Race, ethnicity, and indications for primary cesarean birth: Associations within a national birth center registry.

BACKGROUND: Racial and ethnic disparities in cesarean rates in the United States are well documented. This study investigated whether cesarean inequities persist in midwife-led birth center care, including for individuals with the lowest medical risk. METHODS: National registry records of 174,230 childbearing people enrolled in care in 115 midwifery-led birth center practices between 2007 and 2022 were analyzed for primary cesarean rates and indications by race and ethnicity. The lowest medical risk subsample (n = 70,521) was analyzed for independent drivers of cesarean birth. RESULTS: Primary cesarean rates among nulliparas (15.5%) and multiparas (5.7%) were low for all enrollees. Among nulliparas in the lowest-risk subsample, non-Latinx Black (aOR = 1.37; 95% CI, 1.15-1.63), Latinx (aOR = 1.51; 95% CI, 1.32-1.73), and Asian participants (aOR = 1.48; 95% CI, 1.19-1.85) remained at higher risk for primary cesarean than White participants. Among multiparas, only Black participants experienced a higher primary cesarean risk (aOR = 1.49; 95% CI, 1.02-2.18). Intrapartum transfers from birth centers were equivalent or lower for Black (14.0%, p = 0.345) and Latinx (12.7%, p < 0.001) enrollees. Black participants experienced a higher proportion of primary cesareans attributed to non-reassuring fetal status, regardless of risk factors. Place of admission was a stronger predictor of primary cesarean than race or ethnicity. CONCLUSIONS: Place of first admission in labor was the strongest predictor of cesarean. Racism as a chronic stressor and a determinant of clinical decision-making reduces choice in birth settings and may increase cesarean rates. Research on components of birth settings that drive inequitable outcomes is warranted.

Strong Start Innovation: Equitable Outcomes Across Public and Privately Insured Clients Receiving Birth Center Care.

INTRODUCTION: The Birth Center model of care is a health care delivery innovation in its fourth decade of demonstration across the United States. The purpose of this research was to evaluate the model's potential for decreasing poverty-related health disparities among childbearing families. METHODS: Between 2013 and 2017, 26,259 childbearing people received care within the 45 Center for Medicare and Medicaid Innovation Strong Start birth center sites. Secondary analysis of the prospective American Association of Birth Centers Perinatal Data Registry was conducted. Descriptive statistics described sociobehavioral, medical risk factors, and core clinical outcomes to inform the logistic regression model. Privately insured consumers were independently compared with 2 subgroups of Medicaid beneficiaries: Strong Start enrollees (midwifery-led care with peer counselors) and non-Strong Start Medicaid beneficiaries (midwifery-led care without peer counselors). RESULTS: After controlling for medical risk factors, Strong Start Medicaid beneficiaries achieved similar outcomes to privately insured consumers with no significant differences in maternal or newborn outcomes between groups. Perinatal outcomes included induction of labor (adjusted odds ratio [aOR], 0.86; 95% CI 0.61-1.13), epidural analgesia use (aOR, 1.00; 95% CI, 0.68-1.48), cesarean birth (aOR, 1.16; 95% CI, 0.87-1.53), exclusive breastfeeding on discharge (aOR, 1.11; 95% CI, 0.48-2.56), low Apgar score at 5 minutes (aOR, 1.23; 95% CI, 0.86-1.83), low birth weight (aOR, 1.12; 95% CI, 0.77-1.64), and antepartum transfer of care after the first prenatal appointment (aOR, 1.53; 95% CI, 0.97-2.40). Medicaid beneficiaries who were not enrolled in the Strong Start midwifery-led, peer counselor program demonstrated similar results except for having higher epidural analgesia use (aOR, 1.30; 95% CI, 1.10-1.53) and significantly lower exclusive breastfeeding on discharge (aOR, 0.57; 95% CI, 0.40-0.81) than their privately insured counterparts. DISCUSSION: The midwifery-led birth center model of care complemented by peer counselors demonstrated a pathway to achieve health equity.

Place of Birth Preferences and Relationship to Maternal and Newborn Outcomes Within the American Association of Birth Centers Perinatal Data Registry, 2007-2020.

PURPOSE: The purpose of this study was to describe sociodemographic variations in client preference for birthplace and relationships to perinatal health outcomes. METHODS: Descriptive data analysis (raw number, percentages, and means) showed that preference for birthplace varied across racial and ethnic categories as well as sociodemographic categories including educational status, body mass index, payer status, marital status, and gravidity. A subsample of medically low-risk childbearing people, qualified for birth center admission in labor, was analyzed to assess variations in maternal and newborn outcomes by site of first admission in labor. RESULTS: While overall clinical outcomes exceeded national benchmarks across all places of admission in the sample, disparities were noted including higher cesarean birth rates among Black and Hispanic people. This variation was larger within the population of people who preferred to be admitted to the hospital in labor in the absence of medical indication. CONCLUSION: This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation.

Breastfeeding as a Quality Measure: Demonstrating Levers of the National Quality Strategy.

The purpose of this study is to explore the National Quality Strategy (NQS) levers (measurement and feedback, public reporting, learning and technical assistance, and certification) on state and national breastfeeding performance. The research evaluates the NQS levers of measurement and feedback and public reporting using secondary data analysis of publicly reported data from the National Immunization Survey and the Centers for Disease Control and Prevention Breastfeeding Report Cards between 2008 and 2018, the latest years available. Linear regression explores the association between the prevalence of state-level Baby-Friendly hospitals and state-level breastfeeding rates. Subsequent analyses use event study to test whether state-level Baby-Friendly hospital adoption is associated with higher breastfeeding rates. A 10% increase in Baby-Friendly hospitals at the state level is associated with increased population breastfeeding rates by nearly 5% and a decrease in early formula use (before 2 days of life) by 2% to 9%. Breastfeeding increased by 2% to 5% in the first 2 years following state-level Baby-Friendly initiatives, with subsequent increases up to 10% in the next 4 years. The National Quality Strategy levers of measurement and public reporting combined with certification and learning and technical assistance are associated with increases in exclusive breastfeeding, a national quality metric.

Right care: Improving timeliness and promoting preventive health in a lower socioeconomic reproductive health clinic.

BACKGROUND: Missed prevention opportunities are a financial burden to the US health care system and result in excess consumption of resources, reduced quality of life, increased morbidity, and premature death. LOCAL PROBLEM: High staff turnover and inefficient practices at a local health department caused long patient wait times and missed opportunities for preventive health care. The project aim was to improve timeliness through Right Care in a lower socioeconomic reproductive health clinic while decreasing patient cycle time by 10% in 90 days. METHODS: We used four plan-do-study-act cycles incorporating tests of change that focused on team and patient engagement and two process changes. The interventions included a care coordination huddle, an infant feeding decision aid to better understand patient values, a sexual health screening tool to identify prevention opportunities, and a redesigned patient-centered discharge process to improve efficiency. RESULTS: Over 90 days, the receipt of Right Care increased while patient cycle time decreased by 2.6%. The team improved function with a mean huddle effectiveness score increase from 2 to 4.4 (1-5 Likert scale). Intent to breastfeed increased by 49% (35%-52%), and identification of preventive care needs increased by 320% (15%-63%). Preventive care follow-up remained unchanged at 26% with the new discharge process, identifying weaknesses in the health department referral systems. CONCLUSIONS: Standardized tools and processes improved primary prevention opportunities at a local health department while reducing patient cycle time. The tools improved documentation of intent to exclusively breastfeed, increased preventive care identification, and streamlined the discharge process; while demonstrating a systems-level gap for long-term follow-up.

Improving the Experience of Care: Results of the American Association of Birth Centers Strong Start Client Experience of Care Registry Pilot Program, 2015-2016.

In 2018, the Center for Medicare and Medicaid Innovation in the United States (US) released report demonstrating birth centers as the appropriate level of care for most Medicaid beneficiaries. A pilot project conducted at 34 American Association of Birth Centers (AABC) Strong Start sites included 553 beneficiaries between 2015 and 2016 to explore client perceptions of high impact components of care. Participants used the AABC client experience of care registry to report knowledge, values, and experiences of care. Data were linked to more than 300 process and outcome measures within the AABC Perinatal Data Registry™. Descriptive statistics, t tests, χ analysis, and analysis of variance were conducted. Participants demonstrated high engagement with care and trust in pregnancy, birth, and parenting. Beneficiaries achieved their preference for vaginal birth (89.9%) and breastfeeding at discharge through 6 weeks postpartum (91.7% and 87.6%). Beneficiaries reported having time for questions, felt listened to, spoken to in a way they understood, being involved in decision making, and treated with respect. There were no variations in experience of care, cesarean birth, or breastfeeding by race. Medicaid beneficiaries receiving prenatal care at AABC Strong Start sites demonstrated high levels of desired engagement and reported receiving respectful, accessible care and high-quality outcomes. More investment and research using client-reported data registries are warranted as the US works to improve the experience of perinatal care nationwide.

The Experience of Land and Water Birth Within the American Association of Birth Centers Perinatal Data Registry, 2012-2017.

Consumer demand for water birth has grown within an environment of professional controversy. Access to nonpharmacologic pain relief through water immersion is limited within hospital settings across the United States due to concerns over safety. The study is a secondary analysis of prospective observational Perinatal Data Registry (PDR) used by American Association of Birth Center members (AABC PDR). All births occurring between 2012 and 2017 in the community setting (home and birth center) were included in the analysis. Descriptive, correlational, and relative risk statistics were used to compare maternal and neonatal outcomes. Of 26 684 women, those giving birth in water had more favorable outcomes including fewer prolonged first- or second-stage labors, fetal heart rate abnormalities, shoulder dystocias, genital lacerations, episiotomies, hemorrhage, or postpartum transfers. Cord avulsion occurred rarely, but it was more common among water births. Newborns born in water were less likely to require transfer to a higher level of care, be admitted to a neonatal intensive care unit, or experience respiratory complication. Among childbearing women of low medical risk, personal preference should drive utilization of nonpharmacologic care practices including water birth. Both land and water births have similar good outcomes within the community setting.

Providing effective asthma care at a pediatric patient-centered medical home.

BACKGROUND: A recent assessment of the national annual burden of the cost of asthma among school-aged children was nearly $6 million. In a Midwestern county, the incidence of childhood asthma was 15.8%, which was above both state and national levels. LOCAL PROBLEM: Effective asthma care was not being provided at a rural, pediatric patient-centered medical home due to a lack of standardization. This quality improvement (QI) initiative aimed to increase the mean effective asthma care score to 78% for patients with asthma over the course of 90 days. METHODS: This right care initiative was implemented using a rapid-cycle Plan-Do-Study-Act methodology. Tests of change in the areas of team engagement, patient engagement, and two process measures were analyzed through chart audits and run charts over four cycles. Likert scale surveys were used to analyze qualitative data. INTERVENTIONS: Interventions included developing the Asthma Patient Identification Tool, implementing an asthma education protocol with teach-back, creating standardized smart phrases for effective documentation, and initiating asthma care huddles. RESULTS: The delivery of effective asthma care increased to 84%. The number of patients receiving the asthma education protocol increased to 65%, with 80% of the patients participating in effective teach-back sessions. The mean effective documentation score increased to 92%. CONCLUSIONS: A standardized approach to asthma care grounded in evidence-based guidelines positively affected the delivery of care. Nurse practitioners are effective team leaders for clinical QI initiatives.

Strong Start in birth centers: Socio-demographic characteristics, care processes, and outcomes for mothers and newborns.

BACKGROUND: A recent Center for Medicare and Medicaid Innovation report evaluated the four-year Strong Start for Mothers and Newborns Initiative, which sought to improve maternal and newborn outcomes through exploration of three enhanced, evidence-based care models. This paper reports the socio-demographic characteristics, care processes, and outcomes for mothers and newborns engaged in care with American Association of Birth Centers (AABC) sites. METHODS: The authors examined data for 6424 Medicaid or Children's Health Insurance Program (CHIP) beneficiaries in birth center care who gave birth between 2013 and 2017. Using data from the AABC Perinatal Data Registry™, descriptive statistics were used to evaluate socio-behavioral and medical risks, and core perinatal quality outcomes. Comparisons are made between outcomes in the AABC sample and national data during the study period. RESULTS: Childbearing mothers enrolled at AABC sites had diverse socio-behavioral risk factors similar to the national profile. The AABC sites exceeded national quality benchmarks for low birthweight (3.28%), preterm birth (4.42%), and primary cesarean birth (8.56%). Racial disparities in perinatal indicators were present within the Strong Start sample; however, they were at narrower margins than in national data. The enhanced model of care was notable for use of midwifery-led prenatal, labor, and birth care and decreased hospital admission. CONCLUSIONS: Birth center care improves population health, patient experience, and value. The model demonstrates the potential to decrease racial disparity and improve population health. Reduction of regulatory barriers and implementation of sustainable reimbursement are warranted to move the model to scale for Medicaid beneficiaries nationwide.

Outcomes of childbearing Medicaid beneficiaries engaged in care at Strong Start birth center sites between 2012 and 2014.

BACKGROUND: Variations in care for pregnant women have been reported to affect pregnancy outcomes. METHODS: This study examined data for all 3136 Medicaid beneficiaries enrolled at American Association of Birth Centers (AABC) Center for Medicare and Medicaid Innovation Strong Start sites who gave birth between 2012 and 2014. Using the AABC Perinatal Data Registry, descriptive statistics were used to evaluate socio-behavioral and medical risks, and core perinatal quality outcomes. Next, the 2082 patients coded as low medical risk on admission in labor were analyzed for effective care and preference sensitive care variations. Finally, using binary logistic regression, the associations between selected care processes and cesarean delivery were explored. RESULTS: Medicaid beneficiaries enrolled at AABC sites had diverse socio-behavioral and medical risk profiles and exceeded quality benchmarks for induction, episiotomy, cesarean, and breastfeeding. Among medically low-risk women, the model demonstrated effective care variations including 82% attendance at prenatal education classes, 99% receiving midwifery-led prenatal care, and 84% with midwifery- attended birth. Patient preferences were adhered to with 83% of women achieving birth at their preferred site of birth, and 95% of women using their preferred infant feeding method. Elective hospitalization in labor was associated with a 4-times greater risk of cesarean birth among medically low-risk childbearing Medicaid beneficiaries. CONCLUSIONS: The birth center model demonstrates the capability to achieve the triple aims of improved population health, patient experience, and value.

Navigating the perinatal quality landscape.

The National Quality Strategy, mandated by the Affordable Care Act, outlines the triple aim of better health, better care, and lower costs. Perinatal nurses are integral to the National Quality movement as care providers, leaders, and experts. The most notable accomplishments in perinatal care of the last decade relate to the endorsement of quality measures by the National Quality Forum that provide unified goals and the quality improvement frameworks provided by the Institute for Healthcare Improvement that help systems create action and change through education, team building, process improvement, and structure. Fourteen perinatal quality measures are currently endorsed by the National Quality Forum, 5 of which are mandated by The Joint Commission and required for accreditation. Understanding the current perinatal quality measures and the resources available for implementation is essential to nursing care delivery. Realizing the nurses' role within the quality improvement landscape and mobilizing nationally endorsed quality measures as levers for nurse-led improvement projects promise actualization of marked quality improvement in perinatal care.