Académique Documents
Professionnel Documents
Culture Documents
The relatively recent effort of midwifery scholars has resulted in the development of three middle-range
midwifery theories in the United States. This article examines the three theoretical models that have been
developed to describe the essential components of midwifery practice. The three theorists demonstrate
remarkable consistency in the identification of concepts important to the discipline, which includes the
following essential characteristics of the midwifery paradigm of care: 1) acknowledgment of connections
between the mind and body and the person to the persons life and world; 2) assuming the perspective of
the woman to investigate meaning and her experience of symptoms or conditions, so that a plan of care is
developed by midwife and woman together; and 3) protection and nurturance of the normal in processes
related to womens health, implying a judicious use of technology and intervention. J Midwifery Womens
Health 2004;49:381389 2004 by the American College of Nurse-Midwives.
keywords: nurse-midwifery, midwifery, theory, midwifery model, midwifery research
INTRODUCTION METHODS
The development of specific midwifery theories as a basis of A synopsis of the theories is presented following the
knowledge building for the profession is an important and structure suggested by Chinn and Kramer,4 including the
relatively new strategy for midwifery in the United States. purpose, concepts, definitions, relationships, structure, and
Although midwifery care has been demonstrated to be safe, assumptions. Each theory is evaluated by using the criteria
cost-effective, and satisfying to women, other questions about proposed by Duffey and Muhlenkamp: 1) Does the theory
the processes of midwifery practice remain. A fuller descrip- generate testable hypotheses? 2) Does it have the potential
tion of the process of midwifery care requires a framework for to guide practice? 3) Is the subject of the theory relatively
investigation that is anchored in the defining characteristics broad? 4) Are specific assumptions identified? 5) Are the
and hallmarks of midwifery practice. propositions and the relationships among them explicitly
Theory is important for clinicians, as well as educators stated? And 6) Is the theory parsimonious?5
and academicians, as a guide to problem solving in clinical
practice. Theory assists clinicians in understanding why
particular interventions are or are not effective. In the BACKGROUND
United States, the theories of nurse-midwifery and mid-
Theories of Midwifery Practice
wifery practice have been initiated by nurse-midwives
Ela-Joy Lehrman, Joyce Thompson and colleagues, and Several strategies exist for the development of theory.6 The
Holly Kennedy.13 This article critically examines these work begins by analyzing and defining the important
theoretical models for midwifery practice. The terms mid- constructs and concepts. A construct is a term with a higher
wives or midwifery refer to the general category of the level of abstraction than a concept. Statements are then
profession of midwifery, regardless of certification, educa- developed that demonstrate the relationships between the
tional preparation, or legal status. Nurse-midwifery refers constructs or concepts. This results in a set of concepts,
to the profession of those who have received education in definitions and propositions that projects a systematic
both the professions of nursing and midwifery and who view . . . by designating specific interrelationships among
have been identified as nurse-midwives in the literature concepts for the purposes of describing, explaining, pre-
reviewed. dicting and or controlling phenomena.4 As theories are
constructed, authors refine them by explicitly delineating
the assumptions (knowledge, beliefs, values) that hold the
Address correspondence to Leslie Cragin, CNM, PhD, University of Califor- different aspects of the theory together.6
nia, San Francisco, San Francisco General Hospital, 1001 Potrero Ave., Rm Theories may be categorized in several ways. Grand
6D-29, San Francisco, CA 94110. E-mail: craginl@obgyn.ucsf.edu theories are those that are quite broad in scope, may use
This work was supported by a National Research Service Award from the more abstract concepts, and are difficult to test. Middle-
National Institute of Nursing Research/National Institutes of Health (F31
NR07496-01A1) and by a Student Research Award from the Graduate range theories, such as the midwifery theories proposed
Division at UCSF. here, have practice as their general focus, are more limited
in scope, and are easier to test. A prescriptive theory ally propose to describe a narrower focus within a disci-
predicts the outcome of an intervention.6 pline. Paradigms can be seen as precise, whereas what is
Three middle-range theories have been proposed as represented in practice is more accurately messy and not
midwifery theories in the United States, all within the past able to be isolated from numerous contextual issues. After
20 years.13 They propose and explain concepts that de- conducting a critical analysis of literature, including that of
scribe the domain of midwifery practice (e.g., normalcy of the theories discussed in this article, three defining charac-
birth). The constructs and concepts of the three theories are teristics of a midwifery paradigm were proposed by Cra-
compared in Table 1. The discipline of midwifery exhibits gin7: 1) acknowledging connections between the mind and
many of the characteristics of the beginning stage of theory body and the person to the persons life and world; 2)
development: uncertainty about discipline phenomena, dis- taking on the perspective of the woman to investigate the
crete and independent theories, a search for conceptual meaning and experience of the womans symptoms or
coherence, and the predominance of the goal to develop a conditions, such that a plan of care is developed by midwife
single practice paradigm.6 and patient together; and 3) protecting and nurturing what
is normal in processes related to womens health, imply-
Paradigm of Midwifery Practice ing a judicious use of technology and intervention. Each of
these characteristics is described within the midwifery
Paradigms were originally defined by Kuhn as those aspects
theories, beginning with the work of Wiedenbach.
of a discipline that are shared by its scientific community.6
They are representative of philosophical and epistemolog-
ical principles. The relationships between paradigms and ERNESTINE WIEDENBACH
theory are a source of continuing debate among those who Theory development for midwifery has roots in the work of
study the science of building knowledge (epistemology).6 a nurse-midwife, Ernestine Wiedenbach.6,8 Wiedenbach, a
In general, paradigms reference the full spectrum of beliefs theoretical foremother, is the nurse-midwife and nursing
and knowledge within a discipline, whereas theories usu- theorist credited with a shift in emphasis from nursings use
of the medical model in research to a patient-centered
nursing model.6,8 Wiedenbachs prescriptive theory asserts
Leslie Cragin, CNM, PhD, is an Assistant Clinical Professor in the Depart- that to assist patients in meeting their needs, nurses must
ment of Obstetrician/Gynecologist and Reproductive Science at UCSF. She is
the Director of Administration and Practice of the Nurse-Midwives of San first identify a need for help in the patient, and validate
Francisco where she is beginning to develop clinical research projects. this perception of a need for help before initiating any
Topic Assumption
Health Nurse-midwifery practice focuses on health-oriented care for the recipient. Health, a fluctuating state, is promoted and maintained
through nurse-midwifery care.
Environment Nurse-midwifery practice considers both the internal and external environments influencing a recipients health. The internal
physiologic condition of the recipient is the internal environment.
Client-practitioner Prior to receiving care, a recipient initiates a client-practitioner relationship with a nurse-midwife. . . . In initiating a client-practitioner
relationship relationship, the recipient may be either assigned to nurse-midwifery care or may self-select nurse-midwifery care.
Interdependence The independent aspect of nurse-midwifery practice, as well as the aspects of consultation and collaboration, are encompassed within
the nurse-midwifery practice model.
Scope of practice The scope of nurse-midwifery practice, the different aspects of nurse-midwifery practice function in relation to each other. . . .
Continuity of care, a primary attribute of nurse-midwifery care, is preserved within this model.
Adapted from Lehrman.1
satisfaction and increased self-esteem at level three, intra- Lehrmans work emphasized the importance of women
partum care. as the focus of the theory, a decision based directly on
ACNM philosophy. In Lehrmans view, the moving force
Analysis of the theory is the recipient of care, usually the woman, but
including the neonate when appropriate. This emphasis is
The development of this model represents a high standard
similar to that of Wiedenbach. Lehrman carefully defined
of building theoretical knowledge for the discipline of
each of the primary constructs to be potentially inclusive of
midwifery. The processes used by Lehrman to ensure the
psychosocial, environmental, and other contextual factors
credibility of the theory was thorough, beginning with
when they are operationalized for research. The work of
inductively derived constructs and their definitions and
Morten and colleagues,12 who found that the eight original
moving through development of instruments with appropri-
components could be applied to the postpartum level of
ate reliability and validity testing. The theory meets the
care, extended the usefulness of Lehrmans theory.
minimum criteria proposed by Duffey and Muhlenkamp6 as
demonstrated in Table 3. Specifically, it linked the pro-
cesses of care and the outcomes of care, giving it the JOYCE THOMPSON AND COLLEAGUES
potential to guide practice; the theory broadly considered
Purpose
the full scope of nurse-midwifery practice; five specific
assumptions were discussed; the propositions and their The purpose of the work in theory development by Thomp-
relationships were explicitly stated; and the theory had only son, Oakley, Burke, Jay, and Conklin2 was to delineate the
six primary constructs. major concepts in the overall process of nurse-midwifery
11. American College of Nurse-Midwives. Philosophy of the 21. Doering L. Power and knowledge in nursing: A feminist post-
American College of Nurse-Midwives. Washington (DC): American structuralist view. Adv Nurs Sci 1992;14:24 33.
College of Nurse-Midwives, 1989. 22. Hagell E. Nursing knowledge, womens knowledge: A socio-
logical perspective. J Adv Nurs 1989;14:226 33.
12. Morten A, Kohl M, OMahoney P, Pelosi K. Certified-nurse-
midwifery care of the postpartum patient. J Nurse Midwifery 1991; 23. Harding S. The science question in feminism. Ithaca (NY):
36:276 88. Cornell University Press, 1986.
13. Fawcett J. Analysis of research reports. J Nurse Midwifery 24. Kennedy HP. The essence of nurse-midwifery care: The wom-
1986;31:279 84. ans story. J Nurse Midwifery 1995;40:410 7.