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Abstract: Objective: To examine whether the presence of a birth plan was associated with mode of delivery, obstetrical interventions, and patient satisfaction. Methods: This was a prospective cohort study of singleton pregnancies greater than 34 weeks’ gestation powered to evaluate a difference in mode of delivery. Maternal characteristics, antenatal factors, neonatal characteristics, and patient satisfaction measures were compared between groups. Differences between groups were analyzed using chi‐squared for categorical variables, Fisher exact test for dichotomous variables, and Wilcoxon rank sum test for continuous or ordinal variables. Results: Three hundred women were recruited: 143 (48%) had a birth plan. There was no significant difference in the risk of cesarean delivery for women with a birth plan compared with those without a birth plan (21% vs 16%, adjusted odds ratio [adjOR] 1.11 [95% confidence interval (CI) 0.61‐2.04]). Women with a birth plan were 28% less likely to receive oxytocin (P < .01), 29% less likely to undergo artificial rupture of membranes (P < .01), and 31% less likely to have an epidural (P < .01). There was no difference in the length of labor (P = .12). Women with a birth plan were less satisfied (P < .01) and felt less in control (P < .01) of their birth experience than those without a birth plan. Conclusion: Women with and without a birth plan had similar odds of cesarean delivery. Though they had fewer obstetrical interventions, they were less satisfied with their birth experience, compared with women without birth plans. Further research is needed to understand how to improve childbirth‐related patient satisfaction. [ABSTRACT FROM AUTHOR]

Background To determine whether the mode of delivery was different between women who attended childbirth education ( CBE) class, had a birth plan, or both compared with those who did not attend CBE class or have a birth plan. Methods This is a retrospective cross-sectional study of women who delivered singleton gestations > 24 weeks at our institution between August 2011 and June 2014. Based on a self-report at the time of admission for labor, women were stratified into four categories: those who attended a CBE class, those with a birth plan, both, and those with neither CBE or birth plan. The primary outcome was the mode of delivery. Multivariate logistic regression analyses adjusting for clinical covariates were performed. Results In this study, 14,630 deliveries met the inclusion criteria: 31.9 percent of the women attended CBE class, 12.0 percent had a birth plan, and 8.8 percent had both. Women who attended CBE or had a birth plan were older ( p < 0.001), more likely to be nulliparous ( p < 0.001), had a lower body mass index ( p < 0.001), and were less likely to be African-American ( p < 0.001). After adjusting for significant covariates, women who participated in either option or both had higher odds of a vaginal delivery ( CBE: OR 1.26 [95% CI 1.15-1.39]; birth plan: OR 1.98 [95% CI 1.56-2.51]; and both: OR 1.69 [95% CI 1.46-1.95]) compared with controls. Conclusion Attending CBE class and/or having a birth plan were associated with a vaginal delivery. These findings suggest that patient education and birth preparation may influence the mode of delivery. CBE and birth plans could be used as quality improvement tools to potentially decrease cesarean rates. [ABSTRACT FROM AUTHOR]

Objectives The goals of interconception care are to optimize women's health and encourage adequate spacing between pregnancies. Our study calculated trends in interpregnancy interval (IPI) patterns and measured the association of differing intervals with birth outcomes in California. Methods Women with 'non-first birth' deliveries in California hospitals from 2007 to 2009 were identified in a linked birth certificate and patient discharge dataset and divided into three IPI birth categories: <6, 6-17, and 18-50 months. Trends over the study period were tested using the Cochran-Armitage two-sided linear trend test. Chi square tests were used to test the association between IPI and patient characteristics and selected singleton adverse birth outcomes. Results Of 645,529 deliveries identified as non-first births, 5.6 % had an IPI <6 months, 33.1 % had an IPI of 6-17 months, and 61.3 % had an IPI of 18-50 months. The prevalence of IPI <6 months declined over the 3-year period (5.8 % in 2007 to 5.3 % in 2009, trend p value <0.0001).Women with an IPI <6 months had a significantly higher prevalence of early preterm birth (<34 weeks), low birthweight (<2500 g), neonatal complications, neonatal death and severe maternal complications than women with a 6-17 month or 18-50 month IPI (p < 0.005). Comparing those with a 6-17 month vs 18-50 month IPI, there were increased early preterm births and decreased maternal complications, complicated delivery, and stillbirth/intrauterine fetal deaths among those with a shorter IPI. Conclusions for Practice In California, women with an IPI <6 months were at increased risk for several birth outcomes, including composite morbidity measures. [ABSTRACT FROM AUTHOR]

Background To categorize individual birth plan requests and determine if number of requests and request fulfillment is associated with birth experience satisfaction. Methods This is a sub-analysis of a prospective cohort study of 302 women with singleton pregnancies with and without birth plans. Women with a hard copy of their birth plans who completed a postdelivery satisfaction survey were included in this study. We described the number and type of birth plan requests and associated the number of requests and request fulfillment with overall satisfaction, expectations met, and sense of control. Differences between groups were analyzed using chi-square, Spearman rank correlation, and logistic regression. Results One hundred and nine women presented to Labor and Delivery with a hard copy of their prewritten birth plan. We identified 23 unique requests. The most common requests were no intravenous analgesia (82%) and exclusive breastfeeding (74%). The requests most fulfilled were avoidance of episiotomy (100%) and no operative vaginal delivery (89%). Having a higher number of requests fulfilled correlated with greater overall satisfaction ( p = 0.03), higher chance of expectations being met ( p < 0.01), and feeling more in control ( p < 0.01). Having a high number of requests was associated with an 80 percent reduction in overall satisfaction with the birth experience ( p < 0.01). Conclusions Having a higher number of requests fulfilled was positively associated with birth experience satisfaction, while having a high number of requests was inversely associated with birth experience satisfaction. Further research is needed to understand how to improve birth plan-related birth experience satisfaction. [ABSTRACT FROM AUTHOR]

Objective: To develop a methodology to identify indications and normative rates for elective primary cesarean delivery using administrative data.Data Sources/study Setting: All delivery discharges in 1995, as reported to the California Office of Statewide Health Planning and Development (secondary data).Study Design: Retrospective population based study.Data Collection/extraction: Data were entered into a recursive partitioning algorithm to develop a hierarchy of conditions by which patients with multiple conditions could be sorted with respect to the binary outcome of labor or elective primary cesarean without labor. This hierarchy was examined for its clinical consistency, validated on a second sample, and compared with results obtained from logistic regression.Principal Findings: Four percent (19,664) of delivery discharges in 1995 underwent elective primary cesarean. Twelve clinical conditions contributed to the hierarchy, and accounted for 92.9 percent of all women experiencing elective primary cesarean delivery. The remaining 7.1 percent of the elective primary cesarean cases were classified as "unspecified."Conclusions: A standardized methodology (utilizing recursive partitioning algorithms) for assigning indications for elective primary cesarean is presented. This methodology relies on administrative data, classifies women with complex comorbidity patterns into clinically relevant subpopulations, and can be used to establish normative rates for benchmarking specific indications for cesarean delivery. [ABSTRACT FROM AUTHOR]

The tracking of elective deliveries (ED) prior to 39 gestational weeks has become a mandatory requirement for all hospitals with ≥1,100 deliveries for accreditation by The Joint Commission (TJC); however, the feasibility and accuracy of monitoring efforts remain problematic for many hospitals. Here, we evaluated the feasibility of three operational approaches to tracking ED. We used mixed methods to evaluate the feasibility of 3 different approaches to tracking ED: (1) using administrative data, (2) using electronic medical record (EMR) data, and (3) using targeted data collection in a county-wide quality improvement (QI) effort. For (1), we analyzed data from the California 2009 linked birth cohort dataset, and calculated hospital rates of ED using TJC technical specifications. For (2), we performed a case study of a project that recruited hospitals to provide EMR data for the TJC measure calculation. For (3), we performed a case study of a project that recruited hospitals to prospectively track elective inductions of labor. For (1), hospital discharge data were insufficient without supplementation from the EMR or birth certificate. For (2), legal and operational issues surrounding data sharing, and non-standardized data elements prohibited hospital participation. For (3), the QI approach successfully established policies and data collection systems yet lacked infrastructure to assure sustainability at a hospital or regional level. In summary, ED tracking required the coordination and support of multiple resources to enable hospitals to satisfactorily report on this measure. [ABSTRACT FROM AUTHOR]

Objectives. We examined trends in maternal comorbidities in California. Methods. We conducted a retrospective cohort study of 1 551 017 California births using state-linked vital statistics and hospital discharge cohort data for 1999, 2002, and 2005. We used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify the following conditions, some of which were preexisting: maternal hypertension, diabetes, asthma, thyroid disorders, obesity, mental health conditions, substance abuse, and tobacco use. We estimated prevalence rates with hierarchical logistic regression models, adjusting for demographic shifts, and also examined racial/ethnic disparities. Results. The prevalence of these comorbidities increased over time for hospital admissions associated with childbirth, suggesting that pregnant women are getting sicker. Racial/ethnic disparities were also significant. In 2005, maternal hypertension affected more than 10% of all births to non-Hispanic Black mothers; maternal diabetes affected nearly 10% of births to Asian/Pacific Islander mothers (10% and 43% increases, respectively, since 1999). Chronic hypertension, diabetes, obesity, mental health conditions, and tobacco use among Native American women showed the largest increases. Conclusions. The prevalence of maternal comorbidities before and during pregnancy has risen substantially in California and demonstrates racial/ethnic disparity independent of demographic shifts. [ABSTRACT FROM AUTHOR]

Background We propose a methodology for identifying and analysing 'elective' preterm births ( PTBs) using administrative data, and apply this methodology to California data with the objective of providing a framework to further explore the potential rationales for early delivery. Methods Using the California linked birth cohorts for 1999, 2002 and 2005, singleton PTBs were identified using birth certificate gestational age ≥ 24 and <37 weeks. Through a hierarchical scheme that first removed cases with standard or 'hard' indications for early delivery (e.g. severe preeclampsia, placenta previa), cases of 'elective' PTB were identified with coding for medical intervention, that is, elective caesarean or labour induction. We calculated rates of elective PTB, with subanalyses of early (<34 weeks of gestational age) and late PTB (34 to <37 weeks of gestational age) using hierarchical logistic regression models. Results Of 1 387 565 singleton deliveries, 99 614 (7.2%) were preterm. Elective PTBs increased 27.7% over the 6-year study period, with nearly all cases confined to the late PTB stratum; elective late PTB rates rose from 10.5% to 13.5% of all late PTBs ( P < 0.0001). Indications for delivery in this Elective Group ('soft indications') included prior pelvic floor repair, mental health conditions, fetal anomalies, malpresentation and oligohydramnios. Six per cent of patients with a late PTB had a medical intervention with no hard or soft indication for delivery. Conclusions Using administrative data, we developed a method for identifying and trending the proportion of PTBs that is 'elective'. This method can be used to explore and monitor potential strategies for the prevention of elective PTB. [ABSTRACT FROM AUTHOR]

Objective: Our purpose was to describe variation in elective primary cesarean rates by nonclinical factors.Study Design: With use of California discharge data and American Hospital Association data for 1995, patients were classified into 13 mutually exclusive categories for elective primary cesarean delivery. With use of recursive partitioning algorithms, women in each category were then studied to determine whether nonclinical factors were associated with elective primary cesarean delivery.Results: A total of 463,196 women were delivered at 288 hospitals, and the elective primary cesarean delivery rate was 4.25% (19,664/463,196). Risk for elective primary cesarean delivery varied by clinical condition. The most discriminant risk factors were hospital type (malpresentation, multiple gestation, macrosomia, other hypertension), maternal age (antepartum bleeding, uterine scar, soft tissue disorder, preterm, unspecified), and teaching status (herpes, severe hypertension, unengaged head).Conclusion: This article presents methods that use administrative data to isolate and monitor the impact of nonclinical factors on the use of elective primary cesarean. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to describe the resources and activities associated with childbirth services. Study Design: We adapted models for assessing the quality of healthcare to generate a conceptual framework hypothesizing that childbirth hospital resources and activities contributed to maternal and neonatal outcomes. We used this framework to guide development of a survey, which we administered by telephone to hospital labor and delivery nurse managers in California. We describe the findings by hospital type (ie, integrated delivery system [IDS], teaching, and other [community] hospitals). Results: Of 248 nonmilitary childbirth hospitals in California, 239 (96%)responded; 187 community, 27 teaching, and 25 IDS hospitals reported. The context of services varied across hospital types, with community hospitals more likely to have for-profit ownership, be in a rural or isolated location, and have fewer annual deliveries per hospital. Results included the findings of the following: (1) 24 hour anesthesia availability in 50% of community vs 100% of IDS and teaching hospitals (P < .001); (2) 24 hour in-house labor and delivery physician coverage in 5% of community vs 100% of IDS and 48% of teaching hospitals (P < .001); (3) 24 hour blood bank availability in 88% of community vs 96% of IDS and 100% of teaching hospitals (P = .092); (4) adult subspecialty intensive care unit availability in 33% of community vs 36% of IDS and 82% of teaching hospitals (P < .001); (5) ability to perform emergency cesarean delivery in 30 minutes 100% of the time in 56% of community vs 100% of IDS and 85% of teaching hospitals (P < .001); (6) pediatric care available both day and night in 54% of community vs 63% of IDS vs 76% of teaching hospitals (P = .087); and (7) no neonatal intensive care unit in 44% of community vs 12% of IDS and 4% of teaching hospitals (P < .001). Conclusion: Childbirth services varied widely across California hospitals. Cognizance of this variation and linkage of these data to childbirth outcomes should assist in the identification of key resources and activities that optimize the hospital environment for pregnant women and set the groundwork for identifying criteria for the provision of maternal risk-appropriate care. [ABSTRACT FROM AUTHOR]

Objective: We sought to determine the impact of the laborist staffing model on cesarean rates and maternal morbidity in California community hospitals.Study Design: This is a cross-sectional study comparing cesarean rates, vaginal birth after cesarean rates, composite maternal morbidity, and severe maternal morbidity for laboring women in California community hospitals with and without laborists. We conducted interviews with nurse managers to obtain data regarding hospital policies, practices, and the presence of laborists, and linked this information with patient-level hospital discharge data for all deliveries in 2012.Results: Of 248 childbirth hospitals, 239 (96.4%) participated; 182 community hospitals were studied, and these hospitals provided 221,247 deliveries for analysis. Hospitals with laborists (n = 43, 23.6%) were busier, had more clinical resources, and cared for higher-risk patients. There was no difference in the unadjusted primary cesarean rate for laborist vs nonlaborist hospitals (11.3% vs 11.7%; P = .382) but there was a higher maternal composite morbidity rate (14.4% vs 12.0%; P = .0006). After adjusting for patient and hospital characteristics, there were no differences in laborist vs nonlaborist hospitals for any of the specified outcomes. Hospitals with laborists had higher attempted trial of labor after cesarean rates, and lower repeat cesarean rates (90.9% vs 95.9%; P < .0001). However, among women attempting trial of labor after cesarean, there was no difference in the vaginal birth after cesarean success rate.Conclusion: We were unable to demonstrate differences in cesarean and maternal childbirth complication rates in community hospitals with and without laborists. Further efforts are needed to understand how the laborist staffing model contributes to neonatal outcomes, cost and efficiency of care, and patient and physician satisfaction. [ABSTRACT FROM AUTHOR]

Objective: Measures of maternal mortality and severe maternal morbidity have risen in the United States, sparking national interest regarding hospitals' ability to provide maternal risk-appropriate care. We examined the extent to which hospitals could be classified by increasingly sophisticated maternal levels of care. Study Design: We performed a cross-sectional survey to identify hospital-specific resources and classify hospitals by criteria for basic, intermediate, and regional maternal levels of care in all nonmilitary childbirth hospitals in California. We measured hospital compliance with maternal level of care criteria that were produced via consensus based on professional standards at 2 regional summits funded by the March of Dimes through a cooperative agreement with the Community Perinatal Network in 2007 (California Perinatal Summit on Risk-Appropriate Care). Results: The response rate was 96% (239 of 248 hospitals). Only 82 hospitals (34%) were classifiable under these criteria (35 basic, 42 intermediate, and 5 regional) because most (157 [66%]) did not meet the required set of basic criteria. The unmet criteria preventing assignment into the basic category included the ability to perform a cesarean delivery within 30 minutes 100% of the time (only 64% met), pediatrician availability day and night (only 56% met), and radiology department ultrasound capability within 12 hours (only 83% met). Only 29 of classified hospitals (35%) had a nursery or neonatal intensive care unit level that matched the maternal level of care, and for most remaining hospitals (52 of 53), the neonatal intensive care unit level was higher than the maternal care level. Conclusion: Childbirth services varied widely across California hospitals, and most hospitals did not fit easily into proposed levels. Cognizance of this existing variation is critical to determining the optimal configuration of services for basic, intermediate, and regional maternal levels of care. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to evaluate the use of a childbirth composite morbidity indicator for monitoring childbirth morbidity at hospital and regional levels in California. Study Design Study data were obtained from the 2005 linked maternal and neonatal discharge dataset for California hospitals. The study population was limited to laboring women with singleton, term (≥37 weeks' gestation), inborn, and live births. Women with and without pregnancy complications were stratified into high- and low-risk groups. The composite outcome was defined as any significant morbidity of the mother or newborn infant during the childbirth admission. Submeasures for maternal and neonatal composite morbidity and for severe maternal morbidity were examined with both aggregate and hospital-level analyses. Results Of 377,869 eligible deliveries, 120,218 (31.8%) were categorized as high risk and 257,651 (68.2%) were categorized as low risk. High-risk women had higher morbidity rates for all comparisons. The mean childbirth composite morbidity rate was 21% overall: 28% for high-risk women and 18% for low-risk women. For high- and low-risk strata, the rates of maternal complications were 18% and 13%, and the rates of severe maternal morbidity were 1.4% and 0.5%, respectively. There was substantial variation across hospitals for all measures. Conclusion The childbirth composite morbidity rate is designed to report childbirth complication rates that combine maternal and neonatal morbidity. This measure and its submeasures met the criteria for quality indicator evaluation as specified by the Agency for Healthcare Research and Quality and can be used for benchmarking or for monitoring childbirth outcomes at regional levels. [ABSTRACT FROM AUTHOR]

Objective: To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices.Methods: Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests.Results: Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P≤.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04).Conclusion: Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices. [ABSTRACT FROM AUTHOR]

Objective: To use population data to identify patient characteristics associated with a postpartum maternal emergency department visit within 90 days of discharge after birth.Methods: This retrospective cross-sectional study analyzed linked maternal discharge and emergency department data for all live California births from 2009 to 2011. The primary outcome was at least one emergency department visit within 90 days of hospital discharge after birth. Secondary outcomes included three or more visits within 90 days ("high utilization") and inpatient readmission. Independent variables included demographics (age, race or ethnicity, payer, income) and clinical characteristics (length of stay, antepartum complications, mode of delivery, and severe maternal morbidity at delivery). Multilevel logistic regression identified variables associated study outcomes; we validated the predictive model with a split-sample approach and receiver operating characteristic curve analysis.Results: Of 1,071,232 deliveries included, 88,674 women (8.3%) visited the emergency department at least once in the 90 days after delivery discharge. Emergency department use was significantly associated with Medicaid insurance (adjusted odds ratio [OR] 2.15, 95% CI 2.08-2.21), age younger than 20 years (adjusted OR 2.08, 95% CI 1.98-2.19), severe maternal morbidity at delivery (adjusted OR 1.58, 95% CI 1.49-1.71), antepartum complications (adjusted OR 1.46, 95% CI 1.42-1.50), and cesarean delivery (adjusted OR 1.40, 95% CI 1.37-1.44). Approximately one fifth of visits occurred within 4 days of discharge, and more than half were within 3 weeks. High utilizers comprised 0.5% of the entire sample (5,171 women) and only 1.2% of women presenting for emergency department care were readmitted. Receiver operating curve model analysis using the validation sample supported predictive accuracy for postpartum emergency department use (area under the curve=0.95).Conclusion: One in 12 California women visited the emergency department in the first 90 days after postpartum discharge. Women at increased risk for postpartum emergency department use per our validated model (eg, low income, birth complications) may benefit from earlier scheduled postpartum visits. [ABSTRACT FROM AUTHOR]

The study determines whether hospital-specific rates of gestational pyelonephritis may serve as a measure of the quality of ambulatory maternal care services in California. The rates of preterm birth and congenital neonatal infection were higher among pregnant women with pyelonephritis. Pregnant women on MediCal as payer have a higher risk because poverty may indirectly make them more physiologically vulnerable or because they receive suboptimal care.

Background: Severe maternal morbidity (SMM) is under development as a quality indicator for maternal health care. The aim of this study is to evaluate California hospital performance based on a standardized SMM measure., Methods: California maternal hospital delivery discharge data from 2016 to 2017 were used to develop logistic regression models for SMM, adjusted for clinical risk factors at admission. Data from 2018 were used to test the models and evaluate hospital performance. SMM was defined per the Centers for Disease Control and Prevention, including (excluding) blood transfusion. Independent models were developed for each hospital type: community, teaching, integrated delivery system (IDS), and IDS teaching. Within each type, model-based expected SMM values and observed-to-expected (O/E) ratios were calculated for each hospital. For each hospital type, hospitals were ranked by O/E ratio, and over- and underperforming hospitals were identified using 95% confidence intervals., Results: Rates of SMM including (excluding) transfusion by hospital type were 1.7% (0.9%) for community, 2.7% (1.5%) for teaching, 2.3% (1.2%) for IDS, and 3.0% (1.6%) for IDS teaching hospitals. In higher-volume community hospitals (≥ 500 births/year), the proportion of underperformers including (excluding) transfusion was 20.7% (11.0%). Summing over all hospital types, 25.3% (14.9%) of hospitals were identified as underperformers in that they experienced significantly more SMM events than expected including (excluding) transfusion., Conclusion: California hospital discharge data demonstrated significant hospital variation in standardized childbirth SMM. These data suggest that a standardized SMM measure may help guide and monitor statewide quality improvement efforts., (Copyright © 2021. Published by Elsevier Inc.)

Background: Many Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) partially or completely exclude pregnant women. Both postoperative hemorrhage or hematoma (PSI 9; hemorrhage), and Postoperative Sepsis (PSI 13; infection) appear to be adaptable to pregnancy hospitalizations., Methods: Using the 2009 California Patient Discharge Dataset (N [total] = 508,842), the hemorrhage and infection PSIs were examined for their potential to include pregnant women in gynecological, antepartum, postpartum, and delivery subpopulations. The statewide and hospital-level indicator rates were calculated using hierarchical models adjusted for case mix., Results: Only the delivery population had sufficient cases for hospital-level analysis. Both PSIs required major changes to the technical specifications because of pregnancy-specific codes and coding practices. Nevertheless, these revised indicators identified substantial morbidity that varied widely across hospitals. The hemorrhage indicator rate was 2.50% (95% confidence interval [CI], 2.45-2.54) for all deliveries, compared with 0.26% (95% CI, 0.25-0.27) in the AHRQ population and 0.18% (95% CI, 0.15-0.21) for nonpregnant women of reproductive age. Adjusted hospital rates averaged 2.52%, with a midquartile range of 1.16% to 3.09% Although infection rates were lower for all deliveries than for the AHRQ population (0.18% versus 1.20%), they were highly associated with cesarean versus vaginal birth (0.43% versus 0.05%) and ranged from 0% to 1.15% across hospitals., Conclusions: Although codes and coding practices for pregnancy hospitalizations differ from those used for nonpregnant adults, hospital-level measures of childbirth-associated hemorrhage and infection are feasible, vary widely, and demonstrate considerable opportunity for improvement.

Objective: The objective of the study was to describe the prevalence of changing clinics and "walk-in" deliveries and estimate associated health care costs., Study Design: This was a retrospective review at an urban teaching hospital over a 6 month period. Principal outcome measures were availability of laboratory data at delivery and the number, type, and costs of duplicated tests for patients receiving various amounts of prenatal care (PNC) at our site. The prevalence of changing clinics, walk-in deliveries, and availability of records in our hospital was applied to the Los Angeles County Medicaid population to calculate the estimated cost of repeated prenatal laboratory studies., Results: Of the 1120 patients delivered by our service, 50% received all PNC at our site, 27% transferred PNC to our site, and 23% of patients were walk-ins for delivery only. Medical records were unavailable in 26% of cases, requiring prenatal laboratory studies repeated. Costs varied by amount of PNC on site (range, $107.00-201.00)., Conclusion: Changing clinics and walk-in deliveries are associated with significant health care costs because of redundant laboratory services and personnel costs associated with reviewing and exchanging medical records.

Objective: To review whether California hospitals are adhering to national practice guidelines with regard to vaginal birth after cesarean (VBAC)., Study Design: We performed a content analysis of the American College of Obstetricians and Gynecologists (ACOG) and American Association of Family Physicians published guidelines and identified 39 specific recommendations, which were categorized into the following 5 content areas: patient criteria, procedure, staff and resources, uterine rupture or other complications, and miscellaneous clinical issues. We evaluated individual hospital policies with regard to adherence to 34 recommendations made specifically by ACOG., Results: Of the 225 surveyed hospitals, 167 (74%) allow VBAC, and 22% of these (36 of 167) provided VBAC protocols for review. Approximately 80% of protocols included < 50% of the ACOG items (median, 13.5; range, 3-27 items). The highest percent adherence was observed in the procedure and staff and resources categories, where over two thirds of study hospitals exhibited 75-100% adherence. One third of participating hospitals were less adherent (0-25%) in the categories of patient criteria, uterine rupture or other complications, and miscellaneous clinical issues., Conclusion: In a sample of written VBAC protocols, we found a wide range of adherence to ACOG recommendations, as evidenced by the number and type of items explicitly documented in the protocols.

Objective: The California Perinatal Quality Care Collaborative (CPQCC) was formed to seek perinatal care improvements by creating a confidential multi-institutional database to identify topics for quality improvement (QI). We aimed to evaluate this approach by assessing antenatal steroid administration before preterm (24 to 33 weeks of gestation) delivery. We hypothesized that mean performance would improve and the number of centers performing below the lowest quartile of the baseline year would decrease., Study Design: In 1998, a statewide QI cycle targeting antenatal steroid use was announced, calling for the evaluation of the 1998 baseline data, dissemination of recommended interventions using member-developed educational materials, and presentations to California neonatologists in 1999-2000. Postintervention data were assessed for the year 2001 and publicly released in 2003. A total of 25 centers voluntarily participated in the intervention., Results: Antenatal steroid administration rate increased from 76% of 1524 infants in 1998 to 86% of 1475 infants in 2001 (P < .001). In 2001, 23 of 25 hospitals exceeded the 1998 lower-quartile cutoff point of 69.3%., Conclusions: Regional collaborations represent an effective strategy for improving the quality of perinatal care.

Background: In 2003, the Agency for Healthcare Quality and Research (AHRQ) published its Quality Indicators for healthcare, and set out methodological criteria for the evaluation of potential candidates., Objectives: Because perinatal infections may result from poor obstetrical practices, we intended to describe the variability of maternal and congenital neonatal infections across different types of hospital ownership (e.g., not for profit, government), and to assess whether rates of these infections meet criteria as quality indicators., Research Design: Population-based cohort study., Subjects: All laboring women without maternal, fetal, or placental complications who delivered in California in 1997, and their neonates, as reported through hospital discharge data., Measures: A Bayesian hierarchical logistic regression model was used to quantify the effects of both "patient-level" risk factors such as parity and prior cesarean history, and "hospital-level" risk factors such as ownership and teaching status., Results: The 308,841 mother-newborn pairs in this low-risk study population delivered at 281 hospitals; 0.39% had uterine infections and 1.3% had neonatal infections. Hospital ownership and teaching status were strongly associated with perinatal infection. Secondly, methods used to estimate and analyze hospital-specific infection rates identified hospitals with exceptionally high rates. Twenty-eight hospitals had neonatal infection rates that ranged from 3% to 28%., Conclusions: The methods presented here were consistent with AHRQ methods and criteria for potential Quality Indicators. They also identified hospitals with exceptionally high rates of infectious morbidity. The relationship between hospital ownership and obstetrical practice patterns, and the feasibility of practice improvement, remain to be studied.

Objective: Because postpartum hemorrhage may result from factors related to obstetrical practice patterns, we examined the variability of postpartum hemorrhage and related risk factors (obstetrical trauma, chorioamnionitis, and protracted labor) across hospital types and hospitals in California., Methods: Linked birth certificate and hospital discharge data from 507,410 births in California in 1997 were analyzed. Cases were identified using International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes. Comparisons were made across hospital types and individual hospitals. Risk adjustments were made using 1) sample restriction to a subset of 324,671 low-risk women, and 2) Bayesian hierarchical logistic regression model to simultaneously quantify the effects of patient-level and hospital-level risk factors., Results: Postpartum hemorrhage complicated 2.4% of live births. The incidence ranged from 1.6% for corporate hospitals to 4.9% for university hospitals in the full sample, and from 1.4% for corporate hospitals to 3.9% for university hospitals in the low-risk sample. Low-risk women who delivered at government, HMO and university hospitals had two- to threefold increased odds (odds ratios 1.98 to 2.71; 95% confidence sets ranged from 1.52 to 4.62) of having postpartum hemorrhage compared to women who delivered at corporate hospitals, irrespective of patient-level characteristics. They also had significantly higher rates of obstetrical trauma and chorioamnionitis. Greater variations were observed across individual hospitals., Conclusion: The incidence of postpartum hemorrhage and related risk factors varied substantially across hospital types and hospitals in California. Further studies using primary data sources are needed to determine whether these variations are related to the processes of care.

Background: In collaboration with the California Department of Health Maternal and Child Health Branch, the authors formed a Working Group to identify potential clinical indicators that could be used to inform decision making regarding maternal health care quality., Objective: To develop potential indicators for the assessment of maternal health care quality., Materials and Methods: A Working Group was convened to review information from the published literature and expert opinion. Selection of potential indicators was guided by the following goals: 1) To identify key areas for routine aggregate monitoring; 2) To include perspectives of relevant stakeholders in maternal health care services; 3) To include measures that are comprehensive and reflect a balance between maternal and fetal interests; and 4) To develop measures that would be valid, generalizable, mutable, and feasible., Results: Ninety potential indicators were identified. Each underwent a thorough review based on: its definition, objective, and validity; its contribution to innovation; the cost and timeliness of implementation; its feasibility, acceptability, and potential effectiveness; and its compatibility with ethics, values, and social policy. This process yielded 24 final indicators from the following categories: Health Status and Access (e.g., availability of 24 h inpatient anesthesia); Preconception and Interconception Care (e.g., Pap smear use); Antenatal Care (e.g., hospitalization for uncontrolled diabetes or pyelonephritis); Labor and Delivery Care (e.g., chorioamnionitis or obstetrical hemorrhage), and Postpartum Care (e.g., rate of postpartum visits)., Conclusions: These potential indicators, representative of the women's health continuum, can serve as a foundation to structure the development of consensus and methods for maternal health care quality assessment.

Objective: This study was undertaken to evaluate the relationship of an isolated fetal intracardiac echogenic focus in a population of patients with a mixed risk for aneuploidy when presenting for prenatal diagnosis., Study Design: All women referred to our institution for screening ultrasound were prospectively evaluated for the presence of an intracardiac echogenic focus in the fetal heart. Each patient was evaluated for the presence of clinical risk factors including ultrasound findings, biochemical screening, and maternal age. The population of patients was then described and neonatal outcomes were obtained., Results: A total of 10,875 patients were referred and 176 cases of fetal intracardiac echogenic foci were evaluated. There was an overall prevalence of 1.6% in our population. The patients with other ultrasound findings and/or maternal age older than 35 years who underwent amniocentesis had 3 abnormal karyotypes identified and had identifiable risk factors. In the group less than 35 years, the relative risk was 2.55 of having an amniocentesis for an isolated echogenic focus (with no cases of fetal aneuploidy found) in comparison with our referred group of nonadvanced maternal age patients without any ultrasound markers or findings., Conclusion: This isolated echogenic finding appears to be a benign variant and not an increased risk for fetal aneuploidy. The chromosomal abnormalities were seen in the group with risk factors including maternal age and/or other ultrasound findings. Evaluation of maternal age, biochemical markers, and ultrasound markers should be used together to help determine the risk of patients with an isolated echogenic focus.

Objective: To describe effective methods to engage nurse leaders in structured interview research., Background: The American Organization of Nurse Executives has identified the support of nurse leader participation in research as a key strategy to achieving its education and research objectives, particularly with regard to identifying and documenting nursing sensitive outcomes. Previous studies have delineated several methods to increase participation., Methods: Nurse leaders of California labor and delivery units reporting more than 50 deliveries during 2002 were asked to participate in a structured interview about staffing and clinical policies on their unit. Recruitment methodology involved 3 levels of intervention, including introductory letters, follow-up contacts, and personal encouragement from senior regional leaders and nurse executives., Results: Of the 268 eligible hospitals, 225 (84%) participated in the study. Fifty-four percent (n = 114) of the structured interviews were scheduled upon initial and second contacts by the research coordinator, and 73% (n = 161) were completed at the first scheduled appointment. Unit managers or directors personally completed 91% (n = 205) of the interviews, with only 20 (8.9%) designated to a staff nurse., Conclusions: Nurse leader participation is essential to the success of research dependent on collecting information regarding nurse practices and clinical processes. Using a multilevel approach to engage nurse leaders in research, such as endorsements and "detailing" by opinion leaders, phone calls, electronic mail, and incentives, is an effective strategy.

The caesarean delivery rate has become a commonly used measure intended to reflect the quality of obstetric care. At least 25% of all primary caesarean deliveries occur electively, i.e. to women who are not in labour. This study is intended to validate a previously published model designed to use ICD-9-CM codes to identify and categorise cases of elective primary caesarean delivery by their indication. ICD-9-CM codes were compared with diagnoses written in the medical record for all women without a prior caesarean who delivered in the same month in a single hospital to examine the accuracy of the codes for 12 potential elective primary caesarean indications derived by the published model: malpresentation; bleeding; genital herpes; severe hypertension; uterine scar; multiple gestation; macrosomia; unengaged fetus; maternal soft tissue conditions; other hypertensive conditions; prematurity; and chromosomal anomalies. Of 440 eligible women, a total of 26 (5.9%) had an elective primary caesarean by medical record review vs. [27] (6.1%) by administrative data. Using medical record data as the gold standard, the sensitivity, specificity, and accuracy of administrative data for the identification of elective primary caesarean delivery were 73.1%, 98.1%, and 96.6%, respectively. Administrative coding for all of the 12 conditions was highly specific, although wide variability existed in its sensitivity; its accuracy ranged between 83.9% and 100%. These results suggest that, despite widespread use of caesarean delivery rates obtained through administrative data, more experience is needed to determine which obstetric codes may be sufficiently specific, sensitive, or prevalent to serve a monitoring or surveillance function reflecting the quality of obstetrical care. The results support continued efforts to use administrative data to monitor elective primary caesarean delivery.

Objective: Most health indicators exhibit evidence of ethnic disparity. This study describes the prevalence of clinical conditions that are associated with pregnancy, stratified at age 35 years, and by ethnicity (black, white, Hispanic, other)., Study Design: This was a retrospective, cross-sectional cohort study. We used International Classification of Diseases discharge diagnostic codes from California discharge data to identify 31 maternal, fetal, and placental conditions., Results: At least one condition was present for 26.1% of the 443,532 eligible women. There was variation in risk by age and race/ethnicity and differences by age within ethnic groups. Black women were more at risk; there are 12 conditions for older women, and there are 16 conditions for younger women. Hispanic women showed a higher risk for diabetes mellitus, macrosomia, and severe hypertension. All white women showed a higher risk for cardiac conditions and isoimmunization, whereas older white women also demonstrated an increased risk for herpes infection and multiple gestation., Conclusion: Older women and black women have more morbidity. The degree to which these clinical conditions affect labor management and obstetric outcomes needs further evaluation.