Paradox lost on the U.S.-Mexico border: U.S. Latinas and cesarean rates.

BACKGROUND: We apply Intersectional Theory to examine how compounded disadvantage affects the odds of women having a cesarean in U.S.-Mexico border hospitals and in non-border hospitals. We define U.S. Latinas with compounded disadvantage as those who have neither a college education nor private health insurance. RESULTS: Analyzing quantitative and qualitative data from Childbirth Connection's Listening to Mothers III Survey, we find that, consistent with the notion of the Latinx Health Paradox, compounded disadvantage serves as a protective buffer and decreases the odds of cesarean among women in non-border hospitals. However, the Latinx Health Paradox is absent on the border. CONCLUSION: Our data show that women with compounded disadvantage who give birth on the border have significantly higher odds of a cesarean compared to women without such disadvantage. Further, women with compounded disadvantage who give birth in border hospitals report receiving insufficient prenatal, pregnancy, and postpartum information, providing a direction for future research to explain the border disparity in cesareans.

Bearing witness: United States and Canadian maternity support workers' observations of disrespectful care in childbirth.

BACKGROUND: Disrespectful care and abuse during childbirth are acknowledged global indicators of poor quality care. This study aimed to compare birth doulas' and labor and delivery nurses' reports of witnessing disrespectful care in the United States and Canada. METHODS: Maternity Support Survey data (2781 respondents) were used to investigate doulas' and nurses' reports of witnessing six types of disrespectful care. Multivariate analysis was conducted to examine the effects of demographics, practice characteristics, region, and hospital policies on witnessing disrespectful care. RESULTS: Nearly two-thirds of respondents reported witnessing providers occasionally or often engaging in procedures without giving a woman time or option to consider them. One-fifth reported witnessing providers occasionally or often engaging in procedures explicitly against the patient's wishes, and nurses were more likely to report witnessing this than doulas. Doulas and nurses who expected to leave their job within three years were significantly more likely to report that they witness most types of disrespectful care occasionally or often (OR 1.78-2.43). CONCLUSIONS: Doulas and nurses frequently said that they witnessed verbal abuse in the form of threats to the baby's life unless the woman agreed to a procedure, and failure to provide informed consent. Reports of witnessing some types of disrespectful care in childbirth were relatively uncommon among respondents, but witnessing disrespectful care was associated with an increased likelihood to leave maternity support work within three years, raising implications for the sustainability of doula practice, nursing work force shortages, and quality of maternity care overall.

National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period.

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Hospital-ownership status and cesareans in the United States: The effect of for-profit hospitals.

BACKGROUND: Given the increasing proportion of United States hospitals that are for-profit, we examined whether women who give birth in for-profit hospitals are more likely to have cesareans than women who give birth in not-for-profit hospitals. We hypothesized that cesareans are more likely to occur in for-profit hospitals because of the organizational emphasis on short-term financial indicators, including payment of shareholder dividends. METHODS: We used logistic regression and difference of means tests to analyze data from the Listening to Mothers III survey of women who gave birth in the United States in 2011 and 2012. RESULTS: Controlling for patient-level characteristics, we found that the odds of a woman's having a cesarean were two times higher in for-profit hospitals than in not-for-profit hospitals. We also found for-profit hospitals were significantly more likely to be members of multihospital systems and to have fewer full-time registered nurses and staff members per hospital bed. CONCLUSION: This research suggests that women who give birth in for-profit hospitals are more likely to have cesareans than women who give birth in not-for-profit hospitals. This information is important to women when deciding where to give birth. Knowing which hospital characteristics are associated with a greater likelihood of cesarean is helpful since hospital cesarean rates may be difficult to find. These findings are also informative for obstetric professionals, who can implement improvement initiatives to decrease cesarean rates and improve the overall quality of care for childbearing women in the United States.

Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy.

OBJECTIVE: Maternal mortality rates rose markedly from 2002 to 2006 in California, prompting an in-depth maternal mortality review in a state that comprises one twelfth of the US birth cohort. Cardiovascular disease has emerged as the leading cause of pregnancy-related death in the United States. The primary aim of this analysis was to describe the incidence and type of cardiovascular disease as a cause of pregnancy-related mortality in California. The secondary aims were to describe racial/ethnic and socioeconomic disparities, risk factors, birth outcomes, timing of death and diagnosis, and signs and symptoms of cardiovascular disease and identify contributing factors. STUDY DESIGN: The California Pregnancy-Associated Mortality Review retrospectively examined a case series of 64 cardiovascular pregnancy-related deaths from 2002 through 2006. Two cardiologists independently reviewed complete inpatient and outpatient medical records including laboratory, radiology, electrocardiogram, chest X-ray, echocardiograms, and autopsy findings for each cardiovascular death and classified cause of death by type of cardiovascular disease. Demographic data, racial disparities, risk factors, signs and symptoms, timing of diagnosis and death, birth outcomes, and contributing factors were analyzed using bivariate comparisons with noncardiovascular pregnancy-related deaths and population-based data. RESULTS: Among 2,741,220 California women who gave birth, 864 died while pregnant or within 1 year of pregnancy; 257 of the deaths were deemed pregnancy related, and of these, 64 (25%) were attributed to cardiovascular disease. There were 42 deaths caused by cardiomyopathy, and the pregnancy-related mortality rate from cardiomyopathy was 1.54 per 100,000 births. Dilated cardiomyopathy existed in 29 cases, of which 15 met the definition of peripartum cardiomyopathy. Women with cardiovascular disease were more likely than women who died from noncardiovascular causes to be African-American (39.1% vs 16.1%; P < .01) and more likely to use illicit substances (23.7% vs 9.4%; P < .01). Thirty-seven percent were obese and 20% had a concomitant diagnosis of hypertension or preeclampsia during pregnancy. Health care decisions in the diagnosis or treatment of cardiovascular disease during and after pregnancy contributed to the fatal outcomes. CONCLUSION: African-American race, substance use, and obesity were risk factors for pregnancy-related cardiovascular disease mortality. Chronic disease prevention and better recognition and response to cardiovascular disease during pregnancy are needed to reduce maternal mortality.

Disparity drivers, potential solutions, and the role of a health equity dashboard in the neonatal intensive care unit: a qualitative study.

OBJECTIVE: Racial/ethnic disparities are well-described in the neonatal intensive care unit (NICU). We explored expert opinion on their etiology, potential solutions, and the ability of health equity dashboards to meaningfully capture NICU disparities. STUDY DESIGN: We conducted 12 qualitative semi-structured interviews, purposively selecting a diverse group of neonatal experts. We used grounded theory to develop codes, shape interviews, and conduct analysis. RESULT: We identified three sources of disparity: interpersonal bias, care process and institutional barriers, and social determinants of health, particularly as they affect parental engagement in the NICU. Proposed solutions included racial/cultural concordance, bolstering hospital-based resources, and policy interventions. Health equity dashboards were viewed as useful but limited, because clinical metrics do not account for many of the aforementioned sources of disparities. CONCLUSION: Equity dashboards serve as a motivational starting point for quality improvement; future iterations may require novel, qualitative data sources to identify underlying etiologies of NICU disparities.

Mobile-enhanced Family Integrated Care for preterm infants: A qualitative study of parents' views.

Objective: The Family Integrated Care (FICare) model improves outcomes for preterm infants and parents compared with family-centered care (FCC). FICare with mobile technology (mFICare) may improve uptake and impact. Research on FICare in the United States (US) is scarce and little is known about parents' experience. Methods: We conducted qualitative interviews with nine parents, exploring their NICU experiences, participation in and perceptions of the mFICare program. A directed content analysis approach was used, and common themes were derived from the data. Results: Overall, parents had positive NICU experiences and found mFICare helpful in meeting three common parenting priorities: actively caring for their infant, learning how to care for their infant, and learning about the clinical status of their infant. They described alignment and misalignment with mFICare components relative to their personal parenting priorities and offered suggestions for improvement. Nurses were noted to play key roles in providing or facilitating parent support and encouragement to participate in mFICare and parenting activities. Conclusion: The mFICare program showed potential for parental acceptance and participation in US NICUs. Innovation: The mFICare model is an innovation in neonatal care that can advance the consistent delivery of NICU family-centered care planning and caregiving.Clinical Trial Registration:NCT03418870 01/02/2018.

National Partnership for Maternal Safety: Consensus Bundle on Support After a Severe Maternal Event.

Supporting women, families, and clinicians with information, emotional support, and health care resources should be part of an institutional response after a severe maternal event. A multidisciplinary approach is needed for an effective response during and after the event. As a member of the maternity care team, the nurse's role includes coordination, documentation, and ensuring patient safety in emergency situations. The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women's Health Care, has developed interprofessional work groups to develop safety bundles on diverse topics. This article provides the rationale and supporting evidence for the support after a severe maternal event bundle, which includes structure- and evidence-based resources for women, families, and maternity care providers. The bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning, and it may be adapted by nurses and multidisciplinary leaders in birthing facilities for implementation as a standardized approach to providing support for everyone involved in a severe maternal event.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Venous Thromboembolism.

OBJECTIVE: To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from venous thromboembolism (VTE) by the California Pregnancy-Associated Mortality Review Committee. DESIGN: Qualitative, descriptive design using thematic analysis. SAMPLE: A total of 108 QIOs identified from 29 cases of pregnancy-related deaths from VTE in California from 2002 to 2007. METHODS: We coded and thematically organized the 108 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. RESULTS: Women's lack of awareness of the significance of severe VTE symptoms and the lack of a standardized approach to recognize and respond to VTE signs and symptoms were the most prevalent themes in the Readiness domain. Missing the signs and symptoms of VTE and the resultant missed or delayed diagnosis were predominant themes in the Recognition domain. For Response, issues related to lack of VTE prophylaxis were most frequently noted, along with other themes, including timing of treatment and appropriate follow-up after hospital discharge. CONCLUSION: To decrease the occurrence of maternal death from VTE in the United States, consistent and thorough education regarding VTE signs and symptoms must be given to all women and their families during pregnancy and the postpartum period. Maternity care facilities and providers should implement preventive measures, including standardized use of VTE prophylaxis, improved methods to recognize the signs and symptoms of VTE, and improved follow-up after hospital discharge.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Sepsis.

OBJECTIVE: To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from sepsis by the California Pregnancy-Associated Mortality Review Committee. DESIGN: Qualitative descriptive design using thematic analysis. SAMPLE: A total of 118 QIOs identified from 27 cases of pregnancy-related deaths from sepsis in California from 2002 to 2007. METHODS: We coded and thematically organized the 118 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. RESULTS: Women's delay in seeking care was the central theme in the Readiness domain. In the Recognition domain, health care providers missed the signs and symptoms of sepsis, including elevated temperature, elevated white blood cell count, increased heart rate, decreased blood pressure, mottled skin, preterm labor, headache, and pain. For Response, late antibiotic administration was a central theme; multiple emergent themes included administration of the wrong antibiotics, failure to investigate women's complaints of pain, lack of nurse/provider communication, and lack of follow-up care after hospital discharge. CONCLUSION: To reverse the contribution of sepsis to the rising rate of maternal mortality in the United States, health care facilities and providers need to reduce barriers for women who seek care, recognize early symptoms, and respond with appropriate treatment. This could be achieved by implementation of the Maternal Early Warning Criteria, standardized guidelines such as those from the Surviving Sepsis campaign, and comprehensive discharge education.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Cardiovascular Disease.

OBJECTIVE: To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from cardiovascular disease (CVD) by the California Pregnancy-Associated Mortality Review committee. DESIGN: Qualitative descriptive design using thematic analysis. SAMPLE: A total of 269 QIOs identified from 87 pregnancy-related deaths from CVD in California from 2002 to 2007. METHODS: We coded and thematically organized the 269 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. RESULTS: The most prevalent theme within the Readiness domain was the care of women in a facility or a department within a facility that was not equipped to handle the severity of their CVD conditions. For Recognition, a common theme was an underappreciation of the severity of illness, including high-risk factors and clinical warning signs, which led to inaccurate diagnoses, such as anxiety or asthma, and missed diagnoses of CVD. The lack of recognition of CVD led to delays in treatment or inaccurate treatment, the leading themes in the Response domain. CONCLUSION: Identification of CVD or its risk factors during pregnancy can lead to timely, multidisciplinary approaches to management and birth in facilities that offer appropriately trained health care professionals and appropriate equipment. Maternal mortality can be reduced if signs and symptoms of CVD in women are recognized early and treatment modalities are implemented quickly during pregnancy, childbirth, and the postpartum period.

Translating Maternal Mortality Review Into Quality Improvement Opportunities in Response to Pregnancy-Related Deaths in California.

OBJECTIVE: To describe quality improvement opportunities (QIOs) associated with the five leading causes of pregnancy-related death in California and the methods by which the QIOs were collected by the California Pregnancy-Associated Mortality Review committee. DESIGN: Qualitative, descriptive design using thematic analysis. SAMPLE: A total of 907 QIOs identified from 203 cases of pregnancy-related deaths from cardiovascular disease, preeclampsia/eclampsia, hemorrhage, venous thromboembolism, and sepsis that occurred in California from 2002 to 2007. METHODS: We coded and thematically organized QIO data using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. We refer to the domains collectively as the 4R Framework. RESULTS: We identified key themes across the five leading causes of death. In the Readiness domain, themes were related to overall facility readiness and helping women be prepared and knowledgeable about pregnancy and childbirth. Themes that emerged as central in the Recognition domain addressed the need for clinicians to better recognize risk factors and women's signs and symptoms to ensure an accurate diagnosis. In the Response domain, three themes were predominant, and they were related to the coordination of care, timing of treatment, and follow-up care. CONCLUSION: Results from our study show the utility and transferability of the first three domains of the 4R Framework as applied to quality improvement data from a large statewide maternal mortality review. Nursing leadership is necessary to support and guide national, statewide, and local efforts to improve the quality of maternity care through the implementation of quality improvement at the system, facility, clinician, and patient levels.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Obstetric Hemorrhage.

OBJECTIVE: To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from obstetric hemorrhage by the California Pregnancy-Associated Mortality Review Committee. DESIGN: Qualitative descriptive using thematic analysis. SAMPLE: A total of 159 QIOs identified from 33 cases of pregnancy-related deaths from obstetric hemorrhage in California from 2002 to 2007. METHODS: We coded and thematically organized the 159 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. RESULTS: Thematic findings indicated that facility Readiness would be improved through practice standardization, better organization of equipment to treat hemorrhage, and planning for care of women with risk factors for hemorrhage. Recognition of hemorrhage by health care providers could be improved through accurate assessment of blood loss, risk factors, and early clinical signs of deterioration. Provider Response could be improved through reducing delays in administering blood, seeking consultations, transferring women to higher levels of care within or outside of the facility, and moving on to other treatments if a woman does not respond to current treatment. CONCLUSION: Hemorrhage is the most preventable cause of maternal death in California. Morbidity and mortality from hemorrhage can be prevented if birth facilities and maternity care clinicians align local practices with national safety guidelines.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Preeclampsia/Eclampsia.

OBJECTIVE: To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from preeclampsia/eclampsia by the California Pregnancy-Associated Mortality Review Committee. DESIGN: Qualitative descriptive design using thematic analysis. SAMPLE: A total of 242 QIOs identified from 54 cases of pregnancy-related deaths from preeclampsia/eclampsia in California between 2002 and 2007. METHODS: We coded and thematically organized the 242 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. RESULTS: Standardized Policies and Protocols to manage severe hypertension and respond to obstetric emergencies was the main theme identified in the Readiness domain. For Recognition, issues related to Missed Clinical Warning Signs of worsening preeclampsia/eclampsia were predominant. In the Response domain, the themes Inadequate Assessment and Treatment of severe hypertension and Coordination of Care were most frequently noted. CONCLUSION: Findings from our study suggest numerous opportunities to improve care and outcomes for women who died of preeclampsia/eclampsia in California from 2002 to 2007. Facilities need to adopt and implement standardized policies and protocols about the diagnosis and treatment of preeclampsia/eclampsia. Clinician education about key warning signs is critical, as is ensuring that women understand the signs and symptoms that warrant immediate clinical attention. Death from preeclampsia/eclampsia is very preventable, and efforts to reduce maternal mortality and morbidity from this serious condition of pregnancy are needed at all levels.

Systolic Hypertension, Preeclampsia-Related Mortality, and Stroke in California.

OBJECTIVE: To describe the clinical characteristics of stroke and opportunities to improve care in a cohort of preeclampsia-related maternal mortalities in California. METHODS: The California Pregnancy-Associated Mortality Review retrospectively examined a cohort of preeclampsia pregnancy-related deaths in California from 2002 to 2007. Stroke cases were identified among preeclampsia deaths, and case summaries were reviewed with attention to clinical variables, particularly hypertension. Health care provider- and patient-related contributing factors were also examined. RESULTS: Among 54 preeclampsia pregnancy-related deaths that occurred in California from 2002 to 2007, 33 were attributed to stroke. Systolic blood pressure exceeded 160 mm Hg in 96% of cases, and diastolic blood pressure was 110 or higher in 65% of cases. Hemolysis, elevated liver enzymes, and low platelet count syndrome was present in 38% (9/24) of cases with available laboratory data; eclampsia occurred in 36% of cases. Headache was the most frequent symptom (87%) preceding stroke. Elevated liver transaminases were the most common laboratory abnormality (71%). Only 48% of women received antihypertensive treatment. A good-to-strong chance to alter outcome was identified in stroke cases 66% (21/32), with delayed response to clinical warning signs in 91% (30/33) of cases and ineffective treatment in 76% (25/33) cases being the most common areas for improvement. CONCLUSION: Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia. All but one patient in this series of strokes demonstrated severe elevation of systolic blood pressure, whereas other variables were less consistently observed. Antihypertensive treatment was not implemented in the majority of cases. Opportunities for care improvement exist and may significantly affect maternal mortality.

Never judge a book by its cover: how NICU evaluators reach conclusions about quality of care.

OBJECTIVE: To identify key features in the NICU care delivery context that influence quality of care delivery. STUDY DESIGN: Qualitative study using in-depth, semi-structured interviews with 10 NICU quality experts with extensive experience conducting NICU site visits and evaluating quality of care. Analyses were performed using the method of constant comparison based on grounded theory. RESULTS: Qualitative analysis yielded three major themes: (1) the foundation for high quality care is a cohesive unit culture, characterized by open communication, teamwork, and engagement of families; (2) effective linkages between measurement and improvement action is necessary for continuous improvement; and (3) NICU capacity for improvement is sustained by active support, exchange of skills, and resources from the hospital. CONCLUSIONS: Team cohesion, engagement of families, culture of improvement supported by measurement and institutional support from the hospital are some of the key contextual and managerial features critical to high-quality NICU care.

National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period.

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period.

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.