Assessing Midwives’ Compliance with ACOG Hypertension Guidelines in Underserved Areas

Abstract

Background: Hypertensive disorders of pregnancy (HDP) are leading causes of maternal morbidity and mortality in the United States (US) and contribute significantly to preventable complications. In rural and underserved communities, limited access to specialty care, delayed recognition, and inconsistent application of clinical guidelines increase the risk of adverse outcomes. Certified nurse-midwives (CNMs) play a vital role in early identification and management; however, variability in knowledge and interpretation of diagnostic criteria may impact timely intervention.Purpose: This Doctor of Nursing Practice (DNP) project evaluated and enhanced midwives’ knowledge and clinical recognition of HDP based on the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 222 through an asynchronous educational intervention. The project aimed to improve knowledge, confidence, and application of hypertension management principles among CNMs in a rural Arizona clinic. Methods: This quality improvement (QI) project used a quantitative pre- and post-intervention design guided by Lewin’s Change Theory and Knowles’ Adult Learning Theory. Six CNMs were recruited and completed a pre-survey assessing knowledge, confidence, and guideline adherence. Participants then completed an asynchronous educational module on evidence-based hypertension management, followed by a post-survey. Data were analyzed using descriptive statistics and paired t-tests. Results: All participants completed the study (100%). Baseline knowledge was strong in hypertensive thresholds and emergency management, with gaps in diagnostic classification and pharmacologic sequencing. Post-intervention improvements were noted in protein-to-creatinine ratio criteria and delivery recommendations for severe preeclampsia. Persistent variability remained in classification and seizure prophylaxis management. Self-reported confidence improved across all participants. Conclusions: Although baseline knowledge was substantial, gaps in guideline application persisted. Asynchronous education improved confidence but showed mixed knowledge gains. Ongoing structured education, case-based learning, and decision-support tools are recommended to improve retention, consistency, and maternal outcomes in rural settings.