Advances in Maternal Fetal Medicine: Perinatal Quality Collaboratives Working Together to Improve Maternal Outcomes

A Mixed Methods Evaluation of a Quality Improvement Model to Optimize Perinatal and Primary Care in the Community Health Setting

PURPOSE

Many maternal deaths occur beyond the acute birth encounter. There are opportunities for improving maternal health outcomes through facilitated quality improvement efforts in community settings, particularly in the postpartum period. We used a mixed methods approach to evaluate a collaborative quality improvement (QI) model in 6 Chicago Federally Qualified Health Centers (FQHCs) that implemented workflows optimizing care continuity in the extended postpartum period for high-risk prenatal patients.

METHODS

The Quality Improvement Learning Collaborative focused on the implementation of a registry of high-risk prenatal patients to link them to primary care and was implemented in 2021; study data were collected in 2021-2022. We conducted a quantitative evaluation of FQHC-reported aggregate structure, process, and outcomes data at baseline (2020) and monthly (2021). Qualitative analysis of semistructured interviews of participating FQHC staff focused on the experience of participating in the collaborative.

RESULTS

At baseline, none of the 6 participating FQHCs had integrated workflows connecting high-risk prenatal patients to primary care; by the end of implementation of the QI intervention, such workflows had been implemented at 19 sites across all 6 FQHCs, and 54 staff were trained in using these workflows. The share of high-risk patients transitioned to primary care within 6 months of delivery significantly increased from 25% at baseline to 72% by the end of implementation. Qualitative analysis of interviews with 11 key informants revealed buy-in, intervention flexibility, and collaboration as facilitators of successful engagement, and staffing and data infrastructure as participation barriers.

CONCLUSIONS

Our findings show that a flexible and collaborative QI approach in the FQHC setting can help optimize care delivery. Future evaluations should incorporate the patient experience and patient-level data for comprehensive analysis.

Increasing Access to Contraception: Examining Barriers and Facilitators of Long-Acting Reversible Contraception

Objective(s): To identify barriers and facilitators related to reimbursement processes, device acquisition costs, stocking, and supply of long-acting reversible contraception (LARC) from 27 jurisdictions (26 states/1 territory) participating in the Increasing Access to Contraception Learning Community from 2016 to 2018. Materials and Methods: A descriptive study using qualitative data collected through 27 semistructured key informant interviews was conducted during the final year of the learning community among all jurisdictional teams. Excerpts were extracted and coded by theme, then summarized as barriers or facilitators using implementation science methods. Results: Most jurisdictions (89%) identified barriers to reimbursement processes, device acquisition, stocking, and supply of LARC devices, and 85% of jurisdictions identified facilitators for these domains. Payment methodology challenges and lack of billing and coding processes were identified as the most common barriers to reimbursement processes. Device acquisition cost challenges and lack of delivery facility protocols for billing were the most common barriers to device acquisition, stocking, and supply of LARC. The most common facilitator of reimbursement processes was expanded payment methodology options, whereas supplemental funding for acquisition costs and protocol development were identified as the most common facilitators of device acquisition, stocking, and supply. Conclusion: Revised payment methodologies and broader health systems changes including additional funding sources and protocols for billing, stocking, and supply were used by learning community jurisdictions to address identified barriers. The learning community framework offers a forum for information exchange, peer-to-peer learning, and sharing of best practices to support jurisdictions in addressing identified barriers and facilitators affecting contraception access.

Increasing access to quality care for pregnant and postpartum people with opioid use disorder: Coordination of services, provider awareness and training, extended postpartum coverage, and perinatal quality collaboratives

INTRODUCTION

Fifteen states participating in the Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community (OMNI LC) developed action plan goals and activities to address the rise in opioid use disorder (OUD) among birthing persons. In a separate initiative, Perinatal Quality Collaboratives (PQCs) from 12 states participating in Centers for Disease Control and Prevention (CDC)-supported activities hosted trainings to improve the provision of OUD services and implement protocols for screening and treatment in delivery facilities.

METHODS

This descriptive study synthesizes qualitative data extracted from 15 OMNI LC state action plans, excerpts from qualitative interviews conducted with OMNI LC state teams, and quantitative data from quarterly project performance monitoring reports from 12 CDC-funded PQCs implementing quality improvement activities to address clinical service gaps for pregnant and postpartum people with OUD. Qualitative data were deidentified, coded as barriers or facilitators, then aggregated into emergent themes. Count data are presented for quantitative results.

RESULTS

The OMNI LC states identified a lack of coordinated care among providers, stigma toward people with OUD, discontinued insurance coverage, and inconsistencies in screening and treating birthing people with OUD as barriers to accessing quality care. State-identified facilitators for access to quality care included: 1) improving engagement and communication between providers and other partners to integrate medical and behavioral health services post-discharge, and facilitate improved patient care postpartum; 2) training providers to prescribe medications for OUD, and to address bias and reduce patient stigma; 3) extending Medicaid coverage up to one year postpartum to increase access to and continuity of services; and 4) implementing screening, brief intervention, and referral to treatment (SBIRT) in clinical practice. PQCs demonstrated that increased provider trainings to treat OUD, improvements in implementation of standardized protocols, and use of evidence-based tools can facilitate access to and coordination of services in delivery facilities.

CONCLUSION

State-identified facilitators for increasing access to care include coordinating integrated services, extending postpartum coverage, and provider trainings to improve screening and treatment. PQCs provide a platform for identifying emerging areas for quality improvement initiatives and implementing clinical best practices to provide comprehensive, quality perinatal care for birthing populations.

Strategies to Promote Maternal Health Equity: The Role of Perinatal Quality Collaboratives

Perinatal quality improvement is a method to increase obstetric safety and promote health equity. Increasing trends of maternal deaths, life-threatening complications of pregnancy, and persistent racial inequities are unacceptable. This Narrative Review examines the role and strategies of perinatal quality initiatives and collaboratives to deliver safe and equitable maternity care and the evidence of demonstrated success. Key strategies to promote maternal equity through perinatal quality include communicating equity as a priority through leadership, leveraging data and enhancing surveillance, engaging in strategic partnerships, engaging community, educating clinicians, and implementing practice recommendations through collaboration.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas

BACKGROUND AND OBJECTIVE

The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas.

METHODS

In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation.

RESULTS

Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001).

CONCLUSIONS

Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Examining changes in clinical management and postpartum readmissions for hypertensive disorders of pregnancy over time

OBJECTIVE

In response to 2013 guidelines for hypertensive disorders of pregnancy (HDP), our study examined changes in antenatal management and postpartum readmission (PPR) over time.

STUDY DESIGN

This is a retrospective cohort study of individuals diagnosed antenatally with HDP who delivered at a tertiary care center from 2012 to 2017.

MAIN OUTCOME MEASURES

The primary outcome was postpartum readmission for HDP in 2012-2013 vs 2014-2017. Secondary outcomes included intravenous magnesium administration and prescription for oral (PO) antihypertensive medication during delivery admission. Multivariable logistic regression models assessed differences in outcomes over time, adjusted for age, race, and payer status, for HDP with and without severe features, defined by ACOG criteria.

RESULTS

Of 5,300 eligible individuals, 73.5 % had HDP without severe features and 26.5 % had severe features. The PPR frequency in this cohort was 1.1 % (N = 59). There was no difference in PPR for individuals with HDP without severe features (aOR 0.73; 95 % CI 0.28-1.88) or with severe features (aOR 1.30; 95 % CI 0.50-3.39) by epoch. Magnesium administration for HDP with severe features remained below 80 % over time. Magnesium administration for HDP without severe features and discharge prescriptions for PO medications for HDP with severe features were lower after 2013. Neither magnesium administration nor discharge prescriptions were associated with decreased odds of PPR.

CONCLUSION

Although there was no difference in PPR for HDP after 2013, there were changes in antenatal management of HDP, including decreased magnesium administration for individuals with HDP without severe features and PO medication for individuals with severe features.

How State Perinatal Quality Collaboratives Can Improve Rural Maternity Care

Perinatal Quality Collaboratives (PQCs) are now present in nearly all states and provide important tools and strategies for improving maternal outcomes. State PQCs can focus their strengths to address rural maternal health challenges using support groups of rural hospitals, of tertiary facilities that network with them, and of other PQCs to share best practices for rural hospitals to: (1) Support networks of care and telehealth; (2) Support remote education and training; (3) Implement rural appropriate versions of National Safety Bundles; (4) Engage and support providers beyond obstetricians; and (5) Engage community members and resources.

Intrapartum cardiotocography: an exploratory analysis of interpretational variation

Our aim was to evaluate the intra- and inter-operator agreement in cardiotocography (CTG) traces analysis using the 2015 FIGO classification guidelines, and whether the educational background and the knowledge of anamnestic data can influence the interpretation of CTG traces. A retrospective interpretation of 73 intrapartum CTGs at time 0 (T0) for a first blind interpretation and at time 1 (T1) two months later with additional anamnestic pregnancy information was made by eight different operators (four obstetricians and four midwives with different years of work experience). The intra-observer agreement demonstrates that midwifes are more concordant than obstetricians with a mean of 77.05% versus a mean of 65.75%. There is moderate inter-observer agreement in classifying a CTG trace as 'normal'; on the contrary, there is no consensus on the 'suspect' and 'pathological' classification category.IMPACT STATEMENTWhat is already known on this subject? Interpretation of intrapartum CTG is affected by significant subjective variables with relevant intra- and inter-observer lack of optimal agreement, especially in case of abnormal o pathologic findings.What do the results of this study add? Clinical data seem to play a role in interpretation of suspicious and pathological traces while they do not affect the rate of agreement for normal traces. Midwives tend to be less influenced by anamnestic data in visual CTG interpretation. Instead, obstetricians tend to be more focussed on clinical data and clinical setting that, as a consequence, tend to have great impact on CTG trace interpretation.What are the implications of these findings for clinical practice and/or further research? Cooperation among obstetricians and between obstetricians and midwives should be encouraged in order to optimise CTG reading and improve maternal and neonatal outcomes. Regarding the influence of clinical parameters in classification of intrapartum CTG traces, especially in case of abnormal CTG traces, it should be conceivable to improve medical skills in CTG blind interpretation and further investigate which clinical parameters are mainly related with an augmented risk of foetal asphyxia and adverse neonatal outcomes.

Perinatal quality collaboratives and birth equity

PURPOSE OF REVIEW

The purpose of this review is to discuss how state perinatal quality collaboratives are addressing birth equity to reduce disparities in maternal morbidity and mortality.

RECENT FINDING

Perinatal quality collaboratives are adopting core practices to advance birth equity, reduce disparities and confront racism and bias in obstetric care including securing leadership commitments to equity, providing education on the causes of inequities and mitigation strategies, collecting accurate race/ethnicity data, addressing social determinants of health, and integrating patient and community knowledge, experiences, and narratives in the quality improvement work.

SUMMARY

Inequities in maternal morbidity and mortality particularly affecting Black birthing people are driven by racism, inequities in the social determinants of health, and variations in care practices and quality. Perinatal quality collaboratives are an important resource for driving improvement changes to mitigate these factors and improve outcomes.

VIDEO ABSTRACT

Mason CL, Collier CH, Penny SC. Perinatal Quality Collaboratives and Birth Equity. Produced by CLMB Productions for use in this publication. January 10, 2022, http://links.lww.com/COAN/A86.

Delivery Complications and Postpartum Hospital Use in California

INTRODUCTION

Research on maternal birth outcomes rarely includes postpartum complications with longitudinally linked patient data. We analyze characteristics associated with delivery complications and postpartum hospital use.

METHODS

This population-based cohort study is based on administrative data from California. International Classification of Diseases, 10th Revision, codes were used to categorize the incidence of severe maternal morbidity and other route-specific delivery complications as well as preexisting and pregnancy-related conditions and principal diagnoses for postpartum hospital visits. Postpartum hospital use is a composite outcome defined as emergency department visit or hospital readmission within 90 days of birth admission discharge. Multivariable modified Poisson regression analyses were used to estimate the association of patient-level and hospital-level characteristics with the likelihood of postpartum hospital use.

RESULTS

In 2017, 457,498 birth admissions occurred in California-licensed hospitals, of which 348,828 index births with linked data were analyzed. Among linked births, 34,825 (10.0%) had an inpatient admission (4,206 [1.2%]) or an emergency department visit (30,371 [9.2%]) within 90 days of birth admission discharge. Birth complications included a 1.7% severe maternal morbidity rate, 7.9% rate of vaginal birth complications, 10.0% rate of cesarean birth complications, and 2.9% frequency of long lengths of stay, all of which were significantly associated with postpartum hospital use. Other significant risk factors for postpartum hospital use were preexisting and pregnancy-related conditions, undergoing cesarean birth, being younger than 18 years old, being non-Hispanic Black, living in a high poverty ZIP code, and having Medicaid.

CONCLUSION

One in 10 birthing persons had a hospital visit within 90 days postpartum. Improving postpartum care is an urgent public health priority.

Antepartum hospital use and delivery outcomes in California

BACKGROUND

There are few population-based studies of antepartum emergency department visits and inpatient hospitalizations and their implications for delivery outcomes.

OBJECTIVE

The study aimed to analyze the likelihood of pregnant patients's antepartum hospital use using population-based hospital discharge data for births in California. The study analyzed associations between antepartum hospital use and the likelihood of maternal delivery complications and postpartum hospital use.

STUDY DESIGN

This was a population-based retrospective cohort study of individuals with live births in state-licensed hospitals in California in 2017. Delivery admissions data were linked to antepartum hospital visits within 280 days of a delivery admission and 90 days after a delivery discharge. The most common principal or primary International Classification of Diseases, Tenth Revision-coded diagnoses for antepartum emergency department visits and inpatient hospitalizations were identified and Poisson regression estimates were used to determine the likelihood of antepartum hospital use by maternal demographic and clinical characteristics. Complicated deliveries were defined by International Classification of Diseases, Tenth Revision-coded severe maternal morbidity, vaginal or cesarean delivery complications, or long length of stay after delivery (>4 days for a vaginal delivery and >5 days for a cesarean delivery). Associations between specific types of antepartum visits, complicated deliveries, and postpartum hospital use were analyzed by chi-square tests. Logistic regression estimates were used to determine the significance of associations between antepartum hospital use and likelihood of a complicated delivery.

RESULTS

Of 348,848 deliveries at 246 hospitals in California, in 2017, with linkable data, almost one-third of the patients (30.4% with emergency department visits and 1.2% with inpatient hospital stays) experienced antepartum hospital use. Those who were younger, identified as a racial or ethnic minority, and with a low income, were the most likely to have antepartum hospital use. The most common primary diagnoses for antepartum emergency department visits were threatened abortions (19.6%), urinary tract infections (11.2%), and hemorrhage (9.3%). The most common principal diagnoses for antepartum hospitalizations were preterm labor (14.3%), pyelonephritis (10.2%), and hyperemesis gravidarum (6.3%). Patients with any antepartum hospital use were significantly more likely to experience a delivery complication, even after controlling for conditions coded during the delivery admission. Although having an antepartum emergency department visit was associated with only modestly increased adjusted odds (odds ratio, 1.04; 95% confidence interval, 1.01-1.08) of a complicated delivery, patients with any antepartum hospitalizations, especially those with preterm prelabor rupture of membranes, hypertension, diabetes, or hemorrhage, were at higher risk (odds ratio, 1.38; 95% confidence interval, 1.28-1.47).

CONCLUSION

Antepartum hospital use is frequent and is associated with patient clinical and demographic factors. Addressing the high prevalence of antepartum hospital use should be a part of future quality improvement and health equity efforts focused on improving care for patients with the greatest medical and social needs.