Maternity Nurse

PERSONALITY CHARACTERISTICS OF WOMEN CHOOSING
CERTIFIED NURSE-MID WIVES OR OBSTETRICIANS
FOR MATERNITY CARE
by
Emily Susan Stange
A thesis subm itted to the faculty of

The University of Utah
in partial fulfillment of the requirements for the degree of
Master of Science
College of Nursing
The University of Utah
December 2003
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Copyright © Emily Susan Stange 2003
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THE UNIVERSITY OF UTAH GRADUATE SCHOOL
SUPERVISORY COMMITTEE APPROVAL
of a thesis subm itted by
Emily Susan Stange
This thesis has been read by each m em ber of the following supervisory
committee and by a majority vote has been found to be satisfactory.
sH o s ___________
Chair: Ann P. H utton
fjm j 0$ )&tu_ 7 \ •
M. Dyer
/
Lee Ellington
T /a /a
5/ / ; ^ '
THE UNIVERSITY OF UTAH GRADUATE SCHOOL
FINAL READING APPROVAL
To the Graduate Council of the University of Utah:
I have read the thesis of Emily Susan Stange in its final form and have found
that (1) its format, citations, and bibliographic style are consistent and acceptable;
(2) its illustrative materials including figures, tables, and charts are in place; and
(3) the final m anuscript is satisfactory to the supervisory committee and is ready
for submission to The Graduate School.
03
Date A nnP . Huttoti
Chair, Supervisory Committee
Approved for the Major Departm ent
A JLAAo -
M aureen R. Keefe
Chair/Dean
Approved for the G raduate Council
David S. Chapman
Dean of the Graduate School
ACKNOWLEDGMENTS
Sincere thanks to those who have supported this research in m any ways:
Jane Dyer, Lee Ellington, Ann Hutton, Alexa Doig, Joyce Rathbun, Linda
Alexander, Pete Barnard, Kaydon Lusty, Diana Peterson, Jeff Barton, Christian
Froerer, Rich Irion, Ron Larkin, Kimball Lloyd, Steve Terry, and Erik Stange.
ABSTRACT
This study examined w hether or not there are significant differences in
personality traits betw een w om en who actively choose nurse-midwives instead
of obstetricians for their m aternity health care provider. This study focused on a
specific, "nonvulnerable" group of women who make a conscious choice to have
a nurse-midwife as a provider. Seventy married, primiparous, privately insured
patients who self-selected either a nurse-midwife or a physician were included in
the study. The NEO Five-Factor Inventory was used to assess personality
characteristics of pregnant wom en who utilize nurse-midwives. The inventory
compared their personality profiles with those who use obstetricians. Women
who chose nurse-midwifery care were found to be significantly more O pen to
Experience than wom en who choose obstetric care. The groups differed in their
age and religious preferences, but ANCOVA tests demonstrated that the
difference in the Openness scores was still significant after controlling for the
effects of age and religion. Statements gathered from the patients dem onstrated
that obstetricians' patients are not informed of the services and qualifications of
Certified Nurse-Midwives, while nurse-midwifery patients actively seek out the
time and attention that a nurse-midwife provides them. Implications of the
study, including m arketing tactics, clinical issues, and patient education, are
discussed.
TABLE OF CONTENTS
ABSTRACT......................................................................................................................iv
ACKNOWLEDGMENTS.............................................................................................vii
Chapter
1. INTRODUCTION.................................................................................................1
Theoretical F ram ew ork.......................................................................... 3

Significance of Study to N u r s in g ..........................................................6
P u r p o s e .....................................................................................................8
2. LITERATURE REVIEW ..................................................................................10
In tro d u c tio n ...........................................................................................10

History of Nurse-Midwifery in A m erica............................................11
Feminist C h o ic e s ...................................................................................14
Expansion of Nurse-Midwifery Practice and E d u c a tio n ................16
Characteristics of Nurse-Midwifery P a tie n ts ....................................16
Practice and Philosophy D ifferences..................................................19
Choosing a M aternity Care P ro v id e r.................................................20
Sources of In fo rm a tio n .........................................................................21
Decision M aking Process.......................................................................22
Five-Factor Model of Personality.........................................................24
Summary of L ite ra tu re ........................................................................ 27
3. METHODOLOGY...............................................................................................29
D esig n......................................................................................................29
Setting.......................................................................................................29
S am ple.....................................................................................................30
P rocedures....................................................; ....................................... 30
Ethical Considerations...........................................................................31
Data Collection........................................................................................31
4. RESULTS.............................................................................................................34
S am ple......................................................................................................34
Data A n aly sis..........................................................................................36
Analysis of D ependent Variable: NEO-FFI Scores............................37
Analysis of Covariance: Controlling for Religion and Age 39
Qualitative D a ta .....................................................................................40
1. DISCUSSION......................................................................................................43
Interpretation of NEO-FFI Scores........................................................ 43

Choice of Provider and Implications of "O" Scores.......................... 44
Effects of Age and Religion on NEO-FFI Scores.................................48
Single W om en..........................................................................................49
A ssum ptions............................................................................................51
L im itations..............................................................................................52
Recommendations for Further S tu d y ................................................. 53
C onclusion..............................................................................................54
Appendices
A. LETTER OF CONSENT......................................................................................57
B. DEMOGRAPHIC AND QUALITATIVE SURVEY...................................... 59
C. ITEM EXAMPLES FROM THE NEO OPENNESS SCALE..........................64
REFERENCES.......................................................................................... 66
vi
CHAPTER I
INTRODUCTION
American nurse-midwives have provided maternity care for wom en since
the early part of the 20th century. The last five decades have seen a trem endous
increase in the num ber of Certified Nurse-Midwives in the United States. In 2000,
Certified Nurse-Midwives attended 297, 902 births in the United States, 9.6% of
all normal spontaneous vaginal deliveries (Ventura, Martin, Curtin, Menacker, &
Hamilton, 2002). Since 1989, w hen nurse-midwives were first differentiated from
other types of midwives on birth certificate data, the num ber of births they
attended has steadily increased by 125% (Ventura et al.). In this age of media-
sa w y consumerism, informed choice, internet Web sites, and provider
competition, wom en are becoming more aware of their choices among health
care providers for their m aternity care.
Historically, nurse-midwives have cared for women in underserved
populations, and this trend continues today. A 1999 report on data collected from
Certified Nurse-Midwives dem onstrated that 70% of midwifery patients are
considered to belong to a "vulnerable" population group, due to their insurance
status, race/ethnicity, age, level of education, or residential area (Paine et al.,
1999).
Recently, however, more women have actively sought the care of a nurse-
midwife for their nonmedical, noninterventional, woman-centered approach to
pregnancy, labor, and birth (Bourgeault & Fynes, 1997). Most studies are limited
to demographic information to characterize this "nonvulnerable" group of nurse-
midwifery patients (Galotti, Pierce, Reimer, & Luckner, 2000; Paine et al., 1999;
Parker, 1994; W aldenstrom & Nilsson, 1993). Women actively choosing nurse-
midwifery or "alternative" m aternity care tend to be more educated (Aaronson,
1987; Anderson & Greener, 1991; Rooks et al., 1989; Schneider, 1986;
W aldenstrom & Nilsson), older (Anderson & Greener; Cohen, 1982; Rooks et al.;
Schneider; Woodcock, Read, Moore, Stanley & Bower, 1990), m arried (Anderson
& Greener; Rooks et al; Schneider; W aldenstrom & Nilsson), m ultiparous
(Schneider; W aldenstrom & Nilsson), and less likely to have a particular
religious affiliation (Howell-White, 1997). A few studies (Callister, 1995; Galotti
et al.) have isolated these w om en's motivations, goals, or ideals of childbirth
w hen choosing nurse-m idw ives and have even identified a common locus of
control (Aaronson; W aldenstrom & Nilsson). No studies exist, however, that
identify shared personality traits of w om en who choose nurse-midwives.
This study focused on this specific, "nonvulnerable" group of wom en who
make a conscious choice to have a nurse-midwife as a provider. The study aimed
to explore personality characteristics that m ay influence these w om en to choose
nurse-midwifery care in comparison w ith wom en who seek care from an
obstetrician. Identification of personality traits, if they exist, can be useful to
nurse-midwives to both individualize their services and recruit more wom en to
utilize their services. The NEO Five-Factor Inventory (NEO-FFI)1, a personality
1While the term "NEO" is derived from the personality domains of Neuroticism,
Extraversion, and Openness, it is the proper name of the inventory, and not an
abbreviation.
3
tool developed by psychologists, was used to assess personality characteristics of
pregnant women w ho utilize Certified Nurse-Midwives, and com pared their
personality profiles w ith those w ho use obstetricians.
Theoretical Framework
Pregnancy and childbirth are potentially one of the m ost significant and
memorable experiences in a wom an's life. Many women have set opinions on
w hat they believe the experience of childbirth should be, w hether it be a home
delivery, in the perceived safety of a hospital, a natural birth using prepared
childbirth techniques, or even the perceived comfort of an epidural. These
decisions represent core beliefs of the wom en who make them, w hether they are
consciously aware of them or not.
Health Belief M odel. The Health Belief Model (HBM) is based on
psychological and behavioral theories that hypothesize that an individual's
behavior depends on two variables: (1) the value placed by an individual on a
particular outcome and (2) the individual's estimate of the likelihood that a given
action will result in that outcome (Janz & Becker, 1984; Mikhail, 1981;
Rosenstock, 1974).
The model attem pts to explain health-related behavior at the level of
individual decision-making, and was originally developed to examine
preventive health action—not treating illness. The likelihood that a person will
take action concerning a health condition is determined by the individual's
readiness to take action and by the perceived benefits of action w eighted against
the perceived costs of barriers.
4
Nurse-midwives view m aternity care, in a sense, as preventive care, as
they view pregnancy as a time of health in a w om an's life. In this study the
process of seeking out a m aternity care provider and choosing one provider over
another, be it obstetrician or nurse-midwife, is a preventive health action. The four
dimensions of the HBM, and how it applies to women seeking m aternity care is
as follows.
• Perceived susceptibility. For individuals to take action on a health
related matter, they m ust first feel personally susceptible to the condition. Most
women generally feel that pregnancy is a condition that requires medical
attention, with m ost wom en initiating prenatal care w ithin the first trimester.
• Perceived severity. Individuals m ust feel the health condition is
severe enough that it w ould have at least a m oderate impact on some component
of their life. Women vary in their beliefs on how serious of an "illness"
pregnancy may be. Some women, believing their pregnancy to be high risk may
seek the care of an experienced obstetrician. Others, feeling that pregnancy is a
very normal occurrence in life, m ay instead seek the care of a lay midwife who
attends home births.
• Perceived benefits. A sensation of susceptibility and severity is not
enough for all individuals to take health action. Individuals m ust also believe
that they will in fact benefit from taking a particular health action by reducing
their susceptibility and severity to a health condition. A w om an who feels that an
obstetrician overuses technology may instead seek the care of a nurse-midwife
who relies on a less medical m odel of care. On the other hand, a wom an
attempting a VBAC (vaginal birth after a cesarean) who believes having a care
Individual Perceptions Modifying Factors Likelihood of Action
Dem ographic V ariables (age, sex, race, Perceived benefits of seeking

ethnicity, income, education) health c a re provider
Structural V ariables (knowledge about m inus

pregnancy, prior experience)
Perceived barriers to seeking
Sociopsychological V ariables (social health c a re provider
class, p ee r group, society, personality)
Perceived se riousness of Perceived threat Likelihood of finding a

pregnancy of pregnancy health c a re provider
C u es to Action
Media CNM OB
Advice from
others
N ew spaper
Society Norms
Figure 1. The Health Belief Model as predictor o f seeking prenatal maternity care.
Note. Adapted from Rosenstock, I.M. (1974). Historical Origins of the H ealth Belief Model. Health Education Monographs, 2,
328-335.
provider available for an emergency cesarean section w ould be of benefit, may
seek the care of an obstetrician.
• Perceived barriers. Health actions that have potential negative
aspects, such as cost, pain, inconvenience, or embarrassment, m ay result in
individuals being less likely to take action. A pregnant teenager m ay be so afraid
of her parents discovering her pregnancy that she hides any signs of it altogether
and fails to initiate prenatal care. An uninsured wom an may decide a hospital
birth is too expensive and may decide on a home birth as a cheaper alternative.
These threats to health and benefits of a health action decision are not
enough, however, to stimulate an action. A cue to action is required to trigger the
decision-making process. These cues m ay be internal, such as the physical
symptoms of pregnancy, or external, such as advice from friends or the m ass
media. Other m odifying factors also influence the individual's perceptions of
health and illness, including demographic, sociopsychological, and structural
variables. Many studies docum ented the demographic characteristics of both
obstetrician and nurse-m idwifery patients, as well as the structural variables of
knowledge and prior experience w ith pregnancy. This study examines the
sociopsychological variable of personality and how it contributes to the health
action of seeking and choosing one particular provider over another.
Significance of Study to N ursing
Nurse-m idwives are often considered by the lay public to be untrained
relics of the past, and w ithout a place in m odem health care. Today, nurse-
midwives attend approxim ately 10% of vaginal births in the United States
(Ventura et al., 2002). W hen a wom an first discovers she is pregnant she relies
heavily on the recom m endations of family and friends for a "good doctor"
(Hoerger & Howard, 1995). If 90% of American women are utilizing an
obstetrician or family practice physician for their pregnancy care, it is
understandable that the nam e of a "good nurse-midwife" w ould be passed from
wom an to wom an on a less frequent basis than referrals for other providers.
W hat is it that inspires some wom en to seek the care of the oft-overlooked nurse-
midwife?
Patients of nurse-m idw ives often speak of wanting a "quality birth
experience," one in which they are "in control" and "making decisions"
(Callister, 1995, p. 175). These passionate motivations suggest a wom an who is
independent, accepting of challenge, and seeking meaning from life events.
Studies recognize differences in practice philosophies between nurse-midwives
and obstetricians. Callister writes of the importance of establishing a
"philosophic fit" betw een the childbearing wom an and her care provider
(p. 168).
Many studies (Bell & Mills, 1989; Oakley, Murray, et al., 1996; Oakley,
M urtland, et al., 1995,) have com pared the birth outcomes of nurse-midwives
w ith those of obstetricians. These studies have demonstrated that satisfaction
levels, as well as clinical outcomes, of wom en using nurse-midwives equals or
exceeds that of obstetricians. Since no differences in health and birth outcome
statistics between the tw o groups have been identified, Aaronson (1987)
concluded that the question is no longer which care provider gives "better care,"
but rather "which m odel of care is best for which clients" (p. 225).
Aaronson (1987) also encourages further studies to examine the
significance of provider/ client "fit." Women who desire to be well-educated
about the process of pregnancy m ay appreciate the extended time a nurse-
m idwife spends educating her clients. Nurse-midwives also need to understand
which wom en are not seeking nurse-midwifery care and their reasons for
utilizing other care. Many wom en have misconceptions regarding the
educational level and professionalism of nurse-midwives; others are reassured
by the "expertise" a physician possesses.
There is a great need for nurse-midwives to learn how to appropriately
m arket their services (Bell & Mills, 1989; Williams, 2002). Bell and Mills
discovered once wom en were introduced to nurse-midwifery care it became the
"m ost preferred option" for nearly all their patients (p. 116). By identifying
unique personality traits of wom en who are utilizing a nurse-midwife, nurse-
midwives may be able to individualize their services and reach out to wom en
w ho are not familiar with their philosophy of care.
Purpose
This study was an exploratory investigation to examine the question: are
there significant differences in personality traits between wom en w ho choose
nurse-midwives instead of obstetricians as their maternity health care provider?
Do clients of nurse-midwives tend to be more extraverted or introverted than
those of obstetricians? Are they trusting of others, or more guarded? Do they
actively seek new experiences, or are they more comfortable w ith the tried and
true? The answer to these questions may help nurse-midwives and wom en
"maximize the fit" (Aaronson, 1987, p. 218) between m aternity care providers
and their pregnant clients.
Costa and McCrae (1992) developed the NEO PI-R to identify the
"emotional, interpersonal, experiential, attitudinal, and motivational styles" of
their clients (p. 14). Piedm ont (1998) describes instruments such as the NEO-FFI
and NEO PI-R as those which can identify "fundam ental tem peram ents" of a
person's personality, such as those that "drive, direct, and select behaviors" [italics
added] (p. 4). He also suggests five clinical uses for personality inventories,
including understanding the client [italics added](1998, p. 11). It is for these
reasons—the desire to understand w hat personality characteristic "drives and
directs" a woman to choose her particular health care provider for her
pregnancy—that the NEO-FFI was selected as the research instrum ent for this
study. Not only is it useful in assessing an individual's unique personality traits,
it also has value in identifying traits of larger groups (Piedmont, 1998), as was
the case in this study.
CHAPTER 2
LITERATURE REVIEW
Introduction
Research pertaining to personality characteristics of nurse-m idwifery
patients, as identified by valid and reliable personality inventories, is lacking. As
a result, factors affecting the decision making process of pregnant wom en
choosing a health care provider are not fully understood. The historical
background of m idw ifery in America is very im portant because of how nurse-
midwives are view ed today in the United States. The feminist movement, a
desire for more natural approaches to childbirth, a reduction in the num ber of
practicing obstetricians, and a postw ar baby boom all contributed to the growth
and expansion of nurse-m idw ifery services and education program s in the 1960s
and 70s.
Studies have identified demographic characteristics of wom en choosing
nurse-midwives and distinctions between the practice philosophies of nurse-
midwives and obstetricians. Despite these statistics, most wom en eventually
choose the care of w hom ever is recommended by their friends and family
(Hoerger & H ow ard, 1995). W omen who resist the call of conventional obstetrical
practice remain in the m inority. Are there personality factors that distinguish the
minority from the majority?
11
History of Nurse-Midwifery in America
Throughout history, m idw ives have attended w om en at their births. It
was not until the 19th century, and the daw ning of m odem medicine, that
physicians regularly assum ed pregnancy and childbirth as a medical concern.
The American Medical Association (AMA) was founded in 1847, and later
created four special sections, including obstetrics, in 1859 (Rooks, 1997).
Physicians searched for a way to limit the practice of m idwifery in order to
expand their own practice of medicine.
A study done in 1910 revealed that the United States had the third highest
maternal death rate in developed nations, and an infant m ortality rate of 124
deaths per 1000 live births—one of the highest in developed W estern nations
(Litoff, 1982). Midwives attended nearly half of all births in the United States at
this time (McCool, 1989), although nearly all were of poor, im m igrant women.
Allopathic physicians pointed to midwives as the cause of the poor survival
rates. They then began a propaganda campaign known as the "m idwife
problem," hoping to eradicate m idwifery practices across the nation.
The physicians' cam paign successfully diminished the num ber of
midwives attending births. By the 1930s m idwives attended only 15% of births in
the United States, mostly in the m ral south. Interestingly enough, however, the
maternal death rate actually increased slightly during this 20-year time period
(Walsh, 1991).
Despite this dramatic decrease in the num ber of practicing m idwives, they
continued to w ork w ith populations m any physicians considered undesirable.
Mary Breckinridge, a British prepared nurse-midwife, formed the Frontier
12
Nursing Service (FNS) in rural Kentucky in 1925 with two other British nurse-
midwives and a medical director. They soon built a 25-bed hospital and
supported 11 district nursing centers throughout Leslie County. A study
conducted by M etropolitan Life Insurance Company found that if the services
available in Leslie County were available nationwide there w ould have been
10.000 mothers' lives saved a year, 30,000 fewer stillbirths, and 30,000 m ore
children alive at 1 m onth of age (Tom, 1982).
In New York City, the Maternity Center Association (MCA) was form ed in
1918 in response to a 1915 study linking m aternal and infant m ortality to lack of
prenatal care. Thirty neighborhood centers were established throughout
M anhattan within 2 years, and a need for nurses educated in obstetrics was
quickly identified. Breckinridge, among others, opened the Lobenstine
Midwifery School in New York City, the nation's first nurse-midwifery
education program, in 1931. The school graduated 231 nurse-midwives between
1933 and 1953, all of w hom worked in public health agencies or public clinics,
none in private practice. The school closed in 1958, with an outstanding birth
record; the maternal m ortality rate for MCA births during its 26 years of
operation was 0.9 per 1,000 live births, while the national average was 10.4 per
1.000 (Roberts, 1995).
A third school w as opened in Tuskegee, Alabama, in 1941, preparing
nurse-midwives to deliver care to isolated black women in the south. The school
closed within 5 years, but nurse-midwives had found another area of the country
that needed their services. D uring the 1940s more than 75% of births in the
13
southern states of Mississippi, Alabama, Louisiana, South Carolina, Florida, and
Georgia were attended by midwives (Walsh, 1991).
Nurse-midwifery graduates of the MCA opened the Catholic M aternity
Institute School of Nurse-Midwifery in Santa Fe, New Mexico, in 1944. This
program served Spanish-speaking women of the Santa Fe area, and becam e the
first master's degree program for nurse-midwives in the United States (Rooks,
1997; Varney, 1997; Walsh, 1991). CMI also opened the first out-of-hospital nurse-
midwifery birth center in 1951.
While nurse-midwives were rejoicing the opening of the first birth-center,
physicians had already spent decades convincing American w om en of the need
for their births to be in the "safe, sterile" environm ent of a hospital. W om en were
promised "pain free births" through the use of a combination of scopolamine
and morphine. This "twilight sleep" was available only in hospitals, and upper-
class-women soon endorsed the use of physicians over midwives, and hospital
births over home births. The use of forceps became routine, necessary w hen a
wom an was under the influence of scopolamine, morphine and ether. Midwives,
not educated in the use of forceps, were told to contact a physician if a difficult
delivery necessitated the use of forceps. A popular obstetric textbook, w ritten by
Dr. Joseph DeLee in 1920, advised physicians to "sedate w ith scopolamine . . .
give ether during the second stage, perform an episiotomy, d eliv er... w ith
forceps, give ergot to help the uterus contract, and then repair the episiotom y"
(Rooks, 1997, p. 25). DeLee changed the focus of obstetrics from problem
prevention to "directing la b o r... through a panoply of interventions" (Rooks, p.
14
26). W hat was once a normal physiologic process in a w om an's life becam e a
pathologic event.
This "medicalization of pregnancy" (Cahill, 2001, p. 334) led to the
development and use of electronic fetal monitoring, episiotomies, epidural
anesthesia, lithotomy-only deliveries, forcep and suction deliveries, and cesarean
sections. Maternal choice—of delivery personnel, delivery position, labor
method, labor support, medication—quickly disappeared.
At the end of W orld W ar II, governm ent program s provided federal and
state money for building hospitals. This m ade hospitals m ore accessible to
women for birth. Sixty-three percent of all births were hom ebirths in 1930, but by
1960, 97% of the births were in hospitals (Rooks, 1997). This trem endous increase
in the num ber of hospital births was also accompanied w ith the largest increase
in the nation's birth rate—the postw ar baby boom. Obstetricians and residents
were overwhelmed with the num ber of births, and in the late 1950s began
considering nurse-midwives to be a source of relief (Rooks). This offered nurse-
midwives their first opportunity to attend births in hospitals across the United
States. Until this point, the only hospital in all of America where nurse-m idwives
had been allowed to attend births was the Frontier Nursing Service's small
hospital in Hyden, Kentucky (Rooks).
Feminist Choices
In the 1960s and 1970s, the feminist m ovem ent questioned w om en's
experiences regarding pregnancy and childbirth. Klima (2001) describes radical
feminism not as striving for equality with men, but as providing "an alternative
philosophic fram ework [for] health c a re ... based on a wom en-centered
15
viewpoint, w ith the experiences of w om en as its unifying philosophy" (p. 285).
The feminist m ovem ent began as a dem and for contraception and abortion
rights, b u t quickly included "woman-centered, woman-controlled" health care in
its demands. The w ord "midwife" itself m eans "with wom an" and nurse-
m idwives of the 1960s and 70s were "seen as a symbol of wom en controlling the
reproductive process" (Bourgeault & Fynes, 1997, p. 1055).
Grantly Dick-Read's book on natural childbirth, Childbirth Without Fear:
The Principles and Practices of Natural Childbirth, published in the United States in
1944, inspired w om en to labor w ithout the use of anesthesia. His m ethod led to
the development of the Bradley m ethod of childbirth, a "husband-coached"
approach to natural childbirth. Another natural childbirth approach, Lamaze,
also gained popularity in the 1960s. These natural approaches to childbirth fit
well w ith the philosophy of nurse-midwives. Women, eager to find a care
provider w ho supported the nonmedicated, nonmedical approach to labor and
delivery, actively sought the care of nurse-midwives.
The 1960s and 70s brought about social movements in addition to the
w om en's movement. The "civil rights m ovem ent... the consum er movement,
the antiwar movement, and the back-to-nature/health movement" all
contributed to criticism of medical m anagem ent of childbirth in the 1960s and
70s (Rook, 1997, p. 55). Women w anted to actively participate in the childbirth
experience, and their partners w anted to share the experience. Nurse-m idwives
began serving m ore politically, socially and economically powerful women, and
the dem and for midwifery services, home births, birth centers, and natural
childbirth classes soared.
16
Expansion of Nurse-Midwiferv Practice and Education
In the early 1960s, only 34 nurse-midwives were practicing in the United
States, mostly in Kentucky, New Mexico, and N ew York City where laws
sanctioned their practice. Many nurse-midwives traveled overseas to find
em ploym ent because midwifery opportunities in the United States were so
limited. Yet as the dem and for nurse-midwives grew, m ore opportunities for
em ploym ent were m ade available. By 1968,126 nurse-midwives were practicing
in the United States (Rooks, 1997). Forty-one states, as well as the District of
Columbia, had practicing nurse-midwives by 1977, and almost 67% of employed
nurse-m idwives had a clinical practice. The num ber of nurse-midwifery
education program s increased from seven in the early 1960s to 19 by 1970
(Rooks). By 1975 the num ber of practicing Certified Nurse-Mid wives had
increased to 659, and eventually to 5,927 by 1999 (Kovner & Burkhardt, 2001).
Nurse-m idwives expanded not only in number, but also in the type of
services provided. Once relegated to pregnancy, childbirth, and postpartum care,
nurse m idwives found there was a need for expanded services in varied
populations. The dem and for available contraception in the 1960s and 70s gave
nurse-midwives an opportunity to assist in family planning, as well as treating
sexually transm itted diseases, and other gynecological problems.
Characteristics of Nurse-Midwiferv Patients
Despite the recent use of nurse-m idwives by a higher socio-economic class
of wom en (Bourgeault & Fynes, 1997), nurse-m idwives have not turned their
backs on the underserved population of wom en they once served. A study in
1991 examined all visits m ade to Certified Nurse-M idwives in the United States.
17
O ut of the 5.4 million visits m ade to Certified Nurse-Midwives during 1991,
w om en considered to be "vulnerable" due to economic, ethnic, or geographic
reasons accounted for 7 of 10 visits (Paine et al., 1999, p. 907). W omen of a
race/ethnicity other than European American made 42% of those visits; 44%
were unmarried; 18% were immigrants; 12% lived in a health-professional
shortage area. Parker (1994) found that during the 1980s nurse-m idwives more
commonly attended hospital births of wom en who were "non-white, younger,
less educated, and unm arried" (p. 1139).
The characteristics of the other 30% of women who actively seek out the
care of nurse-midwives are very different from those of the vulnerable
population. This subgroup of w om en are m ost often privately insured, have a
choice of care providers on their health insurance plans, yet are u nder the care of
a nurse-midwife for their pregnancy. Studies have identified several
demographic characteristics of these women. They tend to be m ore educated,
older, married, m ultiparous, and less likely to have a particular religious
affiliation (Aaronson, 1987; Anderson & Greener, 1991; Cohen, 1982; Howell-
White, 1997; Rooks et al., 1989; Schneider, 1986; W aldenstrom & Nilsson, 1993;
Woodcock, Read, Moore, Stanley & Bower, 1990).
Clients of nurse-m idwives tend to be healthy and well-motivated
(Aaronson, 1987), desiring a m ore active role in the birth process and in decisions
relating to childbirth (Callister, 1995; W aldenstrom & Nilsson, 1993) than those
choosing obstetricians. W omen utilizing nurse-midwives for their m aternity care
have a greater need for control, and are focused on having w hat they view as a
"quality birth experience" (Callister, p. 169). Women choosing alternative
18
m aternity care, such as out-of-hospital births a n d /o r nurse-m idwifery care, have
dem onstrated an internal (versus external) locus of control (Aaronson;
W aldenstrom & Nilsson), believing they can m aster their environm ent and
"assume an active approach" (Kist-Kline & Lipnickey, 1989, p. 38) w hen
encountering problems.
Galotti et al. (2000), examined the decision making process of w om en who
chose nurse-midwives over physicians. They found that wom en who even
"considered a m idwife" w ere "more thorough, more informed and
knowledgeable, m ore analytic, having greater breadth of thinking" (p. 324).
Women who chose a nurse-midwife felt "m ore knowledgeable about birth
attendants, more in control... [and] more autonomous" in various decisions (p.
320).
A study focusing on the use of alternative medicine found those w ho use
alternative health care are m ore educated, have a holistic orientation to health,
and are committed to feminism and environmentalism (Astin, 1988). While this
study did not specifically identify nurse-midwifery as a form of alternative
therapies, the practice and profession of midwifery is often considered an
alternative form of medicine, or certainly out of the scope of m ainstream medical
practice. Nurse-m idwives pride themselves in providing m ore than medical care,
and instead treat the whole woman, identifying w ith the "holistic" care the Astin
study addressed (1998, p. 1551). The study also found those who were committed
to feminism were m ore likely to use alternative therapies. As m entioned before,
feminists of the 1960s and 70s supported the nurse-midwives' dedication to
"women treating wom en."
19
Practice and Philosophy Differences
When physicians took births into the hospital during the m iddle of the
20th century, birth increasingly became a m onitored, controlled event, from the
m inute the laboring (or non-laboring) w om an entered the m aternity unit until
she was discharged from the hospital. Nurse-m idwives consider pregnancy and
birth to be a natural physiological event, and have resisted this "medical"
approach (Varney, 1997). While recognizing that the birth process a n d /o r the
laboring wom an can at times dem and the need for technologic intervention,
nurse-midwives strive to treat all births as normal, physiologic life events.
Studies have dem onstrated that patients of both nurse-midwives and
obstetricians are highly satisfied w ith their care, supporting the belief that the
patient-provider "fit" was appropriately m atched (Bell & Mills, 1989; Oakley,
Murray, et al., 1996). Outcomes between nurse-midwives and obstetricians are
also similar; the m ain differences between the two care providers are visible only
in their philosophy of care (Callister, 1995; Oakley, Murray, et al.; Oakley,
M urtland et al., 1995; Rosenblatt et al., 1997).
Women cared for by Certified Nurse-M idwives were less likely to
experience a third or fourth degree laceration (Oakley, Murray, et al., 1996), an
episiotomy (Rosenblatt et al., 1997), an epidural, receive continuous fetal
monitoring, a cesarean section, induction a n d /o r augm entation of labor
(Rosenblatt et al.). Mothers choosing nurse-midwives were more likely than
physicians' patients to am bulate in labor, breastfeed immediately after delivery,
and room with their babies throughout the hospital stay (Oakley, M urray, et al.;
Yankou, Petersen, Oakley & Meyers, 1993;).
20
In the prenatal setting, Certified Nurse-Midwives were m ore likely to
personally teach their patients about nutrition and other health prom otion and
risk reduction activities such as smoking and drinking alcohol (Oakley,
Murtland, et al., 1995). These patients also received fewer antenatal tests,
resulting in lower costs, and benefited from prenatal visits that were
approximately twice as long as those of obstetricians' patients (Oakley,
M urtland, et al.; Yankou et al., 1993).
Choosing a M aternity Care Provider
After identifying such dram atic practice and philosophy differences
between the nurse-midwife and obstetrician, it w ould seem likely for an
expectant mother to consciously choose a care provider who "matched" her own
health care philosophy. Nurse-m idwives view birth as a normal, healthy process
and actively involve their clients in decision making through constant teaching.
Obstetricians view pregnancy and birth as a pathological event, and treat it as a
medical crisis, using state-of-the-art technology to carefully monitor the
pregnancy and labor. Howell-W hite (1997) found that women w ho believe
childbirth to be "risky" and in need of "technical medical intervention are more
likely to select an obstetrician," while those w ho consider childbirth to be
"natural" and "norm al" are m ore likely to choose a nurse-midwife (p. 925).
Hoerger and H ow ard (1995), examined the num ber of pregnant w om en
who sought out prenatal care, and discovered that less than 25% "seriously
considered more than one" health care provider (p. 332). Only w hen a wom an
faced a high-risk pregnancy or high insurance co-payments did she search more
intently for other prenatal care options.
21
Women considered the health care provider's "expertise or quality" the
most important factor in their decision m aking process, but relied alm ost entirely
on recommendations from family and friends (Hoerger & H ow ard, 1995, p. 348).
This referral process supports evidence from another study that exam ined how
patients chose a new physician (nonpregnancy related). A study conducted in
1972 by Booth and Babcock found nearly half of their sample consulted relatives
w hen searching for a new physician, 27% consulted with friends, and "m ost
individuals consulted only w ith one person" (as cited in Hoerger & H ow ard, p.
336). Lupton, Donaldson and Lloyd (1991), also found that recom m endations
from family and friends were the reason m ost frequently cited in selecting of a
physician. A study by the American College of Nurse Midwives also
demonstrated that wom en seek prenatal care providers w ho are "com petent"
(Williams, 2002, p. 2). The definition of "competent" or "expert" will vary from
one woman to another, however, m ost likely in relation to their philosophy of
childbirth.
Sources of Information
When making medical decisions, laypersons have recently been utilizing a
new outlet of information: the internet. In 2000, 60 million U.S. residents used the
Internet to search for health information, and 70% of these users report that the
information they find online influences their decision about medical treatm ent
(Fox & Rainie, 2000). Many wom en are surfing the Internet for inform ation
regarding their pregnancy, and are becoming more informed about pregnancy,
childbirth, and health care provider options.
22
Women may also rely on forms of w ritten communication for
recommendations in choosing a health care provider. These w ritten forms may
include advertisements in newspapers and magazines, brochures, or non-
scholarly journals. Some of these m edias m ay be biased tow ards the medical
profession. For example, in a recent issue of Redbook magazine, an article
advised its readers: "don't let yourself be brushed off onto a nurse practitioner"
(Levine, 2002, p. 64). The article w ent on to erroneously cite a study in which
women, speaking to nurse practitioners over the phone, w ere m ore likely to be
"misdiagnosed." Recommendations such as these m ay unintentionally bias a
wom an toward choosing an obstetrician over a nurse-midwife.
Decision Making Process
Pregnancy is a time in which wom en m ust make several life-altering
decisions. It may be the first major "financial, personal, and health-related
decision" a woman has had responsibility for, and choice in m aking (Galotti et
al., 2000, p. 320). Some decisions m ay not seem like decisions at all, such as the
decision to see a health care provider. For some women, this decision m ay just be
one of many predeterm ined steps that are taken when pregnant. Choosing an
obstetrician as their care provider over a nurse-midwife m ay also be a "non
decision" for those w om en who are unaw are of the services of nurse-midwives.
Others may prefer to take a more active role in health related choices, especially
when the decision involves "lifestyle or value implications," such as pregnancy
and birth (Galotti, 2002, p. 90).
Researchers Petersen, Heesacker, and de Witt M arsh (2001) identified four
different styles of medical decision making: information seeking, information
23
processing (used by those w ho do not seek new information b u t think carefully
about w hat information they have received thus far), advice following (used by
those w ho trust w hat information they have received from experts), and
rum inating (used by those w ho avoid m aking decisions altogether). The authors
found those who were information seekers and information processors "showed
better coping strategies" than those who were advice followers and rum inators
(Galotti, 2002, p. 91).
This supports studies that have found that wom en w ho attend childbirth
classes and receive teaching regarding labor and delivery are less likely to need
pain medication, and are less fearful of the entire experience (Bechelmayr, 1995;
Hetherington, 1990). Nurse-m idwives embrace this approach, believing that
teaching women empowers them to make decisions regarding their pregnancy
and childbirth.
There is no general consensus in the health psychology field as to how
people make health related decisions. Many factors may influence the decision
making process, including the diagnosis, the age of the decision maker, length of
the illness, and others already discussed such as recommendations from friends
and family. Theories—such as locus of control, Health Belief Model, and stages of
change and readiness—address w hy and how people make health related
decisions. Because so m any theories exist, it is difficult to identify one as the
specific method that all pregnant wom en follow. Locus of control is closely
related to personality, and has been studied in relationship w ith decision making
in pregnancy (Callister, 1995; Kist-Kline & Lipnickey, 1989). However,
24
personality as an entity in itself has yet to be examined carefully as. to how it
contributes to decision making, specifically in pregnancy.
Five-Factor Model of Personality
The study and analysis of personality can be a highly subjective
experience in itself. Historically, the "major resources for identifying im portant
dimensions of personality w ere the experiences and insights of individual
personality theorists" (Piedmont, 1998, p. 20). The developm ent of an objective,
inclusive measure of personality has been in development since 1936, w hen
Allport and Odbert identified 17,953 terms in Webster's New International
Dictionary that could "distinguish the behavior of one hum an being from that of
another" (as cited in Piedmont, p. 23). They then grouped these term s into four
broad categories, in order to classify them. This was the first step in identifying
personality dispositions. The next step, developing a system w ith which to apply
the "adjective pool," was an enorm ous task (Piedmont, p. 24). In 1947, Raymond
Cattell developed his 16 PF (Sixteen Personality Factors) Questionnaire, the first
attem pt at identifying an empirical relation between personality traits
(Piedmont). Further research through factor analysis dem onstrated that Cattell's
16 factors could be reduced to the more succinct Five Factor Model (e.g., Boyle,
1989; Goldberg & Digman, 1994; Hofer, H orn & Eber, 1997).These Five Factors of
personality are identified as neuroticism, extraversion, openness to experience,
agreeableness, and conscientiousness.
In 1986, Paul Costa and Robert McCrae developed the NEO Five-Factor
Inventory (NEO-FFI) based on their earlier more inclusive personality tool, the
NEO PI-R (NEO Revised Personality Inventory). Costa and McCrae's personality
25
tools provide a m ethod of m easuring the five domains, and state that the tests
"account for major dimensions in personality questionnaires designed to
measure Jungian functions, M urray's needs, the traits of the Interpersonal
Circumplex, and the DSM-III-R personality disorders" (Costa & McCrae, 1992, p.
14). Costa and McCrae suggest that the NEO-FFI be used in situations w here
time is an issue, as w as the case in this study.
Neuroticism, as defined by Piedmont (1998), is the tendency to experience
negative affect, such as anxiety, depression, and hostility. People high in "N" are
also more prone to have irrational ideals, be less able to control their impulses,
and cope more poorly w ith stress (Costa & McCrae, 1992).
Extraversion does not reflect only sociability, but also the quantity and
intensity of interpersonal interactions. People scoring high in "E" are assertive,
active, cheerful, upbeat, energetic, optimistic and talkative, liking excitement and
stimulation (Piedmont, 1998; Costa & McCrae, 1992). W hat is often considered to
be the opposite of extraversion—introversion—is actually portrayed in the Five-
Factor Model as the absence of extraversion. This distinction is considered "one
of the m ost im portant conceptual advances" in the Five-Factor Model (Costa &
McCrae, p. 15).
The Openness to Experience domain is perhaps the m ost controversial of the
five factors. It is sometimes a struggle to explain the Openness dom ain because it
is so broad of a dimension, incorporating everything from fantasy to behavioral
flexibility to intellectual engagement. Some psychologists have argued that it is
not a factor at all, bu t instead reflects culturedness, intelligence or "intellectance"
(Glisky, Tataryn, Tobias, Kihlstrom & McConkey, 1991). Costa and McCrae have
26
shown, however, that Openness is both "conceptually and empirically distinct"'
from intelligence and culturedness (Glisky et al.).
Openness to Experience is described as the "proactive seeking and
appreciation of new experiences" (Piedmont, 1998, p. 27). Those scoring high in
"O" are "curious about inner and outer worlds" having "experientially richer
lives" than those scoring low in "O" (Costa & McCrae, 1992, p. 15). They have a
need for complexity and an "intrinsic appreciation for experience" (McCrae,
1996, p. 326). Elements of Openness include "active imagination, aesthetic
sensitivity, attentiveness to inner feelings, preference for variety, intellectual
curiosity, and independence of judgm ent" (Costa & McCrae, p. 15). Those who
score low in "O" are both more conventional and conservative in behavior and
outlook, prefer the familiar to the novel, express more m uted emotional
responses (Costa & McCrae), and portray a "down-to-earth utilitarianism "
(McCrae, p. 326). O pen individuals actively seek out new experiences, b u t closed
individuals, while not resistant to new ideas, are simply uninterested.
Agreeableness is similar to Extraversion, in that it reflects the "quality" of
interpersonal interactions (Costa & McCrae, 1992). It differs in the sense that it
"examines the attitudes an individual holds toward other people" [italics added],
rather than w hether or not a person enjoys being with others (Piedmont, 1998, p.
89). These attitudes can range from compassionate, trusting and altruistic to
antagonistic, m anipulative and egocentric.
The final domain, Conscientiousness, is described by some as the Will to
Achieve, Control and Constraint, and is reflective of "the am ount of persistence,
organization, and m otivation to succeed in goal-directed endeavors" (Piedmont,
27
1998, p. 27). High scorers of "C" are "purposeful, strong-willed, and
determined," associated w ith academic and occupational achievement, as well as
fastidiousness and w orkaholic behavior (Costa & McCrae, 1992, p. 16).
The Five-Factor M odel has been regarded as the "preem inent
m easurement paradigm for personality" (Piedmont, 1998, p. 31) in both clinical
and applied contexts, and is used w ith both norm al and clinical populations.
Piedmont proposes that the Five-Factor Model will become the prem iere
personality assessment tool in the future, serving as "the basis for all
conversations about personal disposition" (p. 32). The NEO PI-R is recognized as
being most valuable in research involving personality because it provides such a
"comprehensive assessm ent of the [five] major dimensions of personality" (Costa
& McCrae, 1992, p. 37). H undreds of studies using the NEO-FFI and the NEO PI-
R exist in research literature, docum enting the validity of the instrum ent, as well
as the respect it has garnered in the last few decades of use.
Summary of Literature
American nurse-m idw ives have provided care for women, rich or poor,
Black or White, schooled or nonschooled, for decades. The last five decades has
seen a trem endous increase in the num ber of Certified Nurse-M idwives in the
United States. In this age of m edia-saw y consumerism, wom en are becoming
more aware of their choices of health care providers for their m aternity care.
Nurse-midwives should identify characteristics of their population in order to
more appropriately serve them and individualize their services, as well as to
expand their services to w om en not currently aware of nurse-midwifery services.
No studies differentiate personality traits between women choosing nurse-
28
midwives and obstetricians. This study, w ith the Health Belief Model as a guide
and utilizing the NEO-FFI to objectively m easure personality traits, is a
beginning attem pt to determ ine if choice of a maternity care provider is
significantly associated w ith personality characteristics.
CHAPTER 3
METHODOLOGY
Design
This was an exploratory, descriptive comparison study betw een two
groups of childbearing women: those who utilized obstetricians and those w ho
utilized Certified Nurse-M idwives during their pregnancies. Since the wom en
self-selected their health care provider, the investigator had no control over this
variable.
Setting
The investigator identified tw o practices that appropriately fit the needs of
the study. One was an independent obstetrical practice of six obstetricians, and
the other was a nurse-midwifery practice of four Certified Nurse-M idwives. The
obstetricians and nurse-midwives operate independent clinics and each deliver
at two of the same hospitals. The hospitals are community based, level-two or
three facilities, located approximately 5 miles apart in the suburbs of a large
Mountain West city. The obstetricians currently do not provide medical back-up
to Certified Nurse-Midwives, and the Certified Nurse-Midwives participating in
the study have back-up provided by obstetricians other than those participating
in this study. All six of the obstetricians w ho were approached to participate in
the study were male and three of the four Certified Nurse-M idwives were
female.
30
Sample
A nonprobability sampling strategy was adopted for this study. Since
there were multiple exclusionary elements for the participants (e.g., nonm arried,
multigravid), this tactic reduced variation and allowed for a m ore focused
sample group (Polit & Hungler, 1999).
Women at any stage of their pregnancy were allowed to participate. The
study was limited to primigravidas, in an effort to eliminate a previous
pregnancy's outcome influencing a choice of care provider in a current
pregnancy. Women w ith a history of one or two previous uncomplicated
spontaneous or therapeutic abortions were allowed to participate. O ther
inclusion criteria included English speaking, married, between the ages of 18-35
years, have at least a high school education, and be privately insured. These
criteria were developed to focus on the "nonvulnerable" patients w ho have been
found to actively seek out nurse-midwifery care. Exclusion criteria included any
health complications that w ould require a physician's care during pregnancy.
Procedures
The investigator explained the purpose and m ethod of the study to the
obstetricians and nurse-midwives. Letters of support were signed by all care
providers agreeing to participate in the study. The investigator then worked w ith
ancillary staff to identify potential subjects. Each wom an meeting the criteria of
the study was approached by a staff m em ber and asked to consider participating
in the study. If she agreed, she w as asked to fill out the NEO-FFI questionnaire
and a demographic survey before she left the office.
31
The NEO-FFI w as designed to be administered to individuals age 17 or
older, and generally takes only 10 m inutes to complete. The participants were
given the inventory and w ere allowed to fill out the inventory and survey at any
point during an office visit with their health care provider. The investigator then
collected the inventory and survey before the participant left the clinic.
Ethical Considerations
Several steps w ere taken to ensure the rights of the wom en participating
in the study. The University of Utah's Institutional Review Board initially
reviewed the proposed study. The study w as then presented to the participating
obstetricians' and Certified Nurse M idwives' offices for review and approval.
The women participating in the study read a consent letter stating if the
inventory was returned completed they w ere agreeing to participate in the study
(see Appendix A). The envelopes in which the forms were returned w ere coded,
w ith corresponding codes assigned to each NEO-FFI and dem ographic survey.
No identifying features of the w om en's history or pregnancy w ere used. The
wom en were notified of their right to w ithdraw from the study at any time. Only
the investigator view ed the completed NEO-FFI forms. HIPAA regulations were
also strictly followed, both in the office setting and during data collecting and
analysis.
Data Collection
Demographic d ata. The participants completed a brief dem ographic
survey assessing the following characteristics: age, race, marital status, education
level, religious affiliation, medical insurance status, family income, and
32
employment status (see Appendix B). The participants were also asked to answer
two brief written questions including w ho referred them to their current care,
and if, and why or w hy not, they considered using an alternative care provider
(i.e., using an obstetrician if she was a nurse-midwifery patient).
NEO Five-Factor Inventory. The instrum ent used to analyze personality
traits was the NEO Five-Factor Inventory, know n as the NEO-FFI (see item
examples in Appendix C). The inventory is a short version of the m ore extensive
NEO Personality Inventory-Revised. Costa and McCrae (1992) suggest that the
NEO-FFI be used in situations w hen time is limited, as was the case in this study.
The inventory m easures five major dom ains of personality: Neuroticism,
Extraversion, Openness to Experience, Agreeableness, and Conscientiousness,
using a 60-item scale w ith Likert-style statements, rated on a 5-point response
scale with anchors of 0: strongly disagree and 4: strongly agree. The NEO-FFI has
shown evidence of both convergent and divergent validity (McCrae & Costa,
1992). The NEO-FFI dem onstrates correlations ranging from .77 to .92 w hen
correlated with the full version of the NEO-PI R (Costa & McCrae). W hen
evaluated for internal consistency coefficients ranged from .68 to .86. Costa and
McCrae mention that "the values are smaller than those for the corresponding
NEO PI-R dom ain scales," but that this is both acceptable and expected as "some
precision is traded for speed and convenience" (pp. 53-54).
Mean scores on the NEO PI-R rem ain stable throughout adulthood
(McCrae & Costa, 1990). Piedm ont (1998) explains that since the five personality
domains capture "genotypic qualities" of personality, the traits rem ain stable
over time, with 6-year test-retest values near 0.80 (p. 39). A study led by Costa
33
and McCrae including 10,063 individuals ranging from ages 32 to 88 years found
that the younger individuals were slightly higher in neuroticism, extraversion
and openness to experience, b u t despite that finding still concluded that
"personality is predom inantly stable in adulthood" (Costa, McCrae, Zonderman,
et al., 1986, p. 144). M ore recent longitudinal and cross-cultural studies have also
dem onstrated that there are "m aturational changes" between college age adults
and middle-age, resulting in a m odest decrease in N, E and O, and increases in A
and C adults (Costa & McCrae, 2002, p. 227). Piedmont also acknowledges that
some personality characteristics may change over time, but generally only in
periods of severe emotional stress, such as depression, remission, onset of
psychiatric disorders, and, interestingly enough, religious conversion.
CHAPTER 4
RESULTS
Sample
Subjects were recruited between April and May 2003. Eighty-one wom en
participated in the study. Seventy wom en were eligible according to the criteria
set by the investigator. In accordance w ith study criteria, all of the subjects were
married, privately insured, and primigravidas. Eleven w om en were not included
in the study due to age, marital status, insurance status, education level,
language preference or lack of information provided. Approxim ately 2 eligible
women declined to participate in the study, citing a lack of time to complete the
required questionnaires.
Nearly half (47.1%) of the subjects w ere between the ages of 25 to 30 years
(n = 33), with 42.9% falling between the ages of 18-24 years (n = 30) (see Table 2).
Ten percent (n = 7) of the subjects were over the age of 30. 58.3% of obstetrician
(OB) patients fell between the ages of 18-24, while 61.8% of Certified Nurse-
Midwife (CNM) patients falling between the ages of 25-30. Only 3 OB patients
(8.3%) and 4 CNM patients (11.8%) were over the age of 30.
A majority of the subjects were Anglo-American (92.9%, n - 65), w ith 4
Latina women (5.7%), and 1 Polynesian w om an participating in the study. This is
reflective of the region in which the study was performed w here 79.2% of the city
35
Table 1
Frequency of Demographic Data by Independent Group
OB CNM TOTAL
Demographics n % n N %
Age
18-24 21 58.3 9 26.5 30 42.9
25-30 12 33.3 21 61.8 33 47.1
31-35 3 8.3 4 11.8 7 10.0
Education
High School 8 22.2 5 14.7 13 18.6
2 Year degree 9 25.0 8 23.5 16 22.9
Some college 10 27.8 8 26.5 19 27.1
College degree 8 22.2 8 29.4 18 25.7
Professional 1 2.8 2 5.9 3 4.3
Religion
LDS (Mormon) 31 86.1 18 54.5 49 70.0
Non-LDS 5 13.9 15 45.5 20 22.6
Race
Anglo-American 35 97.2 30 88.2 65 92.9
Latina 1 2.8 2 8.8 2 5.7
Polynesian 0 0 1 2.9 1 1.4
Income
$10,000-24,999 6 17.1 5 14.7 11 15.7
$25,000-49,000 13 37.1 10 32.4 24 34.3
$50,000-74,999 10 28.6 9 26.5 19 27.1
$75,000-99,999 6 17.1 5 14.7 11 15.7
>$100,000 0 0 4 11.8 4 5.7
Employment
None 4 11.1 5 14.7 9 12.9
Part-time 7 19.4 5 14.7 12 17.1
Full-time 25 69.4 24 70.6 49 70.0
36
is Anglo-American, 18.8% Latino and 1.9% Polynesian (U.S. Census Bureau,
Census 2000).
Subjects w ere nearly evenly divided between education groups, w ith 16
subjects (22.9%) possessing a 2-year degree, 19 subjects (27.1%) having attended
less than 4 years of college, and 18 subjects (25.7%) having a 4-year college
degree. Thirteen wom en (18.6%) had a high school or GED equivalent, while
only 4.3% (n = 3) had a professional or graduate degree.
Almost 35% of the subjects (n = 24) were in the income range from
$25,000-49,999, w ith 70% of the subjects (n = 49) currently em ployed full time. An
additional 27.5% (n = 19) were in the income range from $50,000-74,999. No
subjects reported an income level less than $10,000, and only 4 subjects reported
an income greater than $100,000.
Seventy-one percent of the study participants (n = 49) belonged to the
Church of Jesus Christ of Latter Day Saints (Mormon or "LDS"), which is
reflective of the general population in which the study was perform ed. Ten
w om en (14.5%) w ere either Protestant or Catholic, while an additional 8 wom en
(11.6%) claimed no religious affiliation. Nearly all of the OB patients were
members of the LDS church (86.1%, n = 31), while only 54.5% (n = 18) of CNM
patients were LDS.
Data Analysis
Following the data collection, data from the completed questionnaires
were analyzed using SPSS 11.0 for W indows (SPSS Inc., 2002). A chi-square test
was conducted to compare the demographic differences between the OB and
CNM patients. A sam ple size of 70 subjects was used, as well as a .05 level of
37
significance. The demographic characteristics compared w ere age, race,
education, religion, income, and employment. The results of the test were
significant for age (2, N = 70) = 7.35, p = .03 and religion Xi (2, N = 70) = 8.33,
p = <.01. Chi-square test results dem onstrated that the nurse-midwifery patients
were older and less likely to belong to the LDS church than the obstetricians'
patients.
The observed NEO-FFI scores were converted to T-scores by the equation
[(X - M) / SD)] * 10 + 50. The values for the normative Means and Standard
Deviations were taken from Table B-4 in the Professional M anual for the NEO PI-
R and the NEO-FFI, for adult women, Form S (Costa & McCrae, 1992, p. 78).
Scores of 55.5 and above are considered to be high; scores betw een 44.5 and 55.5
are average, and scores below 44.5 are low.
Analysis of Dependent Variable: NEO-FFI Scores
Both groups of OB and CNM patients scored similarly on the Neuroticism
facet of the NEO-FFI, w ith m eans of 48.82 and 45.89 respectively. This places
both groups within the average category, although CNM patients are nearly in
the low category of Neuroticism (see Figure 3).
OB patients scored in the average range of Extraversion as well (M =
54.98, SD = 10.00), while CNM patients barely scored in the high range with their
m ean score of 55.79 (SD = 7.88). The m ean "O" score of the CNM patients of
55.45 (SD= 9.07) places these wom en just barely high in Openness to Experience.
The mean OB score of 46.25 (SD = 6.45) is on the lower end of average.
38
* OB
- - ■ — -CNM
60 -i
>55.5 High
44.5-55.5 A verage
<44.5 Low
N S core E S core O S co re A S co re C Score
Figure 2. NEO-FFI scores of OB and CNM patients.
Both OB and CNM patients scored solidly average in Agreeableness (M =
50.74, SD - 14.59; M = 52.37, SD = 11.77). The scores for Conscientiousness were
also very average in term s of Conscientiousness for both groups. The m ean score
for OB patients was 49.88 (SD = 9.77) and the mean "C" score for the CNM
patients was 48.71 (SD = 9.15).
Independent-sam ples t tests were conducted on the T-scores to evaluate
the difference between m ean group scores on the NEO-FFI (see Table 2). The test
was significant only for the Openness to Experience facet, t (59.32) = -4.86, p =
<.01. Women who w ere patients of OBs (M = 46.25, SD = 6.45) scored lower in
Openness to Experience than w om en w ho were patients of CNMs (M = 55.45, SD
= 9.07). Results of the independent-sam ples t -tests dem onstrated that wom en
who choose nurse-midwifery care are m ore Open to Experience than wom en
w ho choose obstetric care.
39
Table 2
NEO-FFI Results by Provider Group and t-testfor Independent Groups
Score by Group M SD V Range
N Score
OB 48.82 10.38 .22 28.27-71.63
CNM 45.89 9.26 28.27-69.00
£ Score
OB 54.97 10.00 .71 39.42-78.93
CNM 55.79 7.88 39.42-70.34
0 Score
OB 46.25 6.45 <.01* 34.70-63.66
CNM 55.45 9.07 38.11-75.59
A Score
OB 50.74 14.59 .61 10.42-73.71
CNM 52.37 11.70 16.75-77.93
C Score
OB 49.88 9.77 .61 27.44-68.96
CNM 48.71 9.15 23.98-60.31
*p = <.05
Analysis of Covariance: Controlling for Religion and Age
Because the CNM and OB groups differed in their religious preferences
and their age, ANCOVAs were run to control for these variables. This test
demonstrated that the difference between the CNM groups' adjusted m ean "O"
score of 54.43 (SE = 1.40) and the OB groups' adjusted m ean "O" score of 47.14
(SE = 1.33) were still significant after controlling for the effects of age and
religion (F (1, 65) = 12.99, p = < .01).
40
Qualitative Data
All of the wom en completing the study were asked to complete one short
answer question: "If you're seeing a Certified Nurse-Midwife [or, alternatively,
Obstetrician] for your pregnancy, did you ever consider seeing an Obstetrician
[or Certified Nurse-Midwife]?" Checkboxes were provided for Yes and No
responses, and the wom en were then asked, "Why or Why Not?" w ith several
lines provided for short answer responses.
Considering the alternatives. Only 11% (n = 4) of the 36 OB patients said
they had considered seeing a Certified Nurse-Midwife for their pregnancy, or
indicated that they w ould consider it in the future. Interestingly, two of the three
highest OB "O" scores w ere by wom en who indicated they had considered
seeing a nurse-midwife for their pregnancy. Six wom en (17%) simply claimed
they had "never thought about" choosing a nurse-midwife, one in particular
stating "it never even crossed m y m ind." Statements such as these demonstrate
the total absence of nurse-m idwives from the general public's consciousness.
A greater num ber of CNM patients considered an OB for their m aternity
care, although m any discussed their reasons for avoiding OBs altogether. Fifteen
(44%) of the CNM patients stated that they had actually considered an OB for
their care "just to w eigh the options," but several women felt that OBs were "too
steeped in medicine" and w ould just "come in at the last minute" for the birth.
Only 1 woman stated she was looking m ore for a "good female provider" than a
CNM specifically.
Social circles and personal recom mendations. A large num ber (29%) of
CNM patients stated that they chose a nurse-midwife over a physician
41
specifically because of the recommendation from a friend or family member. The
same held true for OB patients: one wom an stated her doctor was
"recom mended by family tradition/' while another never considered m idwifery
care because "everyone I know sees a doctor."
OB patients: Lack of understanding. Approximately 30% (n - 11) of the
OB patients responded in a m anner that demonstrated lack of understanding of
m odem nurse-midwifery practice, stating the often m entioned reason of "I
w anted to have the baby at a hospital," as well as "[there is] no immediately
emergency care available for m e and my baby when using a midwife." Many
statements also reflected concerns over the skill, knowledge, and safety of
CNMs, such as the "technical skill of a doctor is more comforting," or one
responder who "d id n 't w ant to chance it w ith a midwife."
CNM patients: Personal attention and time. The m ost frequent response
from CNM patients was that the time, attention and support that nurse-
midwives offer was w hat drew them to midwifery care. Twelve wom en (35%)
m entioned that a nurse-midwife w ould "advocate for my desires," while
providing "one on one time" and "personalized care," while being "attentive to
m y needs and concerns." W omen stated they chose the "alternative approach" of
a CNM because the care was "more in line with my personal philosophy on
childbirth," viewing "pregnancy as a natural part of life, not as an illness." Time,
individualized care and a nonmedicalized approach to pregnancy and birth are
hallm arks of midwifery care.
Previous care w ith provider. The study focused on prim iparous wom en to
eliminate the possibility of a w om an returning to a previous care provider
42
simply out of habit. However, both obstetricians and nurse-m idwives do not
soley provide obstetric care—both are trained in gynecologic care as well. Several
OB patients stated they chose their obstetrician for this double duty, obviously
not realizing a nurse-midwife could perform these tasks as well. Only four
women (6% of the total) stated that they had already been utilizing their care
provider for gynecologic care prior to their pregnancy, essentially elim inating
this from being a lim itation of the study.
CHAPTER 5
DISCUSSION
Interpretation of NEO-FFI Scores
Both patients of nurse-m idwives and obstetricians tended to exhibit w hat
is considered average, or normal, personality profiles as m easured by the NEO-
FFI. Based on the average Neuroticism, or "N" score, wom en in this study as a
whole were emotionally stable and experienced w hat is considered to be a
normal am ount of psychological distress. Their self-esteem is neither high nor
low, and they are able to deal w ith stress as well as "the average person" (Costa
& McCrae, 1992, p. 25). Those w ho score lower on Neuroticism are m ore secure
and remain relaxed even under stressful conditions.
Patients in this study tended to show moderate to moderately high levels
of Extraversion. The average Extraverted person is m oderately active and
enthusiastic. They generally enjoy being in the company of other people, but also
value their own privacy. More Extraverted subjects are more outgoing and high-
spirited, having a high level of energy. They are also more cheerful and
optimistic.
Women choosing nurse-m idwives and obstetricians both scored in the
average range of Agreeableness. Agreeable patients are good natured, "trusting
but not gullible," and sympathetic. They are cooperative, but can also be
stubborn at times (Costa & McCrae, 1992, p. 9).
44
The nurse-midwifery and obstetricians' patients were also both average in
Conscientiousness as well. The average Conscientious person is know n to be
dependable and som ewhat well-organized. They have clear goals, are
m oderately self-disciplined, b u t not so m uch that they are unable to set aside
w ork for play.
Choice of Provider and Implications of "O" Scores
The only significant difference in scores between the obstetrician and
nurse-midwifery patients was in the Openness to Experience domain. The nurse-
m idwifery patients w ere m ore Open to Experience than the obstetricians'
patients. This finding suggests that wom en who choose nurse-m idwives have
broad interests, are imaginative, and actively seek out new experiences. They
m ay be more willing to entertain unconventional values, and experience
emotions more deeply. They are likely to have a greater appreciation for art and
beauty, and are seen by others as original and curious, as compared to the
w om en who choose obstetricians. An average Open person values the familiar
and is practical in nature. While they m ight be willing to try new experiences,
they do not "seek out novelty for its own sake" (Costa & McCrae, 1992, p. 25).
They are also more traditional and conservative than those scoring higher in
Openness.
A vast am ount of research has been conducted utilizing the NEO PI-R and
the NEO-FFI. Studies have linked Openness, for example, to a w ide variety of
occurrences, such as depression rates, hypnosis and internet use. This study,
which links nurse-midwifery patients and Openness, m ay provide particularly
45
useful information to nurse-m idwives as they attem pt to reach out to new
patients and better serve their current patients.
Depression and O penness. Wolfenstein and Trull (1997) found that
subjects who were currently depressed or had experienced "significant
depressive symptoms in the past" scored higher on Openness to Experience.
McCrae and Costa (1985) report that openness "magnifies the intensity of our
emotions, giving us higher peaks and deeper lows" (p. 151). A curious
phenomenon was reported in patients w ho chose to deliver in an alternative
birthing center w ith fewer physicians in attendance as opposed to the traditional
delivery suite in a hospital (Bradley, Tashevska, & Selby, 1990). The w om en at
the birthing center reported a higher incidence of postpartum depression than
their traditional birth counterparts. If the patients desiring alternative births were
on a whole more Open, this could, in part, explain why they later reported a
higher incidence of postpartum depression.
Although the association betw een Openness and depression was not
examined in the present study, it does have implications for nurse-midwifery
practice. If nurse-midwives are aware that their patients m ay be m ore prone to
postpartum depression they m ay take increasing efforts to decrease the
occurence. These steps m ay include screening for depression with more
frequency, offering counseling services in their office, or simply spending a
greater amount of time discussing a w om an's fears and expectations of birth and
motherhood.
Hvpnotizability and Openness. Glisky et al. (1991) found that Openness is
significantly correlated w ith hypnotizability. This is particularly relevant to
46
nurse-midwives as nurse-midwifery services are beginning to offer
hypnobirthing as an alternative m ethod of childbirth. The nurse-m idwifery
service used in this study, for example, prom otes hypnobirthing as one of several
childbirth options, and one of the nurse-midwives teaches the childbirth portion
of a hypnobirthing class. Generally w om en have no exposure to hypnosis prior
to registering for the hypnobirthing class, so it is unlikely that they are seeking
out this particular nurse-midwifery service because they know themselves to be
hypnotizable. W hat is more likely is that their higher Openness tendencies first
lead them to choose a nurse-midwife, and then later leaves them willing to
participate in the new experience of hypnosis.
Knowing nurse-midwifery patients m ay have greater success w ith
hypnosis may encourage more nurse-midwives to offer this experience to their
patients. Nurse-midwives and hypnotherapists may eventually choose to screen
their patients to identify who w ould benefit m ost from a hypnotized birth.
Perception of health. Nurse-m idwives prom ote pregnancy as a time of
health and growth in a wom an's life. Goodwin and Engstrom (2002) found that
Openness to Experience was related to perceptions of good health both in those
with and w ithout self-reported medical problems. Those low er in Openness
rated themselves in poorer health, w hether or not they reported medical
problems. As mentioned earlier, the medical community and the public views
pregnancy as a medical crisis, in need of medical assistance and intervention.
Nurse-midwives prom ote pregnancy as a time of health. W omen w ho are Open
may be more accepting of this alternative view, and m ore in line w ith the
midwifery philosophy. A nurse-midwifery patient included in this study stated
47
that she chose a nurse-midwife because both she and the nurse-midwife view
pregnancy "as a natural part of life, not an illness." Having identified patients
w ho see themselves in a state of health may allow nurse-midwives to later
suggest further health prom otion activities, such as healthy diets and exercise
habits.
Media and internet use. Previous studies evaluating the Openness
personality trait m ay aide nurse-midwives in marketing. For example, Finn
(1997) explored the relationship between personality traits and m edia use finding
Openness to Experience strongly related to pleasure reading, and negatively
related to TV. Finn's study has the potential for completely redirecting marketing
tactics for nurse-midwives away from television and instead tow ards p rint ads
and articles in magazines.
A study by Tuten and Bosnnjak (2001) associated Openness to Experience
w ith internet use. One obstetric patient in this study who scored a high 56.85 on
Openness, stated that she found her provider through the internet. This
information should provide the incentive to nurse-midwifery practices to
develop or expand their current internet sites in order to attract m ore nurse-
midwifery friendly clients.
This current study has reinforced the findings that the lay public is
misinformed or completely uninformed regarding the services and abilities of
nurse-midwives. W hen asked if they had considered the services of a nurse-
midwife women responded by saying " [it] never occurred to m e" or "never
even thought about it." O ther women were unaware that nurse-m idwives
48
provided gynecologic services in addition to obstetric care, or were unaw are that
nurse-midwives attend births in a hospital setting.
There is a paucity of knowledge in the general public regarding nurse-
midwifery care. Misconceptions regarding the education and skill level of nurse-
midwives are a common occurrence, and can be very frustrating to a provider
trying to expand her practice. Williams (2002) encouraged nurse-m idwives to
m arket themselves to the general public by using phrases such as "licensed,"
"nationally certified/' and "m aster's degree" (p. 2). Identifying those m ost
receptive or "open" to their services m ay be one of the first steps taken to expand
the knowledge of health consumers.
Effects of Age and Religion on NEO-FFI Scores
Chi square tests revealed that the OB and CNM groups did differ
significantly in their ages, w ith CNMs having a higher percentage of older
patients. This is not surprising, as it is consistent with literature that states
wom en who actively seek nurse-midwifery and other alternative forms of
maternity care generally are older (Anderson & Greener, 1991; Cohen, 1982;
Rooks et al., 1989; Schneider, 1986; W aldenstrom & Nilsson, 1993; W oodcock et
al., 1990). Several studies have dem onstrated that NEO PI-R scores rem ain stable
throughout one's adulthood (Costa, McCrae, Zonderman, et al., 1986; McCrae &
Costa, 1990; Piedmont, 1998), decreasing only slightly from college age to post
college adulthood.
The conservative LDS culture from which this sample was draw n m ay
have influenced the data causing more conservative m arried w om en to chose an
obstetrician for care. Interestingly, the fact that fewer nurse-midwifery patients
49
were LDS is in line w ith a study that found that women w ith no religious
affiliation were m uch m ore likely to choose a nurse-midwife than a physician
(Howell-White, 1997). A second study found Openness to be negatively related
to religious fundam entalism, yet positively related to "m ature religiosity and
spirituality" (Saroglou, 2002, p. 15). One m ust keep in m ind that the nurse-
m idwifery patients were not "non-religious," they were term ed "non-LDS" for
statistical purposes only; 10 nurse-m idwifery patients (30.3%) were either
Catholic or Protestant.
The ANCOVA tests dem onstrated that the difference in the Openness
score between the obstetrician and nurse-midwifery patients was not affected by
the groups' age or religious differences. Despite the support offered by these
findings, further study of this phenom enon is recommended in a part of the
country where the culture is not so religiously homogenous.
Single Women
An interesting observation was m ade during the data collection process
about the difference in dem ographics between the obstetrician and nurse-
m idwifery patients. It was not at all difficult to quickly enroll m arried, privately
insured, prim iparous w om en from the obstetric practice. Very few w om en were
excluded because of their m arital status. However, the percentage of w om en
w ho fit these criteria in the nurse-m idwifery practice was m uch smaller. No
statistics were kept on this phenomenon, but between 10 to 20 prim iparous
wom en were excluded from the study simply because they were single.
There are a num ber of possible explanations for this occurrence. Based on
the demographic inform ation that we do have on these two practices, we know
50
that the obstetricians' practice consists of a m uch larger percentage of LDS
women. Couples of the LDS faith are strongly discouraged from sex before
marriage, and if an unw ed wom an becomes pregnant the couple often quickly
marries. Therefore, a higher percentage of this practice is likely to be m arried.
Perhaps single, unw ed wom en simply felt more comfortable w ith a female
provider—in this case a nurse-midwife, and felt that a male obstetrician w ould
be too "paternal." If the pregnancy was a result of a short-term relationship or
even an abusive relationship perhaps a single, pregnant wom an w ould w ish to
avoid contact w ith m en altogether.
Or lastly, since we know that this particular group of m arried nurse-
midwifery patients is m ore Open to Experience, perhaps the same is true for the
single patients of these nurse-midwives as well. It is likely that if a w om an is
comfortable w ith the idea of single motherhood, she is more liberal in her values
and would in turn be m ore Open to Experience. She w ould then be choosing a
nurse-midwife in part because of her personality profile.
While m ost of the single women were not given a study to complete, three
obstetric patients and one nurse-midwifery patient mistakenly completed the
study. The m ean "O" scores for these single wom en was 56.42, higher than the
average "O" score of both nurse-midwives (55.45) and obstetricians (46.25).
Results from McCrae and Costa (1985) support this hypothesis. They found that
open individuals "had a more flexible view of ru le s... [and] rejected traditional
sex roles" (p. 153). Taking this study one step further and including both single
and m arried wom en could have very interesting and robust results.
51
Assumptions
A main assum ption of this study w as that personality plays a significant
role in choice of health care provider. The inference is that personality
characteristics influence one's likelihood of seeking a health care provider, and
that decisions regarding pregnancy and birth have m ultiple factors influencing
their decisions regarding the choice of either obstetrician or nurse-midwife.
Another assum ption was that the w om an was either the prim ary or sole
decision maker regarding her m aternity care provider, and that she w as not
influenced by her partner, family, or friends as to whom she should select for her
maternity care. This certainly was not the case. An overwhelming num ber of
wom en stated they were referred to their current provider by family or friends,
and one women stated she chose her provider because her spouse "felt confident
about this midwife."
The study was controlled for prim iparous women, in an effort to exclude
any women who had utilized a different care provider in a previous pregnancy.
But pregnancy is not the only time in a wom an's life that she m ay need the
services of an obstetrician or nurse-midwife. When asked w hy they chose their
particular health care provider, several wom en stated they had seen that
provider for gynecologic care in the past. One wom an even stated she had
received "bad advice" from an obstetrician regarding birth control pills, and
therefore sought out the care of a nurse-midwife for her obstetric care. Factors
such as these were not controlled for in the study, and it was assum ed that the
women had never seen her care provider prior to her pregnancy.
52
Limitations
The population from w hich the sample was draw n was a lim itation due to
the religious hom ogeneity of the region. Also of note was all six of the
obstetricians are m embers of and leaders in the LDS church, while only one of
the four nurse-midwives is LDS. The LDS church is highly influential in the local
community, and it is likely that the physicians receive m any church-based
patient referrals.
The sample population was also predom inantly Caucasian, and while this
is reflective of the region's population, is not reflective of the nation's racial
demographics. It was also difficult to accurately assess the differences and
influence of age, as the subjects' ages were grouped into ages 18-24, 25-30, and
31-35. In future studies chronological age should be utilized in data analysis, as
opposed to categorization.
Another lim itation of the study is the remaining demographic
characteristics that the study limited itself to: married prim iparous women. The
investigator strictly adhered to pre-set criteria of including only married,
primiparous, educated, and privately insured women in the study. This was
done to purposefully focus on a narrow segment of the population w ho have
been known to actively choose nurse-midwifery care. Many single w om en in
long-term, committed relationships fit every other criteria bu t were excluded
from the study due to their m arital status. The strict inclusion criteria do limit the
generalizability of the study's results, but the small, homogenous sample also
strengthens the results of the study.
53
The study was also lim ited to prim iparous women, in turn limiting the
study's generalizability. The study is also limited by the fact that only two
practices—an obstetric practice of six physicians and a m idwifery practice of four
nurse-midwives— were included in the study. The study focused on a narrow
segment of population: those receiving care from and giving birth at two
suburban medical centers.
As in any study, a larger sample population w ould benefit the study
tremendously as this w ould improve pow er and contribute to greater
understanding of the phenom ena of interest.
Recommendations for Further Study
Further study is recom m ended in a region of the country in which
religious preferences are m ore reflective of the nation's distribution of religions.
A more thorough study should include practices serving a more racially diverse
population. Future studies should also include both m arried and single women,
as this study excluded a large population of single wom en w ho actively chose
nurse-midwifery care.
This study focused only on prim igravid wom en in an effort to exclude
m ultiparous wom en w ho chose the same care provider as for a previous
pregnancy simply out of habit or loyalty. However, if a wom an w as unhappy
with a provider in a previous pregnancy, it m ay be because the "fit" was
inappropriate, and in the future she m ay spend more time finding a care
provider that more closely matches her values. It is possible that in the end she
will find a more appropriate "fit" with a new provider. H er personality traits,
unchanged throughout the entire search process, w ould be of great interest.
54
Future studies should also consider including both prim igravid and m ultigravid
women, paying close attention to those w ho received care from a different type
of provider in a previous pregnancy. A literature review by Walsh (1999)
concurs, identifying no existing studies evaluating wom en "w ho have
experienced an alternative form of care w ith an earlier birth" (p. 166).
Since significant trends in Openness to Experience were identified
utilizing the NEO-FFI in this prelim inary study, future studies are recom m ended
using the more extensive NEO Revised Personality Inventory (NEO PI-R). This
w ould enable investigators to further and m ore thoroughly identify significant
differences in personality that the NEO-FFI was not able to distinguish.
Conclusion
Professionals in the health care field have long joked about the
stereotypical differences betw een nurse-midwifery and obstetrician's patients.
The nurse-midwifery patients induce their labor w ith herbal teas and give birth
in large bathtubs, while the obstetricians' patients schedule their Pitocin-induced
labor at the hospital, and deliver under sterile drapes and the glare of a spotlight
on their perineum. These stereotypes m ay or may not be all that far-fetched, but
w hat has encouraged them all this time? Certified Nurse-M idwives have been
attending births alongside physicians in hospitals and medical centers for over
half a century and produce birth outcomes that equal or exceed those of
physicians, yet these stereotypes persist.
The FIBM focuses on preventive health action w ith which nurse-
midwifery, focusing on pregnancy as a healthy state, aligns well. The HBM
identifies many different variables or "cues to action" that trigger a consum er to
55
take action concerning a health behavior. These cues include internal cues, such
as symptoms, and external cues, such as the media or advice from others. O ther
modifying factors play a role as well, including demographic, sociopsycho-
logical, and structural variables.
W hen a wom an discovers she is pregnant, many variables affect her
decision of when and whom to go to for maternity care. The first m issed
menstrual period may be the first internal cue for m any wom en to seek care,
while others m ay w ait until quickening. External cues may be a TV commercial
rem inding them to take folic acid, or a family member recom mending a
particular provider. The Review of Literature discussed the m ultitude of studies
reflecting the sociopsychological and structural variables that influence provider
choice. Demographic characteristics of both nurse-midwifery and obstetric
patients have shown that while 70% of nurse-midwifery patients are considered
"vulnerable," the remaining 30% of their patients are older, m arried, educated
and actively seeking a unique birth experience.
But why do they seek a unique birth experience, and w hy do they choose
nurse-midwives? This study focused specifically on the sociopsychological
variable of personality to answer this question, and utilized Costa and McCrae's
NEO Five Factor Inventory to do so.
Women who chose a nurse-midwives or a obstetrician for their m aternity
care, while differing in both age and religious preference in this study
population, also had significant difference on the Openness to Experience
subscale of the NEO-FFI. Openness to Experience has been associated with, but
56
not limited to, creativity, liberal views of politics and sex roles, depression,
pleasure reading, internet use, and perceptions of good health.
This study of personality differences between the patients of nurse-
midwives and obstetricians is the first of its kind, breaking new ground in its
discovery of a significant personality difference between these groups of women.
Further studies have the potential to assist in answering questions regarding
motivation, choice, goals, expectations, preferences, and needs of wom en seeking
maternity care.
APPENDIX A
LETTER OF CONSENT
58
D ear Research Participant:
You have been asked to participate in a study as part of my requirem ents for a
M aster of Science in Nursing. This study uses the NEO Five Factor Inventory
(NEO FFI), which measures individual differences. The study will compare
personality characteristics of wom en who choose obstetricians w ith those w ho
choose certified nurse-midwives for maternity care. If the test is able to
differentiate personality traits between those who choose obstetricians from
those w ho choose nurse-midwives, health care providers m ay be able to provide
more focused care to wom en's individual needs.
The NEO FFI takes about 10 m inutes to complete. There are no know n risks to
filling out this study. You will also be asked to fill out a brief survey listing
additional information about yourself. You m ay omit any questions or
statements. You are welcome to complete the test while you w ait for your
appointment, or following the appointment. You are asked, however, to
complete the test before you leave the office.
Before the forms are given to you, they will be labeled to identify w hether the
surveys belong to an obstetric or nurse-midwifery patient. You will be given an
envelope to return your completed forms to the investigator. All inform ation that
you give us during this study is confidential and carefully protected. Your nam e
or any information by which you can be identified will not be included in the
study. Once the surveys have been completed, the prim ary investigator and a
research assistant will enter the results into a computerized statistical program .
The researcher and her assistants will be the only people w ho will see the
completed studies and surveys.
If you have any questions or concerns regarding this research, please contact
Emily Stange at 595-1230 (home) or 718-9531 (cell). If you have questions
regarding your rights as a research subject, or if problems arise which you do not
feel you can discuss w ith the Investigator, please contact the Institutional Review
Board Office at (801) 581-3655.
You are making a decision w hether or not to participate in this study. By

returning the completed surveys you are agreeing to participate in the study.
Thank you very much for reading this letter, and completing the study.
Sincerely,
Emily Stange, RN
APPENDIX B
DEMOGRAPHIC AND QUALITATIVE SURVEY
60
Age
18-24 years □
25-30 years Q]
31-35 years □
Race
Caucasian I I
Latina/Hispanic □
Asian □
Polynesian □
Native American □
Other (please specify) __
Marital Status
Married Q
Single □
Divorced □
Separated I I
Widowed I I
Education Completed
High School or GED □

2-Year College/Technical School □
Some College (less than 4 years) □
4-Year College □
Professional/Graduate School □
Other (please specify)
Religious Affiliation
Protestant □
Catholic □
Latter Day Saint □
Unitarian Universalist □
None □
Other (please specify)
Covered by Medical Insurance for Pregnancy
Yes □
No □
Total Family Income
Less than $10,000 Q

$10,000-$24,999 □
$25,000-$49,999 □
$50,000-$74,999 □
$75,000-$99,999 □
$100,000 or more □
Current Employment
Not employed O
Part-time employment □
Full-time employment [~1
Who referred you to your current health care provider?
Family Q
Friend □
Yellow Pages Q
Advertisement O
Other (please specify) _______________________
62
If you're seeing an Obstetrician for your pregnancy, did you ever

consider seeing a Certified Nurse-Midwife?
Yes □
No □
Why or Why not?
63
If you're seeing a Certified Nurse-Midwife for your pregnancy, did

you ever consider seeing an Obstetrician?
Yes □
No □
Why or Why not?
APPENDIX C
ITEM EXAMPLES FROM THE NEO OPENNESS SCALE
65
"I am intrigued by the patterns I find in art and nature."
"I often try new and foreign foods."
"I have a lot of intellectual curiosity."
"I often enjoy playing w ith theories or abstract ideas."
"I don't like to w aste m y time daydream ing." (negatively scored)
"Once I find the right w ay to do something, I stick to it." (negatively scored)
Note. Reproduced by special permission of the Publisher, Psychological

Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549,
from the NEO Five-Factor Inventory, by Paul Costa and Robert McCrae,
Copyright 1978,1985,1989 by PAR, Inc. Further reproduction is prohibited
without perm ission of Par, Inc.
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PERSONALITY CHARACTERISTICS OF WOMEN CHOOSING

CERTIFIED NURSE-MID WIVES OR OBSTETRICIANS

FOR MATERNITY CARE

Emily Susan Stange

A thesis subm itted to the faculty of

The University of Utah

Copyright 2004 by ProQuest Information and Learning Company.

All rights reserved. This microform edition is protected against

unauthorized copying under Title 17, United States Code.

ProQuest Information and Learning Company

All Rights Reserved

SUPERVISORY COMMITTEE APPROVAL

of a thesis subm itted by

Emily Susan Stange

FINAL READING APPROVAL

To the Graduate Council of the University of Utah:

Approved for the Major Departm ent

Approved for the G raduate Council

This study examined w hether or not there are significant differences in

personality traits betw een w om en who actively choose nurse-midwives instead

specific, "nonvulnerable" group of women who make a conscious choice to have

a nurse-midwife as a provider. Seventy married, primiparous, privately insured

patients who self-selected either a nurse-midwife or a physician were included in

characteristics of pregnant wom en who utilize nurse-midwives. The inventory

who chose nurse-midwifery care were found to be significantly more O pen to

Certified Nurse-Midwives, while nurse-midwifery patients actively seek out the

time and attention that a nurse-midwife provides them. Implications of the

Theoretical F ram ew ork.......................................................................... 3

2. LITERATURE REVIEW ..................................................................................10

In tro d u c tio n ...........................................................................................10

Interpretation of NEO-FFI Scores........................................................ 43

B. DEMOGRAPHIC AND QUALITATIVE SURVEY...................................... 59

C. ITEM EXAMPLES FROM THE NEO OPENNESS SCALE..........................64

American nurse-midwives have provided maternity care for wom en since

sa w y consumerism, informed choice, internet Web sites, and provider

care providers for their m aternity care.

Historically, nurse-midwives have cared for women in underserved

Certified Nurse-Midwives dem onstrated that 70% of midwifery patients are

considered to belong to a "vulnerable" population group, due to their insurance

status, race/ethnicity, age, level of education, or residential area (Paine et al.,

midwife for their nonmedical, noninterventional, woman-centered approach to

to demographic information to characterize this "nonvulnerable" group of nurse-

midwifery or "alternative" m aternity care tend to be more educated (Aaronson,

& Greener; Rooks et al; Schneider; W aldenstrom & Nilsson), m ultiparous

(Schneider; W aldenstrom & Nilsson), and less likely to have a particular

religious affiliation (Howell-White, 1997). A few studies (Callister, 1995; Galotti

et al.) have isolated these w om en's motivations, goals, or ideals of childbirth

control (Aaronson; W aldenstrom & Nilsson). No studies exist, however, that

identify shared personality traits of w om en who choose nurse-midwives.

This study focused on this specific, "nonvulnerable" group of wom en who

make a conscious choice to have a nurse-midwife as a provider. The study aimed

to explore personality characteristics that m ay influence these w om en to choose

nurse-midwifery care in comparison w ith wom en who seek care from an

obstetrician. Identification of personality traits, if they exist, can be useful to

nurse-midwives to both individualize their services and recruit more wom en to

utilize their services. The NEO Five-Factor Inventory (NEO-FFI)1, a personality

tool developed by psychologists, was used to assess personality characteristics of

pregnant women w ho utilize Certified Nurse-Midwives, and com pared their

personality profiles w ith those w ho use obstetricians.

delivery, in the perceived safety of a hospital, a natural birth using prepared

childbirth techniques, or even the perceived comfort of an epidural. These

consciously aware of them or not.

Health Belief M odel. The Health Belief Model (HBM) is based on

psychological and behavioral theories that hypothesize that an individual's