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Psenkova P, Tedla M, Minarcinova L, Zahumensky J. Application of a specific clinical pathway can affect the choice of trial of labor in patients with a history of cesarean delivery. BMC Pregnancy Childbirth 2024; 24:292. [PMID: 38641800 PMCID: PMC11027349 DOI: 10.1186/s12884-024-06429-8] [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: 11/20/2023] [Accepted: 03/15/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Mode of delivery in women with previous history of cesarean delivery (CD) is highly modifiable by the practices of the delivery unit. Vaginal birth after a cesarean (VBAC) delivery is a safe and preferred alternative in most cases. The aim of this study was to assess the impact of adopting a complex set of measures aimed at the mode of delivery in this group. METHODS This was a retrospective observational study comparing two birth cohorts before and after the implementation of a series of quality improvement (QI) interventions. The study cohorts comprised women with a history of cesarean delivery who gave birth in the period before (January 2013 - December 2015) and after (January 2018 - December 2020) the adoption of the QI measures. The measures were focused on singleton term cephalic pregnancies with a low transverse incision in the uterus. Measures included approval of all planned CDs by a senior obstetrician, re-training staff on the use of the FIGO classification for intrapartum fetal cardiotocogram, establishing VBAC management guidelines, encouraging epidural analgesia during trial of labor after cesarean (TOLAC), establishing a labor ward team and introducing a monthly maternity audit. RESULTS Term singleton cephalic pregnancies with previous history of CD accounted for 12.55% of all births in the pre-intervention period and 12.01% in the post-intervention period. The frequency of cesarean deliveries decreased from 89.94% in the pre-intervention period to 64.47% in the post-intervention period (p < 0.0001). We observed a significant increase in TOLAC from 13.18 to 42.12% (p<0.0001) and also an increase in successful VBAC from 76.27 to 84.35% (p < 0.0001). All changes occurred without statistically significant change in overall perinatal mortality. CONCLUSIONS This study demonstrates the feasibility to safely increase trial of labor and vaginal birth after cesarean delivery by implementing a series of quality improvement interventions and clinical pathway changes.
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Affiliation(s)
- Petra Psenkova
- 2nd Department of Gynecology and Obstetrics, University Hospital Bratislava and Comenius University, Ruzinovska 6, Bratislava, 82106, Slovakia
| | - Miroslav Tedla
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital Bratislava and Comenius University, Antolská 11, Bratislava, 851 07, Slovakia
| | - Lenka Minarcinova
- 2nd Department of Gynecology and Obstetrics, University Hospital Bratislava and Comenius University, Ruzinovska 6, Bratislava, 82106, Slovakia.
| | - Jozef Zahumensky
- 2nd Department of Gynecology and Obstetrics, University Hospital Bratislava and Comenius University, Ruzinovska 6, Bratislava, 82106, Slovakia
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Pollock BD, Carranza L, Braswell-Pickering E, Sing CM, Warner LL, Theiler RN. A Simple Risk Adjustment for Hospital-Level Nulliparous, Term, Singleton, Vertex, Cesarean Delivery Rates and Its Implications for Public Reporting. Jt Comm J Qual Patient Saf 2024:S1553-7250(24)00117-X. [PMID: 38744623 DOI: 10.1016/j.jcjq.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND The Joint Commission uses nulliparous, term, singleton, vertex, cesarean delivery (NTSV-CD) rates to assess hospitals' perinatal care quality through the Cesarean Birth measurement (PC-02). However, these rates are not risk-adjusted for maternal health factors, putting this measure at odds with the risk adjustment paradigm of most publicly reported hospital quality measures. Here, the authors tested whether risk adjustment for readily documented maternal risk factors affected hospital-level NTSV-CD rates in a large health system. METHODS Included were all consecutive NTSV pregnancies from January 2019 to April 2023 across 10 hospitals in one health system. Logistic regression, adjusting for age, obesity, diabetes, and hypertensive disorders. was used to calculate hospital-level risk-adjusted NTSV-CD rates by multiplying observed vs. expected ratios for each hospital by the systemwide unadjusted NTSV-CD rate. The authors calculated intrahospital risk differences between unadjusted and risk-adjusted rates and calculated the percentage of hospitals qualifying for different reporting status after risk adjustment using the 30% Joint Commission reporting threshold rate. RESULTS Of 23,866 pregnancies, 6,550 (27.4%) had cesarean deliveries. Across 10 hospitals, the number of deliveries ranged from 393 to 7,671, with unadjusted NTSV-CD rates ranging from 21.0% to 30.5%. Risk-adjusted NTSV-CD rates ranged from 21.5% to 30.4%, with absolute intrahospital differences in risk-adjusted vs. unadjusted rates ranging from -1.33% (indicating lower rate after risk adjustment) to 3.37% (indicating higher rate after risk adjustment). Three of 10 (30.0%) hospitals qualified for different reporting statuses after risk adjustment. CONCLUSION Risk adjustment for age, obesity, diabetes, and hypertensive disorders is feasible and resulted in meaningful changes in hospital-level NTSV-CD rates with potentially impactful consequences for hospitals near The Joint Commission reporting threshold.
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Clark RRS, Peele ME, Srinivas S, Lake ET. Racial disparities in low-risk cesarean birth rates across hospitals. Birth 2024; 51:176-185. [PMID: 37800376 PMCID: PMC10922231 DOI: 10.1111/birt.12778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/24/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND We compared low-risk cesarean birth rates for Black and White women across hospitals serving increasing proportions of Black women and identified hospitals where Black women had low-risk cesarean rates less than or equal to White women. METHODS In this cross-sectional analysis of secondary data from four states, we categorized hospitals by their proportion of Black women giving birth from "low" to "high". We analyzed the odds of low-risk cesarean for Black and White women across hospital categories. RESULTS Our sample comprised 493 hospitals and the 65,524 Black and 251,426 White women at low risk for cesarean who birthed in them. The mean low-risk cesarean rate was significantly higher for Black, compared with White, women in the low (20.1% vs. 15.9%) and medium (18.1% vs. 16.9%) hospital categories. In regression models, no hospital structural characteristics were significantly associated with the odds of a Black woman having a low-risk cesarean. For White women, birthing in a hospital serving the highest proportion of Black women was associated with a 21% (95% CI: 1.01-1.44) increase in the odds of having a low-risk cesarean. DISCUSSION Black women had higher odds of a low-risk cesarean than White women and were more likely to access care in hospitals with higher low-risk cesarean rates. The existence of hospitals where low-risk cesarean rates for Black women were less than or equal to those of White women was notable, given a predominant focus on hospitals where Black women have poorer outcomes. Efforts to decrease the low-risk cesarean rate should focus on (1) improving intrapartum care for Black women and (2) identifying differentiating organizational factors in hospitals where cesarean birth rates are optimally low and equivalent among racial groups as a basis for system-level policy efforts to improve equity and reduce cesarean birth rates.
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Affiliation(s)
- Rebecca R. S. Clark
- Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
| | - Morgan E. Peele
- University of Pennsylvania Population Studies Center, Philadelphia, Pennsylvania, USA
| | - Sindhu Srinivas
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
- Dulles 5-Dept OBGYN, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Eileen T. Lake
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
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Ängeby K, VanGompel EW, Johansson K, Edqvist M. Labor unit culture and attitudes toward supporting vaginal birth-The Swedish version of the labor culture survey (S-LCS)-Psychometric properties. Birth 2024; 51:163-175. [PMID: 37803969 DOI: 10.1111/birt.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 06/27/2023] [Accepted: 09/12/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND In order to evaluate interventions aimed at reducing cesarean births, care practitioners' attitudes are important to measure. The Labor Culture Survey (LCS) is a scale that measures individual and unit attitudes towards supporting vaginal birth. As no equivalent scale exists in Sweden, the aim was to translate, adapt, and validate the LCS and to investigate whether there were differences in attitudes toward supporting vaginal birth between maternity care practitioners. METHODS A cross-sectional study including midwives, physicians, and nurse assistants working with intrapartum care in five labor wards in Sweden. The original LCS was translated into Swedish, and six context-specific items were developed for the Swedish setting (SLCS). The translation was tested for face validity. Psychometric analysis was conducted using exploratory factor analysis with principal component analysis, parallel analysis, and principal axis factoring. Reliability was estimated using Cronbach's alpha. One-way ANOVA and Tukey HSD were calculated to analyze differences in attitudes between professions on the subscales of the S-LCS. RESULTS A total of 539 midwives, physicians, and nurse assistants participated. The final S-LCS showed a five-factor solution with the following subscales: Best Practices to reduce cesarean overuse, Unpredictability of vaginal birth, Unit Microculture, Maternal Agency, and Organizational Oversight. Chronbach alpha values varied from 0.60 to 0.83. Midwives were more supportive towards vaginal birth and less fearful of potential consequences of vaginal birth compared with physicians. CONCLUSIONS The S-LCS demonstrated satisfactory psychometric properties for use in Swedish maternity care. Further work to improve the scale should include additional items reflecting the subscale Maternal Agency.
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Affiliation(s)
- Karin Ängeby
- Centre for Clinical Research and Education, Region Värmland, Sweden
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
| | - Emily White VanGompel
- Departments of Family Medicine and Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois, USA
- The University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Kari Johansson
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Edqvist
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
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DaCosta MC, Mogaka J, Gebhardt L, Goff SL, Qasba N, Attanasio L. Readiness to Implement a Doula-Hospital Partnership Program. J Obstet Gynecol Neonatal Nurs 2024; 53:197-206. [PMID: 38145632 DOI: 10.1016/j.jogn.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/30/2023] [Accepted: 12/03/2023] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE To assess obstetric clinicians' and leaders' baseline knowledge, attitudes, and experience with doulas and their readiness to implement a novel doula-hospital partnership program. DESIGN Survey of obstetric clinicians and leaders before implementation of the doula program. SETTING/LOCAL PROBLEM Academic medical center in Western Massachusetts that was preparing to pilot a doula-hospital partnership program with Black doulas for Black women to address racial disparities in maternal morbidity and mortality. PARTICIPANTS Obstetric clinicians and leaders (N = 48). INTERVENTION/MEASUREMENTS We used established questions from the Organizational Readiness for Implementing Change (ORIC) scale and original questions to assess participants' knowledge, attitudes, and experiences with doulas and their readiness to implement the planned doula program. We distributed the questionnaire to 103 potential respondents. We conducted descriptive and bivariate analyses and analyzed open-ended responses using content analysis. RESULTS Forty-eight participants responded to the survey. Of those who provided intrapartum care (n = 45), all were familiar with doula roles. Respondents who reported having experience working with a doula, 47.3% (n = 18/38) had at least one prior negative experience with a doula and 76.3% (n = 29/38) reported positive experiences with doulas. However, there was a mean score of 12.62 on the attitude toward doulas (scale range: 3-15). The mean score on the ORIC change commitment subscale was 20.65 (range: 15-25) and on the ORIC change efficacy subscale, mean score was 29.31 (range: 19-35). Results did not differ by participants characteristics. CONCLUSION Our findings suggested strong support for and readiness to implement the doula-hospital partnership program.
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Wallace J, Hoehn‐Velasco L, Tilden E, Dowd BE, Calvin S, Jolles DR, Wright J, Stapleton S. An alternative model of maternity care for low-risk birth: Maternal and neonatal outcomes utilizing the midwifery-based birth center model. Health Serv Res 2024; 59:e14222. [PMID: 37691323 PMCID: PMC10771911 DOI: 10.1111/1475-6773.14222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
OBJECTIVE To assess key birth outcomes in an alternative maternity care model, midwifery-based birth center care. DATA SOURCES The American Association of Birth Centers Perinatal Data Registry and birth certificate files, using national data collected from 2009 to 2019. STUDY DESIGN This observational cohort study compared key clinical birth outcomes of women at low risk for perinatal complications, comparing those who received care in the midwifery-based birth center model versus hospital-based usual care. Linear regression analysis was used to assess key clinical outcomes in the midwifery-based group as compared with hospital-based usual care. The hospital-based group was selected using nearest neighbor matching, and the primary linear regressions were weighted using propensity score weights (PSWs). The key clinical outcomes considered were cesarean delivery, low birth weight, neonatal intensive care unit admission, breastfeeding, and neonatal death. We performed sensitivity analyses using inverse probability weights and entropy balancing weights. We also assessed the remaining role of omitted variable bias using a bounding methodology. DATA COLLECTION Women aged 16-45 with low-risk pregnancies, defined as a singleton fetus and no record of hypertension or cesarean section, were included. The sample was selected for records that overlapped in each year and state. Counties were included if there were at least 50 midwifery-based birth center births and 300 total births. After matching, the sample size of the birth center cohort was 85,842 and the hospital-based cohort was 261,439. PRINCIPAL FINDINGS Women receiving midwifery-based birth center care experienced lower rates of cesarean section (-12.2 percentage points, p < 0.001), low birth weight (-3.2 percentage points, p < 0.001), NICU admission (-5.5 percentage points, p < 0.001), neonatal death (-0.1 percentage points, p < 0.001), and higher rates of breastfeeding (9.3 percentage points, p < 0.001). CONCLUSIONS This analysis supports midwifery-based birth center care as a high-quality model that delivers optimal outcomes for low-risk maternal/newborn dyads.
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Affiliation(s)
- Jacqueline Wallace
- American Association of Birth Centers Research CommitteePerkiomenvillePennsylvaniaUSA
| | - Lauren Hoehn‐Velasco
- Department of Economics, Andrew Young School of Policy StudiesGeorgia State UniversityAtlantaGeorgiaUSA
| | - Ellen Tilden
- Nurse‐Midwifery Department, School of NursingOregon Health and Science UniversityPortlandOregonUSA
- Department of OBGYN, School of MedicineOregon Health and Science UniversityPortlandOregonUSA
| | - Bryan E. Dowd
- Division of Health Policy and Management, School of Public HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Steve Calvin
- Department of Obstetrics, Gynecology and Women's HealthUniversity of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | | | - Jennifer Wright
- American Association of Birth Centers Research CommitteePerkiomenvillePennsylvaniaUSA
| | - Susan Stapleton
- American Association of Birth Centers Research CommitteePerkiomenvillePennsylvaniaUSA
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McGaughey P, Howland RE, Dragan KL. Variation in Preterm Birth Rates Across Prenatal Care Sites in New York. J Obstet Gynecol Neonatal Nurs 2024; 53:46-56. [PMID: 37951580 DOI: 10.1016/j.jogn.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/04/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE To investigate variation in preterm birth rates by the site at which prenatal care was received. DESIGN Cross-sectional cohort study. SETTING New York State. PARTICIPANTS Claims and encounter data on singleton live births that were covered by New York Medicaid (N = 154,377). METHODS We analyzed data from New York Medicaid and the American Community Survey. We established sites of prenatal care using geocoded billing addresses for prenatal visits. We calculated descriptive statistics and conducted logistic regression analyses to determine variation in crude and risk-adjusted preterm birth rates by prenatal care site. RESULTS The crude preterm birth rates averaged 7.8% (range = 2.0%-18.7%) by prenatal care site. The adjusted preterm birth rate was 8.0% (range = 2.8%-18.5%) by prenatal care site. Risk-adjusted preterm birth site-level rates at the 90th percentile were 2.7 times higher than those in the 10th percentile. The variation in risk-adjusted preterm birth site-level rates was not fully explained by birth volume, rural site location, or racial and ethnic composition of the patients who received prenatal care at the site. CONCLUSION Wide variation in risk-adjusted preterm birth rates across prenatal care sites exists, and factors beyond known individual demographics and medical factors contribute to the variation. Further research is warranted to identify why receiving care at some prenatal sites is associated with higher risk of preterm birth than receiving care at others.
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Phillips JM, Polyakov D, Amdur RL, Ahmadzia HK. Trial of labor after cesarean: Maternal and neonatal outcomes from the Consortium on Safe Labor. J Neonatal Perinatal Med 2024; 17:1-5. [PMID: 38393923 DOI: 10.3233/npm-230009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
BACKGROUND The aim of our study is to describe maternal and neonatal morbidity and mortality in patients undergoing trial of labor after cesarean from the Consortium on Safe Labor. METHODS This was a secondary analysis of the Consortium on Safe Labor database, a retrospective cohort study over a 7 year study period. Maternal and neonatal outcomes were evaluated based on desired delivery mode: planned elective repeat cesarean delivery or trial of labor after cesarean. RESULTS Of 9858 patients in our analysis, our study population had 4400 patients (45%) who desired trial of labor after cesarean and 5458 patients (55%) who desired elective repeat cesarean delivery. Women who attempted trial of labor after cesarean compared to those who had an elective repeat cesarean delivery were more likely to have an obstetric hemorrhage (adjusted odds ratio 1.6; 95% CI 1.3 -2.0) and blood transfusion (adjusted odds ratio 2.3; 95% CI 1.6 -3.2). CONCLUSION Maternal morbidity in women undergoing trial of labor after cesarean was predominantly hemorrhage-related.
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Affiliation(s)
- J M Phillips
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - D Polyakov
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - R L Amdur
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - H K Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Peahl AF, Low LK, Langen ES, Moniz MH, Aaron B, Hu HM, Waljee J, Townsel C. Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative. Birth 2023. [PMID: 38158784 DOI: 10.1111/birt.12809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 10/06/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics. METHODS We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient. RESULTS Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%). DISCUSSION Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.
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Affiliation(s)
- Alex F Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa Kane Low
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth S Langen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Bryan Aaron
- Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - Hsou Mei Hu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Courtney Townsel
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
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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.
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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
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McLean KA, Souter VL, Nethery E. Expanding midwifery care in the United States: Implications for clinical outcomes and cost. Birth 2023; 50:935-945. [PMID: 37449767 DOI: 10.1111/birt.12748] [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: 05/12/2022] [Revised: 07/22/2022] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND This study compared clinical and financial outcomes for low-risk birthing people between those attended by midwives and those attended by obstetricians during hospital births. METHODS We conducted a retrospective cohort analysis of births from January 1, 2016 to December 31, 2020 at hospitals participating in a perinatal quality improvement collaborative, Obstetrical Care Outcomes Assessment Program (OB COAP), in the Northwest region of the United States and estimated risk ratios using a multivariate regression approach with a modified Poisson binomial for mode of delivery, labor interventions, and newborn outcomes comparing midwife-led to obstetrician-led care. Using publicly available data on average costs of vaginal and cesarean births, we then extrapolated the cost differences in care between midwives and obstetricians. RESULTS Births in the midwife group were less likely to be associated with induction (17.6% vs. 20.3% RR 0.74; 95% CI 0.70-0.78), epidural use (58.9% vs. 76.3% RR 0.78; 95% CI 0.77-0.80), and episiotomy (2.2% vs. 3.4% RR 0.68; 95% CI 0.58-0.81). Cesarean birth was also lower in the midwifery group (7.8% vs. 12.3% RR 0.68, 95% CI 0.62-0.73), without a corresponding increase in risk in adverse neonatal outcomes. We estimated that expanding midwifery care to 100% of low-risk births across the United States could save as much as $340 million per year. CONCLUSIONS Midwifery care is associated with a lower risk of cesarean birth and other interventions versus care provided by obstetricians and is therefore likely lower-cost.
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Affiliation(s)
| | | | - Elizabeth Nethery
- The School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Symum H, Zayas-Castro JL. A Multistate Decomposition Analysis of Cesarean Rate Variations, Associated Health Outcomes, and Financial Implications in the United States. Am J Perinatol 2023; 40:1473-1483. [PMID: 34666396 DOI: 10.1055/s-0041-1736538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Cesarean rates vary widely across the U.S. states; however, little is known about the causes and implications associated with these variations. The objectives of this study were to quantify the contribution of the clinical and nonclinical factors in explaining the difference in cesarean rates across states and to investigate the associated health outcome of cesarean variations. STUDY DESIGN Using the Hospital Cost and Utilization Project State Inpatient Databases, this retrospective study included all nonfederal hospital births from Wisconsin, Florida, and New York. A nonlinear extension of the Oaxaca-Blinder method was used to decompose the contributions of differences in characteristics to cesarean variations between these states. The risk factors for cesarean delivery were identified using separate multivariable logistic regression analysis for each State. RESULTS The difference in clinical and nonclinical factors explained a substantial (~46.57-65.45%) proportion of cesarean variations between U.S. states. The major contributors of variation were patient demographics, previous cesareans, hospital markup ratios, and social determinants of health. Cesarean delivery was significantly associated with higher postpartum readmissions and unplanned emergency department visits, greater lengths of stay, and hospital costs across all states. CONCLUSION Although a proportion of variations in cesarean rates can be explained by the differences in risk factors, the remaining unexplained variations suggest differences in practice patterns and imply potential quality concerns. Since nonclinical factors are likely to play an important role in cesarean variation, we recommend targeted initiatives increasing access to maternal care and improving maternal health literacy. KEY POINTS · Cesarean rates vary widely almost two folds within U.S. states.. · The difference in risk factors explained substantial (~46.57-65.45%) of the cesarean variations.. · Mother race, hospital factors, and social determinants comprised major proportion of explained variation.. · Adverse outcomes and increased expenditures were associated with cesarean than vaginal delivery.. · Significant potential cost savings for Medicaid if the unnecessary cesarean deliveries are reduced..
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Affiliation(s)
- Hasan Symum
- Department of Industrial and Management Systems Engineering, University of South Florida, Tampa, Florida
| | - José L Zayas-Castro
- Department of Industrial and Management Systems Engineering, University of South Florida, Tampa, Florida
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Hamm RF, Moniz MH, Wahid I, Breman RB, Callaghan-Koru JA. Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers. Implement Sci Commun 2023; 4:83. [PMID: 37480135 PMCID: PMC10360260 DOI: 10.1186/s43058-023-00461-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023] Open
Abstract
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.
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Affiliation(s)
- Rebecca F Hamm
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Inaya Wahid
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Rachel Blankstein Breman
- Department of Partnerships, Professional Education and Practice, School of Nursing, University of Maryland, Baltimore, MD, USA
| | - Jennifer A Callaghan-Koru
- Office of Community Health and Research, University of Arkansas for Medical Sciences, Springdale, AR, USA.
- Department of Obstetrics & Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
- Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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Smith DC, Phillippi JC, Tilden EL, Lowe NK, Carlson NS, Neal JL, Blankstein Breman R. Comparing Cesarean Birth Utilization Between US Hospitals: A Demonstration of the Robson Ten-Group Classification System for Use in Quality Improvement and Benchmarking. J Perinat Neonatal Nurs 2023; 37:214-222. [PMID: 37494690 PMCID: PMC10372675 DOI: 10.1097/jpn.0000000000000670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND The World Health Organization-endorsed Robson Ten-Group Classification System (TGCS) is a standard reporting mechanism for cesarean birth, yet this approach is not widely adopted in the United States. OBJECTIVE To describe the application and utility of the TGCS to compare hospital-level cesarean births rates, for use in quality improvement and benchmarking. METHODS We conducted a descriptive, secondary data analysis of the Consortium on Safe Labor dataset using data from 228 438 women's births, from 2002 to 2008, in 12 sites across the United States. We stratified births into 10 mutually exclusive groups and calculated within-group proportions of group size and cesarean birth rates for between-hospital comparisons of cesarean birth, trial of labor after cesarean (TOLAC), and labor induction utilization. RESULTS There is variation in use of cesarean birth, labor induction, and TOLAC across the 12 sites. CONCLUSION The TGCS provides a method for between-hospital comparisons, particularly for revealing usage patterns of labor induction, TOLAC, and cesarean birth. Adoption of the TGCS in the United States would provide organizations and quality improvement leaders with an effective benchmarking tool to assist in reducing the use of cesarean birth and increasing the support of TOLAC.
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Affiliation(s)
- Denise Colter Smith
- College of Nursing, University of Colorado, Aurora (Drs Smith and Lowe); Vanderbilt University School of Nursing, Nashville, Tennessee (Drs Phillippi and Neal); Oregon Health Sciences University Schools of Nursing and Medicine, Portland (Dr Tilden); Emory University School of Nursing, Atlanta, Georgia (Dr Carlson); and School of Nursing, University of Maryland, Baltimore (Dr Blankstein Breman)
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15
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Weinerman AS, Guo Y, Saha S, Yip PM, Lapointe-Shaw L, Fralick M, Kwan JL, MacMillan TE, Liu J, Rawal S, Sheehan KA, Simons J, Tang T, Bhatia S, Razak F, Verma AA. Data-driven approach to identifying potential laboratory overuse in general internal medicine (GIM) inpatients. BMJ Open Qual 2023; 12:e002261. [PMID: 37495257 PMCID: PMC10373691 DOI: 10.1136/bmjoq-2023-002261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Reducing laboratory test overuse is important for high quality, patient-centred care. Identifying priorities to reduce low value testing remains a challenge. OBJECTIVE To develop a simple, data-driven approach to identify potential sources of laboratory overuse by combining the total cost, proportion of abnormal results and physician-level variation in use of laboratory tests. DESIGN, SETTING AND PARTICIPANTS A multicentre, retrospective study at three academic hospitals in Toronto, Canada. All general internal medicine (GIM) hospitalisations between 1 April 2010 and 31 October 2017. RESULTS There were 106 813 GIM hospitalisations during the study period, with median hospital length-of-stay of 4.6 days (IQR: 2.33-9.19). There were 21 tests which had a cumulative cost >US$15 400 at all three sites. The costliest test was plasma electrolytes (US$4 907 775), the test with the lowest proportion of abnormal results was red cell folate (0.2%) and the test with the greatest physician-level variation in use was antiphospholipid antibodies (coefficient of variation 3.08). The five tests with the highest cumulative rank based on greatest cost, lowest proportion of abnormal results and highest physician-level variation were: (1) lactate, (2) antiphospholipid antibodies, (3) magnesium, (4) troponin and (5) partial thromboplastin time. In addition, this method identified unique tests that may be a potential source of laboratory overuse at each hospital. CONCLUSIONS A simple multidimensional, data-driven approach combining cost, proportion of abnormal results and physician-level variation can inform interventions to reduce laboratory test overuse. Reducing low value laboratory testing is important to promote high value, patient-centred care.
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Affiliation(s)
- Adina S Weinerman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yishan Guo
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Sudipta Saha
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Paul M Yip
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
| | - Michael Fralick
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Janice L Kwan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Thomas E MacMillan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jessica Liu
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Shail Rawal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Kathleen A Sheehan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Janet Simons
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, Ontario, Canada
| | - Terence Tang
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Fahad Razak
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Amol A Verma
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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Safrin S. The Impact of Malpractice Damage Caps on C-section Rates and Alternative Approaches. Clin Obstet Gynecol 2023; 66:278-292. [PMID: 37036792 DOI: 10.1097/grf.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
About half of the states in the United States have had noneconomic damage caps in place for at least 8 years. National aggregate data shows that women are just as likely to give birth by cesarean section (C-section) in states with damage caps as in ones without. For the most recent year studied, the national C-section rate for births in states with damage caps was 33.04% compared with a 32.10% ratefor births in states without caps. Other initiatives (malpractice insurance reform, accessible public disclosure of hospital C-section rates, and improved compensation for vaginal delivery) should be considered to reduce C-section rates.
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Hersh AR, Bullard KA, Garg B, Arora M, Mischkot BF, Caughey AB. Analysis of Obstetric Outcomes by Hospital Location, Volume, and Teaching Status Associated With Non-Medically Indicated Induction of Labor at 39 Weeks. JAMA Netw Open 2023; 6:e239167. [PMID: 37093603 PMCID: PMC10126869 DOI: 10.1001/jamanetworkopen.2023.9167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
Importance Non-medically indicated induction of labor has been demonstrated to potentially improve some obstetric outcomes, such as decreasing cesarean birth. It has been reported that rates of cesarean birth and other obstetric outcomes vary among hospitals with different characteristics. Objective To assess whether obstetric outcomes differ between nulliparous individuals with low-risk pregnancies managed with non-medically indicated induction of labor compared with expectant management in different types of hospitals. Design, Setting, and Participants This retrospective cohort study included non-medically indicated induction of labor at 39 weeks' gestation compared with expectant management of singleton, nonanomalous, births in nulliparous women with low-risk pregnancies in California between January 1, 2007, and December 31, 2011. The initial analysis of these data was performed in 2021. Outcomes were assessed by 3 hospital characteristics: location (urban vs rural), obstetric volume, and teaching (academic vs community) status. Volume was categorized based on the average number of births per year and grouped into low (<1200 births per year), medium (1200-2399 births per year), and high (≥2400 births per year). Births with previous or planned cesarean delivery were excluded, and non-medically indicated induction of labor was defined as induction of labor without a specific medical indication. Testing with χ2 and multivariable logistic regression analyses was used for statistical comparisons with a cutoff level of P = .01. Exposure Non-medically indicated induction of labor at 39 weeks' gestation. Main Outcomes and Measures The primary outcome was cesarean birth, and numerous secondary perinatal outcomes were also assessed. Results There were 455 044 births included in this study. When stratified by hospital variables, a number of sociodemographic characteristics were significantly different, such as race and ethnicity, age, body mass index, and insurance type. The adjusted odds ratios (aORs) of cesarean birth were significantly lower in all settings with induction of labor except for low-volume hospitals, in which there was no significant difference (aOR, 0.95; 95% CI, 0.82-1.09). Chorioamnionitis and postpartum hemorrhage were lower with induction of labor among nearly every hospital when stratified by hospital characteristics. Neonatal outcomes were improved in all settings with induction of labor compared with expectant management. Conclusions and Relevance These findings suggest that non-medically indicated induction of labor may be associated with a lower rate of cesarean births and some maternal and neonatal adverse outcomes in a range of hospital settings.
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Affiliation(s)
- Alyssa R Hersh
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland
| | - Kimberley A Bullard
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland
| | - Bharti Garg
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland
| | - Megha Arora
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland
| | - Brooke F Mischkot
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland
| | - Aaron B Caughey
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland
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Gartner DR, Debbink MP, Brooks JL, Margerison CE. Inequalities in cesarean births between American Indian & Alaska Native people and White people. Health Serv Res 2023; 58:291-302. [PMID: 36573019 PMCID: PMC10012218 DOI: 10.1111/1475-6773.14122] [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] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To explore population-level American Indian & Alaska Native-White inequalities in cesarean birth incidence after accounting for differences in cesarean indication, age, and other individual-level risk factors. DATA SOURCES AND STUDY SETTING We used birth certificate data inclusive of all live births within the United States between January 1 and December 31, 2017. STUDY DESIGN We calculated propensity score weights that simultaneously incorporate age, cesarean indication, and clinical and obstetric risk factors to estimate the American Indian and Alaska Native-White inequality. DATA COLLECTION/EXTRACTION METHODS Births to individuals identified as American Indian, Alaska Native, or White, and residing in one of the 50 US states or the District of Columbia were included. Births were excluded if missing maternal race/ethnicity or any other covariate. PRINCIPAL FINDINGS After weighing the American Indian and Alaska Native obstetric population to be comparable to the distribution of cesarean indication, age, and clinical and obstetric risk factors of the White population, the cesarean incidence among American Indian and Alaska Natives increased to 33.4% (95% CI: 32.0-34.8), 3.2 percentage points (95% CI: 1.8-4.7) higher than the observed White incidence. After adjustment, cesarean birth incidence remained higher and increased in magnitude among American Indian and Alaska Natives in Robson groups 1 (low risk, primary), 6 (nulliparous, breech presentation), and 9 (transverse/oblique lie). CONCLUSIONS The unadjusted lower cesarean birth incidence observed among American Indian and Alaska Native individuals compared to White individuals may be related to their younger mean age at birth. After adjusting for this demographic difference, we demonstrate that American Indian and Alaska Native individuals undergo cesarean birth more frequently than White individuals with similar risk profiles, particularly within the low-risk Robson group 1 and those with non-cephalic presentations (Robson groups 6 and 9). Racism and bias in clinical decision making, structural racism, colonialism, or other unidentified factors may contribute to this inequality.
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Affiliation(s)
- Danielle R. Gartner
- Department of Epidemiology & Biostatistics, College of Human MedicineMichigan State UniversityEast LansingMichiganUSA
| | - Michelle P. Debbink
- Department of Obstetrics and GynecologyUniversity of Utah Health and Intermountain HealthcareSalt Lake CityUtahUSA
| | - Jada L. Brooks
- School of NursingUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Claire E. Margerison
- Department of Epidemiology & Biostatistics, College of Human MedicineMichigan State UniversityEast LansingMichiganUSA
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Variation in Opioid Prescribing After Vaginal and Cesarean Birth: A Statewide Analysis. Womens Health Issues 2023; 33:182-190. [PMID: 36151029 DOI: 10.1016/j.whi.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals. METHODS This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12-55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient. RESULTS Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%-60.0%]; cesarean median, 80.4% [range, 43.6%-90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%). CONCLUSIONS Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.
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Thornton PD. VBAC calculator 2.0: Recent evidence. Birth 2023; 50:120-126. [PMID: 36639832 DOI: 10.1111/birt.12705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/07/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023]
Abstract
Following criticism for the use of race as a biological predictor of vaginal birth after cesarean (VBAC), an updated version of the Society for Maternal-Fetal Medicine (SMFM) VBAC calculator has been published. The variable "African American" or "Hispanic" (yes/no), which produced systematically lower chances of VBAC for nonwhites has been replaced with "chronic hypertension requiring treatment" (yes/no). Although there are no published external validation studies to date, developers report accuracy (area under the curve and calibration) nearly identical to the original calculator and it is published online for immediate use. This review examines the history of the calculator, measures of its validity, and recent studies measuring its performance among Hispanics, Blacks, Asians, and others with lower range scores. Underprediction of successful VBAC is evident in the original calculator, especially as predicted VBAC decreases. These studies raise a concern about the use of calculator scores in clinical management, that is, discouraging or restricting access to labor after cesarean (LAC) for parents with lower calculator scores. This raises special concern for minority populations who experience increased cesarean-related morbidity, face obstacles accessing LAC care, and who may benefit disproportionately from increased LAC uptake. Although calculator developers have discouraged using calculator scores to restrict access to LAC, such uses are documented. It is not clear what effect the removal of race will have on calculator performance, and further study is required before calculator scores are used in counseling. This includes studies that include large numbers of low scoring and minority patients.
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Affiliation(s)
- Patrick D Thornton
- College of Nursing, Department of Human Development Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA
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21
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We Do Not Know How People Have Babies: an Opportunity for Epidemiologists to Have Meaningful Impact on Population-Level Health and Wellbeing. CURR EPIDEMIOL REP 2023. [DOI: 10.1007/s40471-023-00321-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Maternal Centric Measurement and Data Gaps in Addressing Maternal Morbidities: A Scoping Review. Matern Child Health J 2023; 27:367-374. [PMID: 36534229 DOI: 10.1007/s10995-022-03516-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The objectives of this project were to (1) describe maternal-centric measures and survey data which are publicly available to evaluate the incidence, frequency, and distribution of maternal morbidity in the postpartum period, and (2) to identify postpartum care quality improvement targets and outline the types of measurement and data required to support them. METHODS We conducted a scoping review of two types of data sources: maternal health quality measures used by providers and payers and nationally-representative survey data sets administered by federal agencies. Each source was searched for keywords associated with pregnancy and the postpartum period. We included quality measures and survey questions that are maternal-centric and addressed the postpartum period. We excluded infant-centric measures and data. Quality measures were organized according to the Donabedian quality model. RESULTS Our analysis demonstrates that existing maternal-centric quality measures and survey data offer limited insight into diagnosis and patient care delivery experiences associated with maternal morbidities during the postpartum period. CONCLUSION There is inadequate maternal-centric data on the incidence, frequency, and distribution of postpartum maternal morbidities and associated care use. This gap reduces the ability of research to estimate the incidence of illness and injury among postpartum women and create targeted quality improvement efforts. Our findings highlight the need for quality measure stewards and data sponsors to enhance data collection and methods to become more inclusive of maternal-centric outcomes during the postpartum period.
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Nguyen AD, Duong GTT, Do DT, Nguyen DT, Tran DA, Phan TTH, Nguyen TK, Nguyen HTT. Primary cesarean section rate among full-term pregnant women with non-previous uterine scar in a hospital of Vietnam. Heliyon 2022; 8:e12222. [PMID: 36544845 PMCID: PMC9761699 DOI: 10.1016/j.heliyon.2022.e12222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/19/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
Aim This article aims to determine the contributing indications for primary cesarean sections among full-term pregnant women with non-previous uterine scars and suggests several potential solutions to reduce the cesarean section rate. Methods This is a descriptive study with data being retrospectively collected from electronic medical records (EMRs) at Hanoi Obstetrics & Gynecology Hospital, Vietnam, in 2020. We studied 23,631 women at ≥37 weeks of gestation with non-previous uterine scars. Main ICD-10 categories of diagnosis on the EMRs were used to classify the indications. The proportions of indications for primary cesarean sections were calculated, thereby offering potential solutions to reduce the cesarean section rate. Results The proportion of cesarean sections among full-term pregnancies with non-previous uterine scars was 40.7%. The most common indications for primary cesarean sections were non-reassuring fetal heart rate tracing (40%), labor arrest (31%), and maternal request (11%). Among the low-risk pregnant women, the cesarean section rate was 35.9%, of which the percentages of labor arrest and non-reassuring fetal heart rate tracings and maternal request were 13.6%, 17.7%, and 4.6%, respectively. Conclusions The proportion of primary cesarean sections among full-term pregnancies with non-previous uterine scars is high; non-reassuring fetal heart rate tracings, labor arrest, and maternal request were three main indications. It is necessary to build the strategies of health organizations regarding the management of clinical practices and the programs improving the knowledge, attitudes, practices of pregnant women and obstetricians regarding cesarean sections.
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Affiliation(s)
- Anh Duy Nguyen
- Hanoi Obstetrics and Gynecology Hospital (HOGH), 100000 Hanoi, Viet Nam
- Hanoi Medical University (HMU), 100000 Hanoi, Viet Nam
- Vietnam National University, Hanoi-University of Medicine and Pharmacy (VNU Hanoi-UMP), 100000 Hanoi, Viet Nam
- Corresponding author.
| | - Giang Thi Tra Duong
- Hanoi Obstetrics and Gynecology Hospital (HOGH), 100000 Hanoi, Viet Nam
- Hanoi Medical University (HMU), 100000 Hanoi, Viet Nam
| | - Dat Tuan Do
- Hanoi Obstetrics and Gynecology Hospital (HOGH), 100000 Hanoi, Viet Nam
- Hanoi Medical University (HMU), 100000 Hanoi, Viet Nam
| | - Duc Tai Nguyen
- Hanoi Obstetrics and Gynecology Hospital (HOGH), 100000 Hanoi, Viet Nam
| | - Duc Anh Tran
- Hanoi Obstetrics and Gynecology Hospital (HOGH), 100000 Hanoi, Viet Nam
- Hanoi Medical University (HMU), 100000 Hanoi, Viet Nam
| | | | - Toan Khac Nguyen
- Hanoi Obstetrics and Gynecology Hospital (HOGH), 100000 Hanoi, Viet Nam
| | - Ha Thi Thu Nguyen
- Hanoi Obstetrics and Gynecology Hospital (HOGH), 100000 Hanoi, Viet Nam
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Zimmo MW, Laine K, Hassan S, Bottcher B, Fosse E, Ali-Masri H, Zimmo K, Falk RS, Lieng M, Vikanes A. Exploring the impact of indication on variation in rates of intrapartum caesarean section in six Palestinian hospitals: a prospective cohort study. BMC Pregnancy Childbirth 2022; 22:892. [PMID: 36461037 PMCID: PMC9716767 DOI: 10.1186/s12884-022-05196-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 11/09/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Caesarean section rates are rising globally. No specific caesarian section rate at either country-level or hospital-level was recommended. In Palestinian government hospitals, nearly one-fourth of all births were caesarean sections, ranging from 14.5 to 35.6%. Our aim was to assess whether variation in odds for intrapartum caesarean section in six Palestinian government hospitals can be explained by differences in indications. METHODS Data on maternal and fetal health were collected prospectively for all women scheduled for vaginal delivery during the period from 1st March 2015 to 30th November 2016 in six government hospitals in Palestine. Comparisons of proportions in sociodemographic, antenatal obstetric characteristics and indications by the hospital were tested by χ2 test and differences in means by one-way ANOVA analysis. The odds for intrapartum caesarean section were estimated by logistic regression. The amount of explained variance was estimated by Nagelkerke R square. RESULTS Out of 51,041 women, 4724 (9.3%) underwent intrapartum caesarean section. The prevalence of intrapartum caesarean section varied across hospitals; from 7.6 to 22.1% in nulliparous, and from 5.8 to 14.1% among parous women. The most common indications were fetal distress and failure to progress in nulliparous, and previous caesarean section with an additional obstetric indication among parous women. Adjusted ORs for intrapartum caesarean section among nulliparous women ranged from 0.42 (95% CI 0.31 to 0.57) to 2.41 (95% CI 1.70 to 3.40) compared to the reference hospital, and from 0.50 (95% CI 0.40-0.63) to 2.07 (95% CI 1.61 to 2.67) among parous women. Indications explained 58 and 66% of the variation in intrapartum caesarean section among nulliparous and parous women, respectively. CONCLUSION The differences in odds for intrapartum caesarean section among hospitals could not be fully explained by differences in indications. Further investigations on provider related factors as well as maternal and fetal outcomes in different hospitals are necessary.
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Affiliation(s)
- Mohammed W. Zimmo
- grid.5510.10000 0004 1936 8921Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway ,grid.55325.340000 0004 0389 8485The Intervention Centre, Oslo University Hospital, Oslo, Norway , Department of Obstetrics and Gynecology, Al Shifa Hospitals, Gaza, Palestine
| | - Katariina Laine
- grid.5510.10000 0004 1936 8921Institute for Clinical Medicine, University of Oslo, Oslo, Norway ,grid.55325.340000 0004 0389 8485Norwegian Research Centre for Women’s Health, Oslo University Hospital, Oslo, Norway
| | - Sahar Hassan
- grid.22532.340000 0004 0575 2412Faculty of Nursing, Pharmacy and Health Professions and Institute of Community and Public Health, Birzeit University, Ramallah, Palestine
| | - Bettina Bottcher
- grid.442890.30000 0000 9417 110XFaculty of Medicine, Islamic University of Gaza, Gaza, Palestine
| | - Erik Fosse
- grid.55325.340000 0004 0389 8485The Intervention Centre, Oslo University Hospital, Oslo, Norway
| | - Hadil Ali-Masri
- grid.55325.340000 0004 0389 8485Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway ,Obstetrics Department, Palestine Medical complex, Ramallah, Palestine
| | - Khaled Zimmo
- grid.55325.340000 0004 0389 8485The Intervention Centre, Oslo University Hospital, Oslo, Norway ,Department of Obstetrics and Gynecology, Al Aqsa Hospital, Gaza, Palestine
| | - Ragnhild Sørum Falk
- grid.55325.340000 0004 0389 8485Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Marit Lieng
- grid.5510.10000 0004 1936 8921Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Gynecology, Oslo University Hospital, Oslo, Norway
| | - Ase Vikanes
- grid.55325.340000 0004 0389 8485The Intervention Centre, Oslo University Hospital, Oslo, Norway
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Cesarean delivery using an ERAS-CD process for nonopioid anesthesia and analgesia drug/medication management. Best Pract Res Clin Obstet Gynaecol 2022; 85:35-52. [PMID: 35995654 DOI: 10.1016/j.bpobgyn.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/13/2022] [Indexed: 12/14/2022]
Abstract
Cesarean delivery (CD) is a surgical delivery of a neonate with surgical access through the maternal abdominal and uterine structures. The Enhanced Recovery After Surgery (ERAS) protocol is a standardized perioperative care program and surgery quality improvement process that has had global spread across numerous surgical disciplines. The medical and surgical use of opioids for pain management and the nonmedical opioid use, over the last three decades, have significantly increased the prevalence of abuse and addiction to opioids. This review summarizes pain, pregnancy substance use, and ERAS-directed analgesia and anesthesia for opioid use reduction or elimination in the operative and postoperative periods. Enhanced recovery (quality and safety) in the surgical CD context requires collaboration, consensus, and appropriate clinical prioritization to allow for the identification of 'the right patient, in the right clinical situation, with the right informed consent, and the right clinical care team and health system'.
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Weiseth A, Plough A, Aggarwal R, Galvin G, Rucker A, Henrich N, Miller K, Subramanian L, Hawrusik R, Berry W, Gullo S, Spigel L, Dever K, Loveless D, Graham K, Paek B, Shah NT. Improving communication and teamwork during labor: A feasibility, acceptability, and safety study. Birth 2022; 49:637-647. [PMID: 35233810 PMCID: PMC9790687 DOI: 10.1111/birt.12630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/15/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND TeamBirth was designed to promote best practices in shared decision making (SDM) among care teams for people giving birth. Although leading health organizations recommend SDM to address gaps in quality of care, these recommendations are not consistently implemented in labor and delivery. METHODS We conducted a mixed-methods trial of TeamBirth among eligible laboring patients and all clinicians (nurses, midwives, and obstetricians) at four high-volume hospitals during April 2018 to September 2019. We used patient and clinician surveys, abstracted clinical data, and administrative claims to evaluate the feasibility, acceptability, and safety of TeamBirth. RESULTS A total of 2,669 patients (approximately 28% of eligible delivery volume) and 375 clinicians (78% response rate) responded to surveys on their experiences with TeamBirth. Among patients surveyed, 89% reported experiencing at least one structured full care team conversation ("huddle") during labor and 77% reported experiencing multiple huddles. There was a significant relationship between the number of reported huddles and patient acceptability (P < 0.001), suggestive of a dose response. Among clinicians surveyed, 90% would recommend TeamBirth for use in other labor and delivery units. There were no significant changes in maternal and newborn safety measures. CONCLUSIONS Implementing a care process that aims to improve communication and teamwork during labor with high fidelity is feasible. The process is acceptable to patients and clinicians and shows no negative effects on patient safety. Future work should evaluate the effectiveness of TeamBirth in improving care experience and health outcomes.
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Affiliation(s)
- Amber Weiseth
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Avery Plough
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Reena Aggarwal
- Obstetrics and GynaecologyUniversity College London HospitalLondonUK
| | - Grace Galvin
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Amber Rucker
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Natalie Henrich
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Kate Miller
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Laura Subramanian
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Rebecca Hawrusik
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - William Berry
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Susan Gullo
- Ariadne LabsBrigham and Women’s HospitalBostonMassachusettsUSA
| | - Lauren Spigel
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Kimberly Dever
- Department of Obstetrics and GynecologySouth Shore HospitalWeymouthMassachusettsUSA
| | | | - Kristin Graham
- Obstetrics and GynecologyOverlake Medical Center & ClinicsBellevueWashingtonUSA
| | - Bettina Paek
- Department of Women’s & Children’sEvergreenHealthKirklandWashingtonUSA
| | - Neel T. Shah
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA,Harvard Medical SchoolBostonMassachusettsUSA,Beth Israel Deaconess Medical CenterBostonMassachusettsUSA
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Smith DC, Thumm EB, Trego L. Psychometric Evaluation of the Collaborative Practice Scale in Certified Nurse-Midwife and Obstetrician Teams. J Nurs Meas 2022; 30:748-761. [PMID: 34518438 DOI: 10.1891/jnm-d-21-00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background and Purpose: Team-based care has been proposed as a means of improving maternity care in the United States. Methods: The study evaluated the individual and group-level psychometric properties of the Collaborative Practice Scale (CPS) among 108 midwives and physicians who provided team-based care in military hospitals. Results: Psychometric properties of the CPS included Cronbach's alpha of .98. Internal consistency was measured with item-to-total correlations from .83 to .94 and inter-item correlations from .71 to .88. Principal components analysis resulted in a single-factor loading, accounting for 80% of total variance. Properties of the scale at the group level; strong within team agreement (r wg( j ) = .94) and between team variance (ICC1 = .15, ICC2 = .65). Conclusion: The CPS demonstrated reliability and validity of the instrument at the individual and group levels. The collaborative process can be measured among midwife-physician teams.
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High Primary Cesarean Section Rates: Strategies for Improvement. Jt Comm J Qual Patient Saf 2022; 48:617-624. [PMID: 36050212 DOI: 10.1016/j.jcjq.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 12/30/2022]
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Spigel L, Plough A, Paterson V, West R, Jurczak A, Henrich N, Gullo S, Corrigan B, Patterson P, Short T, Early L, Bridges M, Pesek E, Pizzitola M, Davis D, Kirby K, Borduz C, Shah N, Weiseth A. Implementation strategies within a complex environment: A qualitative study of a shared decision-making intervention during childbirth. Birth 2022; 49:440-454. [PMID: 34997610 PMCID: PMC9543488 DOI: 10.1111/birt.12611] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Shared decision-making (SDM) may improve communication, teamwork, patient experience, respectful maternity care, and safety during childbirth. Despite these benefits, SDM is not widely implemented, and strategies for implementing SDM interventions are not well described. We assessed the acceptability and feasibility of TeamBirth, an SDM solution that centers the birthing person in decision-making through simple tools that structure communication among the care team. We identified and described implementation strategies that bridge the gap between knowledge and practice. METHODS We conducted a qualitative study among four hospitals in the United States to understand the acceptability and feasibility of TeamBirth. We interviewed 103 clinicians and conducted 16 focus group discussions with 52 implementers between June 2018 and October 2019. We drew on the Consolidated Framework for Implementation Research to understand acceptability and feasibility, and to identify and describe the underlying contextual factors that affected implementation. RESULTS We found that clinicians and implementers valued TeamBirth for promoting clarity about care plans among the direct care team and for centering the birthing person in decision-making. Contextual factors that affected implementation included strength of leadership, physician practice models, and quality improvement culture. Effective implementation strategies included regular data feedback and adapting "flexible" components of TeamBirth to the local context. DISCUSSION By identifying and describing TeamBirth's contextual factors and implementation strategies, our findings can help bridge the implementation gap of SDM interventions. Our in-depth analysis offers tangible lessons for other labor and delivery unit leaders as they seek to integrate SDM practices in their own settings.
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Affiliation(s)
- Lauren Spigel
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | - Avery Plough
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | | | - Rebecca West
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | - Amanda Jurczak
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | - Natalie Henrich
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | - Susan Gullo
- Ariadne LabsBrigham and Women’s HospitalBostonMassachusettsUSA
| | - Brett Corrigan
- Quality Management DepartmentSouth Shore HospitalSouth WeymouthMassachusettsUSA,Maternity CenterSouth Shore HospitalSouth WeymouthMassachusettsUSA
| | - Pam Patterson
- Quality Management DepartmentSouth Shore HospitalSouth WeymouthMassachusettsUSA,Maternity CenterSouth Shore HospitalSouth WeymouthMassachusettsUSA
| | - Trisha Short
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA,Labor and DeliverySaint Francis HospitalTulsaOklahomaUSA
| | - Lisa Early
- Labor and DeliverySaint Francis HospitalTulsaOklahomaUSA
| | - Margie Bridges
- Women and Infant ServicesOverlake Medical Center & ClinicsBellevueWashingtonUSA
| | - Elizabeth Pesek
- Quality DepartmentOverlake Medical Center & ClinicsBellevueWashingtonUSA
| | - Marianne Pizzitola
- Women and Infant ServicesOverlake Medical Center & ClinicsBellevueWashingtonUSA
| | - Dianna Davis
- Operational ExcellenceEvergreenHealth Medical CenterKirklandWashingtonUSA
| | - Keri Kirby
- Quality DepartmentEvergreenHealth Medical CenterKirklandWashingtonUSA
| | - Christina Borduz
- Family Maternity CenterEvergreenHealth Medical CenterKirklandWashingtonUSA
| | - Neel Shah
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | - Amber Weiseth
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
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Defining a Cesarean Delivery Rate for Optimizing Maternal and Neonatal Outcomes. Obstet Gynecol 2022; 140:399-407. [PMID: 35930389 DOI: 10.1097/aog.0000000000004876] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/19/2022] [Indexed: 01/05/2023]
Abstract
After the global cesarean delivery rate nearly doubled between 2000 and 2015, cesarean deliveries now account for nearly one third of births in the United States. Although rates have plateaued, the high national cesarean delivery rate has garnered criticism from both lay and academic communities because it has not been associated with improvements in maternal or neonatal outcomes. Efforts are underway to lower the cesarean delivery rate through implementation of hospital-level and national guidelines. However, the cesarean delivery rate that optimizes maternal and neonatal outcomes is not known. Defining a cesarean delivery rate that optimizes perinatal outcomes and reduces morbidity seems simple. However, there are a host of challenges to such a task, including determining the outcomes that are most meaningful to use, deciding the population that should define the rate, and incorporating person-centered decision making, given that people place different value on different outcomes. Rather than a "call" for cesarean delivery rate reductions of a specific and arbitrary magnitude, we need further attention to defining an evidence-based optimal target. This commentary summarizes current national and international cesarean delivery rate targets, discusses the challenges of identifying an evidence-based national cesarean delivery rate target, and explores future considerations for best defining a cesarean delivery rate target.
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George EK, Shorten A, Lyons KS, Edmonds JK. Factors influencing birth setting decision making in the United States: An integrative review. Birth 2022; 49:403-419. [PMID: 35441421 DOI: 10.1111/birt.12640] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 03/23/2022] [Accepted: 03/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The United States has the highest perinatal morbidity and mortality (M&M) rates among all high-resource countries in the world. Birth settings (birth center, home, or hospital) influence clinical outcomes, experience of care, and health care costs. Increasing use of low-intervention birth settings can reduce perinatal M&M. This integrative review evaluated factors influencing birth setting decision making among women and birthing people in the United States. METHODS A search strategy was implemented within the CINAHL, PubMed, PsycInfo, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided the review, and the Johns Hopkins Nursing Evidence-Based Practice model was used to evaluate methodological quality and appraisal of the evidence. The Whittemore and Knafl integrative review framework informed the extraction and analysis of the data and generation of findings. RESULTS We identified 23 articles that met inclusion criteria. Four analytical themes were generated that described factors that influence birth setting decision making in the United States: "Birth Setting Safety vs. Risk," "Influence of Media, Family, and Friends on Birth Setting Awareness," "Presence or Absence of Choice and Control," and "Access to Options." DISCUSSION Supporting women and birthing people to make informed decisions by providing information about birth setting options and variations in models of care by birth setting is a critical patient-centered strategy to ensure equitable access to low-intervention birth settings. Policies that expand affordable health insurance to cover midwifery care in all birth settings are needed to enable people to make informed choices about birth location that align with their values, individual pregnancy characteristics, and preferences.
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Affiliation(s)
- Erin K George
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA
| | - Allison Shorten
- University of Alabama at Birmingham School of Nursing, Birmingham, Alabama, USA
| | - Karen S Lyons
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA
| | - Joyce K Edmonds
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts, USA
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Brazier E, Borrell LN, Huynh M, Kelly EA, Nash D. Variation and racial/ethnic disparities in Caesarean delivery at New York City hospitals: The contribution of hospital-level factors. Ann Epidemiol 2022; 73:1-8. [PMID: 35728734 DOI: 10.1016/j.annepidem.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE We aimed to quantify general and specific contextual effects associated with Caesarean delivery at New York City (NYC) hospitals, overall and by maternal race/ethnicity. METHODS Among 127,449 singleton, nulliparous births at NYC hospitals from 2015 to 2017, we used multilevel logistic regression to examine the association of hospital characteristics (public/private ownership, teaching status and delivery caseloads) with Caesarean delivery, overall, and by maternal race/ethnicity. We estimated the intra-class correlation (ICC) to examine general contextual effects and 80% interval odds ratios (IOR) and percentage of opposed odds ratios (POOR) to examine specific contextual effects. RESULTS Overall, 27.8% of births were Caesareans. The general contextual (hospital) effect on Caesarean delivery was small (ICC: 1.8%). Hospital characteristics associated with Caesarean delivery differed by maternal race/ethnicity, with delivery in teaching hospitals reducing the odds of Caesarean delivery among White (IOR: 0.31, 0.86; POOR: 4.7%) and Asian women (IOR: 0.41, 0.95; POOR: 7.3%), but not among Black (IOR: 0.51, 1.34; POOR: 30.7%) or Hispanic women (IOR: 0.44, 1.24; POOR: 22.6%). Hospital ownership and caseloads were not associated with Caesarean delivery for any group. CONCLUSION There is little within-hospital clustering of Caesarean delivery, suggesting that Caesarean disparities may not be explained by hospital of delivery.
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Affiliation(s)
- Ellen Brazier
- Institute for Implementation Science in Population Health (ISPH), Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY; Department of Epidemiology & Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY.
| | - Luisa N Borrell
- Department of Epidemiology & Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY
| | - Mary Huynh
- Office of Vital Statistics, Bureau of Vital Statistics, NYC Department of Health and Mental Hygiene, New York, NY
| | - Elizabeth A Kelly
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH
| | - Denis Nash
- Institute for Implementation Science in Population Health (ISPH), Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY; Department of Epidemiology & Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, NY
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Clark RRS, Peele ME, Lake ET. Nursing Resources by Type of Maternity Unit Across Regions of the United States. J Obstet Gynecol Neonatal Nurs 2022; 51:290-301. [PMID: 35278349 PMCID: PMC9086175 DOI: 10.1016/j.jogn.2022.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine variation in nursing resources across three different types of maternity units in five regions of the United States. DESIGN Cross-sectional descriptive. SETTING Maternity units in hospitals in 48 states and the District of Columbia that participated in the 2016 National Database of Nursing Quality Indicator survey. PARTICIPANTS Staff nurses (N = 19,486) who worked in 707 maternity units. METHODS We conducted a secondary analysis of survey data examining nursing resources (work environment, staffing, education, specialty certification) by type of maternity unit, including labor and delivery, labor/delivery/recovery/postpartum, and postpartum. We used descriptive statistics and analysis of variance. RESULTS Participants worked in 707 units (269 labor and delivery units, 164 labor/delivery/recovery/postpartum units, and 274 postpartum units) in 444 hospitals. The work environment was not significantly different across unit types (mean = 2.89-2.94, p = .27). Staffing, education, and specialty certification varied significantly across the unit types (p ≤ .001). In terms of staffing, postpartum units had, on average, almost twice the number of patients per nurse as labor and delivery units (7.51 patients/nurse vs. 4.01 patients/nurse, p ≤ .001) and 1.5 times more patients than labor/delivery/recovery/postpartum units (5.04 patients/nurse vs. 4.01 patients/nurse, p ≤ .001). CONCLUSION Nursing resources varied significantly across types of maternity units and regions of the United States. This variation suggests that improving nursing resources may be a system-level target for improving maternity care in the United States.
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Hanson C, Samson K, Anderson-Berry AL, Slotkowski RA, Su D. Racial disparities in caesarean delivery among nulliparous women that delivered at term: cross-sectional decomposition analysis of Nebraska birth records from 2005-2014. BMC Pregnancy Childbirth 2022; 22:329. [PMID: 35428241 PMCID: PMC9013155 DOI: 10.1186/s12884-022-04666-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/28/2022] [Indexed: 11/21/2022] Open
Abstract
Background Previous studies suggest higher rates of caesarean section among women who identify as racial/ethnic minorities. The objective of this study was to understand factors contributing to differences in caesarean rates across racial and ethnic groups. Methods Data was collected from 2005 to 2014 Nebraska birth records on nulliparous, singleton births occurring on or after 37 weeks gestation (n = 87,908). Risk ratios (RR) and 95% confidence intervals (CI) for caesarean were calculated for different racial and ethnic categories, adjusting for maternal age, marital status, county of residence, education, insurance status, pre-pregnancy BMI, and smoking status. Fairlie decomposition technique was utilized to quantify the contribution of individual variables to the observed differences in caesarean. Results In the adjusted analysis, relative to non-Hispanic (NH) White race, both Asian-NH (RR 1.21, 95% CI 1.14, 1.28) and Black-NH races (RR 1.13, 95% CI 1.08, 1.19) were associated with a significantly higher risk for caesarean. The decomposition analysis showed that among the variables assessed, maternal age, education, and pre-pregnancy BMI contributed the most to the observed differences in caesarean rates across racial/ethnic groups. Conclusion This analysis quantified the effect of social and demographic factors on racial differences in caesarean delivery, which may guide public health interventions aimed towards reducing racial disparities in caesarean rates. Interventions targeted towards modifying maternal characteristics, such as reducing pre-pregnancy BMI or increasing maternal education, may narrow the gap in caesarean rates across racial and ethnic groups. Future studies should determine the contribution of physician characteristics, hospital characteristics, and structural determinants of health towards racial disparities in caesarean rates.
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Carter ED, Walker PN. Estimating c-section coverage: Assessing method performance and characterizing variations in coverage. J Glob Health 2022. [PMID: 35425593 PMCID: PMC8982632 DOI: 10.7189/jogh.21.08002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Cesarean section (c-section) is an essential tool for preventing, stillbirths, maternal, and newborn death. However, data on coverage of medically necessary c-section is limited in low- and middle-income settings. Methods We estimated national c-section coverage using household survey data from 98 low- and middle-income countries. To disaggregate elective and medically necessary c-sections, we estimated the proportion of women in each survey wealth quintile who gave birth via c-section assuming a denominator that 12.5% of births necessitate a c-section delivery. We capped stratum coverage at 100%. We estimated national c-section coverage weighting for the proportion of births occurring in each wealth quintile. We examined 1) variation in estimated c-section by wealth quintile, national income classification, and stage in the obstetric transition, 2) how varying definitions impact the classification of countries' access to c-section, and 3) correlation between c-section and related mortality outcomes. Results Both increasing national and household wealth are associated with increasing levels of c-section coverage and c-section rate. C-section coverage was highly inequitable by wealth within a country. Differentials in coverage were most pronounced in countries with c-section rates below 10%; however, some countries showed significant gaps in c-section coverage in poor subpopulations despite high c-section rates nationally. The choice of indicator and threshold altered whether a country was classified as having adequate access to c-section services. C-section coverage estimates showed a stronger relationship with closely related health outcomes than national c-section rates. Conclusions Generating estimates of c-section coverage is crucial for gauging gaps in c-section access. Our approach for calculating c-section coverage using stratification by wealth to adjust for potential elective c-sections is supported by the strong correlations between household wealth and subnational c-section rate, and the association between our coverage estimates and health outcomes at a national level. Looking at national c-section rates alone may paint an inaccurate picture of c-section access and mask subnational inequities in coverage. The need to accurately measure access to c-section will continue to increase as growth in LMICs drives inequities in coverage and introduces dual concerns related to c-section overuse in some populations while others lack access to care.
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Affiliation(s)
- Emily D Carter
- Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - P Neff Walker
- Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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Carter ED, Walker PN. Estimating c-section coverage: Assessing method performance and characterizing variations in coverage. J Glob Health 2022; 12:08002. [PMID: 35425593 PMCID: PMC8982632 DOI: 10.7189/jogh.12.08002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Cesarean section (c-section) is an essential tool for preventing, stillbirths, maternal, and newborn death. However, data on coverage of medically necessary c-section is limited in low- and middle-income settings. METHODS We estimated national c-section coverage using household survey data from 98 low- and middle-income countries. To disaggregate elective and medically necessary c-sections, we estimated the proportion of women in each survey wealth quintile who gave birth via c-section assuming a denominator that 12.5% of births necessitate a c-section delivery. We capped stratum coverage at 100%. We estimated national c-section coverage weighting for the proportion of births occurring in each wealth quintile. We examined 1) variation in estimated c-section by wealth quintile, national income classification, and stage in the obstetric transition, 2) how varying definitions impact the classification of countries' access to c-section, and 3) correlation between c-section and related mortality outcomes. RESULTS Both increasing national and household wealth are associated with increasing levels of c-section coverage and c-section rate. C-section coverage was highly inequitable by wealth within a country. Differentials in coverage were most pronounced in countries with c-section rates below 10%; however, some countries showed significant gaps in c-section coverage in poor subpopulations despite high c-section rates nationally. The choice of indicator and threshold altered whether a country was classified as having adequate access to c-section services. C-section coverage estimates showed a stronger relationship with closely related health outcomes than national c-section rates. CONCLUSIONS Generating estimates of c-section coverage is crucial for gauging gaps in c-section access. Our approach for calculating c-section coverage using stratification by wealth to adjust for potential elective c-sections is supported by the strong correlations between household wealth and subnational c-section rate, and the association between our coverage estimates and health outcomes at a national level. Looking at national c-section rates alone may paint an inaccurate picture of c-section access and mask subnational inequities in coverage. The need to accurately measure access to c-section will continue to increase as growth in LMICs drives inequities in coverage and introduces dual concerns related to c-section overuse in some populations while others lack access to care.
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Affiliation(s)
- Emily D Carter
- Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - P Neff Walker
- Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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Jolles DR, Montgomery TM, Blankstein Breman R, George E, Craddock J, Sanders S, Niemcyzk N, Stapleton S, Bauer K, Wright J. Place of Birth Preferences and Relationship to Maternal and Newborn Outcomes Within the American Association of Birth Centers Perinatal Data Registry, 2007-2020. J Perinat Neonatal Nurs 2022; 36:150-160. [PMID: 35476769 DOI: 10.1097/jpn.0000000000000647] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE The purpose of this study was to describe sociodemographic variations in client preference for birthplace and relationships to perinatal health outcomes. METHODS Descriptive data analysis (raw number, percentages, and means) showed that preference for birthplace varied across racial and ethnic categories as well as sociodemographic categories including educational status, body mass index, payer status, marital status, and gravidity. A subsample of medically low-risk childbearing people, qualified for birth center admission in labor, was analyzed to assess variations in maternal and newborn outcomes by site of first admission in labor. RESULTS While overall clinical outcomes exceeded national benchmarks across all places of admission in the sample, disparities were noted including higher cesarean birth rates among Black and Hispanic people. This variation was larger within the population of people who preferred to be admitted to the hospital in labor in the absence of medical indication. CONCLUSION This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation.
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Affiliation(s)
- Diana R Jolles
- Frontier University, Tucson, Arizona (Dr Jolles); American Association of Birth Centers Research Committee, Perkiomenville, Pennsylvania (Drs Jolles, Niemcyzk, and Stapleton and Mss Sanders, Bauer, and Wright); Department of Nursing, Temple University College of Public Health, Philadelphia, Pennsylvania (Dr Montgomery); University of Maryland School of Nursing, Baltimore (Dr Blankstein Breman); Boston College Connell School of Nursing, Boston, Massachusetts (Ms George); University of Maryland College of Social Work, Baltimore (Dr Craddock); and Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Ms Sanders and Dr Niemcyzk)
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Morris JM, Bertotti AM. Protocol versus practice: Deviations from guidelines in low-risk twin deliveries in the United States. Birth 2022; 49:147-158. [PMID: 34549453 DOI: 10.1111/birt.12587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 08/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medical guidelines recommend vaginal delivery for low-risk twin pregnancies because cesareans increase the probability of maternal morbidity and mortality. Yet, vaginal delivery rates for twins are considerably lower than for comparable singletons. One explanation for this disparity argues that greater risk associated with twins warrants increased surgical intervention. An alternative explanation is that twin deliveries are more likely to deviate from protocols that advise vaginal birth. METHODS Using the 2017 Natality Detail File (N = 3,197,401), we measured alignment of vaginal birth and trial of labor (TOL) with the American College of Obstetricians and Gynecologists' guidelines for twin and singleton no-indicated-risk births. We calculated predicted probabilities for the population and by maternal race/ethnicity to assess whether low rates of vaginal births among twins are explained by associated risk factors, or by deviations from recommended delivery methods. RESULTS Overall, 31.2% of twins were born vaginally compared with 79.4% of singletons. Controlling for indicated risks, the predicted probability of vaginal birth for twins was 0.49 and 0.85 for singletons. The predicted probability of TOL for twins was 0.18 and 0.47 for singletons. Maternal race/ethnicity was only weakly associated with mode of delivery. These findings indicate that no-indicated-risk twin pregnancies, across maternal racial/ethnic categories, have lower probabilities of vaginal birth and TOL than would be expected with widespread adherence to current guidelines. CONCLUSIONS Given the life-threatening consequences that may result from unnecessary surgical procedures, our findings highlight the need for further research to illuminate medical and nonmedical mechanisms driving nonadherence to clinical guidelines for twin births.
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Bovbjerg ML, Tucker CM, Pillai S. Current Resources for Evidence-Based Practice, March 2022. J Obstet Gynecol Neonatal Nurs 2022; 51:225-237. [PMID: 35150643 DOI: 10.1016/j.jogn.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of systemic racism and its effect on maternal health in the United States and commentaries on reviews focused on barriers and facilitators to HPV vaccination and delayed cord clamping in preterm infants.
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Variations in Low-Risk Cesarean Delivery Rates in the United States Using the Society for Maternal-Fetal Medicine Definition. Obstet Gynecol 2022; 139:235-243. [DOI: 10.1097/aog.0000000000004645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/28/2021] [Indexed: 11/26/2022]
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Clark RR. Research and Professional Literature to Inform Practice, January/February 2022. J Midwifery Womens Health 2022; 67:133-139. [DOI: 10.1111/jmwh.13333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Rebecca R.S. Clark
- Center for Health Outcomes and Policy Research, Center for Global Women's Health University of Pennsylvania School of Nursing, Pennsylvania Hospital, Leonard Davis Institute of Health Economics Philadelphia Pennsylvania
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Zuleta-Tobón JJ. Demostración de la aplicación del Modelo global de referencia para las tasas de cesárea (C-Model) y la Clasificación de Robson en la estimación y la caracterización del exceso de cesáreas institucionales. REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGÍA 2021; 72:396-406. [PMID: 35134286 PMCID: PMC8833240 DOI: 10.18597/rcog.3649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 11/16/2021] [Indexed: 11/24/2022]
Abstract
Objetivo: Hacer un ejercicio académico, con datos locales reales, sobre la aplicación del C-Model v1.0 en cuanto a la manera como se obtiene y utiliza la información para generar el modelo, su aplicación a fin de identificar el posible exceso de cesáreas en una institución y, si se identifica, cómo se aplica la distribución de los partos según los grupos de la Clasificación de Robson para explicar ese exceso. Metodología: A partir de las bases de datos reales de cinco instituciones hospitalarias de Colombia, seleccionadas a conveniencia para lograr el cumplimiento de los objetivos, se estimó la razón estandarizada y la diferencia absoluta entre la proporción observada y la probabilidad esperada de cesárea según el C-Model v1.0 en cada institución. Con base en los supuestos que subyacen a la distribución de los grupos según la Clasificación de Robson, se proponen explicaciones a los excesos y a las diferencias entre las instituciones. Resultados: La razón estandarizada de cesárea aplicando el C-Model identificó excesos del procedimiento diferentes en presencia de proporciones institucionales similares de cesárea. Se encontró variabilidad importante en la proporción de cesárea dentro de grupos de mujeres con características clínicas y obstétricas similares que podría ser la explicación para los excesos detectados. Conclusión: El C-Model permite estimar proporciones de cesárea esperadas según las condiciones específicas de las mujeres atendidas en cada institución; su distribución de acuerdo con la Clasificación de Robson permite explorar el origen y las particularidades de dichas diferencias.
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Affiliation(s)
- John Jairo Zuleta-Tobón
- Centro Nacer, Salud Sexual y Reproductiva, adscrito al Departamento de Ginecología y Obstetricia de la Facultad de Medicina, Universidad de Antioquia, Medellín (Colombia)..
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Wollny K, Metcalfe A, Corrigan C, Drobot A, Gilmour L, Wood S, Wilson RD, Gramlich L, Nelson G. Maternal perceptions of cesarean birth care: A qualitative study to inform ERAS guideline development. Birth 2021; 48:550-557. [PMID: 34137470 DOI: 10.1111/birt.12561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 05/11/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Cesarean birth (CB) is the most common inpatient surgical procedure, and until recently, there were no internationally accepted, standardized clinical guidelines available. The Enhanced Recovery After Surgery (ERAS® ) program aims to improve outcomes through the development of international guidelines (IGs). As an ERAS IG for CB was being developed, this qualitative study was conducted to explore and consolidate women's experiences with CB. METHODS Qualitative methods were used to assess the patient experience with current evidence-based CB protocols across operative phases. Twelve women who experienced CB at a single center in Canada were interviewed using an open-ended, semi-structured interview guide at six weeks postpartum. Two researchers coded the emerging themes separately and compared findings. RESULTS Women described feeling informed, but felt they did not have a choice. Presurgery, women wanted more information about the risks of CB. Preoperatively, women expressed confusion with the procedures, but felt informed about local anesthesia and thermoregulation. Post-CB, women felt informed about pain and nausea control; however, urinary catheter removal was delayed when compared to the ERAS recommendations. Information about postpartum infant care was not well communicated, as many women were uninformed about delayed cord clamping and infant thermoregulation. CONCLUSIONS This qualitative study provides opportunities to improve communication, the patient-practitioner relationship, and the overall satisfaction throughout the CB process. The findings support the implementation of patient decision aids and training with the shared decision model. The improved procedures recommended in the ERAS IG for CB have the potential to deliver significant improvements to patient care and patient satisfaction.
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Affiliation(s)
- Krista Wollny
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Amy Metcalfe
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Crystal Corrigan
- Health Systems Evaluation and Evidence, Alberta Health Services, Edmonton, AB, Canada
| | - Ashley Drobot
- Health Systems Evaluation and Evidence, Alberta Health Services, Edmonton, AB, Canada
| | - Loreen Gilmour
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Stephen Wood
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada
| | - R Douglas Wilson
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada
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Wendling A, Taglione V, Rezmer R, Lwin P, Frost J, Terhune J, Kerver J. Access to maternity and prenatal care services in rural Michigan. Birth 2021; 48:566-573. [PMID: 34145616 DOI: 10.1111/birt.12563] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The United States physician shortages affect rural health care access, including maternity care. Project aims were to identify and characterize prenatal and delivery care in Michigan's rural counties and to explore access to trial of labor after cesarean (TOLAC) services for women in rural Michigan. METHODS Descriptive, cross-sectional design used 2015 Medicaid claims data and public health plan information to identify maternity care services provided within Michigan's rural counties. Publicly available health plan information was used to identify rural maternity hospitals and prenatal care practitioners; findings were verified by Internet searches and telephone interviews. Medicaid claims data were used to determine services provided. High-risk geographic areas were defined as those where women needed to travel >30 miles for maternity-related care. Expected TOLAC rate was determined based on published national birth data; rural hospitals were stratified based on whether they met the expected TOLAC rate, delivered 20%-60% of expected rate, or billed ≤1 TOLAC birth to Medicaid in 2015. RESULTS In Michigan's 57 rural counties, only 29 hospitals provide maternity care. Geographic high-risk areas were identified in the Upper Peninsula and northeast Lower Peninsula of Michigan. Only two rural hospitals billed for the expected rate of TOLAC births; six delivered at a lower rate, and the remaining 21 hospitals provided no TOLAC services, resulting in large areas of the state where women were not offered this option locally. CONCLUSIONS Maternity care services are limited for many rural Michigan women. Findings can be used to target specific strategies to improve access to care for these women. Similar analyses, exploring patterns of maternity care delivery in other rural regions worldwide, may uncover similar or additional inequities.
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Affiliation(s)
- Andrea Wendling
- Michigan State University College of Human Medicine, East Lansing, MI, USA
| | - Valerie Taglione
- Resident physician
- UPHS-Marquette Family Medicine, Michigan State University College of Human Medicine, Marquette, MI, USA
| | - Rachel Rezmer
- Resident physician
- Department of Obstetrics and Gynecology, St. Joseph Mercy - Ann Arbor, Ann Arbor, MI, USA
| | - Poe Lwin
- Department of Internal Medicine, MCWAH-Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI, USA
| | - Jessica Frost
- Resident physician
- Department of Obstetrics and Gynecology, Sparrow MSU/CHM Obstetrics and Gynecology Program, Lansing, MI, USA
| | - Julia Terhune
- Michigan State University College of Human Medicine, East Lansing, MI, USA
| | - Jean Kerver
- Department of Epidemiology & Biostatistics, Michigan State University College of Human Medicine, East Lansing, MI, USA
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Aggarwal R, Plough A, Henrich N, Galvin G, Rucker A, Barnes C, Berry W, Golen T, Shah NT. The design of "TeamBirth": A care process to improve communication and teamwork during labor. Birth 2021; 48:534-540. [PMID: 34245054 PMCID: PMC9290033 DOI: 10.1111/birt.12566] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 05/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite evidence that communication and teamwork are critical to patient safety, few care processes have been intentionally designed for this purpose in labor and delivery. The purpose of this project was to design an intrapartum care process that aims to improve communication and teamwork between clinicians and patients. METHODS We followed the "Double-Diamond" design method with four sequential steps: Discover, Define, Develop, and Deliver. In Discover, we searched professional guidelines and peer-reviewed literature to delineate the challenges to quality of intrapartum care and to uncover options for solutions. In Define, we convened an interdisciplinary group of experts to focus the problem scope and prioritize solution features. In Develop, we created initial prototype solutions. In Deliver, we engaged clinicians and patients in rapid cycle testing to iteratively produce a care process called "TeamBirth" that aims to improve team communication. RESULTS We designed TeamBirth, an intrapartum care process composed of brief team meetings ("huddles") between clinicians and patients. Huddles are navigated by a shared planning board placed in the labor and delivery room in view of the patient and their care team. The board promotes transparent and reliable communication and contains four areas to be acknowledged or discussed: (a) the names of the team members, starting with the patient; (b) the patient's preferences; (c) the care plan for the patient, baby, and labor progress; and (d) when the next team huddle is anticipated. DISCUSSION We identified an opportunity to improve the safety and dignity of childbirth care through an intrapartum care process that promotes reliable and structured communication and teamwork. Future work should evaluate the acceptability and feasibility of implementation and potential impact on safety and experience of care.
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Affiliation(s)
- Reena Aggarwal
- Guy's and St Thomas' NHS Foundation TrustLondonUK,Ariadne LabsBostonMAUSA
| | | | | | | | | | | | | | - Toni Golen
- Beth Israel Deaconess Medical CenterBostonMAUSA,Harvard Medical SchoolBostonMAUSA
| | - Neel T. Shah
- Guy's and St Thomas' NHS Foundation TrustLondonUK,Beth Israel Deaconess Medical CenterBostonMAUSA,Harvard Medical SchoolBostonMAUSA
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Iobst SE, Phillips AK, Wilson C. Shared Decision-Making During Labor and Birth Among Low-Risk, Active Duty Women in the U.S. Military. Mil Med 2021; 187:e747-e756. [PMID: 34850083 DOI: 10.1093/milmed/usab486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/30/2021] [Accepted: 11/10/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The cesarean birth rate of 24.7% in the Military Health System (MHS) is lower than the national rate of 31.7%. However, the MHS rate remains higher than the 15-19% threshold associated with optimal maternal and neonatal outcomes. For active duty servicewomen, increased morbidity associated with cesarean birth is likely to affect the ability to meet the demands of assigned missions. Several decision-points occur during pregnancy and after the onset of labor that can affect the likelihood of cesarean birth including choice of provider, choice of hospital, timing of admission, and type of fetal monitoring. Evidence suggests the overuse of labor interventions may be associated with cesarean birth. Shared decision-making (SDM) is a strategy that can be used to carefully consider the risks, benefits, and alternatives of each labor intervention and is shown to be associated with positive patient outcomes. Most existing evidence explores SDM as an interaction that occurs between women and their providers. Few studies have explored the role of stakeholders such as spouses, family members, friends, labor and delivery nurses, and doulas. Furthermore, little is known about the process of SDM during labor and childbirth in the hospital setting, particularly for active duty women in the U.S. military. The purpose of this study was to propose a framework that explains the process of SDM during labor and childbirth in the hospital setting for active duty women in the U.S. military. MATERIALS AND METHODS A qualitatively driven mixed-methods approach was conducted to propose a framework that explains the process of SDM during labor and childbirth in the hospital setting for active duty women in the U.S. military. Servicewomen were recruited from September 2019 to April 2020. Semi-structured interviews were analyzed using a constructivist grounded theory approach. Participants also completed the SDM Questionnaire (SDM-Q-9). RESULTS Interviews were conducted with 14 participants. The sample included servicewomen from the Air Force (n = 7), Army (n = 4), and Navy (n = 3). Two participants were enlisted and the remainder were officers. Ten births occurred at military treatment facilities (MTFs) and six births took place at civilian facilities. The mean score on the SDM Questionnaire was 86.7 (±11.6), indicating a high level of SDM. Various stakeholders (e.g., providers, labor and delivery nurses, doulas, spouses, family members, and friends) were involved in SDM at different points during labor and birth. The four stages of SDM included gathering information, identifying preferences, discussing options, and making decisions. Events that most often involved SDM were deciding when to travel to the hospital, deciding when to be admitted, and selecting a strategy for pain management. Military factors involved in SDM included sources of information, selecting and working with civilian providers, and delaying labor interventions to allow time for an active duty spouse to travel to the hospital. CONCLUSIONS SDM during labor and birth in the hospital setting is a multi-stage process that involves a variety of stakeholders, including the woman, members of her social and support network, and healthcare professionals. Future research is needed to explore perspectives of other stakeholders involved in SDM.
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Affiliation(s)
- Stacey E Iobst
- Department of Nursing, Towson University, Towson, MD 21252, USA
| | - Angela K Phillips
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, MD 20762, USA
| | - Candy Wilson
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Dubron K, Verschaeve M, Roodhooft F. A time-driven activity-based costing approach for identifying variability in costs of childbirth between and within types of delivery. BMC Pregnancy Childbirth 2021; 21:705. [PMID: 34670514 PMCID: PMC8527632 DOI: 10.1186/s12884-021-04134-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background Recently, time-driven activity-based costing (TDABC) is put forward as an alternative, more accurate costing method to calculate the cost of a medical treatment because it allows the assignment of costs directly to patients. The objective of this paper is the application of a time-driven activity-based method in order to estimate the cost of childbirth at a maternal department. Moreover, this study shows how this costing method can be used to outline how childbirth costs vary according to considered patient and disease characteristics. Through the use of process mapping, TDABC allows to exactly identify which activities and corresponding resources are impacted by these characteristics, leading to a more detailed understanding of childbirth cost. Methods A prospective cohort study design is performed in a maternity department. Process maps were developed for two types of childbirth, vaginal delivery (VD) and caesarean section (CS). Costs were obtained from the financial department and capacity cost rates were calculated accordingly. Results Overall, the cost of childbirth equals €1894,12 and is mainly driven by personnel costs (89,0%). Monitoring after birth is the most expensive activity on the pathway, costing €1149,70. Significant cost variations between type of delivery were found, with VD costing €1808,66 compared to €2463,98 for a CS. Prolonged clinical visit (+ 33,3 min) and monitoring (+ 775,2 min) in CS were the main contributors to this cost difference. Within each delivery type, age, parity, number of gestation weeks and education attainment were found to drive cost variations. In particular, for VD an age > 25 years, nulliparous, gestation weeks > 40 weeks and higher education attainment were associated with higher costs. Similar results were found within CS for age, parity and number of gestation weeks. Conclusions TDABC is a valuable approach to measure and understand the variability in costs of childbirth and its associated drivers over the full care cycle. Accordingly, these findings can inform health care providers, managers and regulators on process improvements and cost containment initiatives. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04134-4.
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Affiliation(s)
- Kathia Dubron
- KU Leuven, University Hospital Leuven, Kapucijnenvoer 33, 3000, Leuven, Belgium.
| | - Mathilde Verschaeve
- KU Leuven, Faculty of Economics and Business, Research Centre Accountancy, Leuven, Belgium
| | - Filip Roodhooft
- KU Leuven, Faculty of Economics and Business, Research Centre Accountancy, Leuven, Belgium.,Vlerick Business School, Accounting and Finance, Gent, Belgium
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Gee LL, Behling DJ, Sweeney NL. Nurses' Knowledge of and Confidence in Perioperative Skills for Emergency Cesarean Birth. Nurs Womens Health 2021; 25:422-429. [PMID: 34627748 DOI: 10.1016/j.nwh.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 07/29/2021] [Accepted: 09/23/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess if nurses' perioperative knowledge of and confidence in perioperative skills for emergency cesarean birth improved after didactic learning and high-fidelity simulation. DESIGN Descriptive, one-group pretest and posttest design. SETTING/LOCAL PROBLEM Level 3 labor and birth unit that averages 3,000 births per year. At the site, there were no current evidence-based programs specifically focused on perioperative skills sustainment of the maternity nursing professional. PARTICIPANTS Registered nurses on a labor and birth unit with at least 1 year of experience completed an online educational course and simulation activity. INTERVENTIONS/MEASUREMENTS Participants were given pretests and posttests to assess knowledge and confidence in emergency cesarean birth perioperative skills. Observations of nurses' pretest and posttest interventions in cesarean births were made to assess changes in competency. Chart reviews were completed to assess changes in decision-to-incision time before and after the intervention. RESULTS Nurses reported greater confidence and knowledge during emergency cesarean birth after participating in the interventions. Other results included decreased decision-to-incision times. None of these results held statistical significance. CONCLUSION This project highlights the need for evidence-based, standardized perioperative maternity education across labor and birth nursing practice.
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Reduction in Cesarean Delivery Rates Associated With a State Quality Collaborative in Maryland. Obstet Gynecol 2021; 138:583-592. [PMID: 34623072 DOI: 10.1097/aog.0000000000004540] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the extent to which hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) to reduce primary cesarean deliveries adopted policy and practice changes and the association of this adoption with state-level cesarean delivery rates. METHODS This prospective evaluation of the MDPQC includes 31 (97%) of the birthing hospitals in the state, which all voluntarily participated in the 30-month collaborative from June 2016 to December 2018. Hospital teams agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. Each hospital's implementation of practices in the bundle was measured through surveys of team leaders at 12 months and 30 months. Half-yearly cesarean delivery rates were calculated from aggregate birth certificate data for each hospital, and differences in rates between the 6 months before the collaborative (baseline) and the 6 months afterward (endline) were tested for statistical significance. RESULTS Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle. CONCLUSION The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births.
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Levine LD, Downes KL, Hamm RF, Srinivas SK. Evaluating the impact of a standardized induction protocol to reduce adverse perinatal outcomes: a prospective cohort study. J Matern Fetal Neonatal Med 2021; 34:3200-3207. [PMID: 31645154 PMCID: PMC7180115 DOI: 10.1080/14767058.2019.1680629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/03/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Our objective was to evaluate the impact of a standardized induction protocol on reducing maternal and neonatal morbidity in women undergoing an induction with an unfavorable cervix. STUDY DESIGN We performed a prospective cohort study of women undergoing an induction from May 2013 to June 2015. Women who were ≥18 years, ≥37 weeks with intact membranes and an unfavorable cervix (Bishop score of ≤6 and cervical dilation ≤2 cm) with no prior cesarean were included. We compared the following outcomes between women managed with the labor protocol versus women in an observation group, managed at the discretion of the provider: Labor length, cesarean delivery, maternal and neonatal morbidity, and neonatal intensive care unit admission for >48 hours. Multivariable models incorporated confounders specific to each outcome. RESULTS 855 women were included (491: labor protocol group; 364: observational group). Women in the labor protocol group had a shorter time to delivery (15.7 hours vs. 18.0 hours, p < .001), a decrease in maternal morbidity (7.3% vs. 11.5%, p = .04), lower rates of NICU admission >48 hours (3.5% vs 8%, p = .005), and a lower neonatal morbidity (3.0% vs. 7.7%, p = .003) compared to women in the observational group. There was no difference in rate of cesarean between the labor protocol and observational groups (27.7% vs. 32.7%, p = .13). When adjusting for confounders, women in the labor protocol group had a 60% reduction in NICU admission >48 hours (RR: 0.41, 95% CI: 0.22-0.76) and a 70% reduction in neonatal morbidity (RR: 0.31, 95% CI: 0.13-0.70). Time to delivery and maternal morbidity were not significantly different in adjusted models. CONCLUSION Utilization of a standardized induction protocol was associated with a significant reduction in neonatal morbidity without increasing the risk of cesarean or maternal morbidity.
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Affiliation(s)
- Lisa D Levine
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Rebecca F Hamm
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sindhu K Srinivas
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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