Hospital employees' perception of Joint Commission International Accreditation: effect of re-accreditation.

Joint Commission International (JCI) accreditation is a recognized leader in healthcare accreditation worldwide. It aims to improve quality of care, patient safety, and organizational performance. Many hospitals do not apply for re-accreditation after JCI status expires. Understanding employees' perceptions of JCI accreditation would benefit hospital management. We aimed to examine whether re-accredited hospital employees perceived more significant benefits and were more likely to recommend JCI to other hospitals than ex-accredited employees. This is a prospective cross-sectional study with a comparison group design. Survey questionnaires, developed from a qualitative study, included perceptions of challenges, benefits, and overall rating of JCI accreditation. An electronic-based questionnaire was distributed to physicians, nurses, medical technicians, and administrative staff in five private Obstetrics and Gynecology hospitals in China, March-April 2023. Descriptive and linear regression analyses were performed. The statistically significant level is P-value <.05. Of 2326 employees, 1854 (79.7%) were included in the study after exclusions, 1195 were re-accredited, and 659 were ex-accredited. Perceptions of JCI accreditation were positive, as both groups reported a mean score >4.0 regarding the overall benefits. Adjusted for covariates, re-accredited employees were more willing to recommend JCI accreditation to other hospitals than ex-accredited employees. Re-accredited employees perceived greater benefits of JCI accreditation and were more willing to recommend it to other hospitals, suggesting that perceived benefits contribute to a desire to maintain and sustain JCI accreditation. Employee participation is vital for its effective implementation. Employees' perceived challenges and benefits may provide insights for healthcare leaders considering pursuing and reapplying for JCI accreditation.

Obstetrical Unit Response to the COVID-19 Pandemic: OUR Study.

OBJECTIVE: This study aimed to describe the response of labor and delivery (L&D) units in the United States to the novel coronavirus disease 2019 (COVID-19) pandemic and determine how institutional characteristics and regional disease prevalence affect viral testing and personal protective equipment (PPE). STUDY DESIGN: A cross-sectional survey was distributed electronically through the Society for Maternal-Fetal Medicine e-mail database (n = 584 distinct practices) and social media between April 14 and 23, 2020. Participants were recruited through "snowballing." A single representative was asked to respond on behalf of each L&D unit. Data were analyzed using Chi-square and Fisher's exact tests. Multivariable regression was performed to explore characteristics associated with universal testing and PPE usage. RESULTS: A total of 301 surveys (estimated 51.5% response rate) was analyzed representing 48 states and two territories. Obstetrical units included academic (31%), community teaching (45%) and nonteaching hospitals (24%). Sixteen percent of respondents were from states with high prevalence, defined as higher "deaths per million" rates compared with the national average. Universal laboratory testing for admissions was reported for 40% (119/297) of units. After adjusting for covariates, universal testing was more common in academic institutions (adjusted odds ratio [aOR] = 1.73, 95% confidence interval [CI]: 1.23-2.42) and high prevalence states (aOR = 2.68, 95% CI: 1.37-5.28). When delivering asymptomatic patients, full PPE (including N95 mask) was recommended for vaginal deliveries in 33% and for cesarean delivery in 38% of responding institutions. N95 mask use during asymptomatic vaginal deliveries remained more likely in high prevalence states (aOR = 2.56, 95% CI: 1.29-5.09) and less likely in hospitals with universal testing (aOR = 0.42, 95% CI: 0.24-0.73). CONCLUSION: Universal laboratory testing for COVID-19 is more common at academic institutions and in states with high disease prevalence. Centers with universal testing were less likely to recommend N95 masks for asymptomatic vaginal deliveries, suggesting that viral testing can play a role in guiding efficient PPE use. KEY POINTS: · Heterogeneity is seen in institutional recommendations for viral testing and PPE.. · Universal laboratory testing for COVID-19 is more common at academic centers.. · N95 mask use during vaginal deliveries is less likely in places with universal testing..

Facility preparedness for an obstetric unit during the Covid-19 pandemic.

Covid-19 infection has placed health systems under unprecedented strain and foresight for preparedness is the key factor to avert disaster. Every facility that provides obstetric service needs a certain level of preparedness to be able to handle at least Covid-suspect pregnant women awaiting test reports, who need to be managed as Covid-positive patients till reports are available. Thus, these facilities need to have triage areas and Covid-suspect labour rooms. Healthcare facilities can have designated areas for Covid-positive patients or have referral linkages with designated Covid-positive hospitals. Preparation includes structural reorganization with setting up a Covid-suspect and Covid-positive facility in adequate space, as well as extensive training of staff about infection control practices and rational use of personal protective equipment (PPE). A systematic approach involving five essential steps of making standard operating procedures, infrastructural reorganization for a triage area and a Covid-suspect labour ward, procurement of PPE, managing the personnel and instituting appropriate infection control practices can ensure uninterrupted services to patients without compromising the safety of healthcare providers.

Patients experiences after hospitalization at Gynecologic Obstetrics Department: Identifying parts for improvement.

OBJECTIVE: Evaluation of the quality of the hospital care at individual departments of the clinic from the patient's perspective using a standard questionnaire. DESIGN: Retrospective observational studies. SETTING: 2nd Department of Obstetrics and Gynecology, University hospital Bratislava, Faculty of Medicine, Comenius University Bratislava, Slovakia. MATERIAL AND METHODS: In the study we included all patients who were hospitalized in II. GPK from 1. 1. 2019 to 1. 3. 2019. When the patient was released, they received a HCAHPS questionnaire. Obtained results were statistically processed and compared with publicly available data from all USA hospitals. RESULTS: We received 481 questionnaires suitable for processing. 53.2% of patients evaluated the clinic as the best possible. 57.4% of patients would definitely recommend the clinic to their family and friends. The biggest difference between patients who rated the clinic as the best and those who rated it low were in nurse communication (OR: 6.19, CI: 4.46-8.63). At maternity ward we haven't found any statistical effect in impact of age, but in nurses communication, pain management, communiation about medicines we found significant statistical differences in impact of different education between women. CONCLUSION: The quality of nurses and doctors communication and instructing patients about medication has a significant impact on the clinic's evaluation. Women with university education at maternity ward evaluate quality of hospital care stricter, regardles of age.

Modified early obstetric warning scores: A promising tool but more evidence and standardization is required.

Early warning systems involve the routine monitoring and recording of vital signs or clinical observations on specifically designed charts with linked escalation protocols. Meeting criteria for abnormal physiological parameters triggers a color-coded or weighted scoring system aimed to guide the frequency of monitoring, need for, and urgency of clinical review. Color-coded systems trigger a clinical response when one or more abnormal observation is recorded in the red zone or two or more mildly abnormal parameters in the amber zone. The principle of maternity-specific early warning systems to structure surveillance for hospitalized women is intuitive. The widespread use and policy support, including recommendations following confidential enquiries and from the National Health Service Litigation Authority, is not, however, currently backed up by a strong evidence base. Research is required to develop predictive models and validate evidence-based maternity-specific early warning systems in the general maternity population.

Introduction of Physician-Nurse Bedside Rounding and Ward Task List to Improve Quality of Care in Gynaecology: Prospective, Single-Blinded, Pre- and Post-Intervention Study.

OBJECTIVE: This study sought to determine whether physician-nurse bedside rounds and ward task list improve quality of care as measured by patient satisfaction, earlier discharge, and reduced trainee interruptions. METHODS: This prospective, single-blind, pre- and post-intervention study included patients admitted to the gynaecology ward at St. Michael's Hospital in Toronto, Ontario, involving a 6-week baseline, 6-week intervention, and 2-week second baseline phase. During the intervention phase, a chief resident and charge nurse rounded at the bedside simultaneously daily. Nurses recorded non-urgent issues on a ward task list. Patients completed a subset of the National Research Corporation Picker satisfaction questionnaire, discharge times were noted, and residents recorded pages (Canadian Task Force Classification II-2). RESULTS: There were 89, 104, and 30 admissions during baseline care, intervention, and second baseline phases, respectively. Mean discharge time in the intervention phase was significantly earlier than baseline (11:18 am ± 1 hour 59 minutes vs. 12:37 pm ± 2 hours 37 minutes, P < 0.001), with early discharges doubling (69% vs. 36%, P < 0.001). Discharge times returned to baseline after the intervention (12:36 pm ± 2 hours 39 minutes). Intervention phase patients appreciated bedside care plans (86 of 94 patients, 92%), with improved National Research Corporation Picker responses, which diminished post-intervention. Paging interruptions were lower during the intervention phase compared with the baseline phase (1.0 ± 1.1 vs. 3.4 ± 2.1, P < 0.001), with non-urgent pages decreasing most (0.5 ± 0.8 vs. 3.0 ± 2.0, P < 0.001). CONCLUSION: Combining physician-nurse bedside rounds and ward task list reduces trainee interruptions, positively affects patient satisfaction, and promotes early discharge. Following these initiatives, discharge time, patient satisfaction, and resident paging interruptions returned to baseline.

Reducing the number of obstetrical beds by challenging traditions.

The aim of this commentary is to describe changes in women's care at an obstetric department that made it possible to reduce the number of beds from 40 to 29. Patient pathways were reviewed and revised using lean methodology. The mean length of stay was reduced from 70 to 59 h and the mean numbers of hospitalizations per woman from 1.26 to 1.20. At the organizational level, we introduced a Family Department, home management of newborns, home monitoring of the women with cardiotocography and blood samples, and intrapartum Group B Streptococcus-PCR. Additionally, an After Birth Clinic and network meetings for vulnerable women were established. In patient pathway, we reduced the hospitalization indicated by preterm premature rupture of membranes, preeclampsia and observation after birth laceration. According to National Patient Satisfaction surveys, there was no decrease in women's satisfaction after reducing the number of beds.

An evaluation by the Norwegian Health Care Supervision Authorities of events involving death or injuries in maternity care.

INTRODUCTION: We aimed to determine how serious adverse events in obstetrics were assessed by supervision authorities. MATERIAL AND METHODS: We selected cases investigated by supervision authorities during 2009-2013. We analyzed information about who reported the event, the outcomes of the mother and infant, and whether events resulted from errors at the individual or system level. We also assessed whether the injuries could have been avoided. RESULTS: During the study period, there were 303 034 births in Norway, and supervision authorities investigated 338 adverse events in obstetric care. Of these, we studied 207 cases that involved a serious outcome for mother or infant. Five mothers (2.4%) and 88 infants (42.5%) died. Of the 207 events reported to the supervision authorities, patients or relatives reported 65.2%, hospitals reported 39.1%, and others reported 4.3%. In 8.7% of cases, events were reported by more than 1 source. The supervision authority assessments showed that 48.3% of the reported cases involved serious errors in the provision of health care, and a system error was the most common cause. We found that supervision authorities investigated significantly more events in small and medium-sized maternity units than in large units. Eighteen health personnel received reactions; 15 were given a warning, and 3 had their authority limited. We determined that 45.9% of the events were avoidable. CONCLUSIONS: The supervision authorities investigated 1 in 1000 births, mainly in response to complaints issued from patients or relatives. System errors were the most common cause of deficiencies in maternity care.

Patients' perception of privacy and confidentiality in the emergency department of a busy obstetric unit.

BACKGROUND: Privacy and confidentiality are central components of patient care and are of particular importance in obstetrics and gynaecology, where clinical situations of a sensitive nature regularly occur. The layout of the emergency department (ED) in maternity units is often not conducive to maintaining privacy. METHOD: Our study aimed to discover if changing the environment could improve patients' experiences in the ED. We surveyed patients and asked specific questions about their perception of privacy in the ED. We then repeated the survey following renovations to the ED which involved replacing curtained patient areas with walled cubicles. RESULTS: There were 75 pre-renovation surveys and 82 post-renovation surveys completed. Before the renovations took place, only 21% (n = 16) found their privacy to be adequate during their visit to the ED. However this rose to 89% (n = 73) post-renovation. CONCLUSION: Our study showed that patients' perception of privacy and confidentiality significantly improved following refurbishment of the ED.

Accessibility of general and specialized obstetric care providers in Germany and England: an analysis of location and neonatal outcome.

BACKGROUND: Health care accessibility is known to differ geographically. With this study we focused on analysing accessibility of general and specialized obstetric units in England and Germany with regard to urbanity, area deprivation and neonatal outcome using routine data. METHODS: We used a floating catchment area method to measure obstetric care accessibility, the degree of urbanization (DEGURBA) to measure urbanity and the index of multiple deprivation to measure area deprivation. RESULTS: Accessibility of general obstetric units was significantly higher in Germany compared to England (accessibility index of 16.2 vs. 11.6; p < 0.001), whereas accessibility of specialized obstetric units was higher in England (accessibility index for highest level of care of 0.235 vs. 0.002; p < 0.001). We further demonstrated higher obstetric accessibility for people living in less deprived areas in Germany (r = - 0.31; p < 0.001) whereas no correlation was present in England. There were also urban-rural disparities present, with higher accessibility in urban areas in both countries (r = 0.37-0.39; p < 0.001). The analysis did not show that accessibility affected neonatal outcomes. Finally, our computer generated model for obstetric care provider demand in terms of birth counts showed a very strong correlation with actual birth counts at obstetric units (r = 0.91-0.95; p < 0.001). CONCLUSION: In Germany the focus of obstetric care seemed to be put on general obstetric units leading to higher accessibility compared to England. Regarding specialized obstetric care the focus in Germany was put on high level units whereas in England obstetric care seems to be more balanced between the different levels of care with larger units on average leading to higher accessibility.

Associated Factors and Quality of Care Received among Maternal Deaths at a Regional Hospital in Ghana: Maternal Death Audit Review.

Maternal death audits are crucial to the reduction of maternal deaths. The aim of this study was to identity factors contributing to maternal deaths at Eastern Regional Hospital of Ghana. Quantitative and qualitative methods were used. Quantitative data on all the maternal deaths from January to December 2012 was extracted from completed audit forms and patients records using a standardized questionnaire. The data were analyzed in Epi-info. Qualitative data was collected through in-depth interviews and focus group discussions with health staff to assess care received and factors leading to death. A total of 43 maternal deaths occurred out of which 37 (86%) were audited. Major causes of deaths were pregnancy induced hypertension (27%) and abortion (21%). Late referrals, poor supervision of junior staff, inadequate numbers of senior clinicians, lack of intensive care facility as well as unavailability and insufficient blood and blood products were the main contributory factors to the deaths. Tertiary health institutions should be adequately equipped, staffed, and funded to address these causes of maternal death.

Are stipulated requirements for the quality of maternity care complied with? / Følges fastsatte kvalitetskrav i fødselsomsorgen?

BACKGROUND: The Directorate of Health's national guide Et trygt fødetilbud ­ kvalitetskrav til fødselsomsorgen [A safe maternity service ­ requirements regarding the quality of maternity care] was published in December 2010 and was intended to provide a basis for an improved and more predictable maternity service. This article presents data from the maternity institutions on compliance with the quality requirements, including information on selection, fetal monitoring, organisation, staffing and competencies. MATERIAL AND METHOD: The information was acquired with the aid of an electronic questionnaire in the period January­May 2015. The form was sent by e-mail to the medical officer in charge at all maternity units in Norway as at 1 January 2015 (n=47). RESULTS: There was a 100 % response to the questionnaire. The criteria for selecting where pregnant women should give birth were stated to be in conformity with the quality requirements. Some maternity institutions failed to describe the areas of responsibilities of doctors and midwives (38.5 % and 15.4 %, respectively). Few institutions recorded whether the midwife was present with the patient during the active phase. Half of the maternity departments (level 2 birth units) reported unfilled doctors' posts, and a third of the university hospitals/central hospitals (level 1 birth units) reported a severe shortage of locum midwives. Half of the level 2 birth units believed that the quality requirements had resulted in improved training, but reported only a limited degree of interdisciplinary or mandatory instruction. INTERPRETATION: The study reveals that there are several areas in which the health enterprises have procedures that conform to national quality requirements, but where it is still unclear whether they are observed in practice. Areas for improvement relate to routines describing areas of responsibility, availability of personnel resources and staff training.

Evaluation of satisfaction with care in a midwifery unit and an obstetric unit: a randomized controlled trial of low-risk women.

BACKGROUND: Satisfaction with birth care is part of quality assessment of care. The aim of this study was to investigate possible differences in satisfaction with intrapartum care among low-risk women, randomized to a midwifery unit or to an obstetric unit within the same hospital. METHODS: Randomized controlled trial conducted at the Department of Obstetrics and Gynecology, Østfold Hospital Trust, Norway. A total of 485 women with no expressed preference for level of birth care, assessed to be at low-risk at onset of spontaneous labor were included. To assess the overall satisfaction with intrapartum care, the Labour and Delivery Satisfaction Index (LADSI) questionnaire, was sent to the participants 6 months after birth. To assess women's experience with intrapartum transfer, four additional items were added. In addition, we tested the effects of the following aspects on satisfaction; obstetrician involved, intrapartum transfer from the midwifery unit to the obstetric unit during labor, mode of delivery and epidural analgesia. RESULTS: Women randomized to the midwifery unit were significantly more satisfied with intrapartum care than those randomized to the obstetric unit (183 versus 176 of maximum 204 scoring points, mean difference 7.2, p = 0.002). No difference was found between the units for women who had an obstetrician involved during labor or delivery and who answered four additional questions on this aspect (mean item score 4.0 at the midwifery unit vs 4.3 at the obstetric unit, p = 0.3). Intrapartum transfer from the midwifery unit to an obstetric unit, operative delivery and epidurals influenced the level of overall satisfaction in a negative direction regardless of allocated unit (p < 0.001). CONCLUSION: Low-risk women with no expressed preference for level of birth care were more satisfied if allocated to the midwifery unit compared to the obstetric unit. TRIAL REGISTRATION: The trial is registered at www.clinicaltrials.gov NCT00857129 . Initially released 03/05/2009.

Reduced neonatal mortality in a regional hospital in Mozambique linked to a Quality Improvement intervention.

BACKGROUND: Neonatal mortality remains a serious health issue especially in low resource countries, where 99% of neonatal deaths occur. Doctors with Africa CUAMM is an Italian non-governmental organization in the field of healthcare that has been working in Africa since 1955. In Mozambique, at the Central Beira Hospital (CBH), it has a project with the aim of supporting the neonatal intensive care unit (NICU) and the Obstetrical Department of the CBH through a multi-level intervention. Our aim was to evaluate the effectiveness of CUAMM continuous Quality Improvement intervention in terms of reduction of the overall neonatal mortality rate in the NICU of CBH. METHODS: A baseline analysis was performed in order to assess the actual standard of neonatal care. Subsequently, the intervention was focused on three main areas: infrastructure, equipment and clinical protocols improvement. A retrospective pre- (2013)/post- (2014) implementation analysis of clinical outcomes was performed. RESULTS: Total population included 4,276 newborns, 2,118 (50%) born in 2013 and 2158 (50%) born after implementation. Baseline characteristics of the two groups were similar apart from a higher incidence of outborn neonates (33% vs 30%, p = 0.02) and a lower incidence of Apgar score < 7 at 5 min (37% vs 43%, p < 0.01). The rates of admissions for asphyxia (22% vs 30%), sepsis (4% vs 7%) and prematurity (18% vs 28%) increased between the two study period. Mortality rate for each of these causes decreased from before to after the implementation: asphyxia (34% vs 19%, p < 0.01), sepsis (39% vs 28%, p = 0.06) and prematurity (43% vs 33%, p < 0.01). CONCLUSION: We found a reduction in mortality rate among newborns admitted to CBH's NICU after the first year of CUAMM intervention. Most of this reduction can be attributed to the decrease in deaths for asphyxia, sepsis and prematurity. A Quality Improvement intervention based on infrastructural, equipment and clinical objectives was associated with a reduction of neonatal mortality rate in a low-resource NICU.

The social practice of rescue: the safety implications of acute illness trajectories and patient categorisation in medical and maternity settings.

The normative position in acute hospital care when a patient is seriously ill is to resuscitate and rescue. However, a number of UK and international reports have highlighted problems with the lack of timely recognition, treatment and referral of patients whose condition is deteriorating while being cared for on hospital wards. This article explores the social practice of rescue, and the structural and cultural influences that guide the categorisation and ordering of acutely ill patients in different hospital settings. We draw on Strauss et al.'s notion of the patient trajectory and link this with the impact of categorisation practices, thus extending insights beyond those gained from emergency department triage to care management processes further downstream on the hospital ward. Using ethnographic data collected from medical wards and maternity care settings in two UK inner city hospitals, we explore how differences in population, cultural norms, categorisation work and trajectories of clinical deterioration interlink and influence patient safety. An analysis of the variation in findings between care settings and patient groups enables us to consider socio-political influences and the specifics of how staff manage trade-offs linked to the enactment of core values such as safety and equity in practice.

Maternal death and obstetric care audits in Nigeria: a systematic review of barriers and enabling factors in the provision of emergency care.

BACKGROUND: Maternal death reviews and obstetric audits identify causes and circumstances related to occurrence of a maternal death or serious complication and inform improvements in quality of care. Given Nigeria's high maternal mortality, the lessons learned from past experiences can provide a good evidence base for informed decision making. We aimed to synthesise findings from maternal death reviews and other obstetric audits conducted in Nigeria through a systematic review, seeking to identify common barriers and enabling factors related to the provision of emergency obstetric care. METHODS: We searched for maternal death reviews and obstetric care audits reported in the published literature from 2000-2014. A 'best-fit' framework approach was used to extract data using a structured data extraction form. The articles that met the inclusion criteria were assessed using a nine point quality score. RESULTS: Of the 1,841 abstracts and titles at initial screening, 329 full text articles were reviewed and 43 papers fulfilled the inclusion criteria. Four types of barriers were reported related to: transport and referral; health workers; availability of services; and organisational factors. Three elements stand out in Nigeria as contributing to maternal mortality: delays in Caesarean section, unavailability of magnesium sulphate and lack of safe blood transfusion services. CONCLUSIONS: Obstetric care reviews and audits are useful activities to undertake and should be promoted by improving the processes used to conduct them, as well as extending their implementation to rural and basic level health facilities and to the community. Urgent areas for quality improvement in obstetric care, even in tertiary and teaching hospitals should focus on organisational factors to reduce delays in conducting Caesarean section and making blood and magnesium sulphate available for all who need these interventions.

Evaluating Quality of Care for Sexually Transmitted Infections in Different Clinical Settings.

BACKGROUND: We examined quality of care across different clinical settings within a large safety-net hospital in Massachusetts for patients presenting with penile discharge/dysuria or vaginal discharge. METHODS: Using a modified Delphi approach, a list of sex-specific sexually transmitted infection (STI) quality measures, covering 7 domains of clinical care (history, examination, laboratory testing, assessment, treatment, additional screening, counseling), was selected as standard of care by a panel of 5 STI experts representing emergency department (ED), obstetrics/gynecology (Ob/Gyn), family medicine (FM), primary care (PC), and infectious disease. Final measures were piloted with 50 charts per sex from the STI Clinic and age, sex, and visit date-matched charts from PC, FM, ED, and Ob/Gyn. Performance was scored as compliance among individual measures within 7 domains, standardized to add up to one to adjust for variable number of measures per domain, with an overall score of 7 indicating complete adherence to standards. RESULTS: Expert review process took 2 weeks and resulted in 24 and 34 final measures for male and female patients, respectively. Performance on 7 clinical domains ranged from 3.16 to 4.36 for male patients and 3.17 to 4.33 for female patients. Sexually transmitted infection clinic seemed to score higher on laboratory testing, additional screening, and counseling, but lower on examination and assessment, and ED seemed to score higher on examination and treatment, PC and FM on laboratory testing for male patients and on examination and treatment for female patients, and Ob/Gyn on treatment. CONCLUSIONS: An instrument to discern standard of care and identify strengths and weaknesses in specific domains of clinical documentation for patients presenting with STI complaints can be developed and implemented for quality evaluation across care settings. Further research is needed on whether these findings can be integrated into site-specific quality improvement processes and linked to cost analyses.

What factors contribute to hospital variation in obstetric transfusion rates?

BACKGROUND AND OBJECTIVES: To explore variation in red blood cell transfusion rates between hospitals, and the extent to which this can be explained. A secondary objective was to assess whether hospital transfusion rates are associated with maternal morbidity. MATERIALS AND METHODS: Linked hospital discharge and birth data were used to identify births (n = 279 145) in hospitals with at least 10 deliveries per annum between 2008 and 2010 in New South Wales, Australia. To investigate transfusion rates, a series of random-effects multilevel logistic regression models were fitted, progressively adjusting for maternal, obstetric and hospital factors. Correlations between hospital transfusion and maternal, neonatal morbidity and readmission rates were assessed. RESULTS: Overall, the transfusion rate was 1.4% (hospital range 0.6-2.9) across 89 hospitals. Adjusting for maternal casemix reduced the variation between hospitals by 26%. Adjustment for obstetric interventions further reduced variation by 8% and a further 39% after adjustment for hospital type (range 1.1-2.0%). At a hospital level, high transfusion rates were moderately correlated with maternal morbidity (0.59, P = 0.01), but not with low Apgar scores (0.39, P = 0.08), or readmission rates (0.18, P = 0.29). CONCLUSION: Both casemix and practice differences contributed to the variation in transfusion rates between hospitals. The relationship between outcomes and transfusion rates was variable; however, low transfusion rates were not associated with worse outcomes.