FEATURES

The Theoretical Basis for Nurse-Midwifery Practice in the

United States: A Critical Analysis of Three Theories
Leslie Cragin, CNM, PhD

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
The development of specific midwifery theories as a basis of
knowledge building for the profession is an important and
relatively new strategy for midwifery in the United States.
Although midwifery care has been demonstrated to be safe,
cost-effective, and satisfying to women, other questions about
the processes of midwifery practice remain. A fuller descrip-
tion of the process of midwifery care requires a framework for
investigation that is anchored in the defining characteristics
and hallmarks of midwifery practice.
Theory is important for clinicians, as well as educators
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
United States, the theories of nurse-midwifery and mid-
wifery practice have been initiated by nurse-midwives
Ela-Joy Lehrman, Joyce Thompson and colleagues, and
Holly Kennedy.13 This article critically examines these
theoretical models for midwifery practice. The terms mid-
wives or midwifery refer to the general category of the
profession of midwifery, regardless of certification, educa-
tional preparation, or legal status. Nurse-midwifery refers
to the profession of those who have received education in
both the professions of nursing and midwifery and who
have been identified as nurse-midwives in the literature
reviewed.
Address correspondence to Leslie Cragin, CNM, PhD, University of Califor-
nia, San Francisco, San Francisco General Hospital, 1001 Potrero Ave., Rm
6D-29, San Francisco, CA 94110. E-mail: craginl@obgyn.ucsf.edu
This work was supported by a National Research Service Award from the
National Institute of Nursing Research/National Institutes of Health (F31
NR07496-01A1) and by a Student Research Award from the Graduate
Division at UCSF.
METHODS
A synopsis of the theories is presented following the
structure suggested by Chinn and Kramer,4 including the
purpose, concepts, definitions, relationships, structure, and
assumptions. Each theory is evaluated by using the criteria
proposed by Duffey and Muhlenkamp: 1) Does the theory
generate testable hypotheses? 2) Does it have the potential
to guide practice? 3) Is the subject of the theory relatively
broad? 4) Are specific assumptions identified? 5) Are the
propositions and the relationships among them explicitly
stated? And 6) Is the theory parsimonious?5
BACKGROUND
Theories of Midwifery Practice
Several strategies exist for the development of theory.6 The
work begins by analyzing and defining the important
constructs and concepts. A construct is a term with a higher
level of abstraction than a concept. Statements are then
developed that demonstrate the relationships between the
constructs or concepts. This results in a set of concepts,
definitions and propositions that projects a systematic
view . . . by designating specific interrelationships among
concepts for the purposes of describing, explaining, pre-
dicting and or controlling phenomena.4 As theories are
constructed, authors refine them by explicitly delineating
the assumptions (knowledge, beliefs, values) that hold the
different aspects of the theory together.6
Theories may be categorized in several ways. Grand
theories are those that are quite broad in scope, may use
more abstract concepts, and are difficult to test. Middle-
range theories, such as the midwifery theories proposed
here, have practice as their general focus, are more limited

Journal of Midwifery & Womens Health www.jmwh.org 381

2004 by the American College of Nurse-Midwives 1526-9523/04/$30.00 doi:10.1016/j.jmwh.2004.04.016
Issued by Elsevier Inc.
 Table 1. Constructs and Concepts of Three Models of Midwifery Practice

Lehrman1 Thompson and Colleagues2 Kennedy3

Constructs
Previous health outcomes The nurse-midwifery care Therapeutics
Practice settings Process Caring
Components of nurse-midwifery care Profession of midwifery
Social support
Psycho-social-physiological adaptation
Transitive health outcomes
Secondary Constructs
Prenatal outcomes Competence Qualities and traits Processes Outcomes
Birth settings Compassion
Intrapartum components of midwifery care Covenant fidelity (not
Intrapartum social support developed as part of the
Adaptation to labor and birth model but included in
Intrapartum outcomes the conclusion)
Concepts
Personable environment Safety Belief in normal, Normal processes, Optimal health, Respect
Labor support Satisfaction Commitment to Vigilance, Respects and empowerment,
Positive presence Respect for human dignity health and family- uniqueness of Enhancing the
Transcendence and self-determination centered care, family, Creates a profession of
Birth satisfaction Respect for cultural and Persistence, setting reflecting the midwifery
Enhanced self-concept ethnic diversity Compassion, womans needs,
Family centeredness Exceptional clinical Updates knowledge,
Health promotion skills, Knowledge of Reviews practice,
self-limits Personal/professional
balance

in scope, and are easier to test. A prescriptive theory
predicts the outcome of an intervention.6
Three middle-range theories have been proposed as
midwifery theories in the United States, all within the past
20 years.13 They propose and explain concepts that de-
scribe the domain of midwifery practice (e.g., normalcy of
birth). The constructs and concepts of the three theories are
compared in Table 1. The discipline of midwifery exhibits
many of the characteristics of the beginning stage of theory
development: uncertainty about discipline phenomena, dis-
crete and independent theories, a search for conceptual
coherence, and the predominance of the goal to develop a
single practice paradigm.6
Paradigm of Midwifery Practice
Paradigms were originally defined by Kuhn as those aspects
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
theory are a source of continuing debate among those who
study the science of building knowledge (epistemology).6
In general, paradigms reference the full spectrum of beliefs
and knowledge within a discipline, whereas theories usu-
Leslie Cragin, CNM, PhD, is an Assistant Clinical Professor in the Depart-
ment of Obstetrician/Gynecologist and Reproductive Science at UCSF. She is
the Director of Administration and Practice of the Nurse-Midwives of San
Francisco where she is beginning to develop clinical research projects.
ally propose to describe a narrower focus within a disci-
pline. Paradigms can be seen as precise, whereas what is
represented in practice is more accurately messy and not
able to be isolated from numerous contextual issues. After
conducting a critical analysis of literature, including that of
the theories discussed in this article, three defining charac-
teristics of a midwifery paradigm were proposed by Cra-
gin7: 1) acknowledging connections between the mind and
body and the person to the persons life and world; 2)
taking on the perspective of the woman to investigate the
meaning and experience of the womans symptoms or
conditions, such that a plan of care is developed by midwife
and patient together; and 3) protecting and nurturing what
is normal in processes related to womens health, imply-
ing a judicious use of technology and intervention. Each of
these characteristics is described within the midwifery
theories, beginning with the work of Wiedenbach.
ERNESTINE WIEDENBACH
Theory development for midwifery has roots in the work of
a nurse-midwife, Ernestine Wiedenbach.6,8 Wiedenbach, a
theoretical foremother, is the nurse-midwife and nursing
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
that to assist patients in meeting their needs, nurses must
first identify a need for help in the patient, and validate
this perception of a need for help before initiating any

382 Volume 49, No. 5, September/October 2004

 Table 2. Assumptions of Lehrmans Nurse-Midwfery Practice Model

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

nursing actions. Wiedenbach, in collaboration with philos- Relationships

ophers Dickoff and James, was instrumental in legitimizing
practice-based theory development for nursing during their
work together at Yale.9 In 1961, the American College of
Nurse-Midwives (ACNM) adopted and developed an ex-
panded version of Wiedenbachs personal philosophy of
nursing as the official ACNM philosophy.10,11 Wieden-
bachs seminal work has informed all three midwifery
theories discussed in this article. Each theorist has included
the tenets central to the philosophy of the ACNM in the
development of her own theoretical concepts.
ELA-JOY LEHRMAN
The first theoretical model to be proposed was the nurse-
midwifery practice model developed and tested by Lehr-
man from 1981 to 1988.1 Lehrmans intention was to
develop a descriptive middle-range theory specific to nurse-
midwifery practice. The theory is complex, containing
primary constructs, secondary constructs, and concepts
delineated in Table 1.
Purpose
The overall purpose of Lehrmans theory is broad and aims
to explain how midwives in the United States provide care.
She noted that while nurse-midwives were conducting
research and building a body of knowledge for nurse-
midwifery practice, few researchers used any theoretical
framework to structure their inquiry, and no theoretical
models specifically related to nurse-midwifery were iden-
tified. Five assumptions underlying the model were identi-
fied and are described in Table 2.
Concepts and Definitions
The six primary constructs that depict midwifery practice were
drawn from the philosophy of the ACNM,11 a literature
review, and conversations with nurse-midwives in clinical
practice. Lehrman also provided definitions for selected
broader concepts (e.g., health and nurse-midwifery practice).
Lehrman proposed a causal model to represent the
cause and effect variables and the direction of their
relationships. The model illustrates that health status a
woman achieves while receiving nurse-midwifery care
(transitive outcomes) is influenced by five other con-
structs: previous health outcomes, practice settings, com-
ponents of nurse-midwifery care, social support, and
psychosocial-physiological adaptation as illustrated in
Figure 1.
The intrapartum care level was used to test the model,
because Lehrman felt intrapartum care was the most distinc-
tive area of nurse-midwifery practice.1 The original theoret-
ical model was not supported by research, and a revised
model, based on the statistically significant relationships
among the variables, was the final model presented.
Structure
A strength of Lehrmans model is the clarity of goals that
guide the purpose and structure of the model. The goals
addressed the intention that the model be applicable across
research, education, and practice. The structure of her
theory provides a clear form for understanding the interre-
lationships between the constructs and the levels of nurse-
midwifery care. The model was proposed to work across
five levels of nurse-midwifery practice: interconceptional,
prenatal care, intrapartum care, postpartum care, and neo-
natal care. In addition to the developmental research done
by Lehrman, one small descriptive study by Morten and
colleagues12 validated Lehrmans theory for postpartum
care. This study identified three new processes (therapeutic
relationships, lateral relationships, and empowerment) of
nurse-midwifery care in addition to the eight identified by
Lehrman. On the basis of the results of their inquiry, the
researchers proposed that there may be a positive relation-
ship between the attitude of the midwife and healthy
outcomes, similar to Lehrmans1 identification of the rela-
tionship between positive presence and the outcomes of

Journal of Midwifery & Womens Health www.jmwh.org 383

Figure 1. Relationships between constructs (concepts) in Lehrmans Nurse Midwifery Practice Model. Modified for simplicity of presentation to display relationships
between selected components of the model. Adapted from Lehrman.1

satisfaction and increased self-esteem at level three, intra-
partum care.
Analysis
The development of this model represents a high standard
of building theoretical knowledge for the discipline of
midwifery. The processes used by Lehrman to ensure the
credibility of the theory was thorough, beginning with
inductively derived constructs and their definitions and
moving through development of instruments with appropri-
ate reliability and validity testing. The theory meets the
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
potential to guide practice; the theory broadly considered
the full scope of nurse-midwifery practice; five specific
assumptions were discussed; the propositions and their
relationships were explicitly stated; and the theory had only
six primary constructs.
Lehrmans work emphasized the importance of women
as the focus of the theory, a decision based directly on
ACNM philosophy. In Lehrmans view, the moving force
of the theory is the recipient of care, usually the woman, but
including the neonate when appropriate. This emphasis is
similar to that of Wiedenbach. Lehrman carefully defined
each of the primary constructs to be potentially inclusive of
psychosocial, environmental, and other contextual factors
when they are operationalized for research. The work of
Morten and colleagues,12 who found that the eight original
components could be applied to the postpartum level of
care, extended the usefulness of Lehrmans theory.
JOYCE THOMPSON AND COLLEAGUES
Purpose
The purpose of the work in theory development by Thomp-
son, Oakley, Burke, Jay, and Conklin2 was to delineate the
major concepts in the overall process of nurse-midwifery

Table 3. Evaluative Criteria for Theory Development

Criteria* Lehrman1 Thompson et al.2 Kennedy3

Does the theory
a) generate testable hypotheses? Yes Yes Yes
b) hold potential to guide practice? Yes Yes Yes
c) address a relatively broad subject? Yes Yes Yes
d) identify specific assumptions Yes Implied Yes
e) explicitly state propositions and relationships? Yes Partial Yes
f) have parsimony? Yes Limited Limited
*From Duffey and Muhlenkamp.5

384 Volume 49, No. 5, September/October 2004

care to develop a middle-range theory of nurse-midwifery
care. Their theory was developed to propose an explanation
for the differences nurse-midwives make when caring for a
woman and her health. The group reviewed the ACNM
Philosophy and Standards of Practice and identified the six
essential concepts of nurse-midwifery practice listed in
Table 1. These are proposed as having a positive relation-
ship with the optimal health and well-being of the woman.
Twenty-four components of the process of nurse-midwifery
care were identified, along with 136 empirically determined
behavioral indicators of those components, identified by
using a content analysis of six prenatal care visits.
Assumptions, while not explicitly identified, could be
derived from the theory. The most important of these is,
. . . the actual health status of any individual is more a
result of his or her environment, socioeconomic means and
personal health habits than of any specific health teaching
or professional intervention.2
Concepts and Definitions
A panel comprised of the theorists and expert nurse-
midwives, a nursing faculty member, and a non-nurse
researcher developed the definitions and behavioral indica-
tors for each component of the six concepts. The results of
the work of the theorists and panel (concepts, definitions,
components, and empirical indicators) were submitted to a
group of 18 nurse-midwifery educators for validation.
Relationships
Describing the foundation for their approach to this work,
the theorists quoted Fawcett: Theories are made up of one
or more concepts, the definitions of those concepts and the
propositions that state something about the concepts.13
However, Thompson and colleagues did not include ex-
plicit propositions about the concepts in their theory.
Structure
Thompson and colleagues acknowledged that the structure
for their theory was difficult to develop relative to the real
world of very complex interactions.2 Nevertheless, they
referred to a wholistic structure in which all the components
are necessary contributors to the process of nurse-mid-
wifery care as defined in the theory. They stated, The
success of nurse-midwifery care requires full integration of
all aspects of this theory in varying proportions dependent
on the needs of the woman seeking this type of health care.
Chinn and Kramer4 state that the structure for a theory
emerges from the relationships within the theory. In this
case, as the relationships of the concepts to one another are
not delineated, the structure of the model is not clear.
Levi14 used the work of Thompson and colleagues as the
theoretical basis for construction of a uniform antepartal
data set to be used by the profession for data collection and
research. The results mainly confirmed the findings of
Journal of Midwifery & Womens Health www.jmwh.org
Thompson and colleagues.2 Levi first analyzed Thompson
and colleagues original videotapes of the six prenatal visits
and identified five additional behaviors not included in the
original components of care. She then collected and ana-
lyzed data at three prenatal care sites (home, birth center,
and hospital). Her content analysis of her own study data
confirmed one of the five (use of touch) identified in the
reanalysis of Thompsons work and identified one other
(use of self as role model, source of information, and source
of emotional support).
Analysis
A major strength of Thompson and colleagues broad
theory is the explicit link between concepts and behavioral
indicators of midwifery care (not shown here; the interested
reader is referred to J Nurse Midwifery 1989;3:120 30.).
The articulation of explicit components or behaviors for
each concept enables researchers to propose specific con-
nections between care and outcomes of care. These item-
ized behaviors become indicators that can serve as guides in
clinical practice and midwifery education.
Thompson and colleagues2 concluded that their pro-
cesses ensured that the concepts identified had content
validity and were comprehensive. They acknowledged the
limitations in the ability of their theory to be tested in
research secondary to two weaknesses: distinctness and
internal homogeneity. In addition, they did not identify a
particular method of concept development or analysis. The
process used for concept development is a critical element
for any theory, especially one that proposes to explain the
overall practice of a profession by using a minimum
number of core concepts. It is helpful to future researchers
and theorists to identify the method used when building a
theory.
The authors were less satisfied with whether they had
established distinctness and internal homogeneity of the
concepts. Although concepts were defined, the components
and behavioral indicators were not, resulting in redundancy
and imprecision14 between some components and behav-
ioral indicators. For example the components, Reduces
Power Differentials and Accepts Person as She Is under
Concept #3, Respecting Human Dignity and Self-Determi-
nation, have many shared behavioral aspects with one
another.14 Levi suggests that the source of this lack of
clarity is rooted in the authors identification of behavioral
components of care that described the activities of care
without fully perceiving and defining the CNMs specific
input (i.e., affective contribution) into the activity.14
Limitations that extend the self-critique of Thompson
and colleagues are 1) the major concepts were formed by
using only an inductive platform based on the ACNM
Philosophy of Care and Standards of Practice; 2) the
concepts, components, and behavioral indicators had lim-
ited validation; 3) there was no formal concept analysis;
385
and 4) there were no formal propositional statements
between the model and outcomes of care.
Other strengths and limitations emerge when the work is
evaluated by using the standards proposed by Duffey and
Muhlenkamp5 as seen in Table 3. The list of empirical
indicators for each of the major components of the concepts
gives this theory a clear potential to guide practice. Hy-
potheses can be developed to explore the relationships
between components and concepts, and between concepts
and implicit outcomes.2 Like Lehrmans theory,1 it aims to
describe the breadth of practice and processes of nurse-
midwifery. The 24 components and 132 behavioral indica-
tors of those components are too numerous for the theory to
be considered parsimonious.
A limitation of this work rests on the lack of a rationale
for using a limited data set (six antepartal visits) to identify
and derive the components and behavioral indicators for the
full scope of midwifery care. Although qualitative research
does not rely on the type of power analysis that drives
sample sizes for quantitative research, criteria for selecting
the type of data and the amount of data to be collected flow
from the chosen methodology.15 In this case, no specific
methodology underlying the inquiry and analysis of this
project was cited. Levis14 theory testing research ad-
dressed this problem with a clear description of the method
(content analysis) and the criteria for sampling. However,
Levis continued use of antenatal care sites for investigation
contributed to the narrow scope of the full range of
midwifery practice on which the theory was developed.
The work of Thompson and colleagues2 is an important
step in the development of theory for midwifery. Further
development would improve the utility of their theory.
They2 suggested that a middle-range theory of nurse-
midwifery should be broad in scope, applying to the full
scope of nurse-midwifery practice rather than solely to the
perinatal scope of practice. Therefore, future theoretical
work should include examination of the entire scope of
practice, not simply that of antenatal care. The answers
obtained from investigation of how Thompson and col-
leagues behavior indicators in this theory would be ex-
tremely useful in linking the midwifery model with out-
comes of care.
HOLLY KENNEDY
Kennedys3,16 theory describes exemplary midwifery prac-
tice and the relationship of exemplary practice to outcomes
of midwifery care. The framework for development of the
theory was Kims17 typology of nursing, specifically the
practice domain, with the process of theory development
informed by critical and feminist theories. The concept of
exemplary practice was derived from the work of Benner
et al.18
Like Lehrman1 and Thompson et al.,2 Kennedy acknowl-
edged that outcomes of midwifery care have been demon-
strated to be excellent, but little is known about how
386
specific aspects of the processes of care are linked to
outcomes. She conducted research using the Delphi
method3,16 to identify 1) the essential characteristics of the
exemplary midwife, 2) the specific outcomes resulting from
care by an exemplary midwife, 3) the process of care used
by an exemplary midwife, and 4) the qualities and traits of
the process of care that are related to specific outcomes. A
full listing of each concept or dimension and the underlying
outcome, process, and quality or trait descriptors can be
found in Table 1 of the article by Ulrich in this issue. The
sample chosen included both midwives identified by their
peers as excellent practitioners and women who had been
cared for by those midwives.
Assumptions
Kennedy16 states two assumptions underlying her model.
They are, A midwife who is exemplary bases her/his
practice on the philosophy and standards for the profession
of midwifery and Exemplary midwifery practice is linked
positively with outcomes for the woman and/or infant.16
The emphasis given to the views of women in creating
the model support the assumption that women are active
participants in structuring their own care. She used a
quotation in her conclusion illustrating this emphasis. The
quotation is used as a reminder that the exemplary midwife
supports the woman in a manner that preserves the wom-
ans personal power and dignity.
Concepts
The major concepts, therapeutics, care, and the profession
seen in Table 1 of the model are referred to as dimensions
of midwifery practice, with outcomes, processes, and
qualities, and traits described for each dimension.
Definitions
The specific outcomes and processes are not completely
defined, but the meanings for most can be derived from the
discussion. For example, in discussing the process of
vigilance, the phrases included attending to the many
details of practice . . . to be sure care was not only safe but
to enhance health . . . following up to be sure the correct
actions or results were obtained.16
Relationships
The general relationships proposed are shown with arrows
in the abstract model Kennedy published.16 The illustration
shows that the qualities of exemplary midwives have a
positive relationship with the processes of care used and
that the processes of care have a positive relationship to the
outcomes of each dimension. Although qualities and traits,
processes, and outcomes are identified for each dimension,
Kennedy16 states that the processes are multidimensional
and do not unilaterally support any specific outcome.
Volume 49, No. 5, September/October 2004
Structure
The ideas of this model are organized in an integrated
manner. That is, they integrate the views of both exemplary
midwives and the recipients of their care to describe the
dimensions, outcomes, processes, and quality or traits of
exemplary midwifery practice. The midwife (dimensions
and process) and the woman she cared for (outcomes) are
represented in the model. In addition, the qualities and traits
of exemplary practice are integrated into the model. Like
Thompsons2 model, this is a holistic model of care.
Kennedy used the word dynamic to describe her model,
acknowledging the constant interaction and shifting empha-
sis in the relationships among various components in the
model.
Analysis
Kennedy16 has proposed the model be tested to determine
1) whether the model represents the way midwifery is
actually practiced, 2) whether the model differentiates
exemplary practice from less than exemplary practice, and
3) whether the model can be linked to the outcomes
identified. The theory meets the first evaluation criteria
listed in Table 3, because each of these could be a testable
hypothesis or lead to more discrete testable hypotheses. For
example, using fieldwork techniques and content analysis,
one could examine the hypothesis that exemplary midwives
in practice support the process normalcy of birth.
However, the dynamic structure, coupled with narrative
descriptions of the outcomes and processes, require that
careful work be done to operationalize these concepts. If
subsequent work links the operationally defined processes
to the stated outcomes, this model would provide excellent
guidance for practicing midwives and educators of mid-
wives alike.
Kennedys theory was broadly developed by using a
consensual process with direct input from midwives
identified by their colleagues as practicing in an exem-
plary manner across all areas of midwifery care. This
breadth was narrowed from all midwifery practice or the
nurse-midwifery process of care to that of exemplary
midwifery care. The scope is somewhat expanded by
intentionally including midwives without regard to their
route of entry into midwifery. This is the only one the three
theories to do so and is a strength of the work.
As previously noted, specific assumptions are identified.
Other assumptions can be derived from the model. The
figure of the abstract model published illustrates generally
the propositions and relationships. Future work should
include the development of operational definitions for the
outcomes and processes of care, and the development of
explicit propositions among the processes of care and their
outcomes.
Use of a descriptive approach to explicate concepts
compared with succinct definitions limits parsimony in the
theory. On the other hand, coming to premature closure
Journal of Midwifery & Womens Health www.jmwh.org
regarding definitions could impair the long-term usefulness
of the theory. Kennedys work, like the work of Bennner et
al.,18 has resonated deeply with clinicians and educators,
and she has continued to develop her theory. Of the three
theories, this is a model of care with the inclusion of
qualities and traits that support the processes identified,
integrates both the heart and hands19 believed by many to
be the best expression of midwifery practice.
DISCUSSION
Nursing and midwifery have been constrained, both pro-
fessionally and in terms of developing an authentic episte-
mology, by an androcentric scientific community (i.e.,
medicine). Although a feminist method was not explicitly
applied in the above analysis, the importance of a continu-
ing analysis of the profession of midwifery from a feminist
perspective is worth noting20 as nurses and midwives
endeavor to develop relevant theoretical knowledge within
male-dominated science and academia.
Feminist frameworks for analysis are especially useful as
they include the perspectives of female experience and
power.21 The feminist perspective for this analysis was
informed by the work of Doering21 and Hagell,22 who have
applied the work of feminist theorists to nursing. They
argue that science, theories of science, and knowledge
development are gender-biased constructs. Despite claims
to the contrary, these are neither value-free nor context-
free.22,23 The empiricists aim to predict and control, to
separate the knower and the thing to be known, has
limited the scope of development of knowledge in domains
where other ways of knowing are acknowledged. Mid-
wifery is such a domain.
Given the relatively youthful stage of theory building
for midwifery, these three theoreticians13,16 have made
major contributions to theoretical knowledge for the disci-
pline. Each has benefited from her scholarly association
with nursing, the theoretical mentor for midwifery, and
each has included key elements of feminist values in her
theory.
The three theories propose models describing midwifery
practice to explain why and how nurse-midwifery care is
associated with positive outcomes of care. The research
methods chosen for development of the theories range from
formally constructed quantitative1 and qualitative13,16 in-
quiries through informal qualitative inquiry.2 The models
are variously accessible for the purposes of further research
and for the ability to guide practice. One question not
addressed by the evaluation criteria is: Do these three
theoretical models fit the defining characteristics of the
midwifery paradigm as proposed by Cragin?7
First, although these are models of the practice of
midwifery, the focus of that practice is women in their
context or as Kennedy24 says, in the fabric of their lives.
Lehrman1 says the moving force through the model was
the recipient of care . . . in most instances a woman . . .
387
however in some instances it could be the fetus, newborn or
the woman and her entire family . . . capable of interaction
within and with her environment. Thompson and her
colleagues acknowledge and implicitly value that providers
are less responsible for the outcomes (health status) of care
than the woman and her environment.
Furthermore, the theories do support the view of women
as interdependent; containing mind, body, and spirit; influ-
encing and influenced by their internal and external envi-
ronments. For example, the models clearly encompass a
broader range of outcomes than physically or biologically
based processes. In fact, each model devotes a relatively
small amount of attention clearly defining those biomedical
outcomes or the therapeutic processes that contribute to
them. Lehrman1 acknowledges past health status outcomes
as contributing to transitive outcomes, but health is defined
as the extent to which dynamic equilibrium of the body-
mind-feelings-environment . . . is maintained.
Although both the processes and components of care are
in the models, each model acknowledges that these are not
wholly sufficient in explaining the outcomes of care. All
models speak of practice as supporting, encouraging, or
empowering the qualities inherent in each recipient, her
circle of support, and her environment. In this way, the
connections among these are validated and incorporated
into care.
Second, the models contain clear evidence that the
womans perspective is a critical element in the compo-
nents and processes of care. In this way, each embraces a
feminist perspective. Kennedys model identified traits that
allow the midwife to take on the perspective of the patient:
tolerance, compassion, interest in others. Lehrman1 defines
positive presence as encompass[ing] the high touch qual-
ities of nurturance, intuitive awareness, sensitivity, personal
attention, knowledge, professional expertise, and presumed
validity of the individual womans subjective experience,
acknowledging the importance of the midwifes incorpora-
tion of the womans subjective experience in framing her
caring practice. Thompson includes indicators, such as
reducing power differential, which implicitly acknowledge
the importance of creating an environment in which a
woman is comfortable to share her perspective with the
midwife.
Third, belief in and support of normalcy is explicitly
identified by Kennedy as a primary process and trait of the
therapeutic dimension. Thompson and colleagues2 defini-
tion of health promotion includes promotion of the natural-
ness of pregnancy and birth. Lehrman1 states her assump-
tion that childbirth is a natural healthy event in a womans
life that could be facilitated by nurse-midwifery care. In an
earlier study, Lehrman1 had identified non-interventionist
care as an aspect of midwifery care, defined as the ability
of the health care provider to focus on the maintenance of
health and the physiologic normalcy of childbirth and the
promotion of increased levels of health by use of natural
388
techniques,12 which captures the essence of the third
characteristic of the midwifery paradigm.
CONCLUSION
It is apparent that development of theoretical knowledge in
midwifery is driven by the practice, from the root work of
Ernestine Wiedenbach.6,8 The theorists have remarkable
consistency in the identification of concepts important to
the discipline, which are much broader in perspective than
concepts derived from a medically based philosophy of
caring for women. The work of the scholars reviewed here
confirms three essential characteristics of the midwifery
paradigm of care: 1) acknowledgment of connections be-
tween the mind and body and the person to the persons life
and world; 2) taking on the perspective of the woman to
investigate meaning and her experience of symptoms or
conditions, such that a plan of care is developed by midwife
and patient together; and 3) protection and nurturance of the
normal in processes related to womens health, implying
a judicious use of technology and intervention.
All the models affirm the principles of a feminist ap-
proach to knowledge development. Meleis states: . . . a fem-
inist approach is one that values the experiences of the
developer, values her intuitions and analyses, values the
clients world and values the clients socio cultural and
political perceptions . . . a theory from a feminist perspective
uses language that is empowering and gender sensitive. . . .
Each of the theories critically reviewed presents a subtly
different representation of midwifery practice. Each makes
a unique contribution to the process of understanding what
is unique to midwifery compared with other caring and
clinical professions. As these theories are tested and used to
guide research, education, and practice, they will be refined.
The process of refinement will enable midwives to continue
developing theoretical knowledge specific to midwifery.
This may, in turn, lead to the development of situation-
specific theories and to finding the answers to important
questions about midwifery practice and the health of
women in our care.
The author gratefully acknowledges the members of her dissertation
committee: Dr. Afaf Meleis, Chair, Dr Suzanne Dibble, and Dr. Leah Albers.
Their guidance was invaluable during the course of study. Special thanks to
Dr. Meleis who inspired a passionate interest in understanding, creating, and
communicating theoretical knowledge about midwifery practice and womens
health.
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