UCSF

Background: Midwifery theory does not adequately address the profession’s increasing reliance on telehealth to offer patients full spectrum care throughout their lifespan. Worldwide, midwives’ concerns about remote care include the lack of touch/smell and basic vital signs like blood pressure readings, the quality and length of the visits, the quality of relationship-building with the patients, and the lack of privacy. Certified nurse-midwives (CNMs) in the United States (US) have found benefits in telehealth, such as a reduction of the barriers to healthcare access and greater flexibility for patients and providers. Yet, there remains a lack of conceptual clarity in midwifery theory that fully situates telehealth within reproductive and sexual health clinical practice. Methods: This dissertation study is a qualitative research study to advance midwifery conceptual knowledge of telehealth integration in clinical care with a more expansive understanding of midwives’ role in sexual and reproductive health care beyond pregnancy. The aims of this dissertation were: 1) to synthesize the existing quantitative, qualitative, and mixed methods studies of midwives’ experience of telehealth worldwide; 2) to propose a relevant starting point using existing technology and midwifery theory to guide the conceptual investigation of this phenomenon; and 3) to explore CNMs’ lived experience of telehealth in order to generate a new theory. Results: The primary findings of the mixed method systematic review of midwives’ experience of telehealth included: 1) perceiving gains and losses when integrating telehealth into clinical practice; 2) balancing increased connectivity with workload; 3) challenges with building relationships via telehealth; 4) centering some patients while distancing others; and 5) experiences of telehealth by age and professional experience. A theoretical basis was explored for midwifery telehealth care provision and research by conceptually analyzing key constructs from the Hierarchy Model for the Means and Targets of Midwifery (HMMTM) and the Technology Acceptance Model 2 (TAM2). The constructs were combined and modified, resulting in the Midwifery Acceptance of Telehealth (MAT), a proposed model that uses a reproductive justice lens. MAT provided relevant sensitizing concepts for use in defining initial domains of interest to aid qualitative data collection. The overarching theory that emerged from the study findings describes the ongoing process of virtual adaptation directly influences CNMs' experience of telehealth. The theory delineates the learning process of modifying and transferring skills, knowledge, behaviors, attitudes, and values to patient visits outside of a physical clinical setting. It links this process to midwives' experience of telehealth as enhancing or disrupting responsive care and connectivity. Telehealth use is perceived by CNMs as promoting connectedness and person-centered care as virtual adaptation progresses. In contrast, when the pace of virtual adaptation is slower, CNMs perceive telehealth use as falling short with concerns about impeding connectivity with patients while causing delays in care, anxiety about missing critical clinical data, and less professional satisfaction. Nevertheless, CNMs continue to value in-person interactions and perceive telehealth as increasing healthcare access for those unable to receive care in traditional clinic settings. Conclusion: The findings of this dissertation research provide conceptual insights into a major ongoing shift in clinical practice and midwifery theory. By normalizing technology as a common and essential way to stay connected, midwives integrate telehealth to respond to their patient’s needs while learning specific strategies to adapt their practice. This dissertation advances and modernizes the conceptual understanding of midwives’ clinical experience by including the reality of telehealth use and care throughout the lifespan.