Midwifery Care: Reflections of Midwifery Clients

Abstract

The purpose of this study was to describe the lived experience of midwifery clients throughout the life span. A qualitative study using a phenomenological approach was employed. In-depth interviews were conducted with a purposive sample of 12 midwifery clients. The research question was: What has been your experience with midwifery care? Interviews were audio-recorded and transcribed verbatim. Data saturation was achieved and analysis procedures from Colaizzi were used. Five themes emerged from the data: 1) decision to seek midwifery care; 2) working together in a therapeutic alliance; 3) formulating a birth plan; 4) childbirth education; and 5) nurse-midwives as primary health-care providers throughout the life span. There is much to learn from listening to the voices of midwifery clients.

According to historical accounts, as women gave birth, they always sought care and support from others. At some point in the cultural evolution, women who were experienced in attending others in childbirth became known as “midwives.” The term midwife means “with woman” (Aveling, 1977; Rooks, 1997; Varney, 1997) and dates back to the 14th century, with its etymology from Old and Middle English. However, accounts dating back to the 2nd century confirm the role of midwives in the birthing process, with the Hebrew Bible containing numerous verses about midwifery, such as Genesis 35:17 and 38:28 and Exodus 1:15-22 (Wansborough, 1985). Furthermore, the mention of birth attendants can be traced to ancient Greek and Roman civilizations as well as in the writings of old Hindu traditions. Evidence of midwifery has been told in myths, texts, and oral traditions. Thus, as a profession, midwifery claims a social role throughout history in all cultures.

Midwifery in today's health-care arena extends well beyond the childbearing season to include aspects of women's health care such as preconception care, perimenopausal and postmenopausal care, family planning and contraception, childbirth education, well-woman gynecology, and primary care throughout the life span. The midwifery model of care is client-focused and family-centered, embracing the holistic and humanistic principles of health maintenance, health promotion, client education, counseling, advocacy, and collaboration. Women from all walks of life use the services of nurse-midwives—from educated professionals to adolescents, midwifery clients represent the complete socioeconomic spectrum. Currently, there is great emphasis for women to seek preconception care to prepare themselves for a healthy pregnancy and a healthy child. Spearheaded by Dr. Michael Lu (2009), this new field of preconception care takes a life-care approach in the care of women and is much akin to the mission of nurse-midwives to provide care for women throughout the life span.

According to the American Midwifery Certification Board (2007), there are approximately 11,546 certified nurse-midwives and certified midwives in the United States. In 2006, the number of midwife-attended births reached a record high of 317,168 (Martin et al., 2007). Midwives are the most common birth attendants in the world (Rooks, 1997; Varney, 1997). Yet, a scarcity of research literature describes midwifery care from the vantage point of women who have experienced midwifery care throughout the life span as well as during the childbearing season.

The purpose of this study was to describe the lived experience of midwifery care in totality, which includes antenatal care, childbirth education, intrapartal care, postpartal care, well-woman gynecology, family planning, and primary care throughout the life span. By listening to the voices of women as they reflect on midwifery care, the essence of their experience was discovered. Such an investigation is timely and relevant in light of today's health-care arena in the United States, with the highest cesarean birth rate coupled with the highest elective epidural anesthesia rate for labor and birth. A movement toward elective cesarean birth is also emerging, with some women wanting to forego labor altogether and schedule a birth in a similar manner to scheduling a haircut or manicure.

Despite the alarming cesarean birth rate and the emergence of more requests for elective cesarean, numerous women still look to midwives for support, advice, and guidance as they seek a natural, informed, participatory experience for the conduct of normal labor and birth. These women marvel at the architecture of their bodies, the determination of their spirit, and the miracle of the process to bring a new life into the world. Yet, they do not seek to do this alone; rather, they rejoice in the partnership they have with a midwife who is “with woman” for the long haul.

Research on midwifery addresses numerous areas of interest in the midwifery model of care. Most of the previous research on midwifery has focused on the following topics:

• client care (Carolan & Hodnett, 2007; Fraser, 1999; Gilje, 1992; Green, Renfrew, & Curtis, 2000; Halldorsdottir & Karlsdottir, 1996; Kennedy, 1995, 2000; Kennedy, Rousseau, & Low, 2003; Page, 2003; Proctor, 1998);

• satisfaction (Goodman, Mackey, & Tavakoli, 2004; Hundley, Milne, Glazener, & Mollison, 1997; Knapp, 1996; Morgan, Fenwick, McKenzie, & Wolfe, 1998; Tinkler & Quinney, 1998; Waldenstrom, 1998);

• support (Berg, Lundgren, Hermansson, & Wahlberg, 1996; Bowers, 2002; Coffman & Ray, 1999; Fleming, 1998; Hodnett, 2002; Hodnett, Gates, Hofmeyr, & Sakala, 2002; Hunter, 2002, 2009; Lavender, Walkinshaw, & Walton, 1999; Tarkka & Paunonen, 1996); and

• outcomes (Gibbins & Thomson, 2001; Green, Coupland, & Kitzinger, 1990; Hardin & Buckner, 2004; Mackey, 1995; Proctor, 1998; Rooks, 1999).

In the realm of caring, Berg et al. (1996) conducted a phenomenological study in Sweden, which described the essential structure of client-midwife interaction during labor and birth as “presence” (p. 14). The researchers noted that presence includes three themes: 1) to be seen as an individual; 2) to have a trusting relationship; and 3) to be supported and guided on one's own terms.

Similarly, Lavender et al. (1999) explored aspects of the childbirth experience deemed “important” by women. The researchers identified the following main themes: support, information, intervention, decision making, pain relief, and participation. Their findings were reinforced by the work of Gibbins and Thomson (2001), who studied women's expectations of the childbirth experience and found active participation and the element of control to be key expectations.

The aforementioned research provides a foundation for the current study and supports the need for greater knowledge development in the area of midwifery care. Thus, the purpose of this study was to describe the lived experience of midwifery clients who chose to receive their health care from nurse-midwives throughout the life span.

METHOD

Design

The current qualitative study used a phenomenological approach to explore the experience of midwifery care from the point of view of midwifery clients. The phenomenological method aims to discover the genuine experience of the phenomenon of interest. The essence of the experience uses language and mindfulness to describe the experience. A study of this nature creates a plethora of rich data that facilitate a better understanding of the participants’ experience.

According to Husserl (1970), phenomenology attempts to describe the experience in terms of essential structures embedded in human phenomena. The phenomenological research approach is congruent with the mission of nursing, midwifery, and childbirth education. By listening to the voices of women as they share their stories depicting the care they received from nurse-midwives, health-care providers and educators can gain a clearer understanding of the experience and validate the benefits the experience has for women. Lifeworld theory posits that in order to understand a social reality, it is necessary for the researcher to analyze knowledge that the interviewees put forth about that reality (Husserl, 1970).

Human Research Participants’ Protection

Prior to beginning the study, I obtained ethical approval from the institutional review board at the university where I was employed. All participants gave informed consent before participating in the study.

Setting

A purposive sample was obtained from the caseload of four private nurse-midwifery practices in New England. With purposive sampling, respondents are chosen based on the purpose of the study. The purposive sampling method is useful for situations where a targeted sample is needed to capture a particular characteristic or experience.

Procurement of the sample was accomplished by placing a poster on a bulletin board at each practice site and by making study brochures available to interested clients. After reading the brochure, potential participants informed the office staff of their interest, and they subsequently received a research packet containing additional information. After a willing participant signed a consent form, and the signature was witnessed by an office staff member, I contacted the woman by telephone. After answering additional questions from the woman, an interview was scheduled. Participants selected the date, time, and location of the interview. Ten participants were interviewed in their homes, and two participants were interviewed in neighborhood cafes.

Participants

The purposive sample consisted of 12 women, all of whom had received prenatal care, labor and birth management, and postpartal care from nurse-midwives for all of their pregnancies. The women had also received well-woman gynecological care, contraceptive care, and primary care from nurse-midwives. Thus, nurse-midwives provided the totality of their health care from their first prenatal visit when they were pregnant with their first child, for all of their subsequent births, for family planning, for well-woman gynecology, and for primary care until the time of this study. Furthermore, all study participants indicated that they intended to continue their health care with nurse-midwives throughout their life span.

All participants were able to read, speak, and comprehend English, which were basic criteria for participating in the study. Seven out of 12 participants had attended childbirth preparation classes taught by nurse-midwives at the time they were expecting their first child. Of the 12 participants, two women had four children, four women had three children, and the remaining six women had two children. The mean age of the women at the time of the interview was 34.5 years old, with a range of 28–40 years. With regard to educational level, three women had associate's degrees, five had bachelor's degrees, three had master's degrees, and one woman had a doctoral degree. All participants reported being married to the father of their children at the time of birth, but three reported being divorced at the time of the study.

Nine women were Caucasian, one was African American, one was Asian American, and one was Hispanic American. All participants described their pregnancies as being low-risk and uncomplicated. All had normal spontaneous vaginal births at community hospitals. All babies were singletons and without congenital anomalies or complications. The 12 participants reported being in good health at the time of the interview.

All participants described their financial status as middle class. Four women reported working full-time, three women reported working part-time, and five women were stay-at-home mothers.

Data Collection

Data were collected from open-ended interviews. Interviews were audio-recorded and transcribed verbatim. Participation was voluntary, and participants could withdraw at any time. Procedures relating to how data would be collected, used, analyzed, and stored were explained to the participants. The women responded to the research question, “What has been your experience with midwifery care?”

I chose this method of data collection because it provides freedom for the participants to tell their stories. Follow-up questions were asked only if necessary for clarification. Data collection took place over a 3-month period until saturation was achieved. Interviews were 45–90 minutes in duration.

I recorded field notes during the interviews, following the notation system of Schatzman and Strauss (1973). This approach included observational, theoretical, and methodological notes. Observational notes are statements bearing upon events experienced through watching and listening. Observational notes provide the who, what, when, where, and how of human activity. Theoretical notes represent self-conscious, controlled efforts to derive meaning from observational notes. Methodological notes are statements that reflect on an operational act that is planned or completed. Methodological notes may offer direction, such as an instruction or a reminder to oneself or even a critique of one's research tactics.

Data Analysis

The taped interviews and field notes were transcribed verbatim. Data were analyzed using procedures adapted from Colaizzi (1978). The audiotapes were listened to several times to gain familiarity with the content. Transcripts were examined line-by-line, and key statements describing participants’ experiences were highlighted and then coded. Codes were defined, categorized, and formulated into theme clusters. Clusters were sorted into themes. Findings were incorporated into an exhaustive description of midwifery care.

It is noteworthy to mention that I have had considerable experience with qualitative research methods and that I initially analyzed the data independently. However, to ensure that the coding and themes reflected the women's experiences, I collaborated on the analysis and description with two other qualitative researchers: a nursing professor and an education professor. They reviewed participants’ responses for clarity, appropriateness, and validity. Both consultants were in agreement with me regarding the emerging themes, and they verified that data saturation had occurred without discovery of any new themes.

Audio-recording the interviews, transcribing each interview verbatim, and completing field notes within 24 hours of the interview strengthened trustworthiness of the present study (Lincoln & Guba, 1985). Each step of the analysis was reviewed and validated by the two consultants. Rigor was maintained through informed consent, confidentiality, and audio-recording the interviews to preserve the validity of the data. Active listening to the tapes enhanced understanding of the meanings the women assigned to their words, which helped maintain the integrity of the interpretation process. Five overarching themes related to midwifery care were derived from the analyses relevant to the purpose of this study. Thematic content was validated with all 12 participants to ensure accurate representation and interpretation.

RESULTS

Five themes emerged from the data as the midwifery clients responded to the research question. All 12 women engaged in storytelling. Each described her experience with midwifery care, which encompassed pregnancy, labor and birth, the postpartum period, well-woman gynecological care, and primary care. Seven participants also injected various tales from childbirth classes taught by nurse-midwives. In general, the women were candid, detailed, reflective, insightful, and sometimes humorous. As they told their stories, they used words such as “meaningful,” “memorable,” “significant,” and “important.”

The following five themes captured the essence of the midwifery care experience for the women in this study: 1) decision to seek midwifery care; 2) working together in a therapeutic alliance; 3) formulating a birth plan; 4) childbirth education; and 5) nurse-midwives as primary health-care providers throughout the life span. To illustrate each theme, exemplar quotations from the participants are presented below.

Decision to Seek Midwifery Care

The women described their various paths to midwifery care. One of the participants, a former pediatric nurse, stated the following:

Basically, I had two criteria that guided my decision…. I wanted a hospital that had a NICU so that if something happened, the baby would not have to be transferred to another facility and separated from me…and I wanted to go to a nurse-midwifery practice because my best friend from childhood is a nurse-midwife. I knew that she could not be with me because she lives on the West Coast—but, I still wanted to be with nurse-midwives.

The same woman added the following:

I guess I feel safe with nurses and totally subscribe to the belief that nurse-midwives are experts in normal birth and know when to get help if needed. I like the fact that they stay with you during labor and don't just come in at the last minute to catch the baby.

Another participant, who was a college instructor, lamented about her unplanned pregnancy and how she felt totally unprepared for the childbearing season. Yet, she drew on her educational background to do “research” to find an appropriate health-care provider and community hospital:

I did my homework and looked at all the various options in my community. I talked to friends, neighbors, and even my insurance company. What sold me on nurse-midwives was a brochure from a local midwifery practice coupled with one from the American College of Nurse-Midwives. The brochures exuded competence, confidence, compassion, and kindness. They convinced me, and I never looked back.

Another participant related that she relied heavily on the recommendations of friends who already had children. She remarked the following:

My friends have always shared the details of their pregnancies, labors, births, and even funny stories from their childbirth classes. So—when I became pregnant with my first child, I simply asked around for recommendations. We tend to seek out the best people to take care of us…so, when it was my turn it was easy. I went to a practice with three nurse-midwives, and it was great.

Another participant, who was a teacher, credited her health maintenance organization with providing information about nurse-midwives as well as obstetricians in her geographic area. She stated the following:

The woman on the phone emphasized that nurse-midwives do a lot of teaching besides taking care of your health needs. She also mentioned that they work in collaboration with OB/GYN MDs if you have complications. She said that you actually have the best of both worlds.

Working Together in a Therapeutic Alliance

Therapeutic alliance is a process that emerges within a health-care provider-client interaction in which both provider and client actively work together toward a goal that is consistent with the client's current health status and lifestyle. Therapeutic alliance involves collaboration to determine goal-directed activities and utilizes a supportive relationship to facilitate achievement of a goal (Doherty, 2009; Madden, 1990; Zetzel, 1956).

Numerous women in the current study verbalized tenets of a therapeutic alliance as they described how they worked together with nurse-midwives at various times during the childbearing season and beyond. For example, a mother of three children stated the following:

Women can be so strong when they come together and work together. I felt a partnership with my midwives—it began during pregnancy, peaked during labor and birth, and continues to this day as I see them for all of my health-care needs.

Another woman described her own unique relationship with her nurse-midwives:

Even though my youngest is 3 years old, I continue seeing my midwives because they provide primary care, contraception, and all the usual stuff. Plus, I have built a relationship with them over the years, and they have come to really know me. It's basically one-stop-shopping for me!

One of the women recalled her three labors with the same nurse-midwife in attendance:

I really feel proud that I never had any pain medication. The reason I was able to do so well was because of my relationship with my midwife, the strength of my marriage, and the strength of myself. And—I don't think I'm unusual. If you give a woman the kind of support I had, she can do a lot! After being with me for three births, my midwife is like a member of my family. We've gotten to know each other quite well over the years.

Many women mentioned a sense of connectedness, positive presence, and sensitivity as they worked with their nurse-midwives. Together, the women and their nurse-midwives focused on the task at hand, which varied considerably depending on the content the women sought to master in childbirth class, the trimester of pregnancy, the phase of labor, or whatever challenged the women's state of wellness. For example, one of the women mentioned the mind-body connection she wanted to achieve during pregnancy and how her nurse-midwives helped her along the way:

My prenatal visits focused on my pregnancy in the fullest sense—mind and body. It seemed like the midwives anticipated my concerns each step of the way. They spent a lot of time teaching, too. They seemed to intuitively know when I had a lot of stuff going on in my life. They listened, and they were there for me.

Another woman recalled how her nurse-midwife offered a unique level of sensitivity during the woman's first labor:

My midwife coached and supported me. She always made me feel involved in the decision making and was so positive and encouraging. She really tuned-in to my feelings and behaviors during labor. There was so much sensitivity.

Another woman commented on the positive presence of her nurse-midwife during the woman's labor:

When my contractions were at their worst and I was having trouble concentrating on my breathing and relaxation, my midwife held my hand, stroked my hair, and leaned in close and told me to “hang in there” and “think positive, progressive thoughts.” She told me to visualize a rose bud opening to a full blossom, the way my cervix would respond to the labor contractions. And, you know, this helped me. The sound of her voice was calming, encouraging, and empowering. She believed in me to do the work of labor, and I drew strength from her words and her presence.

One of the women summarized her feelings in one sentence, stating, “When it comes down to a brief description of the midwifery care I received in labor, I would have to say—my journey became my midwife's journey—that says it all.”

Formulating a Birth Plan

A birth plan is a communication document that involves anticipatory work, reflection, and decision making regarding labor and birth. It describes a woman's wishes for the childbirth event in terms of preferences, activities, interventions, and the general milieu. A birth plan aims to facilitate an open dialogue between the woman, her partner, and her health-care providers concerning labor and birth. The notion of a birth plan results from some form of “childbirth education,” whether it be formal classes or the type of informal education that typically occurs in the context of a prenatal visit.

Several study participants mentioned their nurse-midwives’ assistance in formulating a birth plan. For example, one of the women recalled her introduction to the concept of a birth plan and how the nurse-midwives encouraged her to write a plan:

Around the seventh month of pregnancy, the midwives encouraged everyone to write a birth plan. They helped me do this by getting me to think about what was really important to me during labor and birth. I thought about who I wanted to be with me—my husband and my mother—what kind of music I wanted to listen to—New Age—and what I wanted to do—knit. I also made a list of hopes and fears. It was very helpful to put things down on paper.

Another woman described how the nurse-midwives encouraged her to be flexible in her birth expectations and birth plan:

My first birth plan read like a novel. It described my “ideal” birth, which was a good starting point for me, knowing that I needed to be a little more realistic in some areas. The midwives stressed the importance of flexibility in any birth plan.

The same woman commented on her second birth plan, saying, “With my second daughter, my birth plan came down to a list of things that were important to me. Flexibility was the key to a realistic birth plan.”

Other participants described how the nurse-midwives’ encouragement to develop a birth plan enhanced communication with the women's partners regarding mutual birth preferences and expectations. For example, one of the women commented on collaborating with her husband to develop a birth plan:

The birth plan assignment made me look deeply into myself and figure out what was truly important to me. Then, I collaborated with my husband to make sure we were on the same wavelength for the birth of our child. I think all parents should do this. Planning for the birth is huge, whether it is your first or your fourth.

Another woman shared similar sentiments:

Taking pen in hand and writing things down made it real for me. It also helped [my husband and me] talk about labor and birth in a serious manner, apart from the social nature of childbirth class. It was reassuring to know that all the midwives in the practice would read our birth plan and that a copy of our birth plan would be on my hospital chart.

Childbirth Education

Nurse-midwives typically recommend that first-time parents attend childbirth preparation classes to learn about the physiological and psychological changes that occur during labor and birth. The classes also provide important information about breastfeeding and bottle-feeding, which helps facilitate decision making about a feeding method. The classes additionally provide relaxation exercises and breathing techniques for coping with labor, as well as anticipatory guidance for beginning parenting. Parents expecting a second or third child may opt to take a refresher childbirth class or may decide to forego classes altogether. Often, a determining factor will be the time interval between children.

Several study participants reflected on the importance of childbirth classes taught by nurse-midwives. For example, one of the women stated the following:

My childbirth class experience was especially meaningful because it was taught by a midwife from my practice. This helped me get to know her better. I liked the fact that the midwifery philosophy was carried over to the classes. Everything seemed to come together for me. Things made sense.

Another woman commented on how the classes helped develop a closer bond with her husband as they prepared for their child's birth:

Going to childbirth classes together helped my husband and I face things together. This was especially important for us because his work schedule kept him from attending most of my prenatal appointments. So, we had a special “date” once a week for six weeks for childbirth classes. It worked out great for us!

Another woman described similar sentiments about attending childbirth education classes with her husband:

I can't imagine anyone having their first baby without going to some type of childbirth class. The classes prepared us as a couple to work together during labor and birth. And—I think that most men are less prepared than women.

Nurse-Midwives as Primary Health-Care Providers Throughout the Life Span

Nurse-midwives are primary care providers and are not limited in their scope of practice to take care of women only during the childbearing season. Midwifery clients come to know the wide-ranging scope of nurse-midwifery care, but the general public is often less informed. Many adolescents and young adult women receive their health care from nurse-midwives. Other women who have completed their childbearing simply continue their ongoing health care with the same midwives who attended them for childbirth.

Several study participants commented on the extended care they received from nurse-midwives, beyond their pregnancies and births. For example, one of the participants, a mother of two children, related the following:

I have been going to the same midwifery practice for about 10 years now…. I started with my first pregnancy and never left. The midwives do my annual exams, pap smears, check my diaphragm to make sure the fit is still good for birth control, and they have even cured a few vaginal infections along the way. I have also seen them for a throat culture and flu shot.

Another participant described the extended care she received from her nurse-midwives, following birth:

With the midwives, women are cared for in a special way. They are there for you and go the distance for you. I can say this from personal experience with a postpartum depression after my second child. They got me the help I needed and weathered the storm with me.

One of the women expressed the sentiments of many participants in the study when she described the wide range of individualized care she received from nurse-midwives:

There is a definite sense of caring, trust, commitment, and mutual respect with midwives. They made you feel like you are the only patient in the world. The care is so individualized, whether you are having a baby, selecting a contraceptive method, or just talking about all the stress in your life. They are such good listeners.

Another participant reported a similar viewpoint:

I can honestly say that the midwives in my group are the most honest, caring, down-to-earth women I've ever met. I can tell them about how my kids are driving me crazy, ask them for herbal remedies for my perimenopausal sister, and get a recommendation for a urologist to do my husband's future vasectomy—all in one visit!

DISCUSSION

Although pregnancy introduced the women in this study to nurse-midwifery, the special care they received caused them to continue their health care with nurse-midwives as primary care providers, which gives testimony to the value the women placed on the care they received. The words of these midwifery clients captured the breadth and depth of their lived experience. Their stories attest to the fact that their experiences will be etched in their minds and hearts forever.

The childbearing season is influenced by myriad factors specific to each individual woman. Personal history, contemporary norms, support systems, physiological mechanisms, and psychosocial issues all have bearing on the choices a woman makes and the health care she seeks. Childbirth and parenthood are classified as the most meaningful, life-changing events for the largest segment of our population in the world today.

Memories of midwifery care in this study reflected the women's interest in the right to self-determination concerning their bodies, their babies, and their birth experiences. They possessed a strong desire to trust in their own abilities to give birth. They expressed positive feelings about the care they received in terms of physical comfort, emotional support, education, anticipatory guidance, and participation in decision making. Some women described being “in control” during labor, which they attributed to feeling cared for and safe in their environment with the midwives. Some participants believed their sense of control and well-being was enhanced by the completion of a birth plan.

The findings of this study provide descriptions of women's experiences with midwifery care. The narratives captured the essence of their lived experience and highlighted five themes: 1) decision to seek midwifery care; 2) working together in a therapeutic alliance; 3) formulating a birth plan; 4) childbirth education; and 5) nurse-midwives as primary health-care providers throughout the life span.

Decision to Seek Midwifery Care

The most important decision that a woman makes during the childbearing season is the selection of a health-care provider. This decision will powerfully influence her options and alternatives as she makes plans for labor and birth. Women who choose midwifery care are more likely to be offered a full array of therapeutic modalities for a noninterventive birth.

For well-woman gynecological care, family planning, and basic primary health care, midwives are open to natural, organic, and homeopathic remedies as well as more traditional medications and contraceptive methods. The key is openness to new things, flexibility, patience, respect for “Mother Nature,” and never forgetting to “listen to women.”

Working Together in a Therapeutic Alliance

Human connectedness gives life purpose and meaning. All 12 participants mentioned the importance of their relationship with the midwives. Some women related how a plethora of questions they had were addressed at a prenatal visit. Others valued learning the basic tenets of relaxation in a childbirth preparation class. Many commented on the watchful eye, positive presence, and unrelenting support they received during labor and birth. Others related bouts of postpartum depression or a rocky start with breastfeeding and how the midwives weathered the storm with them. Many shared their joy in being able to continue with their midwives as primary care providers.

Formulating a Birth Plan

Many women valued their birth plan as a communication tool for conveying their wishes to others. They felt a heightened sense of control because they had choices. They viewed their role as one of active participation because they engaged in collaborative decision making with the midwives. These women believed that their realistic and flexible birth plans contributed to their satisfaction and a positive birth experience (Doherty, 2003).

Although nurse-midwives support the notion of a birth plan, a recent study documented the aversion that many labor and delivery nurses have to birth plans (Carlton, Callister, Christiaens, & Walker, 2009). The researchers’ finding poses the question of how nurse-midwives can work effectively with labor and delivery nurses. Open and honest dialogue between the two groups that focuses on the flexibility of a birth plan as a communication tool is paramount. Providing continuing education on the midwifery philosophy of care is also essential because nurses often resist what they do not understand and what is unfamiliar to them. A meeting of the minds and mutual respect can go a long way to improving a tense situation when both groups keep in mind the ultimate goals of a healthy mother and baby and a positive birth experience.

Childbirth Education

Study participants viewed attendance at childbirth preparation classes as an essential learning experience for first-time parents. Women and their partners who understood the physiological and psychological changes that occurred during all segments of the childbearing season related that they felt better prepared and more equipped to handle the life-changing experience of birth. Anticipatory guidance from the midwives helped to make a smooth transition to parenthood and contributed to successful breastfeeding.

Nurse-Midwives as Primary Health-Care Providers Throughout the Life Span

It made perfect sense to the women in this study to continue their care with nurse-midwives beyond their childbearing years. They believed that nurse-midwifery education and practice makes midwives experts in caring for women, coupled with the knowledge that collaboration with physicians as well as other health-care providers may be necessary in dealing with certain health problems.

STUDY LIMITATIONS

In a qualitative study, small sample size is not considered a limitation if data saturation is achieved. However, this study focused on a self-selective and purposive sample, which produced results that are not representative of all women. With this in mind, we must also consider that phenomenology seeks to study persons who have particular knowledge of an experience. Thus, the findings of this study help to understand the experience of women with midwifery care.

One limitation was the fact that this study had a highly educated sample, with all of the participants having some college education and a few even exceeding this level. Another limitation was the lack of cultural diversity, with the majority of participants being Caucasian. In addition, all participants reported being in the middle class in terms of socioeconomic status. Lastly, the fact that the 12 participants uniformly sought all of their health care from nurse-midwives could have influenced the remarks they made during the interviews, which raises the issue of bias and a lack of comparison between nurse-midwives and other health-care providers.

IMPLICATIONS FOR PRACTICE

Past research suggests that a special relationship exists between a midwife and client. The findings of the present study support this contention and demonstrate that midwifery clients embrace the profession's philosophy of care, which can be translated into significant implications for clinical practice, education, and research.

The findings of this study clearly indicate that midwifery clients want their voices to be heard. Their voices actually accomplish several tasks: They inform, educate, and encourage others to seek midwifery care. In addition, they speak to nurses and other health-care providers who may be interested in becoming midwives in the future.

RECOMMENDATIONS FOR FUTURE RESEARCH

The significance of the findings will be determined by their ability to guide future research in midwifery care. Insight into the experience of midwifery clients provides a framework for additional studies. The themes identified in the study form a solid foundation for considering holistic and meaningful aspects of midwifery care and the key roles that midwives play in women's health throughout the life span.

Future research is needed to examine experiences of midwifery clients from diverse ethnic and cultural backgrounds and from other practice settings such as an urban clinic or a rural health center. It is important for all women to learn about midwifery care, and one of the best ways to accomplish this is for them to listen to the voices of other women as they tell their stories.

CONCLUSION

This study offers a snapshot of women who chose midwifery care for their initial childbearing experience and decided to stay with nurse-midwives for the long haul, which encompassed all of their future childbearing experiences, well-woman gynecological care, and primary care throughout the life span. This study extends the body of research about nurse-midwifery care and breaks new ground because it illustrates a continuum of health care for women. The option for women to receive health care from nurse-midwives throughout the life span is not widely known and needs to be better publicized.

Phenomenology as a qualitative research method provided a useful framework to describe midwifery care experiences. This method was a solid match for the research question, analysis, and manner of reporting findings. The phenomenological method is also very responsive to clinical inquiry by health-care professionals.

Women and their families as well as health-care professionals need to listen to the voices of midwifery clients and become informed and enlightened about the midwifery model of care, which can address a plethora of concerns and issues throughout the life span. Research of this nature benefits both the recipients and the providers of health care.