Journal of Midwifery & Women’s Health
www.jmwh.org
Commentary
Collaboration Between Midwives and Nurses: Past, Present, and Future Catherine H. Ivory, PhD, RNC-OB, RN-BC
Midwives and nurses who care for women and newborns both have a rich history. Our respective histories have commonalities and differences. Our commonalities focus on the shared goal of ensuring the health and safety of the women and newborns under our care, while our differences center around our education and respective scopes of practice. Given that maternal morbidity and mortality in the United States are on the rise, national health care focus is shifting to primary and preventative care, and there is increased interest in maternity care, it is important to talk about how our professions collaborate in order to meet our shared goal and mobilize other collaborative opportunities. UNDERSTANDING THE PAST
Early in the 20th century, an increase in maternal mortality led to expansion of both obstetrician-gynecologist practice and European models of midwifery by maternal care-focused public health nurses.1 In the 1950s, nurse-midwives sought specialty status through the American Nurses Association. When it was not granted, the American College of NurseMidwifery, which later became the American College of Nurse-Midwives (ACNM), was formed. Repercussions of the split between nursing and midwifery continued through the remainder of the 20th century.1 At the same time that birth was moving into the hospital, technological interventions for childbearing women increased. As the frontline health care providers in hospital settings, nurses underwent our own professional identity development and tensions. The Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG) formed in 1969. In 1993, NAACOG separated from the American College of Obstetricians and Gynecologists (ACOG) and became the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), creating an independent organization of nurses caring for women across the lifespan and their newborns. AWHONN’s mission is to improve and promote the health of women and newborns. Creating our own professional identity separate from ACOG allowed AWHONN to broaden its support for nurses who care for women and newborns, but it caused tension among nurses and our physician colleagues. Today, AWHONN’s membership is close to 25,000 and includes staff nurses, nurse administrators, nurse educators, and
nurse researchers—as well as nurse-midwives and other advanced practice nurses caring for women and newborns. We are proud that a nurse-midwife is a key member of the AWHONN headquarters staff and that the editors of both AWHONN professional journals—the Journal of Obstetric, Gynecologic, & Neonatal Nursing (JOGNN) and Nursing for Women’s Health—are nurse-midwives. AWHONN’s mission to improve and promote the health of women and newborns fits perfectly with ACNM’s vision to advance the health and well-being of women and newborns by setting the standard for midwifery excellence. A brief grounding in our organizations’ histories is helpful while midwives and nurses remember our shared goal and celebrate all the ways that we have been working together. APPRECIATING THE PRESENT
Address correspondence to Catherine H. Ivory, PhD, RNC-OB, RNBC, Vanderbilt University School of Nursing, 461 21st Avenue South, 411 Godchaux Hall, Nashville, TN 37240. E-mail: catherine.h.ivory@ vanderbilt.edu
AWHONN released a position statement in 1985 in support of midwifery. The AWHONN Board of Directors has revised and reaffirmed this statement regularly, most recently in 2009. The midwifery position statement affirms, among other things, that midwifery care should be available to all women, noting that women should have access to all available information and options for their primary health care and childbirth experiences. The position statement also affirms that thirdparty reimbursement for midwives should be equal to reimbursement for other health care providers offering the same services, and midwives should have increased access to hospital privileges.2 The midwifery position statement, coupled with AWHONN’s mission to promote the health of women and newborns, has led to a number of joint advocacy, quality improvement, and educational activities between AWHONN and ACNM. For example, AWHONN joined ACNM in 2011 as a founding member of the Coalition for Quality Maternity Care. In 2014 alone, the Coalition has jointly advocated to the Centers for Medicare and Medicaid Services (CMS) for 4 quality measures specifically related to maternity care. Together, the coalition appealed to the Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission to include specific recommendations related to maternity care in its future reports. The coalition has supported CMS’ work to implement a quality rating system to assist consumers while they make decisions regarding health care coverage. In addition, it jointly endorsed the Improving Access to Maternity Care Act of 2014. Under ACNM’s leadership, the coalition has expanded to include 23 organizations, and it continues to bring together leading advocates in maternal health.
122
c 2015 by the American College of Nurse-Midwives
1526-9523/09/$36.00 doi:10.1111/jmwh.12305
Recognizing the importance of interdisciplinary care teams, AWHONN, ACNM, and several physician organizations came together in 2011 to issue a call to action for patient safety in labor and delivery, which was copublished in multiple journals, including JOGNN 3 and the Journal of Midwifery & Women’s Health.4 The call to action emphasized the importance of shared decision making and communication, noting: The choices a woman makes during the course of one pregnancy can affect her entire life course; therefore, information about the effect that care choices may have on a woman’s future should be discussed. Decisions about interventions should incorporate the woman’s personal values and preferences and should be made only after she has had enough information to make an informed choice in partnership with her care team. For this and other collaborative work, AWHONN was honored to receive the 2014 Exemplary Partner Award from ACNM. On the consumer front, AWHONN’s Go the Full 40 campaign (www.GoTheFull40.com) is designed to increase awareness among childbearing women and their families about the advantages of waiting for spontaneous labor to begin and avoiding nonmedically indicated labor inductions. The Go the Full 40 message aligns with ACNM’s Healthy Birth Initiative (http://www.midwife.org/ACNM-Healthy-BirthInitiative), which offers tools for women, maternity care providers, hospital policy makers, payers, and other organizations to support and promote the value of healthy, spontaneous labor and birth. The initiative’s online toolkit for providers, BirthTOOLS (www.birthtools.org), has a concise and complete cadre of evidence-based resources such as position statements from AWHONN and other stakeholders. EMBRACING THE FUTURE
In September 2014, AWHONN released a new position statement on the induction and augmentation of labor. The position statement asserts labor as a complex physiologic event involving the intricate interaction of multiple hormones that should not be initiated or altered without a medical indication. AWHONN called on nurses, childbirth educators, physicians, and midwives to proactively discuss the risks and benefits of labor induction and spontaneous labor with pregnant women so they are fully informed of the effects and risks of labor induction without medical need. Our work related to labor induction and augmentation will create additional opportunities to partner with ACNM. Also in 2014, AWHONN released a draft set of Women’s Health and Perinatal Nursing Care Quality measures for feasibility, reliability, and validity testing. These measures are designed to assess maternity care processes. Once testing is complete and the measures are final, these process measures will be tools for quantifying nursing’s specific role in health outcomes for women and newborns. AWHONN welcomes feedback from the midwifery community about our measures and encourages the use of the measures in clinical practice. Several measures that are particularly applicable to midwifery care (eg, 10a: Labor Support; 10b: Partial Labor Support; 11: Journal of Midwifery & Women’s Health r www.jmwh.org
Freedom of Movement During Labor; and 2: Second Stage of Labor, Mother-Initiated Pushing) offer opportunities for midwives to work alongside nurses to promote physiologic birth processes.5 With the passage of the Affordable Care Act in 2010, health promotion, wellness, and new models of care will be more important than ever before. Perinatal nursing practice must move beyond the walls of the hospital, whereas ambulatory and community-based settings are well-established locations for midwifery practice. An additional perinatal nursing-care quality measure developed by AWHONN, which applies to midwifery care and requires collaboration with nursing, is measure 9: Women’s Health and Wellness Coordination Throughout the Life Span.5 Midwives are well positioned to drive the coordination of care for healthy women from adolescence through the childbearing years and beyond. Nursing will need to find our place on this continuum while care (including education, wellness promotion, and support) moves beyond hospital walls and into the community. Care models that include multidisciplinary team members are essential to seamless care transitions. Professional nurses must be present with our midwife and physician colleagues in ambulatory and public health settings as well as inside the hospital. Promoting normal birth is an essential focus of midwifery education. Reports from schools of nursing suggest that women’s health and obstetric content is dwindling from the undergraduate setting. Furthermore, contemporary clinical rotations in undergraduate nursing programs offer fewer opportunities to observe births, and nursing students are subject to the culture of the setting in which these clinical experiences occur. As a result, nurses may not have the same exposure as midwives to normal physiologic birth, and they may have different expectations about what is normal. Such differences present opportunities for us to work together in the classroom, in simulated birth settings, and at the bedside to expose nursing students to the midwifery model of care. The ACNM Midwives Teaching Nurses Caucus is working to promote involvement of midwives in undergraduate nursing education. Members of the caucus have presented at ACNM annual meetings, and AWHONN would welcome abstract submissions on the subject of midwives teaching nurses for our annual convention and statewide section events. The current state of hospital birth includes interventions that nurses may consider commonplace and that midwives may consider unnecessary. Both midwives and nurses may believe that the other is jeopardizing patient care. For example, a midwife might think that a nurse is impeding normal birth by advocating for technological interventions, whereas the nurse perceives that patient safety may be compromised without technological interventions. Such an impasse can lead to poor communication, the biggest threat to patient safety. Outcomes are best when all care providers are valued as members of the health care team and all team members perceive that they are valued for their individual experience and expertise.6 Whenever midwives and nurses can find opportunities to work together on shaping hospital policies, shared governance, and orientation and education processes, we better understand each other’s points of view. As a result, we can improve the care of women and newborns. 123
As the 2014 president of AWHONN, the organization that represents more than 350,000 women’s health and newborn nurses, I believe the opportunities for midwifery and nursing learning and collaboration are endless. Midwives and nurses should be proud of the collaborative work we have already done, and we should be excited about all the things we can do together in the future to promote normal, physiologic birth and ensure excellent outcomes for women and newborns. AUTHOR
Catherine H. Ivory, PhD, RNC-OB, RN-BC, is Assistant Professor of Nursing at Vanderbilt School of Nursing in Nashville, Tennessee. She was the 2014 President of the Association of Women’s Health, Obstetric and Neonatal Nurses. CONFLICT OF INTEREST
The author is on the board of directors of the Association of Women’s Health, Obstetric and Neonatal Nurses. There are no other conflicts of interest to disclose.
124
REFERENCES 1.Dawley K. Perspectives on the past, view of the present: Relationship between nurse-midwifery and nursing in the United States. Nurs Clin North Am. 2002;37(4):747-755. 2.Association of Women’s Health, Obstetric, and Neonatal Nurses. AWHONN Position Statement: Midwifery. J Obstet Gynecol Neonatal Nurs. 2010;39(6):734-737. https://awhonn.org/awhonn/binary.content. do;jsessionid=18DC4DFDA7A95EA82E7AFB308008EF63?name= Resources/Documents/pdf/5 Midwifery.pdf. Accessed December 14, 2014. 3.Association of Women’s Health, Obstetric, and Neonatal Nurses. Quality patient care in labor and delivery: A call to action. J Obstet Gynecol Neonatal Nurs. 2012;41(1):151-153. 4.Quality patient care in labor and delivery: A call to action. J Midwifery Womens Health. 2012;57(2):112-113. 5.Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s Health and Perinatal Nursing Care Quality Refined Draft Measures Specifications. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses; 2014. https://awhonn.org/ awhonn/content.do?name=02 PracticeResources/02 perinatalqualitymeasures.htm. Accessed December 14, 2014. 6.Kennedy HP, Lyndon A. Tensions and teamwork in nursing and midwifery relationships. J Obstet Gynecol Neonatal Nurs. 2008;37(4):426435.
Volume 60, No. 2, March/April 2015
www.jmwh.org
Commentary
Collaboration Between Midwives and Nurses: Past, Present, and Future Catherine H. Ivory, PhD, RNC-OB, RN-BC
Midwives and nurses who care for women and newborns both have a rich history. Our respective histories have commonalities and differences. Our commonalities focus on the shared goal of ensuring the health and safety of the women and newborns under our care, while our differences center around our education and respective scopes of practice. Given that maternal morbidity and mortality in the United States are on the rise, national health care focus is shifting to primary and preventative care, and there is increased interest in maternity care, it is important to talk about how our professions collaborate in order to meet our shared goal and mobilize other collaborative opportunities. UNDERSTANDING THE PAST
Early in the 20th century, an increase in maternal mortality led to expansion of both obstetrician-gynecologist practice and European models of midwifery by maternal care-focused public health nurses.1 In the 1950s, nurse-midwives sought specialty status through the American Nurses Association. When it was not granted, the American College of NurseMidwifery, which later became the American College of Nurse-Midwives (ACNM), was formed. Repercussions of the split between nursing and midwifery continued through the remainder of the 20th century.1 At the same time that birth was moving into the hospital, technological interventions for childbearing women increased. As the frontline health care providers in hospital settings, nurses underwent our own professional identity development and tensions. The Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG) formed in 1969. In 1993, NAACOG separated from the American College of Obstetricians and Gynecologists (ACOG) and became the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), creating an independent organization of nurses caring for women across the lifespan and their newborns. AWHONN’s mission is to improve and promote the health of women and newborns. Creating our own professional identity separate from ACOG allowed AWHONN to broaden its support for nurses who care for women and newborns, but it caused tension among nurses and our physician colleagues. Today, AWHONN’s membership is close to 25,000 and includes staff nurses, nurse administrators, nurse educators, and
nurse researchers—as well as nurse-midwives and other advanced practice nurses caring for women and newborns. We are proud that a nurse-midwife is a key member of the AWHONN headquarters staff and that the editors of both AWHONN professional journals—the Journal of Obstetric, Gynecologic, & Neonatal Nursing (JOGNN) and Nursing for Women’s Health—are nurse-midwives. AWHONN’s mission to improve and promote the health of women and newborns fits perfectly with ACNM’s vision to advance the health and well-being of women and newborns by setting the standard for midwifery excellence. A brief grounding in our organizations’ histories is helpful while midwives and nurses remember our shared goal and celebrate all the ways that we have been working together. APPRECIATING THE PRESENT
Address correspondence to Catherine H. Ivory, PhD, RNC-OB, RNBC, Vanderbilt University School of Nursing, 461 21st Avenue South, 411 Godchaux Hall, Nashville, TN 37240. E-mail: catherine.h.ivory@ vanderbilt.edu
AWHONN released a position statement in 1985 in support of midwifery. The AWHONN Board of Directors has revised and reaffirmed this statement regularly, most recently in 2009. The midwifery position statement affirms, among other things, that midwifery care should be available to all women, noting that women should have access to all available information and options for their primary health care and childbirth experiences. The position statement also affirms that thirdparty reimbursement for midwives should be equal to reimbursement for other health care providers offering the same services, and midwives should have increased access to hospital privileges.2 The midwifery position statement, coupled with AWHONN’s mission to promote the health of women and newborns, has led to a number of joint advocacy, quality improvement, and educational activities between AWHONN and ACNM. For example, AWHONN joined ACNM in 2011 as a founding member of the Coalition for Quality Maternity Care. In 2014 alone, the Coalition has jointly advocated to the Centers for Medicare and Medicaid Services (CMS) for 4 quality measures specifically related to maternity care. Together, the coalition appealed to the Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission to include specific recommendations related to maternity care in its future reports. The coalition has supported CMS’ work to implement a quality rating system to assist consumers while they make decisions regarding health care coverage. In addition, it jointly endorsed the Improving Access to Maternity Care Act of 2014. Under ACNM’s leadership, the coalition has expanded to include 23 organizations, and it continues to bring together leading advocates in maternal health.
122
c 2015 by the American College of Nurse-Midwives
1526-9523/09/$36.00 doi:10.1111/jmwh.12305
Recognizing the importance of interdisciplinary care teams, AWHONN, ACNM, and several physician organizations came together in 2011 to issue a call to action for patient safety in labor and delivery, which was copublished in multiple journals, including JOGNN 3 and the Journal of Midwifery & Women’s Health.4 The call to action emphasized the importance of shared decision making and communication, noting: The choices a woman makes during the course of one pregnancy can affect her entire life course; therefore, information about the effect that care choices may have on a woman’s future should be discussed. Decisions about interventions should incorporate the woman’s personal values and preferences and should be made only after she has had enough information to make an informed choice in partnership with her care team. For this and other collaborative work, AWHONN was honored to receive the 2014 Exemplary Partner Award from ACNM. On the consumer front, AWHONN’s Go the Full 40 campaign (www.GoTheFull40.com) is designed to increase awareness among childbearing women and their families about the advantages of waiting for spontaneous labor to begin and avoiding nonmedically indicated labor inductions. The Go the Full 40 message aligns with ACNM’s Healthy Birth Initiative (http://www.midwife.org/ACNM-Healthy-BirthInitiative), which offers tools for women, maternity care providers, hospital policy makers, payers, and other organizations to support and promote the value of healthy, spontaneous labor and birth. The initiative’s online toolkit for providers, BirthTOOLS (www.birthtools.org), has a concise and complete cadre of evidence-based resources such as position statements from AWHONN and other stakeholders. EMBRACING THE FUTURE
In September 2014, AWHONN released a new position statement on the induction and augmentation of labor. The position statement asserts labor as a complex physiologic event involving the intricate interaction of multiple hormones that should not be initiated or altered without a medical indication. AWHONN called on nurses, childbirth educators, physicians, and midwives to proactively discuss the risks and benefits of labor induction and spontaneous labor with pregnant women so they are fully informed of the effects and risks of labor induction without medical need. Our work related to labor induction and augmentation will create additional opportunities to partner with ACNM. Also in 2014, AWHONN released a draft set of Women’s Health and Perinatal Nursing Care Quality measures for feasibility, reliability, and validity testing. These measures are designed to assess maternity care processes. Once testing is complete and the measures are final, these process measures will be tools for quantifying nursing’s specific role in health outcomes for women and newborns. AWHONN welcomes feedback from the midwifery community about our measures and encourages the use of the measures in clinical practice. Several measures that are particularly applicable to midwifery care (eg, 10a: Labor Support; 10b: Partial Labor Support; 11: Journal of Midwifery & Women’s Health r www.jmwh.org
Freedom of Movement During Labor; and 2: Second Stage of Labor, Mother-Initiated Pushing) offer opportunities for midwives to work alongside nurses to promote physiologic birth processes.5 With the passage of the Affordable Care Act in 2010, health promotion, wellness, and new models of care will be more important than ever before. Perinatal nursing practice must move beyond the walls of the hospital, whereas ambulatory and community-based settings are well-established locations for midwifery practice. An additional perinatal nursing-care quality measure developed by AWHONN, which applies to midwifery care and requires collaboration with nursing, is measure 9: Women’s Health and Wellness Coordination Throughout the Life Span.5 Midwives are well positioned to drive the coordination of care for healthy women from adolescence through the childbearing years and beyond. Nursing will need to find our place on this continuum while care (including education, wellness promotion, and support) moves beyond hospital walls and into the community. Care models that include multidisciplinary team members are essential to seamless care transitions. Professional nurses must be present with our midwife and physician colleagues in ambulatory and public health settings as well as inside the hospital. Promoting normal birth is an essential focus of midwifery education. Reports from schools of nursing suggest that women’s health and obstetric content is dwindling from the undergraduate setting. Furthermore, contemporary clinical rotations in undergraduate nursing programs offer fewer opportunities to observe births, and nursing students are subject to the culture of the setting in which these clinical experiences occur. As a result, nurses may not have the same exposure as midwives to normal physiologic birth, and they may have different expectations about what is normal. Such differences present opportunities for us to work together in the classroom, in simulated birth settings, and at the bedside to expose nursing students to the midwifery model of care. The ACNM Midwives Teaching Nurses Caucus is working to promote involvement of midwives in undergraduate nursing education. Members of the caucus have presented at ACNM annual meetings, and AWHONN would welcome abstract submissions on the subject of midwives teaching nurses for our annual convention and statewide section events. The current state of hospital birth includes interventions that nurses may consider commonplace and that midwives may consider unnecessary. Both midwives and nurses may believe that the other is jeopardizing patient care. For example, a midwife might think that a nurse is impeding normal birth by advocating for technological interventions, whereas the nurse perceives that patient safety may be compromised without technological interventions. Such an impasse can lead to poor communication, the biggest threat to patient safety. Outcomes are best when all care providers are valued as members of the health care team and all team members perceive that they are valued for their individual experience and expertise.6 Whenever midwives and nurses can find opportunities to work together on shaping hospital policies, shared governance, and orientation and education processes, we better understand each other’s points of view. As a result, we can improve the care of women and newborns. 123
As the 2014 president of AWHONN, the organization that represents more than 350,000 women’s health and newborn nurses, I believe the opportunities for midwifery and nursing learning and collaboration are endless. Midwives and nurses should be proud of the collaborative work we have already done, and we should be excited about all the things we can do together in the future to promote normal, physiologic birth and ensure excellent outcomes for women and newborns. AUTHOR
Catherine H. Ivory, PhD, RNC-OB, RN-BC, is Assistant Professor of Nursing at Vanderbilt School of Nursing in Nashville, Tennessee. She was the 2014 President of the Association of Women’s Health, Obstetric and Neonatal Nurses. CONFLICT OF INTEREST
The author is on the board of directors of the Association of Women’s Health, Obstetric and Neonatal Nurses. There are no other conflicts of interest to disclose.
124
REFERENCES 1.Dawley K. Perspectives on the past, view of the present: Relationship between nurse-midwifery and nursing in the United States. Nurs Clin North Am. 2002;37(4):747-755. 2.Association of Women’s Health, Obstetric, and Neonatal Nurses. AWHONN Position Statement: Midwifery. J Obstet Gynecol Neonatal Nurs. 2010;39(6):734-737. https://awhonn.org/awhonn/binary.content. do;jsessionid=18DC4DFDA7A95EA82E7AFB308008EF63?name= Resources/Documents/pdf/5 Midwifery.pdf. Accessed December 14, 2014. 3.Association of Women’s Health, Obstetric, and Neonatal Nurses. Quality patient care in labor and delivery: A call to action. J Obstet Gynecol Neonatal Nurs. 2012;41(1):151-153. 4.Quality patient care in labor and delivery: A call to action. J Midwifery Womens Health. 2012;57(2):112-113. 5.Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s Health and Perinatal Nursing Care Quality Refined Draft Measures Specifications. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses; 2014. https://awhonn.org/ awhonn/content.do?name=02 PracticeResources/02 perinatalqualitymeasures.htm. Accessed December 14, 2014. 6.Kennedy HP, Lyndon A. Tensions and teamwork in nursing and midwifery relationships. J Obstet Gynecol Neonatal Nurs. 2008;37(4):426435.
Volume 60, No. 2, March/April 2015
