Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate

doi:10.1016/j.jcjq.2016.11.008

The Joint Commission Journal on Quality and Patient Safety

Volume 43, Issue 2, February 2017, Pages 53-61

https://doi.org/10.1016/j.jcjq.2016.11.008 Get rights and content

Background

The nulliparous term singleton vertex (NTSV) cesarean delivery rate has been recognized as a meaningful benchmark. Variation in the NTSV cesarean delivery rate among hospitals and providers suggests many hospitals may be able to safely improve their rates. The NTSV cesarean delivery rate at the authors' institution was higher than state and national averages. This study was conducted to determine the influence of a set of quality improvement interventions on the NTSV cesarean delivery rate.

Methods

From 2008 through 2015, at a single tertiary care academic medical center, a multi-strategy approach that included provider education, provider feedback, and implementation of new policies was used to target evidence-based and inferred factors that influence the NTSV cesarean delivery rate. Data on mode of delivery, maternal outcomes, and neonatal outcomes were collected from birth certificates and administrative claims data. The Cochran-Armitage test and linear regression were used to calculate the p-trend for categorical and continuous variables, respectively.

Results

More than 20,000 NTSV deliveries were analyzed, including more than 15,000 during the intervention period. The NTSV cesarean delivery rate declined from 35% to 21% over eight years. The total cesarean delivery rate declined as well. Increase in meconium aspiration syndrome and maternal transfusion were observed.

Conclusion

Quality improvement initiatives can decrease the NTSV cesarean delivery rate. Any increased incidence of fetal or maternal complications associated with decreased NTSV cesarean delivery rate should be considered in the context of the risks and benefits of vaginal delivery compared to cesarean delivery.

Section snippets

Setting

The setting was a single tertiary care academic medical center performing approximately 4,700 deliveries per year during the study period. Intrapartum care was obstetrician-directed in a laborist-type model. Approximately one third of the deliveries were cared for by employed physicians, one third by private practitioners, and one third by a multi-specialty group. A maternal-fetal medicine group provided intrapartum care for complex patients.

Identification of Five Factors

Non-reassuring fetal heart rate tracing is a leading

Study Population

A total of 51,973 deliveries occurred from 2008 through 2015. The number of annual NTSV deliveries ranged from 1,773 to 2,106, with a total of 15,144 NTSV deliveries over the intervention period. There were no meaningful differences in maternal age or insurance status during the intervention period. The proportion of white women decreased over time, but this was due to an increase in the proportion of women who were of unknown race/ethnicity. The proportion of women with gestational

Discussion

Nationwide, there has been a decline in the NTSV cesarean delivery that has exceeded the pace of decline of the overall cesarean delivery rate. In Massachusetts, the decline in NTSV cesarean delivery rate has exceeded all other states with a 19% decrease from 2009 to 2013.⁷ In approximately that same time span, we implemented a multi-strategy approach including provider education, provider feedback, and implementation of new policies to target the following five factors that may influence the

Conclusion

A reduction in NTSV cesarean delivery rate may have a substantial impact on health care. Hospitals can implement quality improvement initiatives reported here to decrease NTSV cesarean delivery rate. Aspects of this project such as provider education, provider feedback, and change in policy are generalizable to many institutions. Interventions to address environmental or cultural concerns can be customized to meet the needs of a particular institution. We believe the involvement of formal

Mary A. Vadnais, MD, is Clinical Instructor, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, and Maternal Fetal Medicine Physician, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Vanguard Medical Associates, Boston.

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Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports.
The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated.
Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as “other” accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01–1.54).
Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.
Assessing hospital differences in low-risk cesarean delivery metrics in Florida
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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.
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.
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.
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.
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.
Improving Nurse Management of the Second Stage of Labor
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To develop, implement, and evaluate an educational program to improve nurses’ management of the second stage of labor.
Evidence-based practice project guided by the Iowa Model–Revised.
Acute care teaching hospital in central California averaging 2,100 births/year with 12 labor, delivery, and recovery rooms and a Level III nursery.
Eighteen registered nurses participated in the educational intervention.
An instructional course addressed contemporary labor management guidelines and delayed and open/closed glottis pushing. Assessment/documentation of maternal–fetal status, progress/fetal descent, and nurse/provider communication were discussed. Participants engaged in an interactive experience regarding maternal positions.
Data collected from the electronic health record included the number of position changes, nurse/provider communication interactions, and minutes from 10 cm to birth and minutes in delayed pushing.
Second-stage labor outcomes for nulliparous patients at term with a singleton in vertex presentation improved with more position changes and percentage of spontaneous vaginal births. Patients of nurses who participated in the educational intervention (n = 18) had a vaginal birth rate of 87.5% and a surgical birth rate of 6.2%. Patients of nurses who did not participate in the educational intervention (n = 31) had a vaginal birth rate of 81.8% and a surgical birth rate of 9.1%.
Based on the positive response to the intervention and improved clinical outcomes, regularly scheduled interactive nursing education focused on strategies to improve the second stage of labor may be beneficial.
The evolution of the labor curve and its implications for clinical practice: the relationship between cervical dilation, station, and time during labor
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The assessment of labor progress is germane to every woman in labor. Two labor disorders—arrest of dilation and arrest of descent—are the primary indications for surgery in close to 50% of all intrapartum cesarean deliveries and are often contributing indications for cesarean deliveries for fetal heart rate abnormalities.
Beginning in 1954, the assessment of labor progress was transformed by Friedman. He published a series of seminal works describing the relationship between cervical dilation, station of the presenting part, and time. He proposed nomenclature for the classification of labor disorders. Generations of obstetricians used this terminology and normal labor curves to determine expected rates of dilation and fetal descent and to decide when intervention was required.
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Reliable assessment of labor progression is important because uncertainty leads to both over-use and under-use of cesarean delivery and neither of these extremes are desirable. This review traces the evolution of labor curves, describes how limitations are being addressed to reduce uncertainty and to improve the assessment of labor progression using modern statistical techniques and multi-dimensional data, and discusses the implications for obstetrical practice.
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Citation Excerpt :
According to [40], clinical guidelines are useful to reduce those rates and, for that reason, to deliver appropriate care to the mother and the fetus. In the same vein, [41] conclude that the reduction in (nulliparous term singleton vertex) cesarean deliveries results in quality improvements. The equity of access to healthcare is another quality dimension.
The Portuguese National Health Service (SNS) was created to provide universal, equal, and tendentiously free care. There are different levels of care (primary, secondary, continued, and palliative) and all of them should deliver quality care services. Quality in healthcare is assessed according to several criteria, such as patient safety, care appropriateness or access. However, over the last years political and economic events have had an impact on the SNS. Hence, structural reforms have occurred, and new healthcare policies have been implemented, mostly focused on improving efficiency and reducing costs. It associated to divestment can increment barriers to access, compromise infrastructures and equipment, and, above all, the service’s quality. This work aims to assess quality of the Portuguese public hospitals (secondary care providers) in this line. To this aim, we adopt a multiple criteria decision aiding approach, applying the Electre Tri-nC method to build a decision model with intervention of an expert, who acts as the decision maker. Hospitals are assessed and assigned to predefined categories, taking into account the hospitals’ performances on various criteria. Each criterion is characterized by different subcriteria, resulting in a complex criteria tree. Thus, to construct a multidimensional scale for each criterion, we propose an innovative approach using an Electre Tri-based method. The results are analyzed and the robustness of the model is tested. This work’s findings may have potential application to healthcare policy and hospital funding in the SNS, in which financial sustainability is a permanent challenge.
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Michele R. Hacker, ScD, is Associate Professor, Obstetrics and Gynecology, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, and Vice Chair for Research, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center.

Neel T. Shah, MD, is Assistant Professor, Obstetrics and Gynecology, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, and Associate Faculty, Ariadne Labs for Health Systems Innovation, Boston.

JoAnn Jordan, BA, is Director of Quality Programs, and Anna M. Modest, MPH, is Clinical Research Assistant, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center.

Molly Siegel, MD, formerly Medical Student, Harvard Medical School, is Resident, Department of Obstetrics and Gynecology, University of California, San Francisco.

Toni H. Golen, MD, is Assistant Professor, Obstetrics and Gynecology, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, and Vice Chair, Quality and Safety, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center.

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Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate

Background

Methods

Results

Conclusion

Section snippets

Setting

Identification of Five Factors

Study Population

Discussion

Conclusion

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

J Midwifery Womens Health

Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Semin Perinatol

Births: preliminary data for 2013

Natl Vital Stat Rep

Complications with cesarean delivery: a review of Maternal-Fetal Medicine Units Network publications

J Matern Fetal Neonatal Med

The cost of having a baby in the United States

Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop

Obstet Gynecol

Healthypeople 2020

Specifications manual for Joint Commission National Quality Measures (v2016A1): measure information form. Perinatal Care PC-02: Cesarean Birth

Trends in low-risk cesarean delivery in the United States, 1990–2013

Natl Vital Stat Rep

Comparative analysis of international cesarean delivery rates using 10-group classification identifies significant variation in spontaneous labor

Am J Obstet Gynecol