Quality Improvement to Decrease Cesarean Birth.

An Initiative to Prevent Surgical Site Infections After Cesarean Birth With a Quality Improvement Care Bundle

The purpose of this study was to compare the nulliparous-term-singleton-vertex (NTSV) and the Society of Maternal-Fetal Medicine (SMFM) cesarean birth metrics as tools for quality improvement efforts based on hospital size. Cesarean birth rates from 275 hospitals from six states were used to evaluate the NTSV metric and 81 hospitals from four states for the SMFM metric. Data were assessed based on delivery volume, their use as an effective tool for ongoing quality improvement programs, and their ability to serve as performance-based payline indicators. The average NTSV and SMFM cesarean birth rates were 25.6 and 13.0%, respectively. The number of deliveries included in the NTSV metric was stable across all hospital sizes (33.1-36.2%). With the SMFM metric, there was a progressive decline in the number of deliveries included, 90.0 versus 69.6%, in relatively small to large facilities. Variability was less and precision increased with the SMFM metric, which reduced the number of hospitals that could be incorrectly categorized when using performance-based predefined cesarean birth rate paylines. The SMFM metric appears to be better suited as a tool for rapid process improvement programs aimed at reducing cesarean birth rates in low-risk patients.

Women and their newborns are at risk of delayed or withheld skin‐to‐skin care (SSC) during a caesarean, which is about one‐third of births, worldwide. To date, no instrument exists to assess health professionals' (HPs) beliefs, and potential barriers and strategies for implementing SSC during a cesarean. The study aims were to (1) develop an instrument, Health Professionals' Beliefs about Skin‐to‐Skin Care During a Cesarean (SSCB), (2) establish its validity and reliability and (3) describe HPs' beliefs about SSC during a caesarean. Quantitative and qualitative analyses were used to test the SSCB and describe HPs' beliefs. SSCB analysis yielded a content validity of 0.83 and reliability of α = 0.9. We grouped all practice roles as either nurses or physicians. The mean rank score for nurses (n = 120, M = 90) was significantly higher (p = 0.001) than physicians (n = 46, M = 79). Despite this difference, scores for both roles reflected support for SSC. Participants identified hospital readiness to implement SSC and maintaining maternal and newborn safety as major issues. SSCB is a valid, reliable instrument to measure HPs' beliefs about SSC during a caesarean birth. HPs can use the SSCB during quality improvement initiatives to improve access to immediate SSC for women who have a caesarean birth. Improved access can enhance breastfeeding outcomes and promote optimal maternal and child health.

Background:To compare outcomes at Mizan-Tepi University Teaching Hospital to national and regional data and to plan quality improvement and research studies based on the results.Methods:This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1, 000 women who delivered at Mizan-Tepi University Teaching Hospital.Results:Our convenience sample was young (median age 24 years) with a primarily school level or less of education (68.6%). Only about 5% of women had a history of prior cesarean birth, 2.1% reported they were human immunodeficiency virus seropositive, and the median number of prenatal visits was four. Women were commonly admitted in spontaneous labor (84.5%), transferred from another facility (49.2%; 96.8% of which were referred from a health center), and had their fetal heart rate auscultated on admission (94.7%). Only 5.2% of women did not deliver within twenty-four hours and the cesarean birth prevalence was 23.4%. Many women were delivered by midwives (73.2%; all unassisted vaginal births), 89.2% were term deliveries, and 92.5% of neonatal birthweights were 2500 grams or heavier. Less than five percent of women delivered stillbirths (4.3%) and 5.7% of livebirths experienced neonatal death by the day of discharge. There were no maternal deaths in the cohort.Conclusion:The prevalence of stillbirth and neonatal death were the most notable findings, while there was no maternal death in the cohort.

<h3>Context</h3> Cesarean delivery is the most performed surgical procedure across hospitals in the United States. The variation in cesarean birth (CB) rates between hospitals is largely unexplained by patient risk or hospital characteristics, suggesting that unit-level culture may play a key role. Using the Labor Culture Survey (LCS), a validated tool to assess individual and group attitudes towards labor and delivery practices, a Michigan study found reduced clinician fear of vaginal birth is associated with reduction in low risk, primary CB rates. <h3>Objective</h3> To evaluate changes in labor unit culture and hospital-level CB rates in Illinois birthing hospitals from the years 2021 to 2024. <h3>Study Design and Analysis</h3> Longitudinal, cross-sectional observational study integrating LCS Likert-style responses with hospital CB rates. <h3>Dataset</h3> The LCS was administered in 2021 and 2024 and linked with state-reported hospital CB rates from the Illinois Department of Public Health. <h3>Population Studied</h3> Family physicians, obstetricians, midwives, and nurses providing intrapartum care in Illinois hospitals. <h3>Intervention/Instrument</h3> The LCS includes six validated scales assessing clinician attitudes, such as fear of vaginal birth, best practices to reduce cesareans, physician oversight, maternal agency, and perceived cesarean safety, and team-level norms, such as vaginal birth microculture and patient safety culture. <h3>Outcome Measures</h3> Response means in CB rates and each subscale were compared between 2021 and 2024. <h3>Results</h3> 1541 clinicians completed the LCS at both time points in Illinois. Team-level norms differed significantly, per paired t-tests, including a more supportive vaginal birth microculture (2.84 vs 3.05; p &lt; 0.0001), and stronger patient safety culture (2.82 vs 2.95; p = 0.001). There was no significant change in individual-level attitudes towards birth (all p values &gt; 0.05) or the cesarean birth rate (25.4% vs. 24.6%; p = 0.25). <h3>Conclusion</h3> While perceived team-level norms shifted in Illinois hospitals from 2021 to 2024 in ways that would indicate greater support for vaginal birth, individual-level attitudes did not shift, nor did the overall cesarean birth rate. This may indicate that individual-level change is needed to change clinical practice; thus, quality improvement efforts need to focus on ensuring individual-level buy-in and education to reduce cesarean overuse.

Poor-quality maternal and newborn care is associated with maternal mortality, stillbirths, and infant deaths and contributes to acute and chronic clinical and psychological morbidity for women who survive. Midwifery care can make an essential contribution to high-quality maternal and newborn services. The participation of educated, trained, motivated, and respected licensed midwives, working effectively with medical and public health colleagues, is associated with a rapid and sustained decrease in maternal and newborn mortality and an improvement in quality of care. A multimethod approach was used to assess the key concepts of quality in maternal and newborn care including safe, effective, accessible, appropriate, affordable, equitable, efficient, and woman-centered care. A framework for quality maternal and newborn care was devised, using the best evidence for effective care practices. This evidence was used to assess the potential effect of midwifery and the workforce groups best able to provide midwifery care. Essential interlinked components of the framework were effective practices, organization of care, philosophy, and values of the care providers working in the health system and characteristics of care providers. Interdisciplinary teamwork and collaboration are inherent in implementing the framework. Women’s views and experiences show the interrelationship between the different components of quality care. Information and education are essential to allow them to learn for themselves. They need to know and understand the organization of services so they can access them in a timely fashion, services need to be provided in a respectful way by staff who generate trust and who are not abusive or cruel, and care should be personalized to their individual needs and offered by empathic and kind providers. Women want health professionals who combine clinical knowledge and skills with interpersonal and cultural competence. Two sources within the Cochrane Library identified high-quality, current evidence on effectiveness of specific practices in maternal/newborn care. Effective practices related to categories of the framework found that 46 (38%) of the 122 effective practices were relevant for all childbearing women and infants, with 26 (21%) being first-line management for women and infants with complications. Fifty practices (41%) required the input of a medical practitioner with advanced skills in obstetrics, neonatology, or medicine. The practice categories of (1) education, information, health promotion; (2) assessment, screening care planning; (3) promotion of normal processes and preventing complications; and (4) first-line management of complications were identified as being within the scope of midwifery. Seventy-two (59%) of the 122 effective practices were within this scope. Outcomes improved by effective practices by midwives include reduced maternal and neonatal mortality and fetal loss, reduced maternal and neonatal morbidity including preterm birth, reduced use of interventions, improved psychosocial outcomes, improved public health outcomes, and improved organizational outcomes. The 72 effective practices were examined to determine whether they portrayed the cross-cutting components of the framework. Ten (14%) of the 72 practices for all childbearing women were intended to support women’s own capabilities with information or advice that they could act on themselves. Sixty-one (85%) of the effective practices related to only 1 phase of maternal and newborn care, usually pregnancy or labor. Only 20 practices (28%) examined any aspect of care after the birth for the mother or newborn. Only midwife-led continuity models of care and community-based packages of care applied across the whole continuum. Sixty-six (92%) of the effective practices related to care of either the woman or fetus, or both; 4 examined the mother and newborn infant, and only 1 examined care of the infant. When the characteristics and effect of midwives providing some or all components of care were examined in various studies, women who had midwife-led care were less likely to have regional analgesia, episiotomy, and instrumental birth and were more likely to have no intrapartum analgesia or anesthesia, spontaneous vaginal birth, attendance at birth by a known midwife, and a longer mean length of labor. No differences were noted between groups for cesarean births. Women receiving midwifery care were less likely to have a preterm birth and fetal loss at less than 24 weeks’ gestation. Most studies reported a higher rate of maternal satisfaction in the midwifery-led continuity care model. A cost-saving effect was noted for midwifery care compared with other models. In 3 case studies of large countries that account for 35% of all births globally, and in which midwives are marginalized or excluded from the health system, the focus on facility-based and emergency care reduced maternal and perinatal mortality. Without the balancing effect of the full spectrum of midwifery care, this strategy led to rapidly growing numbers of unnecessary and expensive interventions and potentially iatrogenic complications and inequalities in the provision of care and outcomes. The new evidence-based framework for high-quality maternal and newborn care incorporates the need to balance community-based preventive and supportive services for all childbearing women and newborns with the elective and emergency services needed by those with complications. The framework differentiates among what and how care is provided and who should provide it. This framework might be used to structure analyses of health system provision, plan new services, or develop an education curriculum. Future planning for maternal and newborn care systems can benefit from incorporating the quality framework into workforce development and resource allocation.

Objective To investigate the nursing intervene of False- response methods without stimulating environment and its effects upon the improvement of obstetric quality. Methods During april-september, 2009, 2000 pregnant women (including the inpatients and those are under pregnant check) are chosen and they are randomly divided into experimental group and control group. There are 1000 pregnant women in each group. In control group, the common methods (without the nursing intervention) are adopted. In experimental group, beside the common methods, the nursing intervention is conducted. Results After nursing intervention, the incidence rate of non response without stimulating is noticeably lower ( P < 0.05 ). The incidence rate of non-response of embryos and rate of Embryos' poor situation are noticeably lowered ( P < 0.01). The rate of vaginal birth increases (P < 0.05) while the rate of Caesarean birth decreases (P < 0.05). The rate of lightly suffocating of new-bom babies is lower (P< 0.01 ). Conclusions Nursing intervene of False- response methods without stimulating environment can reduce the incidence rate of false response and the detection rate can be more exact. It will avoid the over medical intervention and improve the obstetric quality. Key words: Nursing of embryo expecting to come into the world; Experiment without stimulation; False non response; Nursing

814 Impact of quality improvement efforts at a population level: evidence from cesarean birth trends

Health care organizations have a responsibility to reduce racial and ethnic perinatal health disparities. In the United States, Black women experience the worst perinatal outcomes. The process for successfully addressing this problem in clinical practice remains unclear. A community hospital implemented components of the Alliance for Innovation on Maternal Health Reduction of Peripartum Racial/Ethnic Disparities Patient Safety Bundle. The purpose was to collect and share perinatal disparities data, increase staff awareness of perinatal racial and ethnic disparities, and engage staff to address these disparities at the project site. Perinatal care data were reviewed by race and ethnicity and results were shared with staff. Staff were engaged through a series of activities including a Health Equity Party, implicit bias workshop, Snack and Learn sessions, online modules, 2 grand rounds, and the establishment of a Health Equity Committee. Racial and/or ethnic disparities were identified for perinatal outcomes and experience of care indicators including rates of cesarean birth, newborn mortality, and 30-day readmission. Of the staff 137 (65.9%) participated in project activities. The majority of participants were registered nurses (n = 82). Certified nurse-midwives (n = 10) were the profession with the highest rate of attendance (83.3%). Staff developed 26 new recommendations to address racial and ethnic disparities in care. After project implementation, mean scores of High Provider Attribution, an indicator of readiness to address health disparities, increased from preimplementation scores (P = .01). There was also a significant increase in the number of staff who reported engaging in activities to address the health care needs of racial and ethnic minority patients (P < .001). This quality improvement project demonstrated that interventions at the health care organization level can be effective in influencing health care providers and staff to address racial and ethnic perinatal disparities.

ObjectiveWhile birth-related posttraumatic stress disorder (PTSD) rates are rising, obstetric providers are ill-equipped to lead the trauma response. To address this need, we employed the After-Action Review (AAR) method in semistructured interviews with patients who recently underwent unanticipated cesarean deliveries. We performed qualitative analyses to determine if the AAR technique could (1) provide a therapeutic outlet to patients who experienced trauma and (2) elicit patient-derived quality improvement opportunities.Study DesignTwenty patients and their support people were interviewed during the delivery admission, 3 months postpartum, and via an anonymous survey. Two independent coders analyzed transcripts and themes were generated inductively.ResultsAll surveyed patients found this process helpful, and 80% suggested an improvement, including educating patients about cesareans earlier and designating a specific staff member to support the patient during a cesarean or code. Five main themes emerged: (1) Mental adaptation to new care plan (reported by 95%), (2) prioritizing safety of baby (85%), (3) external influences on birth expectations (70%), (4) importance of support from various team members (85%), and (5) balance between autonomy and desiring definitive recommendations (75% vs. 30%). Interviewers found the technique easy to apply.ConclusionAAR provides a novel, effective, and reproducible mechanism for therapeutic debriefing and generating patient-centered opportunities to improve care within obstetrics.

Implementation of Team Communication and Nurse Feedback to Reduce Cesarean Rates.