Karen Trister Grace has spent her career as a midwife and a midwifery educator aside from, appropriately, a nine-month period as a labor and delivery nurse. Educating herself and others has given her perspective. The nursing gig gave her real-world confirmation of why her work as a builder of midwives is so important.
Grace, working toward her PhD at the Johns Hopkins School of Nursing, is co-author of Prenatal and Postnatal Care: A Woman-Centered Approach, now in its second edition. (She wrote the book with Robin G. Jordan and Cindy L. Farley, certified nurse-midwives and midwifery educators at Georgetown University. Grace is originally from Washington, DC.)
To make a point, she shares a story from her nights as a labor and delivery nurse: A woman had been induced all night long with little progress toward a birth. In the morning, to hasten the process, her physician manually broke her water. “What are you doing?” the woman asked him, to which he replied, “Just let me drive the bus, OK?”
No, says Grace, who believes the more nurturing, partnership-based relationship between a woman and a midwife can mean less litigation on those occasions when birth complications do arise. Whereas physicians might tell a woman to blindly trust them, she says, “then something goes wrong and you’re furious.”
Grace explains that midwives have been around for eons but were pushed aside by the rise of (male) physicians and modern medicine. From a historical perspective, that has often presented as sexism and a “top-down, patriarchal approach” to care. She insists that women simply want—and deserve—to be party to the discussions and the decisions regarding their care during pregnancy and beyond. “Most women really want midwifery care … they just don’t know that’s what it’s called.”
She adds that physicians and midwives can and do work in harmony. But only when the pregnant woman drives the bus. She is quick to correct the notion of the midwife as hippie purveyor of “granola and kumbaya” and a “magical birth experience.”
There is no magic—just wisdom, experience, mutual understanding, common sense, and common courtesy.
“It’s simply about a philosophy of care,” Grace says, which can amount to: “non-intervention when intervention is not needed.”
Here, from Karen Trister Grace, are things nurses need to know about a woman-centered approach to prenatal and postnatal care:
- Traditional obstetric medical care emphasizes the needs of the provider rather than the woman’s needs during pregnancy. Woman-centered care describes a philosophy that is based on the needs and preferences of the woman, emphasizing informed choice, continuity of care, active participation, best care practices, provider responsiveness, and accessibility.
- Central tenets of woman-centered care:
- Women have the right to informed choice in the options available to them during pregnancy, labor, birth, and the postnatal period, including the place of birth, who provides care, and where care is provided.
- Women have the moral and legal right to decisions regarding their bodily integrity.
- Women have the right to care that supports their optimal health and that of their baby.
- Women have the right to respect for and inclusion of their cultural beliefs and practices into their care.
- As midwives and women’s health providers, we support physiologic labor and birth. But this support does not begin with the first contraction or water breaking; it begins with the first prenatal appointment and continues into the postpartum period.
- The importance of language—we refer to women as women, not patients or clients, and sometimes not even mothers, acknowledging the fact that not all women who are pregnant are or consider themselves to be mothers, and becoming a mother does not mean losing one’s identity as a woman.
- An example of a woman-centered approach is the way providers view “common discomforts of pregnancy.” We acknowledge that they may not feel common or minor to the woman experiencing them and may be very distressing. Providers often refer to them as “complaints” or document “patient complains of…,” which implies whining and could be referred to more respectfully as “patient reports symptoms of …” We emphasize the importance of changing how these symptoms are viewed and communicated, which benefits women and allows them to feel more comfortable sharing their symptoms.
- Black women have worse health outcomes than white women regardless of education level and financial situation. Chronic stress related to racism, discrimination, and microaggression affects the course of pregnancy and maternal and neonatal outcomes. Providers must examine explicit and implicit bias they bring to the prenatal encounter, as well as structural discrimination in their health systems.
- We recognize the structural roots of the current system of care for childbearing women are heavily influenced by white, male, and medical cultures. Health disparities and health inequity are some of the greatest public challenges we face in the United States, and women’s health providers have a responsibility to be educated on the causes and to work for change.
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