WELL WOMAN GYNECOLOGY: Is It Part of Nurse-Midwifery?

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Just what is “well woman gynecology” and why should the Journal of Nurse-Midwifery devote an entire issue and continuing education home study program to the topic? After all, certified nurse-midwives have developed their reputation and made their impact caring for women during childbearing. Most of us undoubtedly think of ourselves primarily as guardians of holistic family-centered care during pregnancy and birth. Granted, we recognized long ago the need to extend midwifery presence into family planning, but why this overt foray into gynecology? Demand for nurse-midwives in obstetric practice often exceeds supply already. Why should we spread our limited resources even more thinly? Some might even question whether this interest in gynecology is just an excuse to cut back on the 24-hour-a-day commitment to patients that comes with obstetric care. Are we in fact running a risk of forsaking our “true” vocation?

Before we can decide whether we should be in the business of well woman gynecologic care, we should clarify exactly what we are talking about. Two of our colleagues, Ronnie Lichtman, CNM, and Susan Papera, CNM, in the introduction to their widely acclaimed text on the topic,1 offer their definition. Even though gynecology is defined as the “study of the diseases of the female reproductive organs, including the breasts,” the term “well woman gynecology” is not intended as a contradiction. “We are specialists in … health maintenance and experts at screening for disease processes,” they state, but “there is no adequate terminology for this function as it relates to women in particular. There is no distinct name for this body of knowledge.” Thus, they have chosen to use “gynecology” more broadly to encompass the wellness as well as possible illness of the female reproductive system. And, they modify this concept by the term “well woman” to exclude “the independent management of serious medical or gynecologic conditions that require medical or surgical intervention for diagnosis or therapy.”2

Note, as do Lichtman and Papera, the distinction between the term “well woman gynecologic care” and the terms nurse-midwifery programs long used to describe caring for the nonpregnant woman: “interconceptional or family planning care.” It is perhaps ironic that we who take such pride in being advocates for women should have fallen into the trap of defining women by their reproductive functions of conception and bearing children. Did we mean to imply that women who were not “between conceptions” or “planning families” were to be excluded from all that is special about midwifery? Did we intend to suggest that a woman who, by choice or by physiology, would never conceive was thus rendered ineligible for our services? Did we not even think ahead to the day when our maternity clients would reach menopause and still want to see us for the special care and support that made us their choice for maternity care? Surely the answer must be “no” to these questions; we should all embrace this broader, more inclusive term to describe our practice when the client is not pregnant.

Having defined well woman gynecology, is it really part of nurse-midwifery practice? Before we ask if CNMs should be involved in gynecology, we might reexamine a question that has been asked in this column before: What exactly is nurse-midwifery? Is it solely a practice or function, such as prenatal care or delivering babies, or is it more a philosophy of practice? Midwifery was once defined here as embodying “a belief in women … a respect for their being and their potential, and a commitment that stresses the support of health [and] normalcy … in a holistic way.”3 More recently, Burst described midwifery as “… how we approach the woman and include her and her family in the process…. It is how we facilitate normal, natural processes and foster participatory decision-making….”4

Think about what it is we expect from a midwife. Is it just delivering a baby, or is it the acknowledgment of the woman's right to know and her right to choose and control her health care? Is it just prenatal care, or is it the emphasis on education, disease prevention, and health maintenance? If what we expect from a midwife is the promotion of self-determined health and normalcy, coupled with knowledgeable screening for the nonnormal, is there anything that dictates that only those pregnant (or planning to be) need make an appointment? Hopefully not. We are, or we should be, advocates for all women.

There is nothing, then, about gynecologic practice in midwifery that departs from the beliefs that brought us into this profession. But, does this movement into well woman gynecologic care mask a lessening of commitment to our “true” vocation? No one would question that, when added to “full scope” practice, the extension of professional function into gynecology represents the fullest possible scope of midwifery. What if well woman gynecologic care is the sole expression of one's practice? When midwives make a decision to “stay in the office,” be it for prenatal care, family planning, or gynecology, they are sometimes perceived as less than fully committed to the ideals of midwifery. I once overheard a colleague observe, and I suspect there are those who would agree, “I don't believe you are a real midwife unless you get up in the night to be with someone in labor.” In fact there are quite a few midwives who have chosen to redistribute their physical, mental, and emotional energies in ways that, temporarily or not, exclude this aspect of full-scope practice. If they are not “real” midwives, what are they? Are they relegated to second-class status because they do not attend births? We should not accept this. “Real” midwifery, as defined by Burst, “is ‘with woman,’ wherever she may be …,” wherever we work to meet her “needs for advocacy, continuity of care, protection of whatever processes are normal, safe options, inclusion of family, and participatory decisionmaking.”4 Clearly, the beliefs that brought us to the profession of midwifery, the philosophy that forms the basis for our practice of “woman-care,” are as pertinent to gynecology as they are to childbirth. If one views midwifery more as philosophy than function, there is nothing about the site or scope of practice that should diminish one's commitment either to midwifery or to the women we care for.

Having proposed that expansion into well woman gynecologic practice is suitable, even desirable, we need to proceed according to the standards and guidelines we as a profession have embraced. Most importantly, we need the theoretical knowledge base that must serve as foundation for the nurse-midwifery management process. Much we know already. Anatomy and physiology of the female reproductive system form the basis of obstetrics as well as gynecology. Physical examination and procedure skills, as well as caring for the woman who uses contraceptives, have long been deemed within the scope of midwifery practice. So too have management of conditions such as vaginitis, sexually transmitted disease, or urinary tract infection. We do need, though, to expand our knowledge base to encompass other physiologic and gynecologic conditions not traditionally considered part of midwifery.

To this end, or rather to this beginning, the Journal offers this continuing education program. It is intended to update some of those aspects of care that we have long practiced. It serves also as a brief introduction to some of the concepts that fall into the broader definition of well woman care; it in no way, though, represents a comprehensive review of all that can be encompassed in well woman gynecologic practice. For those who wish more, a new reference text,1 edited by CNMs experienced in this field, may provide a fuller discussion of nurse-midwifery management in the area of well woman gynecology. In addition, we invite those CNMs who have already incorporated gynecologic care into their practice to continue to share their knowledge and experience with our readership via review articles or descriptive statistics. As both providers and sometime consumers of care, we should look forward to the continued growth of a midwifery presence in all aspects of women's health.

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