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PURPOSE Currently, 40% of counties in the United States do not have an obstetrician or midwife, and in rural areas the likelihood of childbirth being attended to by a family medicine (FM) physician is increasing. We sought to characterize the effect of the FM presence on unit culture and a key perinatal quality metric in Iowa hospital intrapartum units. METHODS Using a cross-sectional design, we surveyed Iowa physicians, nurses, and midwives delivering intrapartum care at hospitals participating in a quality improvement initiative to decrease the incidence of cesarean delivery. We linked respondents with their hospital characteristics and outcomes data. The primary outcome was the association between FM physician, obstetrician (OB), or both disciplines' presence on labor and delivery and hospital low-risk, primary cesarean delivery rate. Unit culture was compared by hospital type (FM-only, OB-only, or Both). RESULTS A total of 849 clinicians from 39 hospitals completed the survey; 13 FM- only, 11 OB-only, and 15 hospitals with both. FM-only hospitals were all rural, with CONCLUSIONS Birthing hospitals staffed exclusively by FM physicians were more likely to have lower cesarean rates and stronger nursing-rated safety culture. Both access and quality of care provide strong arguments for reinforcing the pipeline of FM physicians training in intrapartum care. Key words: family medicine; cesarean birth; organizational culture, https://doi.org/10.1370/afm.3157 INTRODUCTION The United States is facing multiple maternal health crises including increasing severe maternal morbidity (SMM) and mortality, racial inequities in SMM, and a shrinking footprint of pregnancy care [...]

BackgroundPerinatal quality improvement lacks valid tools to measure adverse hospital experiences disproportionately impacting Black mothers and birthing people. Measuring and mitigating harm requires using a framework that centers the lived experiences of Black birthing people in evaluating inequitable care, namely, obstetric racism. We sought to develop a valid patient-reported experience measure (PREM) of Obstetric Racism© in hospital-based intrapartum care designed for, by, and with Black women as patient, community, and content experts.MethodsPROMIS© instrument development standards adapted with cultural rigor methodology. Phase 1 included item pool generation, modified Delphi method, and cognitive interviews. Phase 2 evaluated the item pool using factor analysis and item response theory.ResultsItems were identified or written to cover 7 previously identified theoretical domains. 806 Black mothers and birthing people completed the pilot test. Factor analysis concluded a 3 factor structure with good fit indices (CFI = 0.931-0.977, RMSEA = 0.087-0.10, R2  > .3, residual correlation

PURPOSE Large-scale efforts to reduce cesarean deliveries have shown varied levels of impact; yet understanding factors that contribute to hospitals' success are lacking. We aimed to characterize unit culture differences at hospitals that successfully reduced their cesarean rates compared with those that did not. METHODS A mixed methods study of California hospitals participating in a statewide initiative to reduce cesarean delivery. Participants included nurses, obstetricians, family physicians, midwives, and anesthesiologists practicing at participating hospitals. Hospitals' net change in nulliparous, term, singleton, and vertex cesarean delivery rates classified them as successful if they achieved either a minimum 5 percentage point reduction or rate of fewer than 24%. The Labor Culture Survey was used to quantify differences in unit culture. Key informant interviews were used to explore quantitative findings and characterize additional cultural barriers and facilitators. RESULTS Out of 55 hospitals, 37 (n = 840 clinicians) meeting inclusion criteria participated in the Labor Culture Survey. Physicians' individual attitudes differed by hospital success on 5 scales: best practices (P = .003), fear (P = .001), cesarean safety (P = .014), physician oversight (P CONCLUSIONS Successful hospitals' culture and context was measurably different from nonresponders. Leveraging these contextual factors may facilitate success. Key words: cesarean section; health care quality; maternity hospital; organizational culture; patient care team, INTRODUCTION Since the Alliance for Maternal Safety released the Safe Reduction of Primary Cesarean/Support for Intended Vaginal Birth safety bundle in 2018, (1) statewide perinatal quality collaboratives have initiated large-scale [...]

Context: The consequences of continued loss of family physicians(FMs) practicing obstetrics in the United States has been characterized in terms of loss of access to care, particularly for rural patients; however, the impact on quality of care needs further study. Reducing the low-risk, primary cesarean rate is a national quality goal. Iowa is a state with a strong FM obstetrics presence where many rural hospitals are staffed exclusively by FMs with general surgery on call for cesarean deliveries. Objective: To characterize the FM impact on cesarean delivery in Iowa birthing hospitals. Study Design: Survey linked with administrative hospital data. Dataset: Hospital characteristics were obtained from the Iowa Department of Public Health or self-reported. Population Studied: Iowa clinicians delivering intrapartum care at hospitals participating in an initiative to reduce cesarean. Instrument: The Labor Culture Survey is a valid measure of individual attitudes, beliefs, and unit culture on intrapartum units. Outcome Measures: Primary outcome was the association between FM, obstetrician, or both disciplines' presence on labor and delivery and hospital low-risk, primary cesarean delivery rate. Unit culture was compared by hospital type (FM-only, OB-only, or both). Results: 849 clinicians from 39 hospitals completed the survey; 12 FM-only, 12 OB-only, and 15 hospitals with both. FM-only hospitals were all rural with less than 1,000 annual births. FMs practicing at FM-only hospitals had been practicing maternity care for longer than FMs at hospitals with both (13 vs 4 years, p=.02). Among hospitals with less than 1,000 annual births, compared to hospitals with both, births at FM-only hospitals had an adjusted 39% lower risk of cesarean (95% CI -0.16 to -0.62%; p, Presenters Emily White VanGompel, MD, MPH, Stephanie Radke, Lavisha Singh, MPH, Francesca Carlock, [...]

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a multicomponent quality improvement initiative in the Chicago, IL, area that used a diabetes-focused clinic visit to overcome barriers that lead to clinical inertia for type 2 diabetes. [ABSTRACT FROM AUTHOR]

Objective: To measure and assess the relationship of patient safety culture to reducing cesarean overuse., Study Setting: Maternity care hospitals in Michigan., Study Design: Cross-sectional observational design, combining individual survey data with hospital characteristics using existing databases. Multivariate Poisson regression assessed the associations between survey scores and hospital nulliparous term singleton vertex cesarean rates. Factor analysis determined the scalability of survey items., Data Collection Methods: Electronic survey distributed at the hospital site level., Principal Findings: A total of 3091 clinicians from 54 out of 57 eligible hospitals completed the survey. Confirmatory factor analysis demonstrated best fit with a univariate model with two local factors. The new scale encompassing both local factors, including vaginal birth microculture and safety culture, is entitled "Unit Norms." The safety culture subdomain demonstrated an association with a reduction in hospital cesarean rate [-0.15; 95% CI: -0.27 to -0.04; incident rate ratio (IRR) 0.86], parallel to but lower in magnitude to vaginal birth microculture (-0.18; 95% CI: -0.35 to -0.02; IRR 0.84)., Conclusions: Vaginal birth microculture remains the strongest predictor of cesarean delivery overuse; however, safety culture characteristics, including teamwork, psychological safety, and communication, correlate with lower cesarean delivery rates. Measuring these aspects of hospitals' culture may be important for other areas of quality improvement initiatives focused on quality and safety., (© The Author(s) 2024. Published by Mary Ann Liebert, Inc.)

Background: One Key Question ® (OKQ) is a tool that embeds a patient-centered screening into routine visits with the goal of making pregnancy intention screening universal, but widespread implementation has not yet been adopted. We aimed to explore the barriers and facilitators of OKQ implementation to better understand how to best implement the tool across different settings., Methods: We invited staff and clinicians from one obstetrics and gynecology clinic and one family medicine clinic, which previously implemented OKQ, to complete surveys and qualitative interviews about their experiences with the tool. The interview guide and thematic analysis of the interview transcripts were informed by the Consolidated Framework for Implementation Research (CFIR)., Main Findings: Major facilitators of OKQ implementation are the simplicity of the tool, engagement of clinic leadership, and compatibility between the perceived goals of the tool and those of practice staff and clinicians. Although participants indicated that OKQ had a minimal impact on clinic workflow during its implementation, preimplementation time concerns were a major barrier to implementation in both clinics. Barriers seen in the family medicine practice included OKQ distracting from the visit agenda, and concerns about the OKQ gold standard protocol of screening each patient at every visit. Participants even suggested asking OKQ only during annual check-up appointments., Conclusions: The perceived alignment between the tool's goals and those of clinic stakeholders was an important facilitator of OKQ implementation success. However, characteristics of the clinic setting, such as competing medical priorities and time constraints, influenced initial attitudes toward the feasibility of the intervention. Clinical Trial Registration Number: NCT03947788., Competing Interests: No competing financial interests exist., (© Meron Ferketa et al., 2022; Published by Mary Ann Liebert, Inc.)