The midwife in Taiwan: an alternative model for maternity care

While more than 99% of all American babies are delivered by obstetricians, the majority of Taiwanese babies are delivered by midwives. The history of traditional and professional midwives in Taiwan is reviewed. Taiwanese midwives operate their businesses according to the principles of client-centered health service. They also serve many social and religious, as well as health, needs of their clients. This system contrasts with that in operation in the U.S. where pregnant women utilize physician-centered, not client-centered, maternity care. The role of the Taiwanese midwife in the management of childbirth is described. Postpartum care provided by the midwife includes nutrition information and initial care of the infant once the mother returns home. The role of the midwife in relation to abortion, adoption and other obstetric and gynecologic services is explained. The American system of childbirth might be made more flexible and acceptable if the client-centered features of the Taiwanese system could be incorporated into the modern American health care system.     

Continuity of Midwifery Care in England: A New Professional Project?

Over the last decade, an increasing amount of research has examined the relationship between gender and professionalization using female professional projects to illustrate how the generic notion of a profession has been a gendered one. This paper develops Witz's (1990) theory of professional strategies in female-dominated occupations particularly regarding midwives in Britain in the twentieth century and suggests that an important dimension that also needs to be critically examined in midwifery history is the interaction of gender and social class within midwifery. Furthermore it documents the traditional emphasis in midwifery on the single woman's career path. This historical analysis has resonance today as midwifery in Britain is undergoing a renaissance. The role of the midwife and the current organization of the maternity services are being reviewed with the intention of providing increased choice and control over the reproductive process for women and increased continuity of care with a midwife. These changes are viewed as midwives' new professional project and the implications for midwives and women discussed. The aim of this paper is to explore the explanatory power of these approaches to current developments in maternity care and by drawing historical parallels, consider the impact that this professionalizing strategy may have for those who are excluded from this process of ‘dual closure’. Furthermore, this paper asks whether this new way of working empowers midwives, women, both or neither?     

Providing mental health care to veterans in rural areas: using telehealth in mobile clinics

The purpose of this article is to provide information to improve the quality of care of veterans living in geographically isolated areas who require treatment for mental health issues. Because interactive care solutions are currently hot topics in the health care community, they should be viewed as possible strategies to meet the needs of this specialty group of veterans. An intervention using a mobile clinic and clinical video telehealth reduces distance barriers by making it possible for mental health specialists to come to rural veterans instead of the veteran attempting to find a way to get to the practitioner, who may be located in a clinic or hospital many miles away. This article focuses on an alternate strategy-telehealth in mobile clinics-as a possible solution to the mental health crisis of veterans in rural areas.     

Toward an assessment of the social role of rural midwives and its implication for the family planning program: an Iranian case study

An axiom of family planning programming is the importance of culturally-appropriate communicators and motivators. Traditional midwives seem ideal for this task but few studies have been done to verify this assumption by analyzing the midwife's social role as perceived by the community. 325 married women and 81 unmarried girls from a "model village" near Shiraz were interviewed by female undergraduates. 82.5% of the women are of childbearing age; 66% married before 14 years; 33% use contraception, mostly the pill, but most want large families because they expect high child mortality rates. Most of the older women are able to assist in childbirth but none, except the village's one recognized midwife, who is considered to have divine backing, will do so except in an emergency. The midwife's activities cause her to be held in low esteem by the community because 1) she has contact with a woman's sexual parts and this fact is public; 2) she has contact with vaginal excretia which are, in Islam, polluting; and 3) she is paid for her services, which labels her as a woman "without shame". The midwife is, however, widely used since women and their husbands fear the trip to the hospital and treatment by a male doctor much more than a midwife-supervised birth. The midwife in the study village had been there only 2 years and feels that she is not fully trusted. She is not consulted on birth control at all, because women expect the pill to be dispensed by doctors and consider other methods as a matter strictly between husband and wife. The midwife's role seems to complement that of the government health authorities rather than compete. The midwife's low status and circumscribed sphere of activity, the weak respect in which her advice is held and the pattern of having only 1 recognized midwife in a village at a time make the midwife a poor agent for family planning services. Her effectiveness as an agent of social change could be improved by training her in hygienic practices of childbirth and by redefining her role-relationship with the community. Studies should be done to identify the areas where traditional birth attendants are the best family planning communicators and those where that role is best left to others.     

Preference for same-race health care providers and perceptions of interpersonal discrimination in health care

This article examines black Americans' preference for black health care providers. Using data from a national survey, we assess how blacks 'perceptions of discrimination are related to preference for same-race health care providers. Overall, the belief that discrimination is frequent in different-race doctor-patient dyads is associated with greater preference for a same-race provider However; the belief that discrimination occurs regardless of a doctor's race reduces preference for a same-race provider Finally, general perceptions of discrimination are distinct from concerns about personally being treated unfairly, and low personal concern about unfair treatment reduces preference for a same-race provider among those who believe that interpersonal discrimination occurs frequently. These results suggest a complex picture of how perceptions of discrimination influence preferred race of health care provider among blacks in the United States.     

Healthcare Use in the Heartland: How Health Care Selection Varies Between Rural,Retirement‐Age Migrants and Long‐Term Residents

One increasingly important problem affecting rural health care selection is the tendency of older residents to bypass local health care providers. This research investigates how the effects of community characteristics and attachment on health care bypass behavior vary between rural retirement‐age migrants and retirement‐age long‐term residents. Non‐health‐related behaviors, such as purchasing goods and services outside one's community during a health care trip, that is, “outshopping,” could influence bypass if individuals combine trips for their medical care with other consumer needs. Basing our work on the outshopping theory, we argue that bypass behavior is one facet of consumer consumption patterns for both rural retirement‐age migrants and long‐term residents. In addition, dissatisfaction with local health care and services like shopping can “push” rural residents to bypass local health care and travel greater distances for primary health care. We further contend that strong community attachment has an opposite “pull” effect that can help to negate the push of outshopping and reduce the likelihood of bypass. Our results reveal retirement‐age migrants are significantly more likely to bypass local primary health care providers than retirement‐age long‐term residents. Furthermore, our analysis bridges the rural health care and retirement community development literature to suggest that outshopping theory can now be applied to rural primary health care bypass behavior.     

Community and individual acceptance: family planning services in the Sudan

The Sudan Community-Based Health Project, initiated by the University of Khartoum in cooperation with the Ministry of Health in 1980, sought to test the proposition that government-trained village midwives could provide maternal-child health and birth spacing services in addition to their ongoing obstetrical duties. The project area encompassed 92,000 people in 93 villages. The 120 midwives serving the project area received training in 4 interventions -- oral rehydration therapy, maternal and child nutrition, immunization, and birth spacing -- and introduced these services by means of 3 rounds of household visits over a 5-month period. Comparison of pre- and post-intervention survey data indicates that village midwives can indeed be used successfully to promote not only contraceptive use, but also health attitudes and practices that are positively associated with fertility regulation. Between the 2 surveys, the percentage of women who ever used contraception increased from 22% to 28%, while the percentage of current users rose from 10% to 13%. Parity was significantly related to current use; each child born multiplied the likelihood of contraceptive acceptance (by a factor of 0.76 in the post-intervention sample). Maternal education was the socioeconomic variable that most enhanced receptivity to contraceptive acceptance after the project's interventions. In terms of community-level variables, village location along the Nile and proximity to a paved road were significant correlates of contraceptive use. When variables related to the project itself were analyzed, women with vaccinated children were found to be twice as likely to contracept as those with nonvaccinated children and women who believed breast feeding should be continued during diarrhea episodes were 1.5 times more likely to use birth spacing than those who did not. Although midwives did not specifically emphasize contraceptive use, it appears women who were encouraged by midwives to take positive steps in the area of child health were also likely to become more innovative in terms of fertility regulation.     

Health,personal mobility and the use of health services in rural Norfolk

Trends towards the centralisation of both primary care and hospital services are increasing the distances that rural residents must travel to receive health care. Contradicting the widely held image of the healthiness of rural people, data from social surveys in Norfolk show that some of the remoter rural areas have populations with a relatively high need for health care. Furthermore, the groups with most need for health care (the old, the disabled, the poor, etc.) are also those with low levels of personal mobility, for whom travelling long distances to centralised health services is particularly difficult. After adjustments have been made for variations in need, it is shown that people in the remoter areas receive much less health care than comparable people in more accessible areas. However, branch surgeries do seem to make the general practitioner service more accessible, particularly to less mobile rural residents.     

Changing health culture in rural Appalachia: Implications for serving the elderly

This article explores the dual themes of place and time as influences on health care service delivery to the rural elderly, through a case study of rural Appalachia. Traditional patterns of indigenous health care practice and values are contrasted with more “professional” formal models of health care service delivery that have entered the region. The result has been a clash of health care cultures. The continuing validity of this perspective is appraised in relation to apparent generational differences between the old-old and the young-old in the degree to which contemporary health care practices and values are adopted. It is concluded that traditional and contemporary health care cultures can be reconciled through an expanded vision of health care service delivery premised on: understanding health care within a total community context; redefining the role of the health practitioner; improving education of both the rural elderly and service providers; and enhancing communication in the rural health care environment.     

Safe Motherhood in the Context of Nepal

ABSTRACT

Nepal ranks low on the Human Development Index and has a high maternal mortality rate. Various factors contribute to the high rate of maternal mortality and include a shortage of health care professionals, limited access to basic maternal health care, poverty, illiteracy, women's low social status, a poorly developed transportation system, a limited communication system, political conflict, and a diverse population. Interviews with pregnant women, observational data, and national statistics provide the basis for suggestions provided by the author. These include upgrading and opening new maternal care facilities, integrating midwives into local health services, providing education on women's health needs during pregnancy, and improving public awareness of the availability of maternal care services.     

The Association Between the New Rural Cooperative Medical System and Health Care Seeking Behavior Among Middle-Aged and Older Chinese

The new rural cooperative medical system (NCMS) is the primary form of social insurance in rural China. This study aims to explore how the NCMS influences the health care seeking behaviors of middle-aged and older Chinese, considering the family and community contexts. A series of multi-level (three-level) models using data from the first wave of the China Health and Retirement Longitudinal Study (CHARLS) are used. We find that the presence of NCMS coverage has a statistically significant association with seeking inpatient and outpatient care but not physical checkups among middle-aged and older rural Chinese: Rural residents insured by NCMS were more likely to seek inpatient and outpatient care than people who were not insured. Other factors at the individual level (such as self-perceived health and number of doctor-diagnosed chronic diseases), the family level (such as living arrangements and household expenditures), and the community level (such as the presence of township hospitals within the community) are also significant predictors of health care seeking behaviors.     

Intersecting Contexts: Understanding Rural Utah Veterans’ Experiences with Accessing VA Health Care

Since the passage of the Rural Veterans Care Act of 2006 research has focused on health care provider issues with less attention given to individual and contextual factors that contribute to the remaining service gap. Adopting the health care user's viewpoint, we focus on two questions: How do health care users perceive access to health care, and which contextual factors are relevant to explaining the failure of recent efforts to increase access by rural veterans? We collected detailed data through focus groups and individual interviews involving veterans and knowledgeable community members in four rural areas of Utah. Framing the analysis of interview data using the sociospatial approach reveals key dimensions of several contexts that affect rural veterans’ access to health care: the historical period of military service that influences attitudes toward use of Veterans Administration health care and access to specialists, regulations of regionally and locally organized insurance coverage that affects access to and coordination of health care, and local social aspects of rural communities that inform use of specific health care sources. These dimensions provide new insights into the conditions that contribute to variations in the vulnerability of rural Utah veterans.     

A Contradiction in the Health Care Delivery System: Problems of Access*

State-wide sample survey data regarding issues and problems frequently incurred in gaining access to health care delivery systems, as well as reports of illness, are utilized in an analysis covariance. The results indicate that the black population reports receiving more preventive health care services than the white population when controlling for all relevant independent variables. This surprising reversal of the most frequently found relationship between black and white populations, coupled with the reporting by the black population of experiencing more difficulty in gaining access to the system for needed help, presents evidence of a contradiction in the delivery of care.     

A Review of: “Dattilio,Frank M. (2010). Cognitive-Behavioral Therapy with Couples and Families: A Comprehensive Guide for Clinicians.”

This conceptual study focuses on health disparities among African Americans in the Arkansas Delta. The author uses an ecosocial perspective to explore several social and individual-level influences upon patients' perceptions of health care quality, including health beliefs and life experiences of discrimination that can lead to not accessing health care systems. The study findings identify community-based strengths that can inform the development of strategies and programs to reduce rural health disparities. The discussion includes the potential implications of the Patient Protection and Affordable Care Act for progress in health care quality and health equality, especially for rural racial/ethnic minorities.     

Alternative prenatal care interventions to alleviate Black–White maternal/infant health disparities

This paper attempts to forward the maternal health literature that critiques standard prenatal care in the United States by drawing on intersectionality, medicalization, and fundamental causation theories. We argue that these theories deepen our understanding of the maternal health experiences of Black women and can help explain why alternative prenatal care interventions have value for Black pregnant women. Alternative models of prenatal care, which include the use of midwives, doulas, and group prenatal care, are associated with equal or better health outcomes for infants and mothers compared to the standard prenatal model in the United States. We begin by drawing on these sociological perspectives to identify gaps in the maternal health literature that is critical of standard biomedical maternal health approaches. We then go on to describe select alternative methods of prenatal care and then provide a summary of the epidemiological literature as it relates to sociodemographic trends in usage and the relative effectiveness of alternative models compared to standard care. We conclude by arguing that a joint, critical application of these three theories can help scholars explain the utility of alternative interventions for African American maternal/infant health and can inform policies that aim to alleviate Black–White maternal/infant health disparities.     

Teachers and health workers: partners in primary health care. Experiences from Papua New Guinea

Primary health care (PHC) involves community health education. When health priorities in rural communities are focused on the vulnerable under-5-years-of-age group then one has to examine who actually cares for this age group and what are the most appropriate means of reaching them through health education programs. In the context of rural communities in Papua New Guinea the linking of school and community health programs has been taking place. Examples and insights from programs where teachers and health workers attempted to find appropriate channels for integrating child and adult education in order to improve the health status of the very young child are described. The school programs used a child to child approach to develop in children a sense of shared responsibility with adults towards better health for themselves, younger children in their care and the environment of the community. The goal was a health program that applied to the whole community, where division between child and adult learning activities was not so sharply drawn, and where formal school programs and nonformal community education programs were to complement and contribute to each other. A campaign against infant diarrhea and death through dehydration was implemented. As a result of a 3-day planning workshop a program was drawn up for schools and communities. The workshop covered causes of diarrhea, fluid loss and dehydration, simple preventive and curative measures, essential hygiene habits and current community practices. Teachers, health workers and community leaders fashioned a program of activities for school children and adults. It was discovered that adults often feel a barrier between themselves and the child's school learning. Also, a gap often exists between what is taught in school and what is needed and can be applied to community health priorities. Thus, an effective community health education program that includes both children and adults in an integrated program will need to cover the varying ages and groups of community members who, with different degrees of responsibility, take care of themselves and others.     

What Explains Divorced Women's Poorer Health? The Mediating Role of Health Insurance and Access to Health Care in a Rural Iowan Sample

Economic restructuring in rural areas in recent decades has been accompanied by rising marital instability. To examine the implications of the increase in divorce for the health of rural women, we examine how marital status predicts adequacy of health insurance coverage and health care access, and whether these factors help to account for the documented association between divorce and later illness. Analyzing longitudinal data from a cohort of over 400 married and recently divorced rural Iowan women, we decompose the total effect of divorce on physical illness a decade later using structural equation modeling. Divorced women are less likely to report adequate health insurance in the years following divorce, inhibiting their access to medical care and threatening their physical health. Full‐time employment acts as a buffer against insurance loss for divorced women. The growth of marital instability in rural areas has had significant ramifications for women's health; the decline of adequate health insurance coverage following divorce explains a component of the association between divorced status and poorer long‐term health outcomes.     

“Midwife to Myself”: Birth Narratives among Women Choosing Unassisted Homebirth*

Most pregnant women in the United States today choose a normative physician‐guided pregnancy followed by a medically managed hospital birth. Some, however, choose the care of a midwife during pregnancy and birth, whether in the hospital or, more rarely, at home. Despite growing research on both these paths, a third option chosen by some women has rarely been studied: a planned birth at home with neither a doctor nor a midwife assisting. In this article, I examine the stories told by women in this under‐researched population to consider how they make and explain this highly unusual choice. Analysis of online birth stories and in‐depth interviews with women who planned and had an unassisted homebirth reveal ways in which these women rely on competing discourses of midwifery and medicine to craft a unique sense of agency in birth.     

Translating collaborative models of mental health care for older adults: using Iowa's experience to inform national efforts

The Patient Protection and Affordable Care Act supports the translation of collaborative models of mental health care, but how the act will affect older adults remains unclear. The authors examined a sample of older Medicare beneficiaries and evaluated how individual characteristics, local service supplies, and other contextual features corresponded with the identification of older persons with psychiatric diagnoses and their access to specialty mental health care providers. Older adults presented a variety of psychiatric disorders, and their access and use of specialty mental health care related to age; sex; diagnosis; supply of mental health, health, and long-term care providers; and whether an older person lived in a rural area. Translation of collaborative models should consider a range of psychiatric conditions, adjust for varying local provider supplies, and consider the challenges in establishing collaborative care within rural areas.