Women’s Experiences of Nurse- Midwifery Presence During Childbirth Presenter: Lauren P. Hunter, PhD, CNM Ph: 858-454-9033 email: [email protected].

Women’s Experiences of Nurse-Midwifery Presence During

ChildbirthPresenter: Lauren P. Hunter, PhD, CNM

Ph: 858-454-9033email: [email protected]

Affiliation : San Diego State University School of Nursing

STTI Chapters: Gamma Gamma, Zeta MuFunding: San Diego State University Faculty-

Grant-In –Aid # 242204

Study Purpose

• To measure postpartum women’s experience of one aspect of nurse-midwifery care, positive presence, during labor and birth in a hospital setting.

Research Questions

Did predominately Latina women who were attended by nurse-midwives in a hospital based nurse-midwifery service perceive a positive nurse-midwife presence during their childbirth experience?What effect did the environmental setting either in hospital birth center (IHBC) or in hospital standard labor and delivery unit (SL&DU) have on the degree of positive nurse-midwifery presence experienced by women?

Research Questions

Was there a relationship between the amount of positive nurse-midwifery presence experienced by women based upon a woman’s demographic variables, such as ethnicity, length of labor, parity, or organizational factors such as number of nurse-midwifery providers?Was there a relationship between the number and type of personal labor support persons present, such as family members, significant others, or doulas, and the degree of positive nurse-midwifery presence experienced by the woman?

Research Questions

Was there a relationship between the use of various types of coping/comfort techniques or medication for pain relief and the degree of positive nurse-midwifery presence experienced by the woman?

Conceptual Definition of Midwifery Positive Presence

• “the extent to which the nurse-midwive’s response to the laboring woman encompasses the high touch qualities of nurturance, intuitive awareness, sensitivity, personal attention, knowledge, professional expertise, presumed validity of the individual woman’s subjective experience”

• “reflects the one-on–one personal attention and constant availability of the nurse-midwife for the woman in labor” (1p. 44)

Conceptual Definition of Midwifery Positive Presence

• Derived from qualitative interviews with women that received CNM care (1)

• The definition was validated using theoretical indexing from the literature (1)

Literature Review

• Essential hallmark of the ACNM is the value of therapeutic presence (2)

• Three American N-M studies (3-5), one metasynthesis (6) and one extensive literature review (7) found presence to be essential from midwive’s and women’s perspectives

• Further qualitative studies from 1990 –2005 verify that the definition remains remains valid from women’s perspectives (8-25)

Study Design

• Descriptive

• Correlational

• Non-Probability Sample

Midwifery Positive Presence Index Instrument (MPPI)

• 29 item 5 response Likert Scale (max score =203)• Unidimensional scale based on the original

conceptual definition of positive presence• Pilot tested on 15 women (Birth Center)• Chronbachs Alpha = .92• Construct Validity = .77• Item to Item Correlation Matrix =.42-.69 • Test Retest = .99• Spearman Brown = .90

Midwifery Positive Presence Index

• Further Testing:• 89 low risk postpartum women (BC and Hospital)• Construct Validity = .64• Principal Components Analysis (Theta Coefficient

= .92)• Content Validity re-verified with a sample of PP

women (post test focus groups)• Cronbach’s Alpha = .92

Sample of MPPI Items

• The nurse-midwife gave me reassurance when things got tough

• The nurse-midwife’s touch was comforting

• The nurse-midwife was an expert at what she/he did

• The nurse-midwife helped me to work with what I was feeling

Setting for Current Study

• Low risk postpartum women

• Large southwestern hospital

• In-Hospital Birth Center

• Standard Labor and Delivery Unit

• CNM Service 14 CNM’s (10 FT and 4 PT)

• 100-125 births /month

Data Collection

• Recruitment:

• Prior to Discharge

• Bilingual Flyer

• Verbal Study Description

• Bilingual RA

• 30 Minutes of Time

• Written Consent/Voluntary Participation

Sample Characteristics (N=238)

Range Mean SD

Age 14-41 25.36 5.97

Gestation 38-42 39.28 1.84

Labor (Hr) 1-41 8.51 6.84

G P 1-13 2.36 1.64

Presence 47-203 186.2 21.7

Sample Characteristics (N=238)

Gravida/Parity Frequency Percent (%)

Primiparas 87 36.7

Multiparas 139 58.7

Grand Multip 11 4.6

Sample Characteristics (N=238)

Ethnicity Frequency Percent (%)

Hispanic 176 73.8

Caucasian 46 19.4

Other 14 6.8

Setting

IHBC 100 43.1

SLDU 100 43.1

Transfer 38 13.8

Sample Characteristics (N=238)

Number of Frequency Percent (%)CNM’sOne 58 24.0Two 94 39.7Three 49 20.7Four 25 10.5Five 9 3.8Six 2 .8

Place of Birth Was Significant

ANOVA (F (2,221) = 3.69, p< .03)

Pair Wise Comparisons

• Presence Mean SD

• IHBC 189.92 15.35

• Transfer 191.55 12.91

• SLDU 180.53 27.85

Comfort/Coping Techniques

Technique Frequency Percent (%)

Warm Compress 159 67.1

Breathing 124 52.3

Music Therapy 114 48.3

Back Rub 109 46.0

Visualization 87 36.7

Massage 71 30.0

Shower 65 27.4

Comfort/Coping Techniques

Technique Frequency Percent (%)

Hot Water Tub 42 17.7

Aromatherapy 38 16.0

Cold Compress 28 11.8

Birth Ball 24 10.1

Position Change 21 8.9

Other 13 5.5

Hypnosis 3 1.3

Comfort/Coping Techniques

Breathing Techniques Were Significant

ANOVA (F (1,224) = 7.46, p =. 007)

• Breathing Tech Mean SD 189.82 16.79

• No Breathing Tech182.26 25.72

Comfort/Coping Techniques

Music Therapy Was Significant

ANOVA F (1,224 = 3.83, p = .05)

• Music Therapy Mean SD 191.68 12.82

• No Music Therapy 181.35 26.55

Not Significant

Characteristics MPPI Score SD

Primipara 183.86 27.86

Multipara 187.98 15.69

1-2 CNM’s 187.42 23.06

3 + CNM’s (Range = 3-6)

183.97 19.20

Medication 183.26 25.87

No Medication 187.97 18.93

Support Persons in ChildbirthNot Significant

Support Person Frequency (%)

• Husband/Partner 192 (81.0)• Mother 64 (27.0)• Doula 50 (21.1) • Sister 38 (16.0)• Other Person 32 (13.5)• Female Friend 23 (9.7)• Mother-in-law 22 (9.3)

Internal Consistency

• Present Study/Cronbach’s Alpha = .856

• Original Pilot Test/Cronbach’s Alpha = .92

• Original Study/Cronbach’s Alpha = .92

Conclusions

• Generalizable to: postpartum, low risk , young, primarily low income, Latina women

• A high level of nurse-midwifery positive presence (186.2) was perceived by women despite today’s current childbirth milieu

Implications for Practice

• Women focus on the content of the care provided more than the model of care

• Quality of interaction is probably more important than the amount of time spent with women

• Encourage the continued use and expansion of nurse-midwives in women’s health care

Implications for Practice

• Increase the number of in-hospital birth centers• Smaller case loads of patients during childbirth so

nurse-midwifery presence can be even more therapeutic

• Breathing techniques and music therapy are helpful adjuncts in midwifery care

• Husbands, and female relatives should also be encouraged to provide support

Future Research

• Examine the MPPI Index:

• in other patient populations

• different midwifery services and settings

• Examine the relationship of midwifery presence to overall satisfaction with labor and birth and other variables of midwifery care

References

• 1. Lehrman EJ. A theoretical framework for nurse-midwifery practice. Unpublished doctoral dissertation, The University of Arizona, Tucson, AZ. 1988.

• 2. American College of Nurse-Midwives. Philosophy of the American College of Nurse-Midwives Washington DC: ACNM, 2004.

• 3. Kennedy H. The essence of nurse-midwifery care. J Nurse-Midwifery 1995;40:410-417.

• 4. Kennedy H. A model of exemplary midwifery practice: Results of a Delphi

• study. J Midwifery Women's Health 2000;45:4-19. • 5. Thompson JD. Oakley D. Burke M. Jay S. Conklin M. Theory building in

nurse-midwifery: The care process. Journal Nurse-Midwifery 1989;34:120-130.

• 6. Kennedy H. Rousseau A. Low L. An exploratory metasynthesis of • midwifery practice in the United States. Midwifery 2003;19:203-214.

References

• 7. Hunter LP. Being with Woman: A guiding concept for the care of laboring • women. JOGGN 2002;31:650-657.• 8. Berg M. Lundgren I. Hermansson E. Wahlberg V. Women's experience of the encounter

with the midwife during childbirth. Midwifery 1996;12:11-15.• 9. Flemming V. (1998). Women-with-midwives-with-women: A model of • interdependence. Midwifery 1998;14:137-143.• 10 Frazer D. Women's perceptions of midwifery care: A longitudinal study to • shape curriculum development. Birth 1999;26:99-107.• 11. Frazer D. Murphy R. Worth-Butler M. A model of competence: The • consumer's perspective. Br J Midwifery 1996;4:576-580.• 12. Halldorsdottir S. Karlsdottir S. Empowerment or discouragement: Women's experience

of caring and uncaring encounters during childbirth. Health Care Women Int 1996a;17:361-379.

• 13. Mosallam M. ThomasL. Ezimokhai M. Women's attitudes towards • psychological support in labour in the United Arab Emirates. Archives Gynecol Obstet

2004;269:181-187.•

References

• 14. Bluff R. Holloway I. They know best: Women’s perceptions of midwifery• care during labor and birth. Midwifery 1992;10:157-164.• 15. Halldorsdottir S. Karlsdottir S. Journeying through labour and delivery:• Perceptions of women who have given birth. Midwifery 1996b;12:48-61.• 16. Hallgren A.& Kihlgren M. Olsson P. Ways of relating during childbirth:

An ethical responsibility and challenge for midwives. Nursing Ethics 2005;12:606-621.

•  17. Tarka M. Paunonen M. Social Support and its impact on mothers’ • experiences of childbirth. J Adv Nursing 1996;23:70-75.• 18. Walker J. Hall S. Thomas M. The experience of labour: A perspective

from those receiving care in a midwife-led unit. Midwifery 1995;11:120-129. • 19. Walsh D. An ethnographic study of women's experience of partnership • caseload midwifery practice: The professional as a friend. Midwifery

199;15:165-176.

References

• 20. Waldenstrom U. Borg I. Olsson B. Skold M. Wall S.. The childbirth experience: A study of 295 new mothers. Birth 1996; 23:144-153.

• 21. Janssen B. Wiegers T. Strengths and weaknesses of midwifery care from the perspective of women. Evid Based Midwifery 2006;4:53-59.

• 22. Lavender T. Walkinshaw S. Walton I. A prospective study of women's views of factors contributing to a positive birth experience. Midwifery 1999;15:328-334.

• 23. Too SK. Do birthplans empower women? A study of their views. Nurs Stand 1996;10:33-37.

• 24. Blix-Lindstrom S. Christensson K. Johansson E. Women's satisfaction with decision-making related to augmentation of labour. Midwifery 2004;20:104-112.

• 25. Lundgren I. (2004). Releasing and relieving encounters: Experiences of pregnancy and childbirth. Scand J Caring Sci 2004;18:368-375.