Impact of an educational program and decision tool on choice of maternity hospital: the delivery decisions randomized clinical trial.

BACKGROUND: Reducing cesarean rates is a public health priority. To help pregnant people select hospitals with lower cesarean rates, numerous organizations publish publically hospital cesarean rate data. Few pregnant people use these data when deciding where to deliver. We sought to determine whether making cesarean rate data more accessible and understandable increases the likelihood of pregnant people selecting low-cesarean rate hospitals. METHODS: We conducted a 1:1 randomized controlled trial in 2019-2021 among users of a fertility and pregnancy mobile application. Eligible participants were trying to conceive for fewer than five months or were 28-104 days into their pregnancies. Of 189,456 participants approached and enrolled, 120,621 participants met entry criteria and were included in analyses. The intervention group was offered an educational program explaining the importance of hospital cesarean rates and an interactive tool presenting hospital cesarean rates as 1-to-5-star ratings. Control group users were offered an educational program about hospital choice and a hospital choice tool without cesarean rate data. The primary outcome was the star rating of the hospital selected by each patient during pregnancy. Secondary outcomes were the importance of cesarean rates in choosing a hospital and delivery method (post-hoc secondary outcome). RESULTS: Of 120,621 participants (mean [SD] age, 27.8 [7.9]), 12,284 (10.2%) reported their choice of hospital during pregnancy, with similar reporting rates in the intervention and control groups. Intervention group participants selected hospitals with higher star ratings (2.52 vs 2.16; difference, 0.37 [95% CI, 0.32 to 0.43] p < 0.001) and were more likely to believe that the hospitals they chose would impact their chances of having cesarean deliveries (38.5% vs 33.1%, p < 0.001) but did not assign higher priority to cesarean delivery rates when choosing their hospitals (76.2% vs 74.3%, p = 0.05). There was no difference in self-reported cesarean rates between the intervention and control groups (31.4% vs 31.4%, p = 0.98). CONCLUSION: People offered an educational program and interactive tool to compare hospital cesarean rates were more likely to use cesarean data in selecting a hospital and selected hospitals with lower cesarean rates but were not less likely to have a cesarean. CLINICAL TRIAL REGISTRATION: Registered December 9, 2016 at clinicaltrials.gov, First enrollment November 2019. ID NCT02987803, https://clinicaltrials.gov/ct2/show/NCT02987803.

Improving communication and teamwork during labor: A feasibility, acceptability, and safety study.

BACKGROUND: TeamBirth was designed to promote best practices in shared decision making (SDM) among care teams for people giving birth. Although leading health organizations recommend SDM to address gaps in quality of care, these recommendations are not consistently implemented in labor and delivery. METHODS: We conducted a mixed-methods trial of TeamBirth among eligible laboring patients and all clinicians (nurses, midwives, and obstetricians) at four high-volume hospitals during April 2018 to September 2019. We used patient and clinician surveys, abstracted clinical data, and administrative claims to evaluate the feasibility, acceptability, and safety of TeamBirth. RESULTS: A total of 2,669 patients (approximately 28% of eligible delivery volume) and 375 clinicians (78% response rate) responded to surveys on their experiences with TeamBirth. Among patients surveyed, 89% reported experiencing at least one structured full care team conversation ("huddle") during labor and 77% reported experiencing multiple huddles. There was a significant relationship between the number of reported huddles and patient acceptability (P < 0.001), suggestive of a dose response. Among clinicians surveyed, 90% would recommend TeamBirth for use in other labor and delivery units. There were no significant changes in maternal and newborn safety measures. CONCLUSIONS: Implementing a care process that aims to improve communication and teamwork during labor with high fidelity is feasible. The process is acceptable to patients and clinicians and shows no negative effects on patient safety. Future work should evaluate the effectiveness of TeamBirth in improving care experience and health outcomes.

Comparing Methods of Identifying Outlying Nurses in Audits of Low-Risk Cesarean Delivery Rates.

BACKGROUND: The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes. PURPOSE: Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers. METHODS: We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated. RESULTS: Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions. CONCLUSIONS: Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.

Variation in guideline-based prenatal care in a commercially insured population.

BACKGROUND: Despite the importance of prenatal care, quality measurement efforts have focused on the number of prenatal visits, or prenatal care adequacy, rather than the services received. It is unknown whether attending more prenatal visits is associated with receiving more guideline-based prenatal care services. The relationship between guideline-based prenatal care and patients' clinical and sociodemographic characteristics has also not been studied. OBJECTIVE: This study aimed to measure the receipt of guideline-based prenatal care among pregnant patients and to describe the association between guideline-based prenatal care and the number of prenatal visits and other patient characteristics. STUDY DESIGN: This was a retrospective descriptive cohort study of 176,092 pregnancy episodes between 2016 and 2019. We used de-identified administrative claims data on commercial enrollees across the United States from the OptumLabs Data Warehouse. We identified the following 8 components of prenatal care that are universally recommended by the American College of Obstetricians and Gynecologists and other guideline-issuing organizations: testing for sexually transmitted infections, obstetric laboratory test panel, urine culture, urinalysis, anatomy scan ultrasound, oral glucose tolerance test, tetanus, diphtheria, and pertussis vaccine, and group B Streptococcus test. We measured the proportion of pregnant patients who received each of these guideline-based services at the appropriate gestational age. We measured the association between guideline-based services and the number of prenatal visits and prenatal care adequacy. We described variation of guideline-based care according to patient age, comorbidities, high deductible health plan enrollment, and their county's rurality, health professional shortage area status, racial composition, median income, and educational attainment. RESULTS: The 176,092 pregnancy episodes were mostly among patients aged 25 to 34 years (63%) with few pregnancy comorbidities (81%) and living in urban areas (92%). Guideline-based care varied by service, from 51% receiving a timely urinalysis to 90% receiving an anatomy scan and 91% completing testing for sexually transmitted infections. Patients with at least 4 prenatal visits received, on average, 6 of the 8 guideline-based services. Guideline-based care did not increase with additional prenatal visits and varied by patient characteristics. Rates of tetanus, diphtheria, and pertussis vaccination were lower in counties with high proportions of minoritized populations, lower education, and lower income. CONCLUSION: In this commercially insured population, receipt of guideline-based care was not universal, did not increase with the number of prenatal visits, and varied by patient- and area-level characteristics. Measuring guideline-based care is feasible and may capture quality of prenatal care better than visit count or adequacy alone.

Patterns of Use of a Price Transparency Tool for Childbirth Among Pregnant Individuals With Commercial Insurance.

Importance: When introduced a decade ago, patient-facing price transparency tools had low use rates and were largely not associated with changes in spending. Little is known about how such tools are used by pregnant individuals in anticipation of childbirth, a shoppable service with increasing out-of-pocket spending. Objective: To measure changes over time in the patterns and characteristics of use of a price transparency tool by pregnant individuals, and to identify the association between price transparency tool use, coinsurance, and childbirth spending. Design, Setting, and Participants: This descriptive cross-sectional study of 2 cohorts used data from a US commercial health insurance company that launched a web-based price transparency tool in 2010. Data on all price transparency tool queries for 2 periods (January 1, 2011, to December 31, 2012, and January 1, 2015, to December 31, 2016) were obtained. The sample included enrollees aged 19 to 45 years who had a delivery episode during 2 periods (November 1, 2011, to December 31, 2012, or November 1, 2015, to December 31, 2016) and were continuously enrolled for the 10 months prior to delivery (N = 253 606). Exposures: Access to a web-based price transparency tool that provided individualized out-of-pocket price estimates for vaginal and cesarean deliveries. Main Outcomes and Measures: The primary outcomes were searches on the price transparency tool by delivery mode (vaginal or cesarean), timing (first, second, or third trimester), and individual characteristics (age at childbirth, rurality, pregnancy risk status, coinsurance exposure, area educational attainment, and area median household income). Another outcome was the association of out-of-pocket childbirth spending with price transparency tool use. Results: The sample included 253 606 pregnant individuals, of whom 131 224 (51.7%) were in the 2011 to 2012 cohort and 122 382 (48.3%) were in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, the mean (SD) age was 31 years (5.2 years) and most individuals had coinsurance for delivery (94 251 [77.0%]). Price searching increased from 5.9% in the 2011 to 2012 cohort to 13.0% in the 2015 to 2016 cohort. In the 2015 to 2016 cohort, 43.9% of searchers' first price query was in their first trimester. The adjusted probability of searching was lower for individuals with a high-risk pregnancy due to a previous cesarean delivery (11.5%; 95% CI, 11.0%-12.1%) vs individuals with low-risk pregnancy (13.4%; 95% CI, 12.9%-14.0%). Use increased monotonically with coinsurance, from 9.2% (95% CI, 8.7%-9.8%) among individuals with no coinsurance to 15.0% (95% CI, 14.4%-15.5%) among individuals with 11% or higher coinsurance. After adjusting for covariates, searching was positively associated with out-of-pocket delivery episode spending. Among patients with 11% coinsurance or higher, early and late searchers spent more out of pocket ($59.57 [95% CI, $33.44-$85.96] and $73.33 [95% CI, $32.04-$115.29], respectively), compared with never searchers. Conclusions and Relevance: The results of this cross-sectional study indicate that the proportion of pregnant individuals who sought price information before childbirth more than doubled within the first 6 years of availability of a price transparency tool. These findings suggest that price information may help individuals anticipate their out-of-pocket childbirth costs.

The design of "TeamBirth": A care process to improve communication and teamwork during labor.

BACKGROUND: Despite evidence that communication and teamwork are critical to patient safety, few care processes have been intentionally designed for this purpose in labor and delivery. The purpose of this project was to design an intrapartum care process that aims to improve communication and teamwork between clinicians and patients. METHODS: We followed the "Double-Diamond" design method with four sequential steps: Discover, Define, Develop, and Deliver. In Discover, we searched professional guidelines and peer-reviewed literature to delineate the challenges to quality of intrapartum care and to uncover options for solutions. In Define, we convened an interdisciplinary group of experts to focus the problem scope and prioritize solution features. In Develop, we created initial prototype solutions. In Deliver, we engaged clinicians and patients in rapid cycle testing to iteratively produce a care process called "TeamBirth" that aims to improve team communication. RESULTS: We designed TeamBirth, an intrapartum care process composed of brief team meetings ("huddles") between clinicians and patients. Huddles are navigated by a shared planning board placed in the labor and delivery room in view of the patient and their care team. The board promotes transparent and reliable communication and contains four areas to be acknowledged or discussed: (a) the names of the team members, starting with the patient; (b) the patient's preferences; (c) the care plan for the patient, baby, and labor progress; and (d) when the next team huddle is anticipated. DISCUSSION: We identified an opportunity to improve the safety and dignity of childbirth care through an intrapartum care process that promotes reliable and structured communication and teamwork. Future work should evaluate the acceptability and feasibility of implementation and potential impact on safety and experience of care.

Variability in cesarean delivery rates among individual labor and delivery nurses compared to physicians at three attribution time points.

OBJECTIVE: To examine the variability in the cesarean delivery (CD) rates of individual labor and delivery nurses compared with physicians at three attribution time points. DATA SOURCES: Medical record data from nine hospitals in Washington State from January 2016 through September 2018. STUDY DESIGN: Retrospective, observational cohort design using an aggregated database of birth records. DATA COLLECTION/EXTRACTION METHODS: Chart-abstracted clinical data from a subset of nulliparous, term, singleton, vertex births attributed at admission, labor management, and delivery to nurses and physicians. Two classification methods were used to categorize nurse- and physician-level CD rates at three attribution time points and the reliability of these methods compared. PRINCIPAL FINDINGS: The sample included 12 556 births, 319 nurses, and 126 physicians. Overall, variation in nurse-level CD rates did not differ significantly across the three attribution time points, and the extent of variation was similar to that observed in physicians. However, agreement between attribution time points varied between 35 percent and 65 percent when classifying individual nurses into the top and bottom deciles. The average reliability of nurse-level CD rates was 32 percent at admission (IQR 22.0 percent to 38.7 percent), 32.6 percent at labor (IQR 23.1 percent to 40.9 percent), and 29.3 percent (IQR 20.9 percent to 35.8 percent) at delivery. The average reliability of physician-level CD rates was higher: 54.2 percent (IQR 38.7 percent to 71.4 percent) at admission, 62.5 percent (IQR 49.0 percent to 79.6 percent) at labor management, and 66.1 percent (IQR 53.7 percent to 81.2 percent) at delivery. CONCLUSION: Feedback on nurse-level CD rates as part of routine clinical quality audits can provide insight into nurse performance in the context of other individual-level and unit-level information. To reliably distinguish individual nurse performance, larger sample sizes are needed.

Does comparing cesarean delivery rates influence women's choice of obstetric hospital?

OBJECTIVES: Despite public reporting of wide variation in hospital cesarean delivery rates, few women access this information when deciding where to deliver. We hypothesized that making cesarean delivery rate data more easily accessible and understandable would increase the likelihood of women selecting a hospital with a low cesarean delivery rate. STUDY DESIGN: We conducted a randomized controlled trial of 18,293 users of the Ovia Health mobile apps in 2016-2017. All enrollees were given an explanation of cesarean delivery rate data, and those randomized to the intervention group were also given an interactive tool that presented those data for the 10 closest hospitals with obstetric services. Our outcome measures were enrollees' self-reported delivery hospital and views on cesarean delivery rates. METHODS: Intent-to-treat analysis using 2-sided Pearson's χ2 tests. RESULTS: There was no significant difference across the experimental groups in the proportion of women who selected hospitals with low cesarean delivery rates (7.0% control vs 6.8% intervention; P = .54). Women in the intervention group were more likely to believe that hospitals in their community had differing cesarean delivery rates (66.9% vs 55.9%; P <.001) and to report that they looked at cesarean delivery rates when choosing their hospital (44.5% vs 33.9%; P <.001). CONCLUSIONS: Providing women with an interactive tool to compare cesarean delivery rates across hospitals in their community improved women's familiarity with variation in cesarean delivery rates but did not increase their likelihood of selecting hospitals with lower rates.

In Pursuit of Value-Based Maternity Care.

Value-based care has become the new paradigm for clinical practice, with significant implications for maternity services, where there is a large opportunity to provide better care at lower cost. Childbirth is the most common reason for hospitalization in the United States and represents the single largest category of hospital-based expenditures. At the same time, the United States ranks low among developed countries on measures of maternal and neonatal health, suggesting that we are not using resources optimally. Improving the value of maternity services will require public policies that measure and pay for quality rather than quantity of care. Equally important, clinicians will need to employ new strategies to deliver value, including considering prices, individualizing the use of new technologies, prioritizing team-based approaches to care, bridging pregnancy and contraception counseling, and engaging expecting families in new ways.

An Exploratory Study of the Relationship between Facility Design and the Provision of Childbirth Care.

INTRODUCTION: Across health care, facility design has been shown to significantly affect quality of care; however, in maternity care, the mechanisms of how facility design affects provision of care are understudied. We aim to identify and illustrate key mechanisms that may explain how facility design helps or hinders clinicians in providing childbirth care. METHODS: We reviewed the literature to select design elements for inclusion. Using a modified Delphi consensus process, we engaged an interdisciplinary advisory board to prioritize these elements with regard to potential effect on care provision. The advisory board proposed mechanisms that may explain how the prioritized facility design elements help or hinder care, which the study team organized into themes. We then explored these themes using semistructured interviews with managers at 12 diverse birth centers and hospital-based labor and delivery units from across the United States. RESULTS: The design of childbirth facilities may help or hinder the provision of care through at least 3 distinct mechanisms: 1) flexibility and adaptability of spaces to changes in volume or acuity; 2) physical and cognitive anchoring that can create default workflows or mental models of care; and 3) facilitation of sharing knowledge and workload across clinicians. DISCUSSION: Facility designs may intentionally or unintentionally influence the workflows, expectations, and cultures of childbirth care.

Assessing the Feasibility of Measuring Variation in Facility Design Among American Childbirth Facilities.

OBJECTIVE: To assess the feasibility of quantifying variation in childbirth facility design and explore the implications for childbirth service delivery across the United States. BACKGROUND: Design has been shown to impact quality of care in childbirth. However, most prior studies use qualitative data to examine associations between the design of patient rooms and patient experience. There has been limited exploration of measures of unit design and its impact on care provision. METHOD: We recruited 12 childbirth facilities that were diverse with regard to facility type, location, delivery volume, cesarean delivery rate, and practice model. Each facility provided annotated floor plans and participated in a site visit or telephone interview to provide information on their design and clinical practices. These data were analyzed with self-reported primary cesarean delivery rates to assess associations between design and care delivery. RESULTS: We observed wide variation in childbirth unit design. Deliveries per labor room per year ranged from 75 to 479. The ratio of operating rooms to labor rooms ranged from 1:1 to 1:9. The average distance between labor rooms and workstations ranged from 23 to 114 ft, and the maximum distance between labor rooms ranged from 9 to 242 ft. More deliveries per room, fewer labor rooms per operating room, and longer distances between spaces were all associated with higher primary cesarean delivery rates. CONCLUSIONS: Clinically relevant differences in design can be feasibly measured across diverse childbirth facilities. The design of these facilities may not be optimally matched to service delivery needs.

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.

Decision Making about Hospital Arrival among Low-Risk Nulliparous Women after Spontaneous Labor Onset at Home.

INTRODUCTION: Postponing hospital admission until the active phase of labor is a recommended strategy to safely reduce the incidence of primary cesarean births. Success of this strategy depends on women's decisions about when to transfer from home to the hospital, a process that is largely absent from research about childbirth. This study aimed to determine the decision-making criteria used by women about when to go to the hospital after the self-identification of labor onset at home. METHODS: A qualitative study was conducted at an academic medical center with a sample of 21 nulliparous women who went into spontaneous labor at home and had term, singleton, and vertex-presentation births. The purposive sample consisted of women who decided to stay at home or go to the hospital in early labor. Birth narratives from in-depth interviews conducted in the postpartum period using a semistructured interview guide were subjected to content analysis. The verbatim transcriptions of the interviews were coded and categorized into a set of decision criteria. RESULTS: Criteria used by women in deciding to go to the hospital or stay at home in early labor included the degree of certainty with the self-identification of labor onset, ability to cope with labor pain, influence of social network members, health care provider advice, and concerns about travel to the hospital. Perception of childbirth risk and the need for reassurance about the normalcy of symptoms and fetal well-being also influenced women's decisions. DISCUSSION: Women use a common set of criteria in deciding when to arrive at the hospital during labor. Antenatal education and telephone triage interventions that incorporate the considerations of women deciding to seek or delay hospital admission in childbirth may facilitate health seeking in more advanced labor. Symptom recognition education about early labor onset and progression could reduce decisional uncertainty.

Common challenges managing bed and staff availability on labor and delivery units in the United States: A qualitative analysis.

BACKGROUND: Managers of labor and delivery units need to ensure that their limited supply of beds and nursing staff are adequately available, despite uncertainty with respect to patient needs. The ability to address this challenge has been associated with patient outcomes; however, best practices have not been defined. METHODS: We conducted a secondary analysis of 96 interviews with nurse and physician managers from 48 labor and delivery units across the United States. Included units represented a diverse range of characteristics, but skewed toward higher volume teaching hospitals. The prior study scored management practice based on their proactiveness (ability to mitigate challenges before they occur). Based on emerging themes, we identified common challenges in managing bed and staff availability and performed an analysis of positive deviants to identify an additional criterion for effective management performance. RESULTS: We identified four key challenges common to all labor and delivery units, (1) scheduling planned cases, (2) tracking patient flow, (3) monitoring bed and staff availability in the moment, and (4) adjusting bed and staff availability in the moment. We also identified "systematicness" (ability to address challenges in a consistent and reliable manner) as an emerging criterion for effective management. We observed that being proactive and systematic represented distinct characteristics, and units with both proactive and systematic practices appeared best positioned to effectively manage limited beds and staffing. DISCUSSION: Labor and delivery unit managers should distinctly assess both the proactiveness and systematicness of their existing management practices and consider how their practices could be modified to improve care.