Midwives Model of Care
December 12, 2013
The text below is from one of my very first courses at Midwives College of Utah. The assignment was to:
Discuss the principles of the Midwives Model of Care and how midwifery care can be utilized to improve outcomes for mothers and infants and increase maternal satisfaction of the birth experience.
Discuss the principles of the Midwives Model of Care and how midwifery care can be utilized to improve outcomes for mothers and infants and increase maternal satisfaction of the birth experience.
The Midwives Model of Care is a maternity care pattern that emphasizes the diverse nature of women and their individual childbirth needs. According to the Midwives Alliance of North America the tenets of this model are: monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle; providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support; minimizing technological interventions; and identifying and referring women who require obstetrical attention (“Midwifery Model,” para. 2). These principles guide adherents to the Midwives Model of Care to provide comprehensive prenatal, childbirth and postpartum education and care. The viewpoint that pregnancy and childbirth are normal life events translates into a different set of skills, tools, language, interventions and relationships between women and their birth attendants. Studies prove that midwives offer better outcomes and increased satisfaction.
The first tenet can be summarized as monitoring the wellbeing of the mother. When midwives care for women they do so in a manner that serves to acknowledge the distinct needs of an individual. Conditions such as fertility, pregnancy and childbearing do not occur in laboratories or in paper case studies. The women are as individually unique as is each birth experience for the mother. No matter how many children she conceives, carries or gives birth to each pregnancy is treated as distinct. Every pregnancy forms a never-to-be-repeated accumulation of circumstances, wellbeing (or frailness), surroundings, and bearing upon her socio-economic status. Midwives offer options to maintain physical, psychological and social health taking in to account all aspects of her life. For example when educating women about prenatal nutrition midwives are more adept at dealing with ethnic dietary preferences. This individualized care for various populations works with a sometimes less than perfect, emotionally charged subject offering workable solutions rather than strict regimens (Davis, 1997).
The extended visits of midwives often lend an opportunity to meet with women in their own environment. This serves to evaluate the support of her family, accessing her mental health, appraising her connections within the community and sharing resources if any of theses factors are unsatisfactory. With a shared decision paradigm midwives form strong relationships where women are free to share any history of trauma that may affect the outcome of the pregnancy or delivery. The authors of the book A Guide to Effective Care in Pregnancy and Childbirth explained how midwives are likely to have a more detailed knowledge of the particular circumstances of individual women. “The care they can give the majority of women… will often be more responsive to their needs” (Elkin et al., 2000).
The second precept of providing the mother with individualized care provides opportunities to re-emphasize that birth is meant to happen simply and without distress or danger. When women are provided individualized care the normalcy of birth is reinforced, holistic care is valued and women are provided continuous support. This precept of individualized care supports the recommended emphasis by Amy Romano and Judith Lothian from their 2008 journal article. They concluded that the research shows implications for prenatal education. “Women need to know about normal physiological birth,” they said.
Continuous support improves outcomes and increases education. To assess the effects of continuous, one-to-one labor support a 2013 Cochrane Library review (Hodnett, Gates, Hofmeyr, & Sakala, 2013) collected data from all published and unpublished randomized controlled trials. The review found that the women who received continuous support were more likely to have a spontaneous vaginal birth, less likely to need analgesia and were more likely to be satisfied. Also their labors were shorter, they were less likely to have a cesarean or instrumental vaginal birth and their babies were less likely to have low five-minute Apgar scores (the Apgar is a test that evaluates a newborn’s physical condition at one and five minutes after birth). Additionally another review by Sandall, Soltani, Gates and Devane (2013) found that women who were randomized to receive midwife-led care compared to women randomized to receive other models of care were, on average, less likely to experience fetal loss before 24 weeks’ gestation and preterm birth before 37 weeks. Hodnett et al. concluded, "Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth" (Hodnett et al., p. 2). In addition to continuity of care during labor most midwives personally provide one-on-one care to their clients every visit. Prenatal assessment has been called the cornerstone of midwifery care (Davis, p. 9). The research shows that continuity of care improves outcomes (Hodnett et al., 2013) but it also increases opportunities for individualized education. In two studies in the U.K. and Australia women who received care from the same caregiver over the course of their pregnancy were more likely to attend childbirth classes, were more able to discuss their worries during pregnancy and felt well-prepared for labor (Elkin et al., 2000).
The underpinning philosophy of the Midwives Model of Care is the natural ability of women to experience birth without routine interventions. Since 1996, the World Health Organization (WHO) has called for the elimination of unnecessary interventions in childbirth (1996). Allowing labor to begin on its own, is the first of the six care practices that the WHO and Lamaze International recommend to promote, protect and support normal physiological birth. "Spontaneous onset of term labor signifies the fetus’ readiness to be born as well as the mother’s physiological receptiveness to the process" (Romano & Lothian, p. 94). The other five care practices recommended by the WHO and Lamaze International are freedom of movement during labor, continuous labor support, spontaneous pushing in nonsupine positions, no routine intervention and no separation of mother and baby. When labor and delivery are powered by the innate human capacity of the woman and fetus it is more likely to be safe and healthy (Romano & Lothian, 2008). When midwives attend to childbearing women their training, skills, tools and relationship paradigms support the process of physiological birth while protecting mothers and babies in a more natural way.
The Johnson and Daviss study (2005) points to another important value held by adherents to the midwives model of care; it may become necessary to transfer care or consult with specialized medical professionals for medical and obstetric complications. It is quite eye-opening to note that of the 5,418 women in the study, 655 (12.1%) were transferred to a hospital. Five out of every six women transferred were transferred before delivery, half for failure to progress, pain relief, or exhaustion. After delivery, only 1.3% of mothers and 0.7% of newborns were transferred to a hospital. The midwife considered the transfer urgent in only 3.4% of intended home-births. These statistics demonstrate the effectiveness of the midwives model of care in detecting the need for specialized care and protecting the health of mothers and babies.
It is not the purpose of this paper to compare the obstetric-led model with the midwifery-led model of care for pregnancy but there are some things that are different when women are cared for by a midwife. At the very core of these differences are paradigms which heavily influence childbirth: Obstetricians (OB/GYN) are mostly trained in a technocratic thought processes whereas most midwives are either humanistic or holistic practitioners. Robbie Davis-Floyd, a Medical/Cultural Anthropologist described these paradigms in a 2001 contribution to the International Journal of Gynecology and Obstetrics. The technocratic paradigm stresses separation, the humanistic model focuses on balance and connection and holistic practitioners embrace connection and integration. These are not steadfast rules, you will find midwives who are more technologically dependent and doctors who incorporate principles of holism. These principles guide the education, protocols, all decisions, and the importance assigned to evaluating and treating variations of normal conditions. Humanistic and holistic models will for example value more highly connection and caring between practitioner and patient, information, decision-making, and responsibility shared between patient and practitioner, and authority and responsibility inherent in each individual (David-Floyd, 2001).
To summarize, the midwives model of care improves outcomes, increases satisfaction and decreases risks. Women feel more prepared for labor, feel more in control, experience less interventions and are generally better educated about their pregnancy and childbirth when these principles are the integral ideals of their care.
The first tenet can be summarized as monitoring the wellbeing of the mother. When midwives care for women they do so in a manner that serves to acknowledge the distinct needs of an individual. Conditions such as fertility, pregnancy and childbearing do not occur in laboratories or in paper case studies. The women are as individually unique as is each birth experience for the mother. No matter how many children she conceives, carries or gives birth to each pregnancy is treated as distinct. Every pregnancy forms a never-to-be-repeated accumulation of circumstances, wellbeing (or frailness), surroundings, and bearing upon her socio-economic status. Midwives offer options to maintain physical, psychological and social health taking in to account all aspects of her life. For example when educating women about prenatal nutrition midwives are more adept at dealing with ethnic dietary preferences. This individualized care for various populations works with a sometimes less than perfect, emotionally charged subject offering workable solutions rather than strict regimens (Davis, 1997).
The extended visits of midwives often lend an opportunity to meet with women in their own environment. This serves to evaluate the support of her family, accessing her mental health, appraising her connections within the community and sharing resources if any of theses factors are unsatisfactory. With a shared decision paradigm midwives form strong relationships where women are free to share any history of trauma that may affect the outcome of the pregnancy or delivery. The authors of the book A Guide to Effective Care in Pregnancy and Childbirth explained how midwives are likely to have a more detailed knowledge of the particular circumstances of individual women. “The care they can give the majority of women… will often be more responsive to their needs” (Elkin et al., 2000).
The second precept of providing the mother with individualized care provides opportunities to re-emphasize that birth is meant to happen simply and without distress or danger. When women are provided individualized care the normalcy of birth is reinforced, holistic care is valued and women are provided continuous support. This precept of individualized care supports the recommended emphasis by Amy Romano and Judith Lothian from their 2008 journal article. They concluded that the research shows implications for prenatal education. “Women need to know about normal physiological birth,” they said.
Continuous support improves outcomes and increases education. To assess the effects of continuous, one-to-one labor support a 2013 Cochrane Library review (Hodnett, Gates, Hofmeyr, & Sakala, 2013) collected data from all published and unpublished randomized controlled trials. The review found that the women who received continuous support were more likely to have a spontaneous vaginal birth, less likely to need analgesia and were more likely to be satisfied. Also their labors were shorter, they were less likely to have a cesarean or instrumental vaginal birth and their babies were less likely to have low five-minute Apgar scores (the Apgar is a test that evaluates a newborn’s physical condition at one and five minutes after birth). Additionally another review by Sandall, Soltani, Gates and Devane (2013) found that women who were randomized to receive midwife-led care compared to women randomized to receive other models of care were, on average, less likely to experience fetal loss before 24 weeks’ gestation and preterm birth before 37 weeks. Hodnett et al. concluded, "Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth" (Hodnett et al., p. 2). In addition to continuity of care during labor most midwives personally provide one-on-one care to their clients every visit. Prenatal assessment has been called the cornerstone of midwifery care (Davis, p. 9). The research shows that continuity of care improves outcomes (Hodnett et al., 2013) but it also increases opportunities for individualized education. In two studies in the U.K. and Australia women who received care from the same caregiver over the course of their pregnancy were more likely to attend childbirth classes, were more able to discuss their worries during pregnancy and felt well-prepared for labor (Elkin et al., 2000).
The underpinning philosophy of the Midwives Model of Care is the natural ability of women to experience birth without routine interventions. Since 1996, the World Health Organization (WHO) has called for the elimination of unnecessary interventions in childbirth (1996). Allowing labor to begin on its own, is the first of the six care practices that the WHO and Lamaze International recommend to promote, protect and support normal physiological birth. "Spontaneous onset of term labor signifies the fetus’ readiness to be born as well as the mother’s physiological receptiveness to the process" (Romano & Lothian, p. 94). The other five care practices recommended by the WHO and Lamaze International are freedom of movement during labor, continuous labor support, spontaneous pushing in nonsupine positions, no routine intervention and no separation of mother and baby. When labor and delivery are powered by the innate human capacity of the woman and fetus it is more likely to be safe and healthy (Romano & Lothian, 2008). When midwives attend to childbearing women their training, skills, tools and relationship paradigms support the process of physiological birth while protecting mothers and babies in a more natural way.
The Johnson and Daviss study (2005) points to another important value held by adherents to the midwives model of care; it may become necessary to transfer care or consult with specialized medical professionals for medical and obstetric complications. It is quite eye-opening to note that of the 5,418 women in the study, 655 (12.1%) were transferred to a hospital. Five out of every six women transferred were transferred before delivery, half for failure to progress, pain relief, or exhaustion. After delivery, only 1.3% of mothers and 0.7% of newborns were transferred to a hospital. The midwife considered the transfer urgent in only 3.4% of intended home-births. These statistics demonstrate the effectiveness of the midwives model of care in detecting the need for specialized care and protecting the health of mothers and babies.
It is not the purpose of this paper to compare the obstetric-led model with the midwifery-led model of care for pregnancy but there are some things that are different when women are cared for by a midwife. At the very core of these differences are paradigms which heavily influence childbirth: Obstetricians (OB/GYN) are mostly trained in a technocratic thought processes whereas most midwives are either humanistic or holistic practitioners. Robbie Davis-Floyd, a Medical/Cultural Anthropologist described these paradigms in a 2001 contribution to the International Journal of Gynecology and Obstetrics. The technocratic paradigm stresses separation, the humanistic model focuses on balance and connection and holistic practitioners embrace connection and integration. These are not steadfast rules, you will find midwives who are more technologically dependent and doctors who incorporate principles of holism. These principles guide the education, protocols, all decisions, and the importance assigned to evaluating and treating variations of normal conditions. Humanistic and holistic models will for example value more highly connection and caring between practitioner and patient, information, decision-making, and responsibility shared between patient and practitioner, and authority and responsibility inherent in each individual (David-Floyd, 2001).
To summarize, the midwives model of care improves outcomes, increases satisfaction and decreases risks. Women feel more prepared for labor, feel more in control, experience less interventions and are generally better educated about their pregnancy and childbirth when these principles are the integral ideals of their care.
References
Midwives Alliance of North America (n.d.). Midwifery Model. Retrieved from http://www.mana.org/about-midwives/midwifery-model
Davis, E. (1997). Heart and Hands. Berkley, CA: Celestial Arts.
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub5.
Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub3.
Enkin, M., Keirse, M. J. N. C., Neilson, J., Crowther, C., Duley, L., Hodnett, E., & Hofmeyr, J. (2000) A guide to effective care in pregnancy and childbirth. New York, NY. Oxford University Press.
Romano, A. M. and Lothian, J. A. (2008), Promoting, Protecting, and Supporting Normal Birth: A Look at the Evidence. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37: 94–105. doi: 10.1111/j.1552-6909.2007.00210.x
World Health Organization. Care in Normal Birth: A Practical Guide. (WHO reference number: WHO/FRH/MSM/96.24) World Health Organization; 1996. Retreived from http://whqlibdoc.who.int/hq/1996/WHO_FRH_MSM_96.24.pdf
Davis-Floyd, R. (2001). The technocratic, humanistic, and holistic paradigms of childbirth. International Journal of Gynecology and Obstetrics, 75, S5-S23.
Johnson, K. & Daviss, B. (2005) Outcomes of planned home births with certified professional midwives: Large prospective study in North America. British Medical Journal 330 doi: http://dx.doi.org/10.1136/bmj.330.7505.1416
Midwives Alliance of North America (n.d.). Midwifery Model. Retrieved from http://www.mana.org/about-midwives/midwifery-model
Davis, E. (1997). Heart and Hands. Berkley, CA: Celestial Arts.
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub5.
Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub3.
Enkin, M., Keirse, M. J. N. C., Neilson, J., Crowther, C., Duley, L., Hodnett, E., & Hofmeyr, J. (2000) A guide to effective care in pregnancy and childbirth. New York, NY. Oxford University Press.
Romano, A. M. and Lothian, J. A. (2008), Promoting, Protecting, and Supporting Normal Birth: A Look at the Evidence. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37: 94–105. doi: 10.1111/j.1552-6909.2007.00210.x
World Health Organization. Care in Normal Birth: A Practical Guide. (WHO reference number: WHO/FRH/MSM/96.24) World Health Organization; 1996. Retreived from http://whqlibdoc.who.int/hq/1996/WHO_FRH_MSM_96.24.pdf
Davis-Floyd, R. (2001). The technocratic, humanistic, and holistic paradigms of childbirth. International Journal of Gynecology and Obstetrics, 75, S5-S23.
Johnson, K. & Daviss, B. (2005) Outcomes of planned home births with certified professional midwives: Large prospective study in North America. British Medical Journal 330 doi: http://dx.doi.org/10.1136/bmj.330.7505.1416
Reflection
Wow! Reading this and reflecting on in nearly three years after writing this paper has given me a great sense of accomplishment. I could have never predicted the number of words I would write on a pages or papers, practice guidelines, and client handouts that I have created since beginning my didactic education for my midwifery degree. I still feel so much passion for the midwifery model of care. After all I have done to date I don't think I would have said the same if I had followed the technocratic or humanistic models that Robbie Davis-Floyd wrote about in her 2001 writings for the International Journal of Gynecology and Obstetrics. I am incredibly grateful for the synergy of the pieces of my education. Books, mentors and life experiences have forged a strong bond in the fabric of my tapestry of learning. For that I cannot find the words to describe or express thanks. The assignment above has a very special place in my heart. I am grateful for the foundation this early research had in my education.
Copyright © 2016 Kathryn S. Ramirez, all rights reserved. Any redistribution or reproduction of part or all of the contents in any form is prohibited.
The contents of this website are for informational purposes only and do not render medical or psychological advice, opinion, diagnosis, or treatment. The information provided through this website should not be used for diagnosing or treating a health problem or disease. It is not a substitute for professional care. If you have or suspect you may have a medical or psychological problem, you should consult your appropriate health care provider. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. Links on this website are provided only as an informational resource, and it should not be implied that we recommend, endorse or approve of any of the content at the linked sites, nor are we responsible for their availability, accuracy or content.