Assessing Quality in Obstetrical Care: Development of Standardized Measures

Integrating Maternity Care Through Bundled Payments In The Netherlands: Early Results And Policy Lessons

Bundled payments are increasingly used globally to move health care delivery in a value-based direction. However, evidence remains scant in key clinical areas. We evaluated bundled payments for maternity care in the Netherlands during the period 2016-18. We used a quasi-experimental difference-in-differences design to measure the association between the bundled payment model and changes in key clinical and economic outcomes. Bundled payments were associated with an increase in outpatient, midwife-led births and a reduction in in-hospital, obstetrician-led births, along with changes in the use of labor inductions and planned versus emergency cesarean deliveries. Total spending on maternity care decreased by US$328 (5 percent) per pregnancy. No changes in maternal or neonatal health outcomes were observed. Several policy lessons emerged. First, bundled payments appeared to help affect providers' behavior in the maternity care setting. Second, bundled payments seemed to exert heterogeneous effects across participating maternity care networks, as the same financial incentive translated into different changes in clinical practices and outcomes. Third, alternative payment models should be designed with clear goals and definitions of success to guide evaluation and implementation.

A call for safety: Anticipating and mitigating risk across an obstetrics and gynecology service line

Delivery of healthcare is a complex interaction of patients, healthcare providers, nurses, ambulatory practices, and hospitals. As the model of health care transitioned, free standing physician practices and hospitals have coalesced to form networks of ambulatory practices and hospitals. This change in the model of healthcare delivery presented challenges to provide safe, quality, cost-effective care for patients, with potentially increased risk to an organization. The development and imbedding of comprehensive safety strategies are imperative to the foundation of this model. Northwell Health, a large health system in the northeastern United States developed a strategy for their Obstetrics and Gynecology Service Line which includes weekly interaction by departmental leadership from each hospital to discuss operations, share concerns and identify potential opportunities to prevent recurrent suboptimal outcomes and improve patient safety. The weekly Safety Call, described in this article is a component of the safety and quality program that has contributed to a 19% decrease in the Weighted Adverse Outcomes Index for the 10 maternity hospitals delivering over 30,000 babies annually within the system since inception. There was also a significant reduction in insurance premiums based on actuarial projections of risk reduction because of the implementation of an Obstetrical Safety Program.

Maternal mortality in the city of Berlin: consequences for perinatal healthcare

OBJECTIVES

The fifth of the United Nations' Millennium Development Goals proposed for 2000-2015 was to improve maternal health, which has only partially been achieved. Worldwide, the maternal mortality ratio is currently estimated at 216/100.000 livebirths, compared to 380/100,000 in 1990. As yet, there has been no published comprehensive analysis of maternal mortality data as it pertains to Berlin and by extension Germany. Aim of the study was to evaluate and analyze the maternal mortality rate of Berlin as a result of shortcomings in healthcare provision and identify possible solutions.

METHODS

The Institute for Quality and Transparency in the Healthcare Sector sourced external quality control from the Qualitätsbüro Berlin to provide maternal mortality data from Berlin hospitals from 2007 to 2020.

RESULTS

Nineteen maternal deaths were registered between 2007 and 2020 in total. Case analysis shows that two main events occur: thrombosis and hemorrhage at 31.6%, respectively, followed by hypertensive disorder (15.8%), and sepsis (15.8%). After detailed analysis of each case report, we determined 8/19 (42.1%) maternal deaths as being potentially preventable given slightly altered circumstances.

CONCLUSIONS

The system of registration of perinatal data in Germany does not allow for a comprehensive recording of maternal death and requires alteration to provide a more accurate picture of the phenomenon of maternal mortality; presumably, there exist twice as many unreported cases. Symptoms, risks, and primary prevention tactics of thromboembolism during pregnancy and birth should be imparted to every licensed professional in individual hospital settings, along with evidence-based simulation training for the event of obstetric or prepartum hemorrhage.

Obstetric Safety and Quality at Istishari Arab Hospital: Where Are We Now and How Can We Improve

Background: Indicators for tracking progress in maternal and newborn health have been recommended by a number of global monitoring initiatives. Quality of care is increasingly recognized as an important aspect of maternal and newborn health, particularly in the labor and delivery and immediate postnatal period. Objectives: The purpose of this study is to estimate the frequency of obstetric complications. Furthermore, in 2018, Istishari Arab Hospital assessed the safety and quality of obstetrical procedures. Identifying risk factors that contributed to adverse events in the obstetric department. Methods: A retrospective study is dependent on the use of electronic medical records from inpatient hospitals. Research was conducted in the field of inquiry in an electronic database, as well as related studies. Maternal morbidity and adverse outcomes were identified using diagnosis and procedure codes from the International Classification of Diseases, 10th Revision (ICD-10-CM) within the health information system. Aside from the paper files. SPSS was used for descriptive, univariate, and multivariate analysis. Results This study included 418 women, with 62.2 percent of them having their babies delivered by CS. The average age of the women in this study was 27.84.8 years, with 58.1 percent of them coming from Ramallah. Following a multivariate analysis using logistic regression, our study discovered a positive correlation with P-value 0.05 between educational level and prior CS on one side and surgical site infection on the other. Furthermore, our study found a link between the rate of CS on one side and maternal age, diabetes, hypertension, and gynecological factors on the other (prematurity, multiple gestation). Conclusion: Regardless of the number, patients with a lower education level or a history of CS have a higher risk of surgical site infection and other complications. By focusing on these factors and increasing awareness and education, we may be able to reduce obstetric complications in the future.

Association between weighted adverse outcome score and race/ethnicity in women and neonates

OBJECTIVE

To examine the association between the Weighted Adverse Outcome Score (WAOS) and race/ethnicity among a large and diverse population-based cohort of women and neonates in the United States.

STUDY DESIGN

This was a retrospective cohort study of women who delivered in the United States between 2011 and 2013. We identified mother-infant pairs with adverse maternal and/or neonatal outcomes. These outcomes were assigned weighted scores to account for relative severity. The association between race/ethnicity and WAOS was examined using chi-square test and multivariable logistic regression.

RESULTS

Compared to White women and their neonates, Black women and their neonates were at higher odds of an adverse outcome.

CONCLUSION(S)

The vast majority of women and neonates had no adverse outcome. However, Black women and their neonates were found to have a higher WAOS. This tool could be used to designate hospitals or regions with higher-than-expected adverse outcomes and target them for intervention.

Rating the seriousness of maternal and child health outcomes linked with pregnancy weight gain

BACKGROUND

Current pregnancy weight gain guidelines were developed based on implicit assumptions of a small group of experts about the relative seriousness of adverse health outcomes. Therefore, they will not necessarily reflect the values of women.

OBJECTIVE

To estimate the seriousness of 11 maternal and child health outcomes that have been consistently associated with pregnancy weight gain by engaging patients and health professionals.

METHODS

We collected data using an online panel approach with a modified Delphi structure. We selected a purposeful sample of maternal and child health professionals (n = 84) and women who were pregnant or recently postpartum (patients) (n = 82) in the United States as panellists. We conducted three concurrent panels: professionals only, patients only, and patients and professionals. During a 3-round online modified Delphi process, participants rated the seriousness of health outcomes (Round 1), reviewed and discussed the initial results (Round 2), and revised their original ratings (Round 3). Panellists assigned seriousness ratings (0, [not serious] to 100 [most serious]) for infant death, stillbirth, preterm birth, gestational diabetes, preeclampsia, small-for-gestational-age (SGA) birth, large-for-gestational-age (LGA) birth, unplanned caesarean delivery, maternal obesity, childhood obesity, and maternal metabolic syndrome.

RESULTS

Each panel individually came to a consensus on all seriousness ratings. The final median seriousness ratings combined across all panels were highest for infant death (100), stillbirth (95), preterm birth (80), and preeclampsia (80). Obesity in children, metabolic syndrome in women, obesity in women, and gestational diabetes had median seriousness ratings ranging from 55 to 65. The lowest seriousness ratings were for SGA birth, LGA birth, and unplanned caesarean delivery (30-40).

CONCLUSION

Professionals and women rate some adverse outcomes as being more serious than others. These ratings can be used to establish the range of pregnancy weight gain associated with the lowest risk of a broad range of maternal and child health outcomes.

Birth outcomes following cesarean delivery on maternal request: a population-based cohort study

BACKGROUND

Data on the effect of cesarean delivery on maternal request (CDMR) on maternal and neonatal outcomes are inconsistent and often limited by inadequate case definitions and other methodological issues. Our objective was to evaluate the trends, determinants and outcomes of CDMR using an intent-to-treat approach.

METHODS

We designed a population-based retrospective cohort study using data on low-risk pregnancies in Ontario, Canada (April 2012-March 2018). We assessed temporal trends and determinants of CDMR. We estimated the relative risks for component and composite outcomes used in the Adverse Outcome Index (AOI) related to planned CDMR compared with planned vaginal delivery using generalized estimating equation models. We compared the Weighted Adverse Outcome Score (WAOS) and the Severity Index (SI) across planned modes of delivery using analysis of variance.

RESULTS

Of 422 210 women, 0.4% (n = 1827) had a planned CDMR and 99.6% (n = 420 383) had a planned vaginal delivery. The prevalence of CDMR remained stable over time at 3.9% of all cesarean deliveries. Factors associated with CDMR included late maternal age, higher education, conception via in vitro fertilization, anxiety, nulliparity, being White, delivery at a hospital providing higher levels of maternal care and obstetrician-based antenatal care. Women who planned CDMR had a lower risk of adverse outcomes than women who planned vaginal delivery (adjusted relative risk 0.42, 95% confidence interval [CI] 0.33 to 0.53). The WAOS was lower for planned CDMR than planned vaginal delivery (mean difference -1.28, 95% CI -2.02 to -0.55). The SI was not statistically different between groups (mean difference 3.6, 95% CI -7.4 to 14.5).

INTERPRETATION

Rates of CDMR have not increased in Ontario. Planned CDMR is associated with a decreased risk of short-term adverse outcomes compared with planned vaginal delivery. Investigation into the long-term implications of CDMR is warranted.

Enhanced Recovery After Cesarean: Current and Emerging Trends

Purpose of Review

What are the latest enhanced recovery elements for cesarean delivery?

Recent Findings

Enhanced recovery after cesarean delivery (ERAC) provides an evidenced-based system to improve maternal outcomes, functional recovery, maternal-infant bonding, and patient experience. Postsurgical recovery has evolved from a one-dimensional pain score to a holistic multidimensional approach emphasizing faster functional recovery. ERAC involves multidisciplinary efforts of the anesthesiologist, obstetrician, nursing, hospital, and patient. Components of ERAC include preoperative patient education, limited fasting, carbohydrate load, limiting opioids intra- and postoperatively, using scheduled non-opioid analgesics and supplementing with advanced therapies for women at higher risk for pain. ERAC protocols reduce opioid consumption, reduce length of stay, and improve maternal and neonatal outcomes.

Summary

Implementing ERAC standardized care will likely be the most important change you can make in your practice to improve outcomes, improve quality care, help address racial disparities, and minimize opioid exposure and potential for addiction.

Adverse obstetric outcomes in two Brazilian maternity hospitals

PURPOSE

Obstetric adverse outcomes (AOs) are an important topic and the use of composite measures may favor the understanding of their impact on patient safety. The aim of the present study was to estimate AO frequency and obstetric care quality in low and high-risk maternity hospitals.

DESIGN/METHODOLOGY/APPROACH

A one-year longitudinal follow-up study in two public Brazilian maternity hospitals. The frequency of AOs was measured in 2,880 randomly selected subjects, 1,440 in each institution, consisting of women and their newborn babies. The frequency of 14 AOs was estimated every two weeks for one year, as well as three obstetric care quality indices based on their frequency and severity as follows: the Adverse Outcome Index (AOI), the Weighted Adverse Outcome Score and the Severity Index.

FINDINGS

A significant number of mothers and newborns exhibited AOs. The most prevalent maternal AOs were admission to the ICU and postpartum hysterectomy. Regarding newborns, hospitalization for > seven days and neonatal infection were the most common complications. Adverse outcomes were more frequent at the high-risk maternity, however, they were more severe at the low-risk facility. The AOI was stable at the high-risk center but declined after interventions during the follow-up year.

ORIGINALITY/VALUE

High AO frequency was identified in both mothers and newborns. The results demonstrate the need for public patient safety policies for low-risk maternity hospitals, where AOs were less frequent but more severe.

Engaging Patients and Professionals to Evaluate the Seriousness of Maternal and Child Health Outcomes: Protocol for a Modified Delphi Study

BACKGROUND

Maternal weight gain during pregnancy is one of the few potentially modifiable risk factors for many adverse maternal and child health outcomes. Defining the optimal pregnancy weight gain range is difficult because, while lower weight gain may prevent some outcomes, such as maternal and child obesity, it may increase the risk of others such as fetal growth restriction and infant death. These health outcomes vary in their seriousness to mothers and their health care providers, and these differences in seriousness should be taken into account when determining optimal weight gain ranges. However, the relative seriousness that women and their care providers place on different health outcomes is unknown.

OBJECTIVE

We will determine the seriousness of 11 maternal and child health outcomes that have been consistently associated with pregnancy weight gain. We will achieve this by engaging patients and maternal and child health professionals using an online modified Delphi panel process.

METHODS

We aim to recruit a racially/ethnically and geographically diverse group of 90 US maternal and child health professionals and 90 women who are pregnant or less than 2 years postpartum. We will conduct 3 concurrent panels using the ExpertLens system, a previously evaluated online modified Delphi system that combines 2 rounds of rating with 1 round of feedback and moderated online discussion. In Round 1, panelists are asked to rate the seriousness of each health outcome on a scale of 0-100 and to provide a rationale for their scores. In Round 2, panelists will review their responses relative to those of other panelists. They will discuss their seriousness ratings anonymously using a moderated online discussion board. In Round 3, participants will revise their Round 1 responses based on group feedback and discussion. Each round will be open for 1-2 weeks.

RESULTS

The study protocol was reviewed by our ethics boards and did not require approval as human research. A pilot study of 6 professionals and 7 patients was completed in December 2019.

CONCLUSIONS

Our numeric estimates of the seriousness of maternal and child health outcomes will enable future studies to determine pregnancy weight gain ranges that balance the risks of low and high weight gain for mothers and children.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/16478.

Composite neonatal morbidity indicators using hospital discharge data: A systematic review

BACKGROUND

Neonatal morbidity is associated with lifelong impairments, but the absence of a consensual definition and the need for large data sets limit research.

OBJECTIVES

To inform initiatives to define standard outcomes for research, we reviewed composite neonatal morbidity indicators derived from routine hospital discharge data.

DATA SOURCES

PubMed (updated on October 12, 2018). The search algorithm was based on three components: "morbidity," "neonatal," and "hospital discharge data."

STUDY SELECTION AND DATA EXTRACTION

Studies investigating neonatal morbidity using a composite indicator based on hospital discharge data were included. Indicators defined for specific conditions (eg congenital anomalies, maternal addictions) were excluded. The target population, objectives, component morbidities, diagnosis and procedure codes, validation methods, and prevalence of morbidity were extracted.

SYNTHESIS

For each study, we assessed construct validity by describing the methods used to select the indicator components and evaluated whether the authors assessed internal and external validity. We also calculated confidence intervals for the prevalence of the morbidity composite.

RESULTS

Seventeen studies fulfilled inclusion criteria. Indicators targeted all (n = 4), low-/moderate-risk (n = 9), and very preterm (VPT, n = 4) infants. Components were similar for VPT infants, but domains and diagnosis codes within domains varied widely for all and low-/moderate-risk infants. Component selection was described for 8/17 indicators and some form of validation reported for 12/17. Neonatal morbidity prevalence ranged from 4.6% to 9.0% of all infants, 0.4% to 8.0% of low-/moderate-risk infants, and 17.8% to 61.0% of VPT infants.

CONCLUSIONS

Multiple neonatal morbidity indicators based on hospital discharge data have been used for research, but their heterogeneity limits comparisons between studies. Standard neonatal outcome measures are needed for benchmarking and synthesis of research results.

Exploring the applicability of the pregnancy and childbirth outcome set: A mixed methods study

OBJECTIVE

The International Consortium for Health Outcomes Measurement developed the Pregnancy and Childbirth (PCB) outcome set to improve value-based perinatal care. This set contains clinician-reported outcomes and patient-reported outcomes. We validated the set for use in the Netherlands by exploring its applicability among all end-users prior to implementation.

METHODS

A mixed-methods design was applied. A survey was performed to assess patients (n = 142), professionals (n = 134) and administrators (n = 35) views on the PCB set. To further explore applicability, separate focus groups were held with representatives of each of these groups.

RESULTS

The majority of survey participants agreed that the PCB set contains the most important outcomes. Patient-reported experience measures were considered relevant by the majority of participants. Perceived relevance of patient-reported outcome measures varied. Main themes from the focus groups were content of the set, data collection timing, implementation (also IT and transparency), and quality-based governance.

CONCLUSION

This study supports suitability of the PCB outcome set for implementation, evaluation of quality of care and shared decision making in perinatal care.

PRACTICE IMPLICATIONS

Implementation of the PCB set may change existing care pathways of perinatal care. Focus on transparency of outcomes is required in order to achieve quality-based governance with proper IT solutions.

A cluster-randomized field trial to reduce cesarean section rates with a multifaceted intervention in Shanghai, China

BACKGROUND

Cesarean section (CS) rate has risen dramatically and stayed at a very high level in China over the past two to three decades. Given the short- and long-term adverse effects of CS, effective strategies are needed to reduce unnecessary CS. We aimed to evaluate whether a multifaceted intervention would decrease the CS rate in China.

METHODS

We carried out a cluster-randomized field trial with a multifaceted intervention in Shanghai, China, from 2015 to 2017. A total of 20 hospitals were randomly allocated into an intervention or a control group. The intervention consisted of more targeted health education to pregnant women, improved hospital CS policy, and training of midwives/doulas for 8 months. The study included a baseline survey, the intervention, and an evaluation survey. The primary outcome was the changes of overall CS rate from the pre-intervention to the post-intervention period. A subgroup analysis stratified by the Robson classification was also conducted to examine the CS change among women with various obstetric characteristics.

RESULTS

A total of 10,752 deliveries were randomly selected from the pre-intervention period and 10,521 from the post-intervention period. The baseline CS rates were 42.5% and 41.5% in the intervention and control groups, respectively, while the post-intervention CS rates were 43.4% and 42.4%, respectively. Compared with the control group, the intervention did not significantly reduce the CS rate (adjusted OR = 0.92; 95% CI 0.73, 1.15). Similar results were obtained in subgroup analyses stratified by the risk level of pregnancy, maternal age, number of previous CS, or parity. Scarred uterus and maternal request remained the primary reasons for CS after the interventions in both groups. The intervention did not alter the perinatal outcomes (adjusted change of risk score = - 0.06; 95%CI - 0.43, 0.31).

CONCLUSIONS

A multifaceted intervention including more targeted prenatal health education, improved hospital CS policy, and training of midwives/doulas, did not significantly reduce the CS rate in Shanghai, China. However, our experience in implementing a multifaceted intervention may provide useful information to other similar areas with high CS use.

TRIAL REGISTRATION

This trial was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn) (ChiCTR-IOR-16009041) on 17 August 2016.

Multicentre cross-sectional study on adverse events and good practices in maternity wards in Brazil and Mexico: same problems, different magnitude

OBJECTIVE

To evaluate the quality of delivery care in maternity wards in Brazil and Mexico based on good practices (GP) and adverse events (AE), in order to identify priorities for improvement.

DESIGN

A multicentre cross-sectional study with data collection from medical records between 2015 and 2016 to compare indicators of maternal and neonatal GP and EA based on the Safe Childbirth Checklist and standardised obstetric quality indicators. Two Brazilian and five Mexican maternity wards participated in the study. Descriptive statistics and χ² tests were performed to assess performance and significant differences between the hospitals investigated.

SAMPLING

We analysed 720 births in Brazil and 2707 in Mexico, which were selected using a systematic random sampling of 30 medical records every fortnight for 12 2-week periods in Brazil and 18 2-week periods in Mexico. We included women and their newborns, excluding those with congenital malformations.

RESULTS

The Mexican hospitals showed greater adherence to GP (58.2%) and a lower incidence of AE (12.9%) than the participating institutions in Brazil (26.8% compliance with GP and 16.0% AE). In spite of these differences, the relative importance of particular quality problems and type of AE are similar in both countries. Tertiary hospitals, caring for women at higher risk, have significantly (p<0.001) higher rates of AE (27.2% in Brazil and 29.6% in Mexico) than institutions attending women at lower risk, where the frequency of AE ranges from 4.7% to 11.2%. Differences were significant (p<0.001) for most indicators of GP and AE.

CONCLUSION

Data from outcome and process measures revealed similar types of failures in the quality of childbirth care in both countries and indicate the need of rationalising the use of antibiotics for the mother and episiotomy, encouraging greater adherence to partograph and to the use of magnesium sulfate for the treatment of severe preeclampsia/eclampsia.

A multidisciplinary approach to improving process and outcomes in unscheduled cesarean deliveries

BACKGROUND

Effective communication between providers of various disciplines is crucial to the quality of care provided on labor and delivery. The lack of standardized language for communicating the clinical urgency of cesarean delivery and the lack of standardized processes for responding were identified as targets for improvement by the Obstetric Patient Safety Committee at the Hospital of the University of Pennsylvania. The committee developed and implemented a protocol aimed at improving the performance of our multidisciplinary team and patient outcomes.

OBJECTIVE

To evaluate whether implementation of a multidisciplinary protocol that standardizes the language and process for performing unscheduled cesarean deliveries had reduced the decision to incision interval and improved maternal and neonatal outcomes.

MATERIALS AND METHODS

This was a retrospective cohort study of patients who underwent unscheduled cesarean delivery pre- and postimplementation of a protocol standardizing language, communication, provider roles, and processes. The primary outcome was cesarean decision to incision interval overall and stratified by fetal and nonfetal indications for delivery. Secondary outcomes included decision to operating room and operating room to incision intervals, operative complications, use of general anesthesia, maternal transfusion, 5-minute Apgar score <6, and umbilical cord arterial pH <7.2. Descriptive statistics were calculated. Continuous variables were tested for normality and compared using the Student t test or Mann-Whitney U test as appropriate. Categorical variables were characterized by proportions and compared by the χ² or Fisher exact test as appropriate.

RESULTS

There were 121 and 119 subjects in the pre-and postimplementation groups respectively, collected from corresponding 3-month periods. There were no significant differences in demographics, comorbidities, or indications for cesarean delivery between groups. Overall median decision to incision interval did not differ between the pre- and postimplementation groups. There was a significant decrease in median decision to incision interval (63 versus 50 minutes, P = .02) in cesarean deliveries performed for nonfetal indications. This was driven by a shorter median decision to operating room interval (32.5 versus 23 minutes, P = .01). The incidences of operative complications (35% [19/55] versus 11% [6/53], P < .01) and cord pH <7.2 (36% [20/55] versus 17% [9/53], P = .02) were also decreased in cesarean deliveries performed for nonfetal indications. The incidences of general anesthesia, maternal transfusion, and 5-minute Apgar score <6 did not differ. Outcomes did not differ between the pre- and postimplementation groups in cesarean deliveries performed for fetal indications.

CONCLUSION

Implementation of a multidisciplinary process improvement protocol that standardizes language, roles, and processes for unscheduled cesarean deliveries was associated with a reduced decision to incision interval and improved maternal and neonatal outcomes in cesarean deliveries performed for nonfetal indications. Standardized process implementation on labor and delivery has the potential to improve patient outcomes.

Development of the Labor and Delivery Outcome Scale (LDOS): Validity and reliability of an intrapartal measurement tool for research use in developed nations

Despite numerous scholarly attempts to understand and improve the health outcomes of childbearing in highly technical, developed countries, a theoretical and methodological deficit persists in regard to capturing a woman and her newborn's intrapartal experience. In an effort to construct a criterion measure and research tool that is not limited to one or two aspects of the labor and delivery experience, the authors created the Labor and Delivery Outcome Scale (LDOS). The LDOS survey was mailed to a nationwide, random sample of 1500 experienced U.S. accoucheurs, including nurse-midwives, family practice physicians, and obstetricians, and they were asked to rate 102 physiological and psychosocial events and outcomes along a Likert scale regarding their relationship to the overall intrapartal experience. The goal of this forced-choice format was to have practitioners quantify the quality of individual labor and delivery experiences. The authors received a total of 391 questionnaires, representing an overall response rate of 26.1%. On a scale of -16 to +16 the scores ranged from -15.7 (SD = 1.5) for the outcome of infant born as fetal demise (stillbirth) to +12.6 (SD = 4.4) for active involvement of support person(s) in assisting woman during labor. Reliability of the instrument was demonstrated with a Cronbach's alpha score of r = 0.92. Criterion-related validity was established, since the LDOS scores were significantly related to type of delivery (vaginal versus Cesarean-section), Apgar scores at 1 and 5 min, gestational age, and the total number of labor and delivery complications experienced. The creation of the LDOS, and the subsequent testing of its reliability and validity as described here, has been an important step toward quantifying for research purposes the intrapartal experience of women in highly technical, developed countries. Potential uses for the LDOS are discussed.

Effect of implementation of the MOREOB program on adverse maternal and neonatal birth outcomes in Ontario, Canada: a retrospective cohort study

Background

In 2002, the MORE^OB (Managing Obstetrical Risk Efficiently) obstetrical patient safety program was phased-in across hospitals in Ontario, Canada. The purpose of our study was to evaluate the effect of the MORE^OB program on rates of adverse maternal and neonatal outcomes.

Methods

A retrospective cohort study, using province-wide administrative hospitalization data. We included maternal and neonatal records between fiscal years 2002–2003 and 2013–2014, for deliveries taking place at the 67 Ontario hospitals where the MORE^OB program was implemented between 2002 and 2012. After accounting for institutional mergers and excluding very small hospitals, 55 hospitals (1,447,073 deliveries) were included.

Multivariable logistic and linear mixed effects regression analysis were used, accounting for secular trends, within hospital correlation and over time correlation, and adjusting for a maternal comorbidity index, hospital annual birth volume, and level of care.

The main outcome measure was a composite individual-level indicator of incidence of any adverse events, and a hospital-level score, called the Weighted Adverse Outcome Score (WAOS) capturing both maternal and neonatal adverse outcomes.

Results

Across the 12 years of follow up, there were 98,789 adverse maternal and neonatal outcomes, a rate of 6.83 per 100 deliveries (6.66 per 100 occurring before, 6.91 per 100 during, and 6.84 per 100 after program implementation). The multivariable analysis found no statistically significant decrease in adverse events associated with program implementation (OR for adverse events after versus before =1.11 (95% CI: 1.06 to 1.17, change in mean WAOS score after minus before =0.15 (− 0.36 to 0.67)).

Conclusions

We did not find a reduction in the incidence of maternal and neonatal adverse outcomes associated with the MORE^OB program, and small yet statistically significant increases in some adverse events were observed.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2296-5) contains supplementary material, which is available to authorized users.

The risk of intrapartum/neonatal mortality and morbidity following birth at 37 weeks of gestation: a nationwide cohort study

Objective

To assess intrapartum/neonatal mortality and morbidity risk in infants born at 37 weeks of gestation compared with infants born at 39–41 weeks of gestation.

Design

Nationwide cohort study.

Setting

The Netherlands.

Population

A total of 755 198 women delivering at term of a singleton without congenital malformations during 2010–14.

Methods

We used data from the national perinatal registry (PERINED). Analysis was performed with logistic regression and stratification for the way labour started and type of care.

Main outcome measures

Intrapartum or neonatal mortality up to 28 days and adverse neonatal outcome (neonatal mortality, 5‐minute Apgar <7, and/or neonatal intensive care unit admission).

Results

At 37 weeks of gestation intrapartum/neonatal mortality was 1.10‰ compared with 0.59‰ at 39–41 weeks (P < 0.0001). Adjusted odds ratio (aOR) for 37 weeks compared with 39–41 weeks was 1.84 (95% CI) 1.39–2.44). Adverse neonatal outcome at 37 weeks was 21.4‰ compared with 12.04‰ at 39–41 weeks (P < 0.0001) with an aOR 1.63 (95% CI 1.53–1.74). Spontaneous start of labour at 37 weeks of gestation was significantly associated with increased intrapartum/neonatal mortality with an aOR of 2.20 (95% CI 1.56–3.10), in both primary (midwifery‐led) care and specialist care. Neither induction of labour nor planned caesarean section showed increased intrapartum/neonatal mortality risk.

Conclusions

Birth at 37 weeks of gestation is independently associated with a higher frequency of clinically relevant adverse perinatal outcomes than birth at 39–41 weeks. In particular, spontaneous start of labour at 37 weeks of gestation doubles the risk for intrapartum/neonatal mortality. Extra fetal monitoring is warranted.

Tweetable abstract

Birth at 37 weeks of gestation gives markedly higher intrapartum/neonatal mortality risk than at 39–41 weeks, especially with spontaneous start of labour.

Tweetable abstract

Birth at 37 weeks of gestation gives markedly higher intrapartum/neonatal mortality risk than at 39–41 weeks, especially with spontaneous start of labour.

Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study

OBJECTIVE

To study the effect of an intervention based on Crew Resource Management team training, including a tool for structured communication, on adverse perinatal and maternal outcomes.

DESIGN

Stepped wedge.

SETTING

The Netherlands.

POPULATION OR SAMPLE

Registry data of 8123 women referred from primary care to a hospital during childbirth, at ≥ 32.0 weeks of singleton gestation and with no congenital abnormalities, in the period 2012-15.

METHODS

Obstetric teams of five hospitals and their surrounding primary-care midwifery practices participated in the intervention. In total, 49 team training sessions were organised for 465 care professionals (75.5% participated). Adverse perinatal and maternal outcomes before, during and after the intervention were analysed using multivariate logistic regression analyses.

MAIN OUTCOME MEASURES

Adverse Outcome Index (AOI-5), a composite measure involving; intrapartum or neonatal death, admission to neonatal intensive care unit, Apgar < 7 at 5 minutes, postpartum haemorrhage and/or perineal tear.

RESULTS

In total, an AOI-5 score was reported in 11.3% of the study population. No significant difference was found in the incidence of the AOI-5 score after the intervention compared with before the intervention (OR 1.07: 95% CI 0.92-1.24).

CONCLUSIONS

We found no effect of the intervention on adverse perinatal and maternal outcomes for women who were referred during childbirth. Team training is appreciated in practice, but evidence on the long-term impact is still limited. Upcoming studies should build on previous research and consider more sensitive outcome measures.

TWEETABLE ABSTRACT

A cluster randomised team training intervention showed no effect on adverse perinatal and maternal outcomes for women referred during childbirth.

Monitoring quality of obstetric care from hospital discharge databases: A Delphi survey to propose a new set of indicators based on maternal health outcomes

Objectives

Most indicators proposed for assessing quality of care in obstetrics are process indicators and do not directly measure health effects, and cannot always be identified from routinely available databases. Our objective was to propose a set of indicators to assess the quality of hospital obstetric care from maternal morbidity outcomes identifiable in permanent hospital discharge databases.

Methods

Various maternal morbidity outcomes potentially reflecting quality of obstetric care were first selected from a systematic literature review. Then a three-round Delphi consensus survey was conducted online from 11/2016 through 02/2017 among a French panel of 37 expert obstetricians, anesthetists-critical-care specialists, midwives, quality-of-care researchers, and user representatives. For a given maternal outcome, several definitions could be proposed and the indicator (i.e. corresponding rate) could be applied to all women or restricted to specific subgroup(s).

Results

Of the 49 experts invited to participate, 37 agreed. The response rate was 92% in the second round and 97% in the third. Finally, a set of 13 indicators was selected to assess the quality of hospital obstetric care: rates of uterine rupture, postpartum hemorrhage, transfusion incident, severe perineal lacerations, episiotomy, cesarean, cesarean under general anesthesia, post-cesarean site infection, anesthesia-related complications, postpartum pulmonary embolism, maternal readmission and maternal mortality. Six were considered in specific subgroups, with, for example, the postpartum hemorrhage rate assessed among all women and also among women at low risk of PPH.

Implications

This Delphi process enabled us to define consensually a set of indicators to assess the quality of hospital obstetrics care from routine hospital data, based on maternal morbidity outcomes. Considering 6 of them in specific subgroups of women is especially interesting. These indicators, identifiable through codes used in international classifications, will be useful to monitor quality of care over time and across settings.

Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care

BACKGROUND

The Safety Program for Perinatal Care (SPPC) seeks to improve safety on labor and delivery (L&D) units through three mutually reinforcing components: (1) fostering a culture of teamwork and communication, (2) applying safety science principles to care processes; and (3) in situ simulation. The objective of this study was to describe the SPPC implementation experience and evaluate the short-term impact on unit patient safety culture, processes, and adverse events.

METHODS

We supported SPPC implementation by L&D units with a program toolkit, trainings, and technical assistance. We evaluated the program using a pre-post, mixed-methods design. Implementing units reported uptake of program components, submitted hospital discharge data on maternal and neonatal adverse events, and participated in semi-structured interviews. We measured changes in safety and quality using the Modified Adverse Outcome Index (MAOI) and other perinatal care indicators.

RESULTS

Forty-three L&D units submitted data representing 97,740 deliveries over 10 months of follow-up. Twenty-six units implemented all three program components. L&D staff reported improvements in teamwork, communication, and unit safety culture that facilitated applying safety science principles to clinical care. The MAOI decreased from 5.03% to 4.65% (absolute change -0.38% [95% CI, -0.88% to 0.12%]). Statistically significant decreases in indicators for obstetric trauma without instruments and primary cesarean delivery were observed. A statistically significant increase in neonatal birth trauma was observed, but the overall rate of unexpected newborn complications was unchanged.

CONCLUSIONS

The SPPC had a favorable impact on unit patient safety culture and processes, but short-term impact on maternal and neonatal adverse events was mixed.

Measuring situation awareness and team effectiveness in pediatric acute care by using the situation global assessment technique

Situation awareness (SA) is an important human factor and necessary for effective teamwork and patient safety. Human patient simulation (HPS) with video feedback allows for a safe environment where health care professionals can develop both technical and teamwork skills. It is, however, very difficult to observe and measure SA directly. The Situation Global Assessment Technique (SAGAT) was developed by Endsley to measure SA during real-time simulation. Our objective was to measure SA among team members during simulation of acute pediatric care scenarios on the medical ward and its relationship with team effectiveness. Twenty-four pediatric teams, consisting of two nurses, one resident, and one consultant, participated in three acute care scenarios, using high-fidelity simulation. Individual SAGAT scores contained shared and complimentary knowledge questions on different levels of SA. Within each scenario, two "freezes" were incorporated to assess SA of each team members' clinical assessment and decision-making. SA overlap within the team (team SA) was computed and compared to indicators of team effectiveness (time to goal achievement, consensus on primary problem, diagnosis, task prioritization, leadership, and teamwork satisfaction). In 13 scenarios (18%), the team failed to reach the primary goals within the prescribed time of 1200 s. There was no significant difference in failure of goal completion between the scripted scenarios; however, there was a significant difference between scenario 3 and the other scenarios in time to goal completion. In all three scenarios, SA overlap level 2 (consensus on primary problem during the first freeze and consensus on diagnosis during the second freeze) leads to significantly faster achievement of the predefined goals. There was a strong relationship between team SA on the primary problem and diagnosis and team SA on task prioritization. Consensus on leadership within the team was low. Teamwork satisfaction was more influenced by knowledge about the importance of the assigned task than outcome of the scenario.Conclusion: The use of SAGAT enables us to measure SA of team members during real-time simulation of acute care scenarios. Although there is no direct connection between team SA and goal achievement, SAGAT provides insight in differences in SA among team members, and the process of shared mental model formation. By measuring SA, issues that may improve team effectiveness (prioritizing tasks, enhancing shared mental models, and providing leadership) can be trained and assessed during medical team simulation, enhancing teamwork in health care settings. What is known? • Teamwork skills such as communication, leadership, and situational awareness have become increasingly recognized as essential for good performance in pediatric resuscitation. However, the assessment of pediatric team performance in these clinical situations has been traditionally difficult. • The Situation Awareness Global Assessment Technique (SAGAT) is a method of objectively and directly measuring SA during a team simulation using "freezes" at predetermined points in time with participants reporting on "what is going on" from their perspective on the situation. What is new? • We assessed SA, and its relationship with team effectiveness, in multidisciplinary pediatric teams performing simulated critical events in critically ill children on the medical ward using the SAGAT model, outside the emergency room setting. • In all three scenarios, consensus on the primary problem (shared mental model) leads to faster achievement of predefined goals. Consensus on leadership was overall low, without a significant impact on goal achievement.

In which groups of pregnant women can the caesarean delivery rate likely be reduced safely in the USA? A multicentre cross-sectional study

OBJECTIVES

To identify obstetrical subgroups in which (1) the caesarean delivery (CD) rate may be reduced without compromising safety and (2) CD may be associated with better perinatal outcomes.

DESIGN

A multicentre cross-sectional study.

SETTING

19 hospitals in the USA that participated in the Consortium on Safe Labor.

PARTICIPANTS

228 562 pregnant women in 2002-2008.

MAIN OUTCOME MEASURES

Maternal and neonatal safety was measured using the individual Weighted Adverse Outcome Score.

METHODS

Women were divided into 10 subgroups according to a modified Robson classification system. Generalised estimated equation model was used to examine the relationships between mode of delivery and Weighted Adverse Outcome Score in each subgroup.

RESULTS

The overall caesarean rate was 31.2%. Repeat CD contributed 29.5% of all CD, followed by nulliparas with labour induction (15.3%) and non-cephalic presentation (14.3%). The caesarean rates in induced nulliparas with a term singleton cephalic pregnancy and women with previous CD were 31.6% and 82.0%, respectively. CD had no clinically meaningful association with perinatal outcomes in most subgroups. However, in singleton preterm breech presentation and preterm twin gestation with the first twin in non-cephalic presentation, CD was associated with substantially improved maternal and perinatal outcomes.

CONCLUSIONS

Women with repeat CD, term non-cephalic presentation, term twins or other multiple gestation and preterm births may be the potential targets for safely reducing prelabour CD rate, while nulliparas or multiparas with spontaneous or induced labour, women with repeat CD, term non-cephalic presentation, term twins or other multiple gestation and preterm births are potential targets for reducing intrapartum CD rate without compromising maternal and neonatal safety in the USA. On the other hand, CD may still be associated with better perinatal outcomes in women with singleton preterm breech presentation or preterm twins with the first twin in non-cephalic presentation.

Temporal trends in severe maternal and neonatal trauma during childbirth: a population-based observational study

OBJECTIVE

Instrumental vaginal delivery is associated with birth trauma to infant and obstetric trauma to mother. As caesarean delivery rates increased during the past decades, the rate of instrumental vaginal delivery declined. We examined concomitant temporal changes in the rates of severe birth trauma and maternal obstetric trauma.

DESIGN

A retrospective observational study.

SETTINGS AND PARTICIPANTS

All hospital singleton live births in Washington State, USA, 2004-2013, excluding breech delivery. Severe birth trauma (brain, nerve injury, fractures and other severe birth trauma) and obstetric trauma (third/fourth degree perineal lacerations, cervical/high vaginal lacerations) were identified from hospitalisation data. Pregnancy and delivery characteristics were obtained from birth certificates. Temporal trends were assessed by the Cochran-Armitage test. Logistic regression was used to obtain adjusted ORs (AORs) and 95% CI.

RESULTS

Overall, 732 818 live births were included. The rate of severe birth trauma declined from 5.3 in 2004 to 4.5 per 1000 live births in 2013 (P<0.001). The decline was observed only in spontaneous vaginal delivery, the rates of fractures and other severe birth trauma declined by 5% and 4% per year, respectively (AOR: 0.95, 95% CI 0.94 to 0.97 and AOR: 0.96, 95% CI 0.93 to 0.99; respectively). The rate of third/fourth degree lacerations declined in spontaneous vaginal delivery from 3.5% to 2.3% (AOR: 0.95; 95% CI 0.94 to 0.95) and in vacuum delivery from 17.3% to 14.5% (AOR: 0.97, 95% CI 0.96 to 0.98). Among women with forceps delivery, these rates declined from 29.8% to 23.4% (AOR: 0.98, 95% CI 0.96 to 1.00).

CONCLUSION

While the rates of fractures and other birth trauma declined among infants delivered by spontaneous vaginal delivery, the rate of birth trauma remained unchanged in instrumental vaginal delivery and caesarean delivery. Among mothers, the rates of severe perineal lacerations declined, except for women with forceps delivery.

Using perinatal morbidity scoring tools as a primary study outcome

Perinatal morbidity scores are tools that score or weight different adverse events according to their relative severity. Perinatal morbidity scores are appealing for maternal-infant health researchers because they provide a way to capture a broad range of adverse events to mother and newborn while recognising that some events are considered more serious than others. However, they have proved difficult to implement as a primary outcome in applied research studies because of challenges in testing if the scores are significantly different between two or more study groups. We outline these challenges and describe a solution, based on Poisson regression, that allows differences in perinatal morbidity scores to be formally evaluated. The approach is illustrated using an existing maternal-neonatal scoring tool, the Adverse Outcome Index, to evaluate the safety of labour and delivery before and after the closure of obstetrical services in small rural communities. Applying the proposed Poisson regression to the case study showed a protective risk ratio for adverse outcome following closures as compared with the original analysis, where no difference was found. This approach opens the door for considerably broader use of perinatal morbidity scoring tools as a primary outcome in applied population and clinical maternal-infant health research studies.

Exploring the Concept of Degrees of Maternal Morbidity as a Tool for Surveillance of Maternal Health in Latin American and Caribbean Settings

Objectives

To assess a birth registry to explore maternal mortality and morbidity and their association with other factors.

Study Design

Exploratory multicentre cross-sectional analysis with over 700 thousand childbirths from twelve Latin American and Caribbean countries between 2009 and 2012. The WHO criteria for maternal morbidity were employed to split women, following a gradient of severity of conditions, into (1) maternal death (MD); (2) maternal near miss (MNM); (3) potentially life-threatening conditions (PLTC); (4) less severe maternal morbidity (LSMM); (5) any maternal morbidity; and (6) women with no maternal morbidity. Their prevalence and estimated risks of adverse maternal outcomes were assessed.

Results

712,081 childbirths had a prevalence of MD and MNM of 0.14% and 3.1%, respectively, while 38% of women had experienced morbidity. Previous maternal morbidity was associated with higher risk of adverse maternal outcomes and also the extremes of reproductive ages, nonwhite ethnicity, no stable partner, no prenatal care, smoking, drug and alcohol use, elective C-section, or induction of labour. Poorer perinatal outcomes were proportional to the severity of maternal outcomes.

Conclusions

The findings corroborate WHO concept regarding continuum of maternal morbidity, reinforcing its importance in preventing adverse maternal outcomes and improving maternal healthcare in different settings.

Increases in Caesarean Delivery Rates and Change of Perinatal Outcomes in Low- and Middle-Income Countries: A Hospital-Level Analysis of Two WHO Surveys

BACKGROUND

Maternal and neonatal outcomes have improved substantially. During the same period, the caesarean delivery rate soared. The aim of this analysis was to determine whether an increase in caesarean rate was associated with an improvement in perinatal outcome at an institutional level in low- and middle-income countries.

METHODS

The WHO Global Survey on Maternal and Perinatal Health (WHOGS) and the WHO Multi-Country Survey on Maternal and Newborn Health (WHOMCS) were two multi-country, facility-based, cross-sectional surveys conducted in 2004-08 and 2010-11, respectively. The increase in caesarean rate and the change of prevalence of adverse perinatal outcomes were calculated using a two-point estimator of percent change annualized (PCA) method. Maternal, perinatal, and neonatal composite indexes were used as the outcomes. A linear mixed model was used to assess the association between the change of caesarean rate and the change of perinatal outcome.

RESULTS

A total of 259 facilities in 20 countries participated in both surveys, with 217 844 women in WHOGS and 227 734 women in WHOMCS. The caesarean rate in these facilities increased, on average, by 4.0% annually, while the prevalence of adverse perinatal outcomes decreased by 4.6% annually. However, after adjustments for potential confounders, no association was found between the increase in caesarean rate and the change of adverse outcome indexes, regardless of whether starting caesarean rates were already high (above 10%) or not.

CONCLUSIONS

In low- and middle-income countries, the increases in caesarean rates were not associated with improved perinatal outcomes regardless of whether the starting caesarean rate was already high or not.

Quality of inpatient care in public and private hospitals in Sri Lanka

OBJECTIVE

To compare the quality of inpatient clinical care in public and private hospitals in Sri Lanka.

METHODS

A retrospective, cross-sectional comparison was done of inpatient quality, in a sample of 11 public and 10 private hospitals in three of 25 districts. Data were collected for 55 quality indicators from medical records of 2523 public and 1815 private inpatient admissions. These covered treatment of asthma, acute myocardial infarction (AMI), childbirth and five other conditions, along with outcome indicators, and medicine prescribing indicators.

RESULTS

Overall quality scores were better in the public sector than the private sector (77 vs 69%). Performance was similar for management of AMI and childbirth and somewhat better in the private sector for management of asthma. The public sector performed better in those indicators that are not constrained by resources (94 vs 81%), but worse in indicators that are highly resource intensive (10 vs 31%). Quality was comparable in assessment and investigation, but the public sector performed better in treatment and management (70 vs 62%) and drug prescribing (68 vs 60%), and modestly worse in terms of outcomes (92 vs 97%).

CONCLUSIONS

For a range of indicators where comparisons were possible, quality of inpatient clinical care in Sri Lanka was comparable to levels reported from upper-middle income Asian countries, and often approaches that in developed countries, although the findings cannot be generalized. Quality in the public sector is better than in the private sector in many areas, despite spending being substantially less. Quality in public hospitals is resource constrained, and needs greater government investment for improvement, but when resource limitations are not critical, the public sector appears able to deliver equal or better quality than the private sector. Overall similarities in quality between the two sectors suggest the importance of physician training and other factors.

Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interdisciplinary Teamwork Training, and Performance Feedback

OBJECTIVE

To improve safety practices and reduce adverse events in perinatal units of acute care hospitals.

DATA SOURCES

Primary data collected from perinatal units of 14 hospitals participating in the intervention between 2008 and 2012. Baseline secondary data collected from the same hospitals between 2006 and 2007.

STUDY DESIGN

A prospective study involving 342,754 deliveries was conducted using a quality improvement collaborative that supported three primary interventions. Primary measures include adoption of three standardized care processes and four measures of outcomes.

DATA COLLECTION METHODS

Chart audits were conducted to measure the implementation of standardized care processes. Outcome measures were collected and validated by the National Perinatal Information Center.

PRINCIPAL FINDINGS

The hospital perinatal units increased use of all three care processes, raising consolidated overall use from 38 to 81 percent between 2008 and 2012. The harms measured by the Adverse Outcome Index decreased 14 percent, and a run chart analysis revealed two special causes associated with the interventions.

CONCLUSIONS

This study demonstrates the ability of hospital perinatal staff to implement efforts to reduce perinatal harm using a quality improvement collaborative. Findings help inform the relationship between the use of standardized care processes, teamwork training, and improved perinatal outcomes, and suggest that a multiplicity of integrated strategies, rather than a single intervention, may be essential to achieve high reliability.

Safety of labour and delivery following closures of obstetric services in small community hospitals

BACKGROUND

In recent decades, many smaller hospitals in British Columbia, Canada, have stopped providing planned obstetric services. We examined the effect of these service closures on the labour and delivery outcomes of pregnant women living in affected communities.

METHODS

We used maternal postal codes to identify delivery records (1998-2014) of women residing in a community affected by service closure. The records were obtained from the British Columbia Perinatal Data Registry. We examined the effect of the closures using a within-communities fixed-effects framework and included similar-sized communities without service closures to control for underlying time trends. The primary outcome was a previously published composite measure of labour and delivery safety, the Adverse Outcome Index, which includes adverse events such as birth injury and unanticipated operative procedures, and includes weights for severity of adverse events. Secondary outcomes included maternal or newborn transfer, and use of obstetric interventions.

RESULTS

We found little evidence that closure of planned obstetric services affected the risk of composite adverse maternal-newborn outcome (-0.4 excess adverse events per 100 deliveries, 95% confidence interval [CI] -2.0 to 1.1), or most other secondary outcomes. The severity of composite outcome events decreased following the closures (rate ratio 0.58, 95% CI 0.36 to 0.89). Closures were associated with increases in use of epidural analgesia (3.4 excess events per 100 deliveries, 95% CI 0.4 to 6.3) and length of antepartum stay (0.6 h, 95% CI 0.1 to 1.0 h).

INTERPRETATION

Closure of planned obstetric services in low-volume hospitals was not associated with an increase or decrease in frequency of adverse events during labour and delivery.

Decreasing Malpractice Claims by Reducing Preventable Perinatal Harm

OBJECTIVE

To evaluate the association of improved patient safety practices with medical malpractice claims and costs in the perinatal units of acute care hospitals.

DATA SOURCES

Malpractice and harm data from participating hospitals; litigation records and medical malpractice claims data from American Excess Insurance Exchange, RRG, whose data are managed by Premier Insurance Management Services, Inc. (owned by Premier Inc., a health care improvement company).

STUDY DESIGN

A quasi-experimental prospective design to compare baseline and postintervention data. Statistical significance tests for differences were performed using chi-square, Wilcoxon signed-rank test, and t-test.

DATA COLLECTION

Claims data were collected and evaluated by experienced senior claims managers through on-site claim audits to evaluate claim frequency, severity, and financial information. Data were provided to the analyzing institution through confidentiality contracts.

PRINCIPAL FINDINGS

There is a significant reduction in the number of perinatal malpractice claims paid, losses paid, and indemnity payments (43.9 percent, 77.6 percent, and 84.6 percent, respectively) following interventions to improve perinatal patient safety and reduce perinatal harm. This compares with no significant reductions in the nonperinatal claims in the same hospitals during the same time period.

CONCLUSIONS

The number of perinatal malpractice claims and dollar amount of claims payments decreased significantly in the participating hospitals, while there was no significant decrease in nonperinatal malpractice claims activity in the same hospitals.

A 'busy day' effect on perinatal complications of delivery on weekends: a retrospective cohort study

Objective

To evaluate whether busy days on a labour and delivery unit are associated with maternal and neonatal complications of childbirth in California hospitals, accounting for weekday/weekend births.

Design

This is a population-based retrospective cohort study.

Setting

Linked vital statistics/patient discharge data for California births between 2009 and 2010 from the Office of Statewide Health Planning and Development.

Participants

All singleton, cephalic, non-anomalous California births between 2009 and 2010 (N=724 967).

Main outcomes

The key exposure was high daily obstetric volume, defined as giving birth on a day when the number of births exceeded the hospital-specific 75th percentile of daily delivery volume. Outcomes were a range of maternal and neonatal complications.

Results

Several maternal and neonatal complications were increased on high-volume days and weekends following adjustment for maternal demographics, annual hospital birth volume and teaching hospital status. For example, compared with low-volume weekdays, the odds of Apgar <7 on low-volume weekend days and high-volume weekend days were 11% (adjusted OR (aOR) 1.11, CI 1.03 to 1.21) and 29% higher (aOR 1.29, CI 1.10 to 1.52), respectively. High volume was associated with increased odds of neonatal seizures on weekdays (aOR 1.33, CI 1.01 to 1.71) and haemorrhage on weekends (aOR 1.11, CI 1.01 to 1.22). After accounting for between-hospital variation, weekend delivery remained significantly associated with increased odds of Apgar score <7, neonatal intensive care unit admission, prolonged maternal length of stay and the odds of neonatal seizures remained increased on high-volume weekdays.

Conclusions

Our findings suggest that weekend delivery is a consistent risk factor for a range of perinatal complications and there may be variability in how well hospitals handle surges in volume.

Complex social intervention for multidisciplinary teams to improve patient referrals in obstetrical care: protocol for a stepped wedge study design

INTRODUCTION

In obstetrics, patients often experience referral situations between different care professionals. In these multidisciplinary teams, a focus on communication and interprofessional collaboration is needed to ensure care of high quality. Crew resource management team training is increasingly being applied in healthcare settings to improve team performance and coordination. Efforts to improve communication also include tools for standardisation such as SBAR (situation, background, assessment, recommendation). Despite the growing adoption of these interventions, evidence on their effectiveness is limited, especially on patient outcomes. This article describes a study protocol to examine the effectiveness of a crew resource management team training intervention aimed at implementing the SBAR tool for structured communication during patient referrals in obstetrical care.

METHODS AND ANALYSIS

The intervention is rolled out sequentially in five hospitals and surrounding primary care midwifery practices in the Netherlands, using a stepped wedge design. The intervention involves three phases over a period of 24 months: (1) preparation, (2) training and (3) follow-up with repeated measurements. The primary outcomes are perinatal and maternal outcomes calculated using the Adverse Outcome Index. The secondary outcomes are the reaction of participating professionals to the training programme, attitudes towards safety and teamwork (Safety Attitudes Questionnaire), cohesion (Interprofessional Collaboration Measurement Scale), use of the tool for structured communication (self-reported questionnaire) and patient experiences. These secondary outcomes from professional and patient level allow triangulation and an increased understanding of the effect of the intervention on patient outcomes.

ETHICS AND DISSEMINATION

The study was approved by the Medical Ethical Committee of the VU University Medical Centre in the Netherlands and the protocol is in accordance with Dutch privacy regulations. Study findings will be presented in publications in peer-reviewed journals and presentations at scientific conferences.

TRIAL REGISTRATION NUMBER

NTR4256; Pre-results.

Feasibility of Implementing a Standardized Clinical Performance Indicator to Evaluate the Quality of Obstetrical Care in British Columbia

OBJECTIVES

To establish the feasibility of implementing a previously-published clinical standardized performance indicator, the Adverse Outcome Index (AOI), using routinely-collected data in a population-based perinatal database and to examine variation in the indicator over time and between hospitals.

METHODS

Maternal and newborn medical record data contained in the British Columbia Perinatal Data Registry, 2004-2013, were used to calculate an AOI (a composite of 10 maternal and newborn adverse events) and its severity-weighted scores, the Weighted Adverse Outcome Score and the Severity Index. Temporal trends in the indices were examined by plotting annual risks and weighted risks with 95% confidence intervals. Hospital-level risks were calculated with 95% confidence intervals, adjusting for patient case-mix.

RESULTS

Among 410,054 singleton deliveries in British Columbia, the risk of AOI was 5.8 per 100, while the Weighted Adverse Outcome Score and Severity Index were 1.6 and 27.4, respectively. The risk of AOI did not change significantly over the study period, while the Severity Index decreased from 29.3 (95% CI 26.7-31.9) in 2004 to 23.9 (22.0-25.8) in 2013. Fifteen of 52 hospitals had risks of AOI significantly above the provincial median. The hospitals' risks of AOI were not correlated with their Severity Indices (r = 0.02).

CONCLUSIONS

The AOI can successfully be estimated using data from a population-based database, and used to monitor trends in safety of labour and delivery over time and between hospitals. The low correlation between frequency and severity of adverse events confirms the importance of considering event severity in perinatal population health surveillance.

Adverse birth outcome: a comparative analysis between cesarean section and vaginal delivery at Felegehiwot Referral Hospital, Northwest Ethiopia: a retrospective record review

Introduction

Some studies favor elective cesarean delivery, and other surveys benefit vaginal delivery, while others emphasize that the quality of care during labor, birth, and immediate postpartum period plays a great role than the route of delivery. However, little information is locally available regarding the incidences of adverse birth outcome with respect to the route of delivery.

Methods

This study was a retrospective analysis of eligible patient records that included 3,003 pregnant women who had undergone either cesarean or vaginal delivery from July 1, 2012, to June 31, 2013. Pretested questionnaire was used to collect the data. The completeness and consistency of the data were checked, cleaned, and double entered to EPI-INFO 3.5.2 and analyzed with SPSS V20. Independent sample t-test and chi-square test were conducted to compare the outcome of vaginal delivery and cesarean section (CS) using index variables. Significance was taken at P<0.05.

Results

Among the enrolled women, 760 mothers had CS delivery and the remaining 2,243 mothers delivered vaginally. Children born through CS (mean =6.83, standard deviation =1.31) had a significantly lower first-minute Apgar score than those in the vaginal delivery group (mean =7.19, standard deviation =1.18, P=0.001). Similarly, the observed respiratory distress syndrome (c²=0.09, P=0.793) and neonatal transfer rate to neonatal intensive care unit (c²=0.086, P=0.766) were more in neonates delivered by CS than those in the vaginally delivered group. Besides, the observed neonatal death (c²=0.675, P=0.411) and maternal death (c²= 8.878, P=0.003) were higher among CS deliveries compared with vaginal deliveries.

Conclusion

Neonatal and maternal morbidity and mortality appear to be more in CS than in vaginal delivery. Therefore, decision to perform CS should be based on clear, compelling, and well-supported justifications.

Triggers, bundles, protocols, and checklists--what every maternal care provider needs to know

The rise in maternal morbidity and mortality has resulted in national and international attention at optimally organizing systems and teams for pregnancy care. Given that maternal morbidity and mortality can occur unpredictably in any obstetric setting, specialists in general obstetrics and gynecology along with other primary maternal care providers should be integrally involved in efforts to improve the safety of obstetric care delivery. Quality improvement initiatives remain vital to meeting this goal. The evidence-based utilization of triggers, bundles, protocols, and checklists can aid in timely diagnosis and treatment to prevent or limit the severity of morbidity as well as facilitate interdisciplinary, patient-centered care. The purpose of this document is to summarize the pertinent elements from this forum to assist primary maternal care providers in their utilization and implementation of these safety tools.

Impact of a labor and delivery safety bundle on a modified adverse outcomes index

BACKGROUND

The Obstetrics Adverse Outcomes Index was designed to measure the quality of perinatal care and includes 10 adverse events that may occur at or around the time of delivery. We hypothesized that adverse outcomes in the labor and delivery suite, including hypoxic ischemic encephalopathy, could be decreased with a combination of interventions, even among high-risk pregnancies.

OBJECTIVE

The objective of the study was to evaluate the impact of a labor and delivery care bundle on adverse obstetrics outcomes as measured by a modified Obstetrics Adverse Outcomes Index, Weighted Adverse Outcomes Index, and Severity Index.

STUDY DESIGN

This is a retrospective cohort study including all women who delivered at our academic, tertiary care institution over a 3 year period of time, before and after the implementation of an intervention to decrease adverse outcomes. Outcome measures consisted of previously reported indices that were modified including the addition of hypoxic ischemic encephalopathy. The adverse outcomes index is a percentage of deliveries with 1 or more adverse events, the weighted adverse outcomes index is the sum of the points assigned to cases with adverse outcomes divided by the number of deliveries, and the severity index is the sum of the adverse outcome scores divided by the number of deliveries with an identified adverse outcome. A segmented regression analysis was utilized to evaluate the differences in the level and trend of each index before and after our intervention using calendar month as the unit of analysis.

RESULTS

During the study period, 5826 deliveries met inclusion criteria. Comparing the pre- and postintervention periods, high-risk pregnancy was more common in the postintervention period (73.5% vs 79.4%, P < .001). Overall, there was a decrease in both the Modified Weighted Adverse Outcomes Index (P = .0497) and the Modified Severity Index (P = 0.01) comparing the pre- and postintervention periods; there was no difference in the Modified Adverse Outcomes Index (P = .43). For low-risk pregnancies, there was no significant difference in the levels for any of the measured indices over the study period (P = .61, P = .41, and P = .34 for the Modified Adverse Outcomes Index, Modified Weighted Adverse Outcomes Index, and Modified Severity Index, respectively). Among the high-risk pregnancies, the monthly Modified Weighted Adverse Outcomes Index decreased by 4.2 ± 1.8 (P = .03). The monthly Modified Severity Index decreased by 53.9 ± 17.7 points from the pre- to the postintervention periods (P = .01) and was < 50% of the predicted Modified Severity Index had the intervention not been implemented. The cesarean delivery rate was increasing prior to the intervention, but the rate was stable after the intervention, and the absolute rate did not differ between the pre- and the postintervention periods (28.4% vs 30.0%, P = .20).

CONCLUSION

Overall and for high-risk pregnancies, the implementation of the labor and delivery care bundle had a positive impact on the Modified Weighted Adverse Outcomes Index and Modified Severity Index but not the Modified Adverse Outcomes Index.

Prevalence of metabolic syndrome in non-diabetic, pregnant Angolan women according to four diagnostic criteria and its effects on adverse perinatal outcomes

BACKGROUND

Metabolic syndrome (MetS) is a cluster of risk factors for type 2 diabetes (Type2 DM) and cardiovascular diseases (CVD), and its prevalence varies based on region, population, and sex. Newborns of women with MetS have a greater risk of adverse perinatal outcomes. This study explores the prevalence of metabolic syndrome in non-diabetic, pregnant Angolan women and the adverse perinatal outcomes associated with it.

METHODS

This cross-sectional study collected the demographic, anthropometric and clinical data of 675 pregnant women in the maternity ward of General Hospital in Huambo, Angola. Metabolic syndrome was defined using four criteria: the third report of the National Cholesterol Education Program Adult Treatment Panel (ATPIII), the Joint Interim Statement (JIS), and definitions by both Bartha et al. and Chatzi et al.

RESULTS

The crude prevalence of metabolic syndrome was 36.6 % based on the JIS definition, 29.2 % based on NCEP ATPIII, 12.6 % based on Chatzi et al. and 1.8 % based on Bartha et al. In general, the prevalence of adverse perinatal outcomes was 14.1 %.

CONCLUSIONS

There was a high prevalence of metabolic syndrome, depending on the criteria used, and thus a great need to harmonize the criteria and cutoff points. Perinatal adverse outcomes were higher in pregnant women with metabolic syndrome.

A literature review of quantitative indicators to measure the quality of labor and delivery care

BACKGROUND

Strengthening measurement of the quality of labor and delivery (L&D) care in low-resource countries requires an understanding of existing approaches.

OBJECTIVES

To identify quantitative indicators of L&D care quality and assess gaps in indicators.

SEARCH STRATEGY

PubMed, CINAHL Plus, and Embase databases were searched for research published in English between January 1, 1990, and October 31, 2013, using structured terms.

SELECTION CRITERIA

Studies describing indicators for L&D care quality assessment were included. Those whose abstracts contained inclusion criteria underwent full-text review.

DATA COLLECTION AND ANALYSIS

Study characteristics, including indicator selection and data sources, were extracted via a standard spreadsheet.

MAIN RESULTS

The structured search identified 1224 studies. After abstract and full-text review, 477 were included in the analysis. Most studies selected indicators by using literature review, clinical guidelines, or expert panels. Few indicators were empirically validated; most studies relied on medical record review to measure indicators.

CONCLUSIONS

Many quantitative indicators have been used to measure L&D care quality, but few have been validated beyond expert opinion. There has been limited use of clinical observation in quality assessment of care processes. The findings suggest the need for validated, efficient consensus indicators of the quality of L&D care processes, particularly in low-resource countries.

Improved obstetric safety through programmatic collaboration

Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p < 0.001). The Weighted Adverse Outcome Score (WAOS) also decreased during the same time period (3.9 vs 2.3, p = 0.001.) Given the improved outcomes noted, our unique program and the process by which it was developed are described in the hopes that others will recognize collaborative partnering with or without insurers as an opportunity to improve obstetric patient safety.

Measuring quality of maternity care

Health-care organisations are required to monitor and measure the quality of their maternity services, but measuring quality is complex, and no universal consensus exists on how best to measure it. Clinical outcomes and process measures that are important to stakeholders should be measured, ideally in standardised sets for benchmarking. Furthermore, a holistic interpretation of quality should also reflect patient experience, ideally integrated with outcome and process measures, into a balanced suite of quality indicators. Dashboards enable reporting of trends in adverse outcomes to stakeholders, staff and patients, and they facilitate targeted quality improvement initiatives. The value of such dashboards is dependent upon high-quality, routinely collected data, subject to robust statistical analysis. Moving forward, we could and should collect a standard, relevant set of quality indicators, from routinely collected data, and present these in a manner that facilitates ongoing quality improvement, both locally and at regional/national levels.