What Does Value Mean to Nurse Midwives?

Leissa Roberts, CNM, DNP, lent a patient-focused perspective to University of Utah Health's Value Discussion on March 21, 2019. Photo: Charlie Ehlert

When a patient makes an appointment to see a provider, their choices are often dictated by outside influences: insurance networks, clinician availability, and referrals to a specialist. But when an expectant mother chooses where to have her baby, the decision is much different.

“Childbirth is one of the things that patients truly plan for,” says Leissa Roberts, associate dean of faculty practice and clinical professor at University of Utah Health College of Nursing. “Our patients are not coming to the hospital to get treated for an acute crisis but rather for an experience.”

That makes certain details of the encounter stand out: the ambiance of a birthing room, the volume and tempo of the music, the color of the bed sheets. A patient coming in to the emergency department for an acute problem may never think about those things. But the unique patient perspective of a laboring mother fundamentally changes the definition of high-value health care for certified nurse midwives.

Such a shift allows nurse midwives to view their patients in a holistic manner, as well. That means assessing the patient as a whole person whose past experiences, current desires, and future plans all feed in to their desire to give birth a certain way. “We’re more aligned with patient choice,” Roberts says. Which is not to say that nurses and midwives aren’t motivated by objective measures of value. 

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Patient experience scores for Roberts’ area of specialty, which encompasses 16 different faculty practices at U of U Health, regularly fall in the 98th percentile. Another major focus is quality measurements: How quickly can the team respond to a post-partum hemorrhage? How efficiently can a patient be fast-tracked for an emergency C-section? By those measures, University of Utah Health ranks high, as well.

But Roberts and her colleagues understand that the definition of quality across the entire health system doesn’t mesh perfectly with the definition of quality for the obstetrical population. “For women who are child-bearing, they’re looking for that X factor,” she says. “Our patients come in and say, ‘Here’s my five-page birth plan; I want to be in the tub, and I want the lights turned down low.’ We may save her baby from a shoulder dystocia or save her life by preventing a post-partum hemorrhage, but the patient may still say, ‘Yeah, but I didn’t get the birth I wanted.’”

The experiences that Roberts and her colleagues have with this unique patient population illustrate a broader disconnect, as well—one between what patients and providers identify as high-value care. For example, in a national survey conducted by University of Utah Health about the perception of value in health care, 88 percent of physicians said that quality was the most important component of value, while only 62 percent of patients agreed. The survey also found that 55 percent of physicians said that knowing and caring about the patient was the most important indicator of high-value care, while only 36 percent of patients said “The provider knows and cares about me” mattered most to them. Patients were more concerned about affordability and the ability to schedule a timely appointment than experiencing complications or medical errors.  

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“I’m not surprised by that disconnect, and I think it’s an area where we have room to explore both sides of the story,” Roberts said. “How do we create a truth for us as providers, delivering high-quality care measured by our existing metrics, while creating that truth for the patient as well?” In her world, that means prioritizing the safety of the mother and her baby while still ensuring that she has the kind of birth that she wants.  

It’s a challenging problem, but Roberts is optimistic that we can create the future of high-value health care by accounting for the perspectives of both patients and providers. “I’m an eternal optimist,” she says, “and the reason why is that I’ve seen changes in health care over the course of 30 years.” 

Perhaps we could take a page from the playbook of Roberts’ research, which focuses on pain evaluation in laboring women. Identifying an area of tension between existing measurements of patient experience and quality metrics, the Coping with Labor Algorithm redefines the way that practitioners apply general metrics to more specific patient populations.

“Changes like that come slowly,” Roberts said. “But the alternative is the failure of the largest part of the U.S. economy, and I can’t see that happening. U of U Health has been pushing the envelope, so I’m optimistic that we’re going to fix these problems.”

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If you'd like to schedule with a Certified Nurse Midwife at the University of Utah for either obstetric or gynecologic care, call 801-581-4014.

By: Nick McGregor

Nick McGregor is a Senior Communications Editor at University of Utah Health.