Midwives Advance Obstetrics Healthcare Delivery Through Research

Leading and supporting clinical research initiatives has become a critical aspect of improving patient care in the Department of Obstetrics and Gynecology.

As part of those research activities, Daisy Goodman, DNP, MPH’14, CARN-AP, CNM, vice chair of research for OB/GYN and director of integrated women’s health services at Dartmouth Health’s perinatal addiction treatment program, serves as the co-principal investigator for a research study called Moms in Recovery (MORE): Defining Optimal Care for Pregnant Women and Infants. The study compares models of delivery for medication for opioid use disorder (MOUD) for pregnant people to learn whether integrating prenatal and addiction care—rather than patients seeing a specialty provider for MOUD and a different provider for prenatal care—improves outcomes of pregnancy.

Another of Goodman’s projects is investigating how to improve access to telehealth to effectively overcome barriers to healthcare and improve outcomes for pregnant people with substance use disorders. The study focuses on people living in rural areas with limited access to maternity care and behavioral health services due to geographic distance or economic circumstances.

In collaboration with colleagues at The Dartmouth Institute and Dartmouth Hitchcock Population Health, Goodman is also studying the department’s implementation of a social determinants of health questionnaire to screen patients at their first prenatal appointment, at 28 weeks’ gestation, and postpartum. This questionnaire is accessible to patients through the secure portal, on a tablet at the office visit, or through a medical interpreter if language interpretation services are needed. When a patient screens positive, the results are sent to one of two teams, depending on the patient’s needs. A community health worker team responds to nonmedical needs, such as transportation, housing, or food security. For patients with more complex or clinical needs, such as partner violence, legal issues impacting health, or mental health assessment, the person is referred to a social worker.

“The screener allows us to better understand how social determinants of health affect clinical outcomes so we can care for the whole person,” Goodman says. “This has a direct benefit for patients in terms of facilitating access to urgently needed resources. For example, about 10% of our patients are screening positive for food insecurity, and we can connect them with supplemental food programs and other critical resources they need.”

Another Dartmouth Health group is conducting research on improving scheduled cesarean birth experiences. Anna Childs, MSN, CNM, is working alongside Julie Braga RES’09, and resident Claire Grzymala PGY-2, on a project to develop researchsupported standards for family-centered cesarean births, particularly for patients who had planned to have a physiologic birth, which uses minimal medical intervention during labor and delivery. Childs conducted grand rounds on the literature, and Grzymala has developed the study, Patient Preferences at Cesarean, into a quality improvement (QI) project.

Sometimes a patient who wants to have a physiologic birth has a single complication, such as the baby being breech, that makes a vaginal birth a less optimal mode of delivery. “When someone is expecting to have an unmedicated birth and they’re told that they need a scheduled cesarean section for safety, that’s really hard on them,” says Childs, a midwife who has scrubbed for cesarean births. Options such as a clear drape and immediate skin-to-skin contact can help improve the cesarean experience and reduce postpartum mood disorders. Family-centered options, such as a support person being in the operating room when the patient receives the epidural, also help reduce anxiety for both patient and partner.

Among its methods, the QI project uses a questionnaire for patients to complete before the scheduled cesarean, so they can consider their wishes and expectations ahead of time. Using this information, the entire medical team can help implement the patient’s desires and improve the birth experience. With supporting research data, Childs, Braga, and Grzymala anticipate this questionnaire can become a resource for clinicians in the future.

“We’re finding ways to make the birth feel like birth and not like surgery,” says Childs, who credits the dedication of all the staff in the department with creating a holistic approach to surgical birth. “Because it’s not just surgery—you’re becoming a parent. Midwives and OB/GYNs are collaborating to find ways to combine clinically safe surgery with the magical mystery of birth.”

Midwives and OB/GYNs are collaborating to find ways to combine clinically safe surgery with the magical mystery of birth.”

Anna Childs, MSN, CNM

Goodman, who holds a Doctor in Nursing Practice (DNP) degree, has garnered funding for her research through grants from the Patient-Centered Outcomes Research Institute (PCORI), the U.S. Health Resource and Service Administration (HRSA) and Point32Health. She notes that doctorally prepared nurses can apply for federal funding as a principal investigator, and they can participate deeply in implementation and research. She is excited that a remote, part-time DNP program was recently started at Colby-Sawyer College in New London, New Hampshire. A PhD in Nursing is also a new option for doctoral preparation for nurses with advanced degrees. Goodman hopes the new programs will encourage more of her colleagues to pursue terminal degrees, and she is particularly enthusiastic about the DNP option.

“The DNP is designed to provide doctorate-level education for someone who is not leaving clinical practice,” Goodman says. “PhD candidates usually step away from the clinical program for their studies and often don’t come back. But the DNP keeps people in clinical care while doing their training, and then later they can think about doing clinical research. This benefits patients because the goal of the DNP is for someone to implement what we know are best practices and then evaluate whether outcomes are what we hoped they would be. It’s the perfect degree to have maximum effect for improving patient care.”