Using improvement science to increase accuracy and reliability of gestational age documentation.

Our aim was to improve the reliability of recording gestational age (GA) in the mother's obstetric record, as this record is used for clinical management, research databases, and eventual transmission to the Ohio Department of Health birth certificates. We performed a prospective cohort study, including all hospital births. We began quality improvement interventions in October 2009. Improvement test cycles were targeted to four working groups, including nursing staff, community obstetric providers, and the process itself. Test cycle results were evaluated to determine which successful interventions could spread further. Rates of process outcome measurements were compared by statistical process control and univariate analysis pre- and postintervention. During the preintervention period, the median daily GA reliability was 25%. To date, over 30 small sample size tests of change have been completed. Of 8795 births studied, significant improvement in GA accuracy/completeness was detected (median postintervention = 78%, p < 0.01). Increased communication of and completion of the prenatal record, in addition to GA recording in high-risk groups, such as premature infants, were also achieved (all p < 0.01). GA reliability can be increased using standardized improvement science methods. Better communication of GA will enable better clinical decisions and foster population-based perinatal research.

Rates of substance and polysubstance use through universal maternal testing at the time of delivery.

OBJECTIVE: To report substance and polysubstance use at the time of delivery. STUDY DESIGN: A cross-sectional study was performed on mothers consented for universal drug testing (99%) during hospital admission at six delivery hospitals in Cincinnati, Ohio. Mass spectrometry urinalysis detected positivity rates of 46 substances. Rates of positive drug tests for individual and common co-occurring substances measured were reported. RESULTS: 2531 maternal samples were tested (88%) and 33% contained cotinine, 11.3% THC, 7.2% opioids, 3.8% cocaine, and 1.9% methamphetamines. Polysubstance use prevalence was as high as 15%. Among mothers testing positive for methadone or buprenorphine, 93% also tested positive for cotinine and 39% tested positive for a third substance in addition to cotinine. CONCLUSIONS: Substance use at delivery is more prevalent than previously reported. Many mothers testing positive for opioids also test positive for other substances, which may increase overdose risk and exacerbate neonatal opioid withdrawal syndrome (NOWS).

Neonatal morbidity after documented fetal lung maturity in late preterm and early term infants.

OBJECTIVE: Fetal lung maturity often is used as the sole criterion that late preterm infants are ready for postnatal life. We therefore tested the hypothesis that fetal lung maturity testing does not predict the absence of morbidity in late preterm infants. STUDY DESIGN: We performed a retrospective cohort study to examine 152 infants who were born in the late preterm (34 0/7 to 36 6/7 weeks) and early term (37 0/7 to 38 6/7 weeks) periods after mature fetal lung indices and compared them with 262 infants who were born at ≥39 weeks' gestation and who were matched by mode of delivery. RESULTS: Despite documented fetal lung maturity, infants who were born at <39 weeks had significantly higher rates of neonatal morbidities compared with infants who were born at ≥39 weeks' gestation. After adjustment for significant covariates, we found that infants who were born at <39 weeks' gestation had an increased risk of composite adverse outcome (odds ratio, 3.66; 95% confidence interval, 1.48-9.09; P < .01). CONCLUSION: Fetal lung maturity testing is insufficient to determine an infant's readiness for postnatal life.

Statewide Quality Improvement Initiative to Reduce Early Elective Deliveries and Improve Birth Registry Accuracy.

OBJECTIVE: To evaluate the success of a quality improvement initiative to reduce early elective deliveries at less than 39 weeks of gestation and improve birth registry data accuracy rapidly and at scale in Ohio. METHODS: Between February 2013 and March 2014, participating hospitals were involved in a quality improvement initiative to reduce early elective deliveries at less than 39 weeks of gestation and improve birth registry data. This initiative was designed as a learning collaborative model (group webinars and a single face-to-face meeting) and included individual quality improvement coaching. It was implemented using a stepped wedge design with hospitals divided into three balanced groups (waves) participating in the initiative sequentially. Birth registry data were used to assess hospital rates of nonmedically indicated inductions at less than 39 weeks of gestation. Comparisons were made between groups participating and those not participating in the initiative at two time points. To measure birth registry accuracy, hospitals conducted monthly audits comparing birth registry data with the medical record. Associations were assessed using generalized linear repeated measures models accounting for time effects. RESULTS: Seventy of 72 (97%) eligible hospitals participated. Based on birth registry data, nonmedically indicated inductions at less than 39 weeks of gestation declined in all groups with implementation (wave 1: 6.2-3.2%, P<.001; wave 2: 4.2-2.5%, P=.04; wave 3: 6.8-3.7%, P=.002). When waves 1 and 2 were participating in the initiative, they saw significant decreases in rates of early elective deliveries as compared with wave 3 (control; P=.018). All waves had significant improvement in birth registry accuracy (wave 1: 80-90%, P=.017; wave 2: 80-100%, P=.002; wave 3: 75-100%, P<.001). CONCLUSIONS: A quality improvement initiative enabled statewide spread of change strategies to decrease early elective deliveries and improve birth registry accuracy over 14 months and could be used for rapid dissemination of other evidence-based obstetric care practices across states or hospital systems.

Findings from a 10-year follow-up of bone mineral density in competitive perimenopausal runners.

OBJECTIVE: To evaluate bone mineral density (BMD) in perimenopausal competitive runners with long-term follow-up. STUDY DESIGN: Fifteen master female runners between 40 and 50 years old who ran at least 20 miles per week were evaluated. BMD was measured by dual-energy x-ray absorptiometry (DEXA) at baseline and at the 10-year follow-up. RESULTS: The median age was 46 and median miles run per week, 25. At baseline, after a median of 11 years of competitive running, hip BMD was above peak bone mass (T-score = 0.8) and that of age-matched controls (Z-score = 1.6), while lumbar spine BMD was below peak bone mass (T-score = -0.8) and equal to that of age-matched controls (Z-score = -0.1). At the 10-year follow-up, hip BMD fell below peak bone mass (T-score = -0.2, p = 0.0004) but was still above that of age-matched controls (Z-score = 0.5, p = 0.002), while there was little change in lumbar spine BMD. CONCLUSION: Competitive running prior to the perimenopausal period seems to be associated with improved hip BMD. However, continued competitive running during the perimenopausal period is not associated with prevention of a perimenopausal hip BMD decline. In contrast, competitive running had little effect on peri-menopausal lumbar spine BMD.

A Statewide Progestogen Promotion Program in Ohio.

OBJECTIVE: To promote use of progestogen therapy to reduce premature births in Ohio by 10%. METHODS: The Ohio Perinatal Quality Collaborative initiated a quality improvement project in 2014 working with clinics at 20 large maternity hospitals, Ohio Medicaid, Medicaid insurers, and service agencies to use quality improvement methods to identify eligible women and remove treatment barriers. The number of women eligible for prophylaxis, the percent prescribed a progestogen before 20 and 24 weeks of gestation, and barriers encountered were reported monthly. Clinics were asked to adopt protocols to identify candidates and initiate treatment promptly. System-level changes were made to expand Medicaid eligibility, maintain Medicaid coverage during pregnancy, improve communication, and adopt uniform data collection and efficient treatment protocols. Rates of singleton births before 32 and 37 weeks of gestation in Ohio hospitals were primary outcomes. We used statistical process control methods to analyze change and generalized linear mixed models to estimate program effects accounting for known risk factors. RESULTS: Participating sites tracked 2,562 women eligible for treatment between January 1, 2014, and November 30, 2015. Late entry to care, variable interpretation of treatment guidelines, maintenance of Medicaid coverage, and inefficient communication among health care providers and insurers were identified as treatment barriers. Births before 32 weeks of gestation decreased in all hospitals by 6.6% and in participating hospitals by 8.0%. Births before 32 weeks of gestation to women with prior preterm birth decreased by 20.5% in all hospitals, by 20.3% in African American women, and by 17.1% in women on Medicaid. Births before 37 weeks of gestation were minimally affected. Adjusting for risk factors and birth clustering by hospital confirmed a program-associated 13% (95% confidence interval 0.3-24%) reduction in births before 32 weeks of gestation to women with prior preterm birth. CONCLUSION: The Ohio progestogen project was associated with a sustained reduction in singleton births before 32 weeks of gestation in Ohio.

A novel amniocentesis model for learning stereotactic skills.

OBJECTIVE: This study developed a lifelike amniocentesis model to allow effective acquisition of the stereotactic skills necessary and comfort level with this procedure. STUDY DESIGN: An amniocentesis model is constructed using a formalin preserved gravid pig uterus. A large Ziploc freezer bag (Dow, Indianapolis, Ind) filled with ultrasound gel is placed on the uterus to simulate the skin and subcutaneous layer. RESULTS: Amniocentesis can be performed in the usual fashion using this lifelike model. No leak was observed in the Ziploc bag (Dow) or gravid uterus despite more than 50 needle insertions. The cost of 4 to 5 learning stations is approximately $50.00. This model enjoys the advantages of being changeable to reproduce a variety of real-life situations, including poly/oligo/anhydramnios, varied fetal positions and different thickness of subcutaneous tissue. CONCLUSION: This low-cost novel model provides realistic tissue resistance and yields a sonographically accurate amniocentesis-training tool. The use of this model permits resident instruction in a nonthreatening environment.

Antenatal steroids for treatment of fetal lung immaturity after 34 weeks of gestation: an evaluation of neonatal outcomes.

OBJECTIVE: To estimate whether antenatal corticosteroids given after fetal lung immaturity in pregnancies at 34 weeks of gestation or more would improve neonatal outcomes and, in particular, respiratory outcomes. METHODS: We compared outcomes of 362 neonates born at 34 weeks of gestation or more after fetal lung maturity testing: 102 with immature fetal lung indices were treated with antenatal corticosteroids followed by planned delivery within 1 week; 76 with immature fetal lung indices were managed expectantly; and 184 were delivered after mature amniocentesis. Primary outcomes were composites of neonatal and respiratory morbidity. RESULTS: Compared with corticosteroid-exposed neonates those born after mature amniocentesis had lower rates of adverse neonatal (26.5% compared with 14.1%, adjusted odds ratio [OR] 0.51, 95% confidence interval [CI] 0.27-0.96) and adverse respiratory outcomes (9.8% compared with 3.3%, adjusted OR 0.33, 95% CI 0.11-0.98); newborns born after expectant management had significantly less respiratory morbidity (1.3% compared with 9.8%, adjusted OR 0.11, 95% CI 0.01-0.92) compared with corticosteroid-exposed newborns. CONCLUSION: Administration of antenatal corticosteroids after immature fetal lung indices did not reduce respiratory morbidity in neonates born at 34 weeks of gestation or more. Our study supports prolonging gestation until delivery is otherwise indicated. LEVEL OF EVIDENCE: II.