Nurse Midwives Create a Meaningful Birth Experience within a Laborist Care Model

Abstract

Objective

In a laborist service, midwives and physicians meet the women they will care for and deliver when those patients present in labor. Laborist midwives and physicians provide evidence-based care while establishing a personalized and patient-centered birth experience. This was an interpretive descriptive project with the aim to: Identify and outline strategies utilized by laborist service midwives to enhance a woman's birth experience.

Methods

An open inquiry design was employed to identify and name common themes and ideas utilized by laborist midwifery to create bonded relationships with the women they attend. Six midwives practicing in a laborist service were interviewed utilizing a semi-structured interview format. The interviews were digitally recorded and transcribed; the transcribed interviews were reviewed to elucidate recurring ideas and themes in midwifery laborist practice. These specific ideas were coded and grouped.

Results

Most midwives interviewed described their participation in the birthing process as a spiritual experience. These laborist midwives expressed a deep commitment to enabling a personal, authentic, and meaningful experience for the women they care for. Despite never meeting the women prior to admission in labor and delivery, all the midwives described specific experiences and strategies they used to create meaningful bonds with women and their families.

Keywords

Laborist Service, Laborist, Birth Experience, Certified Nurse Midwife, Midwife, Interpretive Description

Introduction

The hospitalist model of care has been growing in the United States (U.S.) since Wachter [1] first described the term and role in 1996, this hospitalist trend has extended to the needs of women in labor. First described by Weinstein [2] in 2003, a laborist is a hospitalist who focuses their practice on the care of pregnant women presenting for admission to a hospital's labor and delivery unit [2]. Laborists work to provide care steeped in evidence that is founded in scientific proofs thereby eliminating practices that are not evidence-based [3,4]. The Society of OB/GYN Hospitalists (SOGH) recognizes that a laborist may be either a certified nurse-midwife (CNM/CM) or an obstetrician/gynecologist [5]. Currently, the exact number of laborists currently practicing in the U.S. is not known; however, a 2010 survey by the National Perinatal Information Center/Quality Analytic Services revealed 40% of their member hospitals employed laborists [6,7]. Hospitals and providers using a laborist care model work to ensure personal and meaningful birth experiences, an important consideration for their patients presenting to labor and delivery units [6,8].

A laborist care model can offer many benefits: Reduced cesarean delivery rates, focusing on patient-centered care, improved care quality, increased rates of vaginal birth after previous cesarean (VBAC), increased provider job satisfaction, and immediate provider availability in emergencies [7,9-11]. The presence of a laborist has been associated with a greater standardization of care, increased interdisciplinary cooperation, and a reliable flow of information [4,8,12-15]. Furthermore, hospitals may adopt the laborist model as a means to combat provider fatigue and address both long call shifts and the increasing trend of maternal mortality in the U.S. [4,16]. The laborist model has been met with various degrees of acceptance and repudiation [3,17]; moreover, the laborist model represents a huge change in thinking for both patients and providers [6]. Some believe it is simply not possible to develop a supportive, trusting relationship between a laboring woman and a provider she has just met, such a relationship could only result in an impersonal birth experience [17]. Adding midwives to the laborist model blends both the midwifery and laborist care models and has been associated with improved outcomes [8,18]. Midwives bring expertise in managing normal labor and delivery and offer postpartum support and education. Authoritative professional groups including the American College of Nurse Midwives (ACNM) and SOGH support midwives in the laborist role [5,11,19].

At one hospital in a large metropolitan area, a 'laborist service' model has evolved in which a midwife and an obstetrician/gynecologist work together and share the laborist role. A laborist service may be defined as a hospital-based practice that utilizes interprofessional collaboration to optimize the attention and evidence-based care provided to women during their labor and delivery. A laborist service emphasizes the strengths and skills of both physicians and midwives and encourages interprofessional collaboration and respect. At this hospital, the laborist (midwife or physician) delivers most women who present in labor or for induction of labor. The providers in the laborist service do not work in an office or clinic. Laboring women and delivering providers meet for the first time when the patient is admitted to labor and delivery. All women presenting with uncomplicated pregnancies are managed and delivered by midwives.

Laborist midwives offer a broad coverage of the labor, delivery, and postpartum care units and ensure better cost management versus two physicians sharing the laborist responsibilities [8,20]. Midwives influence a woman's birth experience through the power of presence [21]. Therapeutic presence is demonstrated when midwives take time to explore thoughts, feelings, beliefs, or desires about birth, and respect the individuality of each woman and her family [21]. Midwives work to create a relationships with a laboring woman by demonstrating acceptance, listening, and avoiding the need to 'fix' or alter their patient or her experience [21,22]. It is through presence that midwives personalize a birth experience for a woman she has just met, sometimes by talking, offering a hand to hold, or simply being present.

The purpose of this project was to identify strategies laborist midwives employ to create an inclusive and personal birth experience. Birth, especially first birth, is a life-changing event; an event that ten years later women can recall in acute detail [23]. Women interviewed several years after their birth were able to recall unique details about the experience, and all of the women interviewed placed great value on providers and staff who listened and acknowledged their concerns and wishes [23]. Knowledge and familiarity between a woman and her provider can facilitate a therapeutic relationship during labor and birth; this relationship can positively contribute to a meaningful birth experience [9,23,24]. A therapeutic relationship is a helping relationship based on trust and respect, meeting the needs of the patient, and developing a sensitivity to the individuality of each person [25]. Laborist midwives can develop therapeutic relationships and enhance connections to create productive and meaningful experiences during labor.

Methods

Design

Little information exists about how midwives establish a relationship with the women they care for during birth, yet the midwife/parturient relationship remains at the center of the laboring woman's birth experience. This qualitative, interpretive descriptive project sought to elucidate common themes and techniques employed by laborist midwives to personalize a woman's delivery experience. A framework of interpretive description was utilized for this project to bring structure and rigor to the inductive analysis of the data collected [26]. Interpretive description is a set of strategies employed as a framework for qualitative inquiry [26]. Interpretive description is not a set method or prescription for providers to follow; rather it is a series of guidelines designed to help qualitative investigators begin to explain complex clinical phenomenon [birth] [27].

Participants and methods

Purposeful sampling was used to identify potential participants in this descriptive study. Participants were recruited based on their work with a laborist service and lack of other potential patient contact opportunities. Inclusion criteria for interview participants included: At least a year of midwifery experience, current AMCB certification, at least 6 months experience in the laborist role, and previous practice experience in a non-laborist care model. There are many midwives who care for patients they have never met as part of an 'on call' or 'walk-in call' rotation, however, participant recruitment was specific to those midwives who work exclusively as a laborist. The potential pool of participants was small (six) as there were few midwives who self-identified as exclusively working as a laborist. Potential participants were approached by email and if agreement was given, a date and time was scheduled for the interview. All 6 midwives identified as potential participants agreed to be interviewed. Participants were contacted by email by the primary investigator and a mutually agreeable time and location was scheduled.

Permission to conduct this interpretive descriptive project was obtained from the Institutional Review Board of the University of Alabama. Informed consent was obtained from all participants prior to beginning any interviews. Information about the purpose of the project as well as confidentiality of recordings and transcripts was provided to participants. The participants were not identified by name in the audio recordings and no identifying information was noted on any of the audio transcripts. The primary investigator ensured participant anonymity throughout both the audio recordings and written transcripts.

The same 10 basic questions were asked of all interview participants. The questions evolved from peer discussions and informal meetings between the primary researcher and laborist midwives inquiring how they felt about their roles. During these informal encounters, some midwives, regardless of length of experience, indicated they felt comfortable interacting with a variety of patients and families, even those they were meeting when they presented in labor. Some of the questions were designed to elicit responses that would help describe techniques that led to positive patient interactions. Other questions were specifically designed toward inquiring how, specifically, the laborist midwives initiated their patient/family relationships. The last group of questions was designed to identify how each midwife felt about attending births and their role as a laborist (Table 1).

Data collection and analysis

The interviews were conducted in a private, quiet setting using an investigator-developed, semi-structured interview guide to ensure standardization of questioning of participants. A semi-structured interview allows all participants to be asked the same questions without a defined order but within a defined framework [28]. A semi-structured format allowed the interviewer to use open-ended questions with flexibility in the wording and in an order that flowed more naturally from the topics and experiences shared by the participants [29].

All participant interviews were audio-digitally recorded; the recordings were then transcribed verbatim. The interview transcripts were checked against the audio recording. The audio files were played and re-played while reading the written transcription to verify the accuracy of the written transcripts. Repeated reviews of both the audio and written transcripts compelled the primary investigator to become familiar with recurrent responses and ideas in response to interview questions.

Specific ideas and actions that emerged in response to the different questions were highlighted and then grouped with each question. An emic approach was used to identify recurrent responses that were repeated across participants. Once specific actions and responses were identified and grouped, inductive reasoning was applied to these repeated responses to identify themes and codes in the data [30]. Interpretive description was used as guide when exploring the relationship between the interview questions, responses, and concepts uncovered [29]. The themes that emerged from the data became the categories for analysis [30]. This thematic approach is a means of conducting a hermeneutic analysis to identify non-numerical codes for exploration [29]. The codes were then grouped into coherent categories [30], which were used to develop the project themes [31]. The codes were then subdivided into each of these theme groups: How midwives felt about the laborist role, midwife-patient relationship, and the birth experience. The codes and themes were then matched with the interview question used to elicit the information from the project participants. This redundancy assured that the identified codes and themes used correlated with the data obtained (Table 2).

Sample

Of the 6 nurse midwives interviewed, 100% were female, all six held a master's degree in nursing, and 2 had completed a DNP. All midwives practiced deliveries exclusively within the laborist service at a suburban, community hospital. Four midwives identified as white, non-Hispanic, one as African American, and one as multi-racial. Years of experience as a midwife ranged from 2 to 26 years with an average of 13 years. Participant age ranged from 30 to 57 with an average age of 48.5 years of age. The laborist service midwives attend approximately 50 births per month.

Results

An early codebook was developed by following the literature review, suggestion of themes based on coherent categories, and preliminary coding [30]. The first read of the transcripts and audio review generated a list of recurrent comments. These comments were highlighted and compiled into a list. A second read confirmed the correlation of comments with preliminary codes. The recurrent comments were then paired with the question that generated those comments. This grouped list was then used to identify codes based on each of the questions asked; a short, descriptive phrase was used for the code that evolved from the interview question [30,31] (Table 3).

Laborist role

All the nurse midwives interviewed expressed a high degree of satisfaction with the laborist model of care. Recurrent comments focused on greater patience with the normal process of labor. All the midwives expressed they did not feel rushed to get a patient delivered and believed they intervened in the labor process less often than in previous practices.

There's no rush in patient management, there's much more room to respect the patient and family's wishes and desires. I feel like the patients get better care and more care because we are dedicated to being present. There's more flexibility within the laborist group to wait for change and allow labor to progress rather than rush to delivery.

All the midwives also expressed feeling a greater degree of collegiality and interprofessional cooperation with the physicians they worked with. They stated they felt like the physician-midwife relationship was more respectful, there was better listening in both directions, and the physicians uniformly expressed gratitude and respect for the skill, knowledge, and experience the midwives brought to the laborist service.

I feel like there's a greater level of trust...that also comes with a greater level of respect from the physicians.

This was a sentiment repeated throughout all the midwife interviews. When asked how the laborist role was different from previous practice roles, the idea that repeated most often was that there was no pre-existing relationship with the patient or family. However, as one midwife pointed out, in healthcare, we are often meeting patients for the first time in almost any setting.

...in healthcare you're almost always meeting someone for the first time, whether you're seeing them in the clinic or you're in labor and delivery. I have [more than] 20 years of experience of walking into a room and meeting someone for the first time. I just try to be completely present, a lot of eye contact, and do what I can to help them relax with me, feel connected, and feel safe.

Interviewees were asked how they present themselves and their roles to patients, especially since some of the patients presented from practices that did not have midwives in their care model. There was only one midwife who reported the experience of patients requesting a physician-only birth. All participants described explaining a 'team approach,' nurses, midwives, and physicians working together to provide care and support.

We [midwives] are experts in laboring and delivering women, we are always present, and we are available to spend more time with you. We [midwives] want to keep the power and focus with you [the patient], we are here to facilitate, support, and guide.

Midwife-patient relationship

The interview question designed to establish the foundation of this relationship was 'how do you present or introduce yourself to your patients?' Hospitalization can be a very out of control experience, the first encounter with a patient and her family can affect the patient's whole experience of hospitalization and birth. All the midwives described how they introduce themselves, their experience, and their role in their [the patient's] birth. Five of the midwives (83%) stressed that they try to establish the relationship as patient-focused and she [the patient] and the midwife will work together as a team. The emphasis with this group was keeping the focus on the patient and family (if the patient wished them to be part of the plan) and trying to honor any wishes or dreams she may have for her birth. The 'first date' metaphor was repeated a few times when describing how they establish a relationship with the patient and family.

It's like being on a first date, we're meeting, getting to know each other and laying the foundation for our relationship. We try to find a way to relate on a personal level.

It's important to me that during the introduction they see me not just as a care provider or staff member and [realize] I recognize they are not just a patient in a bed.

Most of the midwives describe this meeting as the time they sit at the bedside (to convey respect and a willingness to listen) and devote themselves and their time to the patient and family. This is the time they will discuss the patient's hopes for labor and delivery and negotiate as needed.

Participants were asked if they ever resist engaging on a personal level with their patients since they know they will never see them again; all interviewees answered 'no.' Even if the patient may be perceived as difficult, several stated that perhaps no one had tried really listening to her concerns or wishes. One midwife felt strongly that her interactions with the patient and family were 'pieces of her labor puzzle, if they don't fit together well, she may have a negative experience.'

The last midwife-patient relationship question focused on delivering bad news; did the laborist midwives perceive this as a greater challenge since they did not have an established relationship with the family. Depending on the laboring woman, bad news could be the need to augment the labor, get an epidural, or explain a failed labor/need for a cesarean delivery. All midwives voiced honesty and respect as key concepts when delivering what the patient may perceive as bad news. Participants also all stated they sit at the bedside to ensure they are speaking at eye-level with the patient rather than standing over the patient. Participants also acknowledged the need to include anyone the patient felt was important into the discussion.

This is a brand-new relationship so it's really important to be respectful. I try to explain what is going on in a way the patient and family will understand. I try to help her understand so she doesn't feel like something has happened to her, rather she's part of the decision in the way her delivery went.

Experience of birth

Two questions were designed to elicit the participant midwife's personal feelings about participating in a woman's labor and birth. All midwives expressed feeling that birth was the best part of midwifery. All participants expressed great satisfaction and feeling 'honored' they were asked to participate in a woman's labor and birth. A common comment was 'each birth is as unique as the mother and family.' When asked how being a woman's birth attendant made them feel, midwife responses varied from embracing the experience as a 'huge responsibility,' 'feeling pride at being invited to share this experience,' and 'wanting to create a positive, lifelong memory of the birth.' One midwife stated that delivering babies was the reason she became a midwife and it is the part of the job she enjoys most.

I became a midwife to deliver babies not to do pap smears and vaginitis and those kinds of issues. This is my dream job, just delivering babies.

The question 'what is your experience of birth or attending births' evolved into 'in a few words, tell me your philosophy of the birth experience.' All participants expressed recognition of birth as a life-changing event, that each patient has a story of her labor and birth, and they get to be part of this family's birth story. Most recognized the importance of their roles and how what they say and do can possibly make an indelible impression on the patient and family.

I'm with them as they join the 'tribe of motherhood,' if we don't support each other and build each other up, we're not doing it right. It's an amazing honor to get to be the first person who touches this baby.

Discussion

All the midwives expressed a high degree of satisfaction with the laborist role. Interviewed midwives verbalized positive responses from the families they cared for. The consistent interprofessional relationship and cooperation with the laborist physicians was a big source of the midwives' job satisfaction. The midwives expressed confidence and trust with the laborist physicians; uniformly, the midwives said the physicians were amenable to consultation or lending help even in the middle of the night. The midwives all expressed a greater perception of trust and collegiality from the physicians, the midwives felt more like a colleague or valued team member than they had in previous practice models.

Most of the midwives expressed the feeling that for them, birth was a spiritual experience. These laborist midwives expressed a deep commitment to enabling a personal, authentic, and meaningful experience for the women they care for. Despite never meeting the women prior to admission in labor and delivery, all the midwives described specific experiences and strategies they used to create meaningful bonds with women and their families. These patient-midwife bonds enabled the creation of meaningful birth experiences for the patient and their families. Finding common ground at the initial meeting was a key point most of the midwives focused on; relating to or connecting with the patient and family on a personal level. Various strategies to open lines of communication included: Noting or commenting on something about the patient or family, her occupation, her nail polish, their college. Most of the midwife participants tried to find something that would connect them on a human level not just as provider-patient. Once a line of communication was established, the midwife and laboring woman would have a discussion, negotiate, and together, lay out the plan for the day. None of the midwives stated they ever resisted engaging themselves on a personal level in the patient-midwife relationship.

The laborist midwives' willingness to engage the patient on a personal level and invest themselves in the relationship was the foundation for a respectful, bonded relationship. As they became more bonded with their patients, the midwives expressed in words or actions their philosophy of birth. For some patients this may be respecting their desire to avoid interventions and let labor progress as naturally as possible, while for others, minimizing pain or discomfort may have been the patient's primary focus. Though all expressed it differently, birth was viewed as a landmark event in every woman's (and family's) life. The midwives interviewed expressed feeling a responsibility to the patient and her family to ensure the laboring woman's birth was a personal and meaningful event.

It may seem improbable that a bonded relationship can occur between a midwife and a laboring woman who first meet on the day (or night) of her delivery. This descriptive project suggests it is possible to create a meaningful relationship and birth experience for a patient a laborist midwife has just met. This relationship is dependent on the midwife's willingness to invest in the relationship with the patient and her family. Listening, respect, and honoring wishes (when safe) are key concepts to fostering this relationship. Connecting on a human and not just an obstetrical level is also key to building a trusting relationship. Speaking at eye level, negotiating, and keeping the patient at the center of care were deemed important to fostering the new relationship.

Implications for practice

A laborist service can potentially address all three IHI components: Improving the health of populations (pregnant women), reducing costs (streamlining the number of providers needed to cover labor and delivery), and improving the experience of care (incorporating midwives to assure an individual and personal birth experience) [3,8-10,24,32,33]. The laborist service model of care may only expand as future data support a reduction in primary cesarean deliveries, decreases in severe maternal morbidity and mortality, and fewer patient safety events [3,9,20,22,23,32]. A laborist service allows the seamless integration of both the obstetric/medical model (problem management) and the midwifery model (considers cultures, attitudes, and feelings about birth) [4,8,22,24]. The provider who attends a patient's birth influences the birth experience and the patient and family's memory of that experience.

Within this group of midwives, establishing a connection with the patients was key to creating a personal and meaningful birth experience for the laboring woman. These social, 'human' connection skills are generally not part of nursing or midwifery curricula. As use of technology in health care and everyday life grows, midwives as a group may need to engage in simulation exercises to learn and reinforce skills needed when establishing a patient-midwife bond. Activities that replicate patient-midwife interactions may be valuable in teaching and reinforcing skills like: Active listening, sitting when speaking to the patient and family, and encouraging the patient to be a partner in care rather than inform her what the plan for her labor will be.

Limitations

This descriptive project is limited by the size of the participants available for interview. There are currently (as of May, 2019) 12,436 actively certified midwives in the U.S. [34]. Despite reaching out to SOGH, ACNM, and the American Midwifery Certification Board (AMCB), there are no good data regarding the number of midwives who practice exclusively as a laborist.

Conflict of Interest

The authors have no conflicts of interest to disclose.

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