Improving Pregnancy Outcome with Nurse-Midwifery Care
For over 50 years, nurse-midwifery care has improved mother and infant outcomes in low-income populations, which are statistically at risk. In rural farming communities, the hills of Appalachia, and inner-city neighborhoods, the introduction of nurse-midwives has resulted in an increased use of prenatal care and a decrease in low birth weight, prematurity, and neonatal and infant mortality.
Since 1926, Frontier Nursing Service's nurse-midwives have cared for poor families in rural Kentucky. After studying the results of their first 1000 births, the Metropolitan Life Insurance company concluded over 50 years ago that the nurse-midwives'care “had effected a revolution in maternal and child health statistics.“1 They noted that greatly reduced rates of maternal and neonatal mortality and stillbirth had resulted from the nurse-midwives'care.
From 1960 to 1963, a demonstration nurse-midwifery program was introduced in Madera County, CA, to relieve a health manpower shortage. The project served a medically indigent farmworker population. Researchers identified the following significant improvements during the program: 1) More prenatal care given more frequently to more expectant mothers; 2) a greater proportion of mothers returning for postpartum examinations; 3) a de-creased prematurity rate; and 4) a decreased neonatal mortality.2
In 1972, a nurse-midwifery program was established to serve low-to moderate-income women in rural Georgia. Evaluation after 3 years showed decreases in neonatal and infant mortality, low birth weight, and prematurity. Health expenditures for perinatal care also declined.3
Nurse-midwives also have been notably successful in increasing birth weight among infants of teenagers. A recent, retrospective study from South Carolina found a significantly lower incidence of low birth weight among babies born to teenage mothers cared for by a certified nurse-midwife (CNM)-managed mul-tidisciplinary team than among infants born to a statewide, matched control group of pregnant adolescents.4 At Lincoln Hospital in New York, a midwifery clinic was begun in 1976 to provide comprehensive prenatal care to poor and minority teenagers. During the program's first year, the rate of low birth weight was reduced by two-thirds among the clinic's population.5
INFANT MORTALITY AND LOW BIRTH WEIGHT: NATIONAL CONCERNS
The positive outcomes achieved by nurse-midwives are noteworthy in light of the growing concern about high rates of low birth weight and infant mortality in the United States.
In 1983, the provisional US infant mortality rate (IMR) was 10.9 per 1000 live births. Seventeen other nations showed lower infant mortality. Although our IMR has been declining throughout the 20th century, our unimpressive international standing has remained fairly constant for the past 20 years.
The racial gap in infant outcomes is a special concern. Nonwhite mothers receive less prenatal care, and are twice as likely to bear a low birth weight baby as are white mothers. In 1982, (the latest year for which race-specific national data are currently available), 5.7% of white newborns and 12.5% of black newborns weighed <2500 g. Black infants die twice as frequently as white infants during the first year of life. In 1982, the black IMR was 19.6 and the white IMR was 10.4.6
Infant mortality is a problem closely linked with poverty. Poverty is associated with barriers to health care and health education, as well as suboptimal nutrition and housing. Minority groups suffer from excessive poverty, as well as higher infant mortality and low birth weight.
RECENT DECLINES IN INFANT MORTALITY
Recent declines in US infant and neonatal mortality have resulted largely from advances in neonatal intensive care, not from an improvement in infant birth weights.7,8 The skill, technology, and money expended to save the lives of very low birth weight infants in the US is unequalled elsewhere in the world. Although a poor woman may not be able to afford prenatal care, her premature baby may be flown to a level III neonatal intensive care unit, where no effort will be spared in caring for the infant. Although the percentage of small and premature babies has declined only slightly since 1970, medical capability of prolonging their lives has increased enormously.
In contrast, the good outcomes achieved by nurse-midwives are not produced by advances in neonatal intensive care. Rather, they result from the provision of early, vigilant, and personal maternity care that incorporates the principles of continuity, participation, and patient education.
STANDARD CLINIC CARE FOR OBSTETRIC PATIENTS
Clinics and hospital maternity units often view low-income patients as high risk, uninformed, or uninterested in health-promoting behavior. Barriers to prenatal care include complicated Medicaid eligibility requirements, as well as denial of affordable care to “illegal aliens” and the working poor. Prenatal visits often feature hours of waiting, followed by a hurried examination. Little time is available for health teaching or discussion of patient concerns. In labor, many medical centers routinely apply the “high-risk” label to all clinic patients, because of the multiple risk factors associated with low socioeconomic status. Birthing routines for these patients commonly include continuous electronic fetal monitoring, confinement to bed, nutritional intake via an obligatory intravenous infusion, and early resort to fetal scalp sampling and other obstetric interventions. The postpartum patient who was cared for by multiple providers during pregnancy and labor may leave the hospital not knowing who to call for help with questions or problems that arise at home.
In such settings, significant numbers of women receive late or no prenatal care. They frequently present in labor with serious problems that might have been resolved successfully during the prenatal period.
WHAT IS SPECIAL ABOUT NURSE-MIDWIFERY CLINIC CARE?
Nurse-midwifery care for the poor differs in several important respects from the above model. The nurse-midwife views clients as motivated to do the best for their families. Health-building behavior is supported and supplemented during patient teaching. Good diet is stressed, and advice is individualized according to the pattern of fetal growth. Breast-feeding is strongly encouraged, and nutrition counseling continues during lactation. Nurse-midwife and client collaborate on plans for improving health habits. As the client learns about and prepares for birth, she is encouraged to think actively about decisions she will be making during labor and postpartum. These include issues as varied as use of medications in labor, infant feeding, and child care.
Because nurse-midwifery care validates and respects her, the mother-to-be to seeks out prenatal care early, and returns more regularly for visits. She is also more compliant in following health plans which she has joined in making.
Nurse-midwives care for poor patients in a variety of settings. Two of the most common are the city/county teaching hospital and the government-funded Maternal and Infant Care Project (MIC). Both settings may use a mixture of physicians, nurse-midwives, and nurse-practitioners as care providers. The patient may see many providers prenatally, and delivery services may be provided by a different staff.
Despite lack of continuity of care, excellent outcomes may result when nurse-midwives deliver patients cared for in this way. Sharp has analyzed 10 years of nurse-midwifery outcomes of caseload and episodic (ie, those assigned to nurse-midwifery care in labor) care patients, and found the outcomes of the episodic care patients to be superior. She comments that this reflects the selective screening done by the nurse-midwives when accepting an unknown patient in labor. The complicated patient will not be accepted. However, nurse-midwifery caseload patients will continue to be observed when certain problems occur that may affect outcome adversely.9
In an episodic care setting, the nurse-midwife's ability to improve pregnancy outcome on a community basis is limited. Although she applies her unique skills and philosophy during each individual patient contact, her impact will be less than if she or a small team of midwives followed a group of patients throughout pregnancy. In these settings, it is difficult to document the effects of nurse-midwifery care, because outcomes result from such a mixture of provider and policy inputs. Nurse-midwives often find such employment unsatisfying. New graduates may work in a public hospital/MIC project for 1 to 2 years to gain experience, and then move on to a practice that provides increased autonomy and continuity of care.
EMERGING MODELS OF NURSE-MIDWIFERY CLINIC CARE
In recent years, another model of nurse-midwifery clinic care has received attention because of the good outcomes it produces. This is the nurse-midwifery service with a defined caseload of patients operating in a public or low cost health facility. These nurse-midwifery services tend to exert greater control over their protocols and practice than do nurse-midwives working without caseloads. The caseload nurse-midwives provide continuity of care and childbirth education and alternatives. They implement more of the midwifery model of care than has been possible traditionally in public maternity settings.
The care provided to public patients by caseload nurse-midwives is similar to that in a good private practice. Nurse-midwives are available for 24-hour per day telephone consultation with clients, and assess women individually regarding interventions and application of obstetric technology. Greater leeway is created to respect the individual's wishes regarding position of birth, episiotomy, birth attendants, bonding, and initiation of breast-feeding. Postpartum care is more individualized, with some centers offering the option of early discharge with home-visit followup. When a patient becomes high risk, the nurse-midwife collaborates in her care with the back-up physician, instead of transferring her to a high-risk clinic.
North Central Bronx
The nurse-midwifery service at the North Central Bronx Hospital (NCB) in New York demonstrates how such a service can work in practice. North Central Bronx is a city hospital serving a poor, largely minority, at-risk obstetric population. Fifteen nurse-midwives are divided into three teams to provide care to all obstetric patients. Each team member follows a caseload of patients throughout pregnancy. One representative from each team is on the in-patient unit 24 hours per day, caring for the team's in-hospital patients. The caseload system facilitates a high degree of accountability among the NCB midwives. Weekly conferences review patient outcomes, and nurse-midwives are responsible for strengthening their care in areas where outcomes have been less than optimal. According to Therese Dondeiro, the director of NCB's nurse-midwifery service, “Someone must be responsible for the care of the patient. When that responsibility is diluted among many people, the outcome suffers. Nurse-midwives here become keenly aware of the results of their practice—they are accountable, as they would be in a private practice.”
Another important service delivery model for low-income patients is the free-standing maternity unit staffed by nurse-midwives. SuClinica Familiar is such a birth center in Texas. An important principle there has been to keep the number of care providers and patients small enough to allow for personalized care. When the demand for services becomes too great, additional units are begun in nearby communities. According to Sister Angela Murdaugh, Director of SuClinica: … (Birth centers) destroy apathetic care. Apathetic care results from being processed by different people at different times in different places; never having anything together under the same roof; never having the same small, familiar group of people caring for you… Individualized care is necessary for people, especially poor people, to understand that they are being cared for; and people must feel cared for to achieve compliance.”10
With the changed political climate of the 1980s, past programs that tried to redress broad socioeconomic inequalities have been reduced drastically. These include MIC projects, community health centers, public hospital care, Medicaid, WIC, food stamps, and programs of community outreach and health education. Because of these program reductions, many health planners are expecting to see an increase in low birth weight rate and infant mortality in the near future.
Nurse-midwifery services, especially those caring for defined caseloads of patients, are remarkably successful in involving women in prenatal care and improving pregnancy outcome in poor communities. The recent report on The Prevention of Low Birth Weight, issued by the-Institute of Medicine recommends “… Greater reliance on CNMs and nurse-practitioners, who have been shown to be particularly effective in managing the care of pregnant women at high risk of low birth weight because of social and economic factors. Maternity programs designed to serve high-risk mothers should increase their use of these providers; and state laws should be supportive of nurse-midwifery practice and of collaboration between physicians, nurse-midwives, and nurse-practitioners.”11
Legislators, health planners, and policy makers need to be made aware of the nurse-midwifery model of care, and the positive results that follow from its application. Documentation of nurse-midwifery quality of care, outcomes, and cost-effectiveness will be an important tool in the creation of high quality, effective maternity care for low-income patients.