A few years ago, the New York Times published an article entitled: “That Ounce of Prevention Grew too Big.”2 The physician author complained that there is not enough time to offer primary care services. Actually, health promotion … the “ounce of prevention” referred to …has always been big. And, it is getting even bigger as the intertwined problems of obesity and diabetes become more prevalent in American society — a problem that has been referred to as the “Diabesity Epidemic.”3,4
Primary care cannot be relegated to annual visits or to physician management alone. As stated in the quote above by Phyllis Leppert, CNM, MD1, the provision of primary health care services is an obligation of all health care providers regardless of professional title. This issue of the Journal of Midwifery & Women's Health focuses on primary health care… the most important service the health care profession has to offer from a midwifery perspective!
Health statistics in the United States reveal some concerning trends. Cardiovascular disease in women is the number one cause of death and disability, particularly when obesity, hypertension, and/or diabetes compound the risk.5 Yet, 61% of adult women are overweight, 25.7% are hypertensive, and 8.7% are diabetic.4 Many of these women are unaware of their compromised health status. In addition, 20% of women in the US today smoke, despite the fact that lung cancer is the most common cancer-related cause of death in females.6 Women are twice as likely as men to suffer from depression, 21% of adult women report instances of intimate partner violence, and 15%–20% do not have health insurance.6
These are tough problems to solve. Women need a therapeutic primary care relationship that thrives over time and at minimum, provides accessibility for initial and ongoing screening of any emerging health issues or concerns (pregnancy-related or not). In addition, health care professionals must possess the ability to ask the right questions, openly and nonjudgmentally, while listening intently to what the client is saying both verbally and nonverbally; mastery of the clinical knowledge and skills that promote health and prevention of disease; expertise in evaluating and managing common health problems, with resources for appropriate referral to medical management when indicated; a user-friendly mechanism for coordinating referrals to assure continuity of care; and a systematic approach for providing informed consent in counseling patients about the risks and benefits of all alternatives. These are services that certified nurse-midwives (CNMs) and certified midwives (CMs) provide everyday.
As triage experts, each patient encounter has to be seized as if it were our one and only opportunity to gather pertinent data. An oral history can be taken simultaneously while doing a head-to-toe physical exam … if a woman has come for an annual checkup or simply to renew her birth control pills. Many may gasp at this notion and think it too time-consuming.
But, it needn't take more than a few minutes. If we sharpen the acuity of our eyes, ears, and olfactory sense, and add a methodical litany of verbal prompts as our fingers move quickly down a woman's body, this comprehensive review of systems may trigger a woman's recollections of symptoms previously ignored. “Any headaches, blurred or double vision, spots before eyes, trouble breathing, persistent cough, difficulty chewing or swallowing, dental problems, frequent colds, dizziness, palpitations, loss of appetite, vomiting, diarrhea, pain, itching, burning, bleeding?” Tobacco, alcohol, or drug use; eating disorders; sexual issues; intimate partner violence; and symptoms of depression should similarly be assessed for regularly, once trust has been established. The early identification of clues that deserve further investigation — the most important element in primary care — is an integral part of the midwifery model of care, and this approach, we believe, is what makes CNMs and CMs such effective primary health care providers.
Long before primary care competencies became a mandated curricular component for midwifery education programs accredited by the American College of Nurse-Midwives (ACNM), our educators always made certain that the knowledge and skills acquired by midwifery students were holistically fine-tuned and primed for clinical excellence. They instilled in us the belief that primary health care screening must be an integral part of each and every patient encounter. The articles in this issue include reliable brief assessments for depression, intimate partner abuse, and eating disorders. They are intended as exemplars for busy clinicians who strive to make every visit a “primary care moment.”
ACNM issued its first position statement proclaiming that nurse-midwives are providers of primary health care for women in 1992 and reaffirmed this statement in 1997.7 The Journal of Nurse-Midwifery published three ACNM-approved Home Study Programs on Primary Care for Women during 1995 and 1996. One year later, “Primary Care of Women” was added to ACNM's Core Competencies for Basic Midwifery Practice (1997), officially making the knowledge, skills, and judgments associated with the assessment and management of common health problems during the reproductive, perimenopausal, and postmenopausal years, requisites for CNMs and CMs. The most recent revision of the core competencies (2002), added perimenarcheal care to the list.8 In 2003, ACNM revised the Standards for the Practice of Midwifery, which now cite primary health care of women as a bona fide service arena for CNMs and CMs.9
More than a decade ago, an editorial in this Journal proclaimed,
“… the hallmark of competent primary care is knowing when to treat, when not to treat, when to just closely monitor, and when to refer the patient for consultation and/or medical intervention … an approach that has traditionally been part and parcel of the midwifery model.”9
As that 1993 editorial concluded, it is “incumbent upon each of us to make absolutely certain that we are competent to provide the most comprehensive primary care possible.”9,10 We “talk the talk”; now, we must make certain that we “walk the walk.” Let us demonstrate to the women we serve, our colleagues in other disciplines, the policy makers, and the holders of the purse strings that midwifery and primary health care are a dynamic duo that offer competent, compassionate, cost-effective, and comprehensive care to essentially healthy women, from pubescence through senescence.