Identification of Clinician Training Techniques as an Implementation Strategy to Improve Maternal Health: A Scoping Review.

Training is a key implementation strategy used in healthcare settings. This study aimed to identify a range of clinician training techniques that facilitate guideline implementation, promote clinician behavior change, optimize clinical outcomes, and address implicit biases to promote high-quality maternal and child health (MCH) care. A scoping review was conducted within PubMed, CINAHL, PsycInfo, and Cochrane databases using iterative searches related to (provider OR clinician) AND (education OR training). A total of 152 articles met the inclusion/exclusion criteria. The training involved multiple clinician types (e.g., physicians, nurses) and was predominantly implemented in hospitals (63%). Topics focused on maternal/fetal morbidity/mortality (26%), teamwork and communication (14%), and screening, assessment, and testing (12%). Common techniques included didactic (65%), simulation (39%), hands-on (e.g., scenario, role play) (28%), and discussion (27%). Under half (42%) of the reported training was based on guidelines or evidence-based practices. A minority of articles reported evaluating change in clinician knowledge (39%), confidence (37%), or clinical outcomes (31%). A secondary review identified 22 articles related to implicit bias training, which used other reflective approaches (e.g., implicit bias tests, role play, and patient observations). Although many training techniques were identified, future research is needed to ascertain the most effective training techniques, ultimately improving patient-centered care and outcomes.

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.

Strategic partnerships for outreach and enrollment: Filling in insurance gaps for Florida's military children and families.

Military-provided health insurance does not adequately cover children with special needs and children of veterans. Medicaid and the Children's Health Insurance Program (CHIP) can help eliminate insurance gaps, if promoted within the military community. This manuscript describes a Military Outreach Program to educate and reach Florida military families about insurance.

Developing a Framework to Promote Children's Health Insurance Enrollment in Florida.

Florida Covering Kids & Families (FL-CKF) at the University of South Florida's Chiles Center for Healthy Mothers and Babies advocates for uninsured children and promotes outreach and enrollment in the state's children's health insurance program, Florida KidCare. FL-CKF facilitates the development of local coalitions to reach children and families throughout the state. Coalitions are provided with one-on-one training and a wide array of tools to increase effectiveness such as coalition-building resources, membership guides, and assistance in building strong local partnerships. FL-CKF places emphasis on creating formalized membership structures so each member knows his or her responsibilities and is accountable for them, partnering with other organizations in the community, and training on how to create and maintain partnerships in the community at large. These approaches help create lasting coalitions and offer an easily replicable approach for others to enhance children's health insurance outreach and enrollment.

Hospital Variations in Unexpected Complications Among Term Newborns.

OBJECTIVES: To examine contributing factors and potential reasons for hospital differences in unexpected newborn complication rates in Florida. METHODS: We conducted a population-based retrospective cohort study of linked birth certificate and hospital discharge records from 2004 to 2013. The study population included 1 604 774 term, singleton live births in 124 hospitals. Severe and moderate complications were identified via a published algorithm. Logistic mixed-effects models were used to examine risk factors for complications and to estimate the percentage of hospital variation explained by factors. Descriptive analyses were performed to explore reasons for the differences. RESULTS: Hospital total complication rates varied from 6.7 to 98.6 per 1000 births. No correlation between severe and moderate complication rates by hospital was identified. Leading risk factors for complications included medically indicated early-term delivery, no prenatal care, nulliparity, prepregnancy obesity, tobacco use, and delivery in southern Florida hospitals. Hospital factors such as geographic location, level of care or birth volume, and Medicaid births percentage explained 35% and 27.8% of variation in severe and moderate complication rates, respectively. Individual factors explained an additional 6% of variation in severe complication rates. Different complication subcategories (eg, infections, hospital transfers) drove the hospital factors that contributed to severe and moderate complications. CONCLUSIONS: Variation in unexpected complication rates is more likely to be related to hospital rather than patient characteristics in Florida. The high proportion of variation explained by hospital factors suggests potential opportunities for improvement, and identifying specific complication categories may provide focus areas. Some of the opportunities may be related to differences in hospital coding practice.

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.

Improving Data, Enhancing Enrollment: Florida Covering Kids & Families CHIPRA Data System.

PURPOSE: According to the Kaiser Family Foundation (2014), 502,866 (11.7 %) of Florida children under 19 years of age are uninsured, giving Florida the second largest number of uninsured children in the United States. Florida Covering Kids & Families (FL-CKF) is dedicated to developing innovative outreach methods for enrolling and retaining eligible children in Florida KidCare, the state's Children's Health Insurance Program. FL-CKF has developed a strong data system that allows it to evaluate the effectiveness and success of statewide enrollment and retention efforts. DESCRIPTION: The data system was created using the Checkbox survey systems. Community and school outreach partners enter data each month on all completed Florida KidCare applications via a secure interface. The system requires data be entered in a uniform format and forces vital data points to be completed. These data are then transmitted to the state to obtain timely application determination information on enrollments. ASSESSMENT: The data system helps FL-CKF to determine which outreach strategies are successful and where changes need to be made to increase effectiveness. The system also provides feedback to community outreach partners in order to enable follow up with families when needed. CONCLUSION: Organizations helping uninsured children apply for health insurance may benefit from creating data collection systems to monitor project efficacy and modify outreach and enrollment strategies for greater effectiveness.

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.

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.

Breastfeeding concerns and experiences of African American mothers.

OBJECTIVE: To explore the perinatal experiences of African American women in Florida for obtaining information about breastfeeding and also their breastfeeding experiences. METHODS: This qualitative study utilized convenience sampling of 253 African American women 18 to 35 years old in three Florida counties. Data were derived from the Healthy Futures Perinatal Research and System Design study. One month after giving birth, face-to face interviews were conducted using an interview schedule. Questions about breastfeeding education and experiences were explored. Taped responses were transcribed and analyzed qualitatively. Through subject-level content analysis, key themes were identified. RESULTS: Most women received some information about breastfeeding during prenatal care. Mothers who chose to breastfeed were usually aware of some of the benefits for the baby and occasionally benefits for themselves. Mothers who did not breastfeed were concerned about pain associated with breastfeeding, time constraints, returning to work or school, personal health choices, or felt uncomfortable with the idea of breastfeeding. Factors facilitating breastfeeding included healthcare providers that encouraged the practice, knowing the advantages, attending a breastfeeding class or support group, breastfeeding in the birth or recovery room, latch assistance, rooming-in, nesting, and the availability of a breast pump. Reasons for supplementation and cessation were latch problems, pain, concerns the baby wasn't getting enough, mother-infant separation, and medical complications. IMPLICATIONS: Intensified prenatal and postpartum efforts to support breastfeeding are needed to increase breastfeeding initiation and duration for African American mothers.

Exploring dental care misconceptions and barriers in pregnancy.

BACKGROUND: Poor oral health is increasingly linked to adverse pregnancy outcomes, including preterm birth and low-birthweight infants. Little is known about childbearing women's experiences in obtaining dental care. The objective of this study was to explore Florida women's experience of barriers in obtaining dental care before and during their pregnancies. METHODS: Study data were derived from a larger data set of a study that examined barriers to prenatal care. One month after giving birth face-to-face interviews were conducted with 253 African American women, 18 to 35 years old, who were residents of one of three Florida counties. Interview questions about women's experiences on obtaining oral health care before and during pregnancy, and recall of guidance about oral health care during prenatal visits were transcribed and analyzed qualitatively. Through subject-level content analysis, key themes were assessed about the participants' perspectives on obtaining oral health care before and during pregnancy. RESULTS: Most participants did not obtain dental care and did not recall receiving dental information during prenatal visits. Barriers to dental care included lack of insurance, difficulty in finding a dentist, low priority given to dental care, misconceptions about the safety and appropriateness of dental care during pregnancy, and sporadic anticipatory guidance during prenatal care. CONCLUSIONS: Misconceptions about the appropriateness of oral health care during pregnancy may affect women's access to and use of this care. Given the implications of poor oral health on possible adverse birth outcomes and its larger connection with the general health of mothers and babies, attention to oral health misconceptions and barriers is warranted.

Missed appointments in perinatal care: response variations in quantitative versus qualitative instruments.

Missed appointments are a significant problem in a healthcare system. They can cause problems for both the practice and the patient. To help a large OB/GYN clinic in South Florida discern typical reasons for missed appointments, a concurrent triangulation design was used in which patient responses on a quantitative mail survey of reasons for missed appointments were compared with those obtained through in-depth interviews. Initial quantitative results indicated appointments were missed due to forgetting, lack of transportation, and lack of childcare. Interview results revealed women had more complicated and emotional reasons behind missed appointments, such as embarrassment, than those identified in the quantitative survey. Interview data revealed that cognitive barriers may be the more likely reason behind missed appointments than structural barriers such as transportation and lack of childcare.