1
|
Jolles DR, Niemczyk N, Hoehn Velasco L, Wallace J, Wright J, Stapleton S, Flynn C, Pelletier-Butler P, Versace A, Marcelle E, Thornton P, Bauer K. The birth center model of care: Staffing, business characteristics, and core clinical outcomes. Birth 2023; 50:1045-1056. [PMID: 37574794 DOI: 10.1111/birt.12745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 02/28/2023] [Accepted: 06/24/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVES Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes. METHODS This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission. RESULTS The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations. CONCLUSIONS FOR PRACTICE Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.
Collapse
Affiliation(s)
- Diana R Jolles
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
- Clinical Faculty, Frontier Nursing University, Hyden, Kentucky, USA
| | - Nancy Niemczyk
- Nurse-Midwife Program, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Jacqueline Wallace
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
| | - Jennifer Wright
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
| | - Susan Stapleton
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
| | - Cynthia Flynn
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
| | | | | | - Ebony Marcelle
- Community of Hope, Washington, District of Columbia, USA
| | | | - Kate Bauer
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
| |
Collapse
|
2
|
Kornelsen J, Lin S, Williams K, Skinner T, Ebert S. System interventions to support rural access to maternity care: an analysis of the rural surgical obstetrical networks program. BMC Pregnancy Childbirth 2023; 23:621. [PMID: 37644407 PMCID: PMC10466771 DOI: 10.1186/s12884-023-05898-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 08/04/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The Rural Surgical Obstetrical Networks (RSON) project was developed in response to the persistent attrition of rural maternity services across Canada over the past two decades. While other research has demonstrated the adverse health and psychosocial consequences of losing local maternity services, this paper explores the impact of a program designed to increase the sustainability of rural services themselves, through the funding of four "pillars": increased scope and volume, clinical coaching, continuous quality improvement (CQI) and remote presence technology. METHODS We conducted in-depth, qualitative research interviews with rural health care providers and administrators in eight rural communities across British Columbia to understand the impact of the RSON program on maternity services. Researchers used thematic analysis to generate common themes across the dataset and interpret findings. FINDINGS Participants articulated six themes regarding the sustainability of maternity care as actualized through the RSON project: safety and quality through quality improvement opportunities, improved access to care through increased surgical volume and OR backup, optimized team function through innovative models of care, improved infrastructure, local innovation surrounding workforce shortages, and locally tailored funding models. CONCLUSION Rural maternity sites benefited from the funding offered through the RSON pillars, as demonstrated by larger volumes of local deliveries, nearly unanimous positive accounts of the interventions by health care providers, and evidence of staffing stability during the study time frame. As such, the interventions provided through the Rural Surgical Obstetrical Networks project as well as study findings on the common themes of sustainable maternity care should be considered when planning core rural health services funding schemes.
Collapse
Affiliation(s)
- Jude Kornelsen
- Centre for Rural Health Research, Department of Family Practice, University of British Columbia, 5950 University Boulevard, 3rd Floor David Strangway Building, Vancouver, British Columbia, V6T1Z3, Canada.
| | - Stephanie Lin
- Faculty of Land and Food Systems, University of British Columbia, British Columbia, Vancouver, Canada
| | - Kim Williams
- Rural Coordination Centre of British Columbia, Vancouver, Canada
| | - Tom Skinner
- Rural Coordination Centre of British Columbia, Vancouver, Canada
| | - Sean Ebert
- Rural Coordination Centre of British Columbia, Vancouver, Canada
| |
Collapse
|
3
|
Kozhimannil KB, Leonard SA, Handley SC, Passarella M, Main EK, Lorch SA, Phibbs CS. Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals. JAMA HEALTH FORUM 2023; 4:e232110. [PMID: 37354537 DOI: 10.1001/jamahealthforum.2023.2110] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2023] Open
Abstract
Importance Identifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts. Objective To assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients. Design, Setting, and Participants This retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks' gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023. Exposures Annual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties. Main Outcome and Measures The main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity. Results Among more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients. Conclusions and Relevance In this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.
Collapse
Affiliation(s)
- Katy Backes Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Stephanie A Leonard
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California
- California Maternal Quality Care Collaborative, Stanford
| | - Sara C Handley
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| | - Molly Passarella
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elliott K Main
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California
- California Maternal Quality Care Collaborative, Stanford
| | - Scott A Lorch
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| | - Ciaran S Phibbs
- Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare System, Menlo Park, California
- Departments of Pediatrics and Health Policy, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
4
|
Carroll C, Planey A, Kozhimannil KB. Reimagining and reinvesting in rural hospital markets. Health Serv Res 2022; 57:1001-1005. [PMID: 35947345 PMCID: PMC9441272 DOI: 10.1111/1475-6773.14047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Caitlin Carroll
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| | - Arrianna Planey
- Department of Health Policy and ManagementUNC Gillings School of Global Public HealthChapel HillNorth CarolinaUSA
| | - Katy B. Kozhimannil
- Division of Health Policy and ManagementUniversity of Minnesota School of Public HealthMinneapolisMinnesotaUSA
| |
Collapse
|
5
|
Arslanian KJ, Vilar-Compte M, Teruel G, Lozano-Marrufo A, Rhodes EC, Hromi-Fiedler A, García E, Pérez-Escamilla R. How much does it cost to implement the Baby-Friendly Hospital Initiative training step in the United States and Mexico? PLoS One 2022; 17:e0273179. [PMID: 36170264 PMCID: PMC9518892 DOI: 10.1371/journal.pone.0273179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 08/03/2022] [Indexed: 11/19/2022] Open
Abstract
The Baby-Friendly Hospital Initiative (BFHI) has been shown to increase breastfeeding rates, improving maternal and child health and driving down healthcare costs via the benefits of breastfeeding. Despite its clear public health and economic benefits, one key challenge of implementing the BFHI is procuring funding to sustain the program. To address this need and help healthcare stakeholders advocate for funds, we developed a structured method to estimate the first-year cost of implementing BFHI staff training, using the United States (US) and Mexico as case studies. The method used a hospital system-wide costing approach, rather than costing an individual hospital, to estimate the average per birth BFHI staff training costs in US and Mexican hospitals with greater than 500 annual births. It was designed to utilize publicly available data. Therefore, we used the 2014 American Hospital Association dataset (n = 1401 hospitals) and the 2018 Mexican Social Security Institute dataset (n = 154 hospitals). Based on our review of the literature, we identified three key training costs and modelled scenarios via an econometric approach to assess the sensitivity of the estimates based on hospital size, level of obstetric care, and training duration and intensity. Our results indicated that BFHI staff training costs ranged from USD 7.27–125.39 per birth in the US and from PPP 2.68–6.14 per birth in Mexico, depending on hospital size and technological capacity. Estimates differed between countries because the US had more hospital staff per birth and higher staff salaries than Mexico. Future studies should examine whether similar, publicly available data exists in other countries to test if our method can be replicated or adapted for use in additional settings. Healthcare stakeholders can better advocate for the funding to implement the entire BFHI program if they are able to generate informed cost estimates for training as we did here.
Collapse
Affiliation(s)
- Kendall J. Arslanian
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States of America
- * E-mail:
| | - Mireya Vilar-Compte
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States of America
- Research Institute for Equitable Development EQUIDE, Universidad Iberoamericana, Mexico City, Mexico
- Department of Public Health, Montclair State University, Montclair, NJ, United States of America
| | - Graciela Teruel
- Research Institute for Equitable Development EQUIDE, Universidad Iberoamericana, Mexico City, Mexico
| | - Annel Lozano-Marrufo
- Research Institute for Equitable Development EQUIDE, Universidad Iberoamericana, Mexico City, Mexico
| | - Elizabeth C. Rhodes
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States of America
- Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, New Haven, CT, United States of America
- Yale Center for Implementation Science, Yale School of Medicine, New Haven, CT, United States of America
| | - Amber Hromi-Fiedler
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States of America
| | - Erika García
- Research Institute for Equitable Development EQUIDE, Universidad Iberoamericana, Mexico City, Mexico
| | - Rafael Pérez-Escamilla
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States of America
| |
Collapse
|
6
|
Chen N, Pan J. The causal effect of delivery volume on severe maternal morbidity: an instrumental variable analysis in Sichuan, China. BMJ Glob Health 2022; 7:bmjgh-2022-008428. [PMID: 35537760 PMCID: PMC9092146 DOI: 10.1136/bmjgh-2022-008428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 04/19/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Findings regarding the association between delivery volume and maternal health outcomes are mixed, most of which explored their correlation. This study aims to demonstrate the causal effect of delivery volume on severe maternal morbidity (SMM) in China. Methods We analysed all women giving birth in the densely populated Sichuan province with 83 million residents in China, during the fourth quarters of each of 4 years (from 2016 to 2019). The routinely collected discharge data, the health institutional annual report data and road network data were used for analysis. The maternal health outcome was measured by SMM. Instrumental variable (IV) methods were applied for estimation, while the surrounding average number of delivery cases per institution was used as the instrument. Results The study included 4545 institution-years of data from 1456 distinct institutions with delivery services, reflecting 810 049 associated delivery cases. The average SMM rate was approximately 33.08 per 1000 deliveries during 2016 and 2019. More than 86% of delivery services were provided by a third of the institutions with the highest delivery volume (≥143 delivery cases quarterly). In contrast, less than 2% of delivery services were offered by a third of the institutions with the lowest delivery volume (<19 delivery cases quarterly). After adjusting the confounders in the IV-logistic models, the average marginal effect of per 1000 cases in delivery volume was −0.162 (95% CI −0.169 to –0.155), while the adjusted OR of delivery volume was 0.005 (95% CI 0.004 to 0.006). Conclusion Increased delivery volume has great potential to improve maternal health outcomes, while the centralisation of delivery services might facilitate maternal health promotion in China. Our study also provides implications for other developing countries confronted with similar challenges to China.
Collapse
Affiliation(s)
- Nan Chen
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, People's Republic of China.,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, People's Republic of China
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, People's Republic of China .,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, People's Republic of China
| |
Collapse
|
7
|
Wouk K, Kinlaw AC, Farahi N, Pfeifer H, Yeatts B, Paw MK, Robinson WR. Correlates of Receiving Guideline-Concordant Postpartum Health Services in the Community Health Center Setting. WOMEN'S HEALTH REPORTS 2022; 3:180-193. [PMID: 35262055 PMCID: PMC8896220 DOI: 10.1089/whr.2021.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/17/2022]
Abstract
Introduction: New clinical guidelines recommend comprehensive and timely postpartum services across 3 months after birth. Research is needed to characterize correlates of receiving guideline-concordant, quality postpartum care in federally qualified health centers serving marginalized populations. Methods: We abstracted electronic health record data from patients who received prenatal health care at three health centers in North Carolina to characterize quality postpartum care practices and to identify correlates of receiving quality care. We used multivariable log-binomial regression to estimate associations between patient, provider, and health center characteristics and two quality postpartum care outcomes: (1) timely care, defined as an initial assessment within the first 3 weeks and at least one additional visit within the first 3 months postpartum; and (2) comprehensive care, defined as receipt of services addressing family planning, infant feeding, chronic health, mood, and physical recovery across the first 3 months. Results: In a cohort of 253 patients, 60.5% received comprehensive postpartum care and 30.8% received timely care. Several prenatal factors (adequate care use, an engaged patient–provider relationship) and postpartum factors (early appointment scheduling, exclusive breastfeeding, and use of enabling services) were associated with timely postpartum care. The most important correlate of comprehensive services was having more than one postpartum visit during the first 3 months postpartum. Discussion: Identifying best practices for quality postpartum care in the health center setting can inform strategies to reduce health inequities. Future research should engage community stakeholders to define patient-centered measures of quality postpartum care and to identify community-centered ways of delivering this care.
Collapse
Affiliation(s)
- Kathryn Wouk
- Department of Maternal and Child Health, Carolina Global Breastfeeding Institute, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, North Carolina, USA
| | - Alan C. Kinlaw
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina School of Pharmacy, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Narges Farahi
- Department of Family Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Henry Pfeifer
- Piedmont Health Services, Chapel Hill, North Carolina, USA
- Department of Physician Assistant Studies, East Carolina University, Greenville, North Carolina, USA
| | - Brandon Yeatts
- Piedmont Health Services, Chapel Hill, North Carolina, USA
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Moo Kho Paw
- Piedmont Health Services, Chapel Hill, North Carolina, USA
| | - Whitney R. Robinson
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
8
|
Thorsen ML, Harris S, McGarvey R, Palacios J, Thorsen A. Evaluating disparities in access to obstetric services for American Indian women across Montana. J Rural Health 2022; 38:151-160. [PMID: 33754411 PMCID: PMC8458487 DOI: 10.1111/jrh.12572] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Pregnant women across the rural United States have increasingly limited access to obstetric care, especially specialty care for high-risk women and infants. Limited research focuses on access for rural American Indian/Alaskan Native (AIAN) women, a population warranting attention given persistent inequalities in birth outcomes. METHODS Using Montana birth certificate data (2014-2018), we examined variation in travel time to give birth and access to different levels of obstetric care (i.e., the proportion of individuals living within 1- and 2-h drives to facilities), by rurality (Rural-Urban Continuum Code) and race (White and AIAN people). FINDINGS Results point to limited obstetric care access in remote rural areas in Montana, especially higher-level specialty care, compared to urban or urban-adjacent rural areas. AIAN women traveled significantly farther than White women to access care (24.2 min farther on average), even compared to White women from similarly rural areas (5-13 min farther, after controlling for sociodemographic characteristics, risk factors, and health care utilization). AIAN women were 20 times more likely to give birth at a hospital without obstetric services and had less access to complex obstetric care. Poor access was particularly pronounced among reservation-dwelling AIAN women. CONCLUSIONS It is imperative to consider racial disparities and health inequities underlying poor access to obstetric services across rural America. Current federal policies aim to reduce maternity care professional shortages. Our findings suggest that racial disparities in access to complex obstetric care will persist in Montana unless facility-level infrastructure is also expanded to reach areas serving AIAN women.
Collapse
Affiliation(s)
- Maggie L. Thorsen
- Department of Sociology and Anthropology, Montana State University, Bozeman, Montana
| | - Sean Harris
- Jake Jabs College of Business and Entrepreneurship, Montana State University, Bozeman, Montana
| | - Ronald McGarvey
- Department of Industrial and Manufacturing Systems Engineering and Truman School of Public Affairs, University of Missouri, Columbia, Missouri
| | - Janelle Palacios
- Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland, California
| | - Andreas Thorsen
- Jake Jabs College of Business and Entrepreneurship, Montana State University, Bozeman, Montana
| |
Collapse
|
9
|
Handley SC, Passarella M, Herrick HM, Interrante JD, Lorch SA, Kozhimannil KB, Phibbs CS, Foglia EE. Birth Volume and Geographic Distribution of US Hospitals With Obstetric Services From 2010 to 2018. JAMA Netw Open 2021; 4:e2125373. [PMID: 34623408 PMCID: PMC8501399 DOI: 10.1001/jamanetworkopen.2021.25373] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care. OBJECTIVE To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study identified US hospitals with obstetric services using the American Hospital Association (AHA) Annual Survey of Hospitals and Centers for Medicare & Medicaid provider of services data from 2010 to 2018. Obstetric hospitals with 10 or more births per year were included in the study. Data analysis was performed from November 6, 2020, to April 5, 2021. EXPOSURE Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births. MAIN OUTCOMES AND MEASURES Outcomes assessed by birth volume category were percentage of births (from annual AHA data), number of hospitals, geographic distribution of hospitals among states, proximity between obstetric hospitals, and urban adjacency defined by urban influence codes, which classify counties by population size and adjacency to a metropolitan area. RESULTS The study included 26 900 hospital-years of data from 3207 distinct US hospitals with obstetric services, reflecting 34 054 951 associated births. Most infants (19 327 487 [56.8%]) were born in hospitals with more than 2000 births/y, and 2 528 259 (7.4%) were born in low-volume (10-500 births/y) hospitals. More than one-third of obstetric hospitals (37.4%; 10 064 hospital-years) were low volume. A total of 46 states had obstetric hospitals in all volume categories. Among low-volume hospitals, 18.9% (1904 hospital-years) were not within 30 miles of any other obstetric hospital and 23.9% (2400 hospital-years) were within 30 miles of a hospital with more than 2000 deliveries/y. Isolated hospitals (those without another obstetric hospital within 30 miles) were more frequently low volume, with 58.4% (1112 hospital-years) located in noncore rural areas. CONCLUSIONS AND RELEVANCE In this cohort study, marked variations were found in birth volume, geographic distribution, proximity, and urban adjacency among US obstetric hospitals from 2010 to 2018. The findings related to geographic isolation and rural-urban distribution of low-volume obstetric hospitals suggest the need to balance proximity with volume to optimize effective referral and access to high-quality perinatal care.
Collapse
Affiliation(s)
- Sara C. Handley
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
| | - Molly Passarella
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heidi M. Herrick
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julia D. Interrante
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis
| | - Scott A. Lorch
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
| | - Katy B. Kozhimannil
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis
| | - Ciaran S. Phibbs
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University School of Medicine, Stanford, California
| | - Elizabeth E. Foglia
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
10
|
Alspaugh A. Updates from the Literature, May/June 2021. J Midwifery Womens Health 2021; 66:407-412. [PMID: 34061457 DOI: 10.1111/jmwh.13252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Amy Alspaugh
- ACTIONS Program, University of California San Francisco, San Francisco, California
| |
Collapse
|
11
|
Sullivan MH, Denslow S, Lorenz K, Dixon S, Kelly E, Foley KA. Exploration of the Effects of Rural Obstetric Unit Closures on Birth Outcomes in North Carolina. J Rural Health 2020; 37:373-384. [PMID: 33289170 DOI: 10.1111/jrh.12546] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Closures of rural labor and delivery (L/D) units have prompted national and state-based efforts to assess the impact on birth outcomes. This study explores local effects of L/D closures in rural areas of North Carolina (NC). METHODS This is a retrospective cohort study of birth outcomes of 4,065 women in 5 rural areas of NC with L/D unit closures between 2013 and 2017. Outcomes were abstracted from birth certificate data from the NC Vital Statistics Reporting System. Localized outcomes 1 year prior to L/D unit closure were compared with outcomes 1 and 2 years post closure, including: (1) birth location and demographics, (2) change in travel patterns for birth, and (3) birth outcomes, including rates of labor induction, cesarean deliveries, maternal morbidity, and neonatal outcomes. FINDINGS Before closures, 25%-56% of deliveries occurred outside county of residence. Commercially insured and college-educated women were more likely to deliver out-of-area. Closures increased travel distance to delivery hospital an average of 7-27 miles. In 2 areas, cesarean delivery rates decreased despite an increase in labor inductions. There was also variability between areas in prenatal care adequacy and breastfeeding. CONCLUSIONS We found that L/D unit closures in rural NC disproportionately affected women on Medicaid. The impact showed area-specific variability, highlighting effects potentially masked by statewide or national analyses. Implications for future L/D closures would be eased by regional coordination and planning to mitigate negative effects, and state and national policies should address the excess burden placed on vulnerable populations.
Collapse
Affiliation(s)
- Margaret H Sullivan
- Mission Hospital McDowell, Marion, North Carolina.,Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Sheri Denslow
- UNC Health Sciences at Mountain Area Health Education Center, Asheville, North Carolina
| | - Kathleen Lorenz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Suzanne Dixon
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Emma Kelly
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Kathleen A Foley
- UNC Health Sciences at Mountain Area Health Education Center, Asheville, North Carolina
| |
Collapse
|
12
|
Jolles D, Stapleton S, Wright J, Alliman J, Bauer K, Townsend C, Hoehn‐Velasco L. Rural resilience: The role of birth centers in the United States. Birth 2020; 47:430-437. [PMID: 33270283 PMCID: PMC7839501 DOI: 10.1111/birt.12516] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 10/23/2020] [Accepted: 11/09/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To explore the role of the birth center model of care in rural health and maternity care delivery in the United States. METHODS All childbearing families enrolled in care at an American Association of Birth Centers Perinatal Data RegistryTM user sites between 2012 and 2020 are included in this descriptive analysis. FINDINGS Between 2012 and 2020, 88 574 childbearing families enrolled in care with 82 American Association of Birth Centers Perinatal Data RegistryTM user sites. Quality outcomes exceeded national benchmarks across all geographic regions in both rural and urban settings. A stable and predictable rate of transfer to a higher level of care was demonstrated across geographic regions, with over half of the population remaining appropriate for birth center level of care throughout the perinatal episode of care. Controlling for socio demographic and medical risk factors, outcomes were as favorable for clients in rural areas compared with urban and suburban communities. CONCLUSIONS Rural populations cared for within the birth center model of care experienced high-quality outcomes. HEALTH POLICY IMPLICATIONS A major focus of the United States maternity care reform should be the expansion of access to birth center models of care, especially in underserved areas such as rural communities.
Collapse
Affiliation(s)
- Diana Jolles
- Frontier Nursing UniversityVersaillesKYUSA,American Association of Birth CentersPerkiomenvillePAUSA
| | | | | | - Jill Alliman
- Frontier Nursing UniversityVersaillesKYUSA,American Association of Birth CentersPerkiomenvillePAUSA
| | - Kate Bauer
- American Association of Birth CentersPerkiomenvillePAUSA
| | | | | |
Collapse
|
13
|
Pearson J, Anderholm K, Bettermann M, Friedrichsen S, Mateo CDLR, Richter S, Onello E. Obstetrical Care in Rural Minnesota: Family Physician Perspectives on Factors Affecting the Ability to Provide Prenatal, Labor, and Delivery Care. J Rural Health 2020; 37:362-372. [PMID: 32602949 DOI: 10.1111/jrh.12478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE With decreasing access to rural obstetrical care, this study aimed to identify factors that contribute to the ability of Minnesota's rural communities to continue to offer obstetrical services locally. The study also sought to characterize attributes that differentiate rural communities that continue to offer obstetrical care from those that do not. METHODS Family medicine physicians practicing in communities of fewer than 20,000 people were interviewed through a phone survey that included multiple choice and open-ended questions. Quantitative and qualitative analyses were performed on data collected from the responses. FINDINGS Within the Minnesota communities represented (N = 25), prenatal care was provided broadly, regardless of whether labor and delivery services were available. For the communities providing local labor and delivery (N = 17), several factors seemed to be key to sustaining these services: having a sufficient cohort of delivering providers, having surgical backup, having accessible confident nurses and nurse anesthetists, sustaining a sufficient annual birth volume at the hospital, and having organizational and administrative support. In addition, supporting anesthesia and analgesic services, access to specialist consultation, having resources for managing and referring both newborn and maternal complications, and sustaining proper equipment were also requisite. CONCLUSIONS Rural Minnesota family medicine physicians practicing in communities providing local labor and delivery care emphasized several essential components for sustainable provision of these services. With awareness of these essential components, rural health care providers, administrators, and policy makers can focus resources and initiatives on efforts that are most likely to support a sustainable and coordinated rural labor and delivery program.
Collapse
Affiliation(s)
- Jennifer Pearson
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth campus, Duluth, Minnesota
| | - Kaitlyn Anderholm
- University of Minnesota Medical School Duluth campus, Duluth, Minnesota
| | - Maren Bettermann
- University of Minnesota Medical School Duluth campus, Duluth, Minnesota
| | | | | | - Sara Richter
- Professional Data Analysts, Minneapolis, Minnesota
| | - Emily Onello
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth campus, Duluth, Minnesota
| |
Collapse
|
14
|
Nidey N, Tabb KM, Carter KD, Bao W, Strathearn L, Rohlman DS, Wehby G, Ryckman K. Rurality and Risk of Perinatal Depression Among Women in the United States. J Rural Health 2019; 36:9-16. [PMID: 31602705 DOI: 10.1111/jrh.12401] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Rural populations may experience more frequent and intense risk factors for perinatal depression than their urban counterparts. However, research has yet to examine rural versus urban differences in a population-based study in the United States. Therefore, this study examined differences in risk of perinatal depression between women living in rural versus urban areas in the United States. METHOD Using 2016 data from the Pregnancy Risk Assessment Monitoring System, we examined the association between rural-urban status and the risk of depression during the perinatal time period. The total analytical sample included 17,229 women from 14 states. The association between rural-urban status and risk of perinatal depression was estimated using logistic regression, adjusting for race/ethnicity, maternal age, and state of residence. A second model adjusted for maternal education, health insurance status, and Women, Infants, and Children Special Supplemental Nutrition Program (WIC). RESULTS Odds of perinatal depression risk were higher by 21% among rural versus urban women (OR = 1.21, 95% CI: 1.05-1.41) adjusted for race, ethnicity, and maternal age. This risk difference became smaller and not significant when adding maternal education, health insurance coverage, and WIC participation. CONCLUSION Findings suggest a rural-urban inequality in perinatal depression risk. Reducing this inequality may require improving socioeconomic conditions and reducing associated risk factors among rural women.
Collapse
Affiliation(s)
- Nichole Nidey
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio.,Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Karen M Tabb
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Knute D Carter
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Wei Bao
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Lane Strathearn
- Center for Disabilities and Development, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa.,Division of Developmental and Behavioral Pediatrics, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Diane S Rohlman
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, Iowa
| | - George Wehby
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Kelli Ryckman
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| |
Collapse
|
15
|
van den Berg N, Radicke F, Stentzel U, Hoffmann W, Flessa S. Economic efficiency versus accessibility: Planning of the hospital landscape in rural regions using a linear model on the example of paediatric and obstetric wards in the northeast of Germany. BMC Health Serv Res 2019; 19:245. [PMID: 31018844 PMCID: PMC6480868 DOI: 10.1186/s12913-019-4016-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 03/15/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Costs for the provision of regional hospital care depend, among other things, on the population density and the maximum reasonable distance to the nearest hospital. In regions with a low population density, it is a challenge to plan the number and location of hospitals with respect both to economic efficiency and to the availability of hospital care close to residential areas. We examined whether the hospital landscape in rural regions can be planned on the basis of a regional economic model using the example which number of paediatric and obstetric wards in a region in the Northeast of Germany is economically efficient and what would be the consequences for the accessibility when one or more of the three current locations would be closed. METHODS A model of linear programming was developed to estimate the costs and revenues under different scenarios with up to three hospitals with both a paediatric and an obstetric ward in the investigation region. To calculate accessibility of the wards, geographic analyses were conducted. RESULTS With three hospitals in the study region, there is a financial gap of €3.6 million. To get a positive contribution margin for all three hospitals, more cases have to be treated than the region can deliver. Closing hospitals in the parts of the region with the smallest population density would lead to reduced accessibility for about 8% of the population under risk. CONCLUSIONS Quantitative modelling of the costs of regional hospital care provides a basis for planning. A qualitative discussion to the locations of the remaining departments and the implementation of alternative healthcare concepts should follow.
Collapse
Affiliation(s)
- Neeltje van den Berg
- University Medicine Greifswald, Institute for Community Medicine, Ellernholzstrasse 1-2, 17489, Greifswald, Germany.
| | - Franziska Radicke
- University Medicine Greifswald, Institute for Community Medicine, Ellernholzstrasse 1-2, 17489, Greifswald, Germany
| | - Ulrike Stentzel
- University Medicine Greifswald, Institute for Community Medicine, Ellernholzstrasse 1-2, 17489, Greifswald, Germany
| | - Wolfgang Hoffmann
- University Medicine Greifswald, Institute for Community Medicine, Ellernholzstrasse 1-2, 17489, Greifswald, Germany
| | - Steffen Flessa
- University of Greifswald, Chair of General Business Administration and Health Care Management, Friedrich-Loeffler-Strasse 70, 17487, Greifswald, Germany
| |
Collapse
|
16
|
Butwick AJ, Bentley J, Wong CA, Snowden JM, Sun E, Guo N. United States State-Level Variation in the Use of Neuraxial Analgesia During Labor for Pregnant Women. JAMA Netw Open 2018; 1:e186567. [PMID: 30646335 PMCID: PMC6324365 DOI: 10.1001/jamanetworkopen.2018.6567] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Neuraxial labor analgesia is recognized as the most effective method of providing pain relief during labor. Little is known about variation in the rates of neuraxial analgesia across US states. Identifying the presence and extent of variation may provide insights into practice variation and may indicate where access to neuraxial analgesia is inadequate. OBJECTIVE To test the hypothesis that variation exists in neuraxial labor analgesia use among US states. DESIGN, SETTING, AND PARTICIPANTS Retrospective, population-based, cross-sectional analysis using US birth certificate data. Participants were 2 625 950 women who underwent labor in 2015. MAIN OUTCOMES AND MEASURES State-specific prevalence of neuraxial analgesia per 100 women who underwent labor and variability in neuraxial analgesia use among states, assessed using multilevel multivariable regression modeling with the median odds ratio and the intraclass correlation coefficient to evaluate variation by state. RESULTS In the study population of 2 625 950 women, 0.1% (n = 2010) were younger than 15 years, 7.0% (n = 183 546) were between the ages of 15 and 19 years, 23.6% (n = 620 118) were between the ages of 20 and 24 years, 29.6% (n = 777 957) were between the ages of 25 and 29 years, 26.0% (n = 683 656) were between the ages of 30 and 34 years, 11.4% (n = 298 237) were between the ages of 35 and 39 years, 2.2% (n = 57 130) were between the ages of 40 and 44 years, and 0.1% (n = 3296) were between the ages of 45 and 54 years. More than 90% were privately insured or insured with Medicaid. Neuraxial analgesia was used by 73.1% (n = 1 920 368) of women. After adjustment for antepartum, obstetric, and intrapartum factors, Maine had the lowest neuraxial analgesia prevalence (36.6%; 95% CI, 33.2%-40.1%) and Nevada the highest (80.1%; 95% CI, 78.3%-81.7%). The adjusted median odds ratio was 1.5 (95% CI, 1.4-1.6), and the intraclass correlation coefficient was 5.4% (95% CI, 4.0%-7.9%). CONCLUSIONS AND RELEVANCE Results of this study suggest that a small portion of the overall variation in neuraxial analgesia use is explained by US states. Unmeasured patient-level and hospital-level factors likely account for a large portion of the variation between states. Efforts should be made to understand what the main reasons are for this variation and whether the variation influences maternal or perinatal outcomes.
Collapse
Affiliation(s)
- Alexander J. Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Jason Bentley
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
| | - Cynthia A. Wong
- Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City
| | - Jonathan M. Snowden
- School of Public Health, Oregon Health & Science University–Portland State University, Portland
| | - Eric Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Nan Guo
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
17
|
Clapp MA, James KE, Melamed A, Ecker JL, Kaimal AJ. Hospital volume and cesarean delivery among low-risk women in a nationwide sample. J Perinatol 2018; 38:127-131. [PMID: 29120454 DOI: 10.1038/jp.2017.173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/11/2017] [Accepted: 09/25/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We sought to determine if hospital delivery volume was associated with a patient's risk for cesarean delivery in low-risk women. STUDY DESIGN This study retrospectively examines a cohort of 1 657 495 deliveries identified in the 2013 Nationwide Readmissions Database. Hospitals were stratified by delivery volume quartiles. Low-risk patients were identified using the Society for Maternal-Fetal Medicine definition (n=845 056). A multivariable logistic regression accounting for hospital-level clustering was constructed to assess the factors affecting a patient's odds for cesarean delivery. RESULTS The range of cesarean delivery rates was 2.4-51.2% among low-risk patients, and the median was 16.5% (IQR 12.8-20.5%). The cesarean delivery rate was higher in the top two-volume-quartile hospitals (17.4 and 18.2%) compared to the bottom quartiles (16.4 and 16.3%) (P<0.001). Hospital volume was not associated with a patient's odds for cesarean delivery after adjusting for patient and other hospital characteristics (P=0.188). CONCLUSION Hospital delivery volume is not an independent predictor of cesarean delivery in this population.
Collapse
Affiliation(s)
- M A Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - K E James
- The Deborah Kelly Center for Outcomes Research, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - A Melamed
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - J L Ecker
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - A J Kaimal
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| |
Collapse
|
18
|
Kozhimannil KB, Hardeman RR, Henning-Smith C. Maternity care access, quality, and outcomes: A systems-level perspective on research, clinical, and policy needs. Semin Perinatol 2017; 41:367-374. [PMID: 28889958 DOI: 10.1053/j.semperi.2017.07.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The quality of maternity care in the United States is variable, and access to care is tenuous for rural residents, low-income individuals, and people of color. Without accessible, timely, and high-quality care, certain clinical and sociodemographic characteristics of individuals may render them more vulnerable to poor birth outcomes. However, risk factors for poor birth outcomes do not occur in a vaccum; rather, health care financing, delivery, and organization as well as the policy environment shape the context in which patients seek and receive maternity care. This paper describes the relationship between access and quality in maternity care and offers a systems-level perspective on the innovations and strategies needed in research, clinical care, and policy to improve equity in maternal and infant health.
Collapse
Affiliation(s)
- Katy B Kozhimannil
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN.
| | - Rachel R Hardeman
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
| | - Carrie Henning-Smith
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
| |
Collapse
|
19
|
Prasad S, Hung P, Henning-Smith C, Casey M, Kozhimannil K. Rural Hospital Employment of Physicians and Use of Cesareans and Nonindicated Labor Induction. J Rural Health 2017; 34 Suppl 1:s13-s20. [PMID: 28318119 DOI: 10.1111/jrh.12240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/17/2017] [Accepted: 02/14/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Workforce issues constrain obstetric care services in rural US hospitals, and one strategy hospitals use is to employ physicians to provide obstetric care. However, little is known about the relationship between hospital employment of maternity care physicians and use of obstetric care procedures in rural hospitals. We examined the association between obstetric physician employment and use of cesareans and nonindicated labor induction. STUDY DESIGN We conducted a cross-sectional analysis of a telephone survey of all 306 rural hospitals providing obstetric care in 9 states from November 2013 to March 2014 and linked the survey data (N = 263, 86% response rate) to all-payer childbirth data on maternity care utilization from 2013 Statewide Inpatient Database (SID) hospital discharge data. METHODS Using logistic regression models, we assessed the proportion of a hospital's maternity care physicians employed by the hospital and estimated its association with utilization of low-risk and nonindicated cesareans, and nonindicated labor induction. RESULTS Rural hospitals that employed family physicians but not obstetricians had lower cesarean rates among low-risk pregnancies. Rural hospitals that employed only obstetricians did not show a relationship between employment and procedure utilization. Across hospitals with both obstetricians and family physicians, a 10% higher proportion of obstetricians employed was associated with 4.6% higher low-risk cesarean rates (4.6% [0.7%-8.4%]), while no significant relationship was found for the proportion of family physicians employed by a hospital. CONCLUSIONS In rural US hospitals, associations between physician employment and obstetric procedure use differed by physician mix and the types of physicians employed.
Collapse
Affiliation(s)
- Shailendra Prasad
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota.,Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Peiyin Hung
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Carrie Henning-Smith
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Michelle Casey
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Katy Kozhimannil
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
20
|
Hutcheon JA, Riddell CA, Strumpf EC, Lee L, Harper S. Safety of labour and delivery following closures of obstetric services in small community hospitals. CMAJ 2016; 189:E431-E436. [PMID: 27821464 DOI: 10.1503/cmaj.160461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 07/12/2016] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND In recent decades, many smaller hospitals in British Columbia, Canada, have stopped providing planned obstetric services. We examined the effect of these service closures on the labour and delivery outcomes of pregnant women living in affected communities. METHODS We used maternal postal codes to identify delivery records (1998-2014) of women residing in a community affected by service closure. The records were obtained from the British Columbia Perinatal Data Registry. We examined the effect of the closures using a within-communities fixed-effects framework and included similar-sized communities without service closures to control for underlying time trends. The primary outcome was a previously published composite measure of labour and delivery safety, the Adverse Outcome Index, which includes adverse events such as birth injury and unanticipated operative procedures, and includes weights for severity of adverse events. Secondary outcomes included maternal or newborn transfer, and use of obstetric interventions. RESULTS We found little evidence that closure of planned obstetric services affected the risk of composite adverse maternal-newborn outcome (-0.4 excess adverse events per 100 deliveries, 95% confidence interval [CI] -2.0 to 1.1), or most other secondary outcomes. The severity of composite outcome events decreased following the closures (rate ratio 0.58, 95% CI 0.36 to 0.89). Closures were associated with increases in use of epidural analgesia (3.4 excess events per 100 deliveries, 95% CI 0.4 to 6.3) and length of antepartum stay (0.6 h, 95% CI 0.1 to 1.0 h). INTERPRETATION Closure of planned obstetric services in low-volume hospitals was not associated with an increase or decrease in frequency of adverse events during labour and delivery.
Collapse
Affiliation(s)
- Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology (Hutcheon), University of British Columbia; Perinatal Services BC (Hutcheon, Lee), Vancouver, BC; Department of Epidemiology, Biostatistics and Occupational Health (Riddell, Strumpf, Harper) and Department of Economics (Strumpf), McGill University, Montréal, Que.
| | - Corinne A Riddell
- Department of Obstetrics and Gynaecology (Hutcheon), University of British Columbia; Perinatal Services BC (Hutcheon, Lee), Vancouver, BC; Department of Epidemiology, Biostatistics and Occupational Health (Riddell, Strumpf, Harper) and Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Erin C Strumpf
- Department of Obstetrics and Gynaecology (Hutcheon), University of British Columbia; Perinatal Services BC (Hutcheon, Lee), Vancouver, BC; Department of Epidemiology, Biostatistics and Occupational Health (Riddell, Strumpf, Harper) and Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Lily Lee
- Department of Obstetrics and Gynaecology (Hutcheon), University of British Columbia; Perinatal Services BC (Hutcheon, Lee), Vancouver, BC; Department of Epidemiology, Biostatistics and Occupational Health (Riddell, Strumpf, Harper) and Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Sam Harper
- Department of Obstetrics and Gynaecology (Hutcheon), University of British Columbia; Perinatal Services BC (Hutcheon, Lee), Vancouver, BC; Department of Epidemiology, Biostatistics and Occupational Health (Riddell, Strumpf, Harper) and Department of Economics (Strumpf), McGill University, Montréal, Que
| |
Collapse
|
21
|
Snowden JM, Kozhimannil KB, Muoto I, Caughey AB, McConnell KJ. A 'busy day' effect on perinatal complications of delivery on weekends: a retrospective cohort study. BMJ Qual Saf 2016; 26:e1. [PMID: 27472947 PMCID: PMC5244816 DOI: 10.1136/bmjqs-2016-005257] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 06/14/2016] [Accepted: 06/17/2016] [Indexed: 12/13/2022]
Abstract
Objective To evaluate whether busy days on a labour and delivery unit are associated with maternal and neonatal complications of childbirth in California hospitals, accounting for weekday/weekend births. Design This is a population-based retrospective cohort study. Setting Linked vital statistics/patient discharge data for California births between 2009 and 2010 from the Office of Statewide Health Planning and Development. Participants All singleton, cephalic, non-anomalous California births between 2009 and 2010 (N=724 967). Main outcomes The key exposure was high daily obstetric volume, defined as giving birth on a day when the number of births exceeded the hospital-specific 75th percentile of daily delivery volume. Outcomes were a range of maternal and neonatal complications. Results Several maternal and neonatal complications were increased on high-volume days and weekends following adjustment for maternal demographics, annual hospital birth volume and teaching hospital status. For example, compared with low-volume weekdays, the odds of Apgar <7 on low-volume weekend days and high-volume weekend days were 11% (adjusted OR (aOR) 1.11, CI 1.03 to 1.21) and 29% higher (aOR 1.29, CI 1.10 to 1.52), respectively. High volume was associated with increased odds of neonatal seizures on weekdays (aOR 1.33, CI 1.01 to 1.71) and haemorrhage on weekends (aOR 1.11, CI 1.01 to 1.22). After accounting for between-hospital variation, weekend delivery remained significantly associated with increased odds of Apgar score <7, neonatal intensive care unit admission, prolonged maternal length of stay and the odds of neonatal seizures remained increased on high-volume weekdays. Conclusions Our findings suggest that weekend delivery is a consistent risk factor for a range of perinatal complications and there may be variability in how well hospitals handle surges in volume.
Collapse
Affiliation(s)
- Jonathan M Snowden
- Department of Obstetrics & Gynecology/Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Katy Backes Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Ifeoma Muoto
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Aaron B Caughey
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - K John McConnell
- Emergency Medicine, Oregon Health and Science University, Portland, Oregon, USA
| |
Collapse
|
22
|
Measuring Quality of Maternal and Newborn Care in Developing Countries Using Demographic and Health Surveys. PLoS One 2016; 11:e0157110. [PMID: 27362354 PMCID: PMC4928810 DOI: 10.1371/journal.pone.0157110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/24/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND One of the greatest obstacles facing efforts to address quality of care in low and middle income countries is the absence of relevant and reliable data. This article proposes a methodology for creating a single "Quality Index" (QI) representing quality of maternal and neonatal health care based upon data collected as part of the Demographic and Health Survey (DHS) program. METHODS Using the 2012 Indonesian Demographic and Health Survey dataset, indicators of quality of care were identified based on the recommended guidelines outlined in the WHO Integrated Management of Pregnancy and Childbirth. Two sets of indicators were created; one set only including indicators available in the standard DHS questionnaire and the other including all indicators identified in the Indonesian dataset. For each indicator set composite indices were created using Principal Components Analysis and a modified form of Equal Weighting. These indices were tested for internal coherence and robustness, as well as their comparability with each other. Finally a single QI was chosen to explore the variation in index scores across a number of known equity markers in Indonesia including wealth, urban rural status and geographical region. RESULTS The process of creating quality indexes from standard DHS data was proven to be feasible, and initial results from Indonesia indicate particular disparities in the quality of care received by the poor as well as those living in outlying regions. CONCLUSIONS The QI represents an important step forward in efforts to understand, measure and improve quality of MNCH care in developing countries.
Collapse
|
23
|
Casey MM, Hung P, Henning-Smith C, Prasad S, Kozhimannil KB. Rural Implications of Expanded Birth Volume Threshold for Reporting Perinatal Care Measures. Jt Comm J Qual Patient Saf 2016; 42:179-87. [PMID: 27025578 DOI: 10.1016/s1553-7250(16)42022-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In 2016 the minimum annual birth volume threshold for required reporting of the Joint Commission Perinatal Care measures by accredited hospitals decreased from 1,100 to 300 births. METHODS Publicly available Joint Commission Quality Check data from April 2014 to March 2015 for three Perinatal Care measures were linked to Medicare Provider of Services and American Hospital Association Annual Survey data. For each measure, hospital-level reporting and performance among accredited hospitals providing obstetric care were compared using Fisher's exact tests. RESULTS Sixty-seven percent of the 2,396 accredited hospitals with obstetric services reported at least one eligible patient for two of the four reported Perinatal Care measures: Elective delivery and exclusive breast milk feeding. Fewer hospitals (35.0%) had data on the antenatal steroids measure; many hospitals may not have any eligible patients for this measure. Hospitals with higher birth volume, those in urban counties, and those with private, nonprofit ownership or system affiliation were more likely to report the perinatal measures (p < 0.001). Across states, reporting rates varied considerably. By hospital volume, performance varied more on the antenatal steroids measure (78.0% to 91.5%) than on the breast milk feeding measure (48.4% to 49.5%) and the elective delivery measure (2.5% to 3.0%). CONCLUSIONS Expansion of the minimum birth volume threshold nearly doubles the number of accredited hospitals required to report the Perinatal Care measures to The Joint Commission. However, 485 accredited hospitals with obstetric services that are either critical access hospitals or have fewer than 300 births annually are still exempt from reporting. Although many rural hospitals remain exempt from reporting requirements, the measures offer an opportunity for both rural and urban hospitals to assess and improve care.
Collapse
Affiliation(s)
- Michelle M Casey
- Rural Health Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, USA
| | | | | | | | | |
Collapse
|
24
|
Primary Maternity Units in rural and remote Australia: Results of a national survey. Midwifery 2016; 40:1-9. [PMID: 27428092 DOI: 10.1016/j.midw.2016.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 05/04/2016] [Accepted: 05/07/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Primary Maternity Units (PMUs) offer less expensive and potentially more sustainable maternity care, with comparable or better perinatal outcomes for normal pregnancy and birth than higherlevel units. However, little is known about how these maternity services operate in rural and remote Australia, in regards to location, models of care, service structure, support mechanisms or sustainability. This study aimed to confirm and describe how they operate. DESIGN a descriptive, cross-sectional study was undertaken, utilising a 35-item survey to explore current provision of maternity care in rural and remote PMUs across Australia. Data were subjected to simple descriptive statistics and thematic analysis for free text answers. SETTING AND PARTICIPANTS Only 17 PMUs were identified in rural and remote areas of Australia. All 17 completed the survey. RESULTS the PMUs were, on average, 56km or 49minutes from their referral service and provided care to an average of 59 birthing women per year. Periodic closures or downgrading of services was common. Low-risk eligibility criteria were universally used, but with some variability. Medically-led care was the most widely available model of care. In most PMUs midwives worked shift work involving both nursing and midwifery duties, with minimal uptake of recent midwifery workforce innovations. Perceived enablers of, and threats to, sustainability were reported. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE a small number of PMUs operate in rural Australia, and none in remote areas. Continuing overreliance on local medical support, and under-utilisation of the midwifery workforce constrain the restoration of maternity services to rural and remote Australia.
Collapse
|
25
|
Thao V, Hung P, Tilden E, Caughey A, Snowden J, Kozhimannil K. Association between Hospital Birth Volume and Maternal Morbidity among Low-Risk Pregnancies in Rural, Urban, and Teaching Hospitals in the United States. Am J Perinatol 2016; 33:590-9. [PMID: 26731180 PMCID: PMC4851580 DOI: 10.1055/s-0035-1570380] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objectives This study aims to examine the relationship between hospital birth volume and multiple maternal morbidities among low-risk pregnancies in rural hospitals, urban non-teaching hospitals, and urban teaching hospitals, using a representative sample of U.S. hospitals. Study Design Using the 2011 Nationwide Inpatient Sample from 607 hospitals, we identified 508,146 obstetric deliveries meeting low-risk criteria and compared outcomes across hospital volume categories. Outcomes include postpartum hemorrhage (PPH), chorioamnionitis, endometritis, blood transfusion, severe perineal laceration, and wound infection. Results Hospital birth volume was more consistently related to PPH than to other maternal outcomes. Lowest-volume rural (< 200 births) and non-teaching (< 650 births) hospitals had 80% higher odds (adjusted odds ratio [AOR] = 1.80; 95% CI = 1.56-2.08) and 39% higher odds (AOR = 1.39; 95% CI = 1.26-1.53) of PPH respectively, than those in corresponding high-volume hospitals. However, in urban teaching hospitals, delivering in a lower-volume hospital was associated with 14% lower odds of PPH (AOR = 0.86; 95% CI = 0.80-0.93). Deliveries in rural hospitals had 31% higher odds of PPH than urban teaching hospitals (AOR = 1.31; 95% CI = 1.13-1.53). Conclusions Low birth volume was a risk factor for PPH in both rural and urban non-teaching hospitals, but not in urban teaching hospitals, where higher volume was associated with greater odds of PPH.
Collapse
Affiliation(s)
- Viengneesee Thao
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Peiyin Hung
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Ellen Tilden
- Department of Nurse-Midwifery, Oregon Health and Sciences University School of Nursing, Portland, Oregon
| | - Aaron Caughey
- Department of Obstetrics and Gynecology, Oregon Health and Sciences University School of Medicine, Portland, Oregon
| | - Jonathan Snowden
- Department of Obstetrics and Gynecology, Oregon Health and Sciences University School of Medicine, Portland, Oregon
| | - Katy Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| |
Collapse
|
26
|
Kozhimannil KB, Henning‐Smith C, Hung P. The Practice of Midwifery in Rural US Hospitals. J Midwifery Womens Health 2016; 61:411-8. [DOI: 10.1111/jmwh.12474] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
27
|
Hung P, Kozhimannil KB, Casey MM, Moscovice IS. Why Are Obstetric Units in Rural Hospitals Closing Their Doors? Health Serv Res 2016; 51:1546-60. [PMID: 26806952 DOI: 10.1111/1475-6773.12441] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To understand hospital- and county-level factors for rural obstetric unit closures, using mixed methods. DATA SOURCES Hospital discharge data from Healthcare Cost and Utilization Project's Statewide Inpatient Databases, American Hospital Association Annual Survey, and Area Resource File for 2010, as well as 2013-2014 telephone interviews of all 306 rural hospitals in nine states with at least 10 births in 2010. Via interview, we ascertained obstetric unit status, reasons for closures, and postclosure community capacity for prenatal care. STUDY DESIGN Multivariate logistic regression and qualitative analysis were used to identify factors associated with unit closures between 2010 and 2014. PRINCIPAL FINDINGS Exactly 7.2 percent of rural hospitals in the study closed their obstetric units. These units were smaller in size, more likely to be privately owned, and located in communities with lower family income, fewer obstetricians, and fewer family physicians. Prenatal care was still available in 17 of 19 communities, but local women would need to travel an average of 29 additional miles to access intrapartum care. CONCLUSIONS Rural obstetric unit closures are more common in smaller hospitals and communities with a limited obstetric workforce. Concerns about continuity of rural maternity care arise for women with local prenatal care but distant intrapartum care.
Collapse
Affiliation(s)
- Peiyin Hung
- Division of Health Policy and Management, University of Minnesota School of Public Health, University of Minnesota, Minneapolis, MN
| | - Katy B Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, University of Minnesota, Minneapolis, MN
| | - Michelle M Casey
- Division of Health Policy and Management, University of Minnesota School of Public Health, University of Minnesota, Minneapolis, MN
| | - Ira S Moscovice
- Division of Health Policy and Management, University of Minnesota School of Public Health, University of Minnesota, Minneapolis, MN
| |
Collapse
|
28
|
Enweronu-Laryea C, Dickson KE, Moxon SG, Simen-Kapeu A, Nyange C, Niermeyer S, Bégin F, Sobel HL, Lee ACC, von Xylander SR, Lawn JE. Basic newborn care and neonatal resuscitation: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth 2015; 15 Suppl 2:S4. [PMID: 26391000 PMCID: PMC4577863 DOI: 10.1186/1471-2393-15-s2-s4] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND An estimated two-thirds of the world's 2.7 million newborn deaths could be prevented with quality care at birth and during the postnatal period. Basic Newborn Care (BNC) is part of the solution and includes hygienic birth and newborn care practices including cord care, thermal care, and early and exclusive breastfeeding. Timely provision of resuscitation if needed is also critical to newborn survival. This paper describes health system barriers to BNC and neonatal resuscitation and proposes solutions to scale up evidence-based strategies. METHODS The maternal and newborn bottleneck analysis tool was applied by 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" that hinder the scale up of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for BNC and neonatal resuscitation. RESULTS Eleven of the 12 countries provided grading data. Overall, bottlenecks were graded more severely for resuscitation. The most severely graded bottlenecks for BNC were health workforce (8 of 11 countries), health financing (9 out of 11) and service delivery (7 out of 9); and for neonatal resuscitation, workforce (9 out of 10), essential commodities (9 out of 10) and service delivery (8 out of 10). Country teams from Africa graded bottlenecks overall more severely. Improving workforce performance, availability of essential commodities, and well-integrated health service delivery were the key solutions proposed. CONCLUSIONS BNC was perceived to have the least health system challenges among the seven maternal and newborn intervention packages assessed. Although neonatal resuscitation bottlenecks were graded more severe than for BNC, similarities particularly in the workforce and service delivery building blocks highlight the inextricable link between the two interventions and the need to equip birth attendants with requisite skills and commodities to assess and care for every newborn. Solutions highlighted by country teams include ensuring more investment to improve workforce performance and distribution, especially numbers of skilled birth attendants, incentives for placement in challenging settings, and skills-based training particularly for neonatal resuscitation.
Collapse
Affiliation(s)
- Christabel Enweronu-Laryea
- Department of Child Health, School of Medicine and Dentistry, College of Health Sciences University of Ghana, Accra, PO Box 4236, Ghana
| | - Kim E Dickson
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, NY 10017, USA
| | - Sarah G Moxon
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Aline Simen-Kapeu
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, NY 10017, USA
| | - Christabel Nyange
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, NY 10017, USA
- Ross University Medical School, 2300 SW 145th Avenue, Miramar, Florida 33027, USA
| | - Susan Niermeyer
- Section of Neonatology, University of Colorado School of Medicine, 13121 E. 17th Avenue, Aurora, CO 80045, USA
| | - France Bégin
- IYCN, UNICEF Headquarters, 3 United Nations Plaza, New York, NY 10017, USA
| | - Howard L Sobel
- Reproductive, Maternal, Newborn, Child and Adolescent Health, Division of NCD and Health through Life-Course, World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Anne CC Lee
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Severin Ritter von Xylander
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| |
Collapse
|
29
|
Kozhimannil KB, Casey MM, Hung P, Han X, Prasad S, Moscovice IS. The Rural Obstetric Workforce in US Hospitals: Challenges and Opportunities. J Rural Health 2015; 31:365-72. [PMID: 25808202 DOI: 10.1111/jrh.12112] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to describe the types and combinations of clinicians who are delivering babies in rural hospitals, their employment status, the relationship between hospital birth volume and staffing models, and the staffing challenges faced by rural hospitals. METHODS We conducted a telephone survey of 306 rural hospitals in 9 states: Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin, from November 2013 to March 2014 to assess their obstetric workforce. Bivariate associations between hospitals' annual birth volume and obstetric workforce characteristics were examined, as well as qualitative analysis of workforce changes and staffing challenges. FINDINGS Hospitals with lower birth volume (<240 births per year) are more likely to have family physicians and general surgeons attending deliveries, while those with a higher birth volume more frequently have obstetricians and midwives attending deliveries. Reported staffing challenges include scheduling, training, census fluctuation, recruitment and retention, and intrahospital relationships. CONCLUSIONS Individual hospitals working in isolation may struggle to address staffing challenges. Federal and state policy makers, regional collaboratives, and health care delivery systems can facilitate solutions through programs such as telehealth, simulation training, and interprofessional education.
Collapse
Affiliation(s)
- Katy B Kozhimannil
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Michelle M Casey
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Peiyin Hung
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Xinxin Han
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Shailendra Prasad
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota.,Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Ira S Moscovice
- University of Minnesota Rural Health Research Center, Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
30
|
Escuriet R, Pueyo MJ, Perez-Botella M, Espada X, Salgado I, Gómez A, Biescas H, Espiga I, White J, Fernandez R, Fusté J, Ortún V. Cross-sectional study comparing public and private hospitals in Catalonia: is the practice of routine episiotomy changing? BMC Health Serv Res 2015; 15:95. [PMID: 25889079 PMCID: PMC4365515 DOI: 10.1186/s12913-015-0753-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 02/17/2015] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND In Spain, the Strategy for Assistance in Normal Childbirth (SANC) promoted a model of care, which respects the physiological birth process and discards unnecessary routine interventions, such as episiotomies. We evaluated the rate of episiotomy use and perineal trauma as indicators of how selective introduction of the SANC initiative has impacted childbirth outcomes in hospitals of Catalonia. METHODS Cross-sectional study of all singleton vaginal term deliveries without instrument registered in the Minimum Basic Data Set (MBDS) of Catalonia in 2007, 2010 and 2012. Hospitals were divided into types according to funding (public or private), and four strata were differentiated according to volume of births attended. Episiotomies and perineal injury were considered dependent variables. The relationship between qualitative variables was analysed using the chi-squared test, and Student's t-test was used for quantitative variables. Comparison of proportions was performed on the two hospital groups between 2007 and 2012 using a Z-test. Logistic regression models were used to analyse the relationship between episiotomy or severe perineal damage and maternal age, volume of births and hospital type, obtaining odds ratios (OR) and 95% confidence intervals (CI). RESULTS The majority of normal singleton term deliveries were attended in public hospitals, where maternal age was lower than for women attended in private hospitals. Analysis revealed a statistically significant (P < 0.001) decreasing trend in episiotomy use in Catalonia for both hospital types. Private hospitals appeared to be associated with increased episiotomy rate in 2007 (OR = 1.099, CI: 1,057-1,142), 2010 (OR = 1.528, CI: 1,472-1,587) and 2012 (OR = 1.459, CI: 1,383-1,540), and a lower rate of severe perineal trauma in 2007 (OR = 0.164, CI: 0.095-0.283), 2010 (OR = 0.16, CI: 0.110-0.232) and 2012 (OR = 0.19, CI: 0.107-0.336). Regarding severe perineal injury, when independent variables were adjusted, maternal age ceased to have a significant correlation in 2012 (OR = 0.994, CI: 0.970-1.018). CONCLUSIONS Episiotomy procedures during normal singleton vaginal term deliveries in Catalonia has decreased steadily since 2007. Study results show a stable incidence trend below 1% for severe perineal trauma over the study period.
Collapse
Affiliation(s)
- Ramón Escuriet
- Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra (UPF), Barcelona, Spain.
- Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - María J Pueyo
- Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
| | - Mercedes Perez-Botella
- University of Central Lancashire, School of Health, Midwifery, Neonatal and Sexual Health Division, Preston, UK.
| | - Xavi Espada
- Institut Català de la Salut, Unitat Atenció a la Salut Sexual i Reproductiva, Granollers, Spain.
- Fundació Hospital Asil de Granollers, Granollers, Spain.
| | - Isabel Salgado
- Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Analía Gómez
- Consorci Sanitari Integral, Hospital General de l'Hospitalet, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Herminia Biescas
- Directorate-General for Health Planning and Research, Ministry of Health of the Government of Catalonia, Barcelona, Spain.
| | - Isabel Espiga
- Women's Health Observatory, Subdirectorate for Quality and Cohesion, Ministry of Health, Social Services and Equality, Madrid, Spain.
| | - Joanna White
- Centre for Research in Anthropology (CRIA-IUL), Lisbon, Portugal.
- Visiting Fellow, King's College, London, UK.
| | - Rosa Fernandez
- Public Health Agency of Catalonia, Maternal and Infant Health Programme, Government of Catalonia, Barcelona, Spain.
| | - Josep Fusté
- The Union, Health and Social Entities Association, Barcelona, Spain.
| | - Vicente Ortún
- Universitat Pompeu Fabra (UPF), Faculty of Economic and Business Sciences, Barcelona, Spain.
| |
Collapse
|