QUALITY CARE: Easier Said than Delivered


  • Lily Hsia C.N.M., M.S., C.P.N.P. Associate Editor

Nurses enter into midwifery because they feel that they can personally provide women with quality care during the maternity cycle and inter-conceptional period. When nurse-midwives enter into health delivery systems, we soon become disenchanted. Many find that the number of women they must care for in one prenatal clinic session far exceeds reasonable expectation. It is the very assembly-line operation we deplored, but must now comply with in order to serve in a busy clinic setting. Some patients get less than ten to fifteen minutes of our time after having waited for two hours. Soon, we as nurse-midwives question our own existence, as well as our motives for continuing to function in this manner.

Where is our personal touch? Where is our caring quality? Where did it go wrong? It seems that the employing agency has a right to expect improvement in maternity care as a result of the employment of nurse-midwives. How accountable are we?

Health care today is one of the most complex human endeavors. It includes all types of practitioners, diverse in their preparation and function, and constantly evolving in their roles because of advancing technology. Each specialty group claims its superspecialized knowledge and skills further contribute to the improvement of care. Great prestige and power were bestowed upon large urban medical centers where ever-expanding facilities, resources, and personnel used to enjoy an unmeasured reputation for excellence. Today, we know that the sophisticated medical technology we encouraged also brought us uncontrolled inflation, dehumanization, and fragmentation. How can we learn to appropriately utilize those advances technology has made in maternity care without becoming entrapped within the machinery? To evaluate when and how technology contributes to quality care in a normal pregnant woman is not always easy when pressures from medical groups beseige us to do such procedures as routine electronic fetal monitoring on laboring women when hard research data are not yet available on the long term effects on the fetus. Patients can no longer be guaranteed that they will be free from the hazards of iatrogenic medicine.

It seems that the issue of quality care is easy to articulate, but hard to evaluate and harder still to implement. What are the issues involved in delivering quality maternity care? As providers, do we have a cohesive and truly functional health care team? Do team members respect each other as colleagues? Is there a collaboration of expertise? Do we agree on patient care philosophy and objectives? Do we individualize our approach according to the needs of the patient? Are the team members competent professionals? How and by whom is their continued competence monitored?

There is a distinct difference between health and health care. As professionals, do we all agree that consumers are responsible for their own health, while we facilitate the maintenance of their health care? If indeed this is our philosophy, maternal and infant morbidity and mortality as well as pregnancy outcomes are the joint responsibility of the patient and her providers. Since mortality and morbidity are important but broad indices of the maternity care delivery outcome, they also reflect the quality of maternity care. However, statistics usually fail to indicate specifically which patient or care provider is responsible for contributing to the high incidence of morbidity and mortality. As nurse-midwives, we need more active research and documentation to distinguish these contributing factors.

The medical profession has traditionally been a biologically based science. It has been slow in integrating various disciplines such as social sciences, economics, nutrition and public health into its medical school curriculum. The reward system in medicine is comparably skewed in that physicians are reimbursed for the curative medicine they practice: they are reimbursed by the patient or third party payer for the number of office visits and type of intervention and treatment made regardless of whether the patient's health status improves or declines. Changes in the incentive structure ought to appropriately emphasize the health and well-being of the patient, as well as the quality of care rendered, if medical practice is to have a very different orientation in the future.

Nurse-midwives have always devoted a significant amount of patient contact time to educating and counseling for childbearing, teaching in nutrition, strengthening of family relationships, and providing emotional support as well as managing the care of mothers throughout the maternity cycle. Although from experience we know that parent education programs have been effective in changing patients' behavior, nurse-midwives need to pinpoint specific factors associated with effectiveness by our own research. Emphasis should be directed toward determining whether behavioral change is temporary or permanent, and what modifications or alternate approaches we can use to increase our effectiveness in delivering maternity care. Since health education is known to be an essential component of care, any quality assessment criteria need to include patient education as a part of care activities. Consumers should be actively involved in assisting providers to determine what type of health education they receive when seeking maternity care. Recent legislation in New York State also requires that informed consent be given when medication and treatments are prescribed to the patient. As nurse-midwives, we should encourage our consumers to establish individualized outcome objectives jointly with us so that we can mutually evaluate and analyze reasons for failure to meet them when our patients are under our care.

On the surface, assessment of quality care consists of the discrepancy between what was done and what ought to have been done. Because of the complexity of interrelated and interdependent factors in the process of health care that includes the provider, the consumer, level of knowledge and technology, standards, organizational structure, cost, social values, etc., evaluation of quality of care is not only an expansive, but an almost insurmountable, task. Government enacted legislation in 1972 authorizing the establishment of Professional Standards Review Organizations to monitor the appropriateness of health services financed by Medicare, Medicaid, and the Maternal and Child Health Program. In 1973, the Health Maintenance Organization Act was passed by Congress requesting a major study of alternative mechanisms for quality assurance on health care. Most of the health professional organizations have continuing education and recertification programs to ensure continued competence of the providers' skills and clinical judgment. It seems despite all the external monitoring mechanisms for quality assurance, consumers are far from being happy about the health care system. Is it too much to ask that consumer satisfaction be an important indicator in assessing health care outcome?

Quality care is costly, but costly care does not always mean quality care. When nurse-midwives say we give quality care, we must be able to measure and demonstrate what we mean. Otherwise, we are just giving lip service.


Nurse-midwifery education is currently offered on a post-RN and Master's degree level. The post-RN program provides a curriculum of theory and clinical experience in nurse-midwifery. The degree program offers preparation in nurse-midwifery in conjunction with a curriculum leading to a Master's degree.

Registered nurses licensed to practice in the United States may apply to an ACNM-approved basic program and upon graduation are eligible to take the American College of Nurse-Midwives national examination for certification.

Graduates of nurse-midwifery programs outside the United States who are registered nurses licensed to practice in the United States may apply to an ACNM-approved refresher program and upon completion of the refresher program are eligible to take the ACNM national examination for certification.

For further information, contact: The American College of Nurse-Midwives 1012 14th St., N.W., Suite 801 Washington, D.C. 20005