The journal article referenced in this post may be accessed here (http://tinyurl.com/2azmhmg) for free, in the event you do not have access to the Journal of Perinatal Education on line - a benefit of Lamaze membership.

Introduction
As a childbirth educator, the Journal of Perinatal Education has been an amazingly helpful tool to me over the years. Look through my copies of JPE, and you'll find dog-eared pages, underline marks in varying ink colors, notes in the margins regarding how to implement a certain piece of knowledge into my class curriculum.

The current issue of JPE delivers yet again, and I want to highlight one article in particular, which I found interesting.

Maternity care and childbirth is, at the very heart of things, an intimate business. And because so many of us have a vested and impassioned interest in how maternity care plays out - no matter what side of the fence we find ourselves on - there have been hundreds of studies completed and published about birth and all things related.

The purpose of this phenomenological study, Midwifery Care: Reflections of Midwifery Clients, by Mary Ellen Doherty, PhD, RN, CNM, 'was to describe the lived experience of midwifery clients throughout the life span.' Not only did this study collect lived-experience data on women's impressions of their midwifery care during pregnancy, labor and birth, but before, during and after their childbearing years as well.

There's a lot to be said for the value of gathering data on care delivered by health professionals from the recipients of that care.

Methods
In-person interviews between Dr. Doherty and self-selected participants from four different New England midwifery practices took place over a three-month period. The interviews, prompted by the open-ended question, 'What has been your experience with midwifery care?' and following brief screening telephone calls, were audiotaped and transcribed verbatim, before grouping responses into broad, and eventually more detailed theme clusters.

One of the theme clusters that emerged during the data compilation and analysis phase of the study was Nurse-Midwives as Primary Health-Care Providers Throughout the Life Span. Many people assume midwives deliver pregnancy-related care only. And, in my experience, some midwives do choose (or are trained) to only offer perinatal care services'as is typical of Certified Professional and Direct Entry Midwifery training. But take a look at the curricula offered by all nurse-midwifery programs, and you'll find several courses on women's health across the lifespan within each program. This is, in fact, one of the core competencies as outlined by the American College of Nurse-Midwives. This element of midwifery care - tending to women from menarche to menopause- seemed to be a recurrent theme in the study participants' responses, as exemplified by this remark:

'I have been going to the same midwifery practice for about 10 years now... I started with my first pregnancy and never left. The midwives do my annual exams, pap smear, check my diaphragm to make sure the fit is still good for birth control, and they have even cured a few vaginal infections along the way.'

Along with the theme of midwifery care across the lifespan, other topics that apparently emerged with great frequency were: Decision to Seek Midwifery Care, Working Together in a Therapeutic Alliance, Formulating a Birth Plan and Childbirth Education. Epitomizing the reason a woman might choose midwifery care, came this statement from one study participant who also happened to be a former pediatric nurse:

'I guess I feel safe with nurses and totally subscribe to the belief that nurse-midwives are experts in normal birth and know when to get help if needed. I like the fact that they stay with you during labor and don't just come in at the last minute to catch the baby.'

Doherty goes on to provide many additional quotes from study participants, demonstrating their experiences with midwife-taught childbirth education classes, birth plan formulation and approaching a woman's health care as a team:

'My midwife coached and supported me. She always made me feel involved in the decision making and was so positive and encouraging. She really tuned in to my feelings and behaviors during labor. There was so much sensitivity.'

Analysis
The twelve participants in Doherty's study seemed to lack the diversity I would like to have seen: on average, they were Caucasian, highly educated and married to their baby's father with a self-proclaimed financial status of 'middle class.' There was some variability in parity (nulliparous through multiparous x 4) and their average age was 34.5 years old. Lastly, the women included in Doherty's study all experienced vaginal, non-complicated births following low-risk, singleton pregnancies. Resultantly, one could argue this subset of participants possessed a commonly biased experience of midwifery care. For these reasons, I initially found myself questioning the overall generalizability of this study and was compelled to want to know more: how many of the women who initially responded to brochures they saw/received at their health care provider's office or the hospital laboratory were actually accepted into the study? What were the inclusion criteria for this (beyond the stated basic criteria of ability to read, speak and comprehend English)? What would the response theme clusters (and individual data) look like with a larger number of participants?

Some of these limitations are addressed by Dr. Doherty and countered with the stipulation that she felt data saturation had been sufficiently achieved during the interview process. She also acknowledged the potential lack of generalizability, but explained this as a common and expected side effect of a phenomenological study. Likewise, the number of study participants becomes less important than in, say an RCT, because data saturation suggests generalizability, in and of itself. An enlightening follow-up study then, (as suggested by Dr. Doherty and expanded upon by yours truly) might be to assess and compare lived experiences of more subjects with varying characteristics, as well as across different models of maternity care (provided by different typesof midwives, as well as family physicians and OBs), yet using the same interview question: 'What has been your experience with your health care provider?'

Final Thoughts
In re-visiting the themes that arose from the participants' own depictions of their midwifery care experiences, the process and outcome of their birth experiences was, interestingly enough, not considered a major theme in and of itself. The experiences associated with midwifery care which seemed to leave a lasting impression on these women revolved around what prompted them tochoose midwifery care in the first place, along with the nature and quality of interaction between themselves and their midwives throughout the duration of their care. Resultantly, this study offers us a categorical glance at the experience a woman might expect to have throughout the spectrum of midwifery care. Aptly put, one of Dr. Doherty's concluding remarks suggests,

'It is important for all women to learn about midwifery care, and one of the best ways to accomplish this is for them to listen to the voices of other women as they tell their stories.'

What are we, as maternity care professionals, doing to facilitate this sharing of stories? Is it our role to connect women with each other and facilitate the oral exchange of lived experiences? If so, how can we best do this?

Post by: Kimmelin Hull, PA, LCCE

Published: December 13, 2010

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