Assessing hospital differences in low-risk cesarean delivery metrics in Florida.

BACKGROUND: Unnecessary cesarean deliveries lead to increased maternal and neonatal morbidities and mortalities. In 2020, Florida had a cesarean delivery rate of 35.9%, the third highest in the nation. An effective quality improvement strategy to reduce overall cesarean delivery rates is to decrease primary cesarean deliveries in low-risk births (nulliparous, term, singleton, vertex). Of note, 3 nationally accepted hospital measures of low-risk cesarean delivery rates include the nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics. Comparing metrics is necessary because accurate and timely measurement is essential to support multihospital quality improvement efforts to reduce low-risk cesarean delivery rates and improve the quality of maternal care. OBJECTIVE: This study aimed to assess differences in hospital low-risk cesarean delivery rates in Florida using 5 different metrics of low-risk cesarean delivery rate based on (1) risk methodology, nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics, and (2) data source, linked birth certificate and hospital discharge records and hospital discharge records only. STUDY DESIGN: This was a population-based study of live Florida births from 2016 to 2019 to compare 5 approaches to calculating low-risk cesarean delivery rates. Analyses were performed using linked birth certificate data and inpatient hospital discharge data. The 5 low-risk cesarean delivery measures were defined as follows: nulliparous, term, singleton, vertex birth certificate; Joint Commission-linked used Joint Commission exclusions; Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions; Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions. Nulliparous, term, singleton, vertex birth certificate was based on data from birth certificates and not using linked hospital discharge data. Designated as nulliparous, term, singleton, vertex, it does not exclude other high-risk conditions. The second and third measures (Joint Commission-linked used Joint Commission exclusions and Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions) use data elements from the full-linked dataset to designate nulliparous, term, singleton, vertex and excluded several high-risk conditions. The last 2 measures (Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions) were based on data from hospital discharge data only and not using linked birth certificate data. These measures generally reflect term, singleton, and vertex because parity could not be assessed adequately on hospital discharge data. Hospital differences between these 5 measures were calculated overall and by neonatal intensive care unit level. RESULTS: Overall, the median of hospital low-risk cesarean rates decreased across the measures, from NTSV-BC 30.7%, to Joint Commission linked 29.1%, and Society for Maternal Fetal Medicine hospital discharge 29.2% with a large decrease to Joint Commission hospital discharge 19.4% and Society for Maternal Fetal Medicine hospital discharge 18.1%. A similar trend was seen by neonatal intensive care unit level. For each of the measures, level II had the highest median low-risk cesarean rates (nulliparous. term, singleton, vertex birth certificate) 32.7%, Joint Commission linked (31.4%), Society for Maternal Fetal Medicine linked: 31.1%, Society for Maternal Fetal Medicine hospital discharge 19.3%), except for level III Joint Commission hospital discharge (20.0%). A comparison of the median number of low-risk births overall and by neonatal intensive care unit level showed a decreasing number across the linked and hospital discharge measures. Again, a wide gap in low-risk cesarean delivery rates was identified between linked measures and hospital discharge measures. However, this gap narrowed as hospital rates increased. CONCLUSION: Quality monitoring of low-risk cesarean delivery rates measured by the nulliparous, term, singleton, vertex metric using the birth certificate was fairly accurate and provided timely assessment for use by Florida hospitals. The nulliparous, term, singleton, vertex birth certificate rates were comparable with low-risk metrics using the linked data source. Overall, metrics used within the same data source had similar rates, with the Society for Maternal-Fetal Medicine metric having the lowest rates. Across data sources, metrics using hospital discharge data only resulted in substantially underestimated rates because of the inclusion of multiparous women and should be interpreted with caution.

Evaluation of Administrative Data for Identifying Maternal Opioid Use at Delivery in Florida.

OBJECTIVES: Studies have shown significant increases in the prevalence of maternal opioid use. Most prevalence estimates are based on unverified ICD-10-CM diagnoses. This study determined the accuracy of ICD-10-CM opioid-related diagnosis codes documented during delivery and examined potential associations between maternal/hospital characteristics and diagnosis with an opioid-related code. METHODS: To identify people with prenatal opioid use, we identified a sample of infants born during 2017-2018 in Florida with a NAS related diagnosis code (P96.1) and confirmatory NAS characteristics (N = 460). Delivery records were scanned for opioid-related diagnoses and prenatal opioid use was confirmed through record review. The accuracy of each opioid-related code was measured using positive predictive value (PPV) and sensitivity. Modified Poisson regression was used to calculate adjusted relative risks (aRR) and 95% confidence intervals (CI). RESULTS: We found the PPV was nearly 100% for all ICD-10-CM opioid-related codes (98.5-100%) and the sensitivity was 65.9%. Non-Hispanic Black mothers were 1.8 times more likely than non-Hispanic white mothers to have a missed opioid-related diagnosis at delivery (aRR:1.80, CI 1.14-2.84). Mothers who delivered at a teaching status hospital were less likely to have a missed opioid-related diagnosis (p < 0.05). CONCLUSIONS FOR PRACTICE: We observed high accuracy of maternal opioid-related diagnosis codes at delivery. However, our findings suggest that over 30% of mothers with opioid use may not be diagnosed with an opioid-related code at delivery, although their infant had a confirmed NAS diagnosis. This study provides information on the utility and accuracy of ICD-10-CM opioid-related codes at delivery among mothers of infants with NAS.

From 2010 to 2017, maternal opioid-related diagnoses at delivery increased by 100% in the US. Most prevalence estimates are based on unverified ICD-10-CM diagnosis codes. Evaluations of maternal opioid-related diagnoses at delivery are extremely limited but essential for utilizing prevalence estimates generated from administrative data.

MCH Leadership Training Program: An Innovative Application of an Implementation Science Framework.

INTRODUCTION: MCH training programs in schools of public health provide specialized training to develop culturally competent and skilled MCH leaders who will play key roles in public health infrastructure. Previous literature has reported on the effectiveness of MCH training programs (e.g., number of trainees, improvement in knowledge/skills); less attention has been devoted to understanding factors influencing program implementation during times of rapid change, while considering internal and external contexts (e.g., global pandemic, social unrest, uncertainty of funding, mental health issues, and other crises). PURPOSE: This article describes a graduate-level MCH leadership training program and illustrates how an implementation science framework can inform the identification of determinants and lessons learned during one year of implementation of a multi-year program. ASSESSMENT: Findings reveal how CFIR can be applicable to a MCH training program and highlight how constructs across domains can interact and represent determinants that serve as both a barrier and facilitator. Key lessons learned included the value of accountability, flexibility, learner-centeredness, and partnerships. CONCLUSION: Findings may apply to other programs and settings and could advance innovative training efforts that necessitate attention to the multi-level stakeholder needs (e.g., student, program, institution, community, and local/regional/national levels). Applying CFIR could be useful when interpreting process and outcome evaluation data and transferring findings and lessons learned to other organizations and settings. Integrating implementation science specifically into MCH training programs could contribute to the rigor, adaptability, and dissemination efforts that are critical when learning and sharing best practices to expand leadership capacity efforts that aim to eliminate MCH disparities across systems.

Refreshing the Perinatal Periods of Risk: A New Reference Group and Nationwide Large-County-Level Analyses.

INTRODUCTION: The Perinatal Periods of Risk approach (PPOR) is designed for use by communities to assess and address the causes of high fetal-infant mortality rates using vital records data. The approach is widely used by local health departments and their community and academic partners to inform and motivate systems changes. PPOR was developed and tested in communities based on data years from 1995 to 2002. Unfortunately, a national reference group has not been published since then, primarily due to fetal death data quality limitations. METHODS: This paper assesses data quality and creates a set of unbiased national reference groups using 2014-2016 national vital records data. Phase 1 and Phase 2 analytic methods were used to divide excess mortality into six components and create percentile plots to summarize the distribution of 100 large US counties for each component. RESULTS: Eight states with poor fetal death data quality were omitted from the reference groups to reduce bias due to missing maternal demographic information. There are large Black-White disparities among reference groups with the same age and education restrictions, and these vary by component. PPOR results vary by region, maternal demographics, and county. The magnitude of excess mortality components varies widely across US counties. DISCUSSION: New national reference groups will allow more communities to do PPOR. Percentile plots of 100 large US counties provide an additional benchmark for new communities using PPOR and help emphasize problem areas and potential solutions.

An Initiative "that you do for one person": Identifying Barriers and Facilitators to Implementing an Immediate Postpartum LARC Initiative in Florida Hospitals.

INTRODUCTION: In the United States (U.S.), perinatal quality improvement collaboratives have pursued implementing immediate postpartum long-acting reversible contraception (LARC) initiatives to increase people's access to contraception and support their fertility desires. This process evaluation aimed to identify barriers and facilitators to implementing an immediate postpartum LARC initiative in Florida. METHODS: Data collection included in-depth qualitative assessments (i.e., interviews, small focus group discussions) with hospitals in pre- and early stages of the implementation process. Snowball sampling was used to recruit participants. Interviews were conducted in-person or via Zoom or phone and were audio-recorded and transcribed verbatim. Four of the five domains within the Consolidated Framework for Implementation Research (e.g., process, intervention characteristics, inner and outer settings) informed the study design and data collection/analysis. RESULTS: Fourteen staff of diverse job roles from five hospitals participated. Factors that facilitated implementation were the strength of the evidence, relative advantage, internal and external networks, and engaging staff. Barriers to implementation included billing and reimbursement and needing significant support from external networks to progress through implementation phases. DISCUSSION: Findings suggest that depending on the task or phase, multiple factors work in tandem to serve as implementation barriers and facilitators. Additionally, evaluating hospitals' progress at the pre- and early implementation phases was critical for quickly finding solutions and benefited other hospitals in different stages. As this initiative requires substantial support, health systems should create and sustain a culture of excellence and efficiency to facilitate implementing initiatives that improve care quality.

Patients and providers' knowledge, attitudes, and beliefs regarding immediate postpartum long-acting reversible contraception: a systematic review.

The American College of Obstetricians and Gynecologists recommends long-acting reversible contraception (LARC) immediately postpartum for preventing unintended pregnancy. This systematic review identified patients' and providers' knowledge, attitudes, and beliefs regarding immediate postpartum LARC use. Web of Science, Embase, PubMed, PsychInfo, and CINHAL databases (from inception to December 2018) were searched using LARC and immediate postpartum as search terms. The inclusion criteria were observational US studies, peer-reviewed, and English language, and the exclusion criterion was published abstracts only. The search yielded 4140 articles, and 18 articles were included in the final sample. Articles focused on women (n = 6) emphasizing patient preferences about the use of postpartum intrauterine devices (IUDs) and comprised samples of postpartum women. Among articles focused on providers (n = 12), knowledge regarding immediate postpartum LARCs varied. Providers reported lack of training and lack of comfort with regard to counseling and insertion as barriers to providing postpartum IUDs. This review identified literature regarding patient and provider perspectives on immediate postpartum LARC. Future work should ascertain patients' and providers' needs and preferences for integrating LARC counseling as a viable contraception option during the immediate postpartum period, ultimately promoting optimal inter-pregnancy intervals and overall health for women and future offspring.

Assessing the Burden of Neonatal Abstinence Syndrome: Validation of ICD-9-CM Data, Florida, 2010-2011.

CONTEXT: On October 1, 2015, the United States transitioned from using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. Continuing to monitor the burden of neonatal abstinence syndrome (NAS) after the transition presently requires use of data dependent on ICD-9-CM coding to enable trend analyses. Little has been published on the validation of using ICD-9-CM codes to identify NAS cases. OBJECTIVE: To assess the validity of hospital discharge data (HDD) from selected Florida hospitals for passive NAS surveillance, based on ICD-9-CM codes, which are used to quantify baseline prevalence of NAS. DESIGN: We reviewed infant and maternal data for all births at 3 Florida hospitals from 2010 to 2011. Potential NAS cases included infants with ICD-9-CM discharge codes 779.5 and/or 760.72 in linked administrative data (ie, HDD linked to vital records) or in unlinked HDD and infants identified through review of neonatal intensive care unit admission logs or inpatient pharmacy records. Confirmed infant cases met 3 clinician-proposed criteria. Sensitivity and positive predictive value were calculated to assess validity for the 2 ICD-9-CM codes, individually and combined. RESULTS: Of 157 confirmed cases, 134 with 779.5 and/or 760.72 codes were captured in linked HDD (sensitivity = 85.4%) and 151 in unlinked HDD (sensitivity = 96.2%). Positive predictive value was 74.9% for linked HDD and 75.5% for unlinked HDD. For either HDD types, the single 779.5 code had the highest positive predictive value (86%), lowest number of false positives, and good to excellent sensitivity. CONCLUSIONS: Passive surveillance using ICD-9-CM code 779.5 in either linked or unlinked HDD identified NAS cases with reasonable validity. Our work supports the use of ICD-9-CM code 779.5 to assess the baseline prevalence of NAS through 2015.

Gestational Weight Loss: Comparison Between the Birth Certificate and the Medical Record, Florida, 2012.

Objective Examine agreement with the medical record (MR) when gestational weight loss (GWL) on the Florida birth certificate (BC) is ≥ 0 pounds (lbs). Methods In 2012, 3923 Florida-resident women had a live, singleton birth where BC indicated GWL ≥ 0 lbs. Of these, we selected a stratified random sample of 2141 and abstracted from the MR prepregnancy and delivery weight data used to compute four estimates of GWL (delivery minus prepregnancy weight) from different sources found within the MR (first prenatal visit record, nursing admission record, labor/delivery records, BC worksheet). We assessed agreement between the BC and MR estimates for GWL categorized as 0, 1-10, 11-19, and ≥ 20 lbs. Results Prepregnancy or delivery weight was missing or source not in the MR for 23-81% of records. Overall agreement on GWL between the BC and the four MR estimates ranged from 39.1 to 57.2%. Agreement by GWL category ranged from 10.6 to 38.0% for 0 lbs, 47.6 to 64.3% for 1-10 lbs, 49.5 to 60.0% for 11-19 lbs, and 47.8 to 67.7% for ≥ 20 lbs. Conclusions Prepregnancy and delivery weight were frequently missing from the MR or inconsistently documented across the different sources. When the BC indicated GWL ≥ 0 lbs, agreement with different sources of the MR was moderate to poor revealing the need to reduce missing data and better understand the quality of weight data in the MR.

The Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality: An Outcome Evaluation From the US South, 2011 to 2014.

OBJECTIVES: To evaluate the impact of the Southern Public Health Regions' (Regions IV and IV) Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality, supported by the US Health Resources and Services Administration. METHODS: We examined pre-post change (2011-2014) for CoIIN strategies with available outcome data from vital records (early elective delivery, smoking) and the Pregnancy Risk Assessment Monitoring System (safe sleep) as well as preterm birth and infant mortality for Regions IV and VI relative to all other regions. RESULTS: For most outcomes, CoIIN improvements were greater in Regions IV and VI than in other regions. For example, early elective delivery decreased by 22% versus 14% in other regions, smoking cessation during pregnancy increased by 7% versus 2%, and back sleep position increased by 5% versus 2%. Preterm birth decreased by 4%, twice that observed in other regions, but infant mortality reductions did not differ significantly. CONCLUSIONS: The CoIIN approach to public health improvement shows promise in accelerating progress in intermediate outcomes and preterm birth. Impact on infant mortality may require additional strategies and sustained efforts.

Pregnancy-Related Deaths, Florida, 1999-2012: Opportunities to Improve Maternal Outcomes.

Objectives To examine pregnancy-related deaths (PRDs) in Florida, to identify quality improvement (QI) opportunities, and to recommend strategies aimed at reducing maternal mortality. Methods The Florida Pregnancy-Associated Mortality Review (PAMR) Committee reviewed PRDs occurring between 1999 and 2012. The PAMR Committee determined causes of PRDs, identified contributing factors, and generated recommendations for prevention and quality improvement. Information from the PAMR data registry, and live births from Florida vital statistic data were used to calculate pregnancy-related mortality ratios (PRMR) and PRD univariate risk ratios (RR) with 95% confidence intervals (CI). Results Between 1999 and 2012, the PRMR fluctuated between 14.7 and 26.2 PRDs per 100,000 live births. The five leading causes of PRD were hypertensive disorders (15.5%), hemorrhage (15.2%), infection (12.7%), cardiomyopathy (11.1%), and thrombotic embolism (10.2%), which accounted for 65% of PRDs. Principal contributing factors were morbid obesity (RR = 7.0, 95% CI 4.9-10.0) and late/no prenatal care (RR = 4.2, 95% CI 3.1-5.6). The PRMR for black women was three-fold higher (RR = 3.3, 95% CI 2.7-4.0) than white women. Among the five leading causes of PRDs, 42.5% had at least one clinical care or health care system QI opportunity. Two-third of these were associated with clinical quality of care, which included standards of care, coordination, collaboration, and communication. The QI opportunities varied by PRD cause, but not by race/ethnicity. Conclusion Gaps in clinical care or health care systems were assessed as the primary factors in over 40% of PRDs leading the PAMR Committee to generate QI recommendations for clinical care and health care systems.

Florida Populations Most at Risk of Not Being Up to Date With Colorectal Cancer Screening.

INTRODUCTION: The purpose of this study was to examine the characteristics of populations at risk of not being up to date on colorectal cancer screening in Florida. METHODS: We used Exhaustive Chi-squared Automatic Interaction Detection, a classification tree analysis, to identify subgroups not up to date with colorectal cancer screening using the 2013 Florida Behavioral Risk Factor Surveillance System. The data set was restricted to adults aged 50 to 75 years (n = 14,756). RESULTS: Only 65.5% of the sample was up to date on colorectal cancer screening. Having no insurance and having a primary care provider were the most significant predictors of not being up to date on screening. The highest risk subgroups were 1) respondents with no insurance and no primary care provider, regardless of their employment status (screening rate, 12.1%-23.7%); 2) respondents with no insurance but had a primary care provider and were employed (screening rate, 32.3%); and 3) respondents with insurance, who were younger than 55 years, and who were current smokers (screening rate, 42.0%). CONCLUSION: Some populations in Florida are at high risk for not being up to date on colorectal cancer screening. To achieve Healthy People 2020 goals, interventions may need to be further tailored to target these subgroups.

Hospital variation in cesarean delivery rates: contribution of individual and hospital factors in Florida.

BACKGROUND: Primary cesarean deliveries are a major contributor to the large increase in cesarean delivery rates in the United States over the past 2 decades and are an essential focus for the reduction of related morbidity and costs. Studies have shown that primary cesarean delivery rates among low-risk women in the United States vary 3-fold across hospitals and are not explained by differences in patient case-mix. However, the extent to which maternal vs hospital characteristics contribute to this variation remains poorly understood because previous studies were limited in scope and did not assess the influence of factors such as maternal ethnicity subgroups or prepregnancy obesity. OBJECTIVE: We assessed the contribution of individual- and hospital-level risk factors to the hospital variation in primary cesarean delivery rates among low-risk women in Florida. STUDY DESIGN: Our population-based retrospective cohort study used Florida's linked birth certificate and hospital discharge records for the period of 2004-2011. The study population was comprised of 412,192 nulliparous, singleton, vertex, live births with labor at 37-40 weeks gestation in 122 nonmilitary delivery hospitals. Data were analyzed with logistic mixed-effects regression with cesarean delivery as the outcome. This approach provided adjusted risk estimates at an individual and hospital level and the estimated percent of hospital variation statewide that was explained by these factors. RESULTS: The primary cesarean delivery rate in the study population was 23.9%, with hospital-specific estimates that ranged from 12.8-47.3%. Leading risk factors for cesarean delivery were maternal age ≥35 years (adjusted relative risk, 2.22), prepregnancy obesity (body mass index, ≥30 kg/m(2); adjusted relative risk, 1.73), medical risk conditions (adjusted relative risk, 1.72), labor induction (adjusted relative risk, 1.52), and delivery in hospitals located in Miami-Dade County (adjusted relative risk, 1.73). Hospital geographic location was a significant effect modifier for prepregnancy obesity, medical conditions, and labor induction (P < .05), with a tendency towards lower adjusted relative risks for these factors in Miami-Dade County relative to other Florida regions. Conversely, Miami-Dade County had an increased prevalence of higher-risk ethnic subgroups, such as Cuban or Puerto Rican mothers, and also substantially higher adjusted relative risks that were associated with practice-related factors, such as delivery during weekday hours. Whereas hospital geographic location contributed to 39.6% of the observed variation statewide, the estimated contribution of maternal ethnicity ranged from 1.6-15.7% among Florida regions. CONCLUSIONS: Hospital geographic location contributes to hospital variation in primary cesarean delivery rates among low-risk women in Florida. In contrast to previous studies, our findings suggest that individual level risk factors such as maternal ethnicity also contribute to some of this variation, with differing extent by region. These individual factors likely interact with practice factors and add to the variation. This study was limited by not including maternal Bishop score before induction or obstetrics provider in the analysis. These were not available on the dataset but likely contribute to the variation. Our findings suggest potential issues to consider in quality improvement efforts, such as the need for future qualitative research that focuses on mothers in higher-risk ethnic subgroups and providers in high-rate hospitals, particularly those in Miami-Dade County. These studies may help to identify potential cultural differences in maternal beliefs and expectations for delivery and maternal reasons for differences in obstetrics practices.

The Impact of ART on Live Birth Outcomes: Differing Experiences across Three States.

BACKGROUND: Research has shown an association between assisted reproductive technology (ART) and adverse birth outcomes. We identified whether birth outcomes of ART-conceived pregnancies vary across states with different maternal characteristics, insurance coverage for ART services, and type of ART services provided. METHODS: CDC's National ART Surveillance System data were linked to Massachusetts, Florida, and Michigan vital records from 2000 through 2006. Maternal characteristics in ART- and non-ART-conceived live births were compared between states using chi-square tests. We performed multivariable logistic regression analyses and calculated adjusted odds ratios (aOR) to assess associations between ART use and singleton preterm delivery (<32 weeks, <37 weeks), singleton small for gestational age (SGA) (<5th and <10th percentiles) and multiple birth. RESULTS: ART use in Massachusetts was associated with significantly lower odds of twins as well as triplets and higher order births compared to Florida and Michigan (aOR 22.6 vs. 30.0 and 26.3, and aOR 37.6 vs. 92.8 and 99.2, respectively; Pinteraction < 0.001). ART use was associated with increased odds of SGA in Michigan only, and with preterm delivery (<32 and <37 weeks) in all states (aOR range: 1.60, 1.87). CONCLUSIONS: ART use was associated with an increased risk of preterm delivery among singletons that showed little variability between states. The number of twins, triplets and higher order gestations per cycle was lower in Massachusetts, which may be due to the availability of insurance coverage for ART in Massachusetts.

Importance of Performance Measurement and MCH Epidemiology Leadership to Quality Improvement Initiatives at the National, State and Local Levels.

Purpose In recognition of the importance of performance measurement and MCH epidemiology leadership to quality improvement (QI) efforts, a plenary session dedicated to this topic was presented at the 2014 CityMatCH Leadership and MCH Epidemiology Conference. This paper summarizes the session and provides two applications of performance measurement to QI in MCH. Description Performance measures addressing processes of care are ubiquitous in the current health system landscape and the MCH community is increasingly applying QI processes, such as Plan-Do-Study-Act (PDSA) cycles, to improve the effectiveness and efficiency of systems impacting MCH populations. QI is maximally effective when well-defined performance measures are used to monitor change. Assessment MCH epidemiologists provide leadership to QI initiatives by identifying population-based outcomes that would benefit from QI, defining and implementing performance measures, assessing and improving data quality and timeliness, reporting variability in measures throughout PDSA cycles, evaluating QI initiative impact, and translating findings to stakeholders. MCH epidemiologists can also ensure that QI initiatives are aligned with MCH priorities at the local, state and federal levels. Two examples of this work, one highlighting use of a contraceptive service performance measure and another describing QI for peripartum hemorrhage prevention, demonstrate MCH epidemiologists' contributions throughout. Challenges remain in applying QI to complex community and systems-level interventions, including those aimed at improving access to quality care. Conclusion MCH epidemiologists provide leadership to QI initiatives by ensuring they are data-informed and supportive of a common MCH agenda, thereby optimizing the potential to improve MCH outcomes.

The Obstetric Hemorrhage Initiative (OHI) in Florida: The Role of Intervention Characteristics in Influencing Implementation Experiences among Multidisciplinary Hospital Staff.

Objectives Obstetric hemorrhage is one of the leading causes of maternal mortality. The Florida Perinatal Quality Collaborative coordinates a state-wide Obstetric Hemorrhage Initiative (OHI) to assist hospitals in implementing best practices related to this preventable condition. This study examined intervention characteristics that influenced the OHI implementation experiences among Florida hospitals. Methods Purposive sampling was employed to recruit diverse hospitals and multidisciplinary staff members. A semi-structured interview guide was developed based on the following constructs from the intervention characteristics domain of the Consolidated Framework for Implementation Research: evidence strength; complexity; adaptability; and packaging. Interviews were audio-recorded, transcribed and analyzed using Atlas.ti. Results Participants (n = 50) across 12 hospitals agreed that OHI is evidence-based and supported by various information sources (scientific literature, experience, and other epidemiologic or quality improvement data). Participants believed the OHI was 'average' in complexity, with variation depending on participant's role and intervention component. Participants discussed how the OHI is flexible and can be easily adapted and integrated into different hospital settings, policies and resources. The packaging was also found to be valuable in providing materials and supports (e.g., toolkit; webinars; forms; technical assistance) that assisted implementation across activities. Conclusions for Practice Participants reflected positively with regards to the evidence strength, adaptability, and packaging of the OHI. However, the complexity of the initiative adversely affected implementation experiences and required additional efforts to maximize the initiative effectiveness. Findings will inform future efforts to facilitate implementation experiences of evidence-based practices for hemorrhage prevention, ultimately decreasing maternal morbidity and mortality.

Infant and maternal characteristics in neonatal abstinence syndrome--selected hospitals in Florida, 2010-2011.

Neonatal abstinence syndrome (NAS) is a constellation of physiologic and neurobehavioral signs exhibited by newborns exposed to addictive prescription or illicit drugs taken by a mother during pregnancy. The number of hospital discharges of newborns diagnosed with NAS has increased more than 10-fold (from 0.4 to 4.4 discharges per 1,000 live births) in Florida since 1995, far exceeding the three-fold increase observed nationally. In February 2014, the Florida Department of Health requested the assistance of CDC to 1) assess the accuracy and validity of using Florida's hospital inpatient discharge data, linked to birth and infant death certificates, as a means of NAS surveillance and 2) describe the characteristics of infants with NAS and their mothers. This report focuses only on objective two, describing maternal and infant characteristics in the 242 confirmed NAS cases identified in three Florida hospitals during a 2-year period (2010-2011). Infants with NAS experienced serious medical complications, with 97.1% being admitted to an intensive care unit, and had prolonged hospital stays, with a mean duration of 26.1 days. The findings of this investigation underscore the important public health problem of NAS and add to current knowledge on the characteristics of these mothers and infants. Effective June 2014, NAS is now a mandatory reportable condition in Florida. Interventions are also needed to 1) increase the number and use of community resources available to drug-abusing and drug-dependent women of reproductive age, 2) improve drug addiction counseling and rehabilitation referral and documentation policies, and 3) link women to these resources before or earlier in pregnancy.

Comprehensive review of sleep-related sudden unexpected infant deaths and their investigations: Florida 2008.

To describe 2008 Florida sleep-related sudden unexpected infant deaths (SUIDs) by describing (a) percentage distribution of medical examiner (ME) cause-of-death determinations; (b) mortality rates by maternal and infant characteristics; (c) prevalence of selected suffocation or sudden infant death syndrome (SIDS) risk and protective factors; (d) frequency of selected scene investigation and autopsy components (including extent of missing data); and (e) percentage with public health program contact. In this population-based study, we identified sleep-related SUIDs occurring among Florida residents from the 2008-linked Florida infant death and birth certificates. Information about the circumstances of death was abstracted from ME, law enforcement, and hospital records. We used frequencies and percentages to describe characteristics of sleep-related SUID cases. Of 215 sleep-related SUID cases, MEs identified 47.9% as accidental suffocation and strangulation in bed, 35.4% as unknown or undetermined cause, and 16.7% as SIDS. Sleep-related SUID most frequently occurred in an adult bed (n = 108; 50.2%). At death, 82.4% of sleep-related SUIDs had ≥1 suffocation or SIDS risk factor with 54.4% infants sharing a sleep surface, 38.1% placed nonsupine, 24.2% placed on a pillow, and 10.2% having head covering. Missing data frequently resulted from incomplete scene investigation and autopsy components. SUID contributed to ≥1 in seven Florida infant deaths in 2008. Approximately 80% of sleep-related SUIDs were reported among infants placed in unsafe sleeping environments. Effective interventions are needed to promote safe sleep among caregivers of Florida infants. These interventions must reach infant caregivers at highest risk and change unsafe sleep practices. The substantial percentage of missing investigation data reinforces the need for standardized reporting.

Ascertainment of medicaid payment for delivery on the iowa birth certificate: is accuracy sufficient for timely policy and program relevant analysis?

The Iowa Department of Public Health annually links Medicaid claims data to the birth certificate. Because the latest version of the birth certificate provides more timely and less costly information on delivery payment source, we were interested in assessing the validity and reliability of the birth certificate payment source compared to Medicaid paid claims. We linked Medicaid paid claims to birth certificates for calendar years 2007-2009 (n = 120,626). We measured reliability by Kappa statistic and validity by sensitivity, specificity, predictive value positive and negative. We examined reliability and validity overall and by maternal characteristics (e.g. age, race, ethnicity, education). The Kappa statistic for the birth certificate payment source indicated substantial agreement (0.78; 95 % CL 0.78-0.79). Sensitivity and specificity were also high, 86.3 % (95 % CL 86.0-86 6 %) and 91.9 % (95 % CL 91.7-92.1 %), respectively. The predictive value positive was 87.0 %. The predictive value negative was 91.4 %. Kappa and specificity were lower among women of racial and ethnic minorities, women younger than age 24, and women with less education. The overall Kappa, sensitivity and specificity generally suggest the birth certificate payment source is as valid and reliable as the linked data source. The birth certificate payment source is less valid and reliable for women of racial and ethnic minorities, women younger than age 24, and those with less education. Consequently caution should be exercised when using the birth certificate payment source for monitoring service use by the Medicaid population within specific population subgroups.

Maternal and hospital characteristics of non-medically indicated deliveries prior to 39 weeks.

Non-medically indicated (NMI) deliveries prior to 39 weeks increase the risk of neonatal mortality, excess morbidity, and health care costs. The study's purpose was to identify maternal and hospital characteristics associated with NMI deliveries prior to 39 weeks. The study included 207,775 births to women without a previous cesarean and 38,316 births to women with a previous cesarean, using data from Florida's 2006-2007 linked birth certificate and inpatient record file. Adjusted risk ratios (ARR) and 95 % confidence intervals (CI) for characteristics were calculated using generalized estimating equation for multinomial logistic regression. Among women without a previous cesarean, NMI deliveries occurred in 18,368 births (8.8 %). Non-medically indicated inductions were more likely in women who were non-Hispanic white (ARR: 1.41, 95 % CI 1.31-1.52), privately-insured (ARR: 1.42, 95 % CI 1.26-1.59), and delivered in hospitals with <500 births per year. Non-medically indicated primary cesareans were more likely in women who were older than 35 years (ARR: 2.96, 95 % CI 2.51-3.50), non-Hispanic white (ARR: 1.44, 95 % CI 1.30-1.59), and privately-insured (ARR: 1.43, 95 % CI 1.17-1.73). Non-medically indicated primary cesareans were also more likely to occur in hospitals with <30 % nurse-midwife births, <500 births per year, and in large metro areas. Among women with previous cesarean, NMI repeat cesareans occurred in 16,746 births (43.7 %). Only weak risk factors were identified for NMI repeat cesareans. The risk factors identified varied by NMI outcome. This information can be used to inform educational campaigns and identify hospitals that may benefit from quality improvement efforts.