Midwifery is a discipline that melds science with art and weaves technology with tradition; it is a humanistic approach to providing quality health care to women, newborns, and their families that recognizes the sacredness of the individual and of the processes of fertility and birth, and that honors women across the life span. Midwives are blessed with a passion for their work. It is the thoughtful and skilled expression of this passion that women under midwives' care so appreciate and that has helped the discipline Of midwifery to thrive. This text is designed with the practicing midwife in mind. The text condenses and outlines clinical care, highlighting the art and science behind the midwifery model of care. It is the authors' goal that this text supports professional midwifery practice as a resource by allowing the focus to remain on the women who come to midwives for care rather than on the administrative task of creating practice-specific clinical practice guidelines.
SECTION 1: THEORETICAL BASIS FOR MIDWIFERY PRACTICE Women first Midwives and other women's health professionals practice within a healthcare system that is increasingly complex. Midwifery and women's health is first and foremost concerned with caring for, about, and with women in a manner that honors their psychosocial and physical needs. Every individual woman deserves to receive care that is safe and satisfying, that foster self-determination and her ability to care for herself. Such care, to be effective, addresses thi individual woman's personal, cultural, and developmental needs. Women look to their health care provider to give guidance consistent with the individual's real and perceived health neec and internal beliefs. As midwives caring for women in our countr$s diverse communities, the ability to listen and to integrate women's concerns into the care provided is an integral component Of mid- wifery practice. aim is to provide care based on the woman's expressed and identified needs through a personalized plan of care that is mutually developed and supported by both thethe woman and the midwife and that reflects the midwife's awareness and sharing of national, regional, and local expectations and recommendations for care. Chapter I Essential Midwifery Practice Midwifery carc is based on providing care that fosters Copyri practice of midwifery and their associated relationships
women's health and related physiologic processes, including those Of pregnancy, labor, and birth, Modern midwifery and women's health care builds on this physiologic non interventionist foundation to include interventions only as necessary and indicated by the individual woman's condition and preferences. Determining which interventions arc necessary and when they are indicated defines midwives' individual practice and Can also be a function Of the environment of care in which the midwife practices. The midwife—woman relationship can be developed and nurtured in every environment of care. Within a trusting relationship with her midwife, a woman can expand her views of health and childbirth, identify her preferences, and envision what is possible for her. The potential for the woman to derive comfort and feelings Of safety is influenced bv both the quality of the midwife—woman relation- (sec Box I-I) For these ethical principles to have a meaningful effect or practice, they must be a touchstone for the midwife's inter- actions with women, for the manner in which professional responsibilities are upheld, and for the decisions that affect the integrity of the profession (ICM, 2008). Ethical issues arc not always clear-cut. Ethical dilemmas arc inherent in midwifery care, and they can bc embedded in the day-to-day provision of care. Sometimes, it is a matter of choosing be- tween what is right and what is easy, which can pose its Own challenges in a busy midwifery or interprofessional practice. The reflective practitioner examines and learns from an ethical perspective in the clinical setting by following the integrity of the decisions made, the actions taken, and both clinical and professional outcomes. Midwifery is a morally important endeavor that promotes the optimal health or
enced by both the quality of the midwife—woman relation- ship and the environment of care. Ethical Midwifery Practice Ethical midwifery practice is based on a human rights framework, which seeks to improve the standard Of care provided to women, children, and families (International Confederation Of Midwives [ICMI, 2008; Thompson, 2004). "lhs framework includes four foundational ethical principles: l. Autonomy: The human right to personal indepen- dence and the capacity to make decisions and act on them 2. Justice: The human right to be treated fairly and with reasoned care important endeavor that promotes the optimal health of women through engagement with women as partners in their care, development or trusting relationships, and advocating for equitable healthcare practices. Decisions are made within the context of the woman's life and community, as well as the professional community Of care, and can influence not only the woman's health care, but also the perception of the individual midwife and the profession Of midwifery. Exemplary Midwifery Practice Exemplary midwifery practice is woman oriented and focuses on excellence in the processes and provision of women's health care, with a primary goal of improving maternal and child health. Exemplary midwives possess high-caliber clinical skills and judgment required to make
with reasoned care 3. Beneficence: The human right to be treated with intent to do good 4. Nonmalfeasancc: The human right to be treated with intent to avoid harm; the classic "First do no harm" directive attributed to Hippocrates These guiding ethical principles are reflected in mid- wifcry's philosophical tenets and have also been codified specifically for midwives by several midwifery orga- niA1tions, including the American College of Nurse- Midwives (ACNM, 2005), the National Association Of Certified Professional Midwives (NACPM, 2004), the Midwives Alliance of North America (MANA, 2010), and critical decisions while providing care characterized by compassion and caring. These qualities arc highly valued by women receiving midwifery care (Kennedy, 2000). pr0- viding care that supports physiologic birth while maintain- ing vigilance for deviation from the wide range Of normal are also highly valued by midwives and their clients. Optimal care practices that support normal physiologic birth often take time and philosophical commitment to im- plemcnt. The midwife practicing in contemporan maternity care settings may be challenged to provide the type of care recognized as most beneficial to the woman and her family. Regardless of practice setting, it is imperative for midwives to continue to strive toward the goal of providing care in -the TCM (2008)vaSÆ1 means to guide midwives in their—vhich the are paramoun
Exemplary midwifery practice also encompasses actions that promote and support the midwifery profession and the individual midwife, supporting professional growth and personal time (Kennedy, 2000). Midwives not only care for women and families; care is also taken to promote the profession and longevity of service, by creating a prac- ticc environment that supports professional growth and personal balance. Respectful Care Awareness and respect of each individual woman's cir- cumstance, background, and worldview is key in develop- ing a trusting midwife—woman relationship. Some cultural variations that can inform women's experience or mid- wifcry carc include socioeconomic Status, race, ethnicity, refugee status, country of origin, ability level, literacy level, history Of abortion, identification as male or nonbi- nary gender category, or identification as lesbian, bisexual, or polyamorous. Social variations that occur on a regional basis or self-identification with a subculture arc other im- portant factors to consider. The first step in developing a trusting and effective relationship with women from differing backgrounds is for the midwife to identify and examine her or his own personal status relative to the variations encountered (Erikson-Schroth, 2014). Often when a person is part of a
majority, her or his status as privileged can become invis- ible and thus normative for the individual (Fredriksen- Goldsen, Hoy-Ellis, Goldesen, Emlet, & Hooyman, 2014). This Can lead to difficulty recognizing that members Of minority groups may perceive experiences differently than the majority. For example, when a lesbian, gay, or transgender in- dividual mentions her or his partner or significant other in conversation, it may involve tremendous forethought about how she or he will be perceived (Erikson-Schroth, 2014). Likewise, when a woman reveals her literacy status or economic status to her midwife there is likely to have been similar consideration prior to revealing Interdisciplinary Care and Collaboration Every midwife, regardless of practice location or practice style, is better able to serve the women who present for Care by developing a network Of professionals who provide a range of essential and supplemental services (Munro, Kornelsen, & Gruybowski, 2013). Healthcare services are enhanced by effective communication and collabora- tion among team members to ensure the woman receives care that fits her needs. The collaborative practice model provides a framework that includes communication, effec- tive team functioning, leadership, and role clarification; fosters a wide variety of professional relationships ranging from informal to highly structured; and supports collabo- -this information. Notably, forwomen Of color and those¯ration between midwives and nurses, midwivesand physi- with other apparent markers of ethnicity or culture, cians, and midwives and other professionals and service
2014). Likewise, when a woman reveals her literacy status or economic status to her midwife there is likely to have been similar consideration prior to revealing this information. Notably, for women of color and those with other apparent markers of ethnicity or culture, "coming out" about race, ethnicity, or culture is not a choice. Negative healthcare experiences associated with bias can result in fear or avoidance of the healthcare system (ACNM, 2012a; American College of Obstetricians and Gynecologists [ACOGI, 201 1). In order to become cultur- ally competent and to facilitate a sense of cultural safety, the intentional examination of personal biases and as- sumptions is needed (Douglas et al., 2014). Creation Of a culturally sensitive environment, such as providing images tive team functioning, leadership, and role clarification; fosters a wide variety of professional relationships ranging from informal to highly structured; and supports collabo- ration between midwives and nurses, midwives and physi- cians, and midwives and other professionals and service providers. Collaborative practice connects midwives with ad- ditional health professionals who provide ongoing or specialty care outside the midwife's practice parameters. Along the way, these other professionals become aware of the services midwives offer and, in turn, can serve as a source of referrals to the midwifery practice. Effective collaborative practice models in women's health carc can form a continuum that extends from the home setting, through office- and community hospital—based care, to
in waiting and exam rooms that reflect the diversity of human experience, demonstrates openness to each person as a unique individual. Intake forms with open-ended questions allow women to dcscribc their race, ethnicity, gcndcr identities, and primary relationships in their own words (Erikson-Schroth, 2014). Behaviors such as avoiding introductions, asking "yes—no" questions, and being nonresponsive to voiced questions or concerns limits the opportunity to develop a trusting relationship and effective communication (see Appendix C). Open-ended questions, validation of expe- riences, and reflection Of what was heard demonstrates interest in the individual within the Context or her or his life. This can create a safe place, where the woman is able to describe what she or he is seeking when accessing regional, tertiary care and specialty services. A health "continuum of care" is based on healthcare professionals partnering with each woman as an individual healthcare consumer (Ting, Sutherland, & Donnelly, 2013). Decisions arc made based on the individual worn- an's unique situation and needs and, when needed, allow the woman to move through differing levels of service as her situation and health needs evolve. effect of a continuum is a seamless transition from midwives to gen- eralist or specialist physicians and back again. Such care is provided based on clinical indications for care and the woman's preferences and is validated through the health record and relevant quality measures. Such a continuum of care recognizes the value Of each discipline and seeks to engage each healthcare profes-
riences, and reflection Of what was heard demonstrates interest in the individual within the context or her or his life. This can create a safe place, where the woman is able to describe what she or he is seeking when accessing healthcare scrviccs (Douglas ct al., 2014). Women's health clinicians who seek to maintain cultural competency iden- tify and reshape their behavior through measures such as intentional, ongoing self-awareness, and observation for markers of personal bias. woman's preferences and is validated through the health record and relevant quality measures. Such a continuum Of care recognizes the value Of each discipline and seeks to engage each healthcare profes- sional as team participants who function at their highest level of education and training. Communication, shared decision making, partnering with women and across disci- plines, and true collaboration are necessary to make this a reality (MacDonald et al., 2015).
Midwives have a responsibility to provide or facilitate access to services as indicated by the individual woman's health, her preferences, and the midwife's scope Of prac- tice (ICM, 2008; Munro, 2014; Ting et al., 2013). Not all services are appropriate for all women. The primary goal of the collaborative relationship is accessing the best care for each woman as needed. The ACNM joint statement with ACOG includes the following assertion, which rein- forces this principle: The American College of Obstetricians and Gynecolo- gists and the American College Of Nurse- Midwives (ACNM) believe health carc is more effective When it occurs in a system that facilitates communica- tion across health carc settings and among providers. [Obstetrician/gynccologistsl and CNMs,'CMs [certified nurse-midwives/certificd midwivesl are equipment, and qualified personnel. Within the ideal sup- portivc healthcare system, midwives will have access to the full range Of services, environments Of care, and pr0- viders including opportunities for collaborative practice focused on meeting women's healthcare needs. No matter where clinicians stand on the continuum of healthcare practices, and regardless of the wide range of environments of carc in which they practice, it remains imperative to understand the broad range Of services available to the women who come to them for care. The women who seek out midwives for care do not live in the healthcare world. Their awareness of available services is influenced by issues of access, the effects of advertis- ing and internet-based information, social and cultural beliefs, the experiences of their friends or relatives, and
[certified nurse-midwives/certified midwives] are ex- pcrts in their respective fields of practice and are edu- catcd, trained, and licensed independent providers who may collaborate with cach other based on the needs of their patient. (ACNM, 201 1) Environments of Care The environments where care is obtained and provided affect each individual's health practices and outcomes. The environment Of care includes the physical location where carc is provided, thc sociocultural milieu, and the prevailing attitudes evident during caring efforts provided by attending clinicians. A woman's autonomy and sense Of control over her circumstances are shaped by her environment. The power dynamics between the woman and the clini- the ever-present popular media. Clinicians who are knowl edgeable of the many options available to women are pre- pared to listen and understand which healthcare choices women are making, thereby increasing their effectiveness in addressing women's needs. The Effects of Health Policy on Midwifery and Women's Health Maternity and women's health policy development and implementation are a function of societal attitudes toward women that arc expressed through the guidelines and recommendations of governmental, nongovernmental, and professional organizations and associations (such as ACNM, ICM, and MANA; Borrell et al., 2014). While high-level policy strategies and recommendations to im-
The power dynamics between the woman and the clini- Cian vary in different environments. In fact, a woman's physiologic response can be affected by changes in the en- vironment Of care; release of powerful stress hormones is mediated by the individual's sense of safety and confidence in her ability to cope with her present circumstances. These physiologic effects can be particularly striking in the environments where labor and birth occur (Buckley, 2015). Midwives practice in many different environments, such as hospitals of various acuity levels, offices, birth centers, clinics, and homes. Across the globe, some mid- wives find themselves practicing in impoverished and low-resource settings. While the practice principles may remain the same regardless of the environment of care, the services and procedures offered Often vary based on sociocultural factors and on access to resources, high-level policy strategies and recommendations to im- prove women's health through ready access to acute and preventive health services are promulgated by organiza- tions such as the Institutes of Medicine (10M) and thc World Health Organimtion (WHO), the interpretation and implementation of those policies occurs at the local level within hospitals and healthcare Systems and by thos who provide care and interact with the individuals receiv• ing care (Berg, Taylor, Woods, & Women's Health Expert panel of the American Academy of Nursing, 2013). Translation Of broad-based women's health policies, such as unintended pregnancy prevention and manageE ment, requires interaction between national policy maker and local stakeholders to develop effective strategies that create positive change. Improvements in gender equality and reduction of health disparities occur with Dolitical
representation of women's and human rights issues that address health and socioeconomic inequities (Borrell et al., 2014). An important global policy initiative to improve maternal health promotes the use Of midwives as primary maternity care providers (Van I-erberghe et al., 2014). Midwives contribute to this effort through involvement in policy-making organizations, representing women's inter- ests and bringing women's voices to the table. Quality Improvement in Health Care Using a quality improvement (QI) process is an effec- tive way to implement desired health policy in practice. Midwives routinely participate in QI activities as part of c•linical practice and midwifery practice management. lm- plcmenting cfTcctivc QI activities provides an opportunity The six goals of the National Quality Strategy can bc ap- plied to support midwifery practice and projects such as the ACNM I-lealthy Birth Initiative, which seeks "to maximize women's opportunity to have a healthy birth using their own natural physiology while avoiding unnecessary proce- dures that may interfere with that process" (ACNM, n.d.). The National Quality Strategy goals include the follow- ing (AHRQ, 201 1): Making care safer by reducing harm caused in the de- livery Of care Ensuring that each person and family are engaged as partners in their care Promoting effective communication and coordination of care
clinical practice and midwifery practice management. lm- plementing effective QI activities provides an opportunity to address specific issues in the practice setting and pro- mote positive change within an accepted framework. The continuous quality improvement (CQI) process strives to build on best practices and emerging evidence to posi- tively affect day-to-day practice and associated healthcare outcomes (Clark, Meyers, Frye, & Pcrlin, 201 1). The practice Of midwifery is a professional endeavor with wide variations in styles of practice. Maternity care in particular is associated with an elevated risk Of litigation Promoting effective communication and coordination of care Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease Working with communities to promote wide use of best practices to enable healthy living Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models due to the potential for lifelong adverse consequences to Improving Midwifery Practice the woman and her baby. Participation in a robust peri- Quality improvement focuses on improving systems of natal QI program can improve maternity and to enhance clinician performance and patient healt practice, positively affect health outcomes for women and outcomes. Examples of QI interventions include impW
prograln unprove practice, positively affect health outcomes for women and their babies, and mitigate the risk of litigation. There is a national move toward continuous system- atic evaluation and improvement of the delivery of health care and associated healthcare outcomes. This move is occurring in conjunction with a parallel process focusing on improving the quality Of the healthcare experience for consumers. The aim of the federal Department of Health and Human Services (DHVIS) National Quality Strategy is to "promote quality health care in which the needs of patients, families and communities guide the actions of all those who deliver and pay for health care" (Agency for Healthcare Research and Quality [AHRQ], 2011 The vi- outcomes. Examples of QI interventions include impW mentation of checklists for Oxytocin use, periodic simu- lated practice of maneuvers to resolve shoulder dystocia, and patient satisfaction surveys. Initiation of new prac- tices is measured and evaluated to determine effective ness and quality outcomes of the intervention. The most successful QI projects promote incremental change that allows for evaluation of the effects of the intervention on outcomes and On associated Systems (the unintended con- sequences effect) so that adjustments can be made based on preliminary results (Health Resources and Services Administration [HRSA], 201 1 In the prcscncc of clear evidence established in the professional literature as im- •sion is of an affordable and accessible healthcare systeml)roving outcomes, full-scale changecan be rapidly imple- that is patient centered, reliable, and safe. Such a system mented using the QI framework to guide problem-solving
Healthcare Research and Quality [AHRQ], 2011). The vi- Sion is of an affordable and accessible healthcare system that is patient centered, reliable, and safe. Such a system provides evidence-supported healthcare interventions by clinicians who acknowledge and are responsive to behav- ioral, social, and environmental determinants of health. evidence established in the professional literature as im- proving outcomes, full-scale change can be rapidly imple- mented using the QI framework to guide problem-solving efforts. When developing a QI project, objective performance measures are developed to measure the effect of the
intervention. Optimal performance measures are clearly writ- ten, reflect current evidence or recommendations for prac- tice, and typically serve to validate either provider and System performance, or patient outcomes and experience. Working within the framework of the facility or practice's QI program sets the stage for effectively creating positive change through group discussion of the proposed clinical change, rmrie,v of the associated topÄpccific literature, and clear definition Of the desired Outcome being sought, Engagement as a team allows for dialogue and debate from all stakeholders (which may include midwives, nurses, 0B/ GYNs, anesthesia personnel, administration, and others depending on the proposed project) on the desired result and an opportunity to reach consensus regarding terms, measures, and implementation strategies. A popular model for 01 is the (or during the course of a project. It allows for correction, amendment to the plan, or, based on findings, abandonment Of the proposed intervention (Figure I-I). Assessment Of current practices is needed to establish starting point or baseline and can demonstrate a need for associated preproject education prior to implementation of the planned change or intervention. One or more desig- nated QI leaders or champions provide direction and sup- port for staff during the implementation phase. Preprojcct staff development on the "nuts and bolts" of the initiative is necessary to ensure that project-specific activities and documentation are performed uniformly. Periodic surveil- lance during the project allows for remedial education, support, or modifications when necessary. Evaluation of results occurs by comparing project outcome statistics to baseline statistics as well as national and local data and
A popular model for QI is the (or Check)-Act (PDSA or PDCA) model. PDSA model uses a circular process for continually evaluating and improving baseline statistics as well as national and local data exploring unanticipated collateral effects that may h', occurred (see Box 1-2). 1) Plan: Opportunity to improve care, systems, or approaches to women's health care is identified, defined, and described. A project is planned, supported by current literature with stakeholder input and identification of interdisciplinary champions. 3) Study: Implementation Of QI project stimulates change in practice and demonstrates related Woman- Centered Change study Desired Chance 2) DO: Identified change and objective criteria for evaluation are developed.
3) Study: Implementation Of QI project stimulates change in practice and demonstrates related outcomes. study Desired Change Evaluation of results Practice change Repeat 4) Act: Alter practice based on QI project results: accept change and integrate into practice, or adapt practice and retest. MidWitery Leadership PDSA cycle
A midwife who practices at two birth facilities notes that there are very different approaches to oxytocin use at each facility. Both facilities limit induction before 39 weeks to medical indications, in accordance with ACOG recom- mendations and established best practice parameters (AGOG, 201 3; Osterman & Martin, 2014). However, after 39 weeks at facility "A" the induction rate is nearly 35%, with corresponding high cesarean and neonatal intensive care unit (NICU) admission rates, whereas at facility 4B" the rate of induction is 15%, and the cesarean rate is less than 20%, with a low rate of transfers to the NICU. One difference the midwife notes is that 2 years ago facility "B" implemented checklists to validate appropriateness of initiation and continuation of oxytocin use. The midwife discusses the issue with the 0B chief of staff and pro- vides a well-organized packet of related literature that includes copies of pre- and continued-use oxytocin check- lists. Together with the facility's QI team leadership, they identify potential mutual benefits to patients, nursing staff, maternity and pediatric practitioners, and administration for implementing oxytocin checklists. On the basis of a brief review of current birth statistics, they outline a QI project proposal to bring to the Perinatal Committee. A readiness assessment demonstrates that 90% of maternity care providers in facility "N' are interested in an effec- tive way to reduce adverse outcomes associated with the high-alert medication oxytocin and they make the pro- posed project a QI priority. The project leadership is formed, with champions in nursing, midwifery, and obstetrics who present a formal review of recent literature, recommendations, and a draft QI project plan for discussion. The group comes to consensus on parameters of the intervention, definitions of project terms, and explores solutions to
The project goal is to reduce the rate of oxytocin induction in women at 39 weeks' gestation or greater, over a 6-month period. The performance measures include uniform application of the oxytocin checklist criteria, and change from baseline rates of oxytocin use and NICU admissions of babies born to women at 39 or more weeks following oxytocin administration. The practice changes selected to drive this project include use Of the checklists, authorization for nursing staff to alter oxytocin dosing based on checklist findings, and expectations for medical and midwifery staff to follow the checklist protocol unless there is a clear indication to deviate from the protocol. Dewiations from the protocol are subject to review and validation by a second maternity care practitioner prior to implementation. A question is added to the Patient Satisfaction survey regarding patient perceptions during oxytocin administration. A model for project debriefing is developed. Debriefing is planned after the first week and then after each month of the project to problem-solve issues that may arise. All nursing and medical/midwifery staff are provided with project education that includes the rationale for the proj- ect, a summary of the literature, and training on use of the tools, associated documentation, and identification of champions for ongoing support during the project. An implementation date is set, and facility "A" begins its QI proj- ect using oxytocin checklists.
SECTION 1: THEORETICAL BASIS FOR MIDWIFERY PRACTICE Women first Midwives and other women's health professionals practice within a healthcare system that is increasingly complex. Midwifery and women's health is first and foremost concerned with caring for, about, and with women in a manner that honors their psychosocial and physical needs. Every individual woman deserves to receive care that is safe and satisfying, that foster self-determination and her ability to care for herself. Such care, to be effective, addresses thi individual woman's personal, cultural, and developmental needs. Women look to their health care provider to give guidance consistent with the individual's real and perceived health neec and internal beliefs. As midwives caring for women in our countr$s diverse communities, the ability to listen and to integrate women's concerns into the care provided is an integral component Of mid- wifery practice. aim is to provide care based on the woman's expressed and identified needs through a personalized plan of care that is mutually developed and supported by both thethe woman and the midwife and that reflects the midwife's awareness and sharing of national, regional, and local expectations and recommendations for care. Chapter I Essential Midwifery Practice Midwifery carc is based on providing care that fosters Copyri practice of midwifery and their associated relationships
women's health and related physiologic processes, including those Of pregnancy, labor, and birth, Modern midwifery and women's health care builds on this physiologic non interventionist foundation to include interventions only as necessary and indicated by the individual woman's condition and preferences. Determining which interventions arc necessary and when they are indicated defines midwives' individual practice and Can also be a function Of the environment of care in which the midwife practices. The midwife—woman relationship can be developed and nurtured in every environment of care. Within a trusting relationship with her midwife, a woman can expand her views of health and childbirth, identify her preferences, and envision what is possible for her. The potential for the woman to derive comfort and feelings Of safety is influenced bv both the quality of the midwife—woman relation- (sec Box I-I) For these ethical principles to have a meaningful effect or practice, they must be a touchstone for the midwife's inter- actions with women, for the manner in which professional responsibilities are upheld, and for the decisions that affect the integrity of the profession (ICM, 2008). Ethical issues arc not always clear-cut. Ethical dilemmas arc inherent in midwifery care, and they can bc embedded in the day-to-day provision of care. Sometimes, it is a matter of choosing be- tween what is right and what is easy, which can pose its Own challenges in a busy midwifery or interprofessional practice. The reflective practitioner examines and learns from an ethical perspective in the clinical setting by following the integrity of the decisions made, the actions taken, and both clinical and professional outcomes. Midwifery is a morally important endeavor that promotes the optimal health or
enced by both the quality of the midwife—woman relation- ship and the environment of care. Ethical Midwifery Practice Ethical midwifery practice is based on a human rights framework, which seeks to improve the standard Of care provided to women, children, and families (International Confederation Of Midwives [ICMI, 2008; Thompson, 2004). "lhs framework includes four foundational ethical principles: l. Autonomy: The human right to personal indepen- dence and the capacity to make decisions and act on them 2. Justice: The human right to be treated fairly and with reasoned care important endeavor that promotes the optimal health of women through engagement with women as partners in their care, development or trusting relationships, and advocating for equitable healthcare practices. Decisions are made within the context of the woman's life and community, as well as the professional community Of care, and can influence not only the woman's health care, but also the perception of the individual midwife and the profession Of midwifery. Exemplary Midwifery Practice Exemplary midwifery practice is woman oriented and focuses on excellence in the processes and provision of women's health care, with a primary goal of improving maternal and child health. Exemplary midwives possess high-caliber clinical skills and judgment required to make
with reasoned care 3. Beneficence: The human right to be treated with intent to do good 4. Nonmalfeasancc: The human right to be treated with intent to avoid harm; the classic "First do no harm" directive attributed to Hippocrates These guiding ethical principles are reflected in mid- wifcry's philosophical tenets and have also been codified specifically for midwives by several midwifery orga- niA1tions, including the American College of Nurse- Midwives (ACNM, 2005), the National Association Of Certified Professional Midwives (NACPM, 2004), the Midwives Alliance of North America (MANA, 2010), and critical decisions while providing care characterized by compassion and caring. These qualities arc highly valued by women receiving midwifery care (Kennedy, 2000). pr0- viding care that supports physiologic birth while maintain- ing vigilance for deviation from the wide range Of normal are also highly valued by midwives and their clients. Optimal care practices that support normal physiologic birth often take time and philosophical commitment to im- plemcnt. The midwife practicing in contemporan maternity care settings may be challenged to provide the type of care recognized as most beneficial to the woman and her family. Regardless of practice setting, it is imperative for midwives to continue to strive toward the goal of providing care in -the TCM (2008)vaSÆ1 means to guide midwives in their—vhich the are paramoun
Exemplary midwifery practice also encompasses actions that promote and support the midwifery profession and the individual midwife, supporting professional growth and personal time (Kennedy, 2000). Midwives not only care for women and families; care is also taken to promote the profession and longevity of service, by creating a prac- ticc environment that supports professional growth and personal balance. Respectful Care Awareness and respect of each individual woman's cir- cumstance, background, and worldview is key in develop- ing a trusting midwife—woman relationship. Some cultural variations that can inform women's experience or mid- wifcry carc include socioeconomic Status, race, ethnicity, refugee status, country of origin, ability level, literacy level, history Of abortion, identification as male or nonbi- nary gender category, or identification as lesbian, bisexual, or polyamorous. Social variations that occur on a regional basis or self-identification with a subculture arc other im- portant factors to consider. The first step in developing a trusting and effective relationship with women from differing backgrounds is for the midwife to identify and examine her or his own personal status relative to the variations encountered (Erikson-Schroth, 2014). Often when a person is part of a
majority, her or his status as privileged can become invis- ible and thus normative for the individual (Fredriksen- Goldsen, Hoy-Ellis, Goldesen, Emlet, & Hooyman, 2014). This Can lead to difficulty recognizing that members Of minority groups may perceive experiences differently than the majority. For example, when a lesbian, gay, or transgender in- dividual mentions her or his partner or significant other in conversation, it may involve tremendous forethought about how she or he will be perceived (Erikson-Schroth, 2014). Likewise, when a woman reveals her literacy status or economic status to her midwife there is likely to have been similar consideration prior to revealing Interdisciplinary Care and Collaboration Every midwife, regardless of practice location or practice style, is better able to serve the women who present for Care by developing a network Of professionals who provide a range of essential and supplemental services (Munro, Kornelsen, & Gruybowski, 2013). Healthcare services are enhanced by effective communication and collabora- tion among team members to ensure the woman receives care that fits her needs. The collaborative practice model provides a framework that includes communication, effec- tive team functioning, leadership, and role clarification; fosters a wide variety of professional relationships ranging from informal to highly structured; and supports collabo- -this information. Notably, forwomen Of color and those¯ration between midwives and nurses, midwivesand physi- with other apparent markers of ethnicity or culture, cians, and midwives and other professionals and service
2014). Likewise, when a woman reveals her literacy status or economic status to her midwife there is likely to have been similar consideration prior to revealing this information. Notably, for women of color and those with other apparent markers of ethnicity or culture, "coming out" about race, ethnicity, or culture is not a choice. Negative healthcare experiences associated with bias can result in fear or avoidance of the healthcare system (ACNM, 2012a; American College of Obstetricians and Gynecologists [ACOGI, 201 1). In order to become cultur- ally competent and to facilitate a sense of cultural safety, the intentional examination of personal biases and as- sumptions is needed (Douglas et al., 2014). Creation Of a culturally sensitive environment, such as providing images tive team functioning, leadership, and role clarification; fosters a wide variety of professional relationships ranging from informal to highly structured; and supports collabo- ration between midwives and nurses, midwives and physi- cians, and midwives and other professionals and service providers. Collaborative practice connects midwives with ad- ditional health professionals who provide ongoing or specialty care outside the midwife's practice parameters. Along the way, these other professionals become aware of the services midwives offer and, in turn, can serve as a source of referrals to the midwifery practice. Effective collaborative practice models in women's health carc can form a continuum that extends from the home setting, through office- and community hospital—based care, to
in waiting and exam rooms that reflect the diversity of human experience, demonstrates openness to each person as a unique individual. Intake forms with open-ended questions allow women to dcscribc their race, ethnicity, gcndcr identities, and primary relationships in their own words (Erikson-Schroth, 2014). Behaviors such as avoiding introductions, asking "yes—no" questions, and being nonresponsive to voiced questions or concerns limits the opportunity to develop a trusting relationship and effective communication (see Appendix C). Open-ended questions, validation of expe- riences, and reflection Of what was heard demonstrates interest in the individual within the Context or her or his life. This can create a safe place, where the woman is able to describe what she or he is seeking when accessing regional, tertiary care and specialty services. A health "continuum of care" is based on healthcare professionals partnering with each woman as an individual healthcare consumer (Ting, Sutherland, & Donnelly, 2013). Decisions arc made based on the individual worn- an's unique situation and needs and, when needed, allow the woman to move through differing levels of service as her situation and health needs evolve. effect of a continuum is a seamless transition from midwives to gen- eralist or specialist physicians and back again. Such care is provided based on clinical indications for care and the woman's preferences and is validated through the health record and relevant quality measures. Such a continuum of care recognizes the value Of each discipline and seeks to engage each healthcare profes-
riences, and reflection Of what was heard demonstrates interest in the individual within the context or her or his life. This can create a safe place, where the woman is able to describe what she or he is seeking when accessing healthcare scrviccs (Douglas ct al., 2014). Women's health clinicians who seek to maintain cultural competency iden- tify and reshape their behavior through measures such as intentional, ongoing self-awareness, and observation for markers of personal bias. woman's preferences and is validated through the health record and relevant quality measures. Such a continuum Of care recognizes the value Of each discipline and seeks to engage each healthcare profes- sional as team participants who function at their highest level of education and training. Communication, shared decision making, partnering with women and across disci- plines, and true collaboration are necessary to make this a reality (MacDonald et al., 2015).
Midwives have a responsibility to provide or facilitate access to services as indicated by the individual woman's health, her preferences, and the midwife's scope Of prac- tice (ICM, 2008; Munro, 2014; Ting et al., 2013). Not all services are appropriate for all women. The primary goal of the collaborative relationship is accessing the best care for each woman as needed. The ACNM joint statement with ACOG includes the following assertion, which rein- forces this principle: The American College of Obstetricians and Gynecolo- gists and the American College Of Nurse- Midwives (ACNM) believe health carc is more effective When it occurs in a system that facilitates communica- tion across health carc settings and among providers. [Obstetrician/gynccologistsl and CNMs,'CMs [certified nurse-midwives/certificd midwivesl are equipment, and qualified personnel. Within the ideal sup- portivc healthcare system, midwives will have access to the full range Of services, environments Of care, and pr0- viders including opportunities for collaborative practice focused on meeting women's healthcare needs. No matter where clinicians stand on the continuum of healthcare practices, and regardless of the wide range of environments of carc in which they practice, it remains imperative to understand the broad range Of services available to the women who come to them for care. The women who seek out midwives for care do not live in the healthcare world. Their awareness of available services is influenced by issues of access, the effects of advertis- ing and internet-based information, social and cultural beliefs, the experiences of their friends or relatives, and
[certified nurse-midwives/certified midwives] are ex- pcrts in their respective fields of practice and are edu- catcd, trained, and licensed independent providers who may collaborate with cach other based on the needs of their patient. (ACNM, 201 1) Environments of Care The environments where care is obtained and provided affect each individual's health practices and outcomes. The environment Of care includes the physical location where carc is provided, thc sociocultural milieu, and the prevailing attitudes evident during caring efforts provided by attending clinicians. A woman's autonomy and sense Of control over her circumstances are shaped by her environment. The power dynamics between the woman and the clini- the ever-present popular media. Clinicians who are knowl edgeable of the many options available to women are pre- pared to listen and understand which healthcare choices women are making, thereby increasing their effectiveness in addressing women's needs. The Effects of Health Policy on Midwifery and Women's Health Maternity and women's health policy development and implementation are a function of societal attitudes toward women that arc expressed through the guidelines and recommendations of governmental, nongovernmental, and professional organizations and associations (such as ACNM, ICM, and MANA; Borrell et al., 2014). While high-level policy strategies and recommendations to im-
The power dynamics between the woman and the clini- Cian vary in different environments. In fact, a woman's physiologic response can be affected by changes in the en- vironment Of care; release of powerful stress hormones is mediated by the individual's sense of safety and confidence in her ability to cope with her present circumstances. These physiologic effects can be particularly striking in the environments where labor and birth occur (Buckley, 2015). Midwives practice in many different environments, such as hospitals of various acuity levels, offices, birth centers, clinics, and homes. Across the globe, some mid- wives find themselves practicing in impoverished and low-resource settings. While the practice principles may remain the same regardless of the environment of care, the services and procedures offered Often vary based on sociocultural factors and on access to resources, high-level policy strategies and recommendations to im- prove women's health through ready access to acute and preventive health services are promulgated by organiza- tions such as the Institutes of Medicine (10M) and thc World Health Organimtion (WHO), the interpretation and implementation of those policies occurs at the local level within hospitals and healthcare Systems and by thos who provide care and interact with the individuals receiv• ing care (Berg, Taylor, Woods, & Women's Health Expert panel of the American Academy of Nursing, 2013). Translation Of broad-based women's health policies, such as unintended pregnancy prevention and manageE ment, requires interaction between national policy maker and local stakeholders to develop effective strategies that create positive change. Improvements in gender equality and reduction of health disparities occur with Dolitical
representation of women's and human rights issues that address health and socioeconomic inequities (Borrell et al., 2014). An important global policy initiative to improve maternal health promotes the use Of midwives as primary maternity care providers (Van I-erberghe et al., 2014). Midwives contribute to this effort through involvement in policy-making organizations, representing women's inter- ests and bringing women's voices to the table. Quality Improvement in Health Care Using a quality improvement (QI) process is an effec- tive way to implement desired health policy in practice. Midwives routinely participate in QI activities as part of c•linical practice and midwifery practice management. lm- plcmenting cfTcctivc QI activities provides an opportunity The six goals of the National Quality Strategy can bc ap- plied to support midwifery practice and projects such as the ACNM I-lealthy Birth Initiative, which seeks "to maximize women's opportunity to have a healthy birth using their own natural physiology while avoiding unnecessary proce- dures that may interfere with that process" (ACNM, n.d.). The National Quality Strategy goals include the follow- ing (AHRQ, 201 1): Making care safer by reducing harm caused in the de- livery Of care Ensuring that each person and family are engaged as partners in their care Promoting effective communication and coordination of care
clinical practice and midwifery practice management. lm- plementing effective QI activities provides an opportunity to address specific issues in the practice setting and pro- mote positive change within an accepted framework. The continuous quality improvement (CQI) process strives to build on best practices and emerging evidence to posi- tively affect day-to-day practice and associated healthcare outcomes (Clark, Meyers, Frye, & Pcrlin, 201 1). The practice Of midwifery is a professional endeavor with wide variations in styles of practice. Maternity care in particular is associated with an elevated risk Of litigation Promoting effective communication and coordination of care Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease Working with communities to promote wide use of best practices to enable healthy living Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models due to the potential for lifelong adverse consequences to Improving Midwifery Practice the woman and her baby. Participation in a robust peri- Quality improvement focuses on improving systems of natal QI program can improve maternity and to enhance clinician performance and patient healt practice, positively affect health outcomes for women and outcomes. Examples of QI interventions include impW
prograln unprove practice, positively affect health outcomes for women and their babies, and mitigate the risk of litigation. There is a national move toward continuous system- atic evaluation and improvement of the delivery of health care and associated healthcare outcomes. This move is occurring in conjunction with a parallel process focusing on improving the quality Of the healthcare experience for consumers. The aim of the federal Department of Health and Human Services (DHVIS) National Quality Strategy is to "promote quality health care in which the needs of patients, families and communities guide the actions of all those who deliver and pay for health care" (Agency for Healthcare Research and Quality [AHRQ], 2011 The vi- outcomes. Examples of QI interventions include impW mentation of checklists for Oxytocin use, periodic simu- lated practice of maneuvers to resolve shoulder dystocia, and patient satisfaction surveys. Initiation of new prac- tices is measured and evaluated to determine effective ness and quality outcomes of the intervention. The most successful QI projects promote incremental change that allows for evaluation of the effects of the intervention on outcomes and On associated Systems (the unintended con- sequences effect) so that adjustments can be made based on preliminary results (Health Resources and Services Administration [HRSA], 201 1 In the prcscncc of clear evidence established in the professional literature as im- •sion is of an affordable and accessible healthcare systeml)roving outcomes, full-scale changecan be rapidly imple- that is patient centered, reliable, and safe. Such a system mented using the QI framework to guide problem-solving
Healthcare Research and Quality [AHRQ], 2011). The vi- Sion is of an affordable and accessible healthcare system that is patient centered, reliable, and safe. Such a system provides evidence-supported healthcare interventions by clinicians who acknowledge and are responsive to behav- ioral, social, and environmental determinants of health. evidence established in the professional literature as im- proving outcomes, full-scale change can be rapidly imple- mented using the QI framework to guide problem-solving efforts. When developing a QI project, objective performance measures are developed to measure the effect of the
intervention. Optimal performance measures are clearly writ- ten, reflect current evidence or recommendations for prac- tice, and typically serve to validate either provider and System performance, or patient outcomes and experience. Working within the framework of the facility or practice's QI program sets the stage for effectively creating positive change through group discussion of the proposed clinical change, rmrie,v of the associated topÄpccific literature, and clear definition Of the desired Outcome being sought, Engagement as a team allows for dialogue and debate from all stakeholders (which may include midwives, nurses, 0B/ GYNs, anesthesia personnel, administration, and others depending on the proposed project) on the desired result and an opportunity to reach consensus regarding terms, measures, and implementation strategies. A popular model for 01 is the (or during the course of a project. It allows for correction, amendment to the plan, or, based on findings, abandonment Of the proposed intervention (Figure I-I). Assessment Of current practices is needed to establish starting point or baseline and can demonstrate a need for associated preproject education prior to implementation of the planned change or intervention. One or more desig- nated QI leaders or champions provide direction and sup- port for staff during the implementation phase. Preprojcct staff development on the "nuts and bolts" of the initiative is necessary to ensure that project-specific activities and documentation are performed uniformly. Periodic surveil- lance during the project allows for remedial education, support, or modifications when necessary. Evaluation of results occurs by comparing project outcome statistics to baseline statistics as well as national and local data and
A popular model for QI is the (or Check)-Act (PDSA or PDCA) model. PDSA model uses a circular process for continually evaluating and improving baseline statistics as well as national and local data exploring unanticipated collateral effects that may h', occurred (see Box 1-2). 1) Plan: Opportunity to improve care, systems, or approaches to women's health care is identified, defined, and described. A project is planned, supported by current literature with stakeholder input and identification of interdisciplinary champions. 3) Study: Implementation Of QI project stimulates change in practice and demonstrates related Woman- Centered Change study Desired Chance 2) DO: Identified change and objective criteria for evaluation are developed.
3) Study: Implementation Of QI project stimulates change in practice and demonstrates related outcomes. study Desired Change Evaluation of results Practice change Repeat 4) Act: Alter practice based on QI project results: accept change and integrate into practice, or adapt practice and retest. MidWitery Leadership PDSA cycle
A midwife who practices at two birth facilities notes that there are very different approaches to oxytocin use at each facility. Both facilities limit induction before 39 weeks to medical indications, in accordance with ACOG recom- mendations and established best practice parameters (AGOG, 201 3; Osterman & Martin, 2014). However, after 39 weeks at facility "A" the induction rate is nearly 35%, with corresponding high cesarean and neonatal intensive care unit (NICU) admission rates, whereas at facility 4B" the rate of induction is 15%, and the cesarean rate is less than 20%, with a low rate of transfers to the NICU. One difference the midwife notes is that 2 years ago facility "B" implemented checklists to validate appropriateness of initiation and continuation of oxytocin use. The midwife discusses the issue with the 0B chief of staff and pro- vides a well-organized packet of related literature that includes copies of pre- and continued-use oxytocin check- lists. Together with the facility's QI team leadership, they identify potential mutual benefits to patients, nursing staff, maternity and pediatric practitioners, and administration for implementing oxytocin checklists. On the basis of a brief review of current birth statistics, they outline a QI project proposal to bring to the Perinatal Committee. A readiness assessment demonstrates that 90% of maternity care providers in facility "N' are interested in an effec- tive way to reduce adverse outcomes associated with the high-alert medication oxytocin and they make the pro- posed project a QI priority. The project leadership is formed, with champions in nursing, midwifery, and obstetrics who present a formal review of recent literature, recommendations, and a draft QI project plan for discussion. The group comes to consensus on parameters of the intervention, definitions of project terms, and explores solutions to
The project goal is to reduce the rate of oxytocin induction in women at 39 weeks' gestation or greater, over a 6-month period. The performance measures include uniform application of the oxytocin checklist criteria, and change from baseline rates of oxytocin use and NICU admissions of babies born to women at 39 or more weeks following oxytocin administration. The practice changes selected to drive this project include use Of the checklists, authorization for nursing staff to alter oxytocin dosing based on checklist findings, and expectations for medical and midwifery staff to follow the checklist protocol unless there is a clear indication to deviate from the protocol. Dewiations from the protocol are subject to review and validation by a second maternity care practitioner prior to implementation. A question is added to the Patient Satisfaction survey regarding patient perceptions during oxytocin administration. A model for project debriefing is developed. Debriefing is planned after the first week and then after each month of the project to problem-solve issues that may arise. All nursing and medical/midwifery staff are provided with project education that includes the rationale for the proj- ect, a summary of the literature, and training on use of the tools, associated documentation, and identification of champions for ongoing support during the project. An implementation date is set, and facility "A" begins its QI proj- ect using oxytocin checklists.
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