A specific specialized midwifery role in primary health care settings

Midwifery in Primary Care

New Directions for Midwives:

Addressing Novel Primary Care Roles

Looking towards the future, radical changes are sweeping the United States healthcare system with the advent of a new public healthcare system. This change and the economic reality of care should motivate all healthcare providers to question of who can best meet the healthcare needs of women. Nurse midwives are advanced practice nurses educated in the field of primary health care for essentially normal women and newborns. Their focus is wellness and health education. Once patients are introduced to the concept of a nurse practitioner and the services provided, the majority are satisfied with the quality of the care received. Evidence suggests that women, if given a choice, prefer the ministrations of a female practitioner over that of a male for their intimate healthcare needs. As a predominantly female group, nurse midwives are an excellent source of qualified providers for women (Avery, 2000). This essay will focus on the expanding role of midwives across the primary care landscape, focusing on their specialized application to providing healthcare to women in relation to peri- and post-menopausal care.

Traditionally, Certified Nurse Midwives were exclusively focused on childbirth. Care by Midwives incorporated the case management regarding pregnancy and parturition along with the evaluation, assessment, treatment and referral to other healthcare providers as required (Raisler, 2000). The model of health care practiced by CNMs is focused on the ambulatory care of women and newborns and emphasizes health promotion, education and disease prevention and sees the woman as central to the process of providing such care (Brown, 1993). In recent years, with the healthcare provider shortage CMN's have expanded their role to include preconception counseling, provision of gynecological and contraceptive services and care of the peri- and post-menopausal woman. CMNs are uniquely suited to providing continuous and comprehensive care by establishing a plan of management with the woman (Avery, 2000). Such care by the CNM is integrated with the woman's cultural, socioeconomic and psychological factors that may influence her health status (Raisler, 2000).

To focus on a specialized novel role for midwives in primary care health provision, the management of peri -- and post-menopausal is an exciting new area. The clinical goals of peri-menopausal treatment are to optimize a woman's health and well-being during and after this transition period. Treatment for the peri-menopausal woman must be individualized, depending on her pattern of symptoms, overall health, hormonal status and personal preferences (Brown, 1993). Unfortunately, because clinical research data on the peri-menopause are limited, health care providers must extrapolate findings from the treatment of postmenopausal women and rely on their own clinical experience when managing symptoms. According to the North American Menopause Society, which developed a consensus opinion on peri-menopausal treatment, management should focus on health optimization, including comprehensive screening for physical and psychological problems, and lifestyle counseling to reduce the incidence of chronic diseases (Avery, 2000). The period of a woman's life that follows after the menopause is called postmenopausal period and during this time, all the symptoms that have been around during the menopause (such as hot flashes, mood swings, gaining weight) slow down until they disappear completely. In contrast, post-menopause is difficult to define with most definitions being that has not had her period for an entire year. In addition, a variety of psychological and physiological changes develop which can have significant repercussions for a woman's health and lifestyle. Similar to peri-menopause management, CNMs are able to providing information, counseling and the judgment required to refer to the necessary healthcare provider (Raisler, 2000). In short, midwives are uniquely suited to expand beyond their traditional childbirth focus to provide greater primary care to women throughout life, with a particular focus on peri -- and post-menopausal management (Brown, 1993).

What is motivating this transition to primary care beyond childbirth within the primary care setting are a variety of factors. Doctor shortages, an aging population and national health care reform have raised the profile of non-physician providers, such as nurses, physician assistants and midwives providing a greater percentage of healthcare (Brown, 1993). With sixteen million more Americans expected to gain health care coverage in the coming years as a result of the Affordable Care Act, access to actual health care providers may become more difficult. This may be especially true for patients with marginal coverage such as Medicaid. Midwives are well suited to careers in primary care (Avery, 2000). Although they comprise a small of the primary care workforce, they represent the fastest growing segment. Furthermore, they are more likely than physicians to practice in underserved areas and to take care of minority patients and those with Medicaid (Horrocks, et al., 2002; Grumbach, et al., 2003).

An interesting study found that the quality of care deliver by Nurse Practitioners is comparable to that of physicians for most indicators studied (Grumbach, et al., 2003). This highlights the possibility of midwives filling a similar valued role. This care could also come at a lower cost. This study demonstrates that primary care practices that utilize non-physician clinicians more extensively have lower costs compared to other primary care practices. Over time, federal laws have slowly expanded the practice environments for non-physician medical providers. In the earliest stages, non-physician clinicians were largely limited to practicing under direct supervision except for a specific role in rural health clinics (Raisler, 2000). Today, they have no geographic restrictions on their practice and can directly bill federal insurance programs Medicare and Medicaid. However, services rendered independently tend to be compensated at a lower rate than services rendered when a physician is present. With the changes of the Affordable Care Act and an expected shortage of physicians looming, the case is made for greater utilization of midwives to provide access to care for the American population (Brown, 1993). To summarize, a variety of studies have found that non-physician providers are able to provide adequate if not comparable care to physicians. Midwives can expand into novel areas to address the numerous issues affecting medical care provision.

To focus now on the methods and challenges involved in menopausal management, women face several distinct health risks related both to aging and to the specific consequences of long-term estrogen deficiency, in particular osteoporosis and cardiovascular disease (McKinlay, et al., 1992). Although many women consider cancer to be the greatest health risk they face as they age, heart disease is actually the leading cause of death among older women following menopause. Moreover, osteoporotic fractures are common and are responsible for considerable morbidity and mortality. In her lifetime, a 50-year-old woman has a 40% risk of experiencing an osteoporotic fracture, including a 17% risk of hip fracture. A woman's risk of developing a hip fracture is equal to her combined risk of breast, uterine, and cervical cancer. In addition, approximately 25% of 80-year-old women have had at least one vertebral fracture. These problems highlight the need for effective counseling before and during the diagnosis of their chronic conditions (e.g. heart disease, osteoporosis) and suggest a means for midwives to contribute to patient health (McKinlay, et al., 1992).

Although we are not yet able to eliminate postmenopausal health problems, advances in medical diagnosis and therapeutics have made it possible to better quantify and control them. For example, an older woman's cardiovascular risk can be quantified through routine monitoring of blood pressure and a serum cholesterol profile. Similarly, osteoporosis -- and the consequent risk of fracture -- can be monitored noninvasively through radiographic assessment of a woman's bone mineral density. Several factors that influence the risk of fracture have been identified -- including genetics, lifestyle factors, nutrition, medical disorders, and drugs -- many of which can be eliminated or modified (Raisler, 2000). Bone mineral density (BMD) is the major measurable determinant of the risk of fragility fractures. Recent prospective studies, however, have identified other factors that influence the risk of fracture, independent of those associated with low BMD. Skeletal factors other than BMD that may increase the risk of hip fracture in women include hip geometry and body height. Low body weight (secondary to poor appetite or poor health) has also been associated with increased fracture risk. Smoking, prior fracture occurrence during adulthood, and maternal history of hip fracture are also independent predictors of hip fracture risk. In addition, nutritional deficiencies and sedentary lifestyle may play a role in fracture pathogenesis. Other factors, some of which are potentially modifiable, operate through effects on the risk of trauma, including decreased visual acuity, neuromuscular impairment, cognitive impairment, residence in a long-term care facility, and use of medications that diminish alertness (McKinlay, et al., 1992).

The evolving ability to define postmenopausal health risks is reflected in a growing interest in disease prevention strategies, including dietary modifications, lifestyle changes, and pharmacologic therapies that can help reduce these risks. Ongoing clinical research continues to further expand our understanding of women's health issues. Notable examples are the 16-year Nurses' Health Study of almost 60,000 female nurses, and the Women's Health Initiative, which is designed to involve over 160,000 postmenopausal women. Findings from these studies should continue to bridge the remaining gaps in our understanding of postmenopausal health. In the meantime, pharmacists must be prepared to counsel women about steps they can take to minimize their risks for osteoporosis and cardiovascular disease. These steps are valuable in enabling a woman to preserve her well-being during the postmenopausal years (Rossouw, et al., 2002)

Midwives can play an important role in educating women of all ages about the prevention and treatment of osteoporosis so that they can make more informed decisions about their own health. For example, midwives should initiate discussions with women of all ages to help prevent, recognize, and treat osteoporosis (Santoro, et al., 1996). In addition, midwives must be prepared to counsel women about both the positive effects of therapies such as hormone replacement therapy, or HRT (i.e., possible cardiovascular protection and decreased risk of osteoporosis), as well as potential negative effects (Santoro and Randolph, 2011). Many women are concerned with the possible increased risk of breast cancer related to HRT, a fear that can be a barrier to utilizing this therapy in the postmenopausal years. An increase in uterine cancer risk and benign uterine conditions increasing vaginal bleeding can also reduce the chances of initiation or adherence to HRT (Rossouw, et al., 2002).

The midwives's role in maintaining the health of older women is increasingly relevant given the expected increase in the postmenopausal population. More than 30 million women in the United States are now in or past menopause, and another 6 million or more will reach this stage of life in the next decade. This trend is reflected globally: The number of postmenopausal women is expected to triple by the year 2030 (Santoro, et al., 1996). Given the predicted increase in the postmenopausal population, the numbers of osteoporotic fractures are likely to increase in the future. For example, the number of hip fractures in the United States is projected to increase by 300% by the year 2040 (Grady, 1991). Midwives are uniquely positioned to participate in maintaining the health of women during and after menopause. Midwives are accessible to the community, have an understanding of women's health and are trained to provide effective information to women (Brown, 1993).

In the past, many women have not reaped the benefits of available postmenopausal therapies due to inadequate physician awareness and communication about the traditional treatment regime, hormone replacement therapy, and poor patient compliance with this therapy. Common reasons for discontinuing HRT include fear of side effects, fear of cancer, loss or abatement of menopausal symptoms, weight gain, physician's recommendation, breast pain and engorgement, and bleeding disturbances. Monthly withdrawal bleeding is an important factor in some women's decision to discontinue HRT. However, monthly bleeding occurs only with cyclical HRT, not with continuous HRT (Santoro and Randolph, 2011). Continuous HRT, however, also frequently causes irregular bleeding or spotting, at least in the first 6 to 9 months of therapy. Women may choose to discontinue HRT due to a lack of information regarding the different regimens. Cessation of HRT is also frequently associated with confusing diagnostic, prescribing, and monitoring practices by healthcare providers. Women who are uncertain about their changing health status and the merits of medication may be particularly affected by such confusing information. Some physicians tend to underestimate women's desire for information about HRT and underrate their concerns about symptomatic conditions such as urinary incontinence (Santoro and Randolph, 2011). Midwives are uniquely able to provide information and reassess an individual woman's health and risk status and to develop a personalized healthcare strategy.

Midwives are well informed about current options for postmenopausal health management are in a unique position to enhance the well-being of older women (Grady, 1991). By increasing acceptance and promoting appropriate use of prescribed medications, midwives can help improve therapeutic outcomes and minimize the potential for adverse events. The ultimate goal is to give older women the tools to protect their long-term health so that they can remain active and independent during the decades that follow menopause. Diet and exercise are important components of the management plan. It is important for patients to understand, however, that dietary supplements (eg, calcium and vitamin D) and exercise alone are insufficient preventive therapy for many women after menopause but should be part of a prevention program (Grady, 1991).