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An exploratory metasynthesis of
midwifery practice in the United
States
Lisa Kane Low

Midwifery

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Rhona O'Connell

Holly P. Kennedy
PhD, CNM, Specialty
Coordinator, Nurse-
Midwifery Education
Program, Assistant
Professor, Department of
Family Health Care
Nursing, University of
California, 2, Koret Way,
Box 0606, San Francisco,
CA 94143- 0606, USA
Amy L. Rousseau
PhD, CNM Director, Claire
M. Lintilhac Nurse-
Midwifery Service, Fletcher
Allen Health Care/
University of Vermont,
USA
Lisa Kane Low
PhD, CNM, Faculty, OB/
GYN and Women’s Studies,
University of Michigan,
USA
(Correspondence to HPK,
E-mail: holly.kennedy@
nursing.ucsf.edu)
Received 19 September
2002
Revised 15 January 2003
Accepted 5 April 2003
An exploratory metasynthesis
of midwifery practice in the
United States
Holly P. Kennedy, Amy L. Rousseau and Lisa Kane Low
Objectives: to conduct a metasynthesis of six qualitative studies of midwifery care and
process; identify common themes and metaphors among the six studies for further
exploration and theory development; and create a framework for further metasynthesis
of qualitative studies of midwifery practice in the USA.
Design: a qualitative metasynthesis to analyse, synthesise, and interpret six qualitative
studies on the process and practice of midwifery care.
Sample and Setting: hospital, birth centre, and home birth settings were represented across
all of the studies. Participants included nurse- and direct-entry midwives who provided
both childbearing and gynaecological care. Recipients of midwifery care also received both
childbearing and gynaecological care.
Findings: four overarching themes were identif|ed: the midwife as an ‘instrument’of care;
the woman as a ‘partner’ in care; an ‘alliance’ between the woman and midwife; and the
‘environment’of care.These were interpretively and conceptually arrayed into a helix
model of midwifery care.
Key conclusions: the f|ndings from this exploratory metasynthesis clearly indicate that the
practice of midwifery is a dynamic partnership between the midwife and the woman, and
reflects an environmental perspective. In a country that has a standard of highly technical
childbirth care, perhaps the most outstanding concept of this model is that of the midwife
as an ‘instrument’of care.The signif|cance of the f|ndings will be determined by their ability
to guide further research efforts to support a standard of midwifery care for all women in
the USA.
Implications for practice: this model offers a benchmark and a structure for considering the
dynamic elements of midwifery practice and key roles that the midwife plays in the health
care of women and babies. & 2003 Elsevier Ltd. All rights reserved.
INTRODUCTION man & Singh 1998), few researchers have tried to
measure and/or describe how midwives achieve
Numerous studies have explored midwifery the remarkable perinatal and women’s health
practice in the USA over the past decades, outcomes for which they are known.
however, few have examined specific processes A survey conducted by the American College
used by midwives, or have attempted to link of Nurse-Midwives (ACNM) with the Maternal
them to health outcomes. Raisler (2000) con- Child Health Bureau examined the perceptions
ducted an extensive review of 140 studies about of nurse-midwives about the effect of managed
nurse-midwifery practice from 1984 to 1998. Her care on their practice (McCloskey et al. 2002).
findings provided a partial overview of the state Several of the most commonly cited changes to
of the science of midwifery in the USA. practice were an increased client load with a
Although the safety and efficacy of nurse- focus on higher productivity. The nurse-mid-
midwifery practice have been firmly established wives believed that these changes directly
(Oakley et al. 1995, Harvey et al. 1996, MacDor- affected their ability to practise a midwifery
Midwifery (2003) 19, 203^214 & 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0266 - 6138(03)00034-2/midw.2002.0361
204 Midwifery
model of care. Some articulated increasing
unwillingness to teach future midwives because
they felt the student would not see ‘true
midwifery’. This study points to a growing
concern about changing practice in the current
health-care arena. These nurse-midwives did not
believe that their model of care was valued in an
environment focused on economic outcomes.
However, they did not have the evidence to
effectively argue how their model of care was
unique, cost-effective, or linked specifically to
perinatal outcomes. This gap in evidence limits
the ability of the midwifery profession to counter
current economic pressures and health policies in
the USA.
Despite the increasing number of qualitative
investigations of midwifery care in the USA,
there has been no attempt to synthesize the
research findings into a collective interpretation
of current knowledge. Sandelowski et al. (1997)
express a concern that unless there is a systematic
approach to examine qualitative findings (about
a specific phenomenon), they can have little
impact on practice and/or policy-making. Clear
delineation of a theoretical link between unique
midwifery care practices with specific outcomes
in the health of women and babies continues to
be elusive. It underscores the critical need to
articulate their relationship in order to support
policy development in the health care of women;
it must be a research priority.
MIDWIFERY PRACTICE IN THE USA
The profession of midwifery in the USA is
complex, from both historical and current
contexts. The profession almost completely
disappeared by the early 1900s with the takeover
by modern obstetrics, but began a constructed
resurgence beginning in the 1920--1930s as it
aligned with nursing and public health to attend
poor women with few services (Varney 1997).
That focus of care has changed somewhat in
current times reflecting both demographic and
economic forces. Today midwives enter the
profession from two general directions in the
USA. The majority come with basic qualifica-
tions in nursing and obtain post-graduate work
in midwifery leading to certification as a certified
nurse-midwife (CNM). These midwives are
certified through the American College of
Nurse-Midwives (ACNM) Certification Council
and must possess a baccalaureate degree; how-
ever, 70% achieve masters level preparation by
graduation (Davis-Floyd 1998). In the mid-1990s
an additional mechanism was created for non-
nurses to achieve basic education as a midwife
through the ACNM leading to the credential of
certified midwife (CM) (Rooks 1997). Midwifery,
as practiced by CNMs, is legal in all of the 50
states of the USA. There are currently over
10000 certified nurse-midwives and certified
midwives with 7000 having membership in the
ACNM; they attended 10% of the births in the
USA in 1999 with almost 98% of those occurring
in the hospital setting (Shah 2002).
The other route to midwifery is termed ‘direct-
entry’ in which future midwives usually appren-
tice with another midwife to learn the skills to
attend women during birth, primarily in the
home setting. In addition, there are some more
structured educational routes to enter midwifery
through this venue. Midwives choosing this route
may be certified through the North American
Registry of Midwives (NARM), the certifying
arm of the Midwives Alliance of North America
(MANA), and are called certified professional
midwives (CPM). Approximately 700 of the
1300--2300 direct-entry midwives in the USA
are CPMs (MANA 2002).
MANA is the organisation that represents
many direct-entry midwives, although one-third
of its membership is comprised of CNMs and
CMs. One of the philosophical concerns of
MANA is that midwives who enter through
nursing may be schooled in a more medical
approach to birth. It is difficult to assess how
many direct-entry midwives are in practice since
they are not always legally recognised, licensed,
or able to achieve reimbursement from insurers.
Practice by direct-entry midwives is legal in 14
states, unavailable due to lack of licensure in
eight states, and illegal in nine states and the
District of Columbia. The status in the other
states is often termed a-legal because the
judicial interpretation is not clear (Davis-Floyd
1999).
The current approach to pregnancy and child-
birth in the USA is highly technologically
oriented, characterised by soaring caesarean
birth and epidural rates. In the current reimbur-
sement system, midwives and doctors must
compete to provide care for women; it is not a
system in which women have access to providers
based on the appropriate of level of care they
need or desire. Health care provided through
managed care organisations determines a wo-
man’s health-care provider and rations health
care by geography, employer, level of reimburse-
ment and prior contractual obligations instead of
assigning appropriate type of care by risk.
Furthermore, the complexity of the Federal
system of care for uninsured mothers has
encouraged the privatisation of some aspects of
care while using public health clinics in others.
This has resulted in the shift to private-sector
care for the population cared for over many
decades by midwives, often without the multi-
layered resources found in the public sphere of
services (McCloskey et al. 2002). Midwives
are then in competition with doctors, who
Metasynthesis of midwifery practice in the US
outnumber midwives dramatically, in both the
public and private sector of health care.
In summary, while midwifery practice in the
USA has grown slowly, but steadily over the past
decades, most of those births occur in the
hospital and smaller and smaller numbers occur
in birth centres or at home. The challenges of the
profession are reflected in the larger health-care
arena of the USA; one in which growing
utilisation of technology and complex reimbur-
sement structures takes precedence over indivi-
dualised, risk-based, personal care. The purpose
of this study strives to understand more com-
pletely the unique attributes of midwifery prac-
tice in the context of that arena.
KNOWLEDGE DEVELOPMENT IN
MIDWIFERY
In an effort to identify theoretically based
midwifery processes of care, it is first important
to understand the foundation of knowledge upon
which midwifery practice is grounded. Carper
(1978) identified four fundamental patterns of
‘knowing’ in nursing that can be used to under-
stand knowledge development in midwifery. The
four patterns are: (a) empiric or scientific knowl-
edge; (b) aesthetics, or how the art of practice is
made visible; (c) personal knowledge, or that
which is experiential and/or subjective; and (d)
ethics, the knowledge of morality in practice. Of
these four patterns it is the ‘art’ or aesthetics of
practice that many midwives consider to be
unique to the profession (Davis 1995). However,
this is an assumption that is not grounded in
scientific inquiry. Therefore, efforts to identify
and measure the art of midwifery practice are
essential to linking the process of care to
outcomes.
In an initial effort to understand a phenom-
enon or experience, qualitative methods are used
to explore the complexity of a phenomenon.
Qualitative inquiry initially allows detailed de-
scriptions of the phenomenon and provides
explanatory evidence to substantively develop a
coherent model reflecting the area of interest
(Kennedy & Lowe 2001). Through this process,
the phenomenon is better understood and
described. Thus exploratory studies begin to
develop the evidence base upon which theory is
grounded (Steeves et al. 1996).
Moving to confirming evidence requires the
identification of discrete variables or concepts,
and eventual measurement of their interactions
and effects. Through the use of quantitative
methods, developing theories can be confirmed,
refined or refuted. Prematurely moving towards
confirmatory methods without a solid theoretical
foundation limits the strength and credibility of
the findings (Stevenson 1990). Furthermore, the
205
potential to overlook aetiological or explanatory
factors is increased.
Our gaps in knowledge about the linkages of
midwifery practice and health outcomes are best
studied with confirmatory methods once the
theoretical base has been established. ‘Efforts
to synthesize existing qualitative research studies
are seen as essential to reaching high analytic
goals and also to enhancing the generalisability
of qualitative research’ (Sandelowski et al. 1997,
p. 367). The purpose of this study was to
continue to synthesize a theoretical base for
midwifery practice. This metasynthesis was con-
ducted as an exploratory study to (1) examine
the collective findings from qualitative studies
about midwifery practice and care, (2) develop a
prototype for a broader and more exclusive
metasynthesis of midwifery practice in the USA,
and (3) develop a theoretical foundation for
future confirmatory research.
METHODS
Metasynthesis, a research method that analyses,
synthesises, and interprets a specified body of
qualitative research, possesses the potential to
provide valuable insight and knowledge about
the distinctive aspects of midwifery care and how
they may be related to specific outcomes. It
provides an organised, yet interpretive approach
to a specific group of qualitative studies (Noblit
& Hare 1988). Sandelowski et al. (1997) define
metasynthesis as ‘the theories, grand narrative,
generalizations, or interpretive translations pro-
duced from the integration of findings from
qualitative studies’ (p. 366). Noblit and Hare
(1988) describe the process as a research method
that creates an interpretation of other studies. As
such, it is much more than a review of the
literature because it results in a broader inter-
pretation; it is a research study unto itself.
Conceptually it might seem similar to a meta-
analysis of quantitative studies, yet it is far more
than an aggregate evaluation; it is an interpretive
move toward theory development. Without the
conduct of such work, researchers are at risk of
only replicating qualitative findings without ever
advancing the state of the science.
Metasynthesis has gained regard over the past
two decades as a method of systematically
interpreting qualitative studies following a pre-
scribed and rigorous approach. Most notably,
the Cochrane Collaboration and Campbell
Methods Group have added it as a strategy for
systematic review to establish a database of
relevant methodological papers, to include evi-
dence from qualitative research into systematic
reviews, to provide a forum for discussion, and
to link expertise in qualitative research and
training (Finch 2003). We chose to use Noblit
206 Midwifery

studies, three were fully excluded and only

Table 1 Steps in the conduct of a metasynthesis (Noblit
& Hare1988
1. Identify the area of interest that a set of studies could
inform.
2. Decide which studies are relevant to the area of
interest.
3. Repeated reading of the studies noting interpretive
metaphors.
4. Determining how the studies are related.
5. Translating studies collectively.
6. Synthesising the translations.
7. Expressing the synthesis.
and Hare’s (1988) steps for conducting a
metasynthesis for our research design and these
are outlined in Table 1. This strategy has been
well employed in many studies and provided
us with a systematic, yet interpretive methodo-
logical approach. A further description of
the procedural implementation of the steps
follows.
Firstly, identify the area of interest that a set of
studies could inform. Each of the authors was
involved in an area of qualitative inquiry on
various aspects of midwifery practice and care.
Commonalities were noted during individual
presentations of the authors’ findings at national
conferences. Based on this experience and a
review of the literature, we believed that a
metasynthesis of qualitative studies of midwifery
practice was the next logical step in theory
development.
Secondly, decide which studies are relevant to
the area of interest. One of the most critical steps
in a metasynthesis is the decision on which
studies will be included. Criteria for inclusion
must be carefully reasoned based on the purpose
of the study, and then systematic literature
searches must identify those that are appropriate
and discard those that are not. To conduct this
metasynthesis on the processes of midwifery care
we chose to examine our early qualitative studies
in this area of interest. This approach enabled us
to fully learn and grasp the method, and prepare
us for a broader future study. Of our nine
partial results were used of a study that had
two arms, based on the inclusion criteria that
the study had to be conducted about mid-
wifery practice from perspectives of midwives
and/or women receiving midwifery care. The
studies used for the metasynthesis are shown in
Table 2.
Thirdly, repeated reading of the studies noting
interpretive metaphors. Each researcher read the
six studies independently and wrote memos to
reflect their thoughts, metaphors, and interpreta-
tions. Through systematic repeated readings each
researcher exhaustively identified the themes and
concepts of each study. This step requires an
ability to absorb, reflect, and step away from
each study as it is examined first in isolation, in
preparation for the next step in which relation-
ships are explored.
Fourthly, determining how the studies are
related. The Atlas.ti t qualitative software pro-
gram was used to organise and manage the
written memos. Eighty-seven initial codes were
identified through content analysis of the memos.
The memos and coding structure were then
systematically analysed and conceptually orga-
nised to ascertain commonalities and themes.
Fifthly, translating studies collectively. Inde-
pendently, the three researchers returned to the
original studies and examined them using the
coding structure developed from the interpretive
memos. This required attention to the metaphors
and concepts in each of the individual studies to
respect the particular aspects of the original
findings, but also allowed comparisons across the
studies.
Sixthly, synthesising the translations. Noblit
and Hare (1988) describe this step as translating
metaphors and concepts across the studies into a
new interpretation of the whole. The interpretive
analysis was completed at this stage and the
findings of the metasynthesis were identified.
Finally, expressing the synthesis. The findings
of the metasynthesis can be disseminated by the

Table 2 Studies included in the metasynthesis

Study Sample Qualitative Design/Data
Analysis Method
Kennedy (1995) 6 women who had been cared for by Phenomenology (Colazzi)
nurse-midwives
Levi (1996) 3 women cared for by nurse-midwives Phenomenology (van Manen)
Levi (2000) 15 videotaped interactions between Content analysis
women (14) and nurse-midwives (5)
Kennedy (2000) 52 midwives nominated as ‘‘exemplary’’ Delphi method (3 rounds, qualitative
in the United States (1 from Canada) and quantitative data); content analysis
and 61 recipients of care by the midwife
panelists
Kane Low (2001) 25 adolescents (11cared for by Extended case methodology
nurse-midwives)
Powers & Kane Low (2002) 12 women cared for by nurse-midwives Semi-structured interviews; content
analysis
Total studies=6 Total participants in sample=174 Total methods=5
Metasynthesis of midwifery practice in the US
usual methods for sharing research findings.
However the findings are expressed, they must
‘enable an audience to stretch and see the
phenomena in terms of others’ interpretations and
perspectives’ (Noblit & Hare 1988, p. 29). The
findings were independently reviewed by a group of
researchers for clarity and cogent meaning resulting
in minor alterations of wording and syntax.
Sample
The study sample consisted of six initial inquiries
of midwifery practice and care by the authors
(Table 2). These six studies were chosen because
they had a common focus: the elucidation of the
process of care provided by midwives. Human
subjects approval is not required for this kind of
study because it is akin to a review of literature
and does not sample research participants
directly. Most of the studies were conducted in
the Northeast, Eastern Seaboard, and Midwest
regions of the USA and one was conducted with
a national sample. Five of the six studies were
with nurse-midwives. One study (Kennedy 2000)
included both nurse- (80%) and direct-entry
midwives (20%). All types of birth settings and
types of midwifery care (childbearing and
gynaecological) were represented. Hereafter, the
term ‘midwife’ will refer to all kinds of midwives
represented in the study and will not differentiate
by type. All of the research participants (mid-
wives and recipients of care) were women; the
use of the feminine pronoun ‘she’ reflects the
sample and is not meant to be exclusionary of
men, who were often present as partners and
family members to the women in the studies.
Table 3 Interpretive themes and attributes
The Midwife as an TheWoman as a
‘instrument’ of care partner in care
 The Midwife as a unique  Woman &/or family
individual as a unique individual
 Presence  Care is tailored to meet
her, or their needs
 Non-judgemental  Self-determination
of care
 Intelligent  Sense of satisfaction
 Competent (clinical  Feels safe
skills & judgment)
 Knowledge of  Feels respected
self & limits
 Advocate
 Compassion
 Commitment
 Calm
 Conf|dent
 Ethical
 Humorous
 Information sharing
 Joy in the work of midwifery
207
FINDINGS
Four overarching themes and their unique
attributes were identified as a result of the
metasynthesis process (Table 3). These four
themes were conceptually arrayed into a helix
model to portray their dynamic and overlapping
nature (Fig. 1). Selected key exemplars for each
of the themes are provided with a general
description of its essence.
The midwife as an ‘INSTRUMENT’of care
The term ‘instrument’ is used to identify how the
midwife, as a unique individual, is able to affect
the process of care in varied ways through the
use of herself. Key attributes of this theme
included being non-judgemental, intelligent, and
clinically competent, as well as holding a know-
ledge and awareness of her limitations. Addi-
tional attributes, unique to the midwife as a
person, included being compassionate, calm,
confident, ethical, and humorous. Sharing in-
formation, advocacy, and being ‘present’ to the
woman when she is in need were also identified.
Finally, experiencing joy in the practice of
midwifery was evident. The following exemplars
demonstrate the manner in which midwives
strategically use themselves as an ‘instrument’
of care. One midwife described this in terms of
body language saying:
I always sit like that with peopleyI hunch
forward someyI try to make people feel like
they’re equal. This is actually just to listen to
[her] story in a way that’s going to make [her]
realize that [she’s] done a lot . . . [she’s] really
An Alliance between the The Environment as a factor
woman and the midwife in the process of care
 Relationship  Normalcy of pregnancy
& birth
 Partnership  Interventions only when
necessary & individualised
to the woman’s needs
 Trust  Creating a sense of safety
 Respect within and  Respect
for the process
 Common goal  Time
 Shared control &  Family centred
decision making
 Dynamic process  Spiritual
 Able to both ‘take
control & let go’ as needed
208 Midwifery
The midwife and woman in alliance
Continual flow – ‘taking control and letting go’ between midwife and woman
Fig. 1 Conceptual representation of the metasynthesis of midwifery care. These two concentric Celtic helices represent the
midwife as an instrument of care on one side in alliance with the woman as her partner on the other side. Midwifery care takes
place in the context of the environment represented by the open spaces within the circles.There is a continual flow between the
woman and the midwife, which represents the ‘taking control and letting go’ as both the midwife and the woman work toward
shared goals.
strong and I think that that’s an important
factor in listening (Levi 2000, p. 34).
Midwives and women in these six studies
noted the use of presence, both physical and
emotional, as a unique feature of midwifery care:
Much of what midwives do during early labor
doesn’t even look like ‘doing’ . . . I speak for
myself and the long honorable tradition of
midwifery when I describe this work as the
mastery of doing ‘nothing.’ It is a specific skill
that must be learned and developed, no less so
than any of those busy medical skills asso-
ciated with the ‘doing-ness’ of hospital-based
obstetrics. As a community midwife, I sit for
many long hours doing this ‘nothing’ silently
observing while listening to the parents talk
about their hopes and dreams, fears and
frustrations’ (Kennedy 2000, p. 12).
The following two women reflect the need and
importance of that presence:
I was a coach for a friend of mine, she’s a
single mom and it was her first baby. The
doctors were in and out in five minutes and
then they’d leave for hours, and then come
back again. And that was, I think, one of the
things that inspired me to have the midwives
because I did not want that. I wanted some-
body that was going to be there and listen and
take the time. I think that made a difference
to [my labor] (Powers & Kane Low 2002,
p. 8).
She was right there and it was as if she was
going to have this baby right along with me
and I found a great deal of comfort physically
and emotionally in that (Kennedy 1995,
p. 415).
Women were also expressive about some of
the more elusive attributes of their midwives. The
ability to be non-judgemental was evident in one
woman’s description of her midwife’s gentle
advice:
The midwife’s encouragement during pushing
was just right. What she said was ‘this is how
some people find it most effective’ which I
thought was really nice because it wasn’t this
is how you should do it (Powers & Kane Low
2002, p. 9).
The following woman perceived a concern by
the midwife, but observed her ability to remain
calm:
She did it in a nice way, but at the same
time you knew she was watching the monitor
and was concerned. She wasn’t nervous
and didn’t panic about it (Kennedy 1995,
p. 414).
Feeling a continual support was seen as special
and important:
The midwife just took so much time. And
every time I had a question, I would call the
number. And I mean 24 hours a day there was
an answer for me and just the support and the
understanding. It was just fabulous (Powers &
Kane Low 2002, p. 8).
The midwife’s demonstration of clinical
competence varied from specific skills to her
general professional demeanor. One midwife
viewed her clinical skill as the foundation of
her work:
Certainly assessment is important in the entire
process of what I do. I am always assessing
what the woman is saying—watching non-
verbal language, listening acutely to what she
is saying and what she isn’t saying (Kennedy
2000, p. 9).
Metasynthesis of midwifery practice in the US
This careful attention to physical care was
echoed by one woman:
One thing that stood out was the excellence of
the medical care, from a purely medical stand-
point—I don’t think I have ever had anyone
check my thyroid before (Kennedy 2000, p. 9).
The midwives believed in providing information
to women and the women saw that as a valuable
part of their care:
Oh gosh [the midwife] was great. She was telling
me to relax and breathe through contractions.
Before that she told me what to eat, how far
along I was, what did it look like. She gave me
packets to read—to learn about stuff that
helped me a lot too (Kane Low 2001, p. 88).
Finally, many of the midwives expressed joy in
their work and believed this was essential to their
own continuance in a demanding profession:
I just enjoy people who are pregnant.
Pregnancy is joyful and needs to be a part
of everything I do (Levi 2000, p. 42).
This particular theme centred on the midwife
as a unique individual and an ‘instrument’ in
care. The following theme adds the other part of
the equation—the woman as a ‘partner’ in care.
The woman as a ‘PARTNER’ in care
Attributes of this theme include the recognition
of the woman [and her family] as uniquely
individual with the midwife tailoring care to
meet her needs. Respect for the woman and her
self-determination was paramount. There was a
goal of helping the woman feel both safe and
satisfied with her care, partially through shared
decision-making between the midwife and the
woman and/or her family. One woman describes
her partnership in the following way:
It was a dialogue and relationship with people
I was interested in getting to know each other
as partnersythey felt honestly, genuinely,
sincerely [and] professionally interested in
getting to know me in all the ways that would
help them, help me (Levi 1996, p. 7).
Women described their sense of feeling safe in
a variety of ways. In this description the woman
connected feeling safe with the midwife to a prior
life experience:
The only comparable experience to the first
time being touched by the nurse-midwife was
being shepherded across a crowded street as a
17-year old, newly arrived foreign exchange
student in Brazil. I remembered my world
turned upside down—and then I felt so taken
care of, I felt so at home, I remember
209
thinking—it’s okay, I’m here now; I’m safe
(Levi 1996, p. 16--17).
Respect for the woman’s self-determination
was often discussed by the women as a unique
and valued feature of their care:
They weren’t making decisions about me but
with me. It was shared informationy. (Levi
1996, p. 8).
Knowing that I had options. Even though it
didn’t seem totally like I had options, but they
always gave me a choice. Even at the point of
the C-section. It was well, we could do the C-
section, or we have the option to continue. I
mean it was always . . . I always had options
and choices (Powers & Kane Low 2002, p. 11).
Tailoring care to their unique needs was also
considered fundamental:
They offered suggestions to me and to my
partner. Why don’t you help her do this or
why don’t you do this a different way. And I
think that helped her a lot too, because I
know there were points where she probably
felt like she didn’t know how to help me, so I
think that was really helpful (Powers & Kane
Low 2002, p. 10).
The focus of this theme was on the woman as a
unique person and ‘partner’ with the midwife.
The following theme describes how the midwife
and the woman form an alliance to navigate the
health-care situation together.
‘ALLIANCE’ in midwifery care
Within the context of midwifery practice, a
relationship was described between the midwife
and the woman that took the form of an alliance.
This relationship was founded upon trust and
mutual respect, with shared control and decision-
making. These attributes contributed to the
achievement of shared or common goals between
the midwife and the woman. The alliance was
dynamic and changing, based on social, emo-
tional, or physical needs. It was influenced by the
uniqueness of the individuals involved, and the
environment in which the care or practice occurs.
Finally, the expression of the alliance allowed an
interplay between the midwife and the woman in
which each was able to ‘take control and let go’
as needed in the current situation.
The dynamic nature of the alliance was
unmistakable as women described a relationship
in which there was trust, both in each other and
in the process as is articulated by the following
quotes:
y she [the midwife] basically told me that
when I felt comfortable pushing to go ahead
and push. Whenever I felt comfortable doing
210 Midwifery
something, she just told me to go ahead and do
it. That made me feel easier too, because that
made me feel that when I was comfortable to do
something then I did’ (Kane Low 2001, p. 94).
I think just keeping the care on the human
scale, and in keeping with trying to educate
people about the process, and at the same
time hear and respond to what they want out
of the process—that’s really important—and
that’s why we were really happy with the
midwives (Powers & Kane Low 2002, p. 9).
Some of the midwives described themselves as
similar to a partner or guide with the woman,
listening carefully to her and helping her to draw
upon her inner strength without taking over:
I see myself as a guide on a canoe trip, ready
to grab the paddle if we hit a snag, but
otherwise watching the water and the pad-
dler’s ability to navigate, giving encourage-
ment and suggestions as needed. One woman
echoed this when describing her birth: It was a
searing, forever-to-be-etched experience, and
my midwife stands out as someone who rode
the river with me (Kennedy 2000, p. 10).
Finally one woman sums up this unique ability
to work as a team with the midwife so that both
could ‘take control and let go’ as needed:
They practiced with skill, experience and an
uncanny knowing of when to step in and
when to let me be (Kennedy 2000, p. 9).
The alliance speaks to the dynamic relation-
ship between the woman and the midwife. The
final theme identified in the metasynthesis was an
environment that reflects the contributions of the
woman and her family, the midwife, and the
alliance between them.
The ‘ENVIRONMENT’ in the process of
midwifery care
The environment created by the midwife re-
inforced the normalcy of pregnancy and birth. It
was one in which the midwife uses interventions
only when necessary and then individualises
them to the woman’s needs. The ‘presence’ of
the midwife was integral to the environment and
contributed to the woman’s sense of feeling
respected through the time and attention pro-
vided. Additional attributes include family
centred care and supporting the spirituality of
the woman in the context of her experience.
To promote an environment of normalcy and
respect, several midwives described their process
and relationship with the woman this way:
Hey, we’re all in this together, and [I] try to
create a sense that this is an okay thing. A lot
of my activities in this first part of the visit are
oriented toward preparing [the woman] for
the worst and expecting and cultivating a
sense of the best (Levi 2000, p. 34).
Yet another midwife asserted the importance of
actively working to keep normalcy at the
forefront:
Remind yourself, your colleagues, your sup-
port workers, and especially the woman, of
the power of normal pregnancy, labor, birth,
postpartum and breastfeeding when no inter-
vention occurs (Kennedy 2000, p. 9).
Although the midwives worked to promote an
environment of normalcy, it was the women’s
experience of this that was emblematic of her
care and that experience:
The midwives were wonderful. That’s why I
picked them. It’s natural you know. I didn’t
have to get an IV and be strapped down. I
never heard of pushing on my side before and
that was the best. I just wish that the regular
doctors would appreciate that. It is a natural
experience (Powers & Kane Low 2002, p. 11).
Within the environment, the midwife had a
sense of when to be present, and when not to be
present:
She stepped into the background and let the
three of us be a family (Kennedy 1995, p. 415).
I just remember being with my girlfriend when
she was in labor and the doctors coming in
just like the last possible moment and then
leaving and you never see them again. It was
really nice because they [the midwives] were
thereyI don’t even think they ever left
(Powers & Kane Low 2002, p. 8).
The midwives used both time and respect to
create an environment in which the woman could
take control and feel as if she could accomplish
her goals. One midwife called it:
ycreating a setting in which the woman
comes first, in which she is taken seriously
(Kennedy 2000, p. 10).
The structure of a prenatal visit contributed to
this woman’s awareness of the setting and her
own sense of dignity:
[The physician] was not helping me to take
responsibility; I felt like a patient. This was
odd, unnecessary, and infantilizing. There was
no dignity in a five minute visit where I was
wearing only a [patient] gown, compared to
the midwife visit where I would be dressed
while we talked (Levi 1996, p. 11).
One woman described the sense of respect for her
time:
I never waited 10 minutes for an appointment.
I just think that there’s a different level of
Metasynthesis of midwifery practice in the US
understanding as far as that my schedule is as
important as hers (Kennedy 1995, p. 414).
Finally, one of the midwives spoke of the need
to understand the context and resources of the
family’s environment as she described working
with a young couple with no food or money to
achieve a healthy pregnancy:
The ups and downs, struggles and accom-
plishments that came like the unfolding of the
skin of an onion, as I learned slowly what
their needs were and how to help them y
(Kennedy 2000, p. 12).
This final theme of the environment of care
reflects an awareness of the midwife’s ability to
create a sense of normalcy and atmosphere for
caring, respect, and success.
Although the four overarching themes inter-
pretively fit and make conceptual sense, there
were several codes that we had to examine very
carefully to understand their placement and
alignment across all of the studies. This included
an understanding of the midwife as a person and
what she brought to the relationship. This was
particularly strong in some of the studies and
more implied in others. A decision was made that
because her actions often conveyed her sense of
self (and use of self) that it should be included in
the theme of ‘instrument of care’ supporting that
the midwife is a person first and clinician second.
Another issue related to the midwife was the lack
of discussion about her professional role across
all studies. This is likely because most of the
studies did not query for this aspect of practice
and it is less likely to come up in discussion as
women describe their care experience. Although
some of the studies provided us with the
complexities of working with other colleagues
and health-care challenges in the professional life
of a midwife, it was not a strong enough theme
to retain. We also had to grapple with some
negative examples of when the processes of care
did not take place. For example, the significance
of partnering with the midwife was demonstrated
by the contrast of when that role of ‘partner’ was
absent. In the following instance, an adolescent
mother was not included in the decision-making
regarding her plan of care because the midwife
only listened to the father of the baby and not to
the adolescent herself:
Well y she [the midwife] talked to me and
told me that she’d be back. I’m thinking
something is wrong. She brings him [the
father of the baby] in there and she is like
‘Do you want to have this baby today?’ I was
like WHAT? He said ‘Yes she does, yes she
does!’ So that is what happened—I wasn’t
ready at all’ (Kane Low 2001, p. 66).
We believed that this negative example was
important to consider, and include because it told
211
us from the woman’s point of view what was
important and how she felt when not included in
the development of the plan of care. It became an
interpretive contrary case for the process of alliance.
The four themes together represent the authors’
interpretations of the collective findings of the six
studies. Each of the themes identified—the
woman, the midwife, the alliance between them,
and the environment of care—overlap and con-
tribute to the dynamic nature of midwifery
practice. The helix (Fig. 1) is used to represent
this dynamic, ever changing process. It symbolises
the midwife’s ongoing assessment of the woman’s
needs and desires, juxtaposed with the cultural,
sociopolitical, and health-care environment in
which it occurs. These tensions metaphorically
create a give and take, back and forth dance
reflecting a philosophical stance of the midwife to
support, and be with women, but also having to
manage meeting the woman’s needs within health-
care settings that may not be aligned with her
desires. Through their alliance, they continue to
work together to accomplish their common goals.
The dance of being able to ‘take control and let
go’ responsively in a given situation by both the
woman and the midwife is captured by the helix,
which encompasses the four themes.
DISCUSSION
This metasynthesis used six studies to interpret
the multidimensional aspects of midwifery prac-
tice in the USA. The collective interpretation
revealed a complex and dynamic interaction
between the woman and the midwife within a
contextual environment of care. Although an
articulation of the ‘art’ of midwifery practice
continues to be subtle, this metasynthesis may
have brought us one step closer to clarity.
As Carper (1978) notes in her identification of
the four fundamental patterns of knowing, ‘each
of the patterns may be conceived as necessary for
achieving mastery in the discipline, but none of
them alone should be considered sufficient.
Neither are they mutually exclusive’ (p. 253).
Clearly the model that resulted from this
metasynthesis demonstrates multiple patterns of
knowing that are integral to the practice of
midwifery. For example, being clinically compe-
tent, calm, and present to the woman were all
important attributes of the midwife.
The personal knowledge of how to use one’s
self as an ‘instrument’ of care in relationship with
the woman is most likely learned and influenced
in many ways. It may come partially from
observing others, but is likely to be swayed by
personal beliefs about pregnancy and birth.
Staying calm so the mother can be reassured is
difficult if one possesses a basic fear about birth.
Being ‘present’ with women implies a level of
212 Midwifery
comfort with intimacy and quiet. A classic study
by Balint (1964) on physician, patient and illness
relationships reflects the ever evolving nature of
this process. ‘The important thing is that
education is not one-sided only. Both patient
and doctor grow together into a better knowl-
edge of one another’ (Balint 1964, p. 249). A
study conducted about nurse practitioners 30
years later describes an alliance similar to what
we have seen with these midwives. The nurse
practitioner, without making distinctions be-
tween medical and social issues, listens to her
patient describe her life and concerns; they
mutually come to a diagnosis after considering
all of the findings (Fisher 1995).
Moral knowledge or agency is also important
to consider. Is there an ethical contract to work
with a woman to help her achieve her goals
during a life-altering event such as birth? An
implied contract assumed by the midwife in
caring for the woman is to see her safely through
the pregnancy, labour, birth, or gynaecological
care. But, is providing safety the only important
factor? Several of the study findings included in
this metasynthesis suggested that the effect of
midwifery care persisted far beyond the actual
event of birth. Although there was not enough
evidence to cluster these into a separate theme,
the words of several women were exceptionally
powerful. When a 15-year old was asked what
she felt good about during her labour and birth
she replied:
Ya, that I can actually be able to do it. I know
it hurts, but I can do it. So I knew in my mind
that I was able to do it . . . when I’m stuck on
a problem, or when I need help with some-
thing, I think—I can do this—I did it through
labor, and this is not as bad as labor, so I can
do this here! I think I am able to do what I put
my mind up to do (Kane Low 2000, p. 118).
Another woman described how her midwife
validated her as a person and helped her to find
strength to travel a difficult road ahead after
giving birth to a child with Down’s syndrome:
My midwife walked a fine line flawlessly. On
the one hand, when I sobbing, told her I
didn’t want to raise a retarded child, she
sympathetically agreed, neither would she.
She thus shared in our common humanity
without making me feel less a person. On the
other hand, she held and treated my baby as a
precious, beautiful gift. That too, helped me
overcome my own fears of being rejected and
stigmatized since my baby was retarded. She
helped me rise to the occasion (Kennedy 2000,
p. 11).
The lifelong effects of care during birth have
been commented upon in other qualitative
studies. Simkin (1991) found that 15--20 years
after birth many women felt that they had
achieved something significant and believed that
their self-confidence and esteem were enhanced.
Yet, others did not have this experience. What is
not known are the key factors for those long-
term memories and effects—could it have any-
thing to do with how they were assisted or guided
in the process, or the sense of control they felt
during a challenging time like labour and birth?
Another perspective on knowing is proposed
by Benner and Wrubel (1989) as ‘embodied
knowledge,’ seen in the performance of complex
skills and pattern recognition by expert nurses.
Benner and her colleagues (Benner 1984; Benner
& Wrubel 1989; Tanner et al. 1993, Benner et al.
1996) have investigated expert knowledge of
nurses in highly skilled settings such as intensive
care units or emergency rooms. The skill sets and
pattern recognition we have identified in the
midwives from these six studies may, or may not,
be quite different from those used with com-
plexly ill clients. They may also represent a
unique skill set and the substantive difference
between obstetrics and midwifery. The ability to
‘take control and let go’ in response to each
woman and each labour represents an expertise
and knowledge that there are many ways to give
birth and that flexibility, rather than rigidity, is
more likely to achieve success. This kind of skill
has been noted in other studies in which the
midwife was likened to a ‘head coach’ or guide
for the journey (Seibold et al. 1999).
When placing this model against the current
landscape of pregnancy and birth care in the
USA, perhaps the most outstanding feature is
that of the concept of the midwife as an
‘instrument’ of care. DeVries (1993) provides a
compelling argument for the decline of midwif-
ery with the increase of technology, noting that
power lies with professions that emphasise risk,
and then are able to step in to control that risk.
Even though the use of technology and inter-
ventive birth practices have soared in the USA,
there is little to show for it; we remain 27th in
infant mortality—the lowest of developed coun-
tries in the world with the highest per capita
expenditure (CDC 2001, Healthy People 2010,
2000). An intriguing notion is that of the midwife
as a technological advancement. If the midwife’s
use of self, belief in normalcy, presence and
alliance could be clearly linked to positive
outcomes at birth and beyond, would implemen-
tation of midwifery as a standard of care
improve the entire maternal-child health-care
system? And would this stand up against many
of the ‘routine’ technologies used in USA labour
and birth practices today?
One limitation of this study is that the work
represents only studies conducted by the authors.
As previously noted, the impetus for the
collaboration between the researchers was
Metasynthesis of midwifery practice in the US
recognition that their works held a common
focus on midwifery practice, despite varied
methods, sample populations, and findings.
Potential methodological limitations within each
of the individual studies are inherited in the
process of conducting a metasynthesis. However,
as noted by Sandelowski et al. (1997), despite
potential limitations in the initial works, the
rigour with which the metasynthesis process is
conducted becomes the standard for the new
analysis. The rigour in this study was congruent
with the guidelines described by Noblit and Hare
(1988). Jensen and Allen (1996) assert that ‘the
meta-synthesis is rooted in the original data and
is credible when it re-presents such faithful
descriptions or interpretations of a human
experience that the people having that experience
would immediately recognize it from those
descriptions or interpretations as their own’
(p. 556). By initially combining work that was
familiar to the three authors, the emphasis was
on developing expertise in the process of
metasynthesis, rather than on concluding with
a final theory. Nevertheless, the resulting model
of this metasynthesis provides a more cogent
description of midwifery practice than any of the
individual studies included had previously of-
fered.
This metasynthesis represents a small sample
of six qualitative studies regarding midwifery
practice. There are more studies on midwifery
practice that need to be included in a larger
metasynthesis before a complete and compre-
hensive model can be advanced for theory
development. The authors have moved forward
with this next daunting step and are currently
conducting an extensive search of the literature
to identify qualitative studies on midwifery
practice that incorporate the midwife’s perspec-
tive, the woman’s perspective, and structural
issues such as legislative and reimbursement
mandates. The search is encompassing many
databases and experts in research on midwifery
and women’s health care from nursing, anthro-
pology, medical, literary, education, psychologi-
cal, and social perspectives.
The resulting model presented from this study
moves the state of science regarding midwifery
practice in the USA forward by offering a
benchmark against which other studies might
be compared. Clearly the practice of midwifery is
dynamic and needs to be considered within the
environment that it occurs. The significance of
these findings will be determined by their ability
to guide further research efforts designed to (1)
evaluate outcomes that address both process and
measurement in perinatal and women’s health;
(2) compare differences in outcomes related to
the midwifery process of care as an intervention;
(3) compare the effects of beliefs about preg-
nancy, birth, and practice on outcomes; (4)
213
compare processes of care between various
health-care providers; and (5) describe the
similarities and differences among various types
of midwifery models.
A number of questions arise from this step in
theory development for midwifery practice in the
USA. The issue of changing midwifery practice,
including institutional or environmental changes
precipitated by economic forces, needs to be
addressed. If midwifery practice is shifting, a
theory of midwifery practice must be responsive
to change, and at the same time not lose the
essence of midwifery care that might be critical
to promoting positive outcomes. While these
issues are not answered here, they should
continue to be part of future debate and
research. Continued theory development in
midwifery practice will aid in this debate.
ACKNOWLEDGMENTS
The author’s acknowledge the ACNM Foundation/
Ortho-McNeil Graduate Fellowship (all three authors
were recipients), the ACNM-RI Chapter, Joyce Thomp-
son, CNM, DrPH, FACNM, FAAN, Joyce Roberts,
CNM, PhD, FACNM, FAAN, Holly Powers, MS, CNM,
FNP, and all the women and midwives who have
participated in the research.
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