Implementation Science is Imperative to the Optimization of Obstetric Care

Deimplementation of Routine Maternal Oxygen Supplementation for Intrauterine Fetal Resuscitation: A Retrospective Cohort Study

OBJECTIVE

 Current practice guidelines for laboring patients with category II intrapartum tracings recommend maternal oxygen supplementation despite emerging randomized data challenging its benefit and utility. We aim to validate that de-implementing maternal oxygen supplementation for fetal resuscitation did not increase the risk of neonatal acidemia in a real-world setting.

STUDY DESIGN

 This is a retrospective observational study conducted at a single tertiary care center from January 2019 to June 2021. All laboring deliveries during the study period were reviewed and eligible participants included singleton or twin pregnancies between 23 and 42 weeks gestational age with persistent category II tracings. Known major fetal anomalies, contraindications to labor, and maternal indication for O2 supplementation, including active coronavirus disease 2019, were excluded. Cohorts were allocated based on the time of delivery. Those occurring prior to our hospital policy change were identified as historical controls and deliveries after April 1, 2020, as the postdeimplementation cohort. The primary outcome was fetal acidemia, defined as umbilical cord pH < 7.2. Secondary outcomes included severe acidemia (pH < 7.0), 5-minute Apgar score <4, and neonatal intensive care admission. Regression analyses controlling for known variables associated with neonatal acidemia generated adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

 Among 9,088 deliveries during the study period, 1,162 tracings were flagged as persistent category II, including 681 (59%) in the postintervention group. The two cohorts had comparable baseline and obstetric characteristics. No difference in neonatal acidemia was observed between the postdeimplementation group and historical controls (13.8 vs. 15.4%, aOR = 0.87, 95% CI: 0.62, 1.22). Severe acidemia, 5-minute Apgar <4, and neonatal intensive care admission were not increased in the postdeimplementation group.

CONCLUSION

 De-implementation of routine maternal oxygen supplementation for fetal resuscitation did not increase the likelihood of neonatal acidemia in a real-world setting, validating guidelines recommending against the intervention.

KEY POINTS

· De-implementation of maternal O2 supplementation for fetal resuscitation did not increase acidemia.. · Real-world experience validates experimental findings regarding maternal oxygenation.. · Other perinatal outcomes reflected no difference in fetal acidemia..

Severe Hypertension in Pregnancy: Progress Made and Future Directions for Patient Safety, Quality Improvement, and Implementation of a Patient Safety Bundle

Hypertensive disorders of pregnancy account for approximately 5% of pregnancy-related deaths in the United States and are one of the leading causes of maternal morbidity. Focus on improving patient outcomes in the setting of hypertensive disorders of pregnancy has increased in recent years, and quality improvement initiatives have been implemented across the United States. This paper discusses patient safety and quality initiatives for hypertensive disorders of pregnancy, with an emphasis on progress made and a patient safety tool: the Alliance for Innovation on Maternal Health's Severe Hypertension in Pregnancy patient safety bundle. Future patient safety and quality directions for the treatment of hypertensive disorders of pregnancy will be reviewed.

Do miscarriage care practice recommendations align with individuals' needs?: A scoping review

OBJECTIVES

Miscarriage is a common occurrence; yet individuals often have negative experiences when receiving miscarriage care, signaling a gap in the quality of miscarriage care. We explore the literature on individuals' experiences with miscarriage care across a variety of dimensions and assess how these experiences align with practice recommendations.

STUDY DESIGN

We conducted a scoping review of peer-reviewed studies in PubMed published in English through April 30, 2022, and focused on individuals' experiences with miscarriage care in healthcare settings and on practice recommendations for providing care in a variety of countries. The search returned 1812 studies; after screening, 41 studies were included in the analysis.

RESULTS

Included studies reported on individuals' experiences with miscarriage care settings and accessibility, information provision, emotional support, decision-making and follow-up. Overall, individuals are often dissatisfied with their miscarriage care experiences. Practice recommendations are generally responsive to these issues.

CONCLUSIONS

Individuals experiencing miscarriage are best served by care that is patient-centered, involves shared decision-making, and addresses individuals' informational and emotional needs. However, the prevalence of individuals' negative experiences with miscarriage care points to the need to address key gaps in and improve the implementation of practice recommendations.

IMPLICATIONS

Future research should focus on documenting the miscarriage experiences of and developing relevant practice recommendations for communities that face the greatest barriers to care, generating evidence on the dimensions that constitute high-quality miscarriage care from patients' perspectives and assessing the barriers and facilitators to effectively implementing existing practice recommendations.

"A Wake-Up Call": A Mixed-Methods Analysis of Barriers to Type 2 Diabetes Prevention After Gestational Diabetes Mellitus

Background

Individuals who have gestational diabetes mellitus (GDM) are advised to engage in physical activity and healthy eating behaviors in the postpartum period to prevent type 2 diabetes. We aimed to understand individual perspectives on incorporating such lifestyle choices during the first postpartum year.

Methods

This was a mixed-methods analysis of data from individuals with GDM who completed surveys and in-depth interviews at 4-12 weeks and 11-13 months postpartum as part of their participation in a feasibility randomized controlled trial on postpartum patient navigation. Participant attitudes were elicited with surveys (structured items with Likert-scale responses) and interviews that focused on barriers to postpartum type 2 diabetes prevention. We used a concurrent, triangulation design to jointly analyze survey data alongside interview data.

Results

Of 40 participants, 39 provided data about their type 2 diabetes prevention activities. Interview themes triangulated with survey results to yield consistent insights about attitudes regarding physical activity and healthy eating. The majority of participants reported that caring for a new baby and family responsibilities made it much harder to be physically active; fewer participants identified cost of exercise, accessing a safe area to exercise, or breastfeeding as barriers. The most common barriers to healthy eating included caring for a new baby, family responsibilities, and work/school schedules. Although proximity and transportation to healthy food sources were uncommon barriers, when they did occur, they were experienced as major burdens.

Conclusion

Individuals who had GDM reported many barriers to implementing recommended postpartum lifestyle choices. Recognizing these unique needs may enhance provision of guidance for type 2 diabetes prevention postpartum.

Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care

The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.

Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers

BACKGROUND

Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA.

METHODS

This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures.

RESULTS

Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research.

CONCLUSIONS

Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.

Attitudes of Clinicians and Patient Safety Culture Before and After the ARRIVE Trial

OBJECTIVE

To assess the attitudes of intrapartum clinicians about elective induction of labor before and after A Randomized Trial of Induction Versus Expectant Management (ARRIVE) and to assess the effect of different attitudes on patient safety culture.

DESIGN

Repeated cross-sectional design.

SETTING

Online surveys.

PARTICIPANTS

Clinicians (883 nurses and 201 physicians in the before-ARRIVE group and 1,741 nurses and 574 physicians in the after-ARRIVE group) who provided intrapartum care at 35 hospitals in California in 2017 and 57 hospitals in Michigan in 2020 and participated in statewide quality improvement efforts to reduce use of cesarean.

METHODS

We used annual nulliparous, term, singleton, vertex cesarean rates to stratify hospitals into performance quartiles. We used cumulative proportional odds logistic regression to examine induction attitudes before and after ARRIVE by role and hospital performance quartile as well as induction attitudes and patient safety culture among clinicians. We used content analysis to examine qualitative data.

RESULTS

After ARRIVE, physicians' attitudes shifted in favor of induction at hospitals within the top three performance categories (top quartile: M = 3.48 vs. 2.81, p < .0001), whereas nurses' attitudes did not change (p = .388). After ARRIVE, attitudes among clinicians were more aligned at hospitals with stronger patient safety cultures. Qualitative themes included The Timing of Induction is Important, Who Should Have Inductions, Need for Clear Protocols and More Staff, and Ideas to Improve the Induction of Labor Process.

CONCLUSION

Physician attitudes about induction were significantly different before versus after ARRIVE, whereas nurse attitudes were not. Differences in attitudes may erode the quality of team-based care; intentional interdisciplinary engagement is essential when implementing ARRIVE findings.

Implementation barriers and enablers of midwifery group practice for vulnerable women: a qualitative study in a tertiary urban Australian health service

Background

Maternity services have limited formalised guidance on planning new services such as midwifery group practice for vulnerable women, for example women with a history of substance abuse (alcohol, tobacco and other drugs), mental health challenges, complex social issues or other vulnerability. Continuity of care through midwifery group practice is mostly restricted to women with low-risk pregnancies and is not universally available to vulnerable women, despite evidence supporting benefits of this model of care for all women. The perception that midwifery group practice for vulnerable women is a high-risk model of care lacking in evidence may have in the past, thwarted implementation planning studies that seek to improve care for these women. We therefore aimed to identify the barriers and enablers that might impact the implementation of a midwifery group practice for vulnerable women.

Methods

A qualitative context analysis using the Consolidated Framework for Implementation Research was conducted at a single-site tertiary health facility in Queensland, Australia. An interdisciplinary group of stakeholders from a purposeful sample of 31 people participated in semi-structured interviews. Data were analysed using manual and then Leximancer computer assisted methods. Themes were compared and mapped to the Framework.

Results

Themes identified were the woman’s experience, midwifery workforce capabilities, identifying “gold standard care”, the interdisciplinary team and costs. Potential enablers of implementation included perceptions that the model facilitates a relationship of trust with vulnerable women, that clinical benefit outweighs cost and universal stakeholder acceptance. Potential barriers were: potential isolation of the interdisciplinary team, costs and the potential for vicarious trauma for midwives.

Conclusion

There was recognition that the proposed model of care is supported by research and a view that clinical benefits will outweigh costs, however supervision and support is required for midwives to manage and limit vicarious trauma. An interdisciplinary team structure is also an essential component of the service design. Attention to these key themes, barriers and enablers will assist with identification of strategies to aid successful implementation. Australian maternity services can use our results to compare how the perceptions of local stakeholders might be similar or different to the results presented in this paper.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08633-8.