Obstetricians learned this lesson the hard way. A century ago, very little in obstetric practice was codified. Care was artisanal, variable, and sometimes dangerous. Based on a theory that childbirth is inherently "pathogenic," prominent American obstetricians recommended sweeping reforms. (DeLee, JB, Principles and Practice of Obstetrics, 1913, first edition). This article is protected by copyright. All rights reserved.
Importance: In recent decades, the global rates of cesarean delivery have rapidly increased. Nonetheless, the influence of cesarean deliveries on surgical complications later in life has been understudied.
Objective: To investigate whether previous cesarean delivery increases the risk of reoperation, perioperative and postoperative complications, and blood transfusion when undergoing a hysterectomy later in life.
Design, Setting, and Participants: This registry-based cohort study used data from Danish nationwide registers on all women who gave birth for the first time between January 1, 1993, and December 31, 2012, and underwent a benign, nongravid hysterectomy between January 1, 1996, and December 31, 2012. The dates of this analysis were February 1 to June 30, 2016.
Exposure: Cesarean delivery.
Main Outcomes and Measures: Reoperation, perioperative and postoperative complications, and blood transfusion within 30 days of a hysterectomy.
Results: Of the 7685 women (mean [SD] age, 40.0 [5.3] years) who met the inclusion criteria, 5267 (68.5%) had no previous cesarean delivery, 1694 (22.0%) had 1 cesarean delivery, and 724 (9.4%) had 2 or more cesarean deliveries. Among the 7685 included women, 3714 (48.3%) had an abdominal hysterectomy, 2513 (32.7%) had a vaginal hysterectomy, and 1458 (19.0%) had a laparoscopic hysterectomy. In total, 388 women (5.0%) had a reoperation within 30 days after a hysterectomy. Compared with women having vaginal deliveries, fully adjusted multivariable analysis showed that the adjusted odds ratio of reoperation for women having 1 previous cesarean delivery was 1.31 (95% CI, 1.03-1.68), and the adjusted odds ratio was 1.35 (95% CI, 0.96-1.91) for women having 2 or more cesarean deliveries. Perioperative and postoperative complications were reported in 934 women (12.2%) and were more frequent in women with previous cesarean deliveries, with adjusted odds ratios of 1.16 (95% CI, 0.98-1.37) for 1 cesarean delivery and 1.30 (95% CI, 1.02-1.65) for 2 or more cesarean deliveries. Blood transfusion was administered to 195 women (2.5%). Women having 2 or more cesarean deliveries had an adjusted odds ratio for receiving blood transfusion of 1.93 (95% CI, 1.21-3.07) compared with women having no previous cesarean delivery.
Conclusions and Relevance: Women with at least 1 previous cesarean delivery face an increased risk of complications when undergoing a hysterectomy later in life. The results support policies and clinical efforts to prevent cesarean deliveries that are not medically indicated.
BACKGROUND : A national imperative to provide value-based care requires new strategies to teach clinicians about high-value care.
OBJECTIVE : We developed a virtual online learning network aimed at disseminating emerging strategies in teaching value-based care.
METHODS : The online Teaching Value in Health Care Learning Network includes monthly webinars that feature selected innovators, online discussion forums, and a repository for sharing tools. The learning network comprises clinician-educators and health system leaders across North America. We conducted a cross-sectional online survey of all webinar presenters and the active members of the network, and we assessed program feasibility.
RESULTS : Six months after the program launched, there were 277 learning community members in 22 US states. Of the 74 active members, 50 (68%) completed the evaluation. Active members represented independently practicing physicians and trainees in 7 specialties, nurses, educators, and health system leaders. Nearly all speakers reported that the learning network provided them with a unique opportunity to connect with a different audience and achieve greater recognition for their work. Of the members who were active in the learning network, most reported that strategies gleaned from the network were helpful, and some adopted or adapted these innovations at their home institutions. One year after the program launched, the learning network had grown to 364 total members.
CONCLUSIONS : The learning network helped participants share and implement innovations to promote high-value care. The model can help disseminate innovations in emerging areas of health care transformation, and is sustainable without ongoing support after a period of start-up funding.
Childbirth is a complex clinical service requiring the coordinated support of highly trained healthcare professionals as well as management of a finite set of critical resources (such as staff and beds) to provide safe care. The mode of delivery (vaginal delivery or cesarean section) has a significant effect on labor and delivery resource needs. Further, resource management decisions may impact the amount of time a physician or nurse is able to spend with any given patient. In this work, we employ queueing theory to model one year of transactional patient information at a tertiary care center in Boston, Massachusetts. First, we observe that the M/G/∞ model effectively predicts patient flow in an obstetrics department. This model captures the dynamics of labor and delivery where patients arrive randomly during the day, the duration of their stay is based on their individual acuity, and their labor progresses at some rate irrespective of whether they are given a bed. Second, using our queueing theoretic model, we show that reducing the rate of cesarean section - a current quality improvement goal in American obstetrics - may have important consequences with regard to the resource needs of a hospital. We also estimate the potential financial impact of these resource needs from the hospital perspective. Third, we report that application of our model to an analysis of potential patient coverage strategies supports the adoption of team-based care, in which attending physicians share responsibilities for patients.
BACKGROUND: Health care costs are an important policy focus in the United States. The magnitude and drivers of variation in the costs of common operative procedures are not well understood. We sought to characterize variation in costs across hospitals.
METHODS: We used data from the Nationwide Inpatient Sample from 2001-2011 for 5 elective operations: colectomy, coronary artery bypass graft, total knee arthroplasty, cesarean section, and lung resection. Hospitals were benchmarked for each using hierarchical risk- and reliability-adjustment methods to generate an observed-to-expected cost ratio, which was adjusted for patient demographics, comorbidity, wage index, and procedure complexity. Hospitals were divided into quintiles. Characteristics of high- and low-quintile hospitals and their adjusted outcomes were examined.
RESULTS: Cost observed-to-expected ratios ranged widely for all 5 procedures: 14.9-fold for colectomy, 5.5-fold for coronary artery bypass graft, 12.5-fold for lung resection, 10.6-fold for total knee arthroplasty, and 28.0-fold for cesarean section. Comparing highest to lowest cost quintiles of hospitals, high-cost hospitals were more likely to serve minority and Medicaid patients. Mortality was elevated significantly in high-cost hospitals for colectomy, coronary artery bypass graft, and lung resection (adjusted odds ratio 1.99, 1.32, 2.57; respectively). Service lines were correlated at low-cost hospitals. There was a significant association between greater procedure volume and low-cost hospitals for colectomy, coronary artery bypass graft, and total knee arthroplasty.
CONCLUSION: Despite robust adjustment, there is wide cost variation for common operative procedures in the United States. High-cost hospitals may need to focus on cost reduction at the hospital level to reduce cost across service lines. Benchmarking costs may identify significant opportunities to promote value, or the balance between cost and quality, in operative care in the United States.
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.
OBJECTIVE: To define, measure, and characterize key competencies of managing labor and delivery units in the United States and assess the associations between unit management and maternal outcomes.
METHODS: We developed and administered a management measurement instrument using structured telephone interviews with both the primary nurse and physician managers at 53 diverse hospitals across the United States. A trained interviewer scored the managers' interview responses based on management practices that ranged from most reactive (lowest scores) to most proactive (highest scores). We established instrument validity by conducting site visits among a subsample of 11 hospitals and established reliability using interrater comparison. Using a factor analysis, we identified three themes of management competencies: management of unit culture, patient flow, and nursing. We constructed patient-level regressions to assess the independent association between these management themes and maternal outcomes.
RESULTS: Proactive management of unit culture and nursing was associated with a significantly higher risk of primary cesarean delivery in low-risk patients (relative risk [RR] 1.30, 95% CI 1.02-1.66 and RR 1.47, 95% CI 1.13-1.92, respectively). Proactive management of unit culture was also associated with a significantly higher risk of prolonged length of stay (RR 4.13, 95% CI 1.98-8.64), postpartum hemorrhage (RR 2.57, 95% CI 1.58-4.18), and blood transfusion (RR 1.87, 95% CI 1.12-3.13). Proactive management of patient flow and nursing was associated with a significantly lower risk of prolonged length of stay (RR 0.23, 95% CI 0.12-0.46 and RR 0.27, 95% CI 0.11-0.62, respectively).
CONCLUSION: Labor and delivery unit management varies dramatically across and within hospitals in the United States. Some proactive management practices may be associated with increased risk of primary cesarean delivery and maternal morbidity. Other proactive management practices may be associated with decreased risk of prolonged length of stay, indicating a potential opportunity to safely improve labor and delivery unit efficiency.
BACKGROUND: The gap between publishing and implementing guidelines differs based on practice setting, including hospital geography and teaching status. On March 31, 2006, a Practice Bulletin published by the American College of Obstetricians and Gynecologists (ACOG) recommended against the routine use of episiotomy and urged clinicians to make judicious decisions to restrict the use of the procedure.
OBJECTIVE: This study investigated changes in trends of episiotomy use before and after the ACOG Practice Guideline was issued in 2006, focusing on differences by hospital geographic location (rural/urban) and teaching status.
METHODS: In a retrospective analysis of discharge data from the Nationwide Inpatient Sample (NIS)-a 20% sample of US hospitals-5,779,781 hospital-based births from 2002 to 2011 (weighted N = 28,067,939) were analyzed using multivariable logistic regression analysis to measure odds of episiotomy and trends in episiotomy use in vaginal deliveries.
RESULTS: The overall episiotomy rate decreased from 20.3% in 2002 to 9.4% in 2011. Across all settings, a comparatively larger decline in episiotomy rates preceded the issuance of the ACOG Practice Guideline (34.0% decline), rather than following it (23.9% decline). The episiotomy rate discrepancies between rural, urban teaching, and urban nonteaching hospitals remained steady prior to the guideline's release; however, differences between urban nonteaching and urban teaching hospitals narrowed between 2007 and 2011 after the guideline was issued.
CONCLUSION: Teaching status was a strong predictor of odds of episiotomy, with urban nonteaching hospitals having the highest rates of noncompliance with evidence-based practice. Issuance of clinical guidelines precipitated a narrowing of this discrepancy.
OBJECTIVE: To examine variation in the cesarean birth rates of women cared for by labor and delivery nurses.
DESIGN: Retrospective cohort study.
SETTING: One high-volume labor and delivery unit at an academic medical center in a major metropolitan area.
PARTICIPANTS: Labor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation.
METHODS: Data were extracted from electronic hospital birth records from January 1, 2013 through June 30, 2015. Cesarean rates for individual nurses were calculated based on the number of women they attended who gave birth by cesarean. Nurses were grouped into quartiles by their cesarean rates, and the effect of these rates on the likelihood of cesarean birth was estimated by a logit regression model adjusting for patient-level characteristics and clustering of births within nurses.
RESULTS: Seventy-two nurses attended 3,031 births. The mean nurse cesarean rate was 26% (95% confidence interval [23.9, 28.1]) and ranged from 8.3% to 48%. The adjusted odds of cesarean for births attended by nurses in the highest quartile was nearly 3 times (odds ratio = 2.73, 95% confidence interval [2.3, 3.3]) greater than for births attended by nurses in the lowest quartile.
CONCLUSION: The labor and delivery nurse assigned to a woman may influence the likelihood of cesarean birth. Nurse-level cesarean birth data could be used to design practice improvement initiatives to improve nurse performance. More precise measurement of the relative influence of nurses on mode of birth is needed.
Background Given increased public reporting of the wide variation in hospital obstetric quality, we sought to understand how women incorporate quality measures into their selection of an obstetric hospital. Methods We surveyed 6141 women through Ovia Pregnancy, an application used by women to track their pregnancy. We used t tests and chi-square tests to compare response patterns by age, parity, and risk status. Results Most respondents (73.2%) emphasized their choice of obstetrician/midwife over their choice of hospital. Over half of respondents (55.1%) did not believe that their choice of hospital would affect their likelihood of having a cesarean delivery. While most respondents (74.9%) understood that quality of care varied across hospitals, few prioritized reported hospital quality metrics. Younger women and nulliparous women were more likely to be unfamiliar with quality metrics. When offered a choice, only 43.6% of respondents reported that they would be willing to travel 20 additional miles farther from their home to deliver at a hospital with a 20 percentage point lower cesarean delivery rate. Discussion Women's lack of interest in available quality metrics is driven by differences in how women and clinicians/researchers conceptualize obstetric quality. Quality metrics are reported at the hospital level, but women care more about their choice of obstetrician and the quality of their outpatient prenatal care. Additionally, many women do not believe that a hospital's quality score influences the care they will receive. Presentations of hospital quality data should more clearly convey how hospital-level characteristics can affect women's experiences, including the fact that their chosen obstetrician/midwife may not deliver their baby.
OBJECTIVES: To examine the clinical utility and cost of follow-up ultrasounds performed as a result of suboptimal views at the time of initial second-trimester ultrasound in a cohort of low-risk pregnant women.
METHODS: We conducted a retrospective cohort study of women at low risk for fetal structural anomalies who had second-trimester ultrasounds at 16 to less than 24 weeks of gestation from 2011 to 2013. We determined the probability of women having follow-up ultrasounds as a result of suboptimal views at the time of the initial second-trimester ultrasound, and calculated the probability of detecting an anomaly on follow-up ultrasound. These probabilities were used to estimate the national cost of our current ultrasound practice, and the cost to identify one fetal anomaly on follow-up ultrasound.
RESULTS: During the study period, 1,752 women met inclusion criteria. Four fetuses (0.23% [95% CI 0.06-0.58]) were found to have anomalies at the initial ultrasound. Because of suboptimal views, 205 women (11.7%) returned for a follow-up ultrasound, and one (0.49% [95% CI 0.01-2.7]) anomaly was detected. Two women (0.11%) still had suboptimal views and returned for an additional follow-up ultrasound, with no anomalies detected. When the incidence of incomplete ultrasounds was applied to a similar low-risk national cohort, the annual cost of these follow-up scans was estimated at $85,457,160. In our cohort, the cost to detect an anomaly on follow-up ultrasound was approximately $55,000.
CONCLUSIONS: The clinical yield of performing follow-up ultrasounds because of suboptimal views on low-risk second-trimester ultrasounds is low. Since so few fetal abnormalities were identified on follow-up scans, this added cost and patient burden may not be warranted.
In high-income countries, medical interventions to address the known risks associated with pregnancy and birth have been largely successful and have resulted in very low levels of maternal and neonatal mortality. In this Series paper, we present the main care delivery models, with case studies of the USA and Sweden, and examine the main drivers of these models. Although nearly all births are attended by a skilled birth attendant and are in an institution, practice, cadre, facility size, and place of birth vary widely; for example, births occur in homes, birth centres, midwifery-led birthing units in hospitals, and in high intervention hospital birthing facilities. Not all care is evidenced-based, and some care provision may be harmful. Fear prevails among subsets of women and providers. In some settings, medical liability costs are enormous, human resource shortages are common, and costs of providing care can be very high. New challenges linked to alteration of epidemiology, such as obesity and older age during pregnancy, are also present. Data are often not readily available to inform policy and practice in a timely way and surveillance requires greater attention and investment. Outcomes are not equitable, and disadvantaged segments of the population face access issues and substantially elevated risks. At the same time, examples of excellence and progress exist, from clinical interventions to models of care and practice. Labourists (who provide care for all the facility's women for labour and delivery) are discussed as a potential solution. Quality and safety factors are informed by women's experiences, as well as medical evidence. Progress requires the ability to normalise birth for most women, with integrated services available if complications develop. We also discuss mechanisms to improve quality of care and highlight areas where research can address knowledge gaps with potential for impact. Evaluation of models that provide woman-centred care and the best outcomes without high costs is required to provide an impetus for change.