A MODEL OF EXEMPLARY MIDWIFERY PRACTICE:
RESULTS OF A DELPHI STUDY
Holly Powell Kennedy, CNM, PhD, FACNM
ABSTRACT
What is unique and exemplary about the midwifery model of
care? Does exemplary midwifery care result in improved
outcomes for the recipient(s) of that care? These are the
questions that the profession of midwifery grapples with today
within the context of a changing health care arena. Exemplary
midwives, and women who had received their care, came to
consensus about these issues in a Delphi study.
A model of exemplary midwifery care is presented based on
the identification of essential elements aligned within three
dimensions: therapeutics, caring, and the profession of mid-
wifery. Supporting the normalcy of pregnancy and birth,
vigilance and attention to detail, and respecting the uniqueness
of the woman, were several of many processes of care
identified. The critical difference that emerged was the art of
doing nothing well. By ensuring that normalcy continued
through vigilant and attentive care, the midwives were content
to foster the normal processes of labor and birth, intervening
and using technology only when the individual situation
required. Health care, whether in the gynecologic setting or
during pregnancy, was geared to help the woman achieve a
level of control of the process and outcome. The ultimate
outcomes were optimal health in the given situation, and the
experience of health care that is both respectful and empow-
ering. The model provides structure for future research on the
unique aspects of midwifery care to support its correlation with
excellent outcomes and value in health care economics. J
Midwifery Womens Health 2000;45:4 19 2000 by the
American College of Nurse-Midwives.
INTRODUCTION
The profession of midwifery* is currently working
within a managed health care climate that may reshape
the way midwives care for women by defining health
care practices in terms of reimbursable dollars, rather
than by clients needs. In their review of the report of the
1998 Pew Health Professions Commission/UCSF Center
for the Health Profession Taskforce on Midwifery, Paine,
Dower, and ONeil (1) underscore the prevailing state of
experimentation in the delivery and management of
health care. The actual report outlines 14 recommenda-
Address correspondence to Holly Powell Kennedy, CNM, PhD, FACNM,
College of Nursing, White Hall, University of Rhode Island, 2 Heathman
Road, Kingston, RI 02881.
* CNMs/CMs and midwives as used herein refer to those midwifery
practitioners who are certified by the American College of Nurse-Mid-
wives (ACNM) or the ACNM Certification Council, Inc; Midwifery refers
to the profession as practiced in accordance with the standards promulgated
by the ACNM.
4 Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
2000 by the American College of Nurse-Midwives
Issued by Elsevier Science Inc.
tions, including a call for extensive research that analyzes
midwifery methods, processes, and practice outcomes
(2). It is only with careful and systematic inquiry about
the nature of midwifery care that the profession can
clearly define and explicate a model of excellence that
can be upheld as a standard for all women.
The science of competent midwifery care has been the
focus of research for over 70 years. The midwifery
literature is replete with studies that suggest that mid-
wifery care is not only safe but also exceptional in
positive maternal and infant outcomes (315). In addi-
tion, various models of midwifery care have been pro-
posed based on different philosophical approaches to
caring for women (16 24). Of these, the middle-range
theory proposed by Thompson et al (24) renders the
clearest description of processes of care placed in a
schema of competence, compassion, and covenant fidel-
ity. This theory includes six conceptual components and
was derived from the Philosophy, Code of Ethics, and
Standards of Practice promulgated by the American
College of Nurse-Midwives (ACNM). An interdiscipli-
nary panel of experts examined videotapes of midwifery
care to determine if these were present and a final review
of the model was conducted by midwifery education
program directors.
Even though the literature suggests that midwives do
provide comparable, competent, and safe care when
compared to obstetricians, there is little research that
specifically links their processes of care to specific
outcomes for the woman, her infant, or her family.
Additionally, there are little data available about direct-
entry, or lay, midwives and their knowledge about
caring for women. Finally, none of the studies discuss the
level of expertise of the midwife, and whether exemplary
practice, or that practice which serves as a model of
excellence in the care of women and infants, makes a
difference in those outcomes. These are critical deficits in
knowledge about midwifery practice; therefore, research
is essential to gain insight about the essential elements of
the midwifery model of care and their relationship to
outcomes.
PURPOSE AND FRAMEWORK
The purpose of this study was to describe exemplary
midwifery practice; in so doing, the following research
1526-9523/00/$20.00 PII S1526-9523(99)00018-5
questions were addressed: 1) What are the essential
characteristics of the exemplary midwife? 2) What are
the specific outcomes of exemplary midwifery practice in
the health of the woman and/or infant? 3) What is the
process of care provided by exemplary midwives? 4)
What aspects of the process of exemplary midwifery
practice are related to specific outcomes in the health of
the woman and/or infant?
Kims practice domain (25) was used as the frame-
work for the study because it was the work of midwives
that was being examined. Kim relates the actual delivery
of care to clients to the practice domain and calls for
investigation on what is, or is not, effective in care.
Critical and feminist theories provided structure for
understanding the environment in which women receive
and/or participate in health care. Both theories contrib-
uted valuable perspectives for consideration of the con-
textual history of women, childbirth, and midwifery,
which are intertwined with the concepts of oppression,
emancipation, and liberation (26 29).
RESEARCH DESIGN
Defining exemplary midwifery practice was the focus of
this study. When semantic clarity is the goal of investi-
gation, a research design that strives for consensus is
warranted. For this reason, the Delphi method was
chosen. This method is named in deference to the ancient
Greek legend of the Delphi oracle who was thought to
give wise and authoritative opinions and decisions (30
31). The modern Delphi method is viewed as a technique
that restructures the group communication process to
bring together expert opinions to formulate a prediction
or set of priorities (3234).
The Delphi method gathers group opinions about a
complex issue without face-to-face interaction. The
group (panelists) is generally considered to be expert
about the topic or issue to be discussed, remaining
anonymous to one another throughout a variety of survey
rounds in which there is controlled feedback about the
groups responses. The survey rounds continue until
consensus is achieved, or there is response stability
(3234). Defining experts can be problematic because
consensus on who holds the most valid knowledge about
Holly Powell Kennedy is the director of the Graduate Program in
Nurse-Midwifery at the University of Rhode Island (URI), Kingston,
Rhode Island, and the URI Center for Midwifery at Memorial Hospital
of Rhode Island. She received a master of science degree specializing as
a family nurse practitioner from the Medical College of Georgia in
1978, a certificate in midwifery from the Frontier School of Family
Nursing and Midwifery in 1985, and a PhD from the University of
Rhode Island. She received the ACNM Region 1 Award of Excellence in
1996 and was one of the first recipients of the ACNM Foundation/
ORTHO-McNeil Pharmaceutical Fellowships for Graduate Education
which provided the majority of the funding for this study.
Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
a particular issue is always debatable; therefore, the
quality of a Delphi study is dependent upon those
experts, as well as the design and the process by which
consensus is identified (3536). Astute attention to the
selection of panelists, careful adherence to the research
protocol, and expert consultation in the method ad-
dressed these issues.
Permission was obtained to conduct the study from the
Institutional Review Board of the University of Rhode
Island, the ACNM Division of Research, and the Board
of Directors of the Midwives Alliance of North America
(MANA). Each participant signed a consent form and
had telephone access to the researcher if needed.
DESCRIPTION OF THE SAMPLES
Delbeques practical approach to Delphi studies was
used to develop the protocol to guide the research (37).
The study sampled two groups: 1) exemplary midwives;
and 2) recipients of midwifery care from those exem-
plars. A Delphi sample is not limited by size, but must be
representative of the experts on the questions to be
addressed.
Midwives were recruited from several pools to serve
as Delphi panelists. The first pool consisted of certified
nurse-midwives (CNMs) who were nominated by the
leadership of the ACNM that included the Board of
Directors (10), education program directors (48), and a
stratified random sample of 62 nurse-midwifery service
directors across the United States. Added to these nom-
inations were invitations to midwives who had been
honored for excellence by the ACNM, including recipi-
ents of the Hattie Hemschemeyer Award, to participate in
the study. The second pool was nominated by the
leadership of MANA and mirrored similar criteria used
for the ACNM, including recipients of the Sage Femme
Award.
One of the goals of this study was to hear the voices of
many experts in midwifery, including those of the
ACNM and MANA. The rationale for nominating both
sets of midwives was twofold: their acknowledged ex-
pertise and their current status as front line health care
practitioners. The findings of the 1998 Pew/USCF Report
on the Future of Midwifery (2) note that although
nurse-midwifery and direct-entry midwives have their
differences, most midwives have much in common,
including a philosophical adherence to the midwifery
model of care. It is for this reason that the knowledge of
experts from both groups was sought. A Delphi study
strives for consensus; therefore, the two groups of mid-
wives were surveyed together and not compared with one
another. The criteria for nomination included demon-
strated excellence in midwifery practice that reflected the
philosophy and standards of the profession. The tech-
nique was similar to Benners method of asking nursing
5
leaders to identify expert nurses for her benchmark TABLE 1
research on expert nursing practice (38). Demographic Data on the Delphi Panelists
There were 142 nominations of exemplary midwives. Ethnic Characteristics
These midwives were sent a letter of invitation that
explained the study and the considerable time commit- Midwife Recipient
Panelists Panelists
ment involved. Although 88 expressed interest in partic- Ethnicity (N, %) (N, %)
ipating, only 64 completed the first Delphi round, which
was considered formal enrollment into the study. The Caucasian 47 90 49 80
Hispanic 2 4 3 5
first round was quite time consuming and was given as a
Native American 1 2 1 2
reason by some for not participating in the study. The Asian 0 0 1 2
other most common reason for nonenrollment was lack No answer 2 4 7 11
of current clinical practice. Additionally, four CNMs Total 52 100 61 100
declined to enroll because non-CNMs were included in
the study. Of the enrolled sample, 52 completed a total of Birth Settings
three Delphi rounds, representing a final response rate of Midwives
81%. (% of 46 in
Each of the exemplary midwives who agreed to current clinical Recipients
Birth Setting practice)* (% of 56)
participate was asked to invite women for whom they had
cared in the past to enter the study. The researcher Out of hospital birth center 10 9
believed it was essential to conduct a parallel investiga- In-hospital birth center 6 34
Hospital LDR or LDRP 60 34
tion with recipients of exemplary midwifery care to gain Home 24 30
their perspective on the research questions. The mid-
wives were given two letters signed by the researcher to Payment Sources for Midwifery Services
mail to two women, with a personal note from them, Midwives Recipients
inviting their participation. A response form was en- Payment Source (n 46) (n 61)
closed with the letter for the woman to return to the
Private insurance 28 41
researcher. These forms were not coded, so women were
Medicaid 33 8
assured that there was no way for the researcher to link HMO/PPO 15 38
the woman to the midwife, thereby assuring anonymity Military 9 2
between the two. Eighty-nine women expressed an inter- Self-pay 20 28
est in the study and 71 formally enrolled by completing Other 2 0
the first Delphi round. The recipients Delphi was com- * Totals are 100% since the majority of midwives attended birth in 1
pleted in two rounds with a final sample of 61, repre- setting and many recipients gave birth to more than one child with a
senting an 86% response rate. Interpreters were offered midwife, sometimes in different settings.

for those who did not read or write English, and were The numeric values for the midwives represent the mean percent of
reimbursement for the particular source of payment.
used by two of the recipients of midwifery care.
The numeric values for the recipients represent the average of identified
The final sample of 52 midwives and 61 recipients of payment sources. The totals do not equal 100% since many used more than
care was evenly distributed across the six ACNM regions one reimbursement strategy.
of the United States, with the exceptions of one midwife
HMO health maintenance organization, PPO preferred provider
and one recipient from Canada. All of the midwifery organization.
panelists were women and the pronoun she will be used
to reference the study sample. The midwives were a
seasoned group of clinicians with a mean of 18 years of midwives were other than Caucasian. Except for the lack
experience, ranging from 1 to 45 years. Their mean age of African Americans, which represents 3.9% of CNMs,
was 49 years with a range of 39 to 73. Their average the midwife sample reflects the ethnic distribution of the
salary was $40,000 to $60,000 per year and they worked ACNM (39). The recipient sample, similarly to the
an average of 40 hours per week. The majority of the midwife group, did not reflect the African American
group identified themselves as Caucasian. The recipients population of the United States.
were younger with a mean age of 36 years, ranging from The majority of the recipients were college graduates
21 to 47. This group was also mostly Caucasian. Salary (73%) and an additional 17% had at least some college
information was not collected on this group. Table 1 education; only 2% had less than a high school educa-
compares the ethnic backgrounds of both groups. Al- tion. The midwives were also well educated with the
though steps were taken to obtain a sample that was following distribution of degrees: 11% doctoral, 70.5%
ethnically diverse, by recruiting from a wide range of masters (62% in nursing and 8.5% non-nursing), 10.5%
practices, only 10% of the recipients and 6% of the baccalaureate (2% nursing and 8.5% non-nursing), 6%

6 Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
associate (4% nursing and 2% non-nursing). Two of the
midwife panelists did not respond to this question. When
compared to Rookss 1997 summary of CNM educa-
tional backgrounds, these levels are similar except for a
higher level of doctorally prepared midwives in this
sample (39). The sample consisted of 76.9% (n 40) of
midwives certified by the ACNM or ACNM Certification
Council, Inc. (ACC) and 19.2% (n 10) certified by the
North American Registry of Midwives (NARM). Two
(3.8%) panelists indicated they held no formal certifica-
tion as a midwife.
Five (8%) of the recipients received only gynecologic
care from the midwives in the study. The remaining 92%
experienced pregnancy and birth with the midwives, and
40% of those had more than one birth attended by a
midwife. The midwives and recipients used a variety of
settings for birth. Of the 46 midwives currently attending
birth, 25% use more than one setting. Birth settings used
by midwives and recipients are compared in Table 1,
along with methods of payment for midwifery care.
The midwives were asked to respond to questions
about their scope of practice. The majority of the panel-
ists did provide at least some direct midwifery care,
although some indicated that their current direct client
time was quite low, or nonexistent because of retirement
or academic positions. There were 46 (88%) midwives in
the study that were in active clinical practice. They
reported an average attendance at 56 births per year
(range, 3 to 184), with a 91% spontaneous vaginal
delivery (SVD) rate, a 6% cesarean section (CS) rate, and
a 3% assisted vaginal delivery (AVD) rate. The recipi-
ents had a total of 102 births attended by midwives and
reported a 94% SVD rate, a 1% CS rate, and a 5% AVD
rate.
DELPHI DATA COLLECTION AND ANALYSIS
The expert panelists were surveyed about the research
questions over multiple rounds. A more complete de-
scription of the method is outlined in Appendix A. The
first round of questions were open ended, requiring
written responses from the panelists, and are listed in
Appendix B. The subsequent survey rounds, developed
from analysis of the first round, required a Lickert-scale
ranking of statements about exemplary midwifery prac-
tice. The rounds continued until there was consensus
about each practice statement.
Delphi methodology requires a continuous utilization
of several analytic methods during the data collection
(37). Content analysis of the narrative data was struc-
tured around three predetermined categories that were
specified in the research questions: qualities and traits,
processes, and outcomes of exemplary midwifery care.
The narrative responses were coded using NUD*IST
(Non-numerical Unstructured Data Indexing Searching
Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
and Theorizing) software to assist in the organization,
searching, and coding of over 7,600 text units that
comprised the data set (40 41). The rankings for each
statement were entered into the Statistical Package for
Social Sciences (SPSS) to measure central tendency (42).
A research jury is used in Delphi methodology to
assist in the analysis of the data (37). This jury must
reflect the composition of the panelists and was com-
prised of a CNM who had been honored for excellence in
the past, a certified professional midwife (CPM) experi-
enced in qualitative method, a research assistant who was
also a student nurse-midwife, and a recipient of exem-
plary midwifery care. The jury validated initial and
subsequent coding, achieving 90% on the coding and full
unanimity after discussion of the items as a group.
A MODEL OF EXEMPLARY MIDWIFERY
PRACTICE
The model proposed was developed by examining the
qualitative data composed of the midwives and recipi-
ents responses, their subsequent ranking of statements
about the processes and outcomes of exemplary mid-
wifery care, and the qualities and traits of the exemplary
midwife. The first step permitted resonance between the
two groups of data. Each category was read sequentially,
comparing commonalties and discord between the mid-
wives and recipients. The next step clustered the state-
ments conceptually. This was done over a series of steps,
allowing for multiple examinations and comparisons. It
was also guided carefully by the conceptualization of
practice in the literature described by Kim (43).
Two dimensions emerged, therapy and care, which
aligned with Kims proposal that practice is based on two
philosophic orientations (43). In addition, another cluster
was identified as the dimension of the profession. These
three dimensions are presented conceptually in Figure 1.
The three dimensions of the model are:
The dimension of therapeutics, which illustrates how
and why the midwife chooses and uses specific ther-
apies when providing care.
The dimension of caring, which depicts how the
midwife demonstrates that she cares for, and about, the
client.
The dimension of the profession, which examines how
midwifery might be enhanced and accepted by exem-
plary practice.
For ease of illustration, Appendix C presents a linear
alignment of retained statements (ranked highest to
lowest) for each dimension. When the recipients input is
aligned with the midwives, it is specified in italics and
parentheses. There are several statements presented in
italics only. These statements were identified, or retained,
by the recipients, but not by the midwives. The fact that
7
FIGURE 1.
Abstract model of the dimensions of exemplary midwifery practice.

8 Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
it was possible to identify specific statements for each
dimension suggests that they have a major contribution
to that dimension rather than to the others. It is recog-
nized, however, that any model is multidimensional and,
in reality, there would be a crossover of the supporting
statements to all the dimensions.
Discussion of the Model
The dimension of therapeutics reflects how the exem-
plary midwife proceeds to choose and use therapies when
providing care in practice. The presiding outcome in this
dimension was optimal health of the woman and/or
infant in the given situation. This outcome was agreed
upon after elimination of specific outcomes such as a low
operative delivery rate, preservation of the perineum,
excellent Apgar scores, and breastfeeding success. While
the midwives noted that these were often present in their
practice, they did not in themselves define exemplary
practice. Rather, it was striving for the optimal outcome
in the situation that prompted their actions, and some-
times that meant calling for a cesarean section or cutting
an episiotomy. One midwife saw this as, better health in
the expected parameters of health; the client should end
up with a healthy baby, an intact body, or improvement
of an illness. While they believed that they did have an
impact on the health of the woman and/or infant, they
noted that improved health of the family was less in their
control; We can facilitate, but we cannot assure respon-
sibility for, or assure these outcomes. The recipients
believed that their midwife prevented problems with
their birth or health, whereas the midwives collapsed this
into the larger category of optimal outcomes.
The midwives believed that the presiding outcome for
this dimension was achieved by a set of processes, which
were clustered into the following two general orienta-
tions: 1) supporting the normal process of birth; and 2)
vigilance and attention to detail. At first glance, these
might appear to be opposite in nature and achievement;
discussions and reflections revealed, however, that they
are intricately connected. The midwives repeatedly artic-
ulated the process of supporting the normalcy of birth.
Remind yourself, your colleagues, your support work-
ers, and especially the woman of the power of normal
pregnancy, labor, birth, postpartum, and breastfeeding
when no interference occurs. This included judicious
and appropriate use of technology, intervening only if
necessary, not hurrying the birth process, personalizing
care, and using a wide array of options and resources
(rather than one in particular) to assist the woman and/or
her family. The recipients agreed that this process re-
flected their experiences. A large part of her providing
the kind of care we wanted is what she didnt do . . . she
didnt rush anything . . . she said to me your body knows
what to do so just let it do it. This required commitment
Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
to the womans health and persistence to help her achieve
her desired goals. This midwife believes that labor and
birth can be trusted and is patient with, and positive
about, the process. They described a midwife that pos-
sesses a maturity and wisdom that is not necessarily
related to age, and which supports her knowledge of
birth.
Juxtaposed to the support of normalcy and low-
technology approach was the midwifes vigilance and
attention to detail. While appearing relaxed and patient,
they were not casual about the care they provided. These
processes were supported by an alert, thorough, and
ongoing assessment. Many viewed this as the solid
foundation of their work noting certainly assessment is
important in the entire process of what I do. Im always
assessing what the woman is saying, watching non-
verbal language, listening acutely to what shes saying
and what she isnt saying. This was considered well
linked to outcomes. As a home birth midwife, my
greatest challenge is exceptional screening and preven-
tive counseling resulting in low mortality and morbidity
rates. Rather than a search for pathology, it appeared to
be an approach that assured continued normalcy, requir-
ing confidence, intelligence, intellectual curiosity, and
clinical objectivity to examine the current situation. One
recipient validated the thoroughness of care stating, One
thing that stood out was the excellence of the medical
care, from purely a medical standpointI dont think
Ive ever had anyone check my thyroid before.
The midwife possessed exceptional clinical skills and
judgement necessary in making critical decisions when
required. Timeliness in clinical actions was also consid-
ered an important process of the vigilant stance. One
described this balance succinctly stating, She knows
when to holler and knows when to shut up. Another
discussed the ability to distinguish normalcy and a
need to intervene in a timely fashion . . . hope is not
sufficient . . . ability to pace interventions moving from
least to most, or respond rapidly to emergent situations.
The midwives agreed upon the practice statement of
using intuition to understand the situation more fully,
initially classifying it as a quality or trait. Comments by
the midwives in the first round included the following:
And Ive learned to pay attention to my own intu-
itionif Im nervous about something its usually smart
to pay attention. I believe that the time intensive care
provided increases my intuitive abilities and spiritual
connection to the mother and babythis results in more
timely transports . . . and ultimately lower mortality and
morbidity. The recipients commented, They practiced
with skill, experience and an uncanny knowing of when
to step in and when to let me be, and she seemed to
know what I was thinking or needing. Nine midwives
debated the nature of intuition on the successive rounds,
which provided the research jury with a greater under-
9
standing of its use in practice. The midwives discussions
on intuition centered on a concern that the exemplary
midwife cannot rely on this alone in clinical practice. It
does not exempt the midwife from expert knowledge or
clinical experience. As the debate continued into the third
round, it clearly seemed to emerge as a process. The
intuitive knowledge backs up the findings as it provides
the practitioner with a motive to investigate the cause.
Intuition is a topic that does not achieve consensus in the
literature, yet the midwives in this study scored it
relatively high in their ranking. Experts on intuition
believe it is an inner knowing that leads to action to
explore a situation further. To respond by intuition is
not the same as thoughtless and automatic respons-
es . . . expert nurses also use a kind of deliberative
rationality to check out their whole intuitions (44). It is
not just a gut sense but requires further investigation,
using the midwifes exceptional clinical skills and judge-
ment to support the judgement. These arguments sup-
ported the decision to reclassify this as a process in
exemplary midwifery practice.
There were a number of practice statements placed
into this dimension. Although this discussion has only
highlighted some of them, the comments by the mid-
wives and recipients support that practice in this dimen-
sion addresses why and how the midwife chooses and
uses specific therapies to address the clients needs.
The dimension of caring was equally important in
exemplary midwifery practice and focused on women as
individuals going through special experiences during
their lives. The outcome for this dimension was the
woman and/or family has a health care, or birth experi-
ence, that is respectful and empowering. This included
that the woman feel safe, well cared for, and satisfied
with her care. The experience permitted the womans
active participation in her care, and achievement of a
level of control of the situation. Empowerment of the
woman and maternal self-esteem were also identified as
outcomes. The recipients did not support an increase in
self-esteem in their rankings, many noting that so much
of this was beyond the influence of their midwife. They
did agree, however, that the midwife assisted them in
gaining confidence to achieve their goals, which could be
interpreted as movement toward enhanced self-esteem.
The processes supporting this dimension were placed in
the following two orientations that dealt with the woman
and her environment: 1) respecting the uniqueness of the
woman and family; and 2) creation of a setting that is
respectful and reflects the womans needs.
Respecting the uniqueness of the woman meant un-
derstanding her as an individual, who she was, her
background (including cultural awareness), advocating
for her needs, and involving her family as she desired.
The midwives saw themselves in some respects as a
partner or guide with the woman, helping her to draw
10 Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
upon her inner strength, listening carefully to her, and
maintaining her confidentiality. 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 paddlers
ability to navigate, giving encouragement and sugges-
tions as needed. One of the recipients echoed this when
describing her birth, It was a searing, forever-to-be-
etched experience, and my midwife stands out as some-
one who rode the river with me.
Positive encouragement and validation of the womans
work and efforts were part of the process of care. Helping
each woman feel good about her experience, praising her
efforts, validating her work, her knowledge of her body;
all were seen as contributing to instilling confidence in
her ability, in herself. This was not empty reassurance or
false praise but rather, was carefully selected to reflect
the womans progress or experience. I try to show the
women the positive things they are doing for their health.
I use words that show their control and knowledge, not
my own.
Creating a respectful setting did not reflect the physi-
cal environment but rather, was one constructed of
respectful actions that included the womans need for
time, information, encouragement, validation, and a sup-
portive presence. One midwife called it creating a
setting in which the woman comes first, in which she is
taken seriously. Women felt important and valued as a
result of the caring respect provided by the midwife. I
was treated like an intelligent person fully capable of
birthing my babies. Some of the qualities and traits
supporting this dimension included an unwavering integ-
rity and honesty, compassion and understanding, the
ability to communicate effectively, and flexibility. In
addition, these midwives possessed a level of humility
that did not diminish their ego strength. They were
tolerant and attempted not to judge others.
Both groups saw gentleness as a process used by the
midwife. While it was originally categorized as a trait, it
emerged more as a process during the discussions. Even
tough examinations are not felt gentle to the woman
respecting the woman and attempting to be as gentle as
possible are important to the womans self-esteem. One
midwife commented that there were times for gentle
and times for fierceness, indicating a process approach
to the situation at hand. The recipients also echoed this as
a process; My deliveries were gentle and unforced.
She recognized my need for her and spoke gently to me
through my contractions.
While gentle, the midwives were also realistic with the
woman and family about their care options and potential
outcomes. I always tell it like it is and then lend support
if necessary. This realistic honesty was perhaps most
reflective of their attributed traits and contributed greatly
to the trust and security the women felt in their care. One
recipient stated, I appreciated the honesty and sincerity
maybe more than anything. When I askedwill this be
painfulthe answer was yes. There was a rich and solid
foundation to the mutual trust that appeared to be built.
Compassion and gentleness was backed up by reliability.
Warmth and interest in the woman as a person was
geared toward a greater understanding of her and her
family, appreciating that this knowledge could be invalu-
able later in the care process. A mother who gave birth to
a child with Down syndrome shared her very intense
reactions to this unanticipated event and how her mid-
wife validated her humanness and strength.
My midwife walked a fine line flawlessly. On the one hand,
when I, sobbing, told her I didnt 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.
The focus of this dimension was to know and under-
stand the woman as a unique individual. Recognition and
respect of her as a person, within the context of her
family, assisted the midwives to provide personalized
and appropriate care that drew upon the womans inner
strengths. Both personal respect and a respectful envi-
ronment provided the structure for this dimension.
The dimension of the profession reflects the environ-
ment in which midwives practice. The orientation of this
dimension of midwifery practice focuses on the delinea-
tion, promotion, and sustenance of midwifery as a
professional role. The midwives in this study believed
that their profession would be enhanced and accepted
because of exemplary practice. The processes included
careful review of their practice personally and by peers,
in addition to continually updating knowledge to support
practice. Sometimes, when there has been an untoward
outcome that I was involved in, I go through an internal
process and painstakingly mentally review over and over
everything I did, to see if I could have done anything
different or better . . . I have come to accept this as part
of what keeps me safe; it is my personal peer review. It
meant that they used evidence to support their actions to
the best of their ability. The midwives also proposed that
they were cost effective. One of the processes aligned in
this dimension was the attempt to balance ones personal
and professional life. I think the exemplary midwife
needs to know how to care for herself or himself,
honoring ones own personal life is essential. This was
often viewed as difficult because of the qualities and
traits associated with the dimension, which included a
commitment to, and passion for, the profession. The
exemplary midwife was considered accountable for her
Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
actions and motivated to achieve excellence in the
practice of midwifery.
What is important about the emergence of this dimen-
sion is that the midwives believed that exemplary mid-
wifery practice is not just concerned with what occurs in
the specific care situation. Exemplary practice also in-
cluded how midwives foster the general professional and
responsible modes of their role. Although they did not
see this as overt leadership or political/professional
activism, it was reflected in their call to excellence and
their belief that this is often acknowledged and respected
by others.
The model was returned to the midwives to indicate if
they believed it reflected their vision of exemplary
midwifery practice. It was also sent to the recipients who
were asked if the model reflected their experience with
midwifery care. Both groups were asked to share a story
about their care that reflected the model.
Forty-nine of the midwives (94%) responded to the
model. Forty (82%) agreed that it fully reflected their
vision of exemplary midwifery practice. The remaining
believed that it mostly reflected their vision of exemplary
practice and added comments that they thought would
help clarify the model. They were asked to indicate what
they thought was most unique about the model, and what
set their practice apart and identified it as exemplary. The
choices were varied and often stated with passion. Belief
in the normalcy of birth, again, emerged to be of great
importance. Others most commonly mentioned were
accountability, compassion, and love for the work of
midwifery. One midwife pondered the latter with a
concern about the message it might send to those reading
the model. While she believed that her love for her work
makes her care special, she recognized just how hard the
work is of the exemplary midwife. During those difficult
times of physical and mental toll, there are moments
when one does not enjoy the work as much as at other
times. Support is needed during those times, and she
stressed that just because a midwife was experiencing a
low time, it did not mean she was not exemplary. The
midwives also consistently identified exceptional clinical
skills and judgment. Recognition of the uniqueness of the
woman, personalizing care, remaining flexible, and use
of intuition also contributed to their particular style of
practice.
Fifty-four of the recipients of care (89%) returned
responses to the model. All but six (89%) ranked the
model as very much reflecting their midwife. The re-
maining six ranked it as mostly describing their experi-
ence providing minor points they believed did not ex-
actly match their midwife. Their comments validated
many parts of the model. They, too, believed the midwife
supported the normalcy of birth. Many revisited how the
midwife validated who they were, her belief in the
womans abilities, and how well she helped the woman
11
cope with the labor and birth. Flexibility in the time
provided for them and consideration of their families was
again mentioned as important. One woman spoke of the
positive effects of midwifery, when midwifery practice
becomes the birthing normthe world will be a gentler
place. Several reflected on experiences with other health
care providers since their midwifery care and were
dismayed to find a disrespect for their time and their
knowledge of their bodies or their children. These events
made them value their midwifery care even more.
THE CRITICAL DIFFERENCE: THE ART
OF DOING NOTHING WELL
The stories the midwives told provided a validation of
their own work in building this model. In the end, it
appeared that they used processes that supported nor-
malcy and health, whether it was in pregnancy and birth
or in gynecologic care. This process of supporting
normalcy could aptly be described as the art of doing
nothing well. Midwives articulated their ability to do
nothing as perhaps more accurately termed to be
present with the woman, intervening only when neces-
sary. One midwife was particularly expressive in describ-
ing this nothingness.
Much of what midwives do during early labor doesnt even
look like doing . . . I speak for myself and the long
honorable tradition of midwifery when I describe this
work as mastery in doing nothing. It is a specific skill
that must be learned and developed, no less so than any of
those busy medical skills associated 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.
The support of the normalcy, as a process in the
dimension of therapeutics, was powerfully juxtaposed
with the processes of vigilance and attention to detail.
The midwives emphasized that intervention in the pro-
cess of labor and birth was guided by the individual
situation. The same midwife who vividly described her
art of doing nothing, also provided many pages of single-
spaced, typed descriptions of the things that she does
doso she can do nothing in the end. These were not
midwives who casually relied on the fact that most
women are healthy, or that most pregnancies and births
are normal. They were sticklers for detail. The women
who were their clients were carefully screened, mea-
sured, educated, and watched over, reminding the re-
searcher of a mother eagle with a sharp eye and gentle
nudge when it was the fledglings time to fly indepen-
dently close by if needed, but trusting the birds ability
to soar. Vigilance and attention to detail were the
necessary ingredients to assure continued normalcy and
12 Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
that the woman and/or fetus are safe and healthy. They
were, however, quick and decisive, stepping in to inter-
vene if something was awry. One midwife told a story of
a birth center birth, which required timely, skilled, and
judicious management of a shoulder dystocia. Amidst
joyous tears and exclamations at the lusty cries of the
infant and the collective sighs of relief, she reflected on
her clinical expertise and calm ability to manage a very
challenging situation with skill.
The attention to detail included going to remarkable
lengths to achieve the very best possible health care for
women. This, at times, appeared to consist of both
protection and advocacy, similar to Carrs (45) descrip-
tion of vigilance as a caring expression of a close,
protective involvement. Sometimes this meant battling
with hospital administrators to get a birthing tub for a
woman who desperately wanted this for her birth. At
other times, the midwife would spend a great deal of
energy and time helping women and partners navigate
social services or finding food for those who had none.
One story related how the midwife did her best to assist
a young couple with no food, money, or resources to
achieve a healthy pregnancy. Even though she believed
that they were not able to accomplish as much as she
would have liked in the first pregnancy, the couple had
two more healthy children in the years to come and
secured a more stable lifestyle. The father called the
midwife years later after the birth of their third child. He
told her that they credited their healthy children to all
they had learned from the midwives, as well as their
commitment to them as a family. This midwife reflected:
The ups and downs, struggles and accomplishments that
came like the unfolding of the skin of an onion, as I learned
slowly what their needs were and how to help them. It was
an endeavor that took time, commitment, caring, and
tolerance for frustration. However, a healthy family unit
was the final outcome, and more than worth it.
In the end, it is the woman who seeks and receives
health care, or births the child, with support by the
midwife. As one recipient of care commented, [she] was
there and attentive but without intervention. Another
described her feeling of achievement in the process of
birth with her midwife. Ive never played football, but if
I had, giving birth with [her] was like catching a winning
touchdown in the fourth quarter of a game against a rival,
feeling tired and sore, but on top of the world. The
critical message is that it was the woman who scored the
touchdown, not the midwife, but together they were a
team that moved toward an identified goal.
LIMITATIONS OF THE STUDY
The results of a Delphi study can be considered to be
what Lincoln and Guba call metaphysical truth, or
those truths that are accepted at their face value (46). The
validity and reliability of a Delphi study are reflected in
the choice of the expert panelists, careful attention to
content analysis and interpretation of the survey data, and
the continual checks of the jurists (3237). Although the
results of any one qualitative study are not considered
generalizable, the results of this study were enhanced by
the representation of experts from around the country.
There were, however, several skewed panel demograph-
ics that must be addressed.
The lack of ethnic diversity within the panelists groups
is concerning. The 1998 Pew/UCSF Report on the Future
of Midwifery notes that the general population of the
U.S. is not reflected in the ethnic representation of
midwives nationally (2). Approximately 73.6% of Amer-
icans and 83.1% of CNMs are Caucasian (39). In this
study, 90% of the midwives and 80% of the recipients of
care indicated they were Caucasian. Approximately 21%
of women attended by CNMs in hospitals are African
American (47), yet this population was not represented in
this study, either in recipients of care, or in the midwife
panelists. The U.S. Hispanic population is growing,
currently standing at 10.2%, however only 5% of the
recipients and 4% of the midwives represented this
ethnic background (2).
The second skewed representation was the level of
education among the panelists. As noted earlier, the
education level of the midwives is fairly similar to that of
CNMs nationally, except for a higher number who held
doctorate degrees. The recipients of care were well
educated (90% college education), but differ from the
populations served by midwives as described by De-
clercq (47). The majority of women cared for by CNMs
(59.4%) in his study had some college, or a college
degree; 37.4% did not. Of those women attended by
CNMs in hospitals, 33.3% had less than a high school
education.
Although data were not collected on the recipients of
care yearly income, methods used for payment of ser-
vices (Table 1) provided a limited picture of socioeco-
nomic status. Only 8% of the recipients of care indicated
payment for services by Medicaid. Although this may
have been under reported because of trends toward
privatization of Medicaid to HMOs, it is in marked
contrast to the midwives reported payment of 33% from
Medicaid.
These disparities within the panels reflect populations
that are historically underrepresented, and whose voices
are traditionally not sought or heard. Scupholme, DeJo-
seph, Strobino, and Paine (48) note that 99% of CNMs
care for vulnerable populations for outcomes relating to
age, socioeconomic status, refugee status, and ethnicity.
Even though the researcher attempted to sample this
population, the endeavor was unsuccessful. One of the
practice statements in the Delphi rounds was considers
Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
cultural background. This was highly ranked by the
midwives, yet ranked much lower by the recipients of
care. When this was compared to the lack of diversity
among the recipients, the research jury believed it re-
flected the homogeneity of the group. Indeed, those
recipients who represented an ethnic background other
than Caucasian, ranked it higher than the other panelists,
one noting, She cant speak to me in my language, but
she understands my culture. The stories and opinions of
a highly educated, well insured, Caucasian population of
recipients of care may be quite different than those of the
populations that were not represented; therefore, it is a
limitation of this study.
Another limitation is reflected in the panelists who
chose to participate. As noted before, only 64 of the 142
nominated midwives enrolled in the study. The majority
who did not enroll simply did not respond to the
invitation, which was issued several times. Those that did
decline most often gave reasons of lack of time, lack of
current clinical practice, and a few CNMs who preferred
not to participate in a joint study with non-CNMs.
Questions are raised about whether the results would
differ if those who had declined had actually participated
in the study. Additionally, one would anticipate that the
midwives would have invited women to participate that
they knew had been satisfied with their care. There was
no way to track the number of invitations from midwives
to recipients or the reasons that the recipients chose not
to participate. If recipients of care had not been satisfied
with their midwifery care, the results of the study may
have been different. Both nonparticipating groups had
the potential to provide valuable perspectives to the study
and also represent a limitation. A study of this type truly
represents a consensus by the panelists at only one point
in time, however, it does provide an inductive platform
for future research to validate the work of these experts
represented in the sample.
IMPLICATIONS FOR MIDWIFERY PRACTICE,
EDUCATION, AND RESEARCH
Thompson and colleagues developed a middle-range
theory of care in 1989 (24) identifying six central
concepts (safe, satisfying, respecting human dignity and
self-determination, respecting cultural and ethnic diver-
sity, family-centered, and health promoting), with com-
ponents and indicators for each. Most of these were also
described by the midwives in this study, and/or experi-
enced by the recipients of their care. VandeVusse (49)
also proposed a model of the essential forces of labor
identified through womens birth stories. These forces,
both internal and external, describe a complexity of
issues that can effect the womans experience and out-
come of her labor and birth. Both of these models
deserve further exploration and comparisons with the
13
results of this study. What the panelists in this Delphi
study have provided is a perspective on how they use
specific processes to achieve outcomes. In addition, they
offer a glimpse of the qualities and traits that they believe
describe the exemplary midwife.
One of the issues raised in the 1998 Pew/UCSF Report
on the Future of Midwifery is the increasing emphasis in
health care on productivity and how that potentially
stands to change practice (2). The midwives raised some
concerns about the measured value of outcomes of health
care, depending upon the lens of the beholder, which
evokes a very important issue facing the health care
industry today. Even the notion that it is a health care
industry conjures a depersonalized factory where the
goal is to produce more with less, where perhaps profit,
rather than quality, is the guiding principle. Thus, the art
of doing nothing well becomes a pivotal issue in the
practice of midwifery in a health care environment that
values technology and a culture that values doing.
Gordon, Benner, and Noddings (50) believe that the
current health care culture has difficulty comprehending
the fact that it is sometimes far harder to be with, to
demonstrate compassion for (ie, suffer with) people at a
moment of crisis than to do for them.
One of the challenges facing the profession is to assist
policymakers and administrators to more fully under-
stand the complexity of defining productivity, particu-
larly in the care of women and their infants. The model
proposed by the midwives in this study suggests that
their productivity may be more appropriately measured
by outcomes in optimal heath, and/or the perceptions of
the mother and family of respect and empowerment from
their care experience. Time spent with women was a
factor. Thus, research must be directed to establishing a
more discrete description of the processes and outcomes
that can be related to productivity. Cost effective care
must be redefined based on the emerging definition of
productivity. Defining optimal health becomes a criti-
cal juncture in this endeavor. Factors to study include:
continuity of care, time spent in office visits and provid-
ing labor support, womens level of knowledge about
their bodies and pregnancy that is correlated with health
outcomes, womens perception of their self-esteem and
parenting ability, in addition to many other processes
identified by the midwives and recipients of care.
Another area to consider is the approach to providing
maternity and gynecologic services to women in the U.S.
Rooks notes several distinct differences between mid-
wifery and medical obstetric practice, however, both
occupy common ground and knowledge (16). She pro-
poses that the two are best used in an interdisciplinary
approach, with midwives caring for the majority of low
risk women, and obstetricians caring for those with more
complex medical problems. Nations with this model
often demonstrate exceptional maternal and infant out-
14 Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
comes (51). The recommendations for an interdiscipli-
nary approach to care are powerful and practical, yet may
go unheeded (2). Most of the midwives in this study,
while recognizing that they worked with collaborating
physicians, also believed that their ability to be an
exemplar rested with themselves, not with the physician.
This was an interesting perspective, and some of their
comments indicated that they sometimes worked with
less than optimal collaborative arrangements. Research
must be conducted that explores the collaborative set-
tings in which these midwives work to reveal important
information about potential models of care that can
improve outcomes.
Midwifery education programs may consider a reex-
amination of their criteria for admission based on the
consensus of these panelists. If the belief that pregnancy
and birth are normal processes is truly representative of
an exemplary midwife, perhaps this should be a screen-
ing parameter for candidates. Those providing references
for future students might also address the qualities and
traits identified by the panelists. Additionally, midwifery
students must be exposed to a variety of care settings in
their education to more fully learn the vast amount of
ways to provide care, and to critically discern the
uniqueness of the midwifery model of care.
The limitations of this study rested primarily with the
distribution of the sample. The voices of women from
vulnerable populations must be heard to expand knowl-
edge on their specific needs, and whether or not mid-
wives provide a model of care that is effective for them.
Additionally, the perspectives of women who received
midwifery care, and found it to be unsatisfactory or
lacking in meeting their needs, is essential. Comparing
these opinions and voices to the current data set would
provide valuable insight about the potential differences
between exemplary and nonexemplary midwifery care.
CONCLUSION
This qualitative study was considered a first stage at-
tempt to define critical elements unique to exemplary
midwifery care. It gathered a consensus opinion from
identified exemplary midwives and women who had
received their care. The model provides a structure for
future research; it is not definitive at this point in time,
and there is still much work to be done. The profession of
midwifery must continue to move toward a fuller under-
standing, and shared agreement, on what processes of
care are related to desired outcomes. Defining those
outcomes is essential, and the midwives in this study
were global and holistic in their decisions about what
they believe to be critical.
Reynolds (52) remarks that theory building is complex
and notes a distinction between understanding how
certain variables affect the expression of others versus
the ability to control variables. He emphasizes that
control of variables is not the necessary criterion for
scientific knowledge. The midwives in this study appear
to have at the heart of their practice an understanding that
control of a situation is complex, and perhaps not the
ultimate goal. Rather, their excellence may rest in their
knowledge and judgement about when taking control of
a physiologic process is necessary, and when it is not.
Gaining knowledge about this continuing balance may
hold the key to understanding how they achieve the
positive outcomes for which they are noted.
This author challenges midwives to become scientists
knowledgeable in presenting evidence that is valued to
the corporate world and boardroom. It is not enough to
say, But were good! The claim must be supported
with evidence of positive outcomes that is linked to their
process of care, and which is of best value. The challenge
for the profession is the same as identified by the
American Hospital Association for the goals of health
care leadership in the coming millennium (53). Mid-
wifery must demonstrate that the individualized compas-
sion of its care can also be aligned with value in health
care economics. This study is a step toward this goal.
Future research is essential to validate models of care,
which are related to short- and long-term outcomes of
improved health for women and their families, and that
are cost effective.
The author acknowledges receiving financial support for this study
from the ACNM Foundation, Ortho-McNeil Pharmaceutical, and the
Rhode Island Chapter of the ACNM. In addition, the author acknowl-
edges the dedication and persistence of the Delphi panelists, and the
exceptional work of the research jury, Penfield Chester, CPM; Michelle
Palmer, CNM; and Sarah Torrey. Their attention to detail added to the
rigor of the study. Finally, thanks to Dr. Eugene Knott for insightful
and expert guidance in the use of the Delphi method and to Dr. Joyce
Roberts for her continued encouragement during the study.
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APPENDIX A
Description of the Delphi Method (3237,40 41)
ROUND ONE
The purpose of the first Delphi round is to obtain qualitative data from the expert panelists about the issue under consideration. It is an
attempt to capture their knowledge in their own voice and is key to the study outcome.
Open-ended questions were developed with the assistance of Delphi methodology and midwifery consultants (Appendix B).
Data were entered into NUD*IST software and evaluated using content analysis; validated by the research jury.
There were 137 statements generated from the midwives first round, and 97 statements generated from the recipients first round
about midwifery practice.
ROUND TWO
The purpose of the second Delphi round is to have the panels begin to prioritize, or rank, issues identified in the first round. In this
study, these were statements about the practice of midwifery.
Statements were developed from the qualitative responses in the first round and placed into a traditional survey format. The
panelists own terms were used as much as possible.
The panelists were asked to rank each statement on a Likert scale. Midwives ranked from least important (1) to most important (7)
in their practice. Recipients of care ranked from least descriptive (1) to most descriptive (7) of their midwifery care experience.
Space was provided with each statement for written responses, if clarification or discussion was desired.
Measures of central tendency were gathered on each statement.
A statement was retained if 75% of the midwife panelists ranked it 6 of the 17 Lickert scale. Using these retention criteria, 42 of
the statements were eliminated in the second round.
The recipient panelists were used to reflect the midwives description of practice. Their statements were compared to the midwives
data and were considered to be strongly supportive when ranked at 7, moderately supportive when ranked at 6, and not supportive
if ranked 6 on the 17 Lickert scale. The recipients completed their work in two rounds.
ROUND THREE
The purpose of the third Delphi round (and subsequent rounds) is to move to consensus on each of the statements.
During this round, the midwife panelists were able to see the distribution of responses on each statement, and the relationship of
their own response to the rest of the midwives.
The survey was returned in the following format to the panelists. Three columns were placed next to each statement. The first
column held the group mean rank for the statement. The second column was hand coded with the panelists individual rank. The
third column was blank.
The panelists were asked to evaluate each statement and make a decision to either retain their own rank, or to move closer to the
mean rank of the group. Space was also provided for comments, clarification, or discussion on each statement.
The third round was analyzed similarly to the second one. Consensus was achieved by the midwives in this round and no statements
were eliminated.

16 Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
APPENDIX B
First Round Delphi Questions
Exemplary Midwives Recipients of Midwifery Care
Describe what you believe to be the essential characteristics of an Please tell me what it is about your midwife that stands out
exemplary midwife. Examples of these might be descriptions of as special or important to you. (For example: how you are
personality, interaction style, or involvement with the woman, treated, personality, etc.)
etc. What is the exemplar midwife like?
What specific outcomes are important as a result of exemplary Describe what you believe were specific results of being
midwifery care? Outcomes can be defined in many ways such as cared for by a midwife. Examples might be how you felt,
Apgar scores, prevention of postpartum hemorrhage, maternal the way you experienced labor and delivery, your health,
self-esteem, or the womans control of her health care to name or perhaps your ability to breastfeed. In other words, what
just a few. What do you think is really important as a result of did you think was really important that happened as a
exemplary midwifery care? result of your midwifery care?
Describe the process of care you provide in your exemplary How would you describe the way your midwife went about
midwifery practice. (Process generally means how you do things. providing care for you? How did she proceed? What
For example, spending time, assuring safety, or your own approaches did she use when issues or problems needed to
competence.) Try to think this one through for all areas of care be handled? What did she actually do in caring for you?
through pregnancy, birth, postpartum, well woman, and care of
the infantwhat is it that you do that serves as exemplary
midwifery practice?
What specifically is it about the process of exemplary midwifery If possible, try to link the things that the midwife did when
care that you believe is related to the outcomes you have caring for you that led to the results of your care that you
identified as important? [Look at the outcomes you have chosen. identified. For example, if the midwife helped you to
See if you can link them to the processes you have identified. For breastfeed effectively, what actions of the midwife can you
example: careful assessment (process) could be linked to specifically link to that result?
prevention of postpartum hemorrhage.]
Would you consider your midwifery care to be the very
best it could have been? If not, what would you have liked
that was not present in your care?
APPENDIX C
Dimensions of Exemplary Midwifery Practice
Dimension of Therapeutics Dimension of Caring Dimension of the Profession
(Reflects the philosophy supporting the (Reflects the philosophy of caring for (Reflects how the profession of midwifery
choice and use of therapies) and about the woman) is affected by the exemplary practice)
Outcomes Outcomes Outcomes
Optimal health of the woman &/or infant The woman & family have a health care Enhancement of the profession of
in the given situation. or birth experience that is respectful & midwifery (includes the development of
empowering. knowledge).
Early recognition of complications with The woman & family feel well cared Equitable or better outcomes when
resolution if possible for and safe (strong consensus by compared to physicians
Grief resolution when applicable (not recipients) Acceptance of the midwifery model of
supported by recipients, perhaps Empowerment of the woman & family care
because it was not applicable to most) (moderate consensus by recipients) Cost-effective care
Positive maternalfamilyinfant The woman would return to the Evidence-based practice
bonding midwife for care (eliminated by
Optimal adaptation to parenting (not midwives; 100% consensus by
supported by recipients) recipients)
Prevention of problems with my birth The woman & family are active
or health (not identified by midwives; participants in the health care or birth
moderate consensus by recipients) experience
Medication-free birth (not identified by Maternal self-esteem (not supported by
midwives; moderate consensus by recipients)
recipients) The woman would refer others to the
Preservation of the perineum midwife for care (eliminated by
(eliminated by midwives; moderate midwives; strong consensus by
consensus by recipients) recipients)
Elimination of substance use (not The woman & family are satisfied with
identified by midwives; of those their care (strong consensus by
recipients in which this was an issue recipients)
there was moderate consensus) The woman feels prepared for the birth
or health care experience (not identified
by midwives; strong consensus by
recipients)
The woman & family are in control in
the health care or birth experience
(strong consensus by recipients)

Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000 17
APPENDIX C (continued)
Dimensions of Exemplary Midwifery Practice
Dimension of Therapeutics
(Reflects the philosophy supporting the
choice and use of therapies)
Processes
Supports the normal process of birth.
Intervenes in birth process only if
appropriate (moderate consensus by
recipients)
Personalizes care (moderate consensus
by recipients)
Draws upon natural resources to assist
women such as rest, nurturing &
nutrition (not supported by recipients)
Avoids routinization of care
Considers all options when providing
care
Utilizes a wide range of resources to
assist the woman (strong consensus by
women)
Patient; does not hurry (strong
consensus by recipients)
Uses a low technology approach to
birth when appropriate
Assures the baby stays with the mother
(not identified by midwives; strong
consensus by recipients)
Vigilance and attention to detail.
Thorough and ongoing assessment
(strong consensus by recipients)
Practices within a circle of safety
Follows up on care (strong consensus
by recipients)
Consults and refers appropriately (not
supported by recipients but may reflect
that it was not needed for most of
them; many of their stories did show
evidence of this as a process)
Timely in clinical actions (strong
consensus by recipients)
Works to prevent problems
Remains alert
Uses intuition to understand the
situation more fully (strong consensus
by recipients)
Care is accessible & available to
woman (strong consensus by
recipients)
Documents care well (strong consensus
by recipients)
Provides continuity of care (eliminated
by midwives; strong consensus by
recipients)
18
Dimension of the Profession
Dimension of Caring (Reflects how the profession of
(Reflects the philosophy of caring for midwifery is affected by the
and about the woman) exemplary practice)
Processes Processes
Respects the uniqueness of the woman & Continually updates own knowledge
her family. Personal introspection of practice
Maintains confidentiality Balances professional/personal life
Listens carefully and responds Peer review of practice
appropriately (strong consensus by
recipients)
Helps the woman draw upon her inner
strength (moderate consensus by
recipients)
Advocates for womans needs and
desires (not supported by recipients,
but perception was that they did not
believe they needed this in their
particular situation; evidence seen in
some of their stories)
Considers cultural background (not
supported by recipients)
Works as a partner with the woman
(strong consensus by recipients)
Involves family as desired by the
woman (strong consensus by
recipients)
Encourages & supports woman in
taking personal responsibility for her
health & health care decisions
(moderate consensus by recipients)
Creates a setting that is respectful and
reflects the womans needs (even in sub-
optimal conditions).
Provides thorough education &
accurate information based on the
womans needs (strong consensus by
recipients)
Provides encouragement & validation
(strong consensus by recipients)
Maintains a supportive presence in
labor; stays with the woman as she
desires (strong consensus by recipients)
Obtains informed consent (moderate
consensus by recipients)
Tries to provide adequate time to meet
the womans needs (strong consensus
by recipients)
Assists the woman in gaining
confidence to achieve her goals (not
identified by midwives; strong
consensus by recipients)
Goes out of her/his way to help meet
the womans needs (not identified by
midwives; moderate consensus by
recipients)
Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000
APPENDIX C (continued)
Dimensions of Exemplary Midwifery Practice
Dimension of Therapeutics
(Reflects the philosophy supporting the
choice and use of therapies)
Dimension of the Profession
Dimension of Caring (Reflects how the profession of
(Reflects the philosophy of caring for midwifery is affected by the
and about the woman) exemplary practice)

Qualities and Traits Qualities and Traits Qualities and Traits

Belief in the normalcy of birth
(strong concensus by recipients)
Clinical objectivity
Knowledge of self & limits
Exceptional clinical skills &
judgement (strong consensus by
recipients)
Commitment to the health of
women & families (strong
consensus by recipients)
Calm (strong consensus by
recipients)
Patience (strong consensus by
recipients)
Confidence (strong consensus by
recipients)
Wisdom
Decisive (strong consensus by
recipients)
Intelligence (strong consensus by
recipients)
Intellectual curiosity
Maturity (strong consensus by
recipients)
Positive outlook
Persistence (strong consensus by
recipients)
Assertive (eliminated by midwives;
moderate consensus by recipients)
Possesses integrity Accountability
Honesty (strong consensus by recipients) Enjoys the work of midwifery
Compassion (caring, kind, empathic & sympathetic) (strong consensus by recipients)
(strong consensus by recipients) Passionate about midwifery and
Trustworthy; reliable (strong consensus by caring for women
recipients) Commitment to the profession of
Commitment to the empowerment of women midwifery
Communication skill Motivation
Flexibility (strong consensus by recipients) Professional presentation (eliminated
Understanding and supportive (strong consensus by by midwives; strong consensus by
recipients) recipients)
Warmth (strong consensus by recipients)
Tolerant
Nonjudgmental (strong consensus by recipients)
Commitment to woman/family-centered care
Gentle (strong consensus by recipients)
Humility
Approachable
Interest in others (strong consensus by recipients)
Nurturing (strong consensus by recipients)
Not focused on self, lets ego go (strong consensus
by recipients)
Realistic (strong consensus by recipients)
A woman and/or a mother (not identified by
midwives, strong consensus by recipients)
Reassuring & soothing (not identified by midwives;
strong consensus by recipients)
Generous & loving spirit (not identified by
midwives; strong consensus by recipients)
Sense of humor (eliminated by midwives; strong
consensus by recipients)
Personable (eliminated by midwives; strong
consensus by recipients)
Spiritual (eliminated by midwives; moderate
consensus by recipients)

GUEST COMMENTARY
This is a breakthrough study and report. It begins to answer that elusive question How are midwives different?
or better yet, How is midwifery different from obstetrics regardless of provider?
I am reminded of the perinatalogist who spoke on managed care a few years back, at an Annual Meeting of the
American College of Nurse-Midwives. When asked about midwives and birth centers in the emerging arena of
managed care, the presenter responded that midwives were well-positioned for managed care but that we would
have to show how we were different than other providers for more of the same would not do. That bothered me
for I thought that we had been doing just that. In fact, it had seemed that it was our very uniqueness that had always
caused us problems with the established status quo. Eventually, I realized that we had been simply showing how
we were as good as but not how we were different.
As good as could be seen as more of the same. This study is a remarkable effort at the how midwifery is
different from obstetrics. It is a beginning of much needed work and should be given research priority by the
profession. Thank you Holly Kennedy for this model study, which will serve us well during the new millennium.
Kitty Ernst, CNM, MPH, FACNM
Mary Breckinridge Chair of Midwifery,
Frontier School of Midwifery & Family Nursing
Director, National Association of
Childbearing Centers Consulting Group

Journal of Midwifery & Womens Health Vol. 45, No. 1, January/February 2000 19