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

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

Three Missed Critical Nursing Care Processes on Labor and Delivery Units During the COVID-19 Pandemic.

OBJECTIVE: To examine the relationships of three missed critical nursing care processes on labor and delivery units with reduced nursing time at the bedside and adequacy of unit staffing during the COVID-19 pandemic in the United States. DESIGN: A cross-sectional survey. SETTING: Online distribution from January 14 to February 26, 2021. PARTICIPANTS: A national convenience sample (N = 836) of registered nurses employed on labor and delivery units. METHODS: We conducted descriptive analyses on respondent characteristics and critical missed care items adapted from the Perinatal Missed Care Survey. We conducted robust logistic regression analyses to assess the relationships of three missed critical nursing care processes (surveillance of fetal well-being, excessive uterine activity, and development of new maternal complications) with reduced nursing time at the bedside and adequacy of unit staffing during the COVID-19 pandemic. RESULTS: Less nursing time at the bedside was associated with greater odds of missing any of the critical aspects of care, adjusted odds ratio = 1.77, 95% confidence interval [1.12, 2.80]. Adequate staffing greater than or equal to 75% of the time was associated with lower odds of missing any of the critical aspects of care compared to adequate staffing less than or equal to 50% of the time, adjusted odds ratio = 0.54, 95% confidence interval [0.36, 0.79]. CONCLUSION: Perinatal outcomes are dependent on the timely recognition of and response to abnormal maternal and fetal conditions during childbirth. In times of unexpected complexity in care and resource constraints, a focus on three critical aspects of perinatal nursing care is needed to maintain patient safety. Strategies that enable bedside presence of nurses, including maintaining adequate unit staffing, may help to mitigate missed care.

Survey of Nursing Faculty Preparation for Guiding DNP Quality Improvement Projects.

BACKGROUND: Quality improvement (QI) projects comprise the majority of University of Maryland School of Nursing (UMSON) Doctor of Nursing Practice (DNP) projects. METHODS: An online survey was completed by 51% (n = 38) of faculty, who teach or mentor DNP students, and was analyzed using quantitative and descriptive methods. RESULTS: Faculty were somewhat or not familiar with developing a QI charter 68.4%, human error theory and error proofing 63.2%, driver diagrams 60.5%, characteristics of high-reliability organizations 60.5%, and Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines 55.3%. The faculty were most interested in learning more about (n = 97 responses) were human error theory and error proofing (28.9%), SQUIRE guidelines (26.3%), statistical process control (21.1%), and implementation strategies and tactics (21.1%). The most commonly identified challenges included identifying QI projects (24%), project time constraints (16%), keeping up-to-date on QI concepts, methods, and tools (12%), and balancing professional workload (10%). CONCLUSIONS: Gaps in self-reported QI knowledge indicate there is a need for further development of DNP and PhD prepared faculty at the UMSON.

Lessons Learned Using Logic Models to Design and Guide DNP Projects.

BACKGROUND: A final culminating project that is derived from a practice immersion experience is a critical part of a doctor of nursing practice (DNP) program. PROBLEM: Many schools use well-designed quality improvement (QI) projects to meet this requirement, but there is no consensus on which QI methods and tools are the most effective for DNP students to demonstrate before graduation. APPROACH: One Mid-Atlantic public university began using QI process models, one of which was a logic model, to guide their DNP projects. This led to subsequent changes in the curriculum, faculty preparation, and practice partner responsibilities. OUTCOME: Many benefits and challenges were identified during the logic model implementation that may benefit other schools seeking to increase consistency and rigor. Although the learning process for students and faculty may be challenging, the outcomes included improved project conceptualization, clarity, concision, and feasibility of goal attainment. CONCLUSIONS: Use of logic models expands DNP students' skills to develop and implement a successful project and supports clinical scholarship.

Practice and Quality Improvement Leaders Survey of Expectations of DNP Graduates' Quality Improvement Expertise.

BACKGROUND: Input from practice leaders will improve how doctor of nursing practice (DNP) education is meeting the needs of the employer and improving patient outcomes. PURPOSE: This article describes the expectations practice leaders have of new DNP graduates' ability to contribute to quality improvement (QI) efforts within health care organizations. METHODS: A survey of practice leaders and QI experts investigated the importance and use of QI knowledge and skills. Practice leaders were also asked about the expectations of DNP graduates at the time of hire. RESULTS: The results of this study support the need for nurses pursuing a DNP in advanced nursing practice to have education and training beyond their area of specialization, specifically in QI methods and tools. CONCLUSIONS: Faculty need to provide DNP students education that includes concepts in QI and leadership to meet the expectations of future employers and the needs of a complex and changing health care system.

Development of a DNP measurement grid to increase the rigor of doctor of nursing practice students' data collection and analysis methods.

A key component of the DNP project rigor is the collection and analysis of data or measurement. A Steering Committee at the University of Maryland formed to improve the quality of DNP projects established a workgroup to evaluate the current measurement content in four DNP core courses with the goal of establishing DNP project measurement criteria across the curriculum. The steps included: Step 1: Identify QI Measurement Methods and Tools. Identify the essential QI measurement methods and tools recommended by national organizations. Step 2: Create a DNP Measurement Grid. Define main data methods topics with subtopics. Step 3: Map the DNP core courses. Using the DNP Measurement Grid criteria determine the measurement content included in each course and student mastery level. The level of mastery was ranked from introduced (awareness), to reinforced (knowledge), to demonstrated (application). Step 4: Evaluate and Refine the DNP Measurement Grid Criteria. Adjustments were made in the DNP curriculum to include topics and subtopics at the desired mastery level. The rigor of data measurement and analysis will be evaluated in future DNP projects. The workgroup's four-step process provides a path that facilitated improving curriculum measurement content. This process may provide guidance for others undertaking similar work.

Structuring Doctor of Nursing Practice project courses to facilitate success and ensure rigor.

There is currently a lack of consensus on the best format for Doctor of Nursing Practice project deliverables. In this article the project course history, current format, and evaluation methods are described for a Doctor of Nursing Practice program during the transition from a sole post-master's option to one that also admitted post-baccalaureate students. The project course format shifted focus from one in which students independently implemented multiple types of projects under the direction of a chairperson and committee to one in which students carried out projects utilizing quality improvement methods and tools under the mentorship of a project faculty advisor and clinical site representative. The integration of quality improvement models is exemplified through course objectives and assignments. Lessons learned through this transition are provided in the hope that the work may benefit other nursing schools with similar programs.

Variation of intrapartum care and cesarean rates among practitioners attending births of low-risk, nulliparous women.

BACKGROUND: Variation in hospital cesarean birth rates across the United States is likely because of differences in practitioner practice patterns. Yet, few studies conducted in the last twenty years have examined the relationships between practitioner characteristics and the use of intrapartum interventions and cesarean birth. The objective of this study was to examine associations among practitioner characteristics and the use of amniotomy, epidural, oxytocin augmentation, and cesarean birth in low-risk women with spontaneous onset of labor. METHODS: A secondary analysis was performed using data collected by the Consortium on Safe Labor. The sample included nulliparous term singleton vertex (NTSV) births with spontaneous onset of labor (n = 13 196) from 2002 to 2007 across eight hospitals. Generalized linear mixed models were conducted to examine outcomes. RESULTS: The cesarean birth rate ranged from 7.2% to 18.9% across hospitals and from 0% to 53.3% across physicians. Practice type (P < .05) and specialty type (P < .0001) were associated with physician cesarean birth rates. Compared with obstetrician/gynecologists, midwives were nearly twice as likely to use no intrapartum interventions (relative risk 1.80 [CI 95 1.45-2.24]) and 26% less likely to use amniotomy-epidural-oxytocin (0.74 [0.62-0.89]). Family practice physicians had a 21% lower likelihood of using amniotomy-epidural-oxytocin (0.79 [0.67-0.94]) and a 53% lower likelihood of performing cesarean births (0.47 [0.35-0.63]). CONCLUSIONS: Wide variation in hospital and physician cesarean birth rates was observed in this sample of low-risk, nulliparous women. Practitioner practice type and specialty were significantly associated with the use of intrapartum interventions. Interprofessional practitioner education could be one strategy to reduce variation of intrapartum care and cesarean birth.

Associations Among Intrapartum Interventions and Cesarean Birth in Low-Risk Nulliparous Women with Spontaneous Onset of Labor.

INTRODUCTION: Cesarean birth rates vary widely across hospitals in the United States, even among women who are considered low-risk for the procedure. This variation has been attributed to differences in health care provider practice, but few studies have explored patterns of labor management in relation to cesarean birth. METHODS: This was a retrospective observational study of 26,259 nulliparous, term, singleton gestation, vertex presentation births following spontaneous onset of labor. Births occurred from 2002 to 2007 in 11 hospitals in the Consortium on Safe Labor. Generalized linear mixed modeling was used to examine the relationship between intrapartum interventions (amniotomy, epidural analgesia, oxytocin augmentation) used individually and in combination and the outcome of cesarean birth. RESULTS: More than 90% of the women in this low-risk sample received at least one intervention regardless of mode of birth. Epidural analgesia was the most frequently applied intervention, both when used as a single intervention (18.7%) and in combination with other interventions (79.9%). The strongest associations between these interventions and cesarean birth were observed when 2 or 3 interventions were applied during labor. Compared with women who received no interventions, the strongest association was observed among women who received amniotomy-oxytocin augmentation (adjusted odds ratio [aOR], 1.89; 95% CI, 1.36-2.62). The use of all 3 interventions (amniotomy-epidural analgesia-oxytocin augmentation) showed a similar positive association with cesarean birth (aOR 1.83; 95% CI, 1.50-2.21). DISCUSSION: Findings show that the combined use of amniotomy, epidural analgesia, and oxytocin augmentation is positively associated with cesarean birth. Additional research is needed to examine the timing and sequence of interventions as well as whether a causal relationship exists between combinations of interventions and cesarean birth in low-risk nulliparous women.

Feasibility of AWHONN's Immediate and Continuous Skin-to-Skin Nursing Care Quality Measures.

Use of skin-to-skin contact after birth supports a newborn's physiologic transition from intra- to extrauterine life, mother-infant bonding, and the initiation of breastfeeding. Nursing Care Quality Measures 3 and 4 (Skin-to-Skin is Initiated Immediately Following Birth and Duration of Uninterrupted Skin-to-Skin Contact) from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) were developed to support quality improvement efforts to increase skin-to-skin contact. AWHONN's nursing care quality measures were found to be feasible in hospitals in which medical records were configured to document the start and stop times of skin-to-skin contact. Electronic health records can be modified so that more accurate quality improvement data on immediate and continuous skin-to-skin contact are available. More accurate data will support validity testing.

Quality Improvement Approach to Eliminate Disparities in Perinatal Morbidity and Mortality.

"Preventable disparities in health outcomes for women during the perinatal period are unacceptable. To successfully combat these inequities, it is important to identify their causes and use quality improvement approaches to eliminate them. Proposed are 5 quality and safety strategies to guide efforts to eliminate disparities and ensure equitable health care for all women and newborns: (1) apply a systems approach based on the Socio-Ecological Model, (2) identify root causes of disparities, (3) identify and eliminate strong but wrong routines, (4) use improvement and implementation science methods and tools, and (5) use data to guide the plan and track progress."

Associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women.

BACKGROUND: Admission in early labor is associated with increased likelihood of cesarean birth, but the context in which this occurs is unclear. Previous research has explored the relationship between dilatation at admission and the use of single intrapartum interventions; however, the majority of women in the United States receive multiple intrapartum interventions. The objective of this study was to examine the associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women with spontaneous onset of labor. METHODS: This was a cross-sectional, observational study of 21 858 nulliparous, singleton, term vertex births that occurred from 2002 to 2007 across nine hospitals in the Consortium on Safe Labor. Outcome measures included the individual and combined use of intrapartum interventions (amniotomy, epidural anesthesia, oxytocin augmentation) and birth mode. RESULTS: In this sample, 92.0% of women received at least one intrapartum intervention and 22.7% received all three interventions. After propensity score adjustment, women were more than twice as likely to receive the combination of amniotomy-epidural-oxytocin when admitted at 0-3 cm (RR 2.83 [95% CI 2.45-3.27]) and 4-5 cm (2.49 [2.15-2.89]) compared to 6-10 cm. Adjusted likelihood of cesarean birth was five times greater for women admitted at 0-3 cm (5.26 [4.36-6.34]) and two times greater for women admitted at 4-5 cm (2.27 [1.86-2.77]) compared to 6-10 cm. CONCLUSIONS: To promote normal physiologic birth, low-risk, nulliparous women should be engaged in shared decision-making about timing of admission after spontaneous onset of labor.

Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing.

The Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing charts an efficient pathway to a maternity care system that reliably enables all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences. The authors are members of a multistakeholder, multidisciplinary National Advisory Council that collaborated to develop this document. This approach preventively addresses troubling trends in maternal and newborn outcomes and persistent racial and other disparities by mobilizing innate capacities for healthy childbearing processes and limiting use of consequential interventions. It provides more appropriate care to healthier, lower-risk women and newborns who often receive more specialized care, though such care may not be needed and may cause unintended harm. It also offers opportunities to improve the care, experience and outcomes of women with health challenges by fostering healthy perinatal physiologic processes whenever safely possible.

Perceptions of Safety Improvement Among Clinicians Before and After Participation in a Multistate Postpartum Hemorrhage Project.

OBJECTIVE: To measure whether implementation of a comprehensive, 18-month, multihospital, multiregion postpartum hemorrhage (PPH) project influenced intrapartum clinicians' perceptions of patient safety. DESIGN: Pre- and post-survey design. SETTING: Survey results from eight hospitals in Georgia, New Jersey, and Washington that participated in the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) PPH Project were included in the final analysis. The number of annual births at the hospitals ranged from 1,290 to 3,567. PARTICIPANTS: There were 473 respondents for the pre-implementation survey: 50.5% (239) were registered nurses, 27.1% (128) were physicians, and 22.4% (106) were other intrapartum clinicians. The post-implementation survey included 426 respondents: 62.9% (268) registered nurses, 18.5% (79) physicians, and 18.6% (79) other intrapartum clinicians. INTERVENTION/MEASUREMENTS: A paired t test was used to compare Safety Attitudes Questionnaire (SAQ) domain scores. Pearson's chi-square test was used to analyze perceptions before and after the intervention. RESULTS: Baseline SAQ scores were high in all six domains. Improvements were noted in five of the six domains measured; none reached statistical significance. A significant improvement was found in reported perception of the quality of nursing care after implementation of the PPH Project. CONCLUSION: SAQ scores remained high and showed some improvement among participating hospitals. Participation in the PPH Project increased overall perceptions of safety among the clinicians at these hospitals.

Healthcare Strategies for Reducing Pregnancy-Related Morbidity and Mortality in the Postpartum Period.

The majority of pregnancy-related deaths in the United States occur in the postpartum period, after a woman gives birth. Many of these deaths are preventable. Researchers and health care providers have been focusing on designing and implementing strategies to eliminate preventable deaths and ethnic and racial disparities. Six healthcare strategies for reducing postpartum maternal morbidity and mortality will be described. These strategies, if provided in an equitable manner by all providers to all women, will assist in closing the disparity in outcomes between black women and women of all other races and ethnicities who give birth throughout the United States.

Structure, Process, and Outcome Data of AWHONN's Postpartum Hemorrhage Quality Improvement Project.

OBJECTIVE: To describe the structures and processes implemented during the Association of Women's Health, Obstetric, and Neonatal Nurses Postpartum Hemorrhage (AWHONN PPH) Project. DESIGN: An 18-month, multiregion, multihospital quality improvement project. SETTING/LOCAL PROBLEM: Fifty-eight hospitals located in Washington, DC; Georgia; and New Jersey. PARTICIPANTS: Volunteer registered nurse hospital leaders implemented the AWHONN PPH bundle, which consisted of structure and process improvements. INTERVENTION/MEASUREMENTS: The process and effectiveness of the implementation of the interventions were measured and compared between baseline and after implementation. RESULTS: All structures and processes showed improvement but were not fully implemented at all sites. Registered nurse participation in drills increased from 0% to 92%, quantification of blood loss increased from 5% to 45%, hemorrhage risk assessment increased from 10% to 70%, prebirth risk assessment increased from 2% to 52%, postbirth risk assessment increased from 2% to 57%, and debriefing increased from 1% to 13%. No statistically significant differences were found in the pre- and postimplementation outcomes measured (maternal deaths, blood products transfused, women with massive transfusions, peripartum hysterectomies during the birth admission, and ICU admissions for women who gave birth and/or had a postpartum hemorrhage). Participants' self-assessments of their monthly implementation efforts (leader intensity) were not correlated with implementation fidelity (the degree to which the intervention was provided as proposed). CONCLUSION: None of the 58 hospitals were able to implement all of the structure and process changes before the end of the 18-month implementation phase. This suggests that an 18-month implementation phase may be too short.

Barriers and Facilitators to Implementation of a Multistate Collaborative to Reduce Maternal Mortality From Postpartum Hemorrhage.

OBJECTIVE: To describe the barriers and facilitators to implementing the Association of Women's Health, Obstetric and Neonatal Nurses Postpartum Hemorrhage (AWHONN PPH) Project experienced by hospital leaders, project champions, and staff. DESIGN: Qualitative descriptive study with a grounded theory approach. SETTING: Hospital leaders, champions, and staff from hospitals in New Jersey and Georgia. PARTICIPANTS: A total of 21 nurses and physicians who worked at six hospitals shared their experiences with regard to implementation of the AWHONN PPH Project. METHODS: Interviews were recorded and transcribed verbatim. Analysis included open, selective, and theoretical coding with a constant comparative method of grounded theory. Analysis was complete when a central process emerged. RESULTS: Successful implementation of most or all of the program elements was facilitated by support from administrators, positive attitudes, active nurse and physician champions, and an existing culture of safety. When these elements were in place, respondents reported that they believed they made a difference. Barriers to implementation included negative attitudes, lack of champions, poor staff buy in, lack of resources, and lack of support from administrators. When barriers were encountered, respondents felt discouraged and disappointed. CONCLUSION: Although the road to full participation and implementation was difficult for some, lessons were learned by all. Suggestions for future projects include a step-by-step approach that begins with education, the creation and celebration of milestones, and the formation of teams to facilitate buy in and empowerment.

Nurses' Knowledge and Teaching of Possible Postpartum Complications.

PURPOSE: The purpose of this study was to assess postpartum nurses' knowledge of maternal morbidity and mortality, and information they shared with women before discharge about identifying potential warning signs of postpartum complications. STUDY DESIGN & METHODS: Registered nurses (RNs) who care for women during postpartum (N = 372) completed an electronic survey. Descriptive statistics and bivariate analyses were used for data analysis. RESULTS: Fifty-four percent of nurse participants were aware of the rising rates of maternal mortality in the United States and 12% accurately reported the correct percentage of deaths that occurred during the postpartum period. Ninety-three percent of nurses were more likely to identify hemorrhage as a leading cause of maternal mortality. On the day of discharge, 67% of RNs spent less than 10 minutes focusing on potential warning signs. Ninety-five percent of RNs reported a correlation between postpartum education and mortality; however, only 72% strongly agreed it was their responsibility to provide this education. Nurse respondents who were over the age of 40 were significantly more likely to report feeling very competent when providing education on all of the postpartum complication variables measured (p values <0.001-0.003). CLINICAL IMPLICATIONS: The majority of nurses in this study were not up-to-date on the rates and timing of maternal mortality during the postpartum period in the United States. They did not always provide comprehensive education to all women prior to discharge from the hospital after childbirth. There is a need for nurses to provide consistent messages about potential warning signs that may ultimately reduce maternal death and severity of maternal complications.

Relationship Between Labor and Delivery Unit Management Practices and Maternal Outcomes.

OBJECTIVE: To define, measure, and characterize key competencies of managing labor and delivery units in the United States and assess the associations between unit management and maternal outcomes. METHODS: We developed and administered a management measurement instrument using structured telephone interviews with both the primary nurse and physician managers at 53 diverse hospitals across the United States. A trained interviewer scored the managers' interview responses based on management practices that ranged from most reactive (lowest scores) to most proactive (highest scores). We established instrument validity by conducting site visits among a subsample of 11 hospitals and established reliability using interrater comparison. Using a factor analysis, we identified three themes of management competencies: management of unit culture, patient flow, and nursing. We constructed patient-level regressions to assess the independent association between these management themes and maternal outcomes. RESULTS: Proactive management of unit culture and nursing was associated with a significantly higher risk of primary cesarean delivery in low-risk patients (relative risk [RR] 1.30, 95% CI 1.02-1.66 and RR 1.47, 95% CI 1.13-1.92, respectively). Proactive management of unit culture was also associated with a significantly higher risk of prolonged length of stay (RR 4.13, 95% CI 1.98-8.64), postpartum hemorrhage (RR 2.57, 95% CI 1.58-4.18), and blood transfusion (RR 1.87, 95% CI 1.12-3.13). Proactive management of patient flow and nursing was associated with a significantly lower risk of prolonged length of stay (RR 0.23, 95% CI 0.12-0.46 and RR 0.27, 95% CI 0.11-0.62, respectively). CONCLUSION: Labor and delivery unit management varies dramatically across and within hospitals in the United States. Some proactive management practices may be associated with increased risk of primary cesarean delivery and maternal morbidity. Other proactive management practices may be associated with decreased risk of prolonged length of stay, indicating a potential opportunity to safely improve labor and delivery unit efficiency.

Improving Postpartum Education About Warning Signs Of Maternal Morbidity and Mortality.

Maternal morbidity and mortality rates remain high in the United States compared with other developed countries. Of particular concern is the rise in postpartum deaths, because many of the risk factors for complications associated with maternal morbidity and mortality may not be clearly identified before a woman's discharge after birth. Although nurses provide some form of postpartum discharge education to all women who give birth, the information women receive on common potential complications is not always consistent or evidence based. By improving postpartum education, nurses may be better poised to teach women how to recognize and respond to warning signs. This article describes a project intended to increase women's access to predischarge education about the risks for postbirth complications.