Lisa L. Paine

The association of childhood sexual abuse with depressive symptoms during pregnancy, and selected pregnancy outcomes

OBJECTIVES The objectives were: (1) to investigate the association during pregnancy of sexual abuse before the age of 18 on depressive symptomatology in pregnancy, controlling for the presence of negative life events and challenges; and (2) to investigate the association of selected pregnancy outcomes (maternal labor and delivery factors, infant birth weight and gestational age) with sexual abuse before age 18. METHODS Three hundred fifty-seven primiparous women aged 18 years and older were interviewed between 28-32 weeks gestation with reference to current functioning and past history (Objective 1). Medical record information was abstracted after delivery for pregnancy, labor and delivery factors, and pregnancy outcomes (Objective 2). RESULTS Thirty-seven percent of the women reported past sexual abuse. Prevalence was not associated with ethnic background, educational level, or hospital payment source. Previously sexually-abused pregnant women reported significantly higher levels of depressive symptomatology, negative life events, and physical and verbal abuse before and during pregnancy. There were no significant associations found between past sexual abuse and labor or delivery variables or newborn outcomes. CONCLUSIONS Previously sexually-abused pregnant women reported a wider constellation of past and current functioning problems than nonabused women although past sexual abuse was not associated with pregnancy outcome. Prenatal care provides a unique opportunity to evaluate the impact of life history and current life events during pregnancy, and to develop a coordinated intervention plan.

PRIMARY CARE FOR WOMEN: Cultural Competence in Primary Care Services

The assessment of cultural competence in providing primary care services (or women is addressed Emphasis is placed on the ways in which cultural competency attainment can ensure the availability of key primary care components to all women, especially those from certain vulnerable populations and those who have specific primary health care needs, A cultural competence continuum is described that will assist providers in an assessment of their own cultural competency levels, as well as those of the service settings in which they practice. Six scenarios are provided, describing experiences at each level of the continuum that may hinder the development and delivery of effective primary care service interventions. Examples of ways in which nurse-midwives can provide leadership in the area of cultural competence in womens primary care are also included.The assessment of cultural competence in providing primary care services for women is addressed. Emphasis is placed on the ways in which cultural competency attainment can ensure the availability of key primary care components to all women, especially those from certain vulnerable populations and those who have specific primary health care needs. A cultural competence continuum is described that will assist providers in an assessment of their own cultural competency levels, as well as those of the service settings in which they practice. Six scenarios are provided, describing experience at each level of the continuum that may hinder the development and delivery of effective primary care service interventions. Examples of ways in which nurse-midwives can provide leadership in the area of cultural competence in womens primary care are also included.

Nurse-midwifery care to vulnerable populations: Phase I: Demographic characteristics of the National CNM sample

The purpose of this article is to describe the extent to which certified nurse-midwives (CNMs) provide care to vulnerable populations in the United States and the source of reimbursement for this care. The data were obtained from the first phase of a national study to address the characteristics of women served and cost of care provided by CNMs. Results were analyzed nationally and by American College of Nurse-Midwives regions. Certified nurse-midwives in all types of practices are providing care to women from populations that are vulnerable to poorer than average outcomes of childbirth because of age, socioeconomic status, refugee status, and ethnicity. Ninety-nine percent of CNMs report serving at least one group of vulnerable women, and CNMs in the inner city and rural practices serve several groups. The vast majority of CNMs are salaried; only 11% receive their primary income from fee-for-service. Fifty percent of the payment for CNM services is from Medicaid and government-subsidized sources whereas less than 20% comes from private insurance. Source of income varies by type of setting in which the CNM attends births. The results suggest that CNMs, as a group, make a major contribution to the care of vulnerable populations.

TWELVE YEARS AND MORE THAN 30,000 NURSE‐MIDWIFE‐ATTENDED BIRTHS: The Los Angeles County + University of Southern California Women's Hospital Birth Center Experience

This article describes the setting, policies, practices, and outcomes of the nurse-managed in-hospital birth center at Los Angeles County + University of Southern California Womens Hospital, where women are selected upon admission for birth center care. A retrospective review of available data was made; when compared with hospital records, the primary data source was found to be 96% accurate. Results of the review indicated that from 1981 to 1992, there were 36,410 birth center admissions and 30,311 births, all attended by nurse-midwives; no intrapartum maternal or fetal deaths occurred among all admissions. The intrapartum transfer rate averaged 17%, and declined steadily from a high of 28% in 1982 to a low of 7% in 1990. More in-depth review showed an overall primary cesarean birthrate of 1.8% and an operative birthrate of 4% among the 25,890 admissions and 22,490 births from 1985 to 1992. Detailed postpartum and newborn outcomes from 1982 to 1986 showed a neonatal intensive care unit admission rate of 1.5% and a one-week newborn readmission rate of 1.3% among newborns discharged within 12 to 24 hours; 85% of all newborns returned for follow-up care. This large longitudinal experience demonstrates excellent outcomes that can be achieved when nurse-midwives, working cooperatively with a multidisciplinary health care team, provide in-hospital birth center care to a predominately low-income Hispanic population using a variety of less-traditional intrapartum management techniques. Broader implications for making alternative maternity care services available for low-income women with nurse-midwives and nurses playing a central role are discussed.

Home Birth in The United States, 1989–1992: A Longitudinal Descriptive Report of National Birth Certificate Data

This study was conducted to profile home birth in the United States from 1989 to 1992 using two birth certificate data sources from the Natality Branch of the National Center for Health Statistics (NCHS). Analysis included published and unpublished descriptive tables about all U.S. home births from 1989 to 1992, and a subset of the 82,210 U.S. home births from 1989 to 1991 that were drawn from NCHS national birth certificate data tapes. Results indicated that less than one-third of reported home births were attended by nurse-midwives or physicians. Distinct regional patterns in the frequency of home births were observed, with higher concentrations in the southwestern and western states. When compared with the average childbearing woman in the United States, mothers who gave birth at home were more likely to be older, have fewer years of education, be married, and be white; they were also more likely to be of higher parity and to receive less prenatal care. Home birth mothers were less likely than average to smoke or drink alcohol prenatally, to have a prenatal medical risk condition or an obstetric complication, or to receive certain prenatal tests. The outcomes of newborns born at home compared favorably to the national average during the same period. Several findings varied considerably by race or ethnicity of the mother.

Investigation of institutional differences in primary cesarean birth rates.

Differences in primary cesarean birth rates between a maternity center staffed by certified nurse-midwives (CNM) with physician backup on the premises and a university teaching hospital staffed by resident and attending physicians were studied. The study sample included 796 and 804 women, similar in demographics, who received their prenatal and intrapartum care in the respective sites in 1977 and 1978. Study results indicate a significantly lower rate of primary cesarean birth at the maternity center than at the university hospital that was independent of institutional differences in the indications for abdominal delivery. Although cesarean birth was related to contracted pelvis (at labor), fetal malpresentation, and placental bleeding at both institutions, it was significantly associated with preeclampsia, primiparity, fetal distress, and maternal age only at the university hospital. There were no noteworthy differences in pregnancy outcomes for women delivered vaginally or by cesarean, except for more newborns with low Apgar scores among primary cesarean births at the university hospital. A likely explanation for these findings is differing labor and delivery management styles between the providers of care at the two institutions.

PRIMARY CARE FOR WOMEN: An Overview of the Role of the Nurse‐Midwife

The nurse-midwifes past, present, and future roles in the primary care of women are explored using a recent Institute of Medicine report on primary care as a framework for discussion. Primary care, the scope of services, and the role of the primary care clinician are described, and specific strategies for a primary care emphasis in basic nurse-midwifery education are addressed. The nurse-midwifes future roles in collaborative practice for the primary care of women and the need for continuing education opportunities in primary care are also discussed.The nurse-midwifes past, present, and future roles in the primary care of women are explored using a recent Institute of Medicine report on primary care as a framework for discussion. Primary care, the scope of services, and the role of the primary care clinician are described, and specific strategies for a primary care emphasis in basic nurse-midwifery education are addressed. The nurse-midwifes future roles in collaborative practice for the primary care of women and the need for continuing education opportunities in primary care are also discussed.

Antepartum fetal assessment: A nurse-midwifery perspective

This article provides an in-depth review of the most current antepartum fetal assessment techniques. Included in this review are both low- and high-technology methods, such as fetal movement counting, nonstress tests, vibroacoustic stimulation, auscultated acceleration tests, contraction stress tests, amniotic fluid index, biophysical profiles, and Doppler velocimetry. The interpretation of antepartum testing using screening test validity concepts is addressed, as is the current and emerging role of the nurse-midwife in fetal assessment. By integrating content on maternal and fetal physiology, including a critical review of current literature, together with relevant clinical information, including protocols, this article provides a useful guide to fetal assessment for nurse-midwives.

The effect of maternal bearing-down efforts on arterial umbilical cord pH and length of the second stage of labor☆

This study was conducted to compare two types of maternal bearing-down techniques as they relate to the fetal and maternal outcomes of arterial umbilical cord blood pH and length of the second stage of labor. A convenience sample was drawn from the laboring women at a 305-bed medical center who met specific inclusion criteria. Women self-selected to one of two bearing-down groups: spontaneous or Valsalva. Subjects were given specific instructions for the chosen method. The Valsalva group was comprised of 14 subjects, and the spontaneous group was comprised of 16 subjects. The groups were found to be comparable after analysis of several variables. Results of statistical analysis using t-test indicated that, in this small sample, there is no relationship between the second stage bearing-down method and arterial umbilical cord blood pH or length of the second stage of labor. These findings support the conclusions of several studies: using the spontaneous bearing-down method does not have a deleterious effect upon the mother or the fetus. Several recommendations are made for future research based on methodological issues raised during this study.

A Comparison Of Visits And Practices Of Nurse‐Midwives And Obstetrician‐Gynecologists In Ambulatory Care Settings

With more than 5 million patient visits annually, certified nurse-midwives (CNMs) substantially contribute to womens health care in the United States. The objective of this study was to describe ambulatory visits and practices of CNMs, and compare them with those of obstetrician-gynecologists (OB/GYNs). Sources of population-based data used to compare characteristics of provider visits were three national surveys of CNMs and two National Ambulatory Medical Care Surveys of physicians. When a subset of 4,305 visits to CNMs in 1991 and 1992 were compared to 5,473 visits to OB/GYNs in similar office-based ambulatory care settings in 1989 and 1990, it was found that a larger proportion of CNM visits were made by women who were publicly insured and below age 25. The majority of visits to CNMs were for maternity care; the majority of visits to OB/GYNs were for gynecologic and/or family planning concerns. Face-to-face visit time was longer for CNMs, and involved more client education or counseling. This population-based comparison suggests that CNMs and OB/GYNs provide ambulatory care for women with diverse demographic characteristics and differing clinical service needs. Enhancing collaborative practice could improve health care access for women, which would be especially beneficial for those who are underserved and vulnerable.