186187CHAPTER 9

Outcome Measurement in Nurse-Midwifery Practice

Julie Marfell

1.  Present an overview of the historical implementation and importance of outcome measurement in nurse-midwifery practice and discuss the role that outcome measurement has in improving modern health care delivery in the arena of maternal and child health

2.  Summarize published examples of nurse-midwifery outcome studies

3.  Outline the use of the American College of Nurse-Midwives (ACNM) Benchmarking Project for use in outcome measurement and quality improvement

4.  Present the Uniform Data Set as a tool for collection of outcome measures and research

1.  Why is outcome measurement an essential practice in nurse-midwifery practice? Briefly describe three reasons.

2.  What four areas did the ACNM Benchmarking Project use to evaluate quality nurse-midwifery care?

3.  How could the ACNM Benchmarking Project be used for nurse-midwifery quality improvement?

4.  What is the Optimality Index?

5.  What classifications of outcome measurements are used for nurse-midwifery practice? Name and define at least three.

188  HISTORICAL PERSPECTIVE

Outcome evaluation of nurse-midwifery practice in the United States is as old as the profession. Mary Breckinridge brought nurse-midwifery to America in 1925 and created the Frontier Nursing Service (FNS). FNS was a demonstration project that provided health care to the rural poor in southeastern Kentucky. Mrs. Breckinridge took the advice of one of her consultants, Dr. McCormack, the health commissioner for the Commonwealth of Kentucky, who said she would be unable to determine the effects of the FNS without a complete assessment of the health status of the community. Her first step in establishing the FNS was to ride over more than 700 square miles to obtain health histories of all the area families so that the impact of the nurse-midwives on horseback could be measured (Breckinridge, 1981).

Meticulous records were kept at the FNS. The Metropolitan Life Insurance Corporation was asked to analyze the data of the first 1,000 births attended by the nurse-midwives at FNS. The results were incredible. Dr. Louis Dublin reported:

Measuring nurse-midwifery outcomes started with the first nurse-midwifery service in the United States and has been an integral component of establishing nurse-midwifery as a profession in the United States.

The success of the nurse-midwifery care provided in the home by Frontier nurses from 1925 to 1975 was reported in 1975 on the 50th anniversary of the FNS (Browne & Isaacs, 1976). The study of the first 10,000 births at FNS by the Metropolitan Life Insurance Company found 11 maternal deaths, two of which were not obstetrics related. This was much lower than the national maternal mortality rate of 36.3 per 10,000 live births for the midpoint years 1939 to 1941. There were fewer premature births, stillbirths, and neonatal deaths for FNS than the rest of the country.

Continuing throughout the history of nurse-midwifery in the United States, outcomes have been studied. Initially, they were scrutinized to determine the safety and feasibility of midwifery care. A classic study was conducted in Madera County, California, in the early 1960s to determine if nurse-midwives could be utilized to assist physicians in providing maternity care in a rural underserved area and to measure the outcomes of this new model of care (Montgomery, 1969). At the time, nurse-midwifery was not recognized or licensed in the state of California, so this project utilized nurse-midwives but labeled them nurse obstetric assistants (NOAs). A before-and-after comparison was done that showed the NOAs could provide the needed care, and the birth outcomes improved dramatically. The number of women who received prenatal care in the first trimester doubled. The percentage of women receiving more than six prenatal visits increased almost 10%. Prematurity rates declined by 5% and the neonatal mortality rate went from 23.9 per 1,000 live births to 10.3 per 1,000 live births. This project highlighted the successful utilization of nurse-midwives, and a report of the project was presented to the California 189Medical Association (CMA) with the hope that they would endorse legislation to allow NOAs to practice in California. However, the CMA did not endorse NOAs, and nurse-midwives were not recognized in California until 1974 (ACNM, 2012).

It is interesting to note that a follow-up study of the Madera County project compared the birth outcomes before, during, and after the use of NOAs (Levy, Wilkinson, & Marine, 1971). In the 3 years following the termination of the NOAs, 9% more women received no prenatal care. Women who did receive prenatal care received fewer visits. The rate of premature infants rose significantly from 6.6% to 9.8%. Neonatal mortality almost tripled going from 10.3 per 1,000 live births when care was provided by the nurse-midwives to 32.1 per 1,000 live births afterward. The authors concluded that the use of nurse-midwives should be encouraged because the maternity outcomes improved during the interim period when they provided care.

Later, studies demonstrated that midwifery outcomes were excellent and there were added benefits of cost-effectiveness and patient satisfaction. Reid and Morris (1979) evaluated the implementation of nurse-midwifery care for the underserved in Georgia in the 1970s and included analysis of cost-effectiveness. There was a substantial increase in the number of women who received early prenatal care, and a reduction in the number of women giving birth with little or no prenatal care for the 3 years after the implementation of the midwifery services compared with the 2 years before. Birth outcomes showed improvement in neonatal mortality, longer gestations, and higher birth weights. Infant mortality rates dropped significantly in the rural counties studied, while there were no differences in the comparison counties. The authors found the cost of prenatal care and hospital care decreased over the course of the project and they were cautiously optimistic, while recommending that future research should include prospective analysis of health expenditures for midwifery care. Anderson and Anderson (1999) found home births cost 68% less than hospital births.

Outcome measurement was also undertaken to determine whether birth centers, which were specifically designed for the practice of the hallmarks of midwifery, were a safe alternative to hospital birth. The landmark prospective study of birth outcomes for over 11,000 women from 84 birth centers was published in the New England Journal of Medicine in 1989 (Rooks et al., 1989). The birth center clients were screened as low risk for maternity complications; hence an out-of-hospital setting was appropriate for their care. There were fewer premature births for women giving birth in the birth center than for all women who gave birth in the United States. The cesarean section rate was 4.4%, which contributed to lower costs for maternity care. The intrapartum transfer rate was 15.8% with 2.3% being emergent transports. The infant outcomes for birth center mothers were comparable to those of women with low-risk pregnancies having hospital births. Patient satisfaction was high with 98.8% of the women who gave birth at the birth centers saying they would recommend a birth center, and 94% would return to the birth center for their next birth. The percentage of satisfaction was slightly lower for the women who were transferred to the hospital during labor with 96.9% recommending it, and 83.3% willing to use it again. The authors concluded that “Few innovations in health services promise lower cost, greater availability, and higher degree of satisfaction with a comparable degree of safety” (p. 1810).

Recent attention has been paid to how the midwifery model of care actually improves pregnancy and birth outcomes, which lowers health care costs for maternity services. The 190Cochrane review found that maternity care led by midwives was beneficial for women (Hatem, Sandall, Devane, Soltani, & Gates, 2009). Women randomized to midwifery-led maternity units had fewer antepartum hospitalizations, fetal losses, instrumental deliveries, and episiotomies. They had more spontaneous vaginal births and early breastfeeding initiation. The women were cared for during labor by a midwife they knew, and they felt a sense of control. The authors concluded that for women without significant medical or obstetrical problems, “Midwifery-led care confers benefits and shows no adverse outcomes” (p. 13).

  CURRENT EXPANSION OF OUTCOME MEASUREMENT

  Benchmarking

ACNM is the professional organization for nurse-midwives with the goal of improving the health and well-being of mothers and infants. The ACNM defines eight standards for the practice of midwifery. One standard specifically addresses the need for evaluation of nurse-midwifery outcomes using a program of quality management that includes data collection, problem identification and resolution, as well as peer review.

To assist midwives to measure the quality of care, ACNM developed a Benchmarking Project in 1997 (Collins-Fulea, Mohr, & Tillett, 2005). This program specifically examined four areas of quality midwifery care. The first area examined functional status that included the physical and emotional well-being of the mother. The second area was cost of care, including both direct and indirect costs. The third area was patient satisfaction, and the fourth area consisted of clinical outcomes. The first benchmarking data were obtained in 2004 from 45 practices attending more than 23,000 births. Results were reported so that each midwifery service could see how it performed compared with the other services for each indicator. Each could contact midwifery services with high performance to learn best practices that could then be modified and incorporated into its own practice for quality improvement. The ACNM Benchmarking Project has continued and expanded. Results from 2011 included data from 203 practices with almost 900 nurse-midwives attending over 69,000 vaginal births (ACNM, 2011).

  UNIFORM DATA SET

The American Association of Birth Centers (AABC) developed the Uniform Data Set (UDS; an online data registry) that collects comprehensive data on both the process and the outcomes of the nurse-midwifery model of care. It is intended that the data set be used to simultaneously collect data from all providers in hospital, birth center, and home birth settings. The UDS is stored on a password-protected secured site and is Health Insurance Portability and Accountability Act (HIPAA) compliant. The UDS also provides the provider with comprehensive statistic reports that include required reports for birth center accreditation, benchmarking reports for the ACNM Benchmarking Project, registration logs, delivery logs, incomplete reports, and custom reports (AABC, 2007).

Stapleton (2011) conducted a validation study of the 189-item UDS. Five birth center practices had a random audit of 2% of their records. Data from the health record were 191compared with data entered into the UDS. There was a high level of consistency between the health records and the UDS with 97.1% of the variables matching. This study shows the reliability of the UDS and encourages its use for research and quality assurance. Using such large data sets will greatly facilitate health policy changes.

Data from the UDS were used in a study by Stapleton, Osborne, and Illuzzi (2013) of 15,574 women planning to give birth in 79 birth centers across the United States. The transfer rate from birth center to hospital was 12% with the majority being nonemergent. Only 6% of the births were by cesarean section with 93% of the women having a vaginal birth. There were no maternal deaths and the fetal and neonatal mortality rate was the same as other studies of births to women with low-risk pregnancies. This study mirrors the results of the National Birth Center Study (NBCS; Rooks et al., 1989) showing the positive and durable results of birth center care.

  PURPOSE OF OUTCOME MEASUREMENT IN NURSE-MIDWIFERY PRACTICE

The most compelling rationale for outcome measurement is that it assists in efforts to improve the quality of health care for patients. A recent report by the ACNM (2008) highlights that high-quality care, which includes high levels of client satisfaction and lower cost, is provided by certified nurse-midwives (CNMs) with equal to or better outcomes than those of obstetricians or gynecologists.

Enhanced cost-effectiveness is another reason for evaluating outcomes. In cost-effectiveness studies, alternative methods of obtaining the same goal are compared. Clients with similar conditions may be treated with alternative approaches, often with significantly different costs but with very similar outcomes. Studies that document the cost-effectiveness of nurse-midwifery practice while maintaining clinical outcomes have long been documented (Cherry & Foster, 1982; Lubic, 1981; Oakley et al., 1996; Reid & Morris, 1979; Stewart & Clark, 1982). Jackson et al. (2003) discuss collaborative care with CNM versus traditional physician-based care and the decrease in length of stay and decreased emergency department visits documented for women in collaborative care. The safety outcomes of the neonate in this study were similar across both groups.

Alternatively, clients of CNMs and physicians with similar conditions may be treated with different approaches and one group may experience superior outcomes. An example of this is that physicians more often perform episiotomies, while the CNMs might try different approaches, such as perineal massage, warm packs, or positioning, to reduce the need for episiotomy and reducing overall perineal trauma during childbirth (Hastings-Tolsma, Vincent, Emeis, & Francisco, 2007; Robinson, Noritz, Cohen, & Liberman, 2000). Another example of comparing different approaches to maternity care is the use of the Optimality Index-US (OI-US), which measures optimal maternity care (Cragin & Kennedy, 2006). Optimal is defined as obtaining the best outcomes with the least amount of intervention while taking into consideration the woman’s physical and emotional status. Cragin and Kennedy (2006) studied 375 women in labor with moderate pregnancy risk status. Midwives provided care for 196 women, and 179 women were cared for by a physician. The mean OI-US was significantly higher for the midwifery care group. The care provided by the midwives included more mobility, oral hydration, nonpharmacologic pain relief, and spontaneous vaginal births than the care provided 192by the physicians. Yet both groups experienced good perinatal outcomes, thus showing that less interventive care during labor for women with moderate-risk factors produces positive outcomes. Finally, outcome measurement gives evidence and support to the practice of midwifery. Examples of how quality outcomes can influence and increase appreciation and accessibility of nurse-midwifery practice in the United States include the 2004 Virginia Governor’s Task Force on Health-Care Reform recommendations for the development and funding of pilot birth centers in rural areas. The purpose of these sites is to demonstrate the effectiveness of midwifery care and increase access to high-quality pregnancy-related care. The recommendations call for the pilot sites collecting and annual reporting of data using the American Association of Birth Centers Uniform Data Set (Governor’s Health Reform Commission, 2007).

The federal government is also intrigued by the positive outcomes of midwifery care and wants to determine whether the midwifery model of care can be a solution to the problem of a high cost with poor outcome maternity care system. The Center for Medicare and Medicaid Innovation has developed Strong Start for Mothers and Newborns (Center for Medicare and Medicaid Innovation, 2012). This initiative is seeking to fund projects related to group prenatal care, birth centers, and maternity homes, all of which are based on the midwifery model of care.

Research is the basis of all clinical practice, a guiding principle shared by all disciplines. It is this requirement for evidence-based practice that is another rationale for outcome measurement in nurse-midwifery practice. While outcome measurement is not synonymous with research, the two methodologies provide empirical support for evidence-based changes in clinical practice.

  CLASSIFICATION OF OUTCOME MEASUREMENT FOR NURSE-MIDWIFERY PRACTICE

There are several approaches to the classification of outcomes within nurse-midwifery practice. Each method provides data for evidence-based clinical practice. The following outcome classifications are discussed: physiological, perceptual, psychosocial, cognitive, functional, and fiscal.

Physiological outcomes are those that have to do with the impact of CNM interventions on the process of birth. The division of physiological outcomes is somewhat arbitrary because all nurses utilize a holistic approach to health care, recognizing the interrelatedness of perceptual and psychosocial outcomes. Physiological outcomes can be further divided into groups of expected birth outcomes as well as adverse outcomes. It may be more helpful in outcome studies to focus on expected birth outcomes and to designate adverse events as variances from the usual and expected outcomes. Both classifications are of interest to CNMs because this information provides direction for clinical care improvement. Examples of physiological outcomes in midwifery practice include blood glucose levels, iron deficiency anemia, fetal heart rate, maternal breathing patterns, and use of relaxation techniques in labor.

Perceptual outcomes are defined in terms of patient satisfaction. This may include satisfaction with CNMs as providers, with the facilities, with the care received, or with the clinical outcomes. It is important to understand that perception refers to the situation as the client views it or understands it. While it may not be entirely congruent with the 193provider’s reality, it does not matter. What does matter is that this is the client’s perception of reality. Perceptual outcomes are crucial to the marketing and public acceptance of nurse-midwifery service.

Psychosocial outcomes are those that have to do with such things as the client’s affective state, self-image, self-esteem, and interpersonal relationships. Examples of psychosocial outcomes that would be of clinical interest to nurse-midwives include maternal–infant bonding, presence of social support, confidence in the ability to care for the infant, comfort with a pregnant body image, and sense of self-actualization associated with childbirth.

Cognitive outcomes include the knowledge and skills that the client will need to safely and effectively care for herself and/or an infant. These would include the knowledge of prenatal nutrition, the signs and symptoms of postpartum infection, and breastfeeding skills.

Functional outcomes have to do with the maintenance or improvement of physical functioning. While there are standardized measures of functional outcomes, such as various activities of daily living or independent activities of daily living scores, most CNM clients are women involved in a healthy childbearing process. There are standardized tools that measure functional outcomes in the postpartum woman; for example, the Childbirth Impact Profile (Tulman, Fawcett, Groblewski, & Silverman, 1990) and the Inventory of Functional Status after Childbirth (Tulman & Fawcett, 1988). Examples of functional outcomes include the ability to care for the infant and readiness to return to a job outside the home.

Fiscal outcomes involve those having to do with the cost of care. Because health care is a business, it is essential that nurse-midwives understand the fiscal aspects of maternity care. Fiscal measures include such things as cost per case, hospitalization costs and length of stay, incremental costs of specialized nursing care during labor, reimbursement by payer, and laboratory costs. There are two approaches to the measurement of fiscal outcomes: cost data and charge data.

  Charge Data Analysis

Some institutions utilize charges as a proxy measurement for costs. Charges are defined as the charges appearing on the client’s bill. Charges are somewhat arbitrary and do include some profit or mark-up amount added to the cost of producing a service or product. Just as a department store adds a mark-up to the charge for clothing or appliances, so does a health care system add a profit amount to the cost of producing a service. Charges are the same for each client for each procedure and do not reflect policy or group discounts. Because contractual payers often receive a provider discount, it is important that charges be studied before the discounts are applied for the purpose of outcome measurement. Charges can be collected from both the client billing records and from the provider professional service records.

  Cost Analysis

Other institutions have a cost accounting system that will permit the measurement of actual costs of client care, that is, the cost of the service being produced. Cost is a complex concept and can be further reduced to a consideration of direct costs (supplies, 194salaries, and rent) and indirect costs (employee benefits, costs allocated by other departments, e.g., a portion of the building maintenance). Some costs are defined as fixed, that is, they do not change with an increase in client volume. An example of a fixed cost would be heat and light costs. Other costs are variable, meaning that they change with client volume. Laundry and housekeeping costs are examples of variable costs.

What is important in fiscal outcome measurement is that CNMs understand what is included in the costs or charges to make appropriate comparisons. Another consideration is that charges in a clinical practice may be bundled. This means that there is a prospective fee determined by an organization for a particular set of services. For example, hospital charges associated with a normal vaginal delivery may be set at $4,000. This is one all-inclusive fee and there will not be additional charges reflected on the client billing record. This approach does make it difficult to determine variation in fiscal outcomes. If there are no other cost data available when charges are bundled, it is difficult to assess the impact of practice changes on costs.

A decision must be made as to the appropriate interval or timing of charge or cost outcome data collection for nurse-midwifery clients. The purpose of the study will determine the period of measurement. If charges are to represent the entire period of pregnancy, one method to consider is to define the period from the date of determination of pregnancy until 2 months after birth to capture the full scope of the charges for the mother. When collecting fiscal data related to infant outcomes, similar decisions regarding the appropriate measurement interval must be made. Because many infants do not remain within the CNM system but move to pediatrician care, this is an important decision.

  DEVELOPING CLIENT OUTCOME MEASURES

Developing client outcome measures is not difficult. It is something that was a part of undergraduate nursing education and included as a step in the nursing process: assessment, analysis, outcome identification, planning, implementation, and outcome evaluation. The CNM builds on that foundation and uses the knowledge and skill base of nurse-midwifery practice to identify and write outcomes supported by evidence-based practice guidelines for clients during the perinatal period. Two basic questions start this process:

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