Journal of Midwifery & Women’s Health
org
American College of Nurse-Midwives
Abstracts from Research Forums Presented at the American
College of Nurse-Midwives’ 62nd Annual Meeting
The American College of Nurse-Midwives (ACNM) Di-
vision of Research, Division of Global Health, and the
Journal of Midwifery & Women’s Health are pleased
to present the abstracts from the 2017 Research Forum
podium presentations. The podium presentations were se-
lected in a blinded peer review process and presented
at the ACNM Annual Meeting in May 2017. The ab-
stracts of completed research were eligible for presenta-
tion and therefore publication. The abstracts presented
here demonstrate the breadth and quality of research being
conducted about midwifery and women’s health by mid-
wifery researchers and our colleagues.
Lisa Hanson, CNM, PhD, Chair, Division of Research
Carrie Klima, CNM, PhD, Chair, Research
Dissemination Section, Division of Research
Jody Lori, CNM, PhD,
Chair, Division of Global Health
Amy Levi, CNM, PhD, Chair, Research Section,
Division of Global Health
State Regulation of Midwifery: Scope of Practice,
Workforce and Clinical Outcomes
Margaret W. Beal, CNM, PhD (MGH Institute of Health Pro-
fessions); Alex Hoyt, RN, PhD (MGH Institute of Health
Professions)
Purpose: To update state scope of practice scores using the
Certified Nurse-Midwife Professional Practice Index (CNM
PPI), a 100-point scoring system of practice authority; to
refine previous work on the association between midwifery
scope of practice and the midwifery workforce; and to expand
on previous research by investigating the impact on birth out-
comes. Research Questions: How has the CNM PPI changed
and what are the current scores? What is the relationship be-
tween the CNM PPI and the number of midwives per 100,000
women aged 15 to 44 years? What associations are there be-
tween the state CNM PPI, CNM workforce, and birth out-
comes? Significance: The maternity care and women’s health
care provider workforce is diminishing and poorly distributed
across the United States. Certified nurse-midwives (CNMs)
and certified midwives (CMs) contribute to this workforce
and have the potential to contribute to the solutions to the
workforce problem. However, significant variation in prac-
tice regulation may influence the midwifery workforce and
birth outcomes. Methods: Using updated CNM PPI scores,
we conducted a state-level ecological analysis of the asso-
ciation between CNMs per capita and CNM birth atten-
dance and refined previous research by adjusting for state
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covariates including education, poverty, population den-
sity, race, uninsurance, and the number of obstetrician-
gynecologists per capita. We then investigated the indepen-
dent and interactive effects of regulation and workforce rates
of preterm birth and low birth rate. Results: In 2013, the av-
erage (standard deviation [SD]) number of CNMs/CMs per
100,000 women aged 15 to 44 years was 20.6 (12.6) and the
average (SD) CNM PPI was 78.8 (10.3). Adjusting for state
covariates, a one-point increase in the CNM PPI was asso-
ciated with a 0.4 (95% confidence interval [CI], 0.2-0.7) in-
crease in the number of CNMs/CMs per 100,000 women aged
15 to 44. CNM PPI was positively associated with midwifery
birth attendance and negatively associated with preterm birth.
Discussion: This research suggests that expanded midwifery
scope of practice has positive associations with states’ mater-
nity care workforce and newborn outcomes.
doi:10.1111/jmwh.12695
The Effects of Placental Transfusion on Placental
Residual Blood Volume and 24 to 48-hour
Hemoglobin and Serum Bilirubin in Term Newborns:
A Randomized Controlled Trial
Debra Erickson-Owens, CNM, PhD (University of Rhode
Island); Judith Mercer, CNM, PhD (University of Rhode
Island; Women and Infants Hospital, Providence, RI)
Purpose: To determine if newborns who receive a full pla-
cental transfusion at birth differ in placental residual blood
volume (PRBV) and 24 to 48-hour hemoglobin (Hb) and to-
tal serum bilirubin (TSB) levels compared to newborns who
receive no placental transfusion. Research Question: Will
newborns who receive a full placental transfusion have less
PRBV, a higher 24 to 48-hour Hb, and no difference in peak
TSB compared to newborns who receive no placental trans-
fusion? Significance: The usual maternity care practice in
the United States is to immediately clamp the umbilical cord
(immediate cord clamping [ICC]) at the time of birth. When
ICC occurs, 20% to 40% of the fetal-placental blood volume
(containing iron-rich red blood cells) is left behind in the
placenta, potentially leading to lower iron stores in infancy.
Methods: A prospective randomized controlled trial was con-
ducted. Seventy-three healthy term pregnant women with sin-
gleton fetuses were enrolled. At birth, they were randomized
to either ICC (⬍20 seconds; n = 36) or delayed cord clamp-
ing (DCC) (ࣙ5 minutes; n = 37) and then placed skin-to-
skin. The primary endpoints were PRBV in mL/kg, Hb (g/dL),
and peak TSB at 24 to 48 hours of age. Primary analyses were
conducted by intention-to-treat and secondary analyses by ac-
tual treatment. Results: Maternal and newborn demographics

c 2017 by the American College of Nurse-Midwives 629
were not significantly different between groups. Mean (stan-
dard deviation [SD]) cord clamping time was 303 (121) sec-
onds (DCC) versus 10 (6) (ICC) seconds (P = .001). Eleven
newborns received cord milking as a proxy for DCC at the
time of cesarean birth or when resuscitation measures were
indicated. There were 9 protocol violations. Newborns ran-
domized to DCC left behind less PRBV (20.0 vs 30.8 mL/kg,
P ⬍ .001). At 24 to 48 hours of age, newborns exposed to DCC
had significantly higher Hb levels (19.5 vs 17.7 g/dL, P = .002)
without a difference in peak TSB levels (DCC = 8.5 vs ICC =
9.0 mg/dL, P = .45) compared to infants with ICC. Two new-
borns in each group had phototherapy. Discussion: New-
borns with ICC left behind more PRBV and had lower Hb
levels at 24 to 48 hours. There was no difference between the
groups on peak TSB levels or other indicators of hyperbiliru-
binemia. The results support the early hematological advan-
tage of DCC while demonstrating no association with an in-
crease in hyperbilirubinemia.
doi:10.1111/jmwh.12694
To Lube or not to Lube: The Effect of Intrapartum
Lubricant use on Vaginal Microbiota
Katie Gresia McElroy, PhD, RN (University of Maryland);
Mary Regan, PhD, RN (University of Maryland)
Purpose: This study aimed to characterize the composition
of vaginal microbiota during labor and to investigate the ef-
fect of lubricant use on its bacterial composition. Research
Questions: What is the composition of vaginal microbiota
in late pregnancy, throughout labor, and in the postpartum
period? Does intrapartum lubricant use affect the composi-
tion of vaginal microbiota during labor? Significance: The
composition of vaginal microbiota is critically important dur-
ing pregnancy because maternal microbes transferred at birth
form the basis of the neonate’s microbiome. Vaginal dys-
biosis, a disruption in composition, is linked with many bi-
ological and behavioral factors, including use of personal
lubricants. Studies show that lubricants can alter microbial
composition and damage the integrity of vaginal epithelium.
These findings are concerning because similar lubricants are
frequently used during labor. However, the effect of lubricant
use on vaginal microbiota during labor has not been studied.
Methods: The prospective cohort study was nested within a
federally-funded study (R01NR014826). Fifteen participants
collected mid-vaginal specimens during pregnancy, labor, and
in the postpartum period, and clinical labor data were ex-
tracted from medical records. 16S rRNA gene profiling was
used for bacterial composition, and multiple linear regression
was used to investigate the effect of intrapartum lubricant use.
Results: The composition of vaginal microbiota varied among
participants, with a notable high abundance of Lactobacil-
lus iners and Gardnerella vaginalis. A significant bivariate
negative correlation between lubricant use and relative abun-
dance of L. crispatus disappeared when controlling for time
since ruptured membranes. A trend between lubricant use and
changes in the composition of vaginal microbiota as measured
630
by the Jensen-Shannon distance was noted but not signifi-
cant. Discussion: The study offers novel information about
the composition of vaginal microbiota during labor and the ef-
fect of lubricant use on its composition. The potential relation-
ship between increased lubricant use and decreased L. crispa-
tus has important clinical significance for perinatal providers
and can be used to begin to build evidence that supports a less
invasive approach to perinatal practice. The study was limited
by a small sample, a lack of control group, and the analysis
of relative abundance, as opposed to absolute abundance. A
larger study is needed to further elucidate the association be-
tween lubricant use and vaginal dysbiosis.
doi:10.1111/jmwh.12693
Mindfulness Childbirth Classes Transform the
Experiences of Postpartum Women
Ira Kantrowitz-Gordon, CNM, PhD (University of Washing-
ton); Shannon Abbott, BSN, RN (University of Washing-
ton); Rachel Hoehn, BSN, RN (Nurse Family Partnership at
ChildStrive)
Purpose: The purpose of this study was to explore women’s
experiences with mindfulness in the year following child-
birth using in-depth interviews. Research Questions: The
specific aims were to understand: 1) how women used mind-
fulness skills to meet the physical, emotional, and relation-
ship challenges in the year after childbirth and 2) how mind-
fulness helped them enhance their positive experience of the
postpartum period. Significance: The postpartum period
can be a challenging experience for many women as they
adjust to the physical and social changes of new mother-
hood. Mindfulness-based interventions have been developed
for stress reduction in a variety of health contexts, includ-
ing pregnancy. Mindfulness-based interventions may provide
strategies for new mothers to handle the challenges of breast-
feeding and to increase acceptance of postpartum physical
changes and image. Limited research has explored the benefits
of mindfulness classes for the postpartum experience and par-
enting. Methods: Twelve women who participated in a Mind-
fulness for Childbirth and Parenting course during pregnancy
were interviewed within the first year postpartum. The semi-
structured interview guide included questions on how partic-
ipants may have used mindfulness to approach a variety of
positive and negative postpartum experiences. Qualitative de-
scription methodology guided the research team in indepen-
dent coding of the transcripts. The team subsequently met to
review and achieve consensus in the development of codes,
categories, and themes in the data. Results: Four themes
were identified in women’s postpartum experiences: 1) chal-
lenges across the postpartum experience; 2) formal practices
of mindfulness to address postpartum challenges; 3) informal
practices to address postpartum challenges; and 4) the life-
changing and transformative effects of mindfulness. These
themes showed a pathway by which participants used mind-
fulness skills to not only address the postpartum challenges,
but to also transform their postpartum experience with a pos-
itive and magical perspective. Discussion: Mindfulness skills
Volume 62, No. 5, September/October 2017
helped class participants to cope with physical and emotional
challenges postpartum and to develop a positive and mean-
ingful relationship with the newborn. Findings have implica-
tions for future research on the postpartum experience and
for optimizing the content of perinatal mindfulness classes to
maximize the benefit during the postpartum year.
doi:10.1111/jmwh.12692
The Phoenix Project: Re-Introducing Group Prenatal
Care
Gina Novick, CNM, PhD (Yale University); Julie A.
Womack, CNM, PhD, FNP-BC (Yale University); Lois S.
Sadler, PhD, RN (Yale University)
Purpose: To develop strategies to implement a sustainable
program of group prenatal care (GPNC) in settings with a
prior history of failing to sustain GPNC. Research Question:
What are prior and current barriers to sustaining group pre-
natal care, and what are key ingredients for successfully sus-
taining group prenatal care in this community? Significance:
Despite evidence that GPNC improves perinatal outcomes
and racial and ethnic health disparities, sustaining GPNC is
challenging. This research is part of a larger project using
community-engaged methods to introduce sustainable GPNC
programs in a community where 2 GPNC programs provid-
ing care to women who have low income and are minorities
were discontinued. In community-engaged research, commu-
nity and academic partners develop collaborative strategies
to modify environments and individual behaviors. This re-
search represents the first phase in this project. Methods: Us-
ing qualitative description, we conducted 16 semi-structured
interviews of stakeholders in 4 settings in one community to
explore interest in and potential strategies for re-introducing
GPNC. Settings were 2 university-affiliated clinics that had
provided GPNC (now discontinued) and 2 clinics with flour-
ishing GPNC programs: one clinic providing GPNC and
another clinic providing group well-child care. Participants
included midwives, physicians, nurses, and administrators.
Interviews were audio-recorded, transcribed, and entered into
ATLAS.ti qualitative software. A priori and inductive cod-
ing schemes were developed; code content was compared
across individuals, types of professionals, and settings. The-
matic development focused on eliciting an understanding of
participant perceptions of what might enhance or impede sus-
tainability. Results: Stakeholders were universally enthusias-
tic about using community-engaged approaches to reintro-
duce GPNC. Participants from settings that had discontinued
GPNC identified pitfalls to avoid and potential alternate im-
plementation strategies; these focused primarily around the
need for adequate resources, staffing, and robust recruitment
strategies. Stakeholders from continuing and discontinued
settings identified key ingredients they believed would pro-
mote sustainability, including vigorous, opt-out recruitment
plans; engaging community health workers in patient recruit-
ment and group facilitation; taking advantage of university re-
sources for clinician training; fostering interdisciplinary ed-
ucation; tailoring existing GPNC models to local population
Journal of Midwifery & Women’s Health r www.jmwh.org
needs; and enlisting sustained and practical buy-in on all lev-
els including top administrators, clinicians, and staff. Discus-
sion: A community-engaged approach holds promise for im-
plementing GPNC in challenging settings. We are continuing
the community-academic partnership, while increasing con-
sumer involvement; developing plans for piloting GPNC in
settings where it was discontinued; developing a GPNC model
that meets community needs; and obtaining administrative
commitment for resources for initial implementation as well
as long-term sustainability.
doi:10.1111/jmwh.12691
Perception of Professional Empowerment among
Midwifery Graduates: School of Midwifery, University
of Chile
Lorena Binfa, CM, MPH, PhD (University of Chile); Tomas
Labarca, CM (University of Chile); Elena Jorquera, CM (Uni-
versity of Chile); Gabriel Cavada, PhD (University of Chile)
Purpose: To identify and compare the perception of profes-
sional empowerment among midwifery students according
to the type of curriculum. Research Question: During
2009, a Competence Based Education (CBE) curriculum
was implemented in the School of Midwifery, University
of Chile to determine if this curriculum is effective in im-
proving professional empowerment. Significance: Studies
of health care professionals note that the quality and safety
of patient care is directly related to the degree of provider
empowerment. Provider empowerment influences plans of
care and contributes to the decision-making outcomes of the
multidisciplinary team. Studies carried out in Chile revealed
that midwifery professionals employed in maternity units do
not feel empowered enough to face a hierarchical and medi-
calized health system; moreover, midwifery students reported
lack of self-confidence among midwives working at Primary
Health Care (PHC) clinics to address the prevalent and
complex psychosocial problems affecting many women. Em-
powerment must be addressed during preservice education,
and it is therefore a central aspect of curricula. Methods: A
structured online interview was conducted among a sample of
147 midwifery graduates of 2 different curricula (content and
competency based vs CBE) of the School of Midwifery at the
University of Chile, through an adaptation of the Perceptions
Midwifery Empowerment Scale (PEMS) developed by
Matthews (2009), translated by the backward-translation
technique, and tested in 10 midwives working in the maternity
unit at the Clinical Hospital of the University of Chile, se-
lected by convenience. This instrument comprises 3 domains:
autonomous practice, effective management, and women-
centered practice. The study was approved by the ethics com-
mittee at the Faculty of Medicine, University of Chile. Results:
Globally, over 80% of the respondents revealed optimal levels
of professional empowerment. According to the domains,
those providing woman-centered care reported the higher
scores, and those who graduated from the CBE curriculum
scored equally well at one-year post graduation in comparison
to those graduates with 5 years or more of clinical experience.
631
Discussion: Studying empowerment becomes very useful
in the development of a competent professional to promote
woman-centered practice. These findings suggest the positive
influence of CBE in enhancing professional empowerment;
however, further and accurate assessment is required to
complement these outcomes.
doi:10.1111/jmwh.12690
Modification of Maternal Sleep Position to Optimise
Fetal Well-being in Late Pregnancy: A Survey in a
Multicultural New Zealand Region
Robin S. Cronin, MMid (University of Auckland, New
Zealand); Carol Chelimo, PhD (University of Auckland,
New Zealand); Edwin A. Mitchell, DSc (University of Auck-
land, New Zealand); Kara Okesene-Gafa, FRANZCOG (Uni-
versity of Auckland, New Zealand); John Thompson, PhD
(University of Auckland, New Zealand); Rennae S. Tay-
lor, MHSc (University of Auckland, New Zealand); B. Lynne
Hutchison, PhD (University of Auckland, New Zealand);
Lesley M.E. McCowan, FRANZCOG (University of Auck-
land, New Zealand)
Purpose: This survey investigated late pregnancy maternal
sleep practices and ability to modify sleep position in order
to generate information on which to base future public health
messages about optimal going-to-sleep position. Research
Question: What are the sleep practices of women in late preg-
nancy, and what are their views about changing going-to-sleep
position if this was recommended? Significance: Maternal
sleep position in late pregnancy is a modifiable risk factor for
late stillbirth. A 2011 study from Auckland, New Zealand, was
the first to demonstrate a 2-fold increased risk for women who
did not go to sleep on their left side the night before the fe-
tus was thought to have died, with the highest risk for women
who settled to sleep supine. This association has since been
confirmed by an Australian and Ghanaian study and a New
Zealand multicentre study. Methods: A random sample of
ethnically-representative women (N = 377), between 28 and
42 weeks’ gestation, were surveyed in 2014 in South Auck-
land, New Zealand, a multicultural and socioeconomically
disadvantaged population with an increased risk of stillbirth.
Factors independently associated with non-left side going-to-
sleep position in late pregnancy were identified using multi-
variable logistic regression. Results: Self-reported going-to-
sleep position in the last week was left (30%), right (22%),
supine (3%), either side (39%), and other (6%). The majority
(68%) had received advice about pregnancy sleep position. A
non-left position was more likely to be reported by women of
Maori (adjusted odds ratio [aOR], 2.64; 95% confidence inter-
val [CI], 1.23-5.66) or Pacific (aOR, 2.91; 95% CI, 1.46-5.78)
ethnicity, and those who did not sleep on the left-hand side
of the bed (aOR, 3.29; 95% CI, 2.03-5.32). Most (87%) non-
left sleepers reported that they would have minimal difficulty
changing to going to sleep on their left side in late pregnancy
if this was better for their fetus. Discussion: The results from
this survey suggest that going-to-sleep position in late preg-
nancy is likely to be readily modifiable. This suggests that a
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public health intervention, about the importance of optimal
late pregnancy going-to-sleep position to optimise fetal well-
being, is likely to be feasible in similar communities with an
increased risk of stillbirth.
doi:10.1111/jmwh.12689
Adaptation of a Screening Tool for Perinatal
Depression and Anxiety in Community-Based
Maternal Health Services in Mali
Molly E. Lasater, MPH (Johns Hopkins University);
Madeleine Beebe, MPH, BSN, RN (Johns Hopkins
University); Kirsten Blomberg, MSN, RN (Johns
Hopkins University); Nicole Warren, CNM, PhD, MPH
(Johns Hopkins University); Ashley Gresh, MSN, MA, RN
(Johns Hopkins University); Katie Hsih, MPhil (Johns Hop-
kins University); Peter Winch, MPH, MD (Johns Hopkins
University)
Purpose: The aim of this research is to adapt and validate a
perinatal depression and anxiety screening tool in Mali, West
Africa for use in community-based maternal mental health
prevention interventions. Research Questions: How do stan-
dardized screening tools for depression and anxiety align with
maternal depression and anxiety symptomatology in Mali? Is
the adapted depression and anxiety screening tool valid and
reliable? Significance: Midwives in low-resource settings such
as Mali provide the majority of maternal health services with
few resources. As with other threats to maternal and newborn
well-being, perinatal depression is a significant cause of mor-
bidity and mortality including poor perinatal outcomes and
infant development. However, mental health issues are rarely
included in maternal health programming, and local mid-
wives have few tools to address the issue. An important com-
ponent of maternal care is screening for depression and anxi-
ety with a tool based on local ethnomedical understandings of
mental health. Western screening tools have been adapted and
validated in other low-income contexts but not in the Malian
context. Such a tool has the potential to provide midwives
with a way to identify women who need mental health sup-
port. Methods: We are using a mixed-methods study to adapt
and validate a postpartum depression and anxiety screening
tool using the DIME Program Research Model: Design, Im-
plementation, Monitoring, and Evaluation. Focus groups and
interviews conducted in Sélingué, Mali in 2016 provided lo-
cal terms and symptomatology upon which to base the adap-
tation of screening tools. A pretest was conducted among lo-
cal midwives in Sélingué in June 2016, and additional pretests
with community women are ongoing; additional interviews
to establish reliability and validity with childbearing women
took place in September of 2016. Results: To date, multi-
ple elements of the Edinburgh Postnatal Depression Scale and
Hopkins Symptom Checklist were expressed locally. Some el-
ements from established screeners were not locally relevant,
and new elements were added to the adapted tool. Discus-
sion: Perinatal depression in low-resource settings requires
locally relevant screening tools. Such tools are necessary for
community-based efforts to integrate perinatal depression
Volume 62, No. 5, September/October 2017
screening, prevention, and intervention into routine care in
Mali.
doi:10.1111/jmwh.12688
Impact of High Patient Volume on Midwifery
Education in Kampala, Uganda
Jocelyn Rinne, RN, BA (Yale University); Oliver Norah
Nabacwa, MS, RN/M (Mulago National Referral Hospi-
tal, Kampala, Uganda); Rose Chalo Nabirye, PhD, MPH,
ADHSM, RN/M (Makerere University, Kampala, Uganda);
Allison Shorten, PhD, RN, RM, FACM (University of Al-
abama at Birmingham, Yale University)
Purpose: The purpose of this study was to understand the bar-
riers to midwifery education within a high-volume hospital
in Kampala, Uganda. Our aim was to determine students’ and
midwives’ perceptions of the educational process in the con-
text of a setting with high patient volume. Research Question:
We hypothesized that when compared with students, prac-
ticing midwives view high patient volume as a greater bar-
rier to education. Significance: Despite advances in mater-
nal care, maternal and infant mortality in sub-Saharan Africa
have continued to lag behind the rest of the world. With an
ongoing rise in pregnancies in this region, urgent attention is
needed to better train, educate, and retain student midwives.
Methods: We conducted a cross-sectional survey-based study
to identify challenges to midwifery education among stu-
dents and midwives based at Mulago National Referral
Journal of Midwifery & Women’s Health r www.jmwh.org
Hospital in Kampala. We surveyed 60 midwives and 51 mid-
wifery students. Likert-scale responses were dichotomized
and chi-square tests were used to examine differences in per-
ceptions between students and midwives. Results: We iden-
tified notable and significant differences in perceptions be-
tween midwives and midwifery students when examining the
impact of patient volume on education and practice. These
differences persisted across multiple questions relating to the
educational process. When compared with students, a larger
proportion of midwives felt that high patient volume impaired
education relating to midwifery knowledge (33% vs 12%, P
⬍ .01) and clinical skills (43% vs 4%, P ⬍ .01), and con-
tributed to high stress levels (75% vs 35%, P ⬍ .01). Dis-
cussion: While there is ample research on educating mid-
wives within a broader global context, limited research has
explored how midwifery training is impacted by high pa-
tient volume. Student midwives may view high patient vol-
ume as an educational opportunity, while practicing midwives
consider high patient volume a barrier to teaching. This dif-
ference may relate to a greater perceived responsibility for
patient care by midwives. Our findings suggest that exces-
sive patient volume may be impairing midwives’ ability to
effectively teach their students the midwifery model of care
while balancing their high patient workload. Additional re-
search is urgently needed to identify how to support mid-
wifery practice in health care environments with high patient
demand.
doi:10.1111/jmwh.12687
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