title: An exploratory metasynthesis of midwifery practice in the United States.
abstract: OBJECTIVE
  To conduct a metasynthesis of six qualitative studies of midwifery care and process; identify common themes and metaphors among the six studies for further exploration and theory development; and create a framework for further metasynthesis of qualitative studies of midwifery practice in the USA.
  
  
  METHODS
  A qualitative metasynthesis to analyse, synthesise, and interpret six qualitative studies on the process and practice of midwifery care.
  
  
  METHODS
  Hospital, birth centre, and home birth settings were represented across all of the studies. Participants included nurse- and direct-entry midwives who provided both childbearing and gynaecological care. Recipients of midwifery care also received both childbearing and gynaecological care.
  
  
  RESULTS
  Four overarching themes were identified: the midwife as an 'instrument' of care; the woman as a 'partner' in care; an 'alliance' between the woman and midwife; and the 'environment' of care. These were interpretively and conceptually arrayed into a helix model of midwifery care.
  
  
  CONCLUSIONS
  The findings from this exploratory metasynthesis clearly indicate that the practice of midwifery is a dynamic partnership between the midwife and the woman, and reflects an environmental perspective. In a country that has a standard of highly technical childbirth care, perhaps the most outstanding concept of this model is that of the midwife as an 'instrument' of care. The significance of the findings will be determined by their ability to guide further research efforts to support a standard of midwifery care for all women in the USA.
  
  
  CONCLUSIONS
  This model offers a benchmark and a structure for considering the dynamic elements of midwifery practice and key roles that the midwife plays in the health care of women and babies.
authors.affiliation: Department of Family Health Care Nursing, University of California, San Francisco 94143-0606, USA. holly.kennedy@nursing.ucsf.edu
authors.forename: Holly P
authors.initials: HP
authors.lastname: Kennedy
authors.forename: Amy L
authors.initials: AL
authors.lastname: Rousseau
authors.forename: Lisa Kane
authors.initials: LK
authors.lastname: Low
mesh_terms: D000739:Anecdotes as Topic; D002983:Clinical Competence; D005260:Female; D006801:Humans; D015201:Meta-Analysis as Topic; D008880:Midwifery / Q000458:organization & administration*; D016294:Models, Nursing; D009721:Nurse Midwives / Q000458:organization & administration*; D024802:Nurse's Role; D009723:Nurse-Patient Relations; D015403:Nursing Evaluation Research; D015404:Nursing Methodology Research; D010043:Outcome and Process Assessment, Health Care; D011247:Pregnancy; D014481:United States