A standardized labor induction protocol: impact on racial disparities in obstetrical outcomes

The Role of the Obstetrics and Gynecology Hospitalist in the Changing Landscape of Obstetrics and Gynecology Practice

As the field of obstetrics and gynecology (Ob/Gyn) evolves, the role of the Ob/Gyn hospitalists has become increasingly integrated into the framework of the specialty. Ob/Gyn hospitalists take on essential responsibilities as competent clinicians in emergent situations and as hospital leaders: maintaining standard of care, collaborating with community practitioners and care teams, promoting diversity, equity, and inclusion practices, and contributing to educational initiatives. The impact of the Ob/Gyn hospitalists is positive for patients, fellow clinicians, and institutions. As the field continues to change and the Ob/Gyn hospitalist develops as an established subspecialty, further research evaluating its role remains essential.

A Longitudinal Multivariable Analysis: State Policies and Opioid Dispensing in Medicare Beneficiaries Undergoing Surgery

BACKGROUND

States have implemented policies to decrease clinically unnecessary opioid prescribing, but few studies have examined how state policies affect opioid dispensing rate trends for surgical patients.

OBJECTIVE

To examine trends in the perioperative opioid dispensing rates for fee-for-service Medicare beneficiaries and the effects of select state policies.

DESIGN AND PARTICIPANTS

A retrospective cohort study using 2006 to 2018 Medicare claims data for individuals undergoing surgical procedures for which opioid analgesic treatment is common.

EXPOSURES

State policies mandating prescription drug monitoring program (PDMP; PDMP policies) use, initial opioid prescription duration limit (duration limit policies), and mandated continuing medical education (CME; CME pain policies) on pain management.

MAIN MEASURES

Opioid dispensing rates, days' supply, and the daily morphine milligram equivalent dose (MMED).

KEY RESULTS

The percentage of Medicare beneficiaries dispensed opioids in the perioperative period increased from 2007 to 2018; MMED and days' supply decreased over the same period, with significant variation by age, sex, and race. None of the three state policies affected the likelihood of Medicare beneficiaries being dispensed perioperative opioids. However, CME pain policies and duration limit policies were associated with decreased days' supply and decreased MMED in the several years following implementation, respectively.

CONCLUSION

While we observed a slight increase in the rate of Medicare beneficiaries dispensed opioids perioperatively and a substantial decrease in MMED and days' supply for those receiving opioids, state policies examined had relatively modest effects on the main measures. Our findings suggest that these state policies may have a limited impact on opioid dispensing for a patient population that is commonly dispensed opioid analgesics to help control surgical pain, and as a result may have little direct effect on clinical outcomes for this population. Changes in opioid dispensing for this population may be the result of broader societal trends than such state policies.

Implementation and Clinical Impact of a Guideline for Standardized, Evidence-Based Induction of Labor

OBJECTIVE

 This study aimed to assess the impact of implementation of an induction of labor (IOL) guideline on IOL length and utilization of evidence-based practices.

STUDY DESIGN

 We conducted a quality improvement project to increase utilization of three evidence-based IOL practices: combined agent ripening, vaginal misoprostol, and early amniotomy. Singletons with intact membranes and cervical dilation ≤2 cm admitted for IOL were included. Primary outcome was IOL length. Secondary outcomes included cesarean delivery and practice utilization. We compared preimplementation (PRE; November 1, 2021 through January 31, 2022) to postimplementation (POST; March 1, 2022 through April 30, 2022) with sensitivity analyses by self-reported race and ethnicity. Cox proportional hazards models and logistic regression were used to test the association between period and outcomes.

RESULTS

 Among 495 birthing people (PRE, n = 293; POST, n = 202), IOL length was shorter POST (22.0 vs. 18.3 h, p = 0.003), with faster time to delivery (adjusted hazard ratio [aHR] 1.38, 95% CI 1.15-1.66), more birthing people delivered within 24 hours (57 vs. 68.8%, adjusted odds ratio [aOR] 1.90 [95% CI 1.25-2.89]), and no difference in cesarean. Utilization of combined agent ripening (31.1 vs. 42.6%, p = 0.009), vaginal misoprostol (34.5 vs. 68.3%, p < 0.001), and early amniotomy (19.1 vs. 31.7%, p = 0.001) increased POST.

CONCLUSION

 Implementation of an evidence-based IOL guideline is associated with shorter induction time. Additional implementation efforts to increase adoption of practices are needed to optimize outcomes after IOL.

KEY POINTS

· Implementation of an IOL guideline is associated with faster time to delivery.. · Evidence-based induction practices were used more often after guideline implementation.. · Adoption of evidence-based induction practices is variable even with a guideline..

Racial disparities in low-risk cesarean birth rates across hospitals

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.

Are Racial Disparities in Cesarean Due to Differences in Labor Induction Management?

OBJECTIVE

 While there are known racial disparities in cesarean delivery (CD) rates, the exact etiologies for these disparities are multifaceted. We aimed to determine if differences in induction of labor (IOL) management contribute to these disparities.

STUDY DESIGN

 This retrospective cohort study evaluated all nulliparous patients with an unfavorable cervix and intact membranes who underwent IOL of a term, singleton gestation at a single institution from October 1, 2018, to September 30, 2020. IOL management was at clinician discretion. Patients were classified as Black, Indigenous, and People of Color (BIPOC) or White based on self-report. Overall rates of CD were compared for BIPOC versus White race. Chart review then evaluated various IOL management strategies as possible contributors to differences in CD by race.

RESULTS

 Of 1,261 eligible patients, 915 (72.6%) identified as BIPOC and 346 (27.4%) as White. BIPOC patients were more likely to be younger (26 years interquartile range (IQR) [22-30] vs. 32 years IQR [30-35], p < 0.001) and publicly insured (59.1 vs. 9.9%, p < 0.001). Indication for IOL and modified Bishop score also differed by race (p < 0.001; p = 0.006). There was 40% increased risk of CD for BIPOC patients, even when controlling for confounders (30.7 vs. 21.7%, p = 0.001; adjusted relative risk (aRR) 1.41, 95% confidence interval (CI) [1.06-1.86]). Despite this difference in CD, there were no identifiable differences in IOL management prior to decision for CD by race. Specifically, there were no differences in choice of cervical ripening agent, cervical dilation at or time to amniotomy, use and maximum dose of oxytocin, or dilation at CD. However, BIPOC patients were more likely to undergo CD for fetal indications and failed IOL.

CONCLUSION

 BIPOC nulliparas are 40% more likely to undergo CD during IOL than White patients within our institution. These data suggest that the disparity is not explained by differences in IOL management prior to cesarean, indicating that biases outside of induction management may be important to target to reduce CD disparities.

KEY POINTS

· The etiologies for racial disparities in cesarean are likely multifaceted.. · In this work, there were no differences by race in measures of labor induction management.. · Biases outside of induction management during labor may be targeted to reduce CD disparities..

Sociodemographic Disparities in Tracheostomy Timing and Outcomes

OBJECTIVE

Tracheostomies are commonly performed in critically ill patients requiring prolonged mechanical ventilation. Although early tracheostomy has been associated with improved outcomes, the reasons for delayed tracheostomy are complex. We examined the impact of sociodemographic factors on tracheostomy timing and outcomes.

METHODS

Medical records were retrospectively reviewed of ventilator-dependent adult patients who underwent tracheostomy from 2021 to 2022. Tracheostomy timing was defined as routine (<21 days) versus late (21 days or more). Sociodemographic variables were compared between cohorts using univariate and multivariate models. Secondary outcomes included hospital length of stay (LOS), decannulation, tracheostomy-related complications, and inhospital mortality.

RESULTS

One hundred forty-two patients underwent tracheostomy after initial intubation: 74.7% routine (n = 106) and 25.4% late (n = 36). In a multivariate model adjusted for age, race, surgical service, tracheostomy technique, and time between consultation and surgery, non-English speaking patients and women were more likely to receive a late tracheostomy compared with English speaking patients and men, respectively (odds ratio [OR] 3.18, 95% confidence interval [CI] 1.03, 9.81, p < 0.05), (OR 3.15, 95% CI 1.18, 8.41, p < 0.05). Late tracheostomy was associated with longer median hospital LOS (62 vs. 52 days, p < 0.05). Tracheostomy timing did not significantly impact mortality, decannulation or tracheostomy-related complications.

CONCLUSION

Despite an association between earlier tracheostomy and shorter LOS, non-English speaking patients and female patients are more likely to receive a late tracheostomy. Standardized protocols for tracheostomy timing may address bias in the referral and execution of tracheostomy and reduce unnecessary hospital days.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:582-587, 2024.

Hospital-level variation in racial disparities in low-risk nulliparous cesarean delivery rates

BACKGROUND

Nationally, rates of cesarean delivery are highest among Black patients compared with other racial/ethnic groups. These observed inequities are a relatively new phenomenon (in the 1980s, cesarean delivery rates among Black patients were lower than average), indicating an opportunity to narrow the gap. Cesarean delivery rates vary greatly among hospitals, masking racial disparities that are unseen when rates are reported in aggregate.

OBJECTIVE

This study aimed to explore reasons for the current large Black-White disparity in first-birth cesarean delivery rates by first examining the hospital-level variation in first-birth cesarean delivery rates among different racial/ethnic groups. We then identified hospitals that had low first-birth cesarean delivery rates among Black patients and compared them with hospitals with high rates. We sought to identify differences in facility or patient characteristics that could explain the racial disparity.

STUDY DESIGN

A population cross-sectional study was performed on 1,267,493 California live births from 2018 through 2020 using birth certificate data linked with maternal patient discharge records. Annual nulliparous term singleton vertex cesarean delivery (first-birth) rates were calculated for the most common racial/ethnic groups statewide and for each hospital. Self-identified race/ethnicity categories as selected on the birth certificate were used. Relative risk and 95% confidence intervals for first-birth cesarean delivery comparing 2019 with 2015 were estimated using a log-binomial model for each racial/ethnic group. Patient and hospital characteristics were compared between hospitals with first-birth cesarean delivery rates <23.9% for Black patients and hospitals with rates ≥23.9% for Black patients.

RESULTS

Hospitals with at least 30 nulliparous term singleton vertex Asian, Black, Hispanic, and White patients each were identified. Black patients had a very different distribution, with a significantly higher rate (28.4%) and wider standard deviation (7.1) and interquartile range (6.5) than other racial groups (P<.01). A total of 29 hospitals with a low first-birth cesarean delivery rate among Black patients were identified using the Healthy People 2020 target of 23.9% and compared with 106 hospitals with higher rates. The low-rate group had a cesarean delivery rate of 19.9%, as opposed to 30.7% in the higher-rate group. There were no significant differences between the groups in hospital characteristics (ownership, delivery volume, neonatal level of care, proportion of midwife deliveries) or patient characteristics (age, education, insurance, onset of prenatal care, body mass index, hypertension, diabetes mellitus). Among the 106 hospitals that did not meet the target for Black patients, 63 met it for White patients with a mean rate of 21.4%. In the same hospitals, the mean rate for Black patients was 29.5%. Among Black patients in the group that did not meet the 23.9% target, there were significantly higher rates of all cesarean delivery indications: labor dystocia, fetal concern (spontaneous labor), and no labor (eg, macrosomia), which are all indications with a high degree of subjectivity.

CONCLUSION

The statewide cesarean delivery rate of Black patients is significantly higher and has substantially greater hospital variation compared with other racial or ethnic groups. The lack of difference in facility or patient characteristics between hospitals with low cesarean delivery rates among Black patients and those with high rates suggests that unconscious bias and structural racism potentially play important roles in creating these racial differences.

Association of Maternal Comorbidity Burden With Cesarean Birth Rate Among Nulliparous, Term, Singleton, Vertex Pregnancies

IMPORTANCE

Cesarean birth rate among nulliparous, term, singleton, vertex (NTSV) pregnancies is a standard quality measure in obstetrical care. There are limited data on how the number and type of preexisting conditions affect mode of delivery among primigravidae, and it is also uncertain how maternal comorbidity burden differs across racial and ethnic groups and whether this helps to explain disparities in the NTSV cesarean birth rate.

OBJECTIVE

To determine the association between obstetric comorbidity index (OB-CMI) score and cesarean delivery among NTSV pregnancies and to evaluate whether disparities in mode of delivery exist based on race and ethnicity group after adjusting for covariate factors.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of deliveries between January 2019 and December 2021 took place across 7 hospitals within a large academic health system in New York and included all NTSV pregnancies identified in the electronic medical record system. Exclusion criteria were fetal demise and contraindication to labor.

EXPOSURE

The OB-CMI score. Covariate factors assessed included race and ethnicity group (American Indian or Alaska Native, Asian or Pacific Islander, Hispanic, non-Hispanic Black, non-Hispanic White, other or multiracial, and declined or unknown), public health insurance, and preferred language.

MAIN OUTCOME AND MEASURES

Cesarean delivery.

RESULTS

A total of 30 253 patients (mean [SD] age, 29.8 [5.4] years; 100% female) were included. Non-Hispanic White patients constituted the largest race and ethnicity group (43.7%), followed by Hispanic patients (16.2%), Asian or Pacific Islander patients (14.6%), and non-Hispanic Black patients (12.2%). The overall NTSV cesarean birth rate was 28.5% (n = 8632); the rate increased from 22.1% among patients with an OB-CMI score of 0 to greater than 55.0% when OB-CMI scores were 7 or higher. On multivariable mixed-effects logistic regression modeling, there was a statistically significant association between OB-CMI score group and cesarean delivery; each successive OB-CMI score group had an increased risk. Patients with an OB-CMI score of 4 or higher had more than 3 times greater odds of a cesarean birth (adjusted odds ratio, 3.14; 95% CI, 2.90-3.40) than those with an OB-CMI score of 0. Compared with non-Hispanic White patients, nearly all other race and ethnicity groups were at increased risk for cesarean delivery, and non-Hispanic Black patients were at highest risk (adjusted odds ratio, 1.43; 95% CI, 1.31-1.55).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of patients with NTSV pregnancies, OB-CMI score was positively associated with cesarean birth. Racial and ethnic disparities in this metric were observed. Although differences in the prevalence of preexisting conditions were seen across groups, this did not fully explain variation in cesarean delivery rates, suggesting that unmeasured clinical or nonclinical factors may have influenced the outcome.

Leveraging quality improvement to promote health equity: standardization of prenatal aspirin recommendations

OBJECTIVE

Aspirin (ASA) is recommended for patients at elevated risk of preeclampsia. Limited data exists on adherence to guidelines for ASA prescription. This project evaluates the implementation of a standardized approach to ASA prescription in an academic OB/Gyn practice.

METHODS

We implemented a quality improvement project to evaluate compliance with the United States Preventative Services Task Force (USPSTF) recommendations for ASA to prevent preeclampsia. Pre-intervention, we analyzed prescription adherence at 201 New Obstetric (NOB) visits. A multi-step intervention was then implemented at 199 NOB visits. Nurses utilized a checklist created from USPSTF guidelines to identify high-risk patients, defined as having ≥1 high-risk factor or ≥2 moderate-risk factors. ASA orders were placed by physicians. A Plan-Do-Study-Act (PDSA) cycle was performed, and changes implemented. Primary outcome was percent of patients screened at RN intake visit (goal = 90%). Secondary outcomes were percent of patients who screened positive that received the ASA recommendation (goal = 80%) and percent screened and recommended by race.

RESULTS

Pre-intervention, 47% of patients met criteria for ASA and 28% received a documented recommendation. Post-intervention, 99% were screened. Half (48%) met criteria for an ASA recommendation and 79% received a recommendation (p = < 0.001). Rates of appropriate recommendation did not differ by Black (80%) vs. non-Black (79%) status (p = 0.25). Subsequent PDSA cycles for 12 months neared 100% RN screening rates. Physicians correctly recommended ASA 80-100% of the time.

CONCLUSION

It is feasible, sustainable and equitable to standardize screening and implementation of ASA to patients at high risk for preeclampsia. Providers can easily reproduce our processes to improve delivery of equitable and reliable preventative obstetric care.

An innovative sequential mixed-methods approach to evaluating clinician acceptability during implementation of a standardized labor induction protocol

BACKGROUND

Implementation outcomes, including acceptability, are of critical importance in both implementation research and practice. The gold standard measure of acceptability, Acceptability of Intervention Measure (AIM), skews positively with a limited range. In an ongoing hybrid effectiveness-implementation trial, we aimed to evaluate clinician acceptability of induction standardization. Here, we describe an innovative mixed-methods approach to maximize the interpretability of the AIM using a case study in maternal health.

METHODS

In this explanatory sequential mixed methods study, we distributed the validated, 4-question AIM (total 4-20) to labor and delivery clinicians 6 months post-implementation at 2 sites (Site 1: 3/2021; Site 2: 6/2021). Respondents were grouped by total score into tertiles. The top ("High" Acceptability) and bottom ("Low" Acceptability) tertiles were invited to participate in a 30-minute semi-structured qualitative interview from 6/2021 to 10/2021 until thematic saturation was reached in each acceptability group. Participants were purposively sampled by role and site. Interviews were coded using an integrated approach, incorporating a priori attributes (Consolidated Framework for Implementation Research constructs) into a modified content analysis approach.

RESULTS

104 clinicians completed the initial survey; 24 were interviewed (12 "High" and 12 "Low" Acceptability). Median total AIM scores were 20/20 IQR[20-20] in the High and 12.5/20 IQR[11-14] in the Low Acceptability groups. In both groups, clinicians were enthusiastic about efforts to standardize labor induction, believing it reduces inter-clinician variability and improves equitable, evidence-based care. In the Low Acceptability group, clinicians stated the need for flexibility and consideration for patient uniqueness. Rarely, clinicians felt labor induction could not or should not be standardized, citing discomfort with medicalization of labor, and concerns with "bulldozing" the patient with interventions. Suggested strategies for overcoming negative sentiment included comprehensive clinician education, as well as involving patients as active participants in the protocol prenatally.

CONCLUSIONS

This study utilized AIM in an innovative sequential mixed-methods approach to characterize clinician acceptability, which may be generalizable across implementation endeavors. By performing this work during a hybrid trial, implementation strategies to improve acceptability emerged (clinician education focusing on respect for flexibility; involving patients as active participants prenatally) for year 2, which will inform future multi-site work.

Efficacy of Propranolol to Reduce Cesarean Delivery in Prolonged Labor: A Randomized Controlled Trial

OBJECTIVE

To evaluate the rates of cesarean delivery in patients with prolonged labor randomized to receive intravenous (IV) propranolol compared with placebo.

METHODS

A double-blind, placebo-controlled, randomized trial was conducted at two hospitals within a large academic health system. Eligible patients were at 36 weeks or more with a singleton gestation and prolonged labor , defined as: 1) prolonged latent phase of labor (dilation less than 6 cm after 8 hours or more with ruptured membranes and receiving oxytocin infusion) or 2) prolonged active phase of labor (dilation 6 cm or greater and less than 1-cm cervical dilation change over 2 hours or more with ruptured membranes and receiving oxytocin infusion). Patients were excluded for severe preeclampsia, maternal heart rate less than 70 beats per minute, maternal blood pressure less than 90/50 mm Hg, asthma, diabetes requiring insulin during labor, or a cardiac contraindication to β-blockade. Patients were randomized to propranolol (2 mg IV) compared with placebo (2 mL normal saline IV), with one possible repeat dose. The primary outcome was cesarean delivery; secondary outcomes included labor duration, shoulder dystocia, and maternal and neonatal morbidity. With an estimated cesarean delivery rate of 45%, α 0.05, and 80% power, we required 163 patients per group to detect a 15% absolute reduction in cesarean delivery rate. A planned interim analysis was performed, and the trial was stopped for futility.

RESULTS

From July 2020 to June 2022, 349 patients were eligible and approached; 164 were enrolled and randomized, with 84 in the propranolol group and 80 in the placebo group. The rate of cesarean delivery was not different between groups (57.1% propranolol vs 57.5% placebo, relative risk [RR] 0.99, 95% CI 0.76-1.29). Results were similar by subgroup of prolonged latent (n=123) and active (n=41) phases of labor and nulliparous (n=137) and multiparous (n=27) patients. Though not statistically significant, the frequency of postpartum hemorrhage was higher in the propranolol group (20% vs 10%, RR 2.02, 95% CI 0.93-4.43).

CONCLUSION

In this multisite, double-blind, placebo-controlled randomized trial, there was no difference in cesarean delivery rate for patients who received propranolol compared with those who received placebo for management of prolonged labor.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT04299438.

Impact of new labor management guidelines on Cesarean rates among low-risk births at New York City hospitals: A controlled interrupted time series analysis

PURPOSE

To examine the impact of the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (ACOG-SMFM) 2014 recommendations for preventing unnecessary primary Cesareans.

METHODS

In a population-based cohort of births in New York City from 2012 to 2016, we used controlled interrupted time series analyses to estimate changes in age-standardized Cesarean rates among nulliparous, term, singleton vertex (NTSV) deliveries.

RESULTS

Among 192,405 NTSV births across 40 hospitals, the age-standardized NTSV Cesarean rate decreased after the ACOG-SMFM recommendations from 25.8% to 24.0% (Risk ratio [RR]: 0.93; 95% CI 0.89, 0.97), with no change in the control series. Decreases were observed among non-Hispanic White women (RR: 0.89; 95% CI 0.82, 0.97), but not among non-Hispanic Black women (RR: 0.97; 95% CI 0.88, 1.07), Asian/Pacific Islanders (RR: 1.01; 95% CI 0.91, 1.12), or Hispanic women (RR: 0.94; 95% CI 0.86, 1.02). Similar patterns were observed at teaching hospitals, with no change at nonteaching hospitals.

CONCLUSIONS

While low-risk Cesarean rates may be modifiable through changes in labor management, additional research, and interventions to address Cesarean disparities, are needed.

Novel Evidence-Based Labor Induction Algorithm Associated with Increased Vaginal Delivery within 24 Hours

OBJECTIVE

This study aimed to assess whether concordance with our proposed labor induction algorithm is associated with an increased rate of vaginal delivery within 24 hours.

STUDY DESIGN

We conducted a retrospective review of 287 induction of labors (IOLs) at a single urban, tertiary, academic medical center which took place before we created an evidence-based IOL algorithm. We then compared the IOL course to the algorithm to assess for concordance and outcomes. Patients age 18 years or over with a singleton, cephalic pregnancy of 36^6/7 to 42^0/7 weeks' gestation were included. Patients were excluded with a Bishop's score >6, contraindication to misoprostol or cervical Foley catheter, major fetal anomalies, or intrauterine fetal death. Patients with 100% concordance were compared with <100% concordant patients, and patients with ≥80% concordance were compared with <80% concordant patients. Adjusted hazard ratios (AHRs) were calculated for rate of vaginal delivery within 24 hours, our primary outcome. Competing risk's analysis was conducted for concordant versus nonconcordant groups, using vaginal delivery as the outcome of interest, with cesarean delivery (CD) as a competing event.

RESULTS

Patients with 100% concordance were more likely to have a vaginal delivery within 24 hours, n = 66 of 77 or 85.7% versus n = 120 of 210 or 57.1% (p < 0.0001), with an AHR of 2.72 (1.98, 3.75, p < 0.0001) after adjusting for delivery indication and scheduled status. Patients with 100% concordance also had shorter time from first intervention to delivery (11.9 vs. 19.4 hours). Patients with ≥80% concordance had a lower rate of CD (11/96, 11.5%) compared with those with <80% concordance (43/191 = 22.5%; p = 0.0238). There were no differences in neonatal outcomes assessed.

CONCLUSION

Our IOL algorithm may offer an opportunity to standardize care, improve the rate of vaginal delivery within 24 hours, shorten time to delivery, and reduce the CD rate for patients undergoing IOL.

KEY POINTS

· Studies on IOL have focused on individual steps. A labor induction algorithm allows for standardization.. · Algorithm concordance is associated with decreased time to delivery.. · Algorithm concordance is associated with decreased CD rate..

Enhanced Recovery after Surgery Protocol to Improve Racial and Ethnic Disparities in Postcesarean Pain Management

OBJECTIVE

The objective of this study was to assess the efficacy of an enhanced recovery after surgery (ERAS) protocol and determine its effect on racial/ethnic disparities in postcesarean pain management.

STUDY DESIGN

We performed an institutional review board-approved retrospective cohort study of scheduled cesarean deliveries before and after ERAS implementation at a single urban academic institution. Pre-ERAS, all analgesic medications were given postoperatively on patient request. The ERAS protocol included preoperative acetaminophen and celecoxib. Postoperatively, patients received scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Oral oxycodone was available as needed, and opioid patient-controlled analgesia was eliminated from the standard order set. The primary outcome was total opioid use in the first 48 hours after cesarean, pre- and post-ERAS, reported in total milliequivalents of intravenous morphine (MME). A secondary analysis of opioid use and pain scores by racial groups was also performed. Chi-square, independent t-tests, analysis of variance, Mann-Whitney U, and Kruskal-Wallis tests were used depending on variable and data normality.

RESULTS

Pre-ERAS and post-ERAS groups included 100 women each. Post-ERAS, total opioid use in 48 hours was less (40.8 vs. 8.6 MME, p < 0.001) and visual analog scale (VAS) pain scores were lower on postoperative day 1 (POD1) and 2 (POD2) (POD1 maximum at rest: 6.7 vs. 5.3, p < 0.001). Pre-ERAS pain scores differed by race with non-Hispanic Black (NHB) patients reporting the highest mean and max VAS pain scores POD1 and POD2 (POD1, maximum VAS at rest: NHB-7.4, non-Hispanic White-6.6, Hispanic-5.8, Asian-4.4, p = 0.006). Post-ERAS, there were no differences in postoperative pain scores between groups with movement on POD1 and POD2.

CONCLUSION

A standardized ERAS protocol for postcesarean pain decreases opioid use and may improve some racial disparities in postcesarean pain control.

KEY POINTS

· ERAS protocols improve postoperative pain control and lower postoperative opioid use.. · Studies show that there are racial and ethnic disparities in postpartum pain control.. · Protocols standardize care and may decrease the effects of provider implicit bias..

Racial and ethnic disparities in the surgical management of tubal ectopic pregnancy

Objective

To evaluate racial and ethnic disparities in the surgical management of ectopic pregnancy over time.

Design

Retrospective cohort study.

Setting

None.

Patients

Surgically-managed cases of patients with tubal ectopic pregnancy within the American College of Surgeons National Surgical Quality Improvement Program database between 2010 and 2019.

Interventions

None.

Main outcome measures

Surgical approach (laparoscopic compared with open) and procedure (salpingectomy compared with salpingostomy/other).

Results

Of 7791 patients undergoing surgical management of tubal ectopic pregnancy, 21.8% identified as Hispanic, 24.5% as Black, 9.4% as Asian/other, and 44.3% as White. Use of laparoscopy increased 1.3% per year from 81.4% in 2010 to 91.0% in 2019 (95% confidence interval [CI], 0.010-0.016). Odds of undergoing laparoscopic surgery were lower in Black (adjusted odds ratio [aOR] 0.52; 95% CI, 0.45-0.61) and Hispanic patients (aOR 0.52; 95% CI, 0.44-0.61) compared with White patients and remained similar over time. The use of salpingectomy increased by 1.1% per year from 80.6% in 2010 to 94.7% in 2019 (95% CI, 0.009-0.014). Odds of undergoing salpingectomy were higher among Black (aOR 1.78, 95% CI 1.43-2.23) and Hispanic patients (aOR 1.54; 95% CI, 1.24-1.93) and lower among Asian patients (aOR 0.73, 95% CI, 0.56-0.95) compared with White patients. These ratios remained similar for Black and Asian patients over time.

Conclusions

Despite the increased use of laparoscopy and salpingectomy in the surgical management of ectopic pregnancy over time, Black and Hispanic patients remain less likely to undergo minimally invasive surgery and more likely to undergo salpingectomy compared with White patients.

Variation and racial/ethnic disparities in Caesarean delivery at New York City hospitals: The contribution of hospital-level factors

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.

From Research to Practice in OBGYN: How to Critically Interpret Studies in Implementation

There is a growing body of research that addresses implementation-focused questions within obstetrics and gynecology. With this document, we provide clinicians with the necessary tools to critically read and interpret literature evaluating an implementation endeavor. We describe the process of implementation research, as well as common study designs and outcomes. Furthermore, we detail pitfalls in the design and analysis of implementation studies, using examples within obstetrics and gynecology. Armed with this knowledge, clinicians may better be able to translate a paper on implementation into improvement efforts in their own clinical practice setting.

The relationship between obstetrical interventions and the increase in U.S. preterm births, 2014-2019

We examined the relationship between obstetrical intervention and preterm birth in the United States between 2014 and 2019. This observational study analyzed 2014-2019 US birth data to assess changes in preterm birth, cesarean delivery, induction of labor, and associated risks. Logistic regression modeled the odds of preterm obstetrical intervention (no labor cesarean or induction) after risk adjustment. The percentage of singleton preterm births in the United States increased by 9.4% from 2014-2019. The percent of singleton, preterm births delivered by cesarean increased by 6.0%, while the percent with induction of labor increased by 39.1%. The percentage of singleton preterm births where obstetrical intervention (no labor cesarean or induction) potentially impacted the gestational age at delivery increased from 47.6% in 2014 to 54.9% in 2019. Preterm interventions were 13% more likely overall in 2019 compared to 2014 and 17% more likely among late preterm births, after controlling for demographic and medical risk factors. Compared to non-Hispanic White women, Non-Hispanic Black women had a higher risk of preterm obstetric interventions. Preterm infants have higher morbidity and mortality rates than term infants, thus any increase in the preterm birth rate is concerning. A renewed effort to understand the trends in preterm interventions is needed to ensure that obstetrical interventions are evidence-based and are limited to those cases where they optimize outcomes for both mothers and babies.

Raising The Stakes To Advance Equity In Black Maternal Health

Penn Medicine has tied executive compensation to the goal of reducing birth-related complications.

Postpartum Outcomes With Systematic Treatment and Management of Postpartum Hypertension

OBJECTIVE

To test the ability of a hospital-wide, bundled quality-improvement initiative to improve postpartum maternal blood pressure control and adherence to postpartum follow-up among patients with hypertensive disorders of pregnancy.

METHODS

This quality-improvement initiative consisted of a bundle of clinical interventions including health care professional and patient education, a dedicated nurse educator, and protocols for postpartum hypertensive disorders of pregnancy care in the inpatient, outpatient and readmission setting. We implemented this initiative in patients with hypertensive disorders of pregnancy starting in January 2019 at the University of Chicago. The study period was divided into four periods, which correspond to preintervention, distinct bundle roll outs, and postintervention. Our primary outcome was postpartum hypertension visit adherence. Secondary outcomes included blood pressure values and antihypertensive medication use in the immediate postpartum and outpatient postpartum time periods. We then stratified our outcomes by race to assess whether the effect size differed.

RESULTS

A total of 926 patients who delivered between September 2018 and November 2019 were included. Postpartum hypertension visit adherence improved from preintervention period compared with the full implementation period (33.5% vs 59.4%, P<.001). Blood pressure in the first 24 hours postpartum decreased from preintervention compared with full implementation (preintervention median [interquartile range] systolic blood pressure 149 mm Hg [138, 159] vs 137 [131, 146] in postimplementation; P<.001). After implementation, fewer patients experienced a blood pressure of 140/90 mm Hg or higher at the first postpartum blood pressure check, when compared with preintervention (39.1% vs 18.5%, P=.004). The effect size did not differ by race.

CONCLUSION

A bundled quality-improvement initiative for patients with hypertensive disorders of pregnancy was associated with improved postpartum visit adherence and blood pressure control in the postpartum period.

Induction of labour in low-resource settings

Due to the disparity in resource availability between low- and high-resource settings, practice recommendations relevant to high-income countries are not always relevant and often need to be adapted to low-resource settings. The adaptation applies to induction of labour (IOL) which is an obstetric procedure that deserves special attention because it involves the initiation of a process that requires regular and frequent monitoring of the mother and foetus by experienced healthcare professionals. Lack of problem recognition and/or substandard care during IOL may result in harm with long-term sequelae. In this article, the authors discuss unique challenges such as insufficient resources (including staff, midwives, doctors, equipment, and medications) that result in occasional inadequate patient monitoring and/or delayed interventions during IOL in low-resource settings. We also discuss modifications in indications and methods for IOL, issues related to human immunodeficiency virus (HIV) infections, the feasibility of outpatient induction, clinical protocols and a minimum dataset for quality improvement projects. Overall, the desire to achieve a vaginal birth with IOL should not cloud the necessity to observe the required safety measures and implement necessary interventions; given that childbirth practices are the major determinants of pregnancy outcomes and patient satisfaction.

Rethinking Bias to Achieve Maternal Health Equity: Changing Organizations, Not Just Individuals

To reduce and eliminate Black–White maternal health disparities, we must enact solutions that address systemic biases.

In this article, we address the limitations of existing implicit bias interventions as a strategy for achieving maternal health equity. We then focus on how institutionally sanctioned racial stereotyping harms Black maternal health and marginalizes a key group in the fight for health equity—Black physicians. Finally, we provide strategies to address racial bias in perinatal health care and structural barriers impeding Black physicians' success.

The Role of Labor Induction in Racial Disparities in Cesarean Delivery

We examined the interaction between race and labor induction in cesarean delivery in a cohort of 600,000 deliveries in the Cerner Health Facts database. Black women had higher likelihood cesarean (28.9 vs. 26.5%) and lower likelihood of induction of labor at delivery compared to white women (27.2 vs. 32.5%). Induction modified the association between race and cesarean-Black women (odds ratio=1.36, 95% confidence interval 1.30, 1.43) who were induced had significantly increased odds of cesarean delivery.