efficacy of these management protocols, because none of the studies included a control group. Although the study designs had limitations, the birth center’s outcomes compared very favorably with other published results.

A recent, prospective cohort study in California compared outcomes, safety, and resource use of birth center care provided by CNMs backed up by physicians with hospital-based physician care for low-income women.37 The birth center served mostly low-risk, Hispanic women and provided case management, health education, nutrition counseling, and social services. Perinatal risk was carefully controlled for, and an intent-to-treat analysis was performed. Birth center care was equally safe, cost less, and used fewer resources and procedures than hospital-based physician care. The large size (n = 2957) and methodological rigor of this study provided important evidence documenting the safety and cost-effectiveness of birth center care for vulnerable women.

Prevention of preterm birth and low birth weight
Preterm birth is one of the most challenging problems in childbirth. Decades of research and interventions have failed to reduce the rate of preterm birth, which is dramatically higher for poor and minority infants. Twelve percent of US births take place at less than 37 weeks’ gestation, including 13% of black, 6.5% of white, and 6.4% of Hispanic births.38 Research interventions that have not demonstrated improved outcomes include bed rest, tocolytic drugs, frequent cervical examinations, cerclage, nutritional interventions, and home uterine activity monitoring.39 Seven studies have examined midwifery care as an intervention to reduce preterm birth.

The only randomized controlled trial among the preterm birth studies was a methodologically strong, multisite study of the effect of CNM care on the incidence of low birth weight.40 High-risk women attending South Carolina health department clinics were randomized to high-risk obstetrician care or CNM care, which included intensive patient education, frequent cervical checks, stress reduction, and counseling about preterm labor prevention, substance abuse, and nutrition. Like other randomized controlled trials of preterm birth prevention, the CNM interventions did not significantly improve birth weight or length of gestation.

Piechnik and Corbett retrospectively compared the incidence of low birth weight among adolescents attending a midwife-managed, multidisciplinary teen clinic with a matched control group assembled from health department records.41 Birth weights were significantly higher in the CNM clinic, with the youngest teens (less than 15 years old) having the most improved birth weights. Because the study was not randomized, it could not establish a causal relationship between the midwife-led interventions and the good infant outcomes.

A cohort study from South Carolina compared the incidence of low birth weight and perinatal mortality in a CNM-managed twin clinic with outcomes of twins from the regular high-risk obstetrician clinic.42 The CNM clinic featured intensive education, frequent cervical checks, individualized nutrition and activity counseling, and care by a single nurse-midwife. Although there was no difference in the overall rate of low birth weight, significantly fewer patients in the CNM clinic gave birth to very low birth weight babies (less than 1500 g), and perinatal mortality and neonatal intensive care unit admissions were lower in this group. This study demonstrated excellent outcomes for women usually classified as too high risk for CNM care.

A population-based, quasi-experimental study in Colorado used multivariate analysis of birth certificate data to compare the impact of a CNM-led maternity program for indigent women in one county with usual obstetrician care in 2 adjacent counties.43 Women in the CNM county had earlier and more frequent prenatal care, but the reduction in prematurity or low birth weight was only marginally significant. The study used an intent-to-treat analysis, and because only 60% of the births in the intervention county were actually attended by a CNM, the effect of the CNM program on outcomes could have been diluted.

MacDorman and Singh44 used 1991 US birth certificate data to compare survival, birth weight, and other outcomes of babies delivered by CNMs or physicians. They controlled for social and medical risk factors and restricted the analysis to singleton vaginal births from 35 to 43 weeks’ gestation. Midwife-attended births had a 19% lower risk of infant mortality, a 33% lower risk of neonatal mortality, and a 31% lower risk of low birth weight. The researchers proposed that the midwives’ (unmeasured) provision of patient education, emotional support, trust, and communication could explain the difference. An important caveat regarding this and other studies based on birth certificate data is that they are unable to account for the transfer of care from midwife to physician during labor, when an emergent situation necessitates an operative birth. Such information can only be collected by using an intent-to-treat analysis, when patients who started labor with a midwife or physician are analyzed in their original groups, regardless of who delivers the baby and signs the birth certificate.

A multisite cohort study in New York compared birth outcomes of indigent mothers receiving enhanced care from nurse-midwives with all county births in the same period.45 Enhanced care for the midwife cohort was provided under the state’s Medicaid-funded Prenatal Care Assistance Program (PCAP), and included case management, referral services, and education about childbirth, nutrition, and exercise. The rate of low birth weight in the PCAP cohort was 35% lower than the overall county rate, and 55% lower than that of other Medicaid patients in the county. This differential was even greater for infants weighing less than 1500 g. Processes of care within the PCAP program were not described, and because the study was not randomized, causality could not be tested. The researchers suggested that women who were more open to childbirth education and behavior change might have self-selected to the PCAP program; once there, intensive midwifery care and enhanced health and social services may have combined to generate good outcomes.

Predicting and reducing low birth weight
CenteringPregnancy, a model of group prenatal care that incorporates social support along with assessment of routine biophysical parameters, is being studied as an intervention to prevent preterm birth and low birth weight. A recent cohort study compared outcomes of poor African American and Hispanic infants whose mothers took part in group prenatal care with matched comparison groups selected from computer records who received usual prenatal care at the same clinics (N = 458).46 Although preterm birth rates were similar, group prenatal care mothers maintained their pregnancies 2 weeks longer than the usual care group (P < .001). Despite the use of matching, the study was vulnerable to self-selection bias, because women who enrolled in group prenatal care might have been different in unmeasured ways from those who did not. The researchers are currently conducting a 5-year randomized controlled trial comparing individual prenatal care, Centering, and Centering enhanced with additional content on risk taking, communication, and negotiation skills. Several other studies of group prenatal care by midwives and others are also underway.

Jesse and Alligood developed a holistic obstetric problem evaluation (HOPE) theory based on psychosocial, spiritual, and perceptual risk factors for preterm birth, and studied its ability to predict infant birth outcomes in low-income women attending 3 prenatal clinics in Tennessee.47 Lack of partner support during pregnancy and African American race predicted variance in infant birth weight. Lower levels of self-esteem, use of drugs or alcohol, and active religiosity predicted shorter length of gestation. Low self-esteem, depression, and a woman’s negative perception of her pregnancy were significant predictors of preterm birth.48 The researchers are currently replicating the study with larger, more ethnically diverse samples and adding focus groups. Future goals of this program of research are to incorporate findings into risk-screening tools and prenatal interventions.

Prevention of preterm birth and low birth weight is an important and seemingly intractable problem. Common sense interventions and enhancements of care by midwives and others often fail to make a difference. Future studies should use the strongest possible research designs, including randomized controlled trials and qualitative methods, and include assessment of mediating factors, such as stress, racism, empowerment, spirituality, and social support along with more traditional measures.

Health system factors affecting midwifery care of the poor
The broader health care environment has a powerful influence on midwives’ ability to practice and provide care to disadvantaged women. Studies have focused on denial of hospital privileges and malpractice insurance, lower reimbursement than physicians, restrictive state regulations, midwives’ lack of knowledge of finance and administration, and the effects of managed care. Taken together, the studies describe a profit-driven health system, with increasing costs and administration and decreasing access and benefits. Midwives have lost jobs and public clinics have closed as Medicaid managed care contracts have moved their patients into managed care organizations or physician- run private practices, which often lack support services to meet their complex needs. Exclusion from managed care organization panels as primary care providers, low reimbursement rates relative to physicians, and loss of autonomy in physician-run settings are additional challenges faced by midwives serving vulnerable women.

An important study of the effects of managed care organizations on midwifery practice was conducted in 1998 via a mail survey of all midwives ever certified by ACNM.49 Health system changes affected the practice of 57% of respondents. The most frequently reported changes were increased client loads (31%), changed style of practice (30%), inability to serve the same populations (20%), decreased client loads (20%), and increased administrative duties (17%). In responses to open-ended questions, midwives described the difficulty of providing appropriate care to poor women who had moved from traditional public health clinics with support services like nutritionists and social workers into managed care organizations that lacked such resources. A second analysis focusing on quantitative data from this survey found that CNMs paid by managed care organizations or private practices saw more clients and attended more births but were less likely to serve vulnerable women than CNMs paid by hospitals or other public or nonprofit institutions.23 The authors recommended further research to determine whether time pressures in managed care organizations limit the provision of time-intensive midwifery care and counseling.

Recommendations for future research
Data collection
Data should be systematically and consistently collected, analyzed, and disseminated to provide evidence that midwives are clinically competent, cost-effective providers who increase access to care and improve outcomes of vulnerable women.

Structure, processes, and outcomes of care
Studies of the health system’s impact on care of the poor must continue, with special attention to the effects of managed care on midwifery practice and the quality of health care for disadvantaged women. Studies must move beyond documenting good outcomes, to focus more on the process of midwifery care, and the link between process and outcomes. In addition to traditional outcome measures, such as Apgar scores, birth weight, and cesarean birth rates, researchers should define and measure hallmarks of midwifery care, including health education, nonintervention, satisfaction with care, labor support, and the use of movement, positioning, and nonpharmacologic methods of pain relief. The use of qualitative methods should help researchers to explore and define these important measures.

Intervention studies and clinical trials
The majority of studies reviewed were descriptive, observational, and retrospective. The time has come for more intervention studies of midwifery care of the poor, including randomized controlled trials and quasi-experimental studies. Although some studies feature interventions carried out by midwives, in others the midwives are the intervention, as described by Kennedy’s qualitative theme of “the midwife as an instrument of care.”50 Studies should take pains to define and measure the elements of midwifery care that produce the outcomes.

Poverty and risk
Modern obstetric care views poor, pregnant women as intrinsically high risk and believes that bad outcomes can best be prevented by intensive screening and technological interventions. Such care is often provided by rotating trainees in high-volume hospitals, where little provider-patient connection is established. Some midwifery interventions discussed in this review challenge this thinking by demonstrating that personalized, low-intervention care can be provided to women at high socioeconomic risk with outstanding results. Risk profiles vary dramatically among sociodemographic groups of vulnerable women, and researchers should refine risk assessment to tailor interventions for counseling and care. More attention should be paid to designing interventions that mobilize women’s strengths, coping abilities, and resiliency, rather than emphasizing only gaps and deficits.

Interdisciplinary collaboration among midwives, statisticians, epidemiologists, social scientists, and others has resulted in some very significant studies of midwifery care of the poor.18, 22, 23, 33, 38, 47and 48 Contributions from other disciplines can take many forms, including assistance with study design, research methodology, cost-analysis, content expertise, or the addition of a broader health policy perspective. Interdisciplinary collaborations may help to look at old problems in new ways or use sophisticated research methods to ask important questions about the care of vulnerable populations. The ACNM Minimum Data Sets are important and useful tools for collecting data across midwifery practices with a common instrument.

Research partnership with women
From a feminist perspective, research on childbirth and women’s health is a means to social change, conducted in partnership with women and for their benefit.51 Feminists try to make the research process cooperative and transparent by including women’s and community groups on research advisory boards to help formulate research questions, design studies, and interpret their results. Sometimes women are asked directly what they want and need from health care, and interventions are designed on the basis of their responses, rather than on researchers’ preconceived objectives. A feminist perspective could add an important new dimension to research on midwifery care of the poor by involving women as partners as well as subjects.

Content areas
Many important issues in childbirth research have not been studied from the viewpoint of poor and vulnerable women (e.g., the impact of childbirth technology on satisfaction with the birth experience, the association of labor interventions such as induction of labor or cesarean birth with the mother’s race and social class, or the use of alternative therapies and healers by ethnic minority and immigrant women). The impact of labor support and continuity of care are also important research questions, given that poor women are less likely to receive bedside support during labor, and more likely to “be delivered” by an unknown provider.

A number of health disparities between poor and African American women compared with other Americans could become important foci for midwifery intervention research because midwives already provide care to the populations at risk, and health education and behavior change interventions to address the issues could be incorporated relatively easily into patient care. These include low rates of breastfeeding, unplanned and unwanted pregnancies, obesity, breast and cervical cancer screening, HIV/STI prevention, domestic violence, and adolescent pregnancy and parenting. Although midwives provide care in all these areas, midwifery care research still focuses almost exclusively on prenatal care and childbirth, with few studies addressing disparities in primary care and women’s health. Table 2 summarizes suggestions for future research.

Table 2.

Potential Research Topics on Midwifery Care of Poor and Vulnerable Women Women’s Health Pregnancy and Birth
Breast and cervical cancer screening Impact of childbirth technology and interventions
Breastfeeding promotion Continuity of caregiver
Prevention of unwanted pregnancies and STIs Increasing rates of cesarean section, operative vaginal birth
Reducing obesity Prevention of low birth weight and preterm birth
Domestic violence Content and structure of prenatal and birth care
Adolescent reproductive health care Cost and benefits of midwifery care
Crosscutting Themes
Document and test innovative, empowering models of care (group prenatal care, birth centers in poor neighborhoods)
Effects of broader health system on midwifery care of the poor
Midwife-patient relationship as a therapeutic intervention
Perception of/demand for/satisfaction with midwifery care
Interventions to increase cultural competence of midwives
Provision of high-quality health care in time- and resource-constrained settings
Interventions to customize care for special populations

Midwives have historically served disadvantaged women, and an impressive body of evidence documents the excellent outcomes of midwifery care over three quarters of a century, in a wide variety of low-resource settings. In the current health care environment, infant mortality is rising, preterm birth is a continuing problem, the health safety net is tearing, and gaps in health behaviors and outcomes between the poor and other Americans are increasing, despite the fact that US per capita health care expenditures and use of obstetric technology are the highest in the world. These realities make research documenting midwives’ contributions to care of vulnerable women more important than ever.

As midwifery grows and enters the mainstream, research on midwifery care of poor and vulnerable women is poised to focus on process as well as outcomes, and to develop and test innovative models of care and interventions to address health disparities. Midwives’ ability to listen to and partner with women, their belief in women’s inner strength and ability to change behavior, and their ability to promote normalcy and empower women make powerful contributions to health, which deserve to be fully described and measured.

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13 M.R. Davidson, Outcomes of high-risk women cared for by certified nurse-midwives, J Midwifery Womens Health 47 (2002), pp. 46–49. SummaryPlus | Full Text + Links | PDF (31 K)

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15 B. Greulich, L.L. Paine, C. McClain, M.K. Barger, N. Edwards and R. Paul, Twelve years and more than 30,000 nurse-midwife attended births The Los Angeles County + University of Southern California women’s hospital birth center experience, J Nurse Midwifery 31 (1994), pp. 185–196. Abstract | Full Text + Links | PDF (866 K)

16 J.T. Fullerton, L. Palinkas and C.M. Cavero, Nurse-midwifery services in one multi-ethnic, underserved community, J Health Care Poor Underserved 2 (1991), pp. 293–306. Abstract-MEDLINE

17 L.M. Schimmel, P. Hogan, B. Boehler, M. DiFelice, A. Cooney and L.D. Schimmel, The Yolo County Midwifery service A descriptive study of 496 singleton birth outcomes, 1990, J Nurse Midwifery 31 (1992), pp. 398–403. Abstract | Full Text + Links | PDF (450 K)

18 E.R. Declercq, Midwifery care and medical complications The role of risk screening, Birth 22 (1995), pp. 68–73. Abstract-MEDLINE

19 S.C. Clarke, J.A. Martin and S.M. Taffel, Trends and characteristics of births attended by midwives, Stat Bull Metrop Insur Co 31 (1997), pp. 9–18. Abstract-MEDLINE

20 A. Scupholme, J. DeJoseph, D.M. Strobino and L.L. Paine, Nurse-midwifery care to vulnerable populations. Phase I. Demographic characteristics of the national CNM sample, J Nurse Midwifery 31 (1992), pp. 341–348. Abstract | Full Text + Links | PDF (509 K)

21 L.L. Paine, J.M. Lang and D.M. Strobino et al., Characteristics of nurse-midwife patients and visits, 1991, Am J Public Health 89 (1999), pp. 906–909. Abstract-MEDLINE | Abstract-EMBASE

22 E.R. Declercq, D.R. Williams, A.M. Koontz, L.L. Paine, E.L. Streit and L. McCloskey, Serving women in need Nurse-midwifery practice in the United States, J Midwifery Womens Health 46 (2001), pp. 11–16. SummaryPlus | Full Text + Links | PDF (42 K)

23 K. Grumbach, L.G. Hart, E. Mertz, J. Coffman and L. Palazzo, Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington, Ann Fam Med 31 (2003), pp. 97–104. Abstract-MEDLINE | Full Text via CrossRef

24 S.D. Stewart, Economic and personal factors affecting the use of nurse-midwives in Michigan, Fam Plann Perspect 30 (1998), pp. 231–235. Abstract-EMBASE | Abstract-MEDLINE | Full Text via CrossRef

25 C.T. Kovner and P. Burkhardt, Findings from the American College of Nurse-Midwives’ Annual Membership Survey, 1995–1999, J Midwifery Womens Health 46 (2001), pp. 24–29. Abstract-MEDLINE

26 M.O. Johnson, Meeting health care needs of a vulnerable population Perceived barriers, J Community Health Nurs 18 (2001), pp. 35–52. Abstract-EMBASE | Abstract-MEDLINE | Full Text via CrossRef

27 J.E. Haas and J.P. Rooks, National survey of factors contributing to and hindering the successful practice of nurse-midwifery. Summary of the American College of Nurse-Midwives Foundation Study, J Nurse Midwifery 31 (1986), pp. 212–215. Abstract | Full Text + Links | PDF (581 K)

28 K. Morrow, Transcultural midwifery Adapting to Hmong birthing customs in California, J Nurse Midwifery 31 (1986), pp. 285–288. Abstract | Full Text + Links | PDF (553 K)

29 S.J. Corse, M.K. McHugh and S.M. Gordon, Enhancing provider effectiveness in treating pregnant women with addictions, J Subst Abuse Treat 12 (1995), pp. 3–12. Abstract | PDF (902 K)

30 V.H. Barkauskas, L. Kane Low and S. Pimlott, Health outcomes of incarcerated pregnant women and their infants in a community based program, J Midwifery Womens Health 47 (2002), pp. 371–379. SummaryPlus | Full Text + Links | PDF (62 K)

31 J.P. Rooks, Midwifery and childbirth in America, Temple University Press, Philadelphia (PA) (1995), p. 153.

32 A. Scupholme, A.G. McLeod and E.G. Robertson, A birth center affiliated with the tertiary care center comparison of outcome, Obstet Gynecol 67 (1986), pp. 598–603. Abstract-EMBASE | Abstract-MEDLINE

33 A. Scupholme and A.S. Kamons, Are outcomes compromised when mothers are assigned to birth centers for care?, J Nurse Midwifery 32 (1987), pp. 211–215. Abstract | Full Text + Links | PDF (624 K)

34 M.E. O’Brien and G. Gilson, Detection and management of gestational diabetes in an out-of-hospital birth center, J Nurse Miwifery 32 (1987), pp. 79–84. Abstract | Full Text + Links | PDF (880 K)

35 G.J. Gilson, M.E. O’Brien, R.W. Vera, A. Block and N. Grubb, Expectant management of premature rupture of membranes at term in a birthing center setting, J Nurse Midwifery 33 (1988), pp. 134–139. Abstract-MEDLINE

36 G.J. Gilson, M.E. O’Brien, R.W. Vera, M.E. Mays, D.R. Smith and C.Y. Ross, Prolonged pregnancy and the biophysical profile A birthing center perspective, J Nurse Midwifery 33 (1988), pp. 171–177. Abstract | Full Text + Links | PDF (909 K)

37 D.J. Jackson, J.M. Lang, W.H. Swartz, T.G. Ganiats, J. Fullerton and J. Ecker et al., Outcomes, safety and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care, Am J Public Health 93 (2003), pp. 999–1006. Abstract-MEDLINE | Abstract-EMBASE

38 J.D. Iams, The epidemiology of preterm birth, Clin Perinatol 30 (2003), p. 651. Abstract-MEDLINE

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40 H.C. Heins, N.W. Nancy, B.J. McCarthy and C.M. Efird, A randomized trial of nurse-midwifery prenatal care to reduce low birth weight, Obstet Gynecol 75 (1990), pp. 341–345. Abstract-EMBASE | Abstract-MEDLINE

41 S.K. Piechnik and M.A. Corbett, Reducing low birth weight among socioeconomically high-risk adolescent pregnancies, J Nurse Midwifery 30 (1985), pp. 88–98. Abstract | Full Text + Links | PDF (1107 K)

42 J.M. Ellings, R.B. Newman, T.C. Hulsey, H.A. Bivins and A. Keenan, Reduction in very low birth weight deliveries and perinatal mortality in a specialized, multidisciplinary twin clinic, Obstet Gynecol 81 (1993), pp. 387–391. Abstract-EMBASE | Abstract-MEDLINE

43 D. Lenaway, T.D. Kospsell, T. Vaughan, G. van Belle, K. Shy and F. Cruz-Uribe, Evaluation of a public-private certified nurse-midwife maternity program for indigent women, Am J Public Health 88 (1998), pp. 675–679. Abstract-MEDLINE | Abstract-Elsevier BIOBASE | Abstract-EMBASE

44 M.F. MacDorman and G.K. Singh, Midwifery care, social and medical risk factors, and birth outcomes in the USA, J Epidemiol Community Health 52 (1998), pp. 310–317. Abstract-MEDLINE | Abstract-Elsevier BIOBASE | Abstract-EMBASE

45 P.F. Visintainer, J. Uman, K. Horgan, A. Ibald, U. Verma and N. Tejani, Reduced risk of low weight births among indigent women receiving care from nurse-midwives, Epidemiol Community Health 54 (2000), pp. 233–238. Abstract-EMBASE | Abstract-Elsevier BIOBASE | Abstract-MEDLINE | Full Text via CrossRef

46 J.R. Ickovics, T.S. Kershaw, C. Westdahl, S.S. Rising, C. Klima and H. Reynolds et al., Group prenatal care and preterm birth weight Results from a matched cohort study at public clinics, Obstet Gynecol 102 (2003), pp. 1051–1057. Abstract

47 D.E. Jesse and M.R. Alligood, Holistic obstetrical problem evaluation (HOPE) Testing a theory to predict birth outcomes in a group of women from Appalachia, Health Care Women Int 23 (2002), pp. 587–599. Abstract-MEDLINE | Full Text via CrossRef

48 D.E. Jesse, W. Seaver and D.C. Wallace, Maternal psychosocial risks predict preterm birth in a group of women from Appalachia, Midwifery 19 (2003), pp. 191–202. Abstract-MEDLINE

49 L. McCloskey, H.P. Kennedy, E.R. Declercq and D.R. Williams, The practice of nurse-midwifery in the era of managed care Reports from the field, Matern Child Health J 6 (2002), pp. 127–136. Abstract-MEDLINE | Full Text via CrossRef

50 H.P. Kennedy, The midwife as an instrument of care, Am J Public Health 92 (2002), pp. 1759–1760. Abstract-EMBASE | Abstract-MEDLINE

51 M. Barnes, Research in midwifery—The relevance of a feminist theoretical framework, Aust Coll Midwives J 12 (1999), pp. 6–10. Abstract | PDF (458 K)

Address correspondence to Jeanne Raisler, CNM, DrPH, FACNM, University of Michigan School of Nursing, 400 North Ingalls, Room 3320, Ann Arbor, MI 48109-0482.
Jeanne Raisler, CNM, DrPH, FACNM, is an Assistant Professor at the University of Michigan School of Nursing, and a Nurse Consultant to HRSA’s Global AIDS Program in which she trains nurses and midwives in sub-Saharan Africa in AIDS care and treatment. She is the Chair of the International Section of the ACNM Division of Research.

Holly Kennedy, CNM, PhD, FACNM, is an Assistant Professor at the University of California San Francisco and Co-Director of its nurse-midwifery education program. She is the Chair of the ACNM Division of Research.

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Journal of Midwifery & Women's Health
Volume 50, Issue 2 , March-April 2005, Pages 113-121

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Amy, come on now. Besides the article I just posted that supports the fact that midwives can greatly improve maternity care of vulnerable populations, midwifery is a good model of care for most women (about 75%). Do you think otherwise?

FYI the last three posts were mine. I was the one who agreed with you that the main reason our infant mortality rate is so high is because of poor access to health care. I'm not hardliner. I think we (those who follow the technocratic medical model of care and those who follow the midwifery of mother-friendly model of maternity care) need to build bridges and be reasonable instead of refusing to listen to each other. Each model has its place.

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