Journal of Midwifery and Women?s Health

Published by Wiley
Online ISSN: 1542-2011
Print ISSN: 1526-9523
Publications
The objective of this study was to compare a Tibetan traditional medicine (the uterotonic Zhi Byed 11 [ZB11]) to oral misoprostol for prophylaxis of postpartum hemorrhage (PPH). We conducted a double-blind randomized controlled trial at three hospitals in Lhasa, Tibet, People's Republic of China. Women (N = 967) were randomized to either ZB11 or misoprostol groups. Postpartum blood loss was measured in a calibrated blood collection drape. The primary combined outcome was incidence of PPH, defined as measured blood loss (MBL) > or = 500 mL, administration of open label uterotonics, or maternal death. We found that the rate of the combined outcome was lower among the misoprostol group (16.1% versus 21.8% for ZB11; P = .02). Frequency of PPH was lower with misoprostol (12.4% versus 17.4%; P = .02). There were no significant differences in MBL > 1000 mL or mean or median MBL. Fever was significantly more common in the misoprostol group (P = .03). The rate of combined outcome was significantly lower among women receiving misoprostol. However, other indices of obstetric hemorrhage were not significantly different.
 
Birth Outcomes for 16,984 Neonates with Planned Home Births in the MANA Stats 2.0 Sample
Between 2004 and 2010, the number of home births in the United States rose by 41%, increasing the need for accurate assessment of the safety of planned home birth. This study examines outcomes of planned home births in the United States between 2004 and 2009. We calculated descriptive statistics for maternal demographics, antenatal risk profiles, procedures, and outcomes of planned home births in the Midwives Alliance of North American Statistics Project (MANA Stats) 2.0 data registry. Data were analyzed according to intended and actual place of birth. Among 16,924 women who planned home births at the onset of labor, 89.1% gave birth at home. The majority of intrapartum transfers were for failure to progress, and only 4.5% of the total sample required oxytocin augmentation and/or epidural analgesia. The rates of spontaneous vaginal birth, assisted vaginal birth, and cesarean were 93.6%, 1.2%, and 5.2%, respectively. Of the 1054 women who attempted a vaginal birth after cesarean, 87% were successful. Low Apgar scores (< 7) occurred in 1.5% of newborns. Postpartum maternal (1.5%) and neonatal (0.9%) transfers were infrequent. The majority (86%) of newborns were exclusively breastfeeding at 6 weeks of age. Excluding lethal anomalies, the intrapartum, early neonatal, and late neonatal mortality rates were 1.30, 0.41, and 0.35 per 1000, respectively. For this large cohort of women who planned midwife-led home births in the United States, outcomes are congruent with the best available data from population-based, observational studies that evaluated outcomes by intended place of birth and perinatal risk factors. Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.
 
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.
 
This article examines how the Frontier Nursing Service (FNS) utilized nurse-midwives to respond to antepartum emergencies such as preterm birth, eclampsia, malpresentation, and hemorrhage in the women of Appalachia in the years 1925 to 1939. Particular attention is given to the preparation that nurse-midwives received during their midwifery education to prevent and respond to emergencies. Using traditional historical research methods and primary source material from the FNS papers in the Special Collections, University of Kentucky Libraries, Lexington, Kentucky, this article describes the nurse-midwives' experiences and how they implemented skills they had learned during their training in Great Britain. Working in the isolated mountainous area of Leslie County, Kentucky-for the most part without direct assistance from physicians-FNS nurse-midwives decreased maternal and neonatal mortality rates. During their first 2000 births, they had only 2 maternal deaths, whereas the national average maternal mortality rate was approximately 7 deaths per 1000 births. The nurse-midwives performed external cephalic versions on a routine basis. For pregnancy and birth emergencies, they administered sedation, gave general anesthesia, and performed invasive lifesaving techniques in order to protect the lives of the women in their care. During these 14 years, their cross-cultural engagement, assessment skills, clinical judgment, and timely interventions improved maternal and child health throughout the region. © 2015 by the American College of Nurse-Midwives.
 
The birth rate for United States teenagers has steadily declined over the past 60 years except for a brief spike in the late 1980s through 1991. The birth rate for 2000 was 11% lower than the rate in 1940. Although this represents 546000 less births compared to the expected number if the birth rate remained at the higher 1991 levels the United States teen birth rate is much higher than the rates for other developed countries. (excerpt)
 
This article reviews the origins of nurse-midwifery in the United States during the early decades of the 20th century and explores professional expansion between 1940 and 1950. Nurse-midwifery emerged from the vision of public health nurses, obstetricians, and social reformers concerned about high maternal and infant mortality rates at the turn of the century. Desirous of promoting child health, they provided prenatal care for pregnant women and assisted physicians, while also supporting women during labor and birth at home. Seeking to expand their specialty by introducing nurse-midwifery, they joined the campaign to eliminate traditional immigrant and African American midwives. By the early 1930s, there were only two sites for the practice of nurse-midwifery in the United States: Frontier Nursing Service and Maternity Center Association. Over the next 20 years, nurse-midwifery expanded in response to physician shortages, the emergence of a childbirth education movement, and women's demands for participation in birth. In the 1940s, the greatest expansion occurred in the South and Southwest in home birth, birthing centers, and an occasional community hospital.
 
From its very inception, the Journal of Midwifery & Women's Health (JMWH) played a critical role in fostering and documenting major shifts in the professional landscape of midwifery through its editorial content. This article traces the history and evolution of JMWH, commemorates its rich heritage and monumental growth over the last half century, highlights issues that have transcended its 50-year history, and acknowledges the contributions of its leadership ...past and present.
 
Introduction: In this study, we examined the perinatal outcomes of planned home births over a 25-year period (1983-2008) in a group of primarily Amish women (98%) attended by certified nurse-midwives (CNMs) in southeastern Pennsylvania. Methods: This was a retrospective, descriptive analysis of data (N = 1836 births) from several CNM practices. Data were abstracted for 25 items, including demographics, labor, and birth. Initially, 2 investigators abstracted 15 records to compare assessments and standardize definitions. Charts were then divided and abstracted individually by one investigator. Several relationships were examined in 2 by 2 tables using the chi-square procedure for the difference in proportions. Maternal and newborn transfers to the hospital were included in the analysis. Results: Of the women who planned home birth for 1836 pregnancies, 1733 of the births occurred at home. Although more than one-third of the women were of high parity (gravida 5-13), rates of postpartum hemorrhage were low (n = 96, 5.5%). There were no maternal deaths. Nearly half of the maternal transfers to the hospital (n = 103, 5.6%) were for ruptured membranes without labor (n = 25, 1.4%) and/or failure to progress (n = 23, 1.3%). The neonatal hospital admission rate also was low (n = 13, 0.75%). Of the 7 (0.4%) early neonatal deaths, all were attributed to lethal congenital anomalies that are common to this population. Discussion: This study is the first to describe the outcomes of planned home births in a primarily Amish population cared for by CNMs. It also adds to the literature on planned home births in the United States and supports the findings from previous studies that women who have home births attended by CNMs have safety profiles equal to or better than profiles of women who had hospital births in similar populations.
 
Maternal mortality is underreported in the United States in part because traumatic deaths are not included in nationally reported maternal mortality ratios. The overall study goal was to compare women whose deaths had been reported to and investigated by a medical examiner and who had evidence of pregnancy to women without evidence of pregnancy in terms of socio-demographic information, toxicology results, and manner and cause of death. A secondary goal was to compare the pregnancy status and gestational age of women with evidence of pregnancy at the time of death in relation to the manner of death, with particular focus on women who died as a result of violent death. Autopsy charts from 1988-1996 for 651 women aged 15 to 50 from the District of Columbia Office of the Chief Medical Examiner whose autopsies included examination of the uterus were reviewed. Medical examiners' classification of manner and specific causes of death were used as the main outcome measures. Overall, the sample reflected demographic characteristics of women of childbearing age in the District of Columbia, with 82% black, 74.6% unmarried, and 46.5% aged 20 to 34. Among the 651 autopsy charts evaluated, 30 (4.6%) documented evidence of pregnancy; 43.3% of the women who died due to homicide with evidence of pregnancy were not included in the 21 pregnancy-related deaths officially reported by the District of Columbia State Center for Health Statistics during the study period, and therefore, were also not included in national maternal mortality ratios. Although not statistically significant, 11% more homicides occurred among women with evidence of pregnancy as compared to non-pregnant women. Pregnant women who died a violent death were significantly more likely than non-pregnant women to have died due to gunshot trauma. A significant proportion of pregnant women were < 21 weeks gestation at the time of their death. Additionally, women in this sample with evidence of pregnancy were over 3 times more likely to have been teenagers compared to non-pregnant women. Medical examiner autopsy records identify violent pregnancy-associated deaths, many of which occur early in pregnancy and are missed by other enhanced case-finding techniques that require a record of a birth or fetal death. These deaths are usually excluded from reported maternal mortality ratios. Few studies have evaluated the prevalence of homicide in women of childbearing age, yet understanding the extent of less commonly associated causes of death during pregnancy such as homicide, may lead to improved identification of preventable problems that contribute to maternal morbidity and mortality. This study, which sheds new light on the identifying and reporting of maternal mortality, and specifically on homicide as a form of violence toward pregnant women, should be of particular interest for all women's health providers, as well as public health professionals, researchers, and advocates who are interested in the design, development, and evaluation of prevention programs, especially those directed toward preventable problems such as domestic violence.
 
Data on attendance at birth by midwives in the United States have been available on the national level since 1989. Rates of certified nurse-midwife (CNM)-attended births more than doubled between 1989 (3.3% of all births) and 2002 (7.7%) and have remained steady since. This article examines trends in midwife-attended births from 1989 to 2009. The data in this report are based on records gathered as part of the US National Standard Certificate of Live Birth from a public use Web site, Vital Stats (http://www.cdc.gov/nchs/VitalStats.htm), that allows users to create and download specialized tables. Between 2007 and 2009, the proportion of all births attended by CNMs increased by 4% from 7.3% of all births to 7.6% and a total of 313,516. This represents a decline in total births attended by CNMs from 2008 but a higher proportion of all births because total US births dropped at a faster rate. The proportion of vaginal births attended by CNMs reached an all-time high of 11.4% in 2009. There were strong regional patterns to the distribution of CNM-attended births. Births attended by "other midwives" rose to 21,787 or 0.5% of all US births, and the total proportion of all births attended by midwives reached an all-time high of 8.1%. The race/ethnicity of mothers attended by CNMs has shifted over the years. In 1990, CNMs attended a disproportionately high number of births to non-white mothers, whereas in 2009, the profile of CNM births mirrors the national distribution in race/ethnicity. Midwife-attended births in the United States are increasing. The geographic patterns in the distribution of midwife-attended births warrant further study.
 
Introduction: Rates of births attended by certified nurse-midwives (CNMs) rose throughout the 1990s and into the early part of this century, when rates leveled at about 7%. Methods: The data in this report are based on records gathered as part of the US National Standard Certificate of Live Birth from the public use Web site, VitalStats, that allows users to create and download specialized tables. Results: For the first time since such data were available in 1989, births attended by CNMs declined from the previous year in absolute terms, as a proportion of all births, and as a proportion of vaginal births. After an all-time high of 317,168 in 2006, CNM-attended births declined marginally to 316,811 in 2007. With total births reaching a US record of 4,316,233 births, the CNM proportion of total births declined for the fifth straight year to 7.3%, the same proportion as in 1999. Births attended by “other midwives” rose substantially to 23,943 although some of that increase may be the result of misclassification of CNM births in some states into the other midwife category. Discussion: The proportion of CNM births has remained steady at between 7.3% and 7.6% since 1999. However, when the number of births attended by CNMs is combined with the number attended by other midwives, their number reached an all-time high in 2007.
 
Data on attendance at birth by midwives in the United States have been available on the national level since 1989, allowing for the documentation of long-term trends. New items on payer source and prepregnancy body mass index (BMI) from a 2003 revision of the birth certificate provide an opportunity to examine additional aspects of US midwifery practice. The data in this report are based on records on birth attendant gathered as part of the US National Standard Certificate of Live Birth from a public use Web site, Vital Stats (http://www.cdc.gov/nchs/VitalStats.htm), which allows users to create and download specialized tables. Analysis of new items on prepregnancy BMI and birth payer source are limited to the 38 states (86% of US births) that adopted the revised birth certificate by 2012. Between 1989 and 2012, the proportion of all births attended by certified nurse-midwives (CNMs) increased from 3.3% to 7.9%. The proportion of vaginal births attended by CNMs reached an all-time high of 11.9%. Births attended by "other midwives" (typically certified professional midwives) rose to a peak of 28,343, or 0.7% of all US births. The distribution of payer source for CNM-attended births (44% Medicaid; 44% private insurance; 6% self-pay) is very similar to the national distribution, whereas the majority (53%) of births attended by other midwives are self-pay. Women whose births are attended by other midwives are less likely (13%) to have a prepregnancy BMI in the obese range than women attended by CNMs (19%) or overall (24%). The total number of births attended by CNMs and other midwives has remained steady or grown at a time when total US births have declined, resulting in the largest proportions of midwife-attended births in the quarter century that such data have been collected. © 2015 by the American College of Nurse-Midwives.
 
Nationwide, the proportion of certified nurse-midwife (CNM)-attended births has increased steadily. We examined trends in CNM-attended singleton spontaneous vaginal births between 1995 and 2004 in Washington State by site of birth, payer source, and hospital birth volume. CNMs were more likely than other providers to care for women at risk for adverse outcomes based on several sociodemographic indicators. The increased rate of CNM-attended births occurred primarily in hospitals and among both Medicaid- and privately-funded births. The rate of CNM-attended births doubled in hospitals with high birth volumes. We recommend future research designed to understand these trends.
 
American College of Nurse-Midwives (ACNM) membership data collected from 1995-1999 offer a description of the evolution of the profession of midwifery, as shown in the characteristics of certified nurse-midwives and certified midwives, including basic demographics, practice characteristics, and employment components. During the period studied, slight increases were noted in age, number of years in practice, salary, and education level. Although the overall proportion of midwives of color did not change appreciably during the 5-year period, the absolute numbers of culturally diverse midwives increased. Student midwives were found to be younger and more culturally diverse than they were in the early 1990s. Data about midwifery practice provide valuable information to health care managers, educators, policy makers, legislators, and professional organizations, which may guide allocation of resources and reflect how members of the professions can influence access to health care for women and their families.
 
In 1998, the screening and treatment practices of certified nurse-midwives (CNMs) for group B streptococcal (GBS) infection during pregnancy were studied and evaluated for their consistency with the 1996 perinatal GBS prevention guidelines of the Centers for Disease Control and Prevention (CDC). Five hundred thirty-nine surveys were completed by CNMs attending the 1998 American College of Nurse-Midwives' Convention. Of these, 502 (94.7%) reported a practice policy for GBS prophylaxis. The Culture-Based Approach was used by 66.7% and the Obstetrical Risk Factor Approach by 28%. Most (69%) reported using multiple culture sites, most commonly the proximal vagina and anorectal area (33.2%), followed by the distal vagina and anorectal area (26.7%), and the anorectal area and proximal and distal vagina (7.1%). Most CNMs (92.5%) reported treating GBS intrapartally, with penicillin the most frequently reported antimicrobial (55.0%) used, and most (94.2%) reporting treatment through labor until birth. Overall, GBS prophylaxis practices among survey respondents comply with 1996 CDC recommendations; however, GBS screening practices show room for improvement and the need for continuing education that emphasizes the CDC guidelines, updates as they become available, and other new literature about the topic. In addition, heightened awareness among all perinatal providers is needed with respect to CDC guidelines, especially as they pertain to variations in culture sites, identification of risk categories, and the selection of appropriate antimicrobial treatment agents.
 
The American College of Nurse-Midwives (ACNM) Certification Council periodically conducts a task analysis study as evidence supporting the content validity of the national certification examination in nurse-midwifery and midwifery. The purpose of this article is to report findings related to the examination of the relationship between professional issues and safe beginning-level midwifery as measured by the 1999-2000 Task Analysis of American Nurse Midwifery and Midwifery Practice. Study findings suggest that newly certified midwives place strong emphasis on the importance of tasks related to the ACNM "Hallmarks of Midwifery," which characterize the art and science of the profession: these include tasks dealing with health promotion and cultural competency. The beginning midwives, however, gave consistently low ratings to tasks related to ACNM "Core Competencies" that mirror the professional responsibilities of midwives; these include tasks related to the history of midwifery, research, or health policy. The study has implications for nurse-midwifery/midwifery educators, experienced midwifery mentors, and other persons interested in reinforcing the relevance of these important professional issues to the new midwife.
 
A master list of tasks, which contained 200 task statements, 23 professional issues statements, and 177 clinical conditions, was divided into three equivalent survey forms and distributed to those certified nurse-midwives (CNMs) and certified midwives (CMs) certified by the ACNM Certification Council, Inc. during the 5-year period from 1995 to 1999. Specific efforts were made to encourage the participation of CMs, because they represented a new professional cohort. A total of 627 valid responses were obtained. Reasonably similar numbers of respondents contributed data related to each of the three versions of the survey form. The responsibilities have expanded substantially within the domains of nonreproductive primary health care and gynecologic care of the well woman, including advances in assisted reproductive technology. A diminished emphasis on the CNM/CM role in the provision of newborn care was documented. The ACC Research Committee recommended the revision of the entry-level certification examination blueprint, and this was approved by the ACC Board of Directors. The specific recommendations included the development of a new primary care domain and the reconfiguration of content emphasis with percentage allocations as follows: Primary Care, 5-10%; Well-Woman/Gynecology, 15-20%; Newborn, 5-10%; Postpartum, 5-10%; Antepartum, 25-30%; Intrapartum, 25-35%; Professional Issues, up to 5%.
 
The national certification examination (NCE) in nurse-midwifery and midwifery is developed, administered, and evaluated by the ACNM Certification Council (ACC). The blueprint for the NCE is based upon a comprehensive list of tasks that describe the knowledge, skills, and abilities expected of the midwifery practitioner at entry into the profession. In 1999, the ACC initiated the third in a series of task analysis studies to ensure the currency and relevance of the task list. This study was considered particularly timely, given that the professional organization, the American College of Nurse-Midwives, had approved pathways to midwifery for individuals whose first degree was not in nursing (the certified midwife) and also had expanded the core competencies for midwifery practice to include responsibilities in the domain of primary care. This manuscript reports the results of the pilot study, in which the specific list of tasks was developed. Three hundred and six ACNM members responded to a preliminary list of tasks, indicating their opinion about whether each specific task was relevant to entry-level midwifery practice. The task list finally derived consists of 219 tasks and 177 clinical conditions, dispersed among seven domains of practice (antepartum, intrapartum, newborn, postpartum, well-woman/gynecology, primary care/health assessment, and professional issues.) The task list represents a comprehensive profile of entry-level practice for nurse-midwives and midwives certified by the ACC.
 
This article addresses the social history of midwifery and nursing on the California frontier between 1835 and 1885. Drawing on the published interviews of Juana Machado de Ridington (1814-1901) and Apolinaria Lorenzana (born in 1795), this study addresses the practice of midwifery in this culturally diverse frontier setting. The identity of the nineteenth-century Californiana midwife was based on the multiple roles she played in the communities she served. In addition to midwife (as we know it today), these identities included the role of lay minister, godmother, foster mother, and interpreter/translator. Previous histories have tended to marginalize these women and have failed to recognize their importance on the frontier both as women and as caretakers. The primary source material available tended to give only secondary attention to these midwives and their experiences. It is important that we preserve a place in history for these midwives and understand as best we can the ways in which they served their communities.
 
Summary of MANA Stats Data Collection Form Versions 
In 2004, the Midwives Alliance of North America's (MANA's) Division of Research developed a Web-based data collection system to gather information on the practices and outcomes associated with midwife-led births in the United States. This system, called the MANA Statistics Project (MANA Stats), grew out of a widely acknowledged need for more reliable data on outcomes by intended place of birth. This article describes the history and development of the MANA Stats birth registry and provides an analysis of the 2.0 dataset's content, strengths, and limitations. Data collection and review procedures for the MANA Stats 2.0 dataset are described, along with methods for the assessment of data accuracy. We calculated descriptive statistics for client demographics and contributing midwife credentials, and assessed the quality of data by calculating point estimates, 95% confidence intervals, and kappa statistics for key outcomes on pre- and postreview samples of records. The MANA Stats 2.0 dataset (2004-2009) contains 24,848 courses of care, 20,893 of which are for women who planned a home or birth center birth at the onset of labor. The majority of these records were planned home births (81%). Births were attended primarily by certified professional midwives (73%), and clients were largely white (92%), married (87%), and college-educated (49%). Data quality analyses of 9932 records revealed no differences between pre- and postreviewed samples for 7 key benchmarking variables (kappa, 0.98-1.00). The MANA Stats 2.0 data were accurately entered by participants; any errors in this dataset are likely random and not systematic. The primary limitation of the 2.0 dataset is that the sample was captured through voluntary participation; thus, it may not accurately reflect population-based outcomes. The dataset's primary strength is that it will allow for the examination of research questions on normal physiologic birth and midwife-led birth outcomes by intended place of birth. (The full text of the paper is available open access from the publisher: https://onlinelibrary.wiley.com/doi/10.1111/jmwh.12165 )
 
Diary excerpts chronicle the experiences of a nurse-midwife on assignment in Kosovo with Doctors of the World, USA, during the winter of 2000.
 
Introduction: The American College of Nurse-Midwives (ACNM) Core Data Survey is an annual membership survey that collects demographic and selected workforce data about certified nurse-midwives (CNMs), certified midwives (CMs), and students enrolled in midwifery education programs accredited by the Accreditation Commission for Midwifery Education. These data are aggregated and published every 3 years. This article presents findings from the analysis of membership data for the years 2009 to 2011. Methods: An online survey is sent annually to all ACNM members who provide ACNM with an e-mail address. The survey instrument for 2009 to 2011 focused on 5 categories: demographics, certification, education, employment, and licensure except for 2011, in which licensure data were collected separately. Results: ACNM members responding to the surveys during 2009, 2010, and 2011 continued to remain predominantly white and female. The average age of CNMs/CMs in 2011 was 51.2 years. The majority had a master's degree as their highest degree, and 9.3% had a doctoral degree. Approximately two-thirds of respondents in each of the 3 survey years identified attendance at births as one of their primary responsibilities. Discussion: Very little change in diversity was observed over the 3 survey years. The number of CNMs earning the doctor of nursing practice degree is increasing, whereas other doctoral degree categories remain stable. The majority of CNMs/CMs continue to identify a broad domain of clinical midwifery practice as their primary responsibility in their employment. The majority of respondents attend births, but the proportion has been decreasing slightly over time. Salaries for midwives continue to rise, but the reasons for this are unclear.
 
A workshop on international research in midwifery was held at the International Confederation of Midwives (ICM) Triennial Congress in Vienna, April 2002. Thirty-five participants from 12 countries took part. The participants themselves defined the agenda, and subsequent discussion addressed the following issues: international research relationships and collaboration; ethical conduct in international research in midwifery; the role of the International Confederation of Midwives in international research; and identifying topics for an international midwifery research agenda. Recommendations arising from this workshop were as follows: develop guidelines and a code of ethics for the conduct of international research in midwifery; continue to actively support research and further develop that support; support education and capacity building for research at basic and continuing education levels; and update on a regular basis the priorities identified for collaborative international studies.
 
In 1996, the Centers for Disease Control and Prevention (CDC) and relevant professional organizations jointly released guidelines for prevention of early-onset neonatal group B streptococcal infections. The guidelines recommended that all obstetric providers and institutions providing intrapartum services follow one of two strategies. This year, on the basis of multistate surveillance data collected since prevention strategies were initiated, the CDC has released revised prevention recommendations. This article reviews the new guidelines and discusses clinical implications for practice in a variety of settings.
 
Persons rely on health care providers to make diagnostic and therapeutic decisions based on the most current information. With areas of practice changing rapidly, providers are challenged to keep abreast of new and changing treatment guidelines. The new Centers for Disease Control and Prevention (CDC) 2002 Sexually Transmitted Disease (STD) Treatment Guidelines provide clinical guidance in the appropriate assessment and management of STDs. This article reviews recent changes in the STD Treatment Guidelines for the most common disease entities and their sequelae encountered by women's health practitioners. The changes noted in this article include new screening recommendations, use of new diagnostics, new treatment algorithms, and changes in therapeutic regimens.
 
Introduction: Midwifery has been regulated and publicly funded in British Columbia since 1998. Midwives are currently concentrated in urban areas; access to care is limited in rural communities. Rural midwifery practice can be challenging because of low birth numbers, solo practice, lack of on-site cesareans and specialist backup, and interprofessional tensions resulting from the integration of midwives into rural maternity care systems. Despite these barriers, rural midwives have made a substantial contribution to rural maternity care in British Columbia. The purpose of this retrospective cohort study is to examine outcomes of midwife-involved births in rural British Columbia in the postregionalization era. Methods: We analyzed the outcomes of all parturient women with postal codes outside of the core urban areas of the province, and their singleton infants without a diagnosed congenital anomaly, who had a midwife involved in their care between April 1, 2003, and March 31, 2008. Outcomes are reported for 6 obstetric service levels. Service levels are assigned to parturient women via maternal postal codes. Women who reside further than 60 minutes from a hospital with maternity services were assigned a distance category (2 levels: >2 hours, 1-2 hours); women residing within one hour of a hospital with maternity services were assigned the level of service available at their catchment hospital (4 levels, ranging from maternity care without cesarean to cesarean provided by general surgeons or obstetricians). Results: Eight percent of rural parturient women had a midwife involved in their care. Rates of planned home birth exceeded the provincial average (26.1%) in 5 of the 6 service levels. Rates of actual home birth were lowest among women who resided 2 or more hours away from maternity services. Obstetric intervention rates were lower for women residing in communities without cesareans or with intermittent access to cesareans. The prevalence of adverse neonatal outcomes was very low across service levels; perinatal mortality was elevated among women residing in communities more than 2 hours away from services. Discussion: Despite numerous challenges, midwives provide safe maternity care to rural parturient women and offer choice of birth place. Given the difficulty of recruiting and retaining maternity care providers to rural settings in British Columbia and across Canada, these findings open the door for a more sustained planning process involving midwives in rural communities. Reasons for the elevated perinatal mortality rate among women who live more than 2 hours away from services should be explored in more detail, perhaps via in-depth interviews with rural midwives who serve this population.
 
The purpose of this study was to describe women's health and hygiene experiences during their deployment to Iraq and Afghanistan during the war years, 2003 through 2010. A phenomenological method described the essential structures embedded in the women's health and hygiene experiences. Colaizzi's method of data analysis was used to guide the discovery of themes. Interview data were gathered from 24 interviews with military nurses who served in the war zones. Female military nurses were specifically selected for this study because of their insight, awareness, and knowledge base. Seven themes emerged from the data and captured the essence of the women's experiences: 1) bathroom trips and facilities: a walk on the wild side; 2) shower challenges: lack of privacy, water problems, and location issues; 3) menstruation: to suppress or not to suppress; 4) staying clean: a monumental task; 5) various infections: annoying distractions; 6) unintended pregnancies: wartime surprises; and 7) safety issues: enemy attacks and sexual assaults. In the current military structure, more women are being deployed to combat zones and will endure the challenges and hardships described in this study. The health and hygiene experiences of deployed women are an important part of their daily lives in combat zones. Educational programs and clinical services need to be tailored to this cadre of women, with focused attention on preparation and anticipatory guidance prior to deployment. Access to health promotion and appropriate clinical services during deployment is critical. Finally, as these women return home as veterans, it is important for all providers to understand the contextual framework of their service and its impact on their lives.
 
Afghanistan is believed to have one of the highest infant and maternal mortality rates in the world. As a result of decades of war and civil unrest, Afghan women and children suffer from poor access to health services, harsh living conditions, and insufficient food and micronutrient security. To address the disproportionately high infant and maternal mortality rates in Afghanistan, the US Department of Health and Human Services pledged support to establish a maternal health facility and training center. Rabia Balkhi Hospital in Kabul, Afghanistan, was selected because this hospital admits approximately 36,000 patients and delivers more than 14,000 babies annually. This article reports the initial observations at Rabia Balkhi Hospital and describes factors that influenced women's access, the quality of care, and the evaluation health care services. This observational investigation examined areas of obstetric, laboratory and pharmacy, and ancillary services. The investigators concluded that profound changes were needed in the hospital's health care delivery system to make the hospital a safe and effective health care facility for Afghan women and children and an appropriate facility in which to establish an Afghan provider training program for updating obstetric skills and knowledge.
 
The American College of Nurse-Midwives (ACNM) Core Data Survey is an annual membership survey that collects demographic and selected workforce data about certified nurse-midwives (CNMs), certified midwives (CMs), and students enrolled in midwifery education programs accredited by the Accreditation Commission for Midwifery Education, who are members of the organization. This article presents findings from the analysis of membership data for the years 2006 to 2008. An e-mail invitation to participate in the online survey was sent to all ACNM members who provided ACNM with an e-mail address. A paper copy of the survey was available upon request. The survey instrument for the years 2006 to 2008 focused on five categories: demographics, certification, education, employment, and licensure. ACNM member respondents continue to remain predominantly white and female. The average age of CNMs/CMs for 2008 is 51 years, and the majority holds a master's degree as their highest degree. Very few advances have been made in the effort to increase the diversity of ACNM membership. The number of CNMs earning doctoral degrees (including the doctor of nursing practice degree) is increasing. A majority of CNMs/CMs continue to identify a broad domain of clinical midwifery practice as their primary responsibility in their primary employment, and hospitals and physician practices remain the largest employers of midwives. Salaries for midwifery-related work are rising, but it is unclear if midwives are earning more because salaries are higher or because the higher salaries reflect market wage adjustments that occur over time.
 
In partnership with the American College of Nurse-Midwives (ACNM), the authors conducted a survey of ACNM members to examine the incidence of lawsuit involvement, the outcomes of the litigation in which they were involved, and coping mechanisms among midwives who had been involved in a lawsuit. In the spring of 2009, a nationwide Web-based survey was completed by ACNM members. In addition to using chi-square tests and nonparametric testing in data analysis, a logistic regression model was used to evaluate predictors of lawsuit involvement. Among 1340 midwives responding to the survey, 32% had been named in a lawsuit at least once. The median number of years in practice when the event leading to lawsuit occurred was 6. The majority of midwifery lawsuits involved hospital births and were settled prior to going to court. Three variables were statistically significant for involvement with litigation: the midwife's age, the number of births attended, and the ACNM region of practice in the United States. Lawsuits among midwives were significantly related to exposure to births over time. Practice patterns and job security were not greatly affected by the experience of a lawsuit. Future cyclic surveys are needed to track the frequency of litigation and the outcomes that lead to lawsuits and to better define the relationships between midwifery practice and medical malpractice litigation.
 
Top-cited authors
Julia S Seng
  • University of Michigan
Lynn Sibley
  • Emory University
Holly Kennedy
  • Yale University
Lisa Kane Low
  • University of Michigan
Judith S Mercer
  • University of Rhode Island