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Problem and background The International Confederation of Midwives (ICM) conducts regular updates to the Essential Competencies for Basic Midwifery Practice to determine the introduction or retention of items in the global scope of midwifery practice guidance document. Aim This article presents the review process that underpinned the deliberation about three specific clinical practices: external cephalic version, prenatal ultrasonography, and tobacco cessation interventions that occurred during the 2016–2017 global update study. Methods A brief outline of the research methodology used in the 2016–2017 study is provided. Literature summaries about safety and effectiveness of three clinical skills are offered. Data addressing global and regional variations in support of each practice and final disposition of the items are documented. Findings External cephalic version did not receive sufficient document support for inclusion in the initial list of items to be tested in the study. Prenatal ultrasonography was supported as an advanced (76.6%) or country-specific (18.8%) skill that midwives could acquire, to promote wider global access for pregnant women. Midwives’ participation in tobacco cessation counselling was supported (≥85%) in each of ICM’s regions. Knowledge about World Health Organization recommendations for nicotine replacement therapy was endorsed as an additional (62.4%) or country-specific (29.3%) skill. Discussion and conclusion The current evidence of safety of midwives performing external cephalic version led to the recommendation that it be considered in the next document update. Conflicting views of midwives’ role in acquiring skills to conduct prenatal ultrasound were evident. There was strong support for participation in smoking cessation counselling, but knowledge of World Health Organization recommendations was not highly endorsed.

Background A respectful, person-centered philosophy of maternity care has been emerging over several decades. Research conducted on behalf of the International Confederation of Midwives (ICM) to identify essential competencies for midwifery practice also identified the knowledge, skills, and professional behaviors that should be hallmarks of respectful maternity care practices among the global community of midwives. Methods A three-round, online, modified Delphi survey was conducted between April 2016 and October 2016. A total of 895 individuals from 90 of the then-current 105 ICM member countries participated, with good representation across English, French, and Spanish speakers, high-income, medium-income, and low-income countries, and educators and clinicians. Results A total of 115 respectful maternity care (RMC)-related items were endorsed by participants in Round 1 or 2. These items received average scores of between 90.24% and 99.10%, well above the 85% threshold required to be identified as within the scope of global midwifery practice. These items were compared with the 12 domains of RMC identified by Shakibazadeh and colleagues that defined respectful care during childbirth in health facilities globally, and with similar RMC frameworks, and were found to be highly congruent, thus demonstrating the high value of RMC within the core of midwifery practice. Discussion ICM survey items were endorsed across all 12 RMC domains proposed by Shakibazadeh et al, and the findings affirmed that across ICM countries and regions, the philosophy of RMC was integrally related to the knowledge, skills, and professional behaviors that emerged as essential for basic midwifery practice.

Objective to design a criterion-referenced assessment tool that could be used globally in a rapid assessment of good practices and bottlenecks in midwifery education programs. Design a standard tool development process was followed, to generate standards and reference criteria; followed by external review and field testing to document psychometric properties. Setting review of standards and scoring criteria were conducted by stakeholders around the globe. Field testing of the tool was conducted in Myanmar. Participants eleven of Myanmar׳s 22 midwifery education programs participated in the assessment. Findings the clinimetric tool was demonstrated to have content validity and high inter-rater reliability in use. Key conclusions a globally validated tool, and accompanying user guide and handbook are now available for conducting rapid assessments of compliance with good practice criteria in midwifery education programming.

Background Scholarly writing, although central to the completion of doctoral studies, is often not supported by systematic teaching/learning approaches that specifically help students to convey scholarship through writing. The purpose of this project was to promote writing as an essential component of scholarship, provide opportunities for students to develop a self-awareness of confidence in writing and challenges to writing, and to improve writing competence. Methods An innovative set of peer-supported interventions was embedded within a core foundational course in a Doctor of Nursing Practice (DNP) programme during the first academic semester as part of a continuing quality improvement process to improve DNP student writing. The first curriculum innovation was a substantive writing assignment, in which students exchanged papers with a classmate and were required to critique both writing conventions (e.g. criteria such as punctuation and citation) and structural and thesis-driven aspects of writing (e.g. criteria such as clarity, organisation and the use of paragraph leading sentences). Students then read their papers aloud, without hesitation while reading, in order to identify any discrepancies between the written words and the audible 'plain language' that would be necessary to enhance clarity. The second innovation was an optional writing workshop in which students received coaching from interdisciplinary mentors and from their peers. Results Evaluation of the implementation of this innovation suggests that mentorship, peer support and the use of commonly spoken language may be useful tools for improving the writing competencies of DNP students. Discussion Students with broad diversity in writing competency, including low levels of proficiency, benefitted from a writing-enriched curriculum given at the start of the course of study. DNP faculty may not themselves be prepared to mentor students for doctoral-level writing.

Task analysis is a descriptive study methodology that has wide application in the health professions. Task analysis is particularly useful in assessment and definition of the knowledge, skills, and behaviors that define the scope of practice of a health profession or occupation. Jhpiego, a US-based nongovernmental organization, has adapted traditional task analysis methods in several countries in assessment of workforce education and practice issues. Four case studies are presented to describe the utility and adaptability of the task analysis approach. Traditional task analysis field survey methods were used in assessment of the general and maternal-child health nursing workforce in Mozambique that led to curriculum redesign, reducing the number of education pathways from 4 to 2. The process of health system strengthening in Liberia, following a long history of civil war conflict, included a traditional task analysis study conducted among 119 registered nurses and 46 certified midwives who had graduated in the last 6 months to 2 years to determine gaps in education and preparation. An innovative approach for data collection that involves "playing cards" to document participant opinions (Task Master, Mining for Data) was developed by Jhpiego for application in other countries. Results of a task analysis involving 54 nurses and 100 nurse-midwives conducted in Lesotho were used to verify the newly drafted scope and standards of practice for nurses and to inform planning for a competency-based preservice curriculum for nursing. The Nursing and Midwifery Council developed a 100-question licensing examination for new graduates following a task analysis in Botswana. The task analysis process in each country resulted in recommendations that were action oriented and were implemented by the country governments. For maximal utility and ongoing impact, a task analysis study should be repeated on a periodic basis and more frequently in countries undergoing rapid change in development of workforce policy.

Background A commitment to increase the enrollment, retention and educational success of United States veterans admitted to a baccalaureate degree nursing program was established through the support of a grant received from HRSA in collaboration with the US Departments of Defense and Veteran Affairs. Method Challenges encountered by the student veterans were identified and programs of mentorship, tutoring, equine therapy and interface with services offered by the University Office of Veteran Affairs were developed. Results Thirty-two student veterans provided positive feedback about their perceptions of academic and personal support provided during their program. Sixteen faculty and staff also described positive experiences about working with the student veteran population. Conclusion The continuous assessment of all program elements indicates that the program is meeting its intended outcomes and serves the purpose of providing the opportunity for returning veterans to choose nursing as a professional healthcare career.

Background many articles published in the decade since promulgation of the Millennium Development Goals have acknowledged the distinct advantages to maternal and newborn health outcomes that can be achieved as a result of expanding access to skilled birth attendant (including midwifery) services. However, these advantages are often predicated on the assumption that the midwifery workforce shares a common definition and identity. Regrettably, a clear delineation of midwifery competencies is rarely addressed. A core set of midwifery competencies is essential to providing the high quality services that lead to the desirable health outcomes described in that body of research. Attribution of improved outcomes to access to midwifery cannot be made without a common understanding of a defined set of services provided to standard by the midwifery workforce across the inter-conceptional and childbearing time frame. The International Confederation of Midwives (ICM) has developed a clear list of competencies that delineate the domains of practice for the fully qualified, professional midwife. These domains frame the educational outcomes that must be conveyed within competency-based education programmes. Purpose this article explores the concept of competency-based education for midwives; first exploring the concept of competency itself, then providing examples of what is already known about competency-based approaches to curriculum design, teacher preparation, teacher support and assessment of student learning. These concepts are linked to the ICM competencies as the unifying construct for education of individuals who share a common definition and identity as midwives.

OBJECTIVE: To assess the impact and sustainability of health, water, and sanitation interventions in Bolivia six years post-project. METHODS: A mixed-method (qualitative-quantitative) study was conducted in 14 rural intervention and control communities in Bolivia in November 2008, six years after the completion of interventions designed to improve knowledge and practices related to maternal and child health and nutrition, community water systems, and household water and sanitation facilities. The degree to which participants had sustained the community and household practices promoted by the interventions was a particular focus. Community site visits were made to evaluate the status (functional condition) and sustainability (state of maintenance and repair) of community and household water and sanitation infrastructure. Key informant interviews and focus group discussions were conducted to assess knowledge and practices, and perceptions about the value of the interventions to the community. RESULTS: Six years post-project, participants remained committed to sustaining the practices promoted in the interventions. The average rating for the functional condition of community water systems was 42% higher than the average rating in control communities. In addition, more than two-thirds of households continued to practice selected maternal and child health behaviors promoted by the interventions (compared to less than half of the households in the control communities). Communities that received integrated investments (development and health) seemed to sustain the practices promoted in the interventions better than communities that received assistance in only one of the two sectors. CONCLUSIONS: Infrastructure for community water systems and household water and sanitation facilities was better built and maintained, and selected maternal and child health behaviors practiced more frequently, in intervention communities versus control communities.

Objective to identify and better understand factors that influence care-seeking behaviour for women's health among indigenous Mayan populations in the highlands of Guatemala. Design adaptation of qualitative anthropological methods involving observations, key informant interviews and focus group discussions (FGDs). Setting Project Concern International's Casa Materna, Huehuetenango, Guatemala. Participants Interviews and FGDs were conducted among 21 clients (current or past) of the Casa Materna and traditional birth attendants; 17 female advocates/promoters of the Casa Materna and related services; and 12 male advocates, including spouses, non-government organisation staff and community health workers. Findings the following findings emerged from focus group data: Women's support groups (WSGs) provided an enabling environment in which women could form friendships, bond, discuss concerns about their reproductive health, and identify concrete ways of addressing them; Supportive friends, family members and advocates influenced women's decisions to seek health care at the Casa Materna; Women's decisions to seek care were often associated with their sense of self-worth and self-esteem, and women's self-esteem was enhanced by their participation in the WSGs; Women's decisions to seek care were influenced by the perception that women would be able to access culturally appropriate, safe and secure health care services at the Casa Materna; The learned behaviour of negotiation with key decision-makers and/or opinion leaders was an effective tool for convincing such individuals of the value of accessing facility-based care; The proven track record, high quality of services and cultural competence offered at the Casa Materna increased the confidence and level of trust of clients and their family members about the care that would be received; Couple-based education and health promotion were effective techniques for achieving behaviour and attitude change among both men and women. Key conclusions the Casa Materna and its community outreach strategy serve an essential purpose in the provision of maternity care for the isolated and vulnerable families of the Guatemalan highlands, by bridging traditional and Western approaches to health care services. The Casa Materna service model plays a critical role in improving women's self-efficacy and ultimately strengthening the social fabric that characterises this high risk and vulnerable population. Implications for practice the Casa Materna model provides a foundation upon which to bridge and strengthen the relationship between community advocates, traditional community-based health care providers, and the government-funded system of health care. The findings of this study should be incorporated into future research to determine the potential for bringing the model to scale.

Introduction Core data are crucial for detailing an accurate profile of the midwifery workforce in the United States. The American College of Nurse-Midwives (ACNM) and the American Midwifery Certification Board, Inc. (AMCB), at the request and with support from the US Health Resources and Services Administration (HRSA), are engaged in a collaborative effort to develop a data collection strategy (the Midwifery MasterFile) that will reflect demographic and practice characteristics of certified nurse-midwives (CNMs) and certified midwives (CMs) in the United States. Methods Two independent datasets, one collected by ACNM in 2012 and one by AMCB in 2013, were examined to determine key workforce information. ACNM data were collected from the online Core Data Survey sent to ACNM members. AMCB data were extracted from information submitted online by applicants seeking initial certification in 2013 and applicants seeking to recertify following 5 years of initial certification. Results The ACNM 2012 survey was partially or fully completed by 36% (n = 2185) of ACNM members (N = 6072). AMCB respondents included 100% of new certificants (N = 539) and those applying for recertification in 2013 (n = 1323) of the total 11,682 certificants in the AMCB database. These two datasets demonstrate that midwives remain largely white, female, and older in age, with most engaged in clinical midwifery while employed primarily by hospitals and medical centers. Differences were reported between the ACNM membership and AMCB certification datasets in the numbers of midwives holding other certifications, working full-time, attending births, and providing newborn care. Discussion The new collaboration among HRSA, ACNM, and AMCB, represented as the Midwifery MasterFile, provides the opportunity to clearly profile CNMs/CMs, distinct from advanced practice registered nurses, in government reports about the health care workforce. This information is central to identifying and marketing the role and contribution of CNMs/CMs in the provision of primary and reproductive health care services.

Current evidence indicates the critical importance of several factors that contribute to improved perinatal outcomes: a facilitating environment at the place of birth, skilled birth attendance, and the continuum of perinatal care for women and newborns. This level of care is often referred to as "first-level" care, and is most readily provided in birthing centers and primary level health facilities. However, there is a body of evidence that has been compiled over the past several decades that addresses the safety of planned home birth, under circumstances that emulate these elements of "first-level" care. These studies demonstrate a remarkable consistency in the generally favorable results of maternal and neonatal outcomes, both over time and among diverse population groups. These outcomes are also favorable when viewed in comparison to various reference groups (birth center births, planned hospital births, and vital statistics). These data should influence policy in support of planned home birth, including policy that endorses building or sustaining a home birth infrastructure in parallel to the efforts to build capacity for facility-based birth. Such public policy would also be in keeping with the fundamental right of women to have choice in childbirth, particularly when options are equally good.

Women who resided on the El Paso, Texas/Juarez, Mexico border (the Paso del Norte region) were surveyed to determine the barriers and facilitators to receiving early and adequate prenatal care. Postpartum interviews and medical chart abstractions were conducted among 493 Hispanic women. Primary facilitators were all factors that made prenatal care services more accessible to women and a priority among other issues competing for time and resources. The factors reported by these women as barriers to timely entry and sustaining enrollment in prenatal care were related to the availability of social support networks and affiliation with the Mexican/Hispanic culture (acculturation).

Our objective was to describe the outcomes of intended home birth among 57 women with a previous cesarean birth. Data were drawn from a larger prospective study of intended homebirth in nurse-midwifery practice. Available data included demographics, perinatal risk information, and outcomes of prenatal, intrapartum, postpartum, and neonatal care. The hospital course was reviewed for those transferred to the hospital setting. Fifty-three of 57 women (93%) had a spontaneous vaginal birth, 1 had a vacuum-assisted birth, and 3 (5.3%) had a repeat cesarean birth. Thirty-one of 32 (97%) women who had a previous vaginal birth after cesarean birth (VBAC) had a successful VBAC; 22 of 25 (88%) women without a history of VBAC successfully delivered vaginally. Fifty (87.7%) of these women delivered in the home setting, whereas 7 (12.3%) delivered in the hospital setting. None of the women experienced uterine rupture or dehiscence. One infant was stillborn. This event was attributed to a postdates pregnancy with meconium. Certified nurse-midwives with homebirth practices must be knowledgeable about the risks for mother and baby, screen clientele appropriately, and be able to counsel patients with regard to potential adverse outcomes. Given what is presently known, VBAC is not recommended in the homebirth setting. It is imperative in the light of current evidence and practice climate to advocate for the availability of certified nurse-midwife services and woman-centered care in the hospital setting.

Summary Objective: to present the evidence for inclusion of selected midwifery tasks (skills) as essential practice competencies for midwives throughout the world. The tasks addressed are those presented to the International Confederation of Midwives (ICM) Council of Delegates in 2002 for discussion and adoption, based on the fact that during field-testing, notable variance was encountered. Key conclusions and implications for practice: evidence-based practice should be characterised by the use of best practices derived from rigorous research, combined with and balanced by client perspectives and the expert judgement based on the critical thinking of the clinician. Much of midwifery practice is considered an art based on common sense, tradition, and woman-centred approaches to caring, as most of the women who seek midwifery care are healthy and require a health-promotion model of care that may not easily lend itself to examination by scientists or clinicians. However, when intervention is indicated to save the lives of mother, baby, or both, those interventions must be based on the best available evidence from a variety of sources leading to the most effective choices for action. The ICM Essential Competencies for Midwifery Practice (2002) are based on evidence derived from a variety of quantitative and qualitative methodologies. Expert clinical consensus may serve as to the best form of evidence at certain points in the evolution of knowledge. Every midwife needs to understand where the gaps exist in supporting traditional practices that have yet to be fully examined in a scientific manner. In summary, a multi-matrix or triangulated approach may be most appropriate to the delineation of evidence underpinning best midwifery practice.

To determine the sensitivity, specificity, and positive predictive value (PPV) of fetal fibronectin (fFN) and to determine its usefulness, in conjunction with selected other clinical assessment measures, in the prediction of preterm birth for women with twin gestations.A prospective, descriptive, longitudinal design.An obstetrical high-risk clinic that received patient referrals from several surrounding communities in central Texas.Forty-eight women identified with twin gestations prior to the 22nd week of pregnancy; primarily of Hispanic ethnicity.A substantial number of outcome variables were assessed in this study. In the present report, data derived from weekly assessments for the identification of the presence of fFN, the diagnosis of bacterial vaginosis, and the measurement of cervical length were reviewed for their relationship to prematurity, birth weight, birth weight discordancy and placental chorionicity.The relative risk of birth prior to 35 weeks gestation, fetal death, or discordance of twin birth weights of greater than 20% was 2.22 (CI: 1.09, 4.55, P0.015) when fFN was found to be positive at any weekly testing after 22 to 24 weeks gestation (sensitivity 76.82%, specificity 58.33%, PPV 66.7%). The presence of fFN was most highly predictive of preterm birth when performed during the 24th to 28th gestational week. Shorter cervical lengths were highly correlated with preterm birth (r = -0.6). An association between bacterial vaginosis and preterm birth was not demonstrated in this sample.Sampling for the presence of fetal fibronectin can be easily accomplished by RNs in labor triage units and by advanced practice nurses in outpatient settings. The identification of fFN, particularly during the 24 to 28 weeks gestational time frame, is highly predictive of preterm birth, and particularly so for women with twin gestations.

OBJECTIVES: The impact of a Medicaid-managed care system on access to prenatal care was investigated. STUDY DESIGN: Postpartum interviews and medical chart abstractions were conducted among 493 Hispanic women who reside on the El Paso Texas/Juarez Mexico border (the Paso del Norte region). Descriptive analysis identified barriers and facilitators to prenatal care. Logistic regression identified the impact of social and demographic characteristics on selected maternal and infant outcomes. RESULTS: The factors reported by these women as barriers to timely entry and sustaining enrollment in prenatal care were related to the availability of social support networks and affiliation with the Mexican/Hispanic culture (acculturation). Having Medicaid-managed care or other insurance was associated with receiving more adequate levels of prenatal care. Women who crossed the border to seek perinatal services were more likely to have infants who received higher levels of neonatal care (odds ratio 0.500; 95% CI [0.264, 0.946]). CONCLUSIONS: The promotion of preconceptional, prenatal, and family planning services is strongly recommended as a strategic, regional, public health intervention.

The goal of the teaching and learning process for health professionals is the acquisition of a fundamental core of knowledge, the demonstration of critical thinking ability, and the demonstration of competency in the performance of clinical skills. Teaching and learning in distance education programs require that the administration, teachers, and students be creative in developing evaluation strategies that can be adapted to the challenges of the cyberspace on-line educational environment. Evaluation standards for distance education programs recently have been delineated by federal agencies, private organizations, and academic accreditation associations. These standards are linked to principles of sound education practice that promote program quality, high levels of student-faculty interaction, and support effective teaching and learning in the distance education context. A growing body of evidence supports the conclusion that technology-enhanced teaching is equivalent in effectiveness compared with traditional methods when student-learning outcomes are the focus of measurement. An allied body of literature offers model approaches that can be useful to educators who must also conduct the evaluation of clinical skills, provide feedback, and promote socialization to the nurse-midwifery/midwifery role for students being educated in whole or in part through instruction delivered at a distance.

Objective. We compared outcomes, safety, and resource utilization in a collaborative management birth center model of perinatal care versus traditional physician-based care. Methods. We studied 2957 low-risk, low-income women: 1808 receiving collaborative care and 1149 receiving traditional care. Results. Major antepartum (adjusted risk difference [RD] = ‐0.5%; 95% confidence interval [CI] = ‐2.5, 1.5), intrapartum (adjusted RD = 0.8%; 95% CI = ‐2.4, 4.0), and neonatal (adjusted RD = ‐1.8%; 95% CI = ‐3.8, 0.1) complications were similar, as were neonatal intensive care unit admissions (adjusted RD= ‐1.3%; 95% CI = ‐3.8, 1.1). Collaborative care had a greater number of normal spontaneous vaginal deliveries (adjusted RD = 14.9%; 95% CI = 11.5, 18.3) and less use of epidural anesthesia (adjusted RD = ‐35.7%; 95% CI = ‐39.5, ‐31.8). Conclusions. For low-risk women, both scenarios result in safe outcomes for mothers and babies. However, fewer operative deliveries and medical resources were used in collaborative care. (Am J Public Health. 2003;93:999‐1006) at a freestanding birth center (The BirthPlace, located in San Diego, Calif) for women who remained at low perinatal risk. These components were integrated within the health care delivery system, which included private medical offices, neighborhood health centers, and community and tertiary hospitals. In the collaborative care model, obstetricians and CNMs were part of the same practice. CNMs provided 95% of prenatal care at 12 clinic sites. During antepartum care, 30% of participants saw only CNMs, 65% were collaboratively managed through consultation or necessary visits with an obstetrician, and 5% required exclusive antepartum management by an obstetrician. 10 In the intrapartum setting, women who remained at low risk and who delivered their babies at the freestanding birth center were managed (or co-managed) by CNMs, whereas women referred to the hospital were managed and delivered by collaborating obstetricians. Medically eligible women were given the option to enroll in the birth center program at the beginning of prenatal care, with the majority (65%‐75%) choosing birth center de

To obtain a snapshot of the maternal and newborn care provided by different types of maternal and child health providers in Latin America and the Caribbean (LAC) to 1) better inform advocacy and programmatic strategies and interventions to improve the quality of those services in the region, and 2) determine the need for more rigorous study of the issues.A rapid assessment of 83 health workers providing antepartum, intrapartum, and immediate postpartum and newborn care (within two hours of birth) in eight LAC countries was conducted in November and December of 2011. Health workers were observed by two-person expert maternal/newborn clinician teams using pretested forms based on international quality-of-care standards. A total of 105 care encounters were observed, primarily in urban, public, referral-level settings. Providers of care included obstetricians, midwives, generalist physicians, medical residents, registered nurses, auxiliary nurses, and students of medicine, midwifery, and nursing.Hand washing, as an indicator of quality of antepartum care, was observed in only 41% of the observed encounters. Labor management often lacked certain elements of respectful maternity care across all provider groups. Several clinical tasks of high importance in the identification and prevention of common complications of antepartum, intrapartum, and immediate postpartum/newborn care were not documented as performed during the observation periods. Providers self-reported limited competence (ability to perform to a defined level of proficiency) in manual removal of the placenta, bimanual compression of the uterus, and newborn resuscitation.The findings suggest that 1) the quality of maternal and newborn care and 2) the competence of maternal and child health providers in the diverse selection of LAC countries that were studied require substantial attention.

Research on the outcomes of midwifery care is hampered by the lack of appropriate instruments that measure both process and outcomes of care in lower risk women. This article describes an effort to adapt an existing measurement instrument focused on the optimal outcomes of care (The Optimality Index-US) to reflect the contemporary style of U.S.-based nurse-midwifery practice. Evidence for content validity of the instrument was derived from literature reports of randomized clinical trials, synthetic reviews, and the clinical consensus of professional reviewers. Eleven perinatal health professionals and consumers, representing disciplines of obstetrics and gynecology, midwifery, epidemiology, and neonatology reviewed the instrument. The instrument was then applied to an existing data set of women who intended to give birth at home (N = 1,286 women) to determine its utility in measuring events in the process and outcome of perinatal health care as managed by nurse-midwives. Results suggest that the tool holds promise for use in outcomes studies of U.S. perinatal care. Further testing of the instrument among diverse multicultural population groups, with various providers, and in diverse birth settings is warranted.

The authors investigated the role of stress and cortisol with patients having pretermlabor (PTL) and preterm birth (PTB). The relationships of maternal cortisol, perceived stress, fetal fibronectin (fFN), and genitourinary infections to PTL and PTB were studied. A prospective, longitudinal, observational study (n = 78) was conducted in a private practice in central Texas. Subjects had 4 blood draws for cortisol measurements grouped by 15-19, 20-22, 23-26, 27-30, and 31-35 weeks of gestation. Subjects had 2 vaginal swabs for fFN, chlamydia, and bacterial vaginosis screens at 23-26 and 27-30 weeks with assessment of psychosocial stress at 23-26 and 31-35 weeks. Statistical analysis was by analysis of variance, Pearson correlations, Fisher exact test, and logistic regression. There were no significant differences between the PTB, PTL, and termgr oups on cortisol levels at any of the gestational periods. Cortisol concentrations at any gestational stage did not correlate with gestational age at birth. A relationship of cortisol to race was observed when comparing Caucasians to other ethnic groups. A correlation (r = 0.42, P < 0.001) between the change in Perceived Stress Scale (PSS) score and gestational age was observed. The greater the decrease in PSS scores, the longer was the gestational age. A significant increase in cortisol at 19-21 weeks (P < 0.04), 23-26 weeks (P < 0.05), and 31-35 weeks (P < 0.01) was observed in patients having genitourinary infection. PTL was also significantly increased in subjects having positive genitourinary infections at either 23-26 weeks or 27-30 weeks (P < 0.01). The sensitivity of fFN to predict PTL collected at 27-30 weeks was 40%, specificity 86%, positive predictive value 55%, and negative predictive value 83%. These results indicate that cortisol is a poor predictor of either PTL or PTB. A decrease in perceived stress during the 2nd trimester was associated with an increase in length of gestation, suggesting the possibility of stress reduction as an appropriate intervention for lengthening gestational age.

The national certification examination in nurse-midwifery/midwifery was adapted to the Puerto-Rican Spanish language. Specific attention was paid to creating a version of the examination that was both culturally and linguistically relevant, while remaining appropriately representative of national standards of practice. The procedures used in translation and cultural adaptation are described. The process used in review of the examination followed usual and customary practice. This included consideration of item critiques received from candidates (qualitative data) and the computation of standard measures of item performance, including item difficulty indices and the standard error of measurement (quantitative data). Additional analyses conducted for this specific purpose included the calculation of an index of differential item performance between both language versions. All measures of assessment indicated that the adapted language version was of high quality and psychometrically equivalent to the English language version, which was the comparison standard.

The national certification examination (NCE) in nurse-midwifery and midwifery is developed, administered, and evaluated by the ACNM Certification Council (ACC). The blueprint for the NCE is based upon a comprehensive list of tasks that describe the knowledge, skills, and abilities expected of the midwifery practitioner at entry into the profession. In 1999, the ACC initiated the third in a series of task analysis studies to ensure the currency and relevance of the task list. This study was considered particularly timely, given that the professional organization, the American College of Nurse-Midwives, had approved pathways to midwifery for individuals whose first degree was not in nursing (the certified midwife) and also had expanded the core competencies for midwifery practice to include responsibilities in the domain of primary care. This manuscript reports the results of the pilot study, in which the specific list of tasks was developed. Three hundred and six ACNM members responded to a preliminary list of tasks, indicating their opinion about whether each specific task was relevant to entry-level midwifery practice. The task list finally derived consists of 219 tasks and 177 clinical conditions, dispersed among seven domains of practice (antepartum, intrapartum, newborn, postpartum, well-woman/gynecology, primary care/health assessment, and professional issues.) The task list represents a comprehensive profile of entry-level practice for nurse-midwives and midwives certified by the ACC.

Objective: To describe the outcomes of intended home birth in the practices of certified nurse-midwives. Methods: Twenty-nine US nurse-midwifery practices were recruited for the study in 1994. Women presenting for intended home birth in these practices were enrolled in the study from late 1994 to late 1995. Outcomes for all enrolled women were ascertained. Validity and reliability of submitted data were established. Results: Of 1404 enrolled women intending home births, 6% miscarried, terminated the pregnancy or changed plans. Another 7.4% became ineligible for home birth prior to the onset of labor at term due to the development of perinatal problems and were referred for planned hospital birth. Of those women beginning labor with the intention of delivering at home, 102 (8.3%) were transferred to the hospital during labor. Ten mothers (0.8%) were transferred to the hospital after delivery, and 14 infants (1.1%) were transferred after birth. Overall intrapartal fetal and neonatal mortality for women beginning labor with the intention of delivering at home was 2.5 per 1000. For women actually delivering at home, intrapartal fetal and neonatal mortality was 1.8 per 1000. Conclusion: Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary. Intrapartal mortality during intended home birth is concentrated in postdates pregnancies with evidence of meconium passage.

Women may choose to initiate, reinitiate, or discontinue hormone replacement therapy (HRT) at any time beyond the perimenopausal period. HRT, exercise, and nutrition are reviewed in terms of their potential benefits as primary and secondary preventive therapies against coronary heart disease, osteoporosis, breast and genital cancers, and the maintenance of cognitive function among older postmenopausal women. Lifestyle alternatives involving nutrition and exercise that offer many of the same benefits as HRT are discussed. Since both pharmacologic and lifestyle interventions offer significant benefit for primary and secondary prevention of disease and disability, each should be offered to women for consideration as they enter the perimenopausal period. Additionally, each can be recommended for initiation even at much older ages and subsequent to adverse health occurrences, such as the experience of breast or genital cancer or a cardiac event. Each should be sustained over the long term. The decision whether to discontinue these interventions among the most elderly will be influenced by other quality of life considerations.

A study of attitudes, beliefs, and behaviors about prenatal care was conducted among Hispanic women who resided on the U.S.-Mexico border. As part of a larger study that included chart reviews of 752 mothers and postpartum interviews of 587 of these women, the 118 women who elected to deliver in the university-affiliated teaching hospital, rather than any of four participating private hospitals, were reviewed separately. This study sought to determine whether the prenatal care behaviors and obstetric outcomes experienced by this subset of women would contribute to any particular adverse impact on the teaching hospital, such as the need for additional intervention services. The most common barriers to prenatal care identified among women in the entire study were the same factors identified among women in the university hospital, including lack of financial means to pay for care, lack of information concerning where to obtain care, inadequate infrastructure of clinic services, sadness, and depression. Maternal and infant outcomes were generally favorable, even for women who did not receive any measure of prenatal care.

Iain Chalmers and the National Perinatal Epidemiology Unit, Oxford, England, developed a comprehensive listing of perinatal care procedures shown to reduce the frequency of adverse outcomes during pregnancy and childbirth. This list was used as a framework for a pilot study conducted in 1992 that reviewed similarities and differences in opinion and practice style between certified nurse-midwives (CNMs) and obstetrician/gynecologists. Twenty CNMs and 57 obstetrician/gynecologists who were active clinical practitioners in San Diego commented on 24 items drawn from Chalmers' work. The CNMs were more likely to favor the availability of social and psychological support variables and to use them in their practice. The groups were more alike than different in their views concerning preventive interventions during the prenatal period. CNMs were more likely to support the availability of alternatives to maternal positions for labor and birth, exhalatory breathing, and delayed pushing and less likely to support the availability of electronic fetal monitoring, epidural anesthesia, episiotomy, and active management of the third stage. A small sample size and limited response rate restricted interpretation and generalizability of these data. Nevertheless the data offer support for other studies with similar findings. They also suggest that health system administrators should inform women and families about differences in practice styles before families select from among the various insurance options that may, in the end, restrict the choice of provider or birth setting.

Background Hemorrhage continues to be a leading cause of maternal death in developing countries. The 2012 World Health Organization guidelines for the prevention and management of postpartum hemorrhage (PPH) recommend oral administration of misoprostol by community health workers (CHWs). However, there are several outstanding questions about distribution of misoprostol for PPH prevention at home births. Methods We conducted an integrative review of published research studies and evaluation reports from programs that distributed misoprostol at the community level for prevention of PPH at home births. We reviewed methods and cadres involved in education of end-users, drug administration, distribution, and coverage, correct and incorrect usage, and serious adverse events. Results Eighteen programs were identified; only seven reported all data of interest. Programs utilized a range of strategies and timings for distributing misoprostol. Distribution rates were higher when misoprostol was distributed at a home visit during late pregnancy (54.5-96.9%) or at birth (22.5-83.6%), compared to antenatal care (ANC) distribution at any ANC visit (22.5-49.1%) or late ANC visit (21.0-26.7%). Coverage rates were highest when CHWs and traditional birth attendants distributed misoprostol and lower when health workers/ANC providers distributed the medication. The highest distribution and coverage rates were achieved by programs that allowed self-administration. Seven women took misoprostol prior to delivery out of more than 12,000 women who were followed-up. Facility birth rates increased in the three programs for which this information was available. Fifty-one (51) maternal deaths were reported among 86,732 women taking misoprostol: 24 were attributed to perceived PPH; none were directly attributed to use of misoprostol. Even if all deaths were attributable to PPH, the equivalent ratio (59 maternal deaths/100,000 live births) is substantially lower than the reported maternal mortality ratio in any of these countries. Conclusions Community-based programs for prevention of PPH at home birth using misoprostol can achieve high distribution and use of the medication, using diverse program strategies. Coverage was greatest when misoprostol was distributed by community health agents at home visits. Programs appear to be safe, with an extremely low rate of ante- or intrapartum administration of the medication.

Background Pre-eclampsia/eclampsia is one of the most common causes of maternal and perinatal morbidity and mortality in low and middle income countries. Magnesium sulfate is the drug of choice for prevention of seizures as part of comprehensive management of the disease. Despite the compelling evidence for the effectiveness of magnesium sulfate, concern has been expressed about its safety and potential for toxicity, particularly among providers in low- and middle-income countries. The purpose of this review was to determine whether the literature published in these global settings supports the concerns about the safety of use of magnesium sulfate. Methods An integrative review of the literature was conducted to document the known incidences of severe adverse reactions to magnesium sulphate, and specific outcomes of interest related to its use. All types of prospective clinical studies were included if magnesium sulfate was used to manage pre-eclampsia or eclampsia, the study was conducted in a low- or middle-income country, and the study included the recording of the incidence of any adverse side effect resulting from magnesium sulfate use. Results A total of 24 studies that compared a magnesium sulfate regimen against other drug regimens and examined side effects among 34 subject groups were included. The overall rate of absent patellar reflex among all 9556 aggregated women was 1.6%, with a range of 0-57%. The overall rate of respiratory depression in 25 subject groups in which this outcome was reported was 1.3%, with a range of 0–8.2%. Delay in repeat administration of magnesium sulfate occurred in 3.6% of cases, with a range of 0-65%. Calcium gluconate was administered at an overall rate of less than 0.2%. There was only one maternal death that was attributed by the study authors to the use of magnesium sulfate among the 9556 women in the 24 studies. Conclusion Concerns about safety and toxicity from the use of magnesium sulfate should be mitigated by findings from this integrative review, which indicates a low incidence of the most severe side effects, documented in studies that used a wide variety of standard and modified drug regimens. Adverse effects of concern to providers occur infrequently, and when they occurred, a delay of repeat administration was generally sufficient to mitigate the effect. Early screening and diagnosis of the disease, appropriate treatment with proven drugs, and reasonable vigilance for women under treatment should be adopted as global policy and practice.

Parents planning a home birth need specific information beyond that which typically is covered in childbirth preparation classes geared for hospital couples. Topics that specifically need to be included in preparation for home birth include the meaning of shared responsibility for the birth at home, informed disclosure of personal and professional data, motivating factors and barriers to a successful birth, coping strategies, preparation of the home environment, contingency plans for referral or emergency transport, and preparation for self-care following the birth.

The ACNM Certification Council is responsible for determining that the national certification examination in nurse-midwifery is not biased toward any protected group. Educational programs of nurse-midwifery have an interest in knowing that their administrasions criteria and educational design have validity. Policy makers have an interest in both of these issues. Nine demographic and preadmission factors were investigated to identify their ability to predict performance on the nurse-midwifery national certification examination. This retrospective analysis included 1,046 candidates who took any one of five criterion-referenced, modified essay forms of the examination between January 1988 and April 1994. Multiple-regression analysis revealed that five factors explained 16.2% of the variance in certification examination performance. These factors included age (as age increased, scores decreased slightly), ethnicity (white and Hispanic candidates received higher scores compared with other groups), years of nursing practice prior to nurse-midwifery education (a slight positive influence for each additional year), highest educational degree obtained (those whoose highest degree was the baccalaureate performed slightly better than candidates with no degree and candidates with graduate degrees), and academic level of the nurse-midwifery education program (certificate, master's, and doctoral level candidates all performed better than candidates from precertification programs certificate candidates performed slightly better than master's candidates). However, even though these variables contributed to a statistically significant model, the actual degree of predicted difference in scores was of little practical significance. Variables that were not predictive of performance included maritial status, U.S. versus foreign education either in nursing or in midwifery, academic level of the registered nursing educational program, and the highest academic degree obtained.

The ACNM Certification Council is responsible to the American College of Nurse-Midwives for the development, administration, and evaluation of a psychometrically sound and legally defensible certification examination in nurse-midwifery. A task analysis study was conducted to investigate the knowledge, skills, and abilities that define American nurse-midwifery practice. A stratified sample of 825 American College of Nurse-Midwives members was asked to rate the frequency of performance and the criticality of 189 nurse-midwifery activities and 109 discrete diagnoses that the nurse-midwife might encounter while providing clinical care. The frequency and criticality ratings were combined to generate an importance weight for each activity. Study data will be used as the basis of the examination blueprint in order to ensure job-related content validity. Aggregate data can also be used for curriculum development, self-assessment, and evaluation research purposes.

Current literature on the safety and efficacy of freestanding birth centers suggests that these centers are safe and have reduced costs for delivery of low-risk women compared with hospitals. Despite these findings, birth centers continue to arouse controversy and remain limited in number. Potential inequality of birth center and hospital subjects as to perinatal risk is cited as the major methodologic flaw in the current research on birth centers. Defining an appropriate comparison group is arguably the most important methodologic issue encountered in these investigations. Defining women as "low risk" according to standard perinatal risk tools is not an adequate measure of comparability, as these criteria are generally not equivalent to those defining birth center eligibility. The key is to identify groups for comparison that, at baseline, would be expected to have similar outcomes. To address this concern, a tool based on the American College of Nurse-Midwives' Nurse-Midwifery Clinical Data Set was developed to identify valid comparison subjects for birth center research. This tool focuses on birth center eligibility as opposed to traditionally defined risk. This article reviews the issues of population comparability in birth center research and presents the results of a validation study using this newly developed tool.

The health of populations residing on either side of the United States-Mexican border has public policy implications for both border communities. A study of barriers to prenatal care for residents of the San Diego, California-Tijuana, Mexico region was conducted. The study was designed specifically to address the availability of health services for women who crossed the border in either direction. This article reports the methodology used in the construction and validation of a dual-language (as opposed to a Spanish language form) survey instrument that was developed for the study. Particular attention is given to the methodology used for language translation to ensure that it would reflect the idiomatic diversity of the multicultural population.

Introduction The American College of Nurse-Midwives (ACNM) Core Data Survey is an annual membership survey that collects demographic and selected workforce data about certified nurse-midwives (CNMs), certified midwives (CMs), and students enrolled in midwifery education programs accredited by the Accreditation Commission for Midwifery Education, who are members of the organization. This article presents findings from the analysis of membership data for the years 2006 to 2008. Methods An e-mail invitation to participate in the online survey was sent to all ACNM members who provided ACNM with an e-mail address. A paper copy of the survey was available upon request. The survey instrument for the years 2006 to 2008 focused on five categories: demographics, certification, education, employment, and licensure. Results ACNM member respondents continue to remain predominantly white and female. The average age of CNMs/CMs for 2008 is 51 years, and the majority holds a master's degree as their highest degree. Discussion Very few advances have been made in the effort to increase the diversity of ACNM membership. The number of CNMs earning doctoral degrees (including the doctor of nursing practice degree) is increasing. A majority of CNMs/CMs continue to identify a broad domain of clinical midwifery practice as their primary responsibility in their primary employment, and hospitals and physician practices remain the largest employers of midwives. Salaries for midwifery-related work are rising, but it is unclear if midwives are earning more because salaries are higher or because the higher salaries reflect market wage adjustments that occur over time.

This article is a retrospective descriptive analysis of the first 1,000 births conducted by the Nurse-Midwifery Group of Fresno County, California, over the period from 1980 to 1985. The multiethnic patient population was of mixed obstetric risk. Nurse-midwifery care was offered within the context of a comprehensive maternity care program in close collaboration with a perinatal health care team. Patient care outcomes were quite favorable when compared with county and state statistics. A perinatal mortality rate of 7.0 1,000 was observed. The incidence of low birth weight infants (5.7%) and the cesarean section rate (7.7%) were also lower than county and state statistics. These data add to the growing body of literature that suggests that nurse-midwifery care, within the structure of collaborative practice, can be effective and advantageous. The nurse-midwifery service made a contribution to access to perinatal care for the residents of this community.

Through a nurse-midwifery service in a mixed urban and rural agricultural community, we compared maternal risk factors, prenatal care, labor and delivery, and adverse birth outcomes in low-income Mexican- American Hispanic, white (Caucasian), and Southeast Asian women—a three-way analysis rarely reported in the literature. Southeast Asian women were older and had more children. Hispanic women bore children at a younger age. Both Southeast Asians and Hispanics made fewer prenatal visits than did Caucasian women, and used less analgesia and anesthesia during delivery. The incidence of Cesarean section (7.7 percent) and low birthweight (5.9 percent) was compared to local, state, and national reference statistics. Prospective case-controlled studies and cost/benefit analyses of nurse-midwifery services could yield more definitive information. But until more precise data are collected for birth certificates, these studies will be difficult.

Topic There is wide variability in regulatory authority, basic education requirements, and titling for nurses in advanced practice roles, that is, certified nurse–midwives (CNMs), certified registered nurse anesthetists (CRNAs), and nurse practitioners (NPs). There is current advocacy for a common identity for advanced practice nurses (APNs), including uniform entry into practice requirements (the doctor of nursing practice [DNP]). Methods Membership survey data were extracted to generate a contemporary profile of characteristics of these categories of practitioners. Results The APN groups are similar in age ( M = 47–48 years) and race (predominantly Caucasian), with the largest proportions of all groups clustering in the age range of 51–54 years. There are more men in the CRNA group (45%). CNMs have the highest proportion of doctoral degrees (4.7%). CRNAs command the highest annual average salary ($140,000). Conclusions Membership survey data can monitor progress toward implementation of proposed educational and regulatory changes. The effect of these proposals on the availability of an experienced APN mentor workforce for DPN students and the availability of an APN workforce for clients remains largely unknown. Standardized indicators of performance and client outcomes may enhance current data collection of membership demographics and enable precise evaluation of outcomes and impact of APN care.

Mothers and their home birth attendants residing in rural Uttar Pradesh (UP), India, were taught to recognize and take action to resolve selected maternal and neonatal life-threatening problems. Community mobilization efforts were designed to reduce delays in transport to emergency obstetric care (EOC) referral units and to increase use of family planning. Retention of knowledge and skills for recognition and intervention for maternal bleeding and newborn sepsis was enhanced when pictorial depictions of the problem or take action message or both were used as memory aids. Advocacy efforts for use of EOC facilities were less successful. The community health promotion and home-based life-saving skills education efforts tested are recommended for replication.

Each of the living presidents of the American College of Nurse-Midwives (ACNM), past and current, was asked to select one or more issues that were of particular importance during her term(s) in office. Some of the issues identified by the presidents were amenable to review using existing quantitative data; this article presents those findings. The substantial increase in growth of ACNM membership in the 1980s and 1990s as well as the plateau that occurred at the beginning of the 21st century is documented. The relationship between ACNM and the professions of nursing, medicine, and other public health providers is illustrated. The increase in the number of Certified Nurse-Midwife/Certified Midwife (CNM/CM) education programs and the evolution and current profile of curriculum models are discussed. Finally, expansion of the scope of midwifery practice and the growing number of opportunities for entrepreneurial practice are presented in terms of current practice profiles, practice sites and settings, various employer-employee relationships, and the variety of financial reimbursement streams. This article is intended to complement the broader body of information about ACNM's history, and particularly, to supplement the richness of information derived from the qualitative and historical research inquiries conducted by others.

A format for obtaining a genetic family health history is presented, along with a discussion of the importance of psychosocial support surrounding the genetic screening process and the responsibility for the maintenance of the privacy of medical records of patients who elect to undergo genetic screening, are presented.

Clinical trials are the primary way the most promising new preventive, diagnostic, therapeutic, and palliative measures move from the basic science laboratory to the bedside. Attracting participants to clinical trials occurs at a painstakingly slow pace, delaying the public's access to new care modalities. Additional ways are needed to increase the public's awareness and understanding of the important role of clinical trials. As key members of the health and social welfare promotion team, nurse-midwives/midwives are well positioned to help advance the public's access to clinical trials information. Generic ethical issues related to human subjects review processes, their specific application to clinical trials, and the impact of recent HIPAA legislation are discussed.

Objective: to delineate the knowledge, skills, and behaviours that would characterise the domain of competencies of the midwife who is educated according to the international definition of the profession. Design: Phase I: a qualitative Delphi study; Phase II: a descriptive survey research process. Participants: a stratified random sample of member organisations of the International Confederation of Midwives (ICM) and regulatory representatives from these same countries. Findings: a list of basic (essential) and additional competencies for midwives who have been educated in keeping with the ICM/WHO/FIGO international definition of the midwife was developed through an interative Delphi process, and then affirmed, using a survey research method. The final list includes 214 individual task statements within six domains of midwifery practice. Implications for practice: this list of competencies can serve as a basis for educational curriculum design, as a guideline for regulatory policy development, as a reference document for individual practitioners in an assessment of their initial and continued competency and by the ICM and its member associations as a resource for advocating for the role of midwifery within health-care systems world-wide.

Preterm birth rates continue to rise in the United States despite the advent of tocolytic agents and the identification of risk factors for preterm birth, such as vaginal infection and a shortened cervix. Although improvement in gestational-age-related survival of preterm infants has occurred as a result of the use of antenatal corticosteroids, neonatal surfactant therapy, and regionalization of perinatal care, there has been no reduction in the incidence of preterm birth. Recently, investigators have appreciated that the etiology of preterm birth is heterogeneous, perhaps accounting for one reason for the failure of current interventions to improve pregnancy outcome. Both abnormal maternal hormonal homeostasis and intrauterine inflammatory responses appear to contribute to a significant proportion of the cases of preterm birth, and the interaction of the maternal endocrine and immunologic systems may contribute to the pathophysiology of this condition. An important modulator of endocrine and immune function is perceived emotional and social stress. Maternal stress has been strongly associated with preterm birth, but the links between maternal stress and resultant aberrations of maternal endocrine and immune function remain difficult to quantify and investigate. However, new insights into the role of perceived maternal stress on gestational length suggest that specific interventions to alleviate stress could contribute to an increase in gestational length and a decrease in the risk for preterm birth. This review addresses the role of maternal stress on the regulation of maternal hormone and inflammatory responses and how aberrations in these systems may lead to preterm birth.

The relationships and predictive abilities of perceived stress, selected clinical risk factors, and corticotropin-releasing hormone (CRH) levels in maternal plasma were investigated for their association with preterm labor (PTL), preterm birth, and gestational age at delivery. An exploratory, prospective, longitudinal research design was used to measure CRH 4 times over pregnancy, perceived stress at 24 and 32 weeks of pregnancy, clinical risk factors, and genitourinary infections in low-income women. Multiple regression analyses revealed that a model of measurement of perceived stress at 24 or 32 weeks, CRH at 24 or 32 weeks, and PTL (indicated by a diagnosis by the physicians on the medical record and greater than 5 contractions per hour on the fetal monitor) was predictive of as much as 0.23 to 0.27 of the variance in gestational age at birth. Entering ethnicity as a variable into a model did not improve the predictive value. An analysis of variance between Caucasian and Hispanic ethnic groups revealed differences in CRH levels. However, simple regression analysis of ethnicity as a predictor showed a weak r 2 with no significance for prediction. There was some evidence of an association of smoking with stress and both PTL and preterm birth. The measurement of stress combined with the measurement of CRH from maternal plasma may improve the prediction of which pregnant women are at risk for preterm birth. The measurement of CRH has potential as an early biological marker of preterm birth.

A master list of tasks, which contained 200 task statements, 23 professional issues statements, and 177 clinical conditions, was divided into three equivalent survey forms and distributed to those certified nurse-midwives (CNMs) and certified midwives (CMs) certified by the ACNM Certification Council, Inc. during the 5-year period from 1995 to 1999. Specific efforts were made to encourage the participation of CMs, because they represented a new professional cohort. A total of 627 valid responses were obtained. Reasonably similar numbers of respondents contributed data related to each of the three versions of the survey form. The responsibilities have expanded substantially within the domains of nonreproductive primary health care and gynecologic care of the well woman, including advances in assisted reproductive technology. A diminished emphasis on the CNM/CM role in the provision of newborn care was documented. The ACC Research Committee recommended the revision of the entry-level certification examination blueprint, and this was approved by the ACC Board of Directors. The specific recommendations included the development of a new primary care domain and the reconfiguration of content emphasis with percentage allocations as follows: Primary Care, 5-10%; Well-Woman/Gynecology, 15-20%; Newborn, 5-10%; Postpartum, 5-10%; Antepartum, 25-30%; Intrapartum, 25-35%; Professional Issues, up to 5%.

The American College of Nurse-Midwives (ACNM) Certification Council periodically conducts a task analysis study as evidence supporting the content validity of the national certification examination in nurse-midwifery and midwifery. The purpose of this article is to report findings related to the examination of the relationship between professional issues and safe beginning-level midwifery as measured by the 1999–2000 Task Analysis of American Nurse Midwifery and Midwifery Practice. Study findings suggest that newly certified midwives place strong emphasis on the importance of tasks related to the ACNM “Hallmarks of Midwifery,” which characterize the art and science of the profession; these include tasks dealing with health promotion and cultural competency. The beginning midwives, however, gave consistently low ratings to tasks related to ACNM “Core Competencies” that mirror the professional responsibilities of midwives; these include tasks related to the history of midwifery, research, or health policy. The study has implications for nurse-midwifery/midwifery educators, experienced midwifery mentors, and other persons interested in reinforcing the relevance of these important professional issues to the new midwife.

Stress is thought to be one of the biopsychosocial factors that contribute to adverse pregnancy outcomes, such as preterm labor and low birthweight. Identification of these factors (as in total number), and measurement of their individually perceived importance (severity) could lead to opportunities for intervention, and improved pregnancy outcome. A pilot study of the Daily Hassles Scale, was conducted in order to determine the appropriateness of its use among pregnant women. Daily hassles were thought to be a valid proxy for prenatal stress. Content and construct validity were determined among a sample of four content experts and 30 pregnant women. The Daily Hassles Scale proved to be a reliable (internally consistent) measure of stress (alpha reliability coefficient of 0.90). Further adaptation of the scale to include hassles specific to pregnancy and further testing of its usefulness among diverse multicultural and ethnic populations is warranted.