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BACKGROUNDBenefits add to the total compensation received by midwives for their professional work in global settings. Some benefits are commonly offered as a package by employers as components of employment contracts. Some benefits may be individually negotiated or may be self-funded by midwives who own their own businesses.PURPOSEIdentify benefits associated with midwifery employment.METHODSBenefits data available to certified nurse-midwives (CNMs) and certified midwives (CMs) in the United States were collected in online surveys conducted in 2004, 2007, 2010, and 2014. Benefits types received and benefits cost-sharing for midwives and their families were compared descriptively.RESULTSMore than 90% of respondents employed full-time in 2014 reported that they received at least 1 of 16 types of benefits in their midwifery-related employment. Professional liability insurance, paid vacation (paid holiday), and paid time off for continuing education were the only benefits reported by 75% or more of respondents in each of 4 survey years. Trends over time reported by U.S. CNMs/CMs employed full-time suggest a decrease in employer contributions to benefit costs. Nearly half of all CNM/CM respondents reported not knowing the basis for calculation of their salary and compensation package.CONCLUSIONChanges appear to indicate increasing employee cost-sharing of benefits packages in recent years for U.S. midwives. Similarities and differences identified for midwives in global settings are discussed, although information on benefits in global settings was limited. Midwives in all settings may gain from education about strategies for negotiation of salary and compensation packages.

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.

Healthcare providers are in a unique position to identify barriers to healthcare for socioeconomically disadvantaged families, provide patient navigation for reducing disparities, and implement system changes for alleviating these barriers. Significant barriers to obtaining pediatric dental care exist for families with young children. This curricular resource describes an interprofessional education program that was conducted with small teams of health science students (nursing, pediatric medicine, dental medicine) at a suburban university. Five objectives were identified to assist students in realizing the barriers faced by socioeconomically disadvantaged families when seeking dental care for their young children. Students were assigned simulated child-patients, along with relevant health, demographic and insurance information and asked to use their cellular smartphones to identify timely and logistically compatible dental care for these simulated patients. Debriefing revealed that students had difficulty identifying appropriate pediatric dental care providers within a wide urban and suburban region. Post-workshop student surveys identified increased awareness of income, care access, and health literacy as factors contributing to health disparities.

A novel, sustainable digital badge-awarding online course was developed to prepare learners with familiarity of patient navigation. Learners offered favorable endorsement of essentially all elements of the program, especially the utility of the Blackboard learning management software program. Quality Matters standards provided a rigorous framework for the challenges of designing, implementing, and evaluating online curricula. Online education is an effective method for meeting the professional development needs of those seeking careers in care coordination/patient navigation.

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.

Background: Writing competency is imperative for Doctor of Nursing Practice (DNP)-prepared advanced practice nurses (APNs), who serve as clinical leaders and educators of the nursing workforce. Method: As part of a writing quality improvement project, a Writing Tutor Round Table program was developed. Interdisciplinary tutors from the campus writing center worked with groups of three to four DNP students to enhance the quality of their written assignments. At an open table in a quiet room, tutors critiqued the writing of one student while the other students listened. Financial records were used to determine the direct cost of the intervention, and participant survey data provided evidence for acceptability. Results: This intervention was a cost effective and highly acceptable experience for both tutors and students. Conclusion: A Writing Tutor Round Table intervention is an acceptable, low-cost, low-faculty burden intervention for improving the quality of writing among APNs. [ J Nurs Educ . 2020;59(3):173–175.]

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.

Judith Fullerton,1 Michelle M Butler,2 Cheryl Aman,3 Tobi Reid,3 Melanie Dowler3 1Retired, School of Medicine, University of California, San Diego, CA, USA; 2Faculty of Science and Health, Dublin City University, Dublin 9, Ireland; 3Midwifery Program, University of British Columbia, Vancouver, BC, Canada Introduction: The International Confederation of Midwives (ICM) represents 132 midwifery associations in 113 countries. The ICM disseminates the Essential Competencies for Basic Midwifery Practice (EC) that describes the global scope of midwifery practice. The basic (core) and expanded (additional or optional) role of midwives in providing abortion-related care services was first described in 2010. A literature review about three items that are particularly critical to access to abortion services was conducted. Findings that emerged in the recent 2016–2017 update study about these three items are presented. Methods: A modified Delphi study was administered via the Internet in a series of three rounds. Thirty-seven statements of abortion-related knowledge and skill were presented. Results: A total of 895 individuals participated. The total of respondents across all three rounds represented 90 of the 105 member countries at the time of the study. The role of midwives in providing comprehensive abortion care, including referral for abortion and provision of postabortion family planning, achieved the necessary 85% agreement to be designated as essential (basic) knowledge or skill for the global scope of midwifery practice. The provision of medication abortion and performance of manual vacuum aspiration abortion were designated as optional for midwives who wished to provide these services. Endorsement of these latter practices was highest in both Francophone and Anglophone regions of Africa, Asian Pacific countries, and countries at a lower state of economic development. Conclusion: The role of midwives in provision of abortion-related care services was reaffirmed in the recent Delphi study to inform the update to the EC. The role of midwives as direct providers of medical and vacuum aspiration abortions was reaffirmed for those individual midwives who wish to obtain the requisite competency to provide those services, in jurisdictions where these services are legally authorized. Keywords: aspiration abortion, medical abortion, abortion providers, comprehensive abortion care, postabortion care, midwives

The American College of Nurse-Midwives represents two cadres of midwifery professionals: certified nurse-midwives who are educated in both midwifery and nursing, and certified midwives who are educated in the discipline of midwifery. Certified nurse-midwives are designated by nursing professional organizations as advanced practice nurses. The United States nursing profession is advancing toward adoption of the Doctor of Nursing Practice degree, as the entry into practice credential for advanced practice nursing. There is no evidence to date to demonstrate differences in clinical practice outcomes between certified nurse-midwives and certified midwives. A secondary analysis of data from a series of compensation and benefits surveys did not demonstrate differences in salaries between respondents who held a practice-focused doctoral degree compared to a master's degree. The requirement of the practice-focused nursing doctoral degree for entry into midwifery practice for certified nurse-midwives would require additional evidence to support both a professional and a business case for such a change in policy. It would also require consideration of the professional and business impact that such a policy would have on certified midwives who do not hold the nursing credential. Equivalent entry into practice pathways would need to be developed.

Objective To obtain consensus amongst midwifery experts globally about the essential competencies for basic midwifery practice. Design A modified Delphi approach, involving a three-round online survey. Participants Midwifery leaders, educators and regulators in all ICM regions, along with representatives of organisations affiliated to ICM. Methods The research team worked closely with a Core Working Group and a Task Force. An initial set of competencies and components was developed through a content analysis of existing competency documents and presented to participants in Round 1 of the survey. Items identified as essential by at least 85% of participants were endorsed. Remaining items and new items identified by participants were returned to participants in Rounds 2 and 3 for further rating. Findings The study achieved a wide sample representative of midwifery experts across all ICM regions and countries, language groups, and income categories. Only a small number of competencies relating to the wider role of the midwife were endorsed as essential competencies. Competencies and components relating to professional and personal attributes were extended. Although most competencies and components relating to core midwifery practice were endorsed as essential competencies, several were rejected relating to abortion-related care, cancer screening, infertility, and gynaecology. Findings are, nevertheless, highly consistent with the scope of practice delineated in the current 2010/2013 version of the ICM Essential Competencies for Basic Midwifery Practice. Key conclusions and implications for practice The extension of professional and personal attributes reflects the recent emphasis on respectful midwifery care. The rejection of most of the additional competencies and components relating to the wider role of the midwife and endorsement of most of those considered to relate to core midwifery practice indicates that the scope of midwifery practice remains essentially unchanged through 2017.

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.

This article describes the program components, program outcomes and challenges of two iterations of a leadership development program that was intended to contribute not only to individual capacity building but also to succession planning within midwifery professional associations. The young midwifery leaders programs were similarly designed, using self-study modules that focused on essential leadership knowledge and skills, and a mentor–mentee relationship to provide guidance and support to selected midwives early in their professional careers. The International Confederation of Midwives (ICM) implemented a 3-year leadership program conducted from 2004 to 2007 for five mentee participants. A collaborative United Nations Population Fund (UNFPA)/ICM team in Latin America designed and implemented an 18-month program with 12 mentees that began in 2013. Examples of leadership outcomes in policy and education include assumption of elected offices in midwifery associations, integration of evidence-based topical content into an established midwifery education program, and development of a new preservice education program in a rural zone of a large country. The vision for the future is to expand this program globally while simultaneously adapting the program content and strategies to reflect the leadership needs of the regional context in which it is implemented.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

This article describes the types of helpful and supportive interactions or communication strategies that characterize the collaborative relationships in which a midwife can engage across the novice-to-expert continuum of professional development. Similarities and distinctions are drawn between the various terms describing types of collaboration and discussed with respect to the added value that each relationship can have for the individual and for the health care team. A conceptual depiction of the essential components of effective teamwork or collaboration is presented. Emphasis is placed on the dynamic nature of the process of developing and sustaining these relationships across the midwife’s professional lifetime.

This article presents an overview of the emergence of professional midwifery in the Caribbean region, beginning with colonial tradition, and linkages with nursing education and practice. Recent actions taken to strengthen the voice of midwifery as an autonomous profession are then described, including the vision for development of a Caribbean Regional Midwives Association (CRMA), which anticipates recognition as a new member status by the International Confederation of Midwives. CRMA members are engaged in efforts to build individual practitioner capacity in clinical practice and education, through shared activities and resources. CRMA members are also working toward regionalization of a midwifery core curriculum and common standards for regulation.

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: a 2-year study was conducted to develop Global Standards for Midwifery Education in keeping with core documents of the International Confederation of Midwives. Elements of the standards were based on evidence available in the published and unpublished literature. Companion Guidelines to assist in implementing the standards were also developed. Design: a modified Delphi survey process was conducted in two rounds following item validation by a panel of midwifery education experts. Setting: a global survey conducted in 88 countries. Participants: midwifery educators and clinicians associated with midwifery education located in any of the ICM member association countries. Additional participants included an Expert Midwifery Resource Group, other Key Stakeholders, midwifery regulators and policy makers. A total of 241 individuals from 46 ICM member association countries and ten non-member countries responded to one or both of the survey rounds. Measurements: survey respondents expressed an opinion on whether to retain or to delete any of the proposed components of the standards. Version one had 109 proposed components and version two had 111 items for consideration. Findings: a majority consensus of .80 was required to accept an item without further deliberation. The Education Standards Task Force (expert panel) made final decisions in the four instances where this level of consensus was not reached, retaining all four items. The panel also amended the wording of selected items or added new items based on feedback received from survey respondents. The final document contains 10 Preface items, 35 glossary terms, and 37 discrete standards with 27 sub-sections.

Objective a 2-year study was conducted to update the core competencies for basic midwifery practice, first delineated by the International Confederation of Midwives in 2002. A competency domain related to abortion-related care services was newly developed. Design a modified Delphi survey process was conducted in two phases: a pilot item affirmation study, and a global field survey. Setting a global survey conducted in 90 countries. Participants midwifery educators or clinicians associated with midwifery education schools and programmes located in any of the ICM member association countries. Additional participants represented the fields of nursing, medicine, and midwifery regulatory authorities. A total of 232 individuals from 63 member association and five non-member countries responded to one or both of the surveys. The achieved sample represented 42% of member association countries, which was less than the 51% target. However, the sample was proportionally representative of ICM's nine global regions. Measurements survey respondents expressed an opinion whether to retain or to delete any of 255 statements of midwifery knowledge, skill, or professional behaviour. They also indicated whether the item should be a basic (core) item of midwifery knowledge or skill that would be included as mandatory content in a programme of midwifery pre-service education, or whether the item could be added to the fund of knowledge or acquired as an additional skill by those who would need or wish to include the item within the scope of their clinical practice. Findings a majority consensus of .85 was required to accept the item without further deliberation. An expert panel made final decisions in all instances where consensus was not achieved. The panel also amended the wording of selected items, or added new items based on feedback received from survey respondents. The final document contains 268 items organised within seven competency domains.

The global health community has implemented several initiatives over the past in the interest of accelerating country-by-country progress toward the Millennium Development Goal of improving maternal health. Skilled attendance at every birth has been recognized as an essential component of approaches for reducing maternal and perinatal morbidity and mortality.Midwives have been acknowledged as a preferred cadre of skilled birth attendant. The International Confederation of Midwives (ICM) speaks for the global community of fully qualified (professional) midwives. The ICM document entitledEssential Competencies for Basic Midwifery Practiceis a core policy statement that defines the domains and scope of practice for those individuals who meet the international definition of midwife. This article explores the meaning of competence and competency as core concepts for the midwifery profession. An understanding of the meaning of these terms can help midwives speaking individually at the clinical practice level and midwifery associations speaking at the policy level to articulate more clearly the distinction of fully qualified midwives within the skilled birth attendant and sexual and reproductive health workforce. Competence and competency are fundamental to the domains of midwifery education, legislation, and regulation, and to the deployment and retention of professional midwives.

Nurse researchers and educators often engage in outreach to narrowly defined populations. This article offers examples of how variations on the snowball sampling recruitment strategy can be applied in the creation of culturally appropriate, community-based information dissemination efforts related to recruitment to health education programs and research studies. Examples from the primary author's program of research are provided to demonstrate how adaptations of snowball sampling can be used effectively in the recruitment of members of traditionally underserved or vulnerable populations. The adaptation of snowball sampling techniques, as described in this article, helped the authors to gain access to each of the more-vulnerable population groups of interest. The use of culturally sensitive recruitment strategies is both appropriate and effective in enlisting the involvement of members of vulnerable populations. Adaptations of snowball sampling strategies should be considered when recruiting participants for education programs or for research studies when the recruitment of a population-based sample is not essential.

A commitment to enhancing the diversity of the nursing workforce is reflected in the recruitment and retention strategies designed by Stony Brook University with support of a grant received from the Department of Health and Human Services, Health Resources and Services Administration. Three specific student retention strategies are evaluated in terms of their influence on student inclusion and promotion of student success. A review of the cultural competence of teaching and learning strategies and the promotion of cultural self-awareness underpinned these strategies. A mentorship program designed to provide individual support for students, particularly for those engaged in distance learning, proved to be challenging to implement and underused by students. Students found other means of support in their workplace and through individual connections with the faculty. Instructional programs that enhanced individual skills in the use of computer hardware and software were particularly effective in promoting student success.

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.

This article discusses issues to be considered by nurse researchers when groups should be used as the unit of randomization. Advantages and disadvantages are presented, with statistical calculations needed to determine the effective sample size. Examples of these concepts are presented using data from the Black Cosmetologists Promoting Health Program. Different hypothetical scenarios and their impact on sample size are also presented. Given the complexity of calculating the sample size when using groups as the unit of randomization, it is advantageous for researchers to work closely with statisticians when designing and implementing studies that anticipate the use of groups as the unit ofrandomization.

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.

The processes and procedures used to promote interrater reliability in the abstraction of data from medical records are described. Several proactive strategies that serve the purpose of leading to standard interpretations of clinical data are discussed. These include (a) establishment of priorities for the sources of information; (b) creation of orders of value for the likeliness of validity of recorded data; (c) standardization of terminology; and (d) reaffirmation of decisions, based on an evolving body of evidence. Lessons learned from this project can assist nurse researchers to develop high-quality information retrieval methods, when multiple observers (or abstractors) are used during a medical record abstraction data collection process.

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.

Gender is a factor in the risk assessment for many diseases. It may also impact on the way in which men assess their personal health or illness status and take action to prevent illness or promote well-being. This paper is focused on three objectives: (i) to foster an understanding of gender differences in health promoting behaviors; (ii) to review three health issues affecting males for which dissemination of health education, increased personal awareness and early detection may be beneficial in the reduction of morbidity and mortality; and (iii) to offer suggestions for nurses and other health care professionals to promote positive patient-provider interactions within a health-care framework for action.

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.

In 1996, the Division of Accreditation (DOA) of the American College of Nurse-Midwives (ACNM) preaccredited the first direct entry program of midwifery education for candidates who already possess undergraduate degrees in non-nursing disciplines. Inaugurated through the partnership of the State University of New York Health Science Center at Brooklyn and the North Central Bronx Hospital, this 1-year, postbaccalaureate, certificate program of studies graduated two integrated classes of 22 registered nurse (RN) and nine direct entry (DE) students between 1997 and 1998. This article presents the experience of the first 2 years of this innovative program, focusing on the profiles of the DE students, their achievements, and their experiences entering the workforce. All of the data comparing nurse and non-nurse student progress through the program of studies strongly support the conclusion that, within an ACNM DOA preaccredited/accredited midwifery education program, DE students can achieve standards of academic excellence and clinical competency that are at least equivalent to those demonstrated by their RN peers.