Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California

A new index for obstetrics safety and quality of care: integrating cesarean delivery rates with maternal and neonatal outcomes

BACKGROUND

Cesarean delivery rates have been used as obstetrical quality indicators. However, these approaches do not consider the accompanying maternal and neonatal morbidities. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses preexisting high-risk maternal factors and associated maternal and neonatal morbidities and is universally acceptable to all stakeholders, including patients, healthcare providers, payers, and governmental agencies.

OBJECTIVE

This study aimed to (1) establish a new single metric for obstetrical quality improvement among nulliparous patients with term singleton vertex-presenting fetus, integrating cesarean delivery rates adjusted for preexisting high-risk maternal factors with associated maternal and neonatal morbidities, and (2) determine whether obstetrician quality ranking by this new metric is different compared with the rating based on individual crude and/or risk-adjusted cesarean delivery rates. The single metric has been termed obstetrical safety and quality index.

STUDY DESIGN

This was a cross-sectional study of all nulliparous patients with term singleton vertex-presenting fetuses delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed, including a review of maternal high-risk factors and maternal and neonatal outcomes. Maternal and neonatal medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean delivery rates and rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the obstetrical safety and quality index for each obstetrician. The final ranking based on the obstetrical safety and quality index was compared with the initial ranking by crude cesarean delivery rates. Maternal and neonatal morbidities were analyzed as ≥1 and ≥2 maternal and/or neonatal complications.

RESULTS

These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) medical records were reviewed to determine crude and adjusted cesarean delivery rates by obstetricians and quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05; 95% confidence interval, -0.54 to 0.60) to the final ranking based on the obstetrical safety and quality index. Of note, 8 of 12 obstetricians shifted their rank quartiles after adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 maternal and/or neonatal complication and ranking based on ≥2 maternal and/or neonatal complications (rho=0.63; 95% confidence interval, 0.08-0.88).

CONCLUSION

Ranking based on crude cesarean delivery rates varied significantly after considering high-risk maternal conditions and associated maternal and neonatal outcomes. Therefore, the obstetrical safety and quality index, a single metric, was developed to identify ways to improve clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared toward patient safety, balancing cesarean delivery rates with optimal maternal and neonatal outcomes. This metric could be used to compare obstetrical quality not only among individual obstetricians but also among hospitals that practice obstetrics.

Prevention of Failure to Rescue in Obstetric Patients: A Realist Review

BACKGROUND

At least 40% of maternal deaths are attributable to failure to rescue (FTR) events. Nurses are positioned to prevent FTR events, but there is minimal understanding of systems-level factors affecting obstetric nurses when patients require rescue.

AIMS

To identify the nurse-specific contexts, mechanisms, and outcomes underlying obstetric FTR and the interventions designed to prevent these events.

METHODS

A realist review was conducted to meet the aims. This review included literature from 1999 to 2020 to understand the systems-level factors affecting obstetric nurses during FTR events using a human factors framework designed by the Systems Engineering Initiative for Patient Safety.

RESULTS

Existing interventions addressed the prevention of maternal death through education of clinicians, improved protocols for care and maternal transfer, and an emphasis on communication and teamwork.

LINKING EVIDENCE TO ACTION

Few researchers addressed task overload or connected employee and organizational outcomes with patient outcomes, and the physical environment was minimally considered. Future research is needed to understand how systems-level factors affect nurses during FTR events.

FIGO Statement: Vaccination in pregnancy

Pregnant women and their fetuses are among the vulnerable populations that can be severely affected by communicable diseases. As such, some vaccines such as the influenza and the Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccines are strongly recommended in each pregnancy, with generally safe profiles. Other vaccines can be offered based on risk factors, and only when the benefits of receiving them outweigh the risks. Development of vaccines against group B streptococcus infection and respiratory syncytial virus infection are of great importance. In this paper, the recommendations for administration of each vaccine during pregnancy are discussed. The FIGO Committee for Safe Motherhood and Newborn Health Committee endorses the recommendations to vaccinate all pregnant women against influenza during the influenza season at any time during the pregnancy and against Tdap preferably between the 27th and 36th weeks of pregnancy in each pregnancy.

WOMEN'S SAFETY CULTURE IN CHILDBIRTH AND RELATED INSTITUTIONAL FACTORS

ABSTRACT Objective: to analyze the safety culture of women in childbirth and related institutional factors based on the perceptions of nursing and medical professionals. Methods: a mixed, sequential explanatory study, conducted with nursing technicians, nurses and physicians of the obstetric center of a public maternity hospital in the city of Rio de Janeiro. Data collection took place from May to July 2018. The Hospital Survey on Patient Safety Culture questionnaire and descriptive statistical treatment were applied. Then, 12 semistructured interviews and thematic content analysis were applied and, finally, this data set was integrated. Results: most of the dimensions of the safety culture are weakened, especially in the areas of institutional organization, and the team lacks knowledge about the actions of the Patient Safety Center in the institution, the uniformity of care is deficient and the number of personnel for care is limited. The safety management process and work organization need adaptations. Conclusion: the safety culture of women requires improvements in team training, skilled care, work organization, and commitment of local management to qualified and safe care in hospital births.

Addressing Maternal Mortality And Morbidity In California Through Public-Private Partnerships

In 2006, noting a rise in maternal deaths and complications, the California Department of Public Health launched efforts to investigate maternal deaths. In that year, the California Maternal Quality Care Collaborative was formed as a public-private partnership to lead maternal quality improvement activities. Key steps undertaken over the next decade included linking public health surveillance to actions, mobilizing a broad range of public and private partners, developing a rapid-cycle Maternal Data Center to support and sustain quality improvement initiatives, and implementing a series of data-driven large-scale quality improvement projects. While US maternal mortality has worsened in the 2010s, by 2013 California's rate had been cut in half to a three-year average of 7.0 maternal deaths per 100,000 live births. The state's rate had become comparable to the average rate in Western Europe (7.2 per 100,000). In this article we describe the key steps undertaken by the California Department of Public Health and the California Maternal Quality Care Collaborative that supported change at large scale. Special challenges for implementation are also discussed.

Serum markers of B-cell activation in pregnancy during late gestation, delivery, and the postpartum period

PROBLEM

B cells are vital for the normal evolution of pregnancy due to their humoral and possible regulatory activities. Our group and others have documented that circulating B-cell subsets undergo changes from normal late pregnancy to the postpartum period. However, the underlying mechanisms are poorly understood. Therefore, this study examined the degree of B-cell activation in normal pregnancy by analyzing the levels of serum markers in healthy pregnant women during the third trimester of pregnancy, the day of delivery, and the postpartum period.

METHOD OF STUDY

A prospective study including pregnant and non-pregnant women attending routine care was undertaken at a hospital clinic. Sociodemographic and clinical data were collected, along with peripheral blood samples. The serum levels of soluble CD23 (sCD23), B-cell-activating factor (BAFF), kappa (κ) and lambda (λ) free light chains (FLC), IgA, IgG, and IgM were quantified.

RESULTS

Our study included 43 third trimester pregnant and 35 non-pregnant women. In the pregnant women, the median levels of sCD23, BAFF, IgG, and κ FLC were significantly higher during the postpartum period than during the third trimester of pregnancy. Compared to the non-pregnant women, the third trimester pregnant women had higher median BAFF levels and lower sCD23, IgA, IgG, and FLC levels.

CONCLUSION

Changes in serum markers of B-cell kinetics that occur during pregnancy often persist into the postpartum period and affect the secretion of immunoglobulins from different classes. Further studies are needed to clarify the biological significance of our observations.

A conceptual framework for the impact of obesity on risk of cesarean delivery

Cesarean deliveries accounted for 32.2% of nearly 4 million births in the United States in 2014. Obesity affects a third of reproductive-age women and is associated with worse cesarean delivery outcomes. Studies have shown that increasing maternal body mass index correlates linearly with cesarean delivery rates, but little is known about the potential mediating and moderating mechanisms. Thus, a conceptual framework for understanding how obesity correlates with risk of cesarean delivery is crucial to determining safe ways to reduce the cesarean delivery rate among obese gravidas. Based on an extensive review and synthesis of the literature, we present a conceptual framework that posits how obesity may operate through several pathways to lead to a cesarean delivery. Our framework explores the complexity of obesity as an exposure that operates through potential mediating pathways, a moderator of cesarean delivery risk, and a covariate with other cesarean delivery risk factors. Among nulliparas, obesity appears to operate through 3 main proximal mediating mechanisms to increase risk of cesarean delivery including: (1) preexisting comorbidities and obstetric complications; (2) a slower progression of first-stage labor, potentially increasing the risk of cesarean delivery secondary to failure to progress; and (3) a prolongation of pregnancy, which is associated with risk of maternal postdates. For multiparas, a fourth proximal mediator of prior uterine scar may also increase cesarean delivery risk. Distal mediating mechanisms, which operate through one of the proximal mechanisms, may include an induction of labor or planned prelabor cesarean delivery. Obesity may also moderate the likelihood of cesarean delivery by interacting with clinician-level or hospital-level factors. Future research should assess the validity of this framework and seek to understand the relative contributions of each potential pathway between obesity and cesarean delivery. This will allow for evidence-based recommendations to reduce preventable cesareans among obese women by targeting modifiable mediators and moderators of the relationship between obesity and increased risk of cesarean delivery.