Reduction in Cesarean Delivery Rates Associated With a State Quality Collaborative in Maryland

Spatial and Racial/Ethnic Variation in the Prevalence of Cesarean Delivery in a South Carolina Medical Center

INTRODUCTION

While racial/ethnic disparities in cesarean delivery have been noted in the literature, less is known about the intersection between individual-level race/ethnicity and community-level social vulnerability as factors in cesarean delivery. The goal was to use medical record data from a large medical center combined with census tract-level data to examine patterns of social vulnerability, racial population distribution, and prevalence of cesarean delivery.

METHODS

Data were obtained from electronic medical records of patients from a large medical center in South Carolina from 2019 to 2020. The outcome variable was cesarean delivery (yes/no), and covariates included the year of delivery; age of patient; race/ethnicity; spoken language; BMI categories; clinical indications of anemia, hypertension, preeclampsia, and diabetes; and census tract Social Vulnerability Index (SVI). Generalized linear mixed models for multilevel binary logistic regression were used to test the main hypothesis that the census tract level Social Vulnerability Index is positively associated with cesarean delivery.

RESULTS

Among a total of 5011 patients, we found that non-Hispanic Black mothers were more likely to have cesarean deliveries compared with non-Hispanic White mothers. After controlling for census tract-level SVI, the individual-level race/ethnicity association was no longer significant. Significant spatial autocorrelation across census tracts was evident for cesarean delivery prevalence, non-Hispanic Black population, and SVI. A high prevalence of cesarean delivery tended to cluster with high SVI and a high non-Hispanic Black population.

CONCLUSIONS

We found that non-Hispanic Black mothers were more likely to have cesarean deliveries, which was explained by census tract differences in the SVI.

Disentangling Safety Culture's Role in Reducing Cesarean Overuse: Creating a Revised Labor Culture Survey

Objective

To measure and assess the relationship of patient safety culture to reducing cesarean overuse.

Study Setting

Maternity care hospitals in Michigan.

Study Design

Cross-sectional observational design, combining individual survey data with hospital characteristics using existing databases. Multivariate Poisson regression assessed the associations between survey scores and hospital nulliparous term singleton vertex cesarean rates. Factor analysis determined the scalability of survey items.

Data Collection Methods

Electronic survey distributed at the hospital site level.

Principal Findings

A total of 3091 clinicians from 54 out of 57 eligible hospitals completed the survey. Confirmatory factor analysis demonstrated best fit with a univariate model with two local factors. The new scale encompassing both local factors, including vaginal birth microculture and safety culture, is entitled "Unit Norms." The safety culture subdomain demonstrated an association with a reduction in hospital cesarean rate [-0.15; 95% CI: -0.27 to -0.04; incident rate ratio (IRR) 0.86], parallel to but lower in magnitude to vaginal birth microculture (-0.18; 95% CI: -0.35 to -0.02; IRR 0.84).

Conclusions

Vaginal birth microculture remains the strongest predictor of cesarean delivery overuse; however, safety culture characteristics, including teamwork, psychological safety, and communication, correlate with lower cesarean delivery rates. Measuring these aspects of hospitals' culture may be important for other areas of quality improvement initiatives focused on quality and safety.

Implementation and outcomes of a system-wide women’s health ‘team goal’ to reduce maternal morbidity for black women: a prospective quality improvement study

Objective

In response to the unacceptable racial disparities in US obstetric outcomes, our health system established a formal goal to reduce maternal morbidity for black women. Here, we describe our process for meeting this equity-focused goal in the context of diverse implementation climates at 5 inpatient sites.

Study design

To meet the system goal, we established a collaborative of multidisciplinary, site-based teams. The validated 18-question Implementation Climate Scale (ICS) was distributed to site clinicians at baseline. Sites focused on haemorrhage, performing case reviews of black women meeting morbidity criteria. Comparing cases by site, site-specific areas for improvement in haemorrhage risk assessment, prevention and management emerged. Evidence-based practices (EBPs) were then selected, tailored and implemented by site. Monthly system-wide team meetings included (1) metric tracking and (2) site presentations with discussions around barriers/facilitators to EBP implementation. Maternal morbidity rates among black women were compared the year before goal development (1 July 2019–30 June 2020) to the year after (1 July 2020–30 June 2021).

Results

Mean ICS scores for inpatient obstetric units differed by site (p=0.005), with climates more supportive of implementation at urban/academic hospitals. In response to case reviews, sites reported implementing 2 to 8 EBPs to meet the goal. Despite different ICS scores, this process was associated with significant reductions in maternal morbidity for black women from pregoal to postgoal development overall and at sites 1, 2 and 3, with non-statistically significant reductions at sites 4 and 5 (overall: −29.4% reduction, p<0.001).

Conclusions

A health system goal of reducing maternal morbidity for black women led to a data-driven, collaborative model for implementing site-tailored interventions. If health systems prioritise equity-focused goals, sites can be supported in implementing EBPs that improve care.

Defining a Cesarean Delivery Rate for Optimizing Maternal and Neonatal Outcomes

After the global cesarean delivery rate nearly doubled between 2000 and 2015, cesarean deliveries now account for nearly one third of births in the United States. Although rates have plateaued, the high national cesarean delivery rate has garnered criticism from both lay and academic communities because it has not been associated with improvements in maternal or neonatal outcomes. Efforts are underway to lower the cesarean delivery rate through implementation of hospital-level and national guidelines. However, the cesarean delivery rate that optimizes maternal and neonatal outcomes is not known. Defining a cesarean delivery rate that optimizes perinatal outcomes and reduces morbidity seems simple. However, there are a host of challenges to such a task, including determining the outcomes that are most meaningful to use, deciding the population that should define the rate, and incorporating person-centered decision making, given that people place different value on different outcomes. Rather than a "call" for cesarean delivery rate reductions of a specific and arbitrary magnitude, we need further attention to defining an evidence-based optimal target. This commentary summarizes current national and international cesarean delivery rate targets, discusses the challenges of identifying an evidence-based national cesarean delivery rate target, and explores future considerations for best defining a cesarean delivery rate target.

Perinatal quality collaboratives and birth equity

PURPOSE OF REVIEW

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

RECENT FINDING

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

SUMMARY

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

VIDEO ABSTRACT

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