Impact of a labor and delivery safety bundle on a modified adverse outcomes index

Quality improvement and outcomes for neonates with hypoxic-ischemic encephalopathy: obstetrics and neonatal perspectives

Despite significant improvement in perinatal care and research, hypoxic ischemic encephalopathy (HIE) remains a global healthcare challenge. From both published research and reports of QI initiatives, we have identified a number of distinct opportunities that can serve as targets of quality improvement (QI) initiatives focused on reducing HIE. Specifically, (i) implementation of perinatal interventions to anticipate and timely manage high-risk deliveries; (ii) enhancement of team training and communication; (iii) optimization of early HIE diagnosis and management in referring centers and during transport; (iv) standardization of the approach when managing neonates with HIE during therapeutic hypothermia; (v) and establishment of protocols for family integration and follow-up, have been identified as important in successful QI initiatives. We also provide a framework and examples of tools that can be used to support QI work and discuss some of the perceived challenges and future opportunities for QI targeting HIE.

Association between weighted adverse outcome score and race/ethnicity in women and neonates

OBJECTIVE

To examine the association between the Weighted Adverse Outcome Score (WAOS) and race/ethnicity among a large and diverse population-based cohort of women and neonates in the United States.

STUDY DESIGN

This was a retrospective cohort study of women who delivered in the United States between 2011 and 2013. We identified mother-infant pairs with adverse maternal and/or neonatal outcomes. These outcomes were assigned weighted scores to account for relative severity. The association between race/ethnicity and WAOS was examined using chi-square test and multivariable logistic regression.

RESULTS

Compared to White women and their neonates, Black women and their neonates were at higher odds of an adverse outcome.

CONCLUSION(S)

The vast majority of women and neonates had no adverse outcome. However, Black women and their neonates were found to have a higher WAOS. This tool could be used to designate hospitals or regions with higher-than-expected adverse outcomes and target them for intervention.

Organizational strategies to optimize women's safety during labor and birth: A scoping review

BACKGROUND

Safety is a priority for organizations that provide maternity care, however, preventable harm and errors in maternity care remain. Maternity care is considered a high risk and high litigation area of health care. To mitigate risk and litigation, organizations have implemented strategies to optimize women's safety. Our objectives were to identify the strategies implemented by organizations to optimize women's safety during labor and birth, and to consider how the concept of safety is operationalized to measure and evaluate outcomes of these strategies.

METHOD

This scoping review was conducted using the Joanna Briggs Institute Scoping Review Methodology. Published peer-reviewed literature indexed in CINAHL, Medline, and Embase, databases from 2010 to 2020, were reviewed for inclusion. Fifty studies were included. Data were extracted and thematically analyzed.

RESULTS

Three categories of organizational strategies were identified to optimize women's safety during labor and birth: clinical governance, models of care, and staff education. Clinical governance programs (n = 30 studies), specifically implementing checklists and audits, models of care, such as midwifery led-care (n = 11 studies), and staff training programs (n = 9 studies), were predominately for the management of obstetric emergencies. Outcome measures included morbidity and mortality for woman and newborns. Three studies discussed women's perceptions of safety during labor and birth as an outcome measure.

CONCLUSIONS

Organizations utilize a range of strategies to optimize women's safety during labor and birth. The main outcome measure used to evaluate strategies was focused on clinical outcomes for the mother and newborn.

Pregnancy and birth outcomes after SARS-CoV-2 vaccination in pregnancy

BACKGROUND

SARS-CoV-2 infection during pregnancy is associated with significant maternal morbidity and increased rates of preterm birth. For this reason, COVID-19 vaccination in pregnancy has been endorsed by multiple professional societies, including the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, despite the exclusion of pregnant women from initial clinical trials of vaccine safety and efficacy. However, to date, little data exist regarding the outcomes of pregnant patients after COVID-19 vaccination.

OBJECTIVE

To assess the safety and efficacy of COVID-19 vaccines in pregnant patients.

STUDY DESIGN

A comprehensive vaccine registry was combined with a delivery database for an integrated healthcare system to create a delivery cohort that included vaccinated patients. Maternal sociodemographic data were examined to identify factors associated with COVID-19 vaccination. Pregnancy and birth outcomes were analyzed, including a composite measure of maternal and neonatal pregnancy complications, the Adverse Outcome Index.

RESULTS

Of 2002 patients in the delivery cohort, 140 (7.0%) received a COVID-19 vaccine during pregnancy, and 212 (10.6%) experienced a COVID-19 infection during pregnancy. The median gestational age at first vaccination was 32 weeks (range, 13 6/7–40 4/7 weeks), and patients vaccinated during pregnancy were less likely than unvaccinated patients to experience COVID-19 infection before delivery (2/140 [1.4%] vs 210/1862 [11.3%]; P<.001). No maternal COVID-19 infection occurred after the vaccination of pregnant patients. Factors significantly associated with increased likelihood of vaccination in a multivariable logistic regression model included older age, higher level of maternal education, being a nonsmoker, use of infertility treatment for the current pregnancy, and lower gravidity. Compared with unvaccinated patients, no significant difference in the composite adverse outcome (7/140 [5.0%] vs 91/1862 [4.9%]; P=.95) or other maternal or neonatal complications, including thromboembolic events and preterm birth, was observed in vaccinated patients.

CONCLUSION

In this birth cohort, vaccinated pregnant women were less likely than unvaccinated pregnant patients to experience COVID-19 infection, and COVID-19 vaccination during pregnancy was not associated with increased pregnancy or delivery complications. The cohort was skewed toward late pregnancy vaccination, and thus, findings may not be generalizable to vaccination during early pregnancy.

Adverse outcomes of childbirth in high-risk maternity hospitals

Abstract Objectives: to analyze adverse outcomes in teaching maternity hospitals in Maceió, Alagoas, Brazil. Methods: a cross-sectional, retrospective and analytical study was carried out with a random sample of 480 medical records of postpartum women in 2016 using the Adverse Outcome Index: in-hospital maternal death, neonatal in-hospital death> 2500g and> 37 weeks, uterine rupture, unplanned maternal admission to intensive care unit, delivery trauma to the newborn, return to the operating room, admission to an intensive neonatal unit with >2500g and > 37 weeks for more than one day, Apgar <7 at the fifth minute, maternal hemotransfusion and fourth-degree perineal laceration. The data were analyzed using the Statistical Package for Social Sciences software version 22.0. Results: the results showed a 21% rate of adverse outcomes, at a rate of 26.4 for every 1,000 births, with a greater occurrence of neonatal intensive care admission with>2500g and>37 weeks for more than one day (52. 5%), maternal blood transfusion (20.8%) and unplanned maternal admission in intensive care (17.8%). Conclusions: the evaluation of adverse outcomes evidenced a high proportion of births with undesirable results, which allowed the analysis of the outlook of unfavorable outcomes related to safety in maternity wards through the use of indicators.

Methodology for sampling women at high maternal risk in administrative data

Background

In population level studies, the conventional practice of categorizing women into low and high maternal risk samples relies upon ascertaining the presence of various comorbid conditions in administrative data. Two problems with the conventional method include variability in the recommended comorbidities to consider and inability to distinguish between maternal and fetal risks. High maternal risk sample selection may be improved by using the Obstetric Comorbidity Index (OCI), a system of risk scoring based on weighting comorbidities associated with maternal end organ damage. The purpose of this study was to compare the net benefit of using OCI risk scoring vs the conventional risk identification method to identify a sample of women at high maternal risk in administrative data.

Methods

This was a net benefit analysis using linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. We compared the value identifying a sample of women at high maternal risk using the OCI score to the conventional method of dichotomous identification of any comorbidities. Value was measured by the ability to select a sample of women designated as high maternal risk who experienced severe maternal morbidity or mortality.

Results

The high maternal risk sample created with the OCI had a small but positive net benefit (+ 0.6), while the conventionally derived sample had a negative net benefit indicating the sample selection performed worse than identifying no woman as high maternal risk.

Conclusions

The OCI can be used to select women at high maternal risk in administrative data. The OCI provides a consistent method of identification for women at risk of maternal morbidity and mortality and avoids confounding all obstetric risk factors with specific maternal risk factors. Using the OCI may help reduce misclassification as high maternal risk and improve the consistency in identifying women at high maternal risk in administrative data.

Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study

OBJECTIVE

To study the effect of an intervention based on Crew Resource Management team training, including a tool for structured communication, on adverse perinatal and maternal outcomes.

DESIGN

Stepped wedge.

SETTING

The Netherlands.

POPULATION OR SAMPLE

Registry data of 8123 women referred from primary care to a hospital during childbirth, at ≥ 32.0 weeks of singleton gestation and with no congenital abnormalities, in the period 2012-15.

METHODS

Obstetric teams of five hospitals and their surrounding primary-care midwifery practices participated in the intervention. In total, 49 team training sessions were organised for 465 care professionals (75.5% participated). Adverse perinatal and maternal outcomes before, during and after the intervention were analysed using multivariate logistic regression analyses.

MAIN OUTCOME MEASURES

Adverse Outcome Index (AOI-5), a composite measure involving; intrapartum or neonatal death, admission to neonatal intensive care unit, Apgar < 7 at 5 minutes, postpartum haemorrhage and/or perineal tear.

RESULTS

In total, an AOI-5 score was reported in 11.3% of the study population. No significant difference was found in the incidence of the AOI-5 score after the intervention compared with before the intervention (OR 1.07: 95% CI 0.92-1.24).

CONCLUSIONS

We found no effect of the intervention on adverse perinatal and maternal outcomes for women who were referred during childbirth. Team training is appreciated in practice, but evidence on the long-term impact is still limited. Upcoming studies should build on previous research and consider more sensitive outcome measures.

TWEETABLE ABSTRACT

A cluster randomised team training intervention showed no effect on adverse perinatal and maternal outcomes for women referred during childbirth.

The Hard Work of Improving Outcomes for Mothers and Babies: Obstetric and Perinatal Quality Improvement Initiatives Make a Difference at the Hospital, State, and National Levels

Quality improvement efforts are an increasingly expanding focus for perinatal care providers across the United States. From successful hospital-level initiatives, there has been a growing effort to use and implement quality improvement work in substantive and meaningful ways. This article summarizes the foundations of maternal-focused, birth-focused, and neonatal-focused quality improvement initiatives to highlight the underpinnings and potential future directions of current state-level perinatal quality care collaboratives.

Clinical perspective: creating an effective practice peer review process-a primer

Peer review serves as an important adjunct to other hospital quality and safety programs. Despite its importance, the available literature contains virtually no guidance regarding the structure and function of effective peer review committees. This Clinical Perspective provides a summary of the purposes, structure, and functioning of effective peer review committees. We also discuss important legal considerations that are a necessary component of such processes. This discussion includes useful templates for case selection and review. Proper committee structure, membership, work flow, and leadership as well as close cooperation with the hospital medical executive committee and legal representatives are essential to any effective peer review process. A thoughtful, fair, systematic, and organized approach to creating a peer review process will lead to confidence in the committee by providers, hospital leadership, and patients. If properly constructed, such committees may also assist in monitoring and enforcing compliance with departmental protocols, thus reducing harm and promoting high-quality practice.