Midwifery Practices Win National Recognition for Quality of Care

From the University of Colorado Hospital Insider

From The University of Colorado Hospital Insider

Two midwifery practices on the Anschutz Medical Campus in Aurora, Colorado have been recognized by a nationwide professional organization for offering exemplary, high-quality care to patients.

The Center for Midwifery and University Nurse-Midwives at University of Colorado Hospital, both certified nurse midwifery practices, earned National Best Practice Awards from the Silver Spring, MD.-based American College of Nurse Midwives (ACNM).

The two were among 90 midwife practices that voluntarily submitted data for nearly three dozen benchmark measures to the ACNM during calendar year 2009. The practices collectively represented some 400 midwives who participated in more than 35,000 deliveries. The organization classified practices as small, medium and large by the number of deliveries they performed.

The hospital’s Center for Midwifery (or CFM) – classified as a medium-size practice – earned Best Practice recognition from the ACNM in five quality-of-care categories:
• Lowest rate of infants whose length of stay (LOS) exceeded the maternal LOS
• Lowest rate of total labor inductions
• Lowest rate of inductions at less than 41 weeks estimated gestational age (EGA)
• Highest rate of breast feeding initiation
• Lowest rate of 3rd/4th degree lacerations (a measurement of obstetrical trauma during vaginal delivery)

University Nurse-Midwives (UNM) – which was classified as a large practice – received recognition for lowest induction rates (total and less than 41 weeks EGA) and for the lowest rate of episiotomies (incisions of the perineum during labor).

The practices, which specialize in providing prenatal, labor and delivery and post-natal care for women with low-risk pregnancies who desire natural child birth, have been collecting benchmark data since 2007, noted Nurse- Midwifery Services Director Erica Schwartz, DNP, MSN, CNM. “The statistics, in turn, help women make more informed decisions about their choice of care,” she said. “These [data] are indicators that are specific to nurse midwifery,” she said. “Women like to know the statistics for a practice that wants to be their provider, so we make the data accessible to them.”

The benchmarks illustrate the underlying philosophy of care at each practice, said CFM Assistant Service Director and Senior Instructor Jessica Anderson, MSN, CNM.

“We use interventions only as needed,” Anderson noted. Inducing labor at less than 41 weeks EGA without medical indications, she explained, increases the likelihood of delivery by cesarean section (C section). In addition, many hospitals will not perform vaginal deliveries on women who have had a previous C section, although that is not the case at UCH. “We encourage women to attempt a vaginal birth after C-section if appropriate,” Anderson said.

“Our emphasis is on evidence-based practice,” said Kate Koschoreck, MSN, CNM, a UNM senior instructor who collected the data submitted to the ACNM. Early induction, she noted, is used only when there is a medical indication, like cases of a membrane that ruptures before labor, hypertension, low amniotic fluid or if medications are needed to treat gestational diabetes. Occasionally, the practice will also induce labor when a woman’s partner is in the military and has returned home with only a small window of time to see the birth of his son or daughter.

Similarly, the practice performs episiotomies only as medically indicated, Koschoreck noted. “They’re done if delivery is not imminent and there is concern for the baby’s well being,” she said. It’s also done in some cases of female circumcision, which makes vaginal delivery more difficult.

However, the reasons for avoiding unnecessary episiotomies are equally sound, Koschoreck added. “Tearing can worsen after an episiotomy and can extend to a 3rd or 4th degree laceration,” she said. “Such severe tearing – which extends in varying degrees to the anal sphincter – can lead to incontinence, infection and persistent pain,” she said.

Meanwhile, both midwifery practices continue to evaluate their performance, Schwartz said. An interdisciplinary review panel of midwives and OB/Gyns, she noted, “looks at adverse outcomes to evaluate trends and identify changes that might have to be made in all obstetrical practices at UCH.” So far, the reviews have identified things that might be done differently in individual cases, rather than “clustering” of problems, she reported.

A Nurse-Midwifery Best Practice Committee reviews current research to make sure the nurse-midwives are providing evidence-based care, Koschoreck added. A journal club also looks at current medical research on clinical issues such as vaginal birth after C-sections and presents information to the practice providers.

“We’ve also made global changes to our scheduling so that no deliveries are scheduled before [mothers] are at 39 weeks unless medically indicated,” Anderson noted.

“We can take a systems approach to care because of the great relationships we have with other providers,” Schwartz concluded, “and the fact that they follow best practices as well. It’s a reflection of the collegiality we have.”

For more on the ACNM, visit http://www.midwife.org/.