Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

BACKGROUND AND OBJECTIVE: The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. METHODS: In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. RESULTS: Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). CONCLUSIONS: Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Association Between Breastfeeding Discouragement and Breastfeeding Behaviors.

OBJECTIVE: To examine the association between subjective norms and breastfeeding behaviors and to assess whether individual characteristics modify this association. DESIGN: Retrospective cohort study. SETTING: Florida, 2004 to 2005; Louisiana, 2004; and Ohio, 2009 to 2010. PARTICIPANTS: Stratified systematic sample of respondents who completed the Pregnancy Risk Assessment Monitoring System (PRAMS) survey from three states (N = 5,378). METHODS: We used PRAMS data to examine the associations between three independent variables (breastfeeding discouragement by others and number and type of normative referents) and three breastfeeding behaviors (breastfeeding initiation and breastfeeding duration at 4 weeks and 10 weeks after birth) using multivariable log binomial regression. We also examined whether maternal characteristics modified the association between breastfeeding discouragement by others and breastfeeding behaviors. RESULTS: Respondents who reported that others discouraged them from breastfeeding were more likely to initiate breastfeeding (adjusted relative risk (RR) = 0.78, 95% confidence interval [CI] [0.64, 0.96]) than those who were not discouraged. Furthermore, in the total sample, breastfeeding discouragement from others was not associated with breastfeeding discontinuation by 4 weeks and 10 weeks after birth. Breastfeeding discouragement from health care providers was associated with a greater incidence of noninitiation among respondents who reported breastfeeding discouragement from others (adjusted RR = 2.82, 95% CI [1.88, 4.22]). CONCLUSIONS: Findings suggest that women may be motivated to initiate breastfeeding because of their beliefs and emotions despite being discouraged by others. However, discouragement by health care providers was associated with decreased initiation. This underscores a need for the continued implementation and scale-up of evidence-based maternity care practices and education of providers and the public to support breastfeeding.

Postpartum Health Care Use After Gestational Diabetes and Hypertensive Disorders of Pregnancy.

Objective: To examine postpartum health care utilization after a pregnancy complicated by gestational diabetes (GD) and hypertensive disorders of pregnancy (HDP) using nationally representative data. Materials and Methods: We examined longitudinal pooled panel data from the 1996-2007 Medical Expenditure Panel Survey with linked data from Pregnancy Detail Files on adult women (>18) with singleton pregnancies who reported an infant delivery. Multivariable weighted logistic regression analyses, including interactions, examined the associations between pregnancy complications (GD/HDP) and three postpartum health care utilization outcomes, adjusting for demographic characteristics. Results: The unweighted sample size included 304 women. Overall, 32% did not report an office visit within 12 weeks postpartum, and 15% did not report an office visit within 1 year postpartum. In addition, 15% had ≥1 emergency room (ER) visit 1 year postpartum. Women with GD/HDP compared with those with neither complication had more ER visits 1 year postpartum (unadjusted mean 4.9 vs. 2.3; p < 0.01). In multivariable analyses, GD and HDP were not independently associated with outcomes. However, education marginally modified the pregnancy complication-office visit 1 year postpartum relationship (p = 0.06). Other demographic characteristics were independently associated with each postpartum health care utilization outcome after adjustment. Conclusions: Women with GD/HDP did not differ from women with neither complication on postpartum utilization outcomes. Less educated women with GD/HDP were more likely to miss an office visit within 1 year postpartum than less educated women with neither complication. Certain subgroups of women were more likely to forego timely and appropriate postpartum care. Efforts to improve care coordination and insurance coverage access during the postpartum period are needed.