Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Provider, Education; Hospital, Chart audit and feedback, Elective induction policy, Guideline change and implementation, Quality improvement HEALTH_CARE_PROVIDER_PRACTICE Provider Training/Education HOSPITAL Chart Audit and Feedback Elective Induction Policy Guideline Change and Implementation Quality Improvement

Intervention Description: At a large Southern US women's hospital, new measures were made to reduce the rates of cesarian delivery at the facility. Endeavors were led by nurse / doctor leaders (VP & chief of staff). These included monitoring, benchmarking & disseminating information about CD at the facility; new protocols for oxytocin administration; Bishop's score assessment; elective CD performed only at 39 weeks; new protocols and intrapartum alternative positioning devices, the process of laboring down, and closed glottis pushing attempts in second-stage labor.

Intervention Results: Collectively, these interdisciplinary interventions have resulted in significant decreases in overall cesarean birth rates and comparable significant reductions in the NTSV cesarean rates.

Conclusion: Concerted efforts to reduce rates of nonmedically indicated cesarean birth have resulted in the development and implementation of comprehensive action plans aimed at effecting reductions and enhancing overall obstetric quality care.

Setting: One large obstetric hospital in the Southern USA

Population of Focus: NTSV births

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Chart Audit and Feedback Guideline Change and Implementation Organizational Changes Peer Review Quality Improvement

Intervention Description: To improve quality and safety of care to our obstetric and neonatal patients (presenting between 34 0/7 and 36 6/7 weeks) by lowering the overall induction rate, lowering the elective induction rate less than 39 weeks, decreasing the unanticipated admissions of late preterm infants to the special care nursery (SCN), decreasing the number of transports out of our level II SCN to a higher level III neonatal intensive care unit, and increasing safety culture scores of the Family Birth Center staff at Mercy Hospital Anderson, Cincinnati, OH.

Intervention Results: Rate of CS among electively induced women at the level II hospital decreased from 37.4% (2005) to 31.5% (2006) to 25% (2007). From 2005 to 2006, one year after hospital review was launched, there was a 5.9% decrease in CS (p<0.05)2. From 2006 to 2007, two years after hospital review was launched and supplemental changes to elective induction policies and practices were made, there was a 6.5% decrease in CS (p<0.05)2.

Conclusion: In 2007, outcomes including total induction rate, elective induction rate for less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and SCN unanticipated admissions of infants 34 0/7 to 36 6/7 weeks' gestation (late preterm infants) were compared with these same measures in 2005.

Study Design: QE: pretest-posttest

Setting: 1 level-II maternity hospital in Ohio

Population of Focus: Nulliparous women who gave birth between January 2005 to December 20072

Data Source: Not specified

Sample Size: n=2,172

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital)

Intervention Description: The availability of postpartum care through telehealth, either via video and audio or audio only, starting on March 16, 2020. Before this date, all postpartum visits at our institution were performed in-person. However, after this date, outpatient obstetrics clinics recommended telehealth postpartum visits as the primary modality for visits while also offering some limited in-person postpartum visits.

Intervention Results: Subjects in the postimplementation group were at 90% increased odds of attending a postpartum visit compared with those in the preimplementation group, even when controlling for race, prenatal care provider, parity, gestational age at delivery, and insurance status. Patients in the postimplementation group were also more likely to be screened for postpartum depression (86.3% vs 65.1%; P<.001)

Conclusion: Availability of telehealth during the COVID-19 pandemic is associated with increased postpartum visit attendance and postpartum depression screening. However, telehealth was also associated with a decrease in use of long-acting reversible contraception or permanent sterilization.

Study Design: Retrospective cohort study

Setting: Department of Obstetrics & Gynecology, University of Pennsylvania

Population of Focus: Postpartum women enrolled in Medicaid

Sample Size: 1,759 (780 in preimplementation group 799 in postimplementation group(

Age Range: 25-34

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Guideline Change and Implementation HEALTH_CARE_PROVIDER_PRACTICE Active Management of Labor

Intervention Description: This was a prospective cohort study of nulliparous women to determine how a new structured protocol of oxytocin augmentation within a single hospital obstetric department impacted labor outcomes. The new protocol instructs birth attendants to diagnose “prolonged labor” based on the World Health Organization (WHO) partograph before commencing oxytocin infusion for augmentation. Data from the hospital were collected prospectively and compared for two time-period cohorts: the historic control cohort (2009–2010) and the study period cohort (2012–2013). Nulliparous women with singleton, term deliveries (>37 weeks), cephalic presentation, and spontaneous onset of labor (Ten-Group Classification System (TGCS) group 1) were included in the analysis.

Intervention Results: The study cohort and control cohort comprised 1103 (26.2%) and 1399 (33.1%) of all laboring women, respectively (p < .01). The protocol was followed satisfactorily in 78% of the study cohort. The use of oxytocin augmentation was reduced in the study cohort versus the control cohort; 41.3 versus 48.9% (p < .01); mean oxytocin infusion duration was shorter (100 versus 123 min; p < .01); and mean total oxytocin dose decreased (1009 versus 1293 mU; p < .01). The cesarean section rate was 5.9% in the study cohort versus 8.0% in the control cohort (p = .04). The estimated mean duration of the active phase of labor increased by 47 min (p < .01) after the implementation. The frequency of estimated postpartum hemorrhage >1000 ml was higher, 4.9 versus 2.0% (p < .01), but the use of blood transfusions remained stable, 2.5 versus 2.7% (p = .78), the study cohort versus control cohort, respectively.

Conclusion: Implementation of a protocol of structured use of oxytocin augmentation reduced the frequency, dosage, and duration of oxytocin without increasing the cesarean section rate in TGCS group 1.

Setting: Obstetric Department of Sørlandet Hospital, Kristiansand, Norway

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention Development/Improvement of Services Continuing Education of Hospital Providers HOSPITAL HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Creation of a small baby program requires special resources and multidisciplinary engagement.

Intervention Results: While it took pre-planning to time routine exams with cares, this approach resulted in a significant decrease in apnea, bradycardia, and desaturation events than previously observed.

Conclusion: We have described benefits, challenges, and practical approaches to creating and maintaining a small baby program that could be a model for the development of special programs for other sub-populations within in the NICU.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Provider Training/Education HOSPITAL Quality Improvement

Intervention Description: A hospital-wide safe sleep bundle, based on a hospital-acquired conditions (HAC) model, was implemented in September 2017. Interventions were chosen by team members during multidisciplinary team meetings. Four key time points and/or interventions across the study period were (1) nursing education on the safe sleep bundle; 2) policy update and implementation; (3) collection and sharing of audit data; and (4) peer-to-peer bundle checklist reviews during registered nurse shift handoffs and electronic medical record (EMR) input. Other notable education interventions included subject matter expert training by guest speakers from the University of Pennsylvania and education to parents through updating newborn video instruction and increased exposure to appropriate safe sleep modeling.

Intervention Results: Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%.

Conclusion: Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children's hospital.

Setting: Penn State Children's Hospital

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Provider Training/Education HOSPITAL Guideline Change and Implementation Quality Improvement

Intervention Description: This quality improvement initiative used a systematic approach to reduce nulliparous cesarean birth rates, aligning with recommendations developed by the Council on Patient Safety in Women's Health Care: Patient Safety Bundle on the Safe Reduction of Primary Cesarean Births. Health care providers and nurses received education on contemporary labor management guidelines developed by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine Obstetric Care Consensus regarding safe prevention of primary cesarean deliveries and nurses were instructed on labor support techniques. The preguideline implementation period was January 1, 2015, to June 30, 2015. The postguideline implementation period was July 1, 2016, to December 31, 2016. The primary outcome measured was the nulliparous, term, singleton, vertex cesarean birth rate.

Intervention Results: There were 434 women identified in the preguideline period and 401 women in the postguideline period. The nulliparous, term, singleton, vertex cesarean birth rate decreased from 27.9% to 19.7% [odds ratio (OR) 0.63, CI 0.46-0.88]. There were improvements in health care provider compliance with following the labor management guidelines from 86.2% to 91.5% (OR 1.73, 95% CI 1.11-2.70), the use of maternal position changes from 78.7% to 87.5% (OR 1.86, 95% CI 1.29-2.68), and use of the peanut birthing ball from 16.8% to 45.2% (OR 3.83, 95% CI 2.84-5.16) as provisions for labor support.

Conclusion: Implementing a systematic approach for care of nulliparous women is associated with a decrease in term, singleton, vertex cesarean birth rates.

Setting: Two rural community hospitals and one urban community hospital in North Carolina

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Hospital Policies Provider Training/Education

Intervention Description: Despite policy and guideline recommendations to support planned, effective postnatal care, national surveys of women's views of maternity care have consistently found in-patient postnatal care, including support for breastfeeding, is poorly rated.

Intervention Results: Post intervention there were statistically significant differences in the initiation (p = 0.050), duration of any breastfeeding (p = 0.020) and duration of exclusive breastfeeding to 10 days (p = 0.038) and duration of any breastfeeding to three months (p = 0.016). Post intervention, women were less likely to report physical morbidity within the first 10 days of birth, and were more positive about their in-patient care.

Conclusion: It is possible to improve outcomes of routine in-patient care within current resources through continuous quality improvement.

Study Design: QE: pretest-posttest

Setting: Large maternity unit in the south of England

Population of Focus: Women on the postnatal ward who were >16 years old, able to speak and read English, and who had not experienced a stillbirth or neonatal death

Data Source: Mother self-report

Sample Size: Pretest (n=751/741)3 Posttest (n=725/725)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Midwifery PROVIDER/PRACTICE HOSPITAL Chart Audit and Feedback Organizational Changes Quality Improvement POPULATION-BASED SYSTEMS Community — Outreach Outreach COMMUNITY COMMUNITY

Intervention Description: To improve quality of care by offering more women a safe and attractive normal vaginal delivery. The target group was primarily nulliparous women at term with spontaneous onset of labor and cephalic presentation.

Intervention Results: The CS rate in nulliparous women at term with spontaneous onset of labor decreased from 10% in 2006 to 3% in 2015. During the same period the overall CS rate dropped from 20% to 11%. The prevalence of children born at the unit with umbilical cord pH <7 and Apgar score <4 at 5 min were the same over the years studied. At present, 95.2% of women delivering at our unit are satisfied with their delivery experience.

Conclusion: The CS rates have declined after implementing the nine items of organizational and cultural changes. It seems that a specific and persistent multidisciplinary activity with a focus on the Robson group 1 can reduce CS rates without increased risk of neonatal complications.

Study Design: Time trend analysis

Setting: 1 public, medium-sized tertiary level obstetric unit

Population of Focus: Nulliparous women who gave birth between January 2006 and October 2015

Data Source: Not specified

Sample Size: n=~900 (880-924) per year

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Continuing Education of Hospital Providers POPULATION-BASED SYSTEMS STATE Policy/Guideline (State) Funding Support Perinatal Committees/Councils

Intervention Description: Vital records data (1971 to 1978) were used to assess the change in neonatal and fetal mortality in Colorado in relationship to the regionalization of perinatal health care within the state.

Intervention Results: There has been a decrease in neonatal mortality rate from 13.4 to 6.9 during a period of time when there was a minimal decrease in the incidence of low-birth weight infants. The improved neonatal mortality has been associated with a shift in the frequency of birth of very low-birth weight (VLBW) infants to hospitals with level II and III perinatal services and relatively greater survival rates of VLBW infants born in these hospitals as compared to those born in level I hospitals. There was no decrease in fetal mortality in the same period of time.

Conclusion: These date suggest that outreach education in perinatal medicine should now emphasize current knowledge and methods for reducing antepartum deaths.

Study Design: QE: pretest-posttest

Setting: All Colorado hospitals Three level III, seven level II, remaining level I

Population of Focus: Infants born weighing greater than one lb.

Data Source: Data from the Bureau of Vital Records, Colorado State Health Department.

Sample Size: Pretest: 1.8% (n=2,818) Posttest: 1.8% (n=2,967) Infants born weighing one to four lbs.

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Guideline Change and Implementation HOSPITAL

Intervention Description: To examine the impact of the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (ACOG-SMFM) 2014 recommendations for preventing unnecessary primary Cesareans.

Intervention Results: Among 192,405 NTSV births across 40 hospitals, the age-standardized NTSV Cesarean rate decreased after the ACOG-SMFM recommendations from 25.8% to 24.0% (Risk ratio [RR]: 0.93; 95% CI 0.89, 0.97), with no change in the control series. Decreases were observed among non-Hispanic White women (RR: 0.89; 95% CI 0.82, 0.97), but not among non-Hispanic Black women (RR: 0.97; 95% CI 0.88, 1.07), Asian/Pacific Islanders (RR: 1.01; 95% CI 0.91, 1.12), or Hispanic women (RR: 0.94; 95% CI 0.86, 1.02). Similar patterns were observed at teaching hospitals, with no change at nonteaching hospitals.

Conclusion: While low-risk Cesarean rates may be modifiable through changes in labor management, additional research, and interventions to address Cesarean disparities, are needed.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Access to Provider through Hotline HOSPITAL Continuing Education of Hospital Providers POPULATION-BASED SYSTEMS INTER-HOSPITAL SYSTEMS Maternal/In-Utero Transport Systems STATE Policy/Guideline (State) Consultation Systems (Inter-Hospital Systems) Consultation Systems (Hospital) Telemedicine Systems (Inter-Hospital Systems) Telemedicine Systems (Hospital)

Intervention Description: To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001–2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical center's maternal fetal medicine practice.

Intervention Results: Perceived risk, age, education, and prenatal care characteristics of women affected the likelihood of use of the NICU. The perceived availability of local expertise was associated with a lower likelihood that preterm infants would deliver at the NICU. ANGELS did not increase the overall use of NICU, but it did shift some deliveries to the academic setting.

Conclusion: Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.

Study Design: Time trend analysis

Setting: All Arkansas hospitals Five level III hospitals from 2001- 2005, six in 2006

Population of Focus: Infants born at <35 weeks GA

Data Source: Data from Medicaid claims for pregnancy linked to birth certificates for women covered by Medicaid in Arkansas

Sample Size: Total (n= 5,150) 2001 (n= 812) 2002 (n= 1,105) 2003 (n= 824) 2004 (n= 824) 2005 (n= 887) 2006 (n= 698) Infants born at <35 weeks GA

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER Access to Provider through Hotline HOSPITAL Continuing Education of Hospital Providers STATE Policy/Guideline (State)

Intervention Description: In this longitudinal observational study, linked vital records and Medicaid claims records for 29,124 preterm births (April 2001–December 2012) to Medicaid covered women were used to examine factors predicting whether deliveries occurred at hospitals with neonatology-staffed NICUs. The factors associated with delivery are estimated and compared for baseline and three post-implementation periods.

Intervention Results: Rates for NICU preterm deliveries increased from 28 to 37% over the time period. Compared to baseline, adjusted NICU delivery rates in the middle and late implementation periods were statistically significant (p < 0.001). Negative impacts of long travel times were reduced, while impacts of obstetrician prenatal care changed from negative to positive association.

Conclusion: Findings validate the ANGELS initiative premise: academic specialists, working with community-based care providers, can improve perinatal regionalization.

Setting: Hospitals in Arkansas

Population of Focus: Medicaid-covered women in Arkansas

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy HOSPITAL

Intervention Description: To assess adverse perinatal outcomes and caesarean section of low-risk women receiving elective induction of labour at 41 weeks or expectant management until 42 weeks according to their preferred and actual management strategy.

Intervention Results: From 2012–2016, 3642 women out of 6088 eligible women for the INDEX RCT, participated in the cohort study for observational data collection (induction of labour n = 372; expectant management n = 2174; unknown preference/management strategy n = 1096). Adverse perinatal outcome occurred in 1.1 % (4/372) in the induction group versus 1.9 % (42/2174) in the expectant group (adjRR 0.56; 95 %CI: 0.17–1.79), with severe adverse perinatal outcome occurring in 0.3 % (1/372) versus 1.0 % (22/2174), respectively (adjRR 0.39; 95 % CI: 0.05–2.88). There were no stillbirths among all 3642 women; one neonatal death occurred in the unknown preference/management group. Caesarean section rates were 10.5 % (39/372) after induction and 8.9 % (193/2174) after expectant management (adjRR 1.32; 95 % CI: 0.95–1.84). A higher incidence of adverse perinatal outcome was observed in nulliparous compared to multiparous women. Nulliparous 1.8 % (3/170) in the induction group versus 2.6 % (30/1134) in the expectant management group (adjRR 0.58; 95 % CI 0.14–2.41), multiparous 0.5 % (1/201) versus 1.1 % (

Conclusion: In this cohort study among low-risk women receiving the policy of their preference in late-term pregnancy, a non-significant difference was found between induction of labour at 41 weeks and expectant management until 42 weeks in absolute risks of composite adverse (1.1 % versus 1.9 %) and severe adverse (0.3 % versus 1.0 %) perinatal outcome. The risks in this cohort study were lower than in the trial setting. There were no stillbirths among all 3642 women. Caesarean section rates were comparable.

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative PATIENT_CONSUMER Quality Improvement/Practice-Wide Intervention Expert Support (Provider)

Intervention Description: The aims of Mississippi Communities and Hospitals Advancing Maternity Practices (CHAMPS) were to (1) increase breastfeeding initiation and exclusivity and (2) decrease racial disparities in breastfeeding by increasing the number of Baby-Friendly hospitals in the state from 2014 to 2020.

Intervention Results: Between 2014 and 2020, the number of Baby-Friendly hospitals in Mississippi rose from 0 to 22. Breastfeeding initiation in the hospitals increased from 56% to 66% (P < .05), and the disparity between Black and White dyads decreased by 17 percentage points, an average of 0.176 percentage points each month (95% confidence interval: −0.060 to −0.292). Exclusivity increased from 26% to 37% (P < .05). Skin-to-skin and rooming-in rates increased significantly for all dyads: 31% to 91% (P < .01) for skin-to-skin after vaginal birth, 20% to 86% (P < .01) for skin-to-skin after cesarean delivery, and 19% to 86% (P < .01) for rooming-in.

Conclusion: Over the course of the CHAMPS program, there were significant increases in breastfeeding initiation and exclusivity, and decreases in racial inequities in breastfeeding initiation.

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy HOSPITAL

Intervention Description: To determine the impact of offering elective labour induction at 39 weeks gestation on perinatal and maternal outcomes in nulliparous people with low-risk pregnancies.

Intervention Results: A total of 174 patients were included. Of these patients, 56 (32.2%) underwent elective induction of labour between 390 and 396 weeks gestation over the period of June 2020 to December 2021, whereas 118 (67.8%) were expectantly managed from 390 weeks gestation over the period of September 2018 to March 2020. Compared with expectant management, those in the 39+ weeks induction group had a significantly lower risk of cesarean delivery (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.15–0.99), composite adverse maternal outcomes (OR 0.34; 95% CI 0.12–0.97), and composite adverse perinatal outcomes (OR 0.26; 95% CI 0.074–0.92).

Conclusion: Our results suggest that elective induction of labour at 39 weeks gestation and over in low-risk nulliparous people is associated with lower risks of cesarean delivery, composite adverse maternal outcomes, and composite adverse perinatal outcomes than expectant

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Provider Training/Education HOSPITAL Chart Audit and Feedback Guideline Change and Implementation Quality Improvement Policy/Guideline (State) STATE Collaboration with Local Agencies (Health Care Provider/Practice) Collaboratives Policy/Guideline (Hospital)

Intervention Description: Hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. As a requirement of participation, hospital teams sent at least one team member to each collaborative event. Activities included a June 2016 in-person kick off meeting for two to three representatives from each hospital to familiarize them with the cesarean delivery bundle and the requirements of participation, followed by conference calls that occurred every month in the first year and every 2 months in the second year. Additional in-person meetings for all hospital teams took place at 12 months and at the end of the collaborative (November 2018). Nice webinars on related clinical topics were presented throughout the 30-month period. The collaborative director provided facilitation support to site teams through calls and visits when requested by the site team or when site participation lapsed.

Intervention Results: Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle.

Conclusion: The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births.

Setting: 31 Maryland birthing hospitals

Population of Focus: Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0–23) already in place before the collaborative and implementing a median of four (range 0–17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P5.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P,.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the “Response” domain of the bundle.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Continuing Education of Hospital Providers POPULATION-BASED SYSTEMS INTER-HOSPITAL SYSTEMS Maternal/In-Utero Transport Systems Follow-Up Given On Transferred Patients STATE Perinatal Committees/Councils NICU Bed Registry/Electronic Bulletin Board

Intervention Description: To determine whether perinatal care in southwestern Ontario is regionalized, to identify trends over time in referral patterns, to quantify trends in perinatal death rates and to identify trends in perinatal death rates that give evidence of regionalization.

Intervention Results: Between 1982 and 1985 the antenatal transfer rate increased from 2.2% to 2.8% (p less than 0.003). The proportion of births of infants weighing 500 to 1499 g increased from 49% to 69% at the level III hospital. The neonatal transfer rate increased from 26.2% to 47.9% (p less than 0.05) for infants in this birth-weight category and decreased from 10.2% to 7.1% (p less than 0.03) for infants weighing 1500 to 2499 g. The death rate among infants of low birth weight was lowest among those born at the level III centre and decreased at all centres between 1982 and 1985.

Conclusion: Perinatal care in southwestern Ontario is regionalized and not centralized; regionalization in southwestern Ontario increased between 1982 and 1985.

Study Design: QE: pretest-posttest

Setting: Southwestern Ontario One level III, one modified level III and 30 level II or I

Population of Focus: Births greater than 500 gm

Data Source: Data obtained from hospital delivery room books and for 31 of the 32 hospitals, from hospital charts of women and neonates.

Sample Size: Pretest: 1.17% (n= 194) Posttest: 1.31% (n= 211) Infants born weighing 500-1499 gm

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Referrals Administration/Practice Management Quality Improvement HOSPITAL PATIENT_CONSUMER Patient Reminder/Invitation HEALTH_CARE_PROVIDER_PRACTICE EMR Reminder

Intervention Description: Researchers implemented process changes in 3 phases: phase 1, changing the screening instrument and adding decision support; phase 2, adding automatic reminders; and phase 3, adding a referral option for autism evaluations in primary care. We analyzed the proportion of visits with autism screening at 2 intervention clinics before and after implementation of process changes versus 27 community clinics (which received only automatic reminders in phase 2) with χ2 test and interrupted time series.

Intervention Results: In 12 233 visits over 2 years (baseline and phased improvements), autism screening increased by 52% in intervention clinics (58.6%-88.8%; P < .001) and 21% in community clinics (43.4%-52.4%; P < .001). In phase 1, interrupted time series trend for screening in intervention clinics increased by 2% per week (95% confidence interval [CI]: 1.1% to 2.9%) and did not increase in community clinics. In phase 2, screening in the community clinics increased by 0.46% per week (95% CI: 0.03% to 0.89%). In phase 3, the intervention clinic providers referred patients for diagnostic evaluation 3.4 times more frequently (95% CI: 2.0 to 5.8) than at baseline.

Conclusion: We improved autism screening and referrals by changing the screening instrument, adding decision support, using automatic reminders, and offering autism evaluation in primary care in intervention clinics. Automatic reminders alone improved screening in community clinics.

Setting: Pediatric and community clinics

Population of Focus: Pediatricians and staff

Intervention Components (click on component to see a list of all articles that use that intervention): Development/Improvement of Services Needs Assessment Consultation Systems (Hospital) HOSPITAL Reorganization of Neonatal Services NATIONAL

Intervention Description: The natural extension of inpatient-focused neonatal neurocritical care (NNCC) programs is the evaluation of long-term neurodevelopmental outcomes in the same patient population.

Intervention Results: To achieve this goal, we devised a two-clinic follow-up model at Children's Wisconsin: HOPE (Healthy Outcomes Post-ICU Engagement) and DREAM: Developmentally Ready: Engagement for Achievement of Milestones) clinics. Those infants with significant neurologic diagnoses attend DREAM clinic, while all other high-risk neonatal intensive care unit (NICU) infants are seen in the HOPE clinic.

Conclusion: These clinic models allow for a targeted approach to post-NICU care, which has improved family engagement and perceptions of value.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Hospital Policies POPULATION-BASED SYSTEMS COMMUNITY Community Health Services Policy Provider Training/Education

Intervention Description: To assess the effectiveness of the Baby Friendly Community Initiative (BFCI) on exclusive breast feeding at 6 months.

Intervention Results: The crude rates of exclusive breast feeding at discharge, 3 and 6 months, and of any breast feeding at 6 and 12 months increased at each round of data collection after baseline in the early and late intervention groups. At the end of the project, 10% of infants were exclusively breast fed at 6 months and 38% were continuing to breast feed at 12 months. However, the comparison by adjusted rates and logistic regression failed to show statistically significant differences between groups and rounds of data collection in the intention-to-treat analysis, as well as when compliance with the intervention and training coverage was taken into account.

Conclusion: The study failed to demonstrate an effect of the BFCI on the rates of breast feeding. This may be due, among other factors, to the time needed to observe an effect on breast feeding following this complex intervention.

Study Design: QE: pretest-posttest time-lagged nonequivalent control group

Setting: 18 Local Health Authorities (LHAs) in 9 regions of Italy

Population of Focus: Women living in the area covered by LHA, with infants > 2000g, who spoke Italian, English, French, or Spanish (or who had a relative who spoke these languages), and without a postpartum condition that required admission to the NICU

Data Source: Mother self-report

Sample Size: Early Intervention Group5 • Enrolled (n=2846) • 12-month follow-up (n=2474) Late Intervention Group • Enrolled (n=2248) • 12-month follow-up (n=1931)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Hospital Policies Baby Friendly Hospital Initiative Provider Training/Education

Intervention Description: Breastfeeding rates and related hospital practices need improvement in Italy and elsewhere.

Intervention Results: No statistically significant differences in both groups, before and after training, of exclusive breastfeeding at 6 months

Conclusion: Training for at least three days with a course including practical sessions and counselling skills is effective in changing hospital practices, knowledge of health workers, and breastfeeding rates.

Study Design: QE: pretest-posttest time-lagged nonequivalent control group

Setting: 8 hospitals (3 general hospitals and 1 teaching hospital in southern Italy, 3 general hospitals and 1 teaching hospital in central and northern Italy)

Population of Focus: Women with healthy infants > 2000g

Data Source: Mother self-report

Sample Size: Group 1 • Phase 1 (n=529) • Phase 2 (n=515) • Phase 3 (n=516) Group 2 • Phase 1 (n=483) • Phase 2 (n=342) • Phase 3 (n=284)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Policy/Guideline (Hospital)

Intervention Description: it focused on evaluating the impact of the extension of mandatory vaccination for infants born on or after January 1, 2018, in France. The study aimed to measure the impact of this new vaccination policy on vaccine coverage rates and the mothers' perception of vaccination through an online survey ,[object Object],. The communication strategy implemented to promote this new policy was also mentioned, indicating that it may have had a positive impact on the opinion of mothers regarding vaccination ,[object Object],.

Intervention Results: The study reported several key results: 1. Vaccine Coverage Rates (VCRs): The study observed a significant increase in VCRs for certain vaccines, particularly for Hepatitis B and meningococcal C vaccines. The VCR for at least one dose of the Hepatitis B vaccine showed an 8.1 point progression, and the VCR for meningococcal C vaccination increased by 31 points ,[object Object],, ,[object Object],. 2. Mothers' Opinion: The proportion of mothers who were favorable to mandatory vaccination and believed to be rather well or highly informed about vaccination significantly increased in 2018 compared to 2017. This suggests a changing mindset among mothers regarding vaccination, potentially influenced by the extension of mandatory vaccination and the communication strategy implemented to promote this new policy ,[object Object],, ,[object Object],, ,[object Object],. These results indicated a positive impact of the extension of mandatory vaccination on both mothers' opinions regarding vaccination and infant VCRs ,[object Object],, ,[object Object],, ,[object Object],, ,[object Object],.

Conclusion: These first results showed a positive impact of the extension of mandatory vaccination on mothers’ opinion regarding vaccination and on infant VCRs.

Study Design: The study utilized an online survey to measure the impact of the new mandatory vaccination policy on vaccine coverage rates and mothers' perceptions of vaccination. The survey included a sample of 1000 mothers of 0- to 11-month-old infants and was conducted over multiple years to assess changes over time ,[object Object],. Additionally, the study also involved the measurement of vaccine coverage rates for at least one dose at 6 months of age in infants included between 2016 and 2018 ,[object Object],.

Setting: The study was conducted in France, focusing on the impact of the extension of mandatory vaccination on infant vaccine coverages ,[object Object],. The research involved professionals from various healthcare institutions, including hospitals and universities across different cities in France ,[object Object],.

Population of Focus: The target audience of this study is healthcare professionals, policymakers, and the general public interested in understanding the impact of mandatory vaccination on infant vaccine coverages and the opinion of mothers towards vaccination in France. The study provides valuable insights into the effectiveness of mandatory vaccination policies and the importance of communication strategies in promoting vaccination programs ,[object Object],.

Sample Size: The study utilized a sample size of 1000 mothers of 0- to 11-month-old infants for the online survey conducted to assess the impact of mandatory vaccination on vaccination coverage rates and mothers' opinions regarding vaccination ,[object Object],.

Age Range: The age range of the infants included in the study was 6 to 8 months old ,[object Object],.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Provider Training/Education HOSPITAL Continuing Education of Hospital Providers Policy/Guideline (Hospital) Educational Material (Provider) Guideline Change and Implementation

Intervention Description: We hypothesized that a pragmatic, multilevel treatment model including (ask, advise, refer [AAR]) coupled with individualized, telephone-based behavioral counseling promoting child tobacco smoke exposure (TSE) reduction would demonstrate greater child TSE reduction than would standard AAR.

Intervention Results: Complete case analysis demonstrated that compared with control parents (29.9%), significantly more parents in the experimental condition (45.8%) eliminated their children’s exposure to all sources of tobacco smoke both inside and outside their homes at 3-month follow-up. In addition, more parents in AAR/counseling than in AAR/attention control eliminated all sources of TSE (45.8% vs. 29.9%) and quit smoking (28.2% vs. 8.2%).

Conclusion: The results indicate that the integration of clinic- and individual-level smoking interventions produces improved TSE and cessation outcomes relative to standalone clinic AAR intervention. Moreover, this study was among the first in which researchers demonstrated success in embedding AAR decision aids into electronic health records and seamlessly facilitated TSE intervention into routine clinic practice.

Study Design: RCT

Setting: Community (home)

Population of Focus: Tobacco-smoking parents living in low-income, urban communities with children <11 years old exposed daily to tobacco smoke in the home. Additional inclusion criteria: daily smoker, >17 years old, and speaking English

Data Source: Structured telephone interviews for baseline data collection and 3-month follow-up.

Sample Size: 334 providers. 327 participants (n=163 AAR and counseling, n=164 AAR and control)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Lactation Consultant Telephone Support Hospital Policies PROVIDER/PRACTICE Other (Provider Practice)

Intervention Description: The purpose of this study was to determine whether implementing a program based on a clinical protocol affects breastfeeding rates within a pediatric primary care setting. Increasing breastfeeding rates is an important public health initiative identified by multiple agencies.

Intervention Results: The results of this evaluation were positive for exclusive breastfeeding, with group comparisons showing a statistically significant increase in exclusive breastfeeding rates at all 5 time points.

Conclusion: Our diverse patient population within a pediatric practice had increased initiation rates and exclusive breastfeeding rates after implementation of the ABM's breastfeeding-friendly protocol. Families who receive care in a pediatric primary care setting that has implemented the ABM clinical protocol may have increased rates of exclusive breastfeeding.

Study Design: QE: pretest-posttest

Setting: 2 locations (1 suburban, 1 rural) of a single practice in northern VA

Population of Focus: Women with healthy, singleton births of ≥ 37 GA , who entered the practice within the first week of birth and returned for health maintenance visits at 2, 4, and 6 months

Data Source: Medical record review

Sample Size: Pre-Intervention (n=376) Post-Intervention (n=381)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Development/Improvement of Services HOSPITAL

Intervention Description: Effects of maternal transport on admission patterns at a tertiary care center.

Intervention Results: The number of maternal transports to the level III hospital increased from 65 before intervention to 280 after intervention. This was accompanied by a corresponding increase in number of infants admitted to the NICU who were born to transferred women from 43 before intervention to 201 after intervention, suggesting some of the increase in maternal transfer was due to anticipated neonatal care needs. The authors do not comment on statistical significance of this result.

Conclusion: Patterns of modern perinatal care are materially changing the delivery of health care at tertiary care facilities.

Study Design: Time trend analysis

Setting: Rhode Island and southeastern Massachusetts One tertiary center and 13 other obstetric facilities

Population of Focus: Total live births >500 gm in tertiary center

Data Source: Data from annual hospital statistics. Maternal transport data only available for 1978 and later.

Sample Size: 1973 (n=5,300) 1984 (n=7,317) Total live births >500 gm in tertiary center

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Hospital Policies Baby Friendly Hospital Initiative

Intervention Description: Maternity care practices influence breastfeeding outcomes long after women leave the birth setting. We conducted this study to describe, from mothers' perspective, maternity care practices associated with breastfeeding at 3 and 6 months. Six study sites were either designated as Baby-Friendly or were in the process of achieving this designation.

Intervention Results: Our multisite study supports implementing low cost and evidence-based interventions such as immediate and uninterrupted SSC and rooming in to improve breastfeeding exclusivity.

Conclusion: Findings highlight the ongoing need to bridge the gap between hospital discharge and community breastfeeding support, including workplace accommodations.

Study Design: Cross sectional descriptive replication study

Setting: Two large academic medical centers, one in the Northeast and two in the South-central region of the US, and two smaller teaching hospitals and community hospitals in the Northeast and South-central region of the US

Population of Focus: Women who gave birth during the data collection period at each study site

Sample Size: 672 women

Age Range: Women ages 18-48

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination Telemedicine Systems (Hospital)

Intervention Description: The intervention described in this study is a virtual wraparound care program called "vKids." The program provided comprehensive care coordination, education, parental support, acute care triage, and virtual visits to children with medical complexity (CMC) and their families. The program utilized a virtual team of pediatric physicians, pediatric nurse practitioners, pediatric nurses, and social workers to address the medical and social needs of patients and families. The program was designed to address the challenges faced by families of CMC, including geographic barriers, transportation challenges, and the lack of reimbursement for the level of support services and care coordination needed.

Intervention Results: Eighty (n = 80) children were included in the economic evaluation, and 75 had sufficient data for analysis. Compared to the 12 months before enrollment, patients had a 35.3% reduction in hospitalizations (p = 0.0268), a 43.9% reduction in emergency visits (p = 0.0005), and a 16.9% reduction in overall charges (p = 0.1449). Parents expressed a high degree of satisfaction, with a 70% response rate and 90% satisfaction rate.

Conclusion: We implemented a virtual care model to provide in-home support and care coordination for medically complex children and adolescents and used an economic framework to assess changes in utilization and cost. The program had high engagement rates and parent satisfaction, and a pre/postanalysis demonstrated statistically significant reduction in hospitalizations and ED visits for this high-cost population. Further economic evaluation is needed to determine sustainability of this model in a value-based payment system.

Study Design: The study utilized a retrospective cohort design to measure the pre-intervention and post-intervention utilization for inpatient, outpatient, and emergency department settings, as well as the cost of care and patient satisfaction for children with medical complexity (CMC). The economic framework was used to evaluate the outcomes of the virtual wraparound care program, and data for study participants were extracted from the HIDI dataset for all inpatient and outpatient visits across all hospitals in the state between October 1, 2017, and March 31, 2020.

Setting: The study was conducted in the United States, specifically in the states of Missouri, Tennessee, and North Carolina. The program was implemented in a virtual care setting, providing wraparound care to address the medical and social needs of patients and families using a virtual team of pediatric physicians, pediatric nurse practitioners, pediatric nurses, and social workers.

Population of Focus: The target audience for the study includes healthcare professionals, policymakers, and researchers interested in pediatric care, particularly for children with medical complexity (CMC). Additionally, the findings of the study may be relevant to healthcare administrators and organizations seeking to implement or improve virtual care programs for pediatric patients with complex medical needs. The study's focus on the economic evaluation and outcomes of a virtual wraparound care program makes it particularly relevant to those interested in innovative care models and their impact on healthcare utilization and patient satisfaction.

Sample Size: The study included a total of 80 children with medical complexity (CMC) for the economic evaluation, and 75 of these children had sufficient data for analysis. The sample size of 75 patients was used for the pre- and post-analysis of the program's impact on hospitalizations, emergency department visits, and overall charges.

Age Range: 0-19 years

Intervention Components (click on component to see a list of all articles that use that intervention): Hospital Policies Social Media

Intervention Description: The intervention included in-hospital vaccinations for stable preterm infants, vaccination counseling for outpatient follow-up, and online dissemination of vaccine scientific data through social media.

Intervention Results: The study found that the intervention was associated with higher coverage and timeliness of routine immunizations in preterm infants.

Conclusion: Increasing vaccine confidence through web-based interventions could have a positive impact on vaccination acceptance of parents of preterm infants, although timeliness results still delayed. There is a strong need to develop different and effective vaccination strategies to protect this very vulnerable population.

Study Design: The study used a historical cohort design, comparing the interventional 2016-2017 cohort with a preterm cohort from 2013-2014 and a regional pediatric population cohort from 2016-2017.

Setting: The study was conducted in a single NICU in Italy with a specific protocol for vaccination of preterm infants

Population of Focus: The target audience was families of preterm infants.

Sample Size: The study evaluated a cohort of preterm infants born from 2016 to 2017, regularly followed in the outpatient clinic up to 2 years of life.

Age Range: The study focused on preterm infants, but the age range was not specified.

Intervention Components (click on component to see a list of all articles that use that intervention): Chart Audit and Feedback Policy/Guideline (Hospital) HOSPITAL

Intervention Description: To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes.

Intervention Results: A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported.

Conclusion: A reduction in CB rate may be safely achieved through implementing a multifaceted strategy

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Patient Reminder/Invitation Educational Material PROVIDER/PRACTICE Provider Reminder/Recall Systems Quality Improvement/Practice-Wide Intervention Designated Clinic/Extended Hours Female Provider Needs Assessment PATIENT_CONSUMER HOSPITAL

Intervention Description: Translational research (TR) and continuous quality improvement (CQI) processes used to identify and address barriers and facilitators to Pap smear screening within an urban Aboriginal Community Controlled Health Service (ACCHS).

Intervention Results: There was a statistically significant increase in Pap smear numbers during Plan-Do-Study-Act (PDSA) cycles, continuing at 10 months follow up.

Conclusion: he use of TR with CQI appears to be an effective and acceptable way to affect Pap smear screening. This model is transferrable to other settings and other health issues.

Study Design: QE: pretest-posttest

Setting: An urban Aboriginal Community Controlled Health Service (ACCHS)

Population of Focus: All women within eligible age range

Data Source: Electronic medical records

Sample Size: Total (N=213)

Age Range: 18-70

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Baby Friendly Hospital Initiative

Intervention Description: In October 2012, the Maryland State Department of Health launched the Maryland Hospital Breastfeeding Policy Recommendations, which included best practices in mother-baby care, and encouraged all birthing hospitals to adopt evidence-based practices to promote breastfeeding. In 2016, four Maryland hospitals were newly designated as Baby-Friendly and were located in southern, central, and northeastern Maryland. The study evaluated whether the receipt of specific Steps was associated with breastfeeding practices through 6 months in the Maryland WIC.

Intervention Results: Reported adherence to 10-Steps policies ranged from 10%–85% (lowest for Step 9, highest for Step 10) and only Step 9 (give no pacifiers or artificial nipples to breastfeeding infants) differed according to Baby-Friendly Hospital status. Greater exposure to the 10 Steps was positively associated with exclusive breastfeeding during hospitalization. The lack of perceived adherence to Step 6 (no food or drink other than human milk), Step 9, and the International Code of Marketing of Breast-milk Substitutes (no formula, bottles, or artificial nipples) significantly decreased the likelihood of exclusive breastfeeding through 6 months.

Conclusion: Maternal perception of Baby-Friendly Step adherence was associated with exclusive breastfeeding.

Study Design: Cross-sectional 2 group comparison study

Setting: WIC Program and community hospitals in southern, central, and northeastern Maryland

Population of Focus: Postpartum women recruited through WIC clinics

Sample Size: 182 women

Age Range: Mothers older than 18 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: (1) To compare maternal perceptions about maternity practices in Baby-Friendly Hospitals and non-Baby-Friendly Hospitals; (2) to evaluate the associations between degree of exposure to the Baby-Friendly 10 Steps and breastfeeding practices through the first 6 months; and (3) to evaluate whether the receipt of specific Steps was associated with breastfeeding practices through 6 months.

Intervention Results: Reported adherence to 10-Steps policies ranged from 10%–85% (lowest for Step 9, highest for Step 10) and only Step 9 (give no pacifiers or artificial nipples to breastfeeding infants) differed according to Baby-Friendly Hospital status. Greater exposure to the 10 Steps was positively associated with exclusive breastfeeding during hospitalization. The lack of perceived adherence to Step 6 (no food or drink other than human milk), Step 9, and the International Code of Marketing of Breast-milk Substitutes (no formula, bottles, or artificial nipples) significantly decreased the likelihood of exclusive breastfeeding through 6 months.

Conclusion: Maternal perception of Baby-Friendly Step adherence was associated with exclusive breastfeeding.

Intervention Components (click on component to see a list of all articles that use that intervention): NATIONAL Policy/Guideline (National) HOSPITAL Development/Improvement of Services

Intervention Description: We performed a cross-sectional study and linked 2014 American Hospital Association survey and State Inpatient Database data from seven representative states. We used American Hospital Association–reported hospital characteristics and State Inpatient Database procedure codes to assign a level of maternal care to each hospital. We then assigned each patient to a minimum required level of maternal care (I–IV) based on maternal comorbidities captured in the State Inpatient Database. Our outcome was delivery at a hospital with an inappropriately low level of maternal care. Comorbidities associated with delivery at an inappropriate hospital were assessed using descriptive statistics.

Intervention Results: The analysis included 845,545 deliveries occurring at 556 hospitals. The majority of women had risk factors appropriate for delivery at level I or II hospitals (85.1% and 12.6%, respectively). A small fraction (2.4%) of women at high risk for maternal morbidity warranted delivery in level III or IV hospitals. The majority (97.6%) of women delivered at a hospital with an appropriate level of maternal care, with only 2.4% of women delivering at a hospital with an inappropriate level of maternal care. However, 43.4% of the 19,988 high-risk patients warranting delivery at level III or IV hospitals delivered at level I or II hospitals. Women with comorbidities likely to benefit from specialized care (eg, maternal cardiac disease, placenta previa with prior uterine surgery) had high rates of delivery at hospitals with an inappropriate level of maternal care (68.2% and 37.7%, respectively).

Conclusion: Though only 2.41% of deliveries occurred at hospitals with an inappropriate level of maternal care, a substantial fraction of women at risk for maternal morbidity delivered at hospitals potentially unequipped with resources to manage their needs. Promoting triage of high-risk patients to hospitals optimized to provide risk-appropriate care may improve maternal outcomes with minimal effect on most deliveries.

Setting: Seven states (Florida, Massachusetts, New Jersey, New York, North Carolina, Oregon, and Washington)

Population of Focus: Women with high-risk maternal medical conditions

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Continuing Education of Hospital Providers Development/Improvement of Services

Intervention Description: In the Thames Valley region of the UK in 2012-2014, covering 27 000 births per annum, about 50% of extremely premature babies were born in a specialist centre. Audit showed a number of potential areas for improvement. We used regional place of birth data and compared the place of birth of extremely premature babies for 2 years before our intervention and for 4 years (2014-2018) after we started. We aimed to improve the proportion of neonates born in a specialist centre with three interventions: increasing awareness and education across the region, by improving and simplifying the referral pathway to the local specialised centre, and by developing region-wide guidelines on the principal precursors to preterm birth: preterm labour and expedited delivery for fetal growth restriction.

Intervention Results: There were 147 eligible neonates born within the network in the 2 years before the intervention and 80 (54.4%) were inborn in a specialised centre. In the 4 years of and following the intervention, there were 334 neonates of whom 255 were inborn (76.3%) (relative risk of non-transfer 0.50 (95% CI 0.39 to 0.65), p<0.001). Rates showed a sustained improvement.

Conclusion: The proportion of extremely premature babies born in specialist centres can be significantly improved by a region-wide quality improvement programme. The interventions and lessons could be used for other areas and specialties.

Setting: Network of hospitals in the Thames Valley region of UK

Population of Focus: Extremely premature babies born within network

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Training/Education Educational Material (provider) Audit/Attestation (provider) PROFESSIONAL_CAREGIVER Education/Training (caregiver) HOSPITAL Quality Improvement Crib Card

Intervention Description: This quality improvement project used an interprofessional, multimodal approach to improve sleep safety for hospitalized infants. The working group for this project included the Director of Quality Improvement for the Department of Pediatrics, a Pediatric Hospitalist, a Senior Advanced Practice Nurse in Pediatrics, Senior Associate Counsel for the Office of Counsel, and a medical student with a background in social work. The interdisciplinary group met to review and discuss improvements to communication and facilitated the development of five family interventions: a designated safe sleep web page, a clear bedside guide to safe sleep, additional training for nursing staff in motivational interviewing, a card audit system, and electronic health record smart phrases. A short survey was conducted to assess how the safe sleep toolkit has been useful to care providers in the Children’s Hospital. 

Intervention Results: With the initial pilot implementation of the K-cards, staff reported increased ease of audits. Adherence to recommended safer sleep measures was a major barrier in previous attempts to improve institutional sleep safety (1). By making adherence easier, providers may be more likely to both participate in quality improvement tracking measures and follow-up with families directly.

Conclusion: These coordinated interventions reflect advantages of an interprofessional and family-centered approach: building rapport and achieving improvements to infant sleep safety.

Setting: Golisano Children’s Hospital

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Guideline Change and Implementation

Intervention Description: The objectives of this retrospective cohort review were to determine the rate of adherence to the 2014 ACOG/SMFM guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) and to compare guideline adherence with physician cesarean delivery (CD) rates and obstetric/neonatal outcomes. There were 591 cesarean deliveries that met inclusion criteria for this study. Of these, 263 were performed for failed induction and 328 for AOD.

Intervention Results: Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003).

Conclusion: Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.

Setting: Single urban academic center

Population of Focus: Nulliparous and multiparous primary cesarean delivery patients

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Baby Friendly Hospital Initiative Quality Improvement/Practice-Wide Intervention Hospital Policies Provider Training/Education

Intervention Description: To conduct a national quality improvement initiative between 2011 and 2015. The initiative was entitled Best Fed Beginnings and enrolled 90 hospitals in a nationwide initiative to increase breastfeeding and achieve Baby-Friendly designation.

Intervention Results: Overall breastfeeding increased from 79% to 83% (t = 1.93; P = .057), and exclusive breastfeeding increased from 39% to 61% (t = 9.72; P < .001).

Conclusion: A nationwide initiative of maternity care hospitals accomplished rapid transformative changes to achieve Baby-Friendly designation. These changes were accompanied by a significant increase in exclusive breastfeeding.

Study Design: QE: pretest-posttest

Setting: 90 hospitals from 3 geographic regions

Population of Focus: Hospitals with low breastfeeding rates, readiness for change, establishment of a BabyFriendly/breastfeeding steering committee, data about sociodemographic characteristics of population served, geographic location based on regions with low breastfeeding rates and BFHI accreditation, commitment of senior leadership, and experience with quality improvement methods

Data Source: Medical record review

Sample Size: Intervention (N=89) N=hospitals

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Provider Training/Education Quality Improvement/Practice-Wide Intervention Baby Friendly Hospital Initiative

Intervention Description: The Best Fed Beginnings (BFB) initiative was specifically aimed to enable 90 hospitals to earn Baby-Friendly USA assessment scheduled by the end of the collaborative project. Given the size of this initiative, BFB was conducted as 3 simultaneous Breakthrough Series collaborative projects comprising hospitals from 3 geographic regions. Hospitals assembled multidisciplinary teams that included parent partners and community representatives. Three in-person learning sessions were interspersed with remote learning and tests of change, and a Web-based platform housed resources and data for widespread sharing.

Intervention Results: By April 2016, a total of 72 (80%) of the 90 hospitals received the Baby-Friendly designation, nearly doubling the number of designated hospitals in the United States. Participation in the Best Fed Beginnings initiative had significantly high correlation with designation compared with hospital applicants not in the program (Pearson’s r [235]: 0.80; P < .01). Overall breastfeeding increased from 79% to 83% (t = 1.93; P = .057), and exclusive breastfeeding increased from 39% to 61% (t = 9.72; P < .001).

Conclusion: A nationwide initiative of maternity care hospitals accomplished rapid transformative changes to achieve Baby-Friendly designation. These changes were accompanied by a significant increase in exclusive breastfeeding.

Study Design: Evaluation data

Setting: Hospitals nationwide

Population of Focus: Hospitals across the country seeking to achieve Baby-Friendly designation

Sample Size: 90 Baby-Friendly Hospitals

Intervention Components (click on component to see a list of all articles that use that intervention): Parent Mentors Policy/Guideline (Hospital) Quality Improvement

Intervention Description: Six million children are uninsured, despite two-thirds being eligible for Medicaid/CHIP, and minority children are at especially high-risk. The study team conducted a randomized trial of the effects of parent mentors on insuring minority children. Parent mentors were experienced parents with ≥1 Medicaid/CHIP-covered child who received 2 days of training, then assisted families for 1 year with insurance applications, retaining coverage, medical homes, and social needs; controls received traditional Medicaid/CHIP outreach. Parent mentors were recruited from June 2011 to August 2013 at a hospitalbased Resident Continuity Clinic, charter school, and via established parent mentor referrals. Interviews were conducted to identify optimal candidates characterized by reliability, timeliness, persistence, and desire to help families with uninsured children. From 31 candidates interviewed, 15 parent mentors were chosen. Parent mentors received monthly stipends for each family mentored. Parents mentors and intervention participants were matched by race/ethnicity and zip code, whenever possible. Latino families were matched with fluently bilingual Latino parent mentors. Session content for the 2-day training was based on training provided to community case managers in the research team’s previous successful RCT and addressed 9 topics (e.g., why health insurance is so important; being a successful parent mentor; parent mentor responsibilities; Medicaid and CHIP programs and the application process; the importance of medical homes).

Intervention Results: In the Kids’ HELP trial, the intervention was more effective than traditional outreach/enrollment in insuring uninsured minority children, resulting in 95% of children obtaining insurance vs. 68% of controls. The intervention also insured children faster, and was more effective in renewing coverage, improving access to medical and dental care, reducing out-of-pocket costs, achieving parental satisfaction and quality of care, and sustaining insurance after intervention cessation. This is the first RCT to evaluate the effectiveness of parent mentors in insuring uninsured children. Kids’ HELP could possibly save $12.1 to $14.1 billion. Parent mentors were more effective in improving access to primary, dental, and specialty care; reducing unmet needs, achieving parental satisfaction with care, and sustaining long-term coverage. Parent mentors resulted in lower out-ofpocket costs for doctor and sick visits, higher well-child care quality ratings, and higher levels of parental satisfaction and respect from children’s physicians. Findings suggest that parent mentors and analogous peer mentors for adults might prove to be highly costeffective interventions for reducing or eliminating insurance disparities and insuring all Americans.

Conclusion: PMs are more effective than traditional Medicaid/CHIP methods in insuring uninsured minority children, improving health care access, and achieving parental satisfaction, but are inexpensive and highly cost-effective.

Study Design: RCT

Setting: Community (Communities in Dallas County, Texas with the highest proportions of uninsured and low-income minority children)

Population of Focus: Parents and Children

Sample Size: 237 participants; 114 in the control group and 123 in the intervention group

Age Range: 0-18 years

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative HEALTH_CARE_PROVIDER_PRACTICE Professional Support

Intervention Description: We assessed the association between BF-related hospital practices (rooming-in, support from hospital staff, and provision of a pro-formula gift pack) and the odds of any or exclusive BF through 5 mo among infants and mothers enrolled in WIC.

Intervention Results: Rooming-in and strong hospital staff support were associated with higher odds of any BF at 1, 3, and 5 mo postpartum. Provision of a pro-formula gift pack was negatively associated with any BF at all time points and with exclusive BF at 1 mo. Each additional BF-friendly hospital practice experienced was associated with 47% to 85% higher odds of any BF over the first 5 mo and 31% to 36% higher odds of exclusive BF over the first 3 mo.

Conclusion: Exposure to BF-friendly hospital practices was associated with BF beyond the hospital stay. Expanding BF-friendly policies at the hospital could increase BF rates in the United States WIC-served population.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Provider Training/Education HOSPITAL Quality Improvement Visual Display (Hospital)

Intervention Description: The purpose of this study was to improve safe sleep practice (SSP) adherence by healthcare providers working with infants admitted to an inpatient pediatric unit in an urban academic center, specifically increasing compliance on five core SSP (supine, alone in the crib, no objects in crib, appropriate bundling, and flat crib). Targeted pediatric hospitalists (attending physicians who exclusively work in the hospital setting), residents, and nurses working on the general pediatric wards were invited to complete a safe sleep survey prior to receiving a brief educational intervention tailored to their specific provider group. All participants received the same basic information on the current rates of SIDS, associated disparities, current hospital practices, AAP-endorsed safe sleep practices, and the impact of healthcare provider practices on caregivers. In-person presentations, handouts, posters, and “Ask me about safe sleep” buttons for nursing staff were among the teaching tools used. Efficacy of the intervention was assessed by comparing audits of sleeping infants in hospital rooms prior to (baseline) and following (post-intervention) the education sessions.

Intervention Results: This Quality Improvement project evaluated a staff education intervention using a pre- and post-design. Surveys of providers determined baseline SSP knowledge. Adherence to SSP in the hospital was audited before and after education. One hundred pre-intervention infant sleep placement observations were recorded and 123 were collected post-intervention.

Conclusion: This quality improvement project suggests that the inpatient setting provides opportunities for providers to demonstrate SSP but that healthcare providers often do not follow SSP in practice. Continued education can lead to improvements in SSP adherence ensuring that hospitals are modeling SSP for the families of infants.

Setting: The University of Chicago Medicine Comer Children’s Hospital

Population of Focus: Pediatric healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Labor Support Midwifery HOSPITAL Peer Review Quality Improvement

Intervention Description: In efforts to help reduce the primary C-section rate, the hospital participated in the American College of Nurse-Midwives Healthy Birth Initiative. Strategies employed included use of intermittent auscultation, upright labor positioning, an early labor lounge, one-to-one labor support, and team huddles.

Intervention Results: The baseline nulliparous, term, singleton, vertex cesarean rate in 2015 was 29.3%. In 2016, after 1 year of implementation of the project, the hospital decreased nulliparous, term, singleton, vertex cesarean rate to 26.1%-a reduction of 10%. In 2017, the rate was decreased to 25.3%-a reduction by 3.7%.

Conclusion: The multicomponent bundle incorporated proven quality improvement strategies and engaged numerous champions and stakeholders, including midwifery students.

Setting: Urban academic hospital in the Midwest

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Prolonged Second Stage of Labor HOSPITAL Guideline Change and Implementation Quality Improvement Collaboratives Policy/Guideline (Hospital)

Intervention Description: Standardized second-stage labor evidence-based practice recommendations were structured into an interdisciplinary “5 Ps practice bundle” (patience, positioning, physiologic resuscitation, progress, preventing urinary harm) and implemented across 34 birthing hospitals. The second-stage labor practices were derived from the Association of Women's Health, Obstetric and Neonatal Nurses and the American College of Nurse-Midwives professional guidelines. The recommendations are designed to support the laboring woman's normal physiologic processes and avoid unnecessary interventions.

Intervention Results: Significant improvements were observed in second-stage practices. Association of Women's Health, Obstetric and Neonatal Nurses' perinatal nursing care quality measure Second-Stage of Labor: Mother-Initiated Spontaneous Pushing significantly improved [pre-implementation 43% (510/1,195), post-implementation 76% (1,541/2,028), p < .0001]. Joint Commission Perinatal Care-02: nulliparous, term, singleton, vertex cesarean rate significantly decreased (p = 0.02) with no differences in maternal morbidity, or negative newborn birth outcomes. Unexpected complications in term births significantly decreased in all newborns (p < 0.001), and for newborns from vaginal births (p = 0.03). Birth experience satisfaction rose from the 69th to the 81st percentile.

Conclusion: Clinical implications: Implementing 13 evidence-based second-stage labor practices derived from the Association of Women's Health, Obstetric and Neonatal Nurses and the American College of Nurse-Midwives professional guidelines achieved our goals of safely reducing primary cesarean birth among low-risk nulliparous women, and optimizing maternal and fetal outcomes associated with labor and birth. By minimizing routine interventions, nurses support physiologic birth and improve women's birth satisfaction.

Setting: 34 birthing hospitals in the Trinity Health System

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Provider Training/Education Provision of Safe Sleep Item Assessment (Provider) HOSPITAL Quality Improvement Policy/Guideline (Hospital) Crib Card CAREGIVER Education/Training (caregiver) Assessment (caregiver) Educational Material (caregiver)

Intervention Description: The aims of this project were to increase the percentage of infants following safe sleep practices in the NICU before discharge and to determine if improving compliance with these practices would influence parent behavior at home.

Intervention Results: Audit data showed that there was a significant increase in the rate of supine positioning from 39% at baseline to 83% at follow-up (p<0.001). Parental surveys showed that there was a significant increase in the rate of supine position from 73% at baseline to 93% at follow-up (p<0.05).

Conclusion: Multifactorial interventions improved compliance with safe sleep practices in the NICU and at home.

Study Design: QE: pretest-posttest

Setting: Children’s Memorial Hermann Hospital NICU in Houston, TX

Population of Focus: Infants in open cribs eligible for safe sleep practices; Parents of infants after discharge

Data Source: Crib audit/infant observation; Parent report

Sample Size: Baseline (n=62) Follow-up (n=79); Baseline (n=66) Follow-up (n=98)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Provider Training/Education HOSPITAL Quality Improvement Policy/Guideline (Hospital) Crib Card Sleep Environment Modification Promotional Event POPULATION-BASED SYSTEMS COMMUNITY Social Media CAREGIVER Education/Training (caregiver) Educational Material (caregiver) Visual Display (Community)

Intervention Description: To improve sleep environment safety for inpatient infants.

Intervention Results: The proportion of infant cribs without loose objects in them increased (32-72%, p = .025), and safe sleep positioning remained stable (82% vs. 95%, p = .183).

Conclusion: Staff education, swaddle sleep sacks, and bedside storage containers were associated with improved sleep safety among pediatric inpatients at our institution and may help at other institutions.

Study Design: QE: pretest-posttest

Setting: University of Iowa Children’s Hospital

Population of Focus: Infants less than 1 year of age developmentally ready for a crib and asleep

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=22) Follow-up 1 (not reported) Follow-up 2 (n=37) Follow-up 3 (n=18)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy HOSPITAL Policy/Guideline (Hospital)

Intervention Description: To determine if there were changes in obstetrical practices and perinatal outcomes in the United States after the ARRIVE trial publication.

Intervention Results: There were 1,966,870 births in the pre-ARRIVE group and 609,322 in the post-ARRIVE group. The groups differed in age, race, body mass index, marital status, infertility treatment, and smoking history (P<.001). After adjusting for these differences, the post-ARRIVE group was more likely to undergo induction (36.1% vs 30.2%; adjusted odds ratio, 1.36 [1.36–1.37]) and deliver by 39+6 weeks of pregnancy (42.8% vs 39.9%; adjusted odds ratio, 1.14 [1.14–1.15]). The post-ARRIVE group had a significantly lower rate of cesarean delivery than the pre-ARRIVE group (27.3 % vs 27.9%; adjusted odds ratio, 0.94 [0.93–0.94]). Patients in the post-ARRIVE group were more likely to receive a blood transfusion (0.4% vs 0.3%; adjusted odds ratio, 1.43 [1.36–1.50]) and be admitted to medical intensive care unit (0.09% vs 0.08%; adjusted odds ratio, 1.20 [1.09–1.33]). Neonates in the post-ARRIVE group were more likely to need assisted ventilation at birth (3.5% vs 2.8%; adjusted odds ratio, 1.28 [1.26–1.30]) and >6 hours (0.6% vs 0.5%; adjusted odds ratio, 1.36 [1.31–1.41]). The neonates in the post-ARRIVE group were more likely to have low 5-minute APGAR scores (0.4% vs 0.3%; adjusted odds ratio, 0.91 [0.86–0.95]). Neonatal intensive care unit admission did not differ between the 2 groups (4.9% vs 4.9%; adjusted odds ratio, 1.01 [0.99–1.03]). There were no differences in neonatal seizures (0.04% vs 0.04%; adjusted odds ratio, 0.97 [0.84–1.13]), and surfactant use (0.08% vs 0.07%; adjusted odds ratio, 1.05 [0.94–1.17]) between the 2 groups.

Conclusion: There were more inductions of labor, more deliveries at 39 weeks’ gestation, and fewer cesarean deliveries in the year after the ARRIVE trial publication. The small but statistically significant increase in some adverse maternal and neonatal outcomes should be explored to determine if they are related with concurrent changes in obstetrical practices.

Intervention Components (click on component to see a list of all articles that use that intervention): Consultation Systems (Inter-Hospital Systems) Educational Material (Provider)

Intervention Description: The DC Mental Health Access in Pediatrics (DC MAP) program is a child psychiatry access program (CPAP) that provides telephonic consultation services to primary care providers (PCPs) in Washington, DC. The program aims to increase access to mental health services for children and adolescents by providing PCPs with real-time access to child psychiatry experts who can offer guidance on diagnosis, treatment, and care coordination. The program also provides PCPs with information about community resources and referral options available to their patients. The program is staffed by a team of child psychiatrists, psychologists, and social workers who provide consultation services to PCPs on a range of mental health concerns, including depression, anxiety, ADHD, and behavioral problems,.

Intervention Results: DC MAP consult volume increased 349.3% over the first 5 years. Services requested included care coordination (85.8%), psychiatric consultation (21.4%), and psychology/social work consultation (9.9%). Of psychiatry-involved consultations, PCPs managed patient medication care with DC MAP support 50.5% of the time. Most (94.1%) PCPs said they would recommend colleagues use DC MAP, and 29.6% reported diverting patients from the emergency departments using DC MAP.

Conclusion: Yes, the study reported statistically significant findings, including a significant increase in consultation volume over the first 5 years of the program, as well as a significant difference between baseline and 1 year of participation in PCPs' ability to receive more timely care coordination services for their patients with mental health needs,,. Additionally, paired t-tests were conducted to analyze self-report data about PCP beliefs related to mental health services collected at baseline and again 1 year later, indicating statistically significant changes in PCP beliefs over time.

Study Design: The study design is a retrospective analysis of data collected from the DC Mental Health Access in Pediatrics program between May 2015 and May 2020. The study used a mixed-methods approach, including descriptive statistics and paired t-tests to analyze self-report data about PCP beliefs related to mental health services collected at baseline and again 1 year later.

Setting: The study was conducted in the primary care setting, specifically in pediatric primary care practices in Washington, D.C.. The DC Mental Health Access in Pediatrics program was designed to provide consultation services to primary care providers in order to enhance their ability to meet the mental health needs of their pediatric patients.

Population of Focus: The target audience for the study includes primary care providers (PCPs) who care for pediatric patients, as well as professionals involved in pediatric mental health care, such as child psychiatrists, psychologists, and other mental health specialists. The study aims to evaluate the effectiveness of the Child Psychiatry Access Program (CPAP) in supporting PCPs in addressing the mental health needs of children and adolescents in the primary care setting.

Sample Size: The study received 3,389 consultation requests from primary care providers (PCPs) between May 2015 and May 2020. This indicates a substantial sample size for evaluating the effectiveness of the Child Psychiatry Access Program (CPAP) in Washington, D.C.

Age Range: According to the PDF file, the DC Mental Health Access in Pediatrics program provides mental health consultation services for youth aged 0-21 years.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Elective Induction Policy

Intervention Description: In this multicenter trial, 6,106 low-risk nulliparous women were randomly assigned to either expectant management (3044) or labor induction (3062) at 39 weeks 0 days to 39 weeks 4 days.. The primary outcome was a composite of perinatal death or severe neonatal complications; the principal secondary outcome was cesarean delivery.

Intervention Results: A total of 3062 women were assigned to labor induction, and 3044 were assigned to expectant management. The primary outcome occurred in 4.3% of neonates in the induction group and in 5.4% in the expectant-management group (relative risk, 0.80; 95% confidence interval [CI], 0.64 to 1.00). The frequency of cesarean delivery was significantly lower in the induction group than in the expectant-management group (18.6% vs. 22.2%; relative risk, 0.84; 95% CI, 0.76 to 0.93).

Conclusion: Induction of labor at 39 weeks in low-risk nulliparous women did not result in a significantly lower frequency of a composite adverse perinatal outcome, but it did result in a significantly lower frequency of cesarean delivery. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ARRIVE ClinicalTrials.gov number, NCT01990612 .).

Setting: 41 hospitals participating in the Maternal–Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Population of Focus: Low risk nulliparous women

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The purpose of this study was to evaluate whether Baby Friendly Hospital (BFH) designation in Maryland improved breastfeeding practices among Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participants.

Intervention Results: From pre to post intervention no differences in breastfeeding initiation or any breastfeeding at 6 months were attributable to BFH status. There was some evidence that BFH designation in 2016 was associated with an absolute percent change of 2.4% (P = 0.09) for any breastfeeding at 3 months.

Conclusion: Few differences in breastfeeding outcomes among WIC participants were attributable to delivery in a BFH. Results from this study inform policy about maternity practices impacting WIC breastfeeding outcomes. More study needed to determine the impact of BFH delivery on differences in breastfeeding outcomes between sub-groups of women.

Intervention Components (click on component to see a list of all articles that use that intervention): Provider Training/Education Continuing Education of Hospital Providers Assessment

Intervention Description: To evaluate the effectiveness of a bespoke short training programme, which incorporated interactive and didactic teaching with printed and electronic resources.

Intervention Results: Training was associated with significant improvements in the specificity of depression judgements (52.0% for the intervention group and 47.2% for the control group, P = 0.039), and there was a non-significant increase in sensitivity (64.5% compared to 61.5% P = 0.25). Nurses’ knowledge about depression improved (standardised mean difference = 0.97 [95% CI 0.58 to 1.35], P < 0.001); and confidence about their professional role in relation to depression increased.

Conclusion: This school nurse development programme, designed to convey best practice for the identification and care of depression, delivered significant improvements in some aspects of depression recognition and understanding, and was associated with increased confidence in working with young people experiencing mental health problems.

Study Design: Cluster randomized controlled trial

Setting: School nurse services from 13 Primary Care Trusts in London

Population of Focus: School nurses

Sample Size: 146 school nurses

Age Range: School pupils (aligns with ages 12-17)

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Access to Provider through Hotline HOSPITAL Continuing Education of Hospital Providers POPULATION-BASED SYSTEMS INTER-HOSPITAL SYSTEMS Maternal/In-Utero Transport Systems Consultation Systems (Inter-Hospital Systems) Consultation Systems (Hospital) Telemedicine Systems (Inter-Hospital Systems) Telemedicine Systems (Hospital) STATE Policy/Guideline (State)

Intervention Description: Telemedicine has been used successfully for medical care and education but it has never been utilized to modify patterns of delivery in an established state network.

Intervention Results: Medicaid deliveries at the regional perinatal centers increased from 23.8% before the intervention to 33% in neonates between 500 and 999 grams (p<0.05) and was unchanged in neonates between 2001-2500 grams.

Conclusion: Telemedicine is an effective way to translate evidence based medicine into clinical care when combined with a general educational conference. Patterns of deliveries appear to be changing so that those newborns at highest risk are being referred to the regional perinatal centers.

Study Design: Time trend analysis

Setting: All Arkansas hospitals

Population of Focus: Infants born weighing 500-2499 gm. Data not given for other study years.

Data Source: Data from Arkansas Vital Statistics Data System linked with corresponding hospitalization records from Arkansas Hospital Discharge Data System.

Sample Size: Total (n= 12,258) 2001 (n= 2,965) 2004 (n= 3,154)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Peer-Review of Provider Decisions Elective Induction Policy Guideline Change and Implementation PATIENT_CONSUMER Intensive Therapy Psychoeducation

Intervention Description: We conducted a retrospective study was conducted in the Centre Hospitalier Universitaire Vaudois (CHUV) including all births between the 1st January 1997 and 31st December 2011 to analyze the cesarean section (CS) rate using the different groups of the Robson classification in a Swiss maternity hospital.

Intervention Results: The overall CS rate was 29 %, mainly related to group 5 (multiparous with previous CS) and group 2 (nulliparous women induced or who had CS before labor). The study also shows that induction of labor on maternal request in nulliparous at term (group 2a) increased significantly the risk of CS compared to induction of labor for medical reason (p<0.001).

Conclusion: The Robson classification system appears as a simple tool for monitoring CS rates. The main strategies for reducing CS rates will be through better selection of women for VBAC (vaginal birth after caesarean) and limitation of induction of labor, especially in nulliparous women.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Development/Improvement of Services Continuing Education of Hospital Providers Needs Assessment POPULATION-BASED SYSTEMS INTER-HOSPITAL SYSTEMS Maternal/In-Utero Transport Systems Agreement for Level III Hospital to Accept All Patients STATE Funding Support Perinatal Committees/Councils

Intervention Description: A major objective was to develop and maintain a regionalized system of care. Such a system has been developed but differed from traditional systems by using regional level II centers. Iowa's low population density necessitated this modification.

Intervention Results: Level I hospitals currently manage low-risk patients and report very low mortality rates. Level II facilities receive high-risk referrals, but selective referral occurs since the tertiary center accounts for a disproportionate number of fetal and neonatal deaths, and births weighting less than 1500 g.

Conclusion: Other regions may benefit from similar approaches to development of regionalized systems of care and evaluation of the same.

Study Design: QE: pretest-posttest

Setting: All Iowa hospitals Pretest: 129 level I, 11 level II, and one level III hospital Posttest: 118 level I, 11 level II, and one level III hospital

Population of Focus: All infants born at ≥20 weeks GA and ≤1500 gm

Data Source: Data from Iowa State Health Department matched birth and infant death certificates.

Sample Size: Pretest (n= 432) Posttest (n= 343)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Development/Improvement of Services Continuing Education of Hospital Providers Needs Assessment POPULATION-BASED SYSTEMS INTER-HOSPITAL SYSTEMS Maternal/In-Utero Transport Systems Agreement for Level III Hospital to Accept All Patients Perinatal Committees/Councils STATE

Intervention Description: A voluntary system of regionalized perinatal health care was developed in Iowa to provide accessible services for a rural population.

Intervention Results: The intervention in Iowa focused on increasing both level III and level II VLBW births due to population density concerns in Iowa. Among all VLBW infants, there were changes in the birth location distribution. Of these infants, there was a statistically significant increase in percentage born in level III hospitals from 6.7% to 22.6% (p<0.05)1 and an increase in births in level II hospitals from 26.9% to 35.6%. The percentage born in level I centers decreased from 68.2% to 41.8%.

Conclusion: The concept of a mortality risk ratio (neonatal deaths/<1,500 gm live births) is suggested as a method of reviewing mortality data from the perspective of risks inherent in the population served.

Study Design: QE: pretest-posttest

Setting: All Iowa hospitals Pretest: 130 level I, 10 level II, and one level III hospital Posttest: 122 level I, 10 level II, and one level III hospital

Population of Focus: All live births <1500 gm

Data Source: Data from Iowa State Health Department matched birth and infant death certificates.

Sample Size: Pretest (n= 440) Posttest (n= 402)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Continuing Education of Hospital Providers Peer-Review of Provider Decisions POPULATION-BASED SYSTEMS INTER-HOSPITAL SYSTEMS Maternal/In-Utero Transport Systems Consultation Systems (Inter-Hospital Systems) Consultation Systems (Hospital) Agreement for Level III Hospital to Accept All Patients Medical Staff Integration

Intervention Description: Not available

Intervention Results: After the intervention, there was a statistically significant decrease in the number of VLBW infants born in a level II hospital (p<0.01).

Conclusion: Not available

Study Design: QE: pretest-posttest

Setting: Minnesota: Abbott-Northwestern/ Minneapolis Children’s Perinatal Center and Fairview-Southdale Hospital (Level II)

Population of Focus: All births at level II hospital

Data Source: Data source not provided.

Sample Size: Pretest (n= 2,573) Posttest (n= 2,722)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital) Family-Based Interventions

Intervention Description: Services for Children with Special Healthcare Needs (CSHCN) have been challenging in terms of cost and access to appropriate healthcare services. The objectives of this study were to examine cost, caring, and family-centered care in relationship to pediatric specialty services integrating telemedicine visits compared to traditional face-to-face visits only for (CSHCN) in rural, remote, and medically underserved areas.

Intervention Results: Results indicated no significant differences in family costs when the telemedicine group was compared to traditional face-to-face care. When the telemedicine group was asked to anticipate costs if telemedicine was not available, there were significant differences found across all variables, including travel miles, cost of travel, missed work hours, wages lost, child care cost, lodging cost, other costs, and total family cost (p < 0.001). There were no differences in the families' perceptions of care as caring. Parents/guardians perceived the system of care as significantly more family-centered when using telemedicine (p = 0.003).

Conclusion: The results of this study underscore the importance of facilitating access to pediatric specialty care by use of telemedicine. We endorse efforts to increase healthcare access and decrease cost for CSHCN by expanding telemedicine and shaping health policy accordingly.

Study Design: Prospective, quasiexperimental study

Setting: Department of Health Children's Medical Services (CMS), Title V Program

Population of Focus: Parents or legal guardians of Children with Special Healthcare Needs (CSHCN) enrolled in the Florida Department of Health Children's Medical Services (CMS), Title V Program in the Southeast Region of Florida. The sample included families with household incomes below 200% of the Federal Poverty Level (FPL) who had children requiring pediatric specialty care.

Sample Size: 222 parents or legal guardians of CSHCN receiving pediatric specialty care. The traditional group (n = 110) included families receiving face-to-face pediatric specialty care and the telemedicine group (n = 112) included families who had telemedicine visits along with traditional face-to-face pediatric specialty care.

Age Range: Adult parents or legal guardians of chlildren receiving care ages 0 to 17 years

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital)

Intervention Description: Postpartum home telehealth with remote blood pressure monitoring.

Intervention Results: Significantly more women in the intervention group than the control group had at least one blood pressure measured within ten days postpartum (202 [94.4%] vs. 129 [60.3%], aRR 1.59, 95% CI: 1.36–1.77). Postpartum home telehealth with remote blood pressure monitoring was associated with reduced readmissions compared to standard care. The intervention group had fewer hypertension-related readmissions compared to the control group (1 [0.5%] vs. 8 [3.7%], aRR 0.12; 95% CI: 0.01–0.96).

Conclusion: Telehealth with remote blood pressure monitoring and standardized management of postpartum hypertension was associated with reduced readmissions compared to standard care. The study suggests that telehealth with remote blood pressure monitoring offers a promising strategy for achieving higher acquisition of blood pressure measurements, early identification and treatment of uncontrolled hypertension, and ultimately reducing hospital readmissions.

Study Design: Non-randomized control trial

Setting: The UnityPoint Health-Meriter healthcare facility and the Department of Obstetrics and Gynecology at the University of Wisconsin, Madison

Population of Focus: Postpartum women with hypertensive disorders of pregnancy

Sample Size: 428 women (214 control group; 214 intervention group)

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We sought to evaluate posthospital breastfeeding outcomes among women who deliver at a baby friendly hospital (BFH) by (1) estimating exclusive breastfeeding rates at the postpartum visit (PPV), (2) quantifying the exclusive breastfeeding discontinuation rate, and (3) identifying which factors are associated with breastfeeding discontinuation.

Intervention Results: At hospital discharge, 71.1% of the participants were EBF, 21.7% were CF, and 7.2% were EFF. At the PPV, the frequency of the primary outcome of EBF was 31.6% (95% confidence interval: 25.2–38.8); 34.6% (28.0–41.9) were CF, and 33.8% (27.3–41.1) were EFF. Therefore, the EBF absolute and relative discontinuation rates were 39.5% and 55.6%, respectively. No demographic factors, delivery characteristics, or maternal medical morbidities were associated with EBF in the multivariable logistic regression. However, women in the EBF group were more likely to report a workplace environment conducive to breastfeeding and partner and friend support.

Conclusion: Significant breastfeeding discontinuation rates occur even among women who deliver at a BFH. Our findings suggest that multifactorial interventions, including a focus on the prevention of formula introduction, are needed in the early postpartum period to achieve higher EBF rates at the PPV.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement Provider Training/Education Crib Card HOSPITAL HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This project aimed to improve infant sleep practices in a 10-bed level I nursery using visual cues (crib cards) and nursing education.

Intervention Results: safe sleep practices improved from 32% (30/95) preintervention to 75% (86/115) postintervention (P < 0.01).

Conclusion: This study demonstrates that implementing a quality improvement initiative to improve infant sleep practices in a low-volume nursery is feasible and impactful.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Provider Training/Education HOSPITAL Crib Card Visual Display (Hospital) CAREGIVER Education/Training (caregiver)

Intervention Description: To increase the percentage of eligible infants engaging in safe sleep practices (SSP) in two level III neonatal intensive care units (NICUs) in the Boston, Massachusetts area.

Intervention Results: Of 755 cases, 395 (52.3%) were assessed to be eligible for SSP. From the pre- to post-intervention period, there was a significant improvement in overall compliance with SSP (25.9 to 79.7%; P-value<0.001). Adherence to each component of SSP also improved significantly following the intervention.

Conclusion: Safe infant sleep practices can be integrated into the routine care of preterm infants in the NICU. Modeling SSP to families far in advance of hospital discharge may improve adherence to SSP at home and reduce the risk of sleep-related morbidity and mortality in this vulnerable population of infants.

Study Design: QE: pretest-posttest

Setting: Two level III NICUs at South Shore Hospital and St Elizabeth’s Medical Center in MA

Population of Focus: Infants eligible for safe sleep practices as determined by an algorithm and clinical status of the infant

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=112) Follow-up (n=118)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Guideline Change and Implementation Organizational Changes Quality Improvement POPULATION-BASED SYSTEMS NATIONAL Policy/Guideline (National)

Intervention Description: To determine the success of a program designed to reduce the cesarean section rate in a rural community hospital, to identify reasons for any reduction in the rate and to identify any accompanying increases in the maternal and neonatal morbidity and mortality rates.

Intervention Results: The overall cesarean section rate decreased from 23% in 1985 to 13% in 1989 (p = 0.001). Among the nulliparous women the rate decreased from 23% to 12%, but the difference was insignificant (p = 0.069); this decrease was due to a drop in the number of dystocia-related cesarean sections. The rate among vaginal birth after cesarean section (VBAC) -eligible multiparous women decreased from 93% to 36% (p less than 0.001) because of an increased acceptance of VBAC by the patients and the physicians. The rate among multiparous women ineligible for VBAC was virtually unchanged.

Conclusion: The program was accompanied by a significant decrease in the cesarean section rate. Rural hospitals with facilities and personnel for emergency cesarean sections should consider the introduction of a similar program.

Study Design: Time trend analysis

Setting: 1 small, rural hospital

Population of Focus: Nulliparous women who gave birth between January 1985 and December 19892

Data Source: Not specified

Sample Size: n=456

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER Educational material HEALTH_CARE_PROVIDER_PRACTICE Quality Improvement/Practice-Wide Intervention Hospital Policies Provider Training/Education

Intervention Description: The purpose of this system-wide quality improvement project was to create a breastfeeding-friendly pediatric practice. This breastfeeding support initiative was implemented at a multisite rural Illinois pediatric practice. The policy included: (a) breastfeeding promotion recommendations; (b) provider, nurse, and staff roles; (c) patient education and resources; and (d) breastfeeding-friendly atmosphere guidelines. An evidence-based breastfeeding policy was developed, staff education sessions were conducted, private lactation rooms were created, and breastfeeding photographs/posters were displayed throughout the offices. Lactation support services were publicized throughout the offices. Lactation support services were publicized via signs and social media postings.

Intervention Results: Overall breastfeeding rates were higher at each time point after implementation. Statistically significant increases occurred at the newborn and 1-month visits, with a modest improvement at 2 and 4 months.

Conclusion: This project demonstrated an improvement in breastfeeding duration rates. It is anticipated that this practice-wide standard of care change will promote breastfeeding throughout the first 12 months of life.

Study Design: Pre-post intervention

Setting: Multisite rural IL pediatric practice

Population of Focus: Mothers with breastfeeding infants from newborn to 4 months seen for well-child visits at a pediatric practice

Sample Size: 71 infants preintervention and 18 infants postintervention

Age Range: Newborn to infants 4 months old

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Organizational Changes Hospital Laborist PROFESSIONAL_CAREGIVER Consensus Guideline Implementation

Intervention Description: Cesarean delivery is a key performance metric with maternal health implications and significant financial impact. Our hypothesis is that the initiation of a full-time dedicated laborist staff decreases cesarean delivery.

Intervention Results: The cesarean delivery rate for no laborist care was 39.2%, for community physician laborist care was 38.7%, and for full-time laborists was 33.2%. With adjustment via logistic regression, full-time laborist presence was associated with a significant reduction in cesarean delivery when contrasted with no laborist (odds ratio, 0.73; 95% confidence interval, 0.64-0.83; P < .0001) or community laborist care (odds ratio, 0.77; 95% confidence interval, 0.67-0.87; P < .001). The community laborist model was not associated with an effect upon cesarean delivery.

Conclusion: A dedicated full-time laborist staff model is associated with lower rates of cesarean delivery. These findings may be used as part of a strategy to reduce cesarean delivery, lower maternal morbidity and mortality, and decrease health care costs.

Study Design: Retrospective cohort

Setting: 1 tertiary hospital in Nevada

Population of Focus: Nulliparous women who gave birth between October 2006 and October 2011

Data Source: Not specified

Sample Size: Total (n=6,206) Intervention (n=2,654) Modified intervention (n=1,722) Control (n=1,830)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Continuing Education of Hospital Providers HOSPITAL

Intervention Description: To implement developmental care accurately, neonatal intensive care unit nurses should have a proper understanding and sufficient knowledge in this field.

Intervention Results: The Developmental Care perception scores before the intervention in the control and intervention groups were 83.40 ± 11.36 and 84.53 ± 9.48, respectively, showing no statistically significant difference (P = 0.67). Also, Developmental Care perception scores after the intervention in the control and intervention groups were 83.16 ± 13.73, and 94.70 ± 6.89, respectively, showing a statistically significant difference (P < 0.001). The results of paired t-test showed that the mean knowledge score in the control group before and after the intervention was not statistically significant (P < 0.903), while in the intervention group there was a statistically significant difference between the mean knowledge score before and after the intervention (P < 0.001). The Developmental Care Knowledge scores before the intervention in the control and intervention groups were 52.66 ± 18.08 and 77.16 ± 17.20, respectively, showing a statistically significant difference (P = 0.001). Also, Developmental Care Knowledge scores after the intervention in the control and intervention groups were 53.66 ± 26.55and 90.33 ± 13.82, respectively, showing a statistically significant difference (P < 0.001). The results of paired t-test showed that the mean knowledge score in the control group before and after the intervention was not statistically significant, while in the intervention group there was a statistically significant difference between the mean knowledge score before and after the intervention. The results of this study showed that virtual education for the developmental care of premature infants plays an effective role in the perception and knowledge of nurses working in the neonatal intensive care unit.

Conclusion: The development of e-learning packages for developmental care and their availability for nurses can be a step to improve the quality of nursing care for infants admitted to the NICU.

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital)

Intervention Description: To determine whether the introduction of telemedicine at a rural pediatric clinic was associated with reduced disparities in visit attendance. A retrospective cohort study was conducted of all clinic visits from 1 January 2019 to 31 December 2021. Visit types were divided into telemedicine visits, in-person urgent, and in-person non-urgent visits. Visits were stratified into periods based on the statewide pandemic response.

Intervention Results: A total of 8,412 patients with 54,746 scheduled visits were analyzed. Visits were less likely to be completed for older patients, Black patients, and patients with Medicaid insurance than their counterparts. Despite a pandemic-era increase in telemedicine utilization, disparities in visit completion that were present in the pre-pandemic era persisted after stay-at-home orders were lifted.

Conclusion: The adoption of telemedicine did not reduce pre-existing disparities in visit attendance. Further work is needed to identify the reasons for the disparities and improve visit attendance of historically disadvantaged patient populations.

Study Design: Retrospective cohort study

Setting: A rural academic pediatric primary care clinic serving children across the rural area of North Carolina

Population of Focus: Established patients aged 18 years or younger who received care at a rural academic pediatric primary care clinic in North Carolina

Sample Size: 8,412 children and youth

Age Range: Children and youth 0-18 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital)

Intervention Description: A remote, text message-based blood pressure monitoring program known as Heart Safe Motherhood.

Intervention Results: 192 (96.5%) participants submitted at least 1 blood pressure measurement via text message to the program. Elevated blood pressures were recorded for 70 (35%) participants, 32 (16%) of whom were started on oral antihypertensives after discussing their blood pressure measurements with an on-call provider. A total of 10 participants (5%) required hypertension-related readmission after delivery.

Conclusion: Postpartum participants are willing and capable of using the Heart Safe Motherhood program for remote blood pressure monitoring and reported high satisfaction with the program across multiple sites. Our study demonstrated that this remote blood pressure monitoring program can be implemented successfully and demonstrated replicable efficacy at diverse sites.

Study Design: Prospective implementation design

Setting: Three different academic settings in the U.S.

Population of Focus: Postpartum people with hypertensive disorders of pregnancy (HDP) who were enrolled in the Heart Safe Motherhood program.

Sample Size: 199 participants across three academic medical centers

Age Range: Childbearing age

Intervention Components (click on component to see a list of all articles that use that intervention): Screening Tool Implementation Policy/Guideline (Hospital) Assessment (patient/consumer) Screening in Nontraditional Settings

Intervention Description: The intervention described by the article to increase postpartum depression (PPD) screening is the implementation of a PPD screening program in a Pediatric Emergency Department (PED) setting . The study found that PED-based screening had a positive impact through PPD screening, education, and resources, and helped to identify PPD in mothers who had not been screened previously.

Intervention Results: The results found that 27% of mothers (n=209) screened positive for PPD, with 7% reporting suicidal thoughts . Additionally, 47% of mothers had never previously been screened for PPD, including 58% of PPD screen-positive mothers . The study also assessed maternal attitudes toward screening and found that PED-based screening had a positive impact through PPD screening, education, and resources, and helped to identify PPD in mothers who had not been screened previously

Conclusion: Approximately 1 in 4 mothers screened positive for PPD in a PED, with almost 1 in 10 reporting suicidal thoughts. The majority of PPD screen–positive mothers had not been screened previously. Our study helps to inform future efforts for interventions to support mothers of young infants who use the PED for care.

Study Design: To answer your question, the study design/type is a pilot cohort study of a convenience sample of mothers of infant patients

Setting: The study was conducted in a Pediatric Emergency Department (PED)

Population of Focus: The target audience for the study is healthcare providers, particularly those who work in pediatric emergency departments and are involved in the care of mothers and infants

Sample Size: The sample size for the study was 209 mothers of infant patients who presented to a PED from June 2015 to January 2016

Age Range: The study included mothers of infant patients 6 months or younger presenting to a Pediatric Emergency Department

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Hospital Policies Baby Friendly Hospital Initiative

Intervention Description: This study examines changes in Baby-Friendly hospital practices, breastfeeding outcomes, and their relationships with Baby-Friendly hospital status among WIC-enrolled children in Los Angeles County.

Intervention Results: In 2017, mothers surveyed were more likely to engage in Baby-Friendly hospital practices compared with 2008. Any and exclusive breastfeeding outcomes at 1 and 3 months significantly increased since 2014, and breastfed infants were more likely to have mothers who participated in Baby-Friendly hospital practices. The more Baby-Friendly hospital practices mothers met, the better the breastfeeding outcomes. However, there is room for improvement in the uptake of Baby-Friendly hospital practices in Baby-Friendly hospitals.

Conclusion: Effort is needed to ensure Baby-Friendly hospitals have support to continuously comply with all steps to maintain Baby-Friendly designation, and non-Baby-Friendly hospitals have support to incorporate these practices into hospital protocols.

Study Design: Triennial cross-sectional survey

Setting: Los Angeles County hospitals

Population of Focus: Infants born in Los Angeles County hospitals, no older than 2 years of age at the time of the survey whose mothers were interviewed

Sample Size: 6,449 infants and their mothers

Age Range: Infants under 2 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Chart Audit and Feedback

Intervention Description: The Robson classification was introduced in Lithuanian hospitals, prospectively classifying all the deliveries in 2012 and repeating the analysis in 2014. The overall C-section rate, sizes of the Robson groups of women, and C-section rate in each group was calculated and the results were discussed. In 2013 all the data from hospitals were analyzed and a summit conference was organized specifically for the project. The attendees of the meeting included administrators of the participating hospitals, members of the Lithuanian Society of Ob-Gyns, the Lithuanian Health Ministry, and the Lithuanian Parliament. During the conference the C-section rates among different hospitals and different groups of women were compared and discussed. The general consensus to try and reduce the cesarean section rate was accepted.

Intervention Results: Nineteen Lithuanian hospitals participated in the study. They represented 84.1% of the deliveries (23,742 out of 28,230) in 2012 and 88.5% of the deliveries (24,653 out of 27,872) in 2014. The CS rate decreased from 26.9% (6379/23,742) in 2012 to 22.7% (5605/24,653) in 2014 (p < 0.001). The greatest contributions to the overall CS rate were made by groups 1, 2 and 5. The greatest decrease in the CS rate was detected in group 2. The absolute contribution to the overall CS rate decreased from 4.9% to 3.8%.

Conclusion: The Robson classification can work as an audit tool to identify the groups that have the greatest impact on the CS rate. It also helps to develop a strategy focussing on the reduction of the CS rate.

Setting: 19 Lithuanian hospitals

Population of Focus: All women who gave birth

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Guideline Change and Implementation

Intervention Description: This was a retrospective cohort study that compared maternal and neonatal outcomes before and after the implementation of the 2014 Obstetric Care Consensus on the safe prevention of primary cesarean delivery issued by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM). The study included 11,464 women.

Intervention Results: The study included 11,464 women. The CD rate in the 2nd stage of labor has increased significantly from 4% to 5.9% in the post-guidelines period (OR 1.48, 95% CI 1.16-1.89, p = .001). After a sub-analysis of specific subgroups, and adjustment for confounders, the increase was solely observed in nulliparous women (aOR 1.418, 95% CI 1.067-1.885, p = .016). Furthermore, increased odds for vaginal operative delivery were observed in the multiparous women in the post-guidelines period (2.7% vs. 4.1%, p = .046).

Conclusion: The implementation of the new ACOG and SMFM guidelines was not associated with a change in the CD rate performed at the 2nd stage of labor in the whole study population. However, there was a rise in the CD rate performed at the 2nd stage in nulliparous women. Furthermore, there was an increase in operative deliveries in the whole study population, especially in multiparous women, without an apparent increase in other immediate adverse neonatal or maternal outcomes.

Setting: A single university-affiliated medical center

Population of Focus: Nulliparous and multiparous women reaching the second stage of labor, at term

Intervention Components (click on component to see a list of all articles that use that intervention): Guideline Change and Implementation HOSPITAL

Intervention Description: In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) published an Obstetric Care Consensus for safe prevention of primary cesarean delivery. We aimed to assess whether these guidelines decreased the primary CD rate during the second stage of labor, in our department.

Intervention Results: The study included 11,464 women. The CD rate in the 2nd stage of labor has increased significantly from 4% to 5.9% in the post-guidelines period (OR 1.48, 95% CI 1.16–1.89, p = .001). After a sub-analysis of specific subgroups, and adjustment for confounders, the increase was solely observed in nulliparous women (aOR 1.418, 95% CI 1.067–1.885, p = .016). Furthermore, increased odds for vaginal operative delivery were observed in the multiparous women in the post-guidelines period (2.7% vs. 4.1%, p = .046).

Conclusion: The implementation of the new ACOG and SMFM guidelines was not associated with a change in the CD rate performed at the 2nd stage of labor in the whole study population. However, there was a rise in the CD rate performed at the 2nd stage in nulliparous women. Furthermore, there was an increase in operative deliveries in the whole study population, especially in multiparous women, without an apparent increase in other immediate adverse neonatal or maternal outcomes.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Hospital Policies Baby Friendly Hospital Initiative Provider Training/Education Expert Support (Provider)

Intervention Description: In 2010, the Hawaii State Department of Health received support from the CDC to launch the Baby-Friendly Hawaii Project to increase the number of Hawaii hospitals that provide maternity care consistent with the Ten Steps to Successful Breastfeeding and increase the rate of women who remain exclusively breastfeeding throughout their hospital stay. The BFHP employed six strategies based on a model developed by the New York City Department of Health and Mental Hygiene: engage hospitals, enlist support, recruit champions, assess hospitals, conduct site visits and trainings, and monitor outcomes. Populations targeted for BFHP were registered nurses, lactation consultants, and other hospital staff, as well as expectant mothers at all 11 Hawaii maternity hospitals during the project period.

Intervention Results: Since 2010, 52 hospital site visits, 58 trainings, and ongoing technical assistance were administered, and more than 750 staff and health professionals from BFHP hospitals were trained. Hawaii’s overall quality composite Maternity Practices in Infant Nutrition and Care score increased from 65 (out of 100) in 2009 to 76 in 2011 and 80 in 2013, and Newborn Screening Data showed an increase in statewide exclusive breastfeeding from 59.7% in 2009 to 77.0% in 2014.

Conclusion: Implementation and findings from the BFHP can inform future planning at the state and federal levels on maternity care practices that can improve breastfeeding.

Study Design: Program evaluation

Setting: Maternity hospitals in Hawaii

Population of Focus: Registered nurses, lactation consultants, and other hospital staff and expectant mothers at all 11 Hawaii maternity hospitals

Sample Size: 750 staff and health professionals

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Transition Assistance PATIENT/CONSUMER HOSPITAL Continuing Education of Hospital Providers POPULATION-BASED SYSTEMS INTER-HOSPITAL SYSTEMS Neonatal Back-Transport Systems Consultation Systems (Inter-Hospital Systems) Consultation Systems (Hospital) Telemedicine Systems (Inter-Hospital Systems) Telemedicine Systems (Hospital)

Intervention Description: Assessed a telemedicine (TM) network's effects on decreasing deliveries of very low birth weight (VLBW, <1500 g) neonates in hospitals without Neonatal Intensive Care Units (NICUs) and statewide infant mortality.

Intervention Results: Deliveries of VLBW neonates in targeted hospitals decreased from 13.1 to 7.0% (P=0.0099); deliveries of VLBW neonates in remaining hospitals were unchanged. Mortality decreased in targeted hospitals (13.0% before TM and 6.7% after TM). Statewide infant mortality decreased from 8.5 to 7.0 per 1000 deliveries (P=0.043).

Conclusion: TM decreased deliveries of VLBW neonates in hospitals without NICUs and was associated with decreased statewide infant mortality.

Study Design: QE: pretest-posttest

Setting: All Arkansas hospitals (Nine selected as telemedicine hospitals due to high patient volume)

Population of Focus: Infants born weighing <1500 gm

Data Source: Medicaid data for VLBW infants as indicated by ICD-9 diagnosis codes from hospital and physician claims for pregnancy. Data infant with birth and infant death certificates.

Sample Size: Pretest (n= 383) Posttest (n= 384)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Hospital Policies Baby Friendly Hospital Initiative

Intervention Description: To evaluate the impact of transition to Baby-Friendly certification on underserved populations at the University of New Mexico hospital. The journey towards Baby Friendly designation proceeded in four phases. The study team examined inpatient breastfeeding related clinical practices and short-term breastfeeding duration rates among patients of the midwifery service during the transition to Baby Friendly status. The purpose was twofold: (a) to evaluate the impact of BFHI implementation on the short-term duration of both any breastfeeding and exclusive breastfeeding, and (b) to determine the impact of exposure to the inpatient Ten Steps on short-term breastfeeding duration, both individually and cumulatively.

Intervention Results: Implementation of the BFHI and cumulative exposure to the Ten Steps increased short-term duration of any breastfeeding and exclusive breastfeeding at 2-6 weeks postpartum. Exposure to all six of the inpatient Ten Steps increased the odds of any breastfeeding by 34 times and exclusive breastfeeding by 24 times. Exposure to Step 9 (“Give no pacifiers or artificial nipples”) uniquely increased the likelihood of any breastfeeding at 2-6 weeks postpartum by 5.7 times, whereas Step 6 (“Give infants no food or drink other than breastmilk”) increased the rate of exclusive breastfeeding by 4.4 times at 2-6 weeks postpartum.

Conclusion: These findings demonstrate that the Baby Friendly Hospital Initiative can have a positive impact on breastfeeding among underserved populations.

Study Design: Quasi-experimental, retrospective cohort design

Setting: University of New Mexico Hospital

Population of Focus: Mother-baby pairs pre-BFHI and post-BFHI delivering at the hospital

Sample Size: 1004 mother-infant pairs (449 in the pre-BFHI cohort & 555 in the post-BFHI cohort)

Age Range: Mothers age 20-33 and their infants at 2-6 weeks postpartum

Intervention Components (click on component to see a list of all articles that use that intervention): Provider Audit/Practice Audit Policy/Guideline (Hospital)

Intervention Description: The interventions included correcting physician, nurse, and parent assumptions regarding HepB vaccination, standardizing the process of providing the vaccine, and establishing vaccine receipt at birth as the normative standard.

Intervention Results: The study demonstrated a significant increase in newborn HepB vaccination rates at the time of hospital discharge and within the first 12 hours of life.

Conclusion: Multidisciplinary collaboration, scripting, and provider and staff education regarding the risks of hepatitis B virus, benefits of HepB vaccine, and strategies to discuss HepB vaccination with parents significantly increased vaccination rates. Further efforts to improve vaccination rates to within 12 hours are preferable.

Study Design: - Study design: The study used a quality improvement intervention design.

Setting: The study was conducted in the mother-baby unit (MBU) of a tertiary urban medical center.

Population of Focus: The target audience was healthcare professionals, including physicians and nurses, as well as parents of newborns. - Sample size: The study included 1,000 newborns.

Sample Size: The study included 1,000 newborns.

Age Range: The study focused on newborns receiving the hepatitis B vaccine at birth.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Provider Training/Education Provision of Safe Sleep Item HOSPITAL Policy/Guideline (Hospital) Sleep Environment Modification CAREGIVER Education/Training (caregiver) Educational Material (caregiver) HEALTH_CARE_PROVIDER_PRACTICE Audit/Attestation

Intervention Description: The purpose of this study was to improve safe sleep practices for infants in nonneonatal pediatric units with implementation of specific interventions.

Intervention Results: Safe sleep was observed for 4.9% of 264 infants at baseline and 31.2% of 234 infants postintervention (P<.001). Extra blankets, the most common of unsafe items, were present in 77% of cribs at baseline and 44% postintervention. However, the mean number of unsafe items observed in each sleeping environment was reduced by >50% (P=.001).

Conclusion: Implementation of site-specific interventions seems to improve overall safe sleep in inpatient pediatric units, although continued improvement is needed. Specifically, extra items are persistently left in the sleeping environment.

Study Design: QE: pretest-posttest

Setting: Eight children’s hospitals

Population of Focus: Infants aged 0 to 6 months admitted to the general pediatric unit (excluding infants in the NICUs, PICUs, and maternal fetal units)

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=234) Follow-up (n=210)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Telemedicine Systems (Hospital)

Intervention Description: Telehealth implementation of postpartum care during COVID

Intervention Results: In the preimplementation period, Black patients were less likely to attend a postpartum visit than non-Black patients (63.9% in Black patients vs 88.7% in non-Black patients; adjusted odds ratio, 0.48; 95% confidence interval, 0.29-0.79). In the postimplementation period, there was no difference in postpartum visit attendance by race (79.1% in Black patients vs 88.6% in non-Black patients; adjusted odds ratio, 0.74; 95% confidence interval, 0.45-1.21). In addition, significant differences across races in postpartum depression screening during the preimplementation period became nonsignificant in the postimplementation period. Telehealth implementation for postpartum care significantly reduced racial disparities in postpartum visit attendance (interaction P=.005).

Conclusion: Telehealth implementation for postpartum care during the COVID-19 pandemic was associated with decreased racial disparities in postpartum visit attendance.

Study Design: Retrospective cohort study

Setting: Urban tertiary care center with two clinical sites providing remote telehealth care

Population of Focus: Black and non-Black birthing people pre- and post-pandemic

Sample Size: 1579

Age Range: 27-35

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy HOSPITAL

Intervention Description: This article evaluates the impact of adopting a practice of elective induction of labor (eIOL) at 39 weeks among nulliparous, term, singleton, vertex (NTSV) pregnancies in a statewide collaborative.

Intervention Results: When compared with all expectantly managed women, eIOL was associated with a higher cesarean birth rate (30.1 vs. 23.6%, p < 0.001). When compared with a propensity score-matched cohort, eIOL was not associated with a difference in cesarean birth rate (30.1 vs. 30.7%, p = 0.697). Time from admission to delivery was longer for the eIOL cohort compared with the unmatched (24.7 ± 12.3 vs. 16.3 ± 11.3 hours, p < 0.001) and matched (24.7 ± 12.3 vs. 20.1 ± 12.0 hours, p < 0.001) cohorts. Expectantly managed women were less likely to have a postpartum hemorrhage (8.3 vs. 10.1%, p = 0.02) or operative delivery (9.3 vs. 11.4%, p = 0.029), whereas women who underwent an eIOL were less likely to have a hypertensive disorder of pregnancy (5.5 vs. 9.2%, p < 0.001).

Conclusion: eIOL at 39 weeks may not be associated with a reduced NTSV cesarean delivery rate.

Intervention Components (click on component to see a list of all articles that use that intervention): PROFESSIONAL_CAREGIVER Provision of Safe Sleep Item Educational Material (caregiver) HOSPITAL Sleep Environment Modification

Intervention Description: This was a multicenter prospective study in which exposed/unexposed mothers answered questionnaires (by telephone and online) one month after giving birth. The exposed group consisted of mothers who had given birth in a maternity hospital of the ELENA perinatal network in which an embroidered sleeping bag with a safe-sleep message was used as a preventive action; the unexposed group of mothers gave birth in a maternity hospital of the RP2S network, without this specific preventive action. Devised by the perinatal network to promote and encourage back sleeping, the embroidered “I sleep on my back” (baby) sleeping bags are systematically used in postpartum recovery rooms.

Intervention Results: A total of 540 mothers participated in the study: 245 in the exposed group and 295 in the unexposed group. In the exposed group, 87.3% of infants slept exclusively on their back versus 75.9% in the unexposed group (P<0.001); 91% of the mothers reported having actually used the sleeping bag. Except for room-sharing, compliance with the other sleeping recommendations was higher in the exposed group.

Conclusion: Sleeping practices when infants were 1 month old were not optimal in our study population. A simple preventive initiative in maternity hospitals, using the embroidered "I sleep on my back" sleeping bags, is relevant and effective in improving compliance with the sleeping recommendations for infants at home.

Setting: Three maternity hospitals in the ELENA perinatal network in France

Population of Focus: Mothers of newborns

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Elective Induction Policy Guideline Change and Implementation Quality Improvement POPULATION-BASED SYSTEMS NATIONAL Policy/Guideline (National)

Intervention Description: Estimate the frequency of failure to follow the French consensus guidelines for elective induction, and assess how failure affects the rate of cesarean delivery.

Intervention Results: Women with electively induced and spontaneous labor had identical cesarean rates (4.1%). The guidelines were not followed in 23.2% of elective inductions. The risk of cesarean was higher after induction with a Bishop score <5, than after spontaneous labor (adjusted OR = 4.1, 95% CI [1.3–12.9]), while elective induction with a favourable cervix did not increase the cesarean risk. In nulliparas, failure to follow the guidelines tripled the risk of cesarean (adjusted OR = 3.2 [1.0–10.2]). On the other hand, elective induction of labor for women with a favourable cervix did not increase the risk of cesarean over the risk with spontaneous labor.

Conclusion: Elective induction does not appear to increase the cesarean rate when the guidelines are met. Electively inducing labor with a low Bishop score increased the risk of cesarean, especially in nulliparas.

Study Design: Retrospective cohort

Setting: 138 maternity units

Population of Focus: Nulliparous women who gave birth between June 2001 and May 20022

Data Source: Not specified

Sample Size: Total (n=2,052) Intervention (n=69) Control (n=1,983)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative HEALTH_CARE_PROVIDER_PRACTICE Hospital Policies Other Education

Intervention Description: Identify practices associated with breastfeeding maintenance, examine breastfeeding-related hospital practices by hospital designation level (Baby Friendly vs. Gift vs. none), and assess racial disparities in hospital practices and breastfeeding maintenance.

Intervention Results: Breastfeeding in the hospital, infant only receiving breast milk, and breastfeeding within one hour after birth were positively associated and receiving a gift pack with formula was negatively associated with breastfeeding maintenance in both NHW and NHB women. Associations were stronger in NHW compared to NHB mothers.

Conclusion: We identified several practices significantly associated with breastfeeding maintenance. However, racial disparities indicate a need for population-specific supportive practices.

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy HOSPITAL

Intervention Description: The purpose of our study is to compare the maternal and neonatal outcomes of induction of labor (IOL) versus expectant management at 39 weeks of gestation.

Intervention Results: IOL and expectant group had similar cesarean delivery rate (18.2% vs. 15.9%, p = 0.570). The delivery time from admission was longer in IOL group (834 ± 527 vs. 717 ± 469 min, p = 0.040). The IOL group was less likely to have Apgar score at 5 min < 7 than in expectant group (0.8% vs. 5.4%, p = 0.023). Multivariate analysis showed that IOL at 39 weeks was not an independent risk factor for cesarean delivery (relative risk 0.64, 95% confidence interval: 0.28–1.45, p = 0.280). Maternal and neonatal adverse outcomes, including cesarean delivery rate, were similar to women in IOL at 39 weeks of gestation compared to expectant management in nulliparous women.

Conclusion: IOL at 39 weeks of gestation could be recommended even when the indication of IOL is not definite.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Quality Improvement Crib Card HEALTH_CARE_PROVIDER_PRACTICE Provider Training/Education Nurse/Nurse Practioner Audit/Attestation

Intervention Description: A multi-pronged, safe sleep quality improvement initiative was introduced in three inpatient pediatric hospitals. The intervention included: 1) nursing education, 2) identification of nurse "safe sleep" champions, 3) crib cards, 4) crib audits, and 5) weekly reporting of data showing nursing unit ABC compliance via tracking boards. A pre/post analysis of infants <12 months old was performed using a convenience method of sampling. The goal was ABC compliance of ≥25% for the post-intervention period.

Intervention Results: There were 204 cribs included pre-intervention and 274 cribs post-intervention. Overall, there was not a significant change in sleep position/location (78.4 to 76.6%, p = 0.64). There was a significant increase in the percent of infants sleeping in a safe sleep environment following the intervention (5.9 to 39.8%, p < 0.01). Overall ABC compliance, including both sleep position/location and environment, improved from 4.4% pre-intervention to 32.5% post-intervention (p < 0.01). There was no significant variability between the hospitals (p = 0.71, p = 1.00).

Conclusion: The AAP's safe sleep recommendations are currently not upheld in children's hospitals, but safer sleep was achieved across three children's campuses in this study. Significant improvements were made in sleep environment and overall safe sleep compliance with this multi-pronged initiative.

Setting: Three children's hospital campuses

Population of Focus: Hospital staff

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER Educational Material Professional Support HEALTH_CARE_PROVIDER_PRACTICE Baby Friendly Hospital Initiative COMMUNITY Individual Supports

Intervention Description: The Westside Healthy Start Program (WHS), located in Chicago, Illinois, developed an ongoing multilevel approach to breastfeeding promotion. Key elements of the WHS breastfeeding model include individual education and counseling from pregnancy to 6 months postpartum and partnership with a local safety-net hospital to implement the Baby Friendly Hospital Initiative and provide lactation support to delivering patients. All WHS participants receive general breastfeeding education from case managers throughout pregnancy (such as information about breastfeeding benefits) and one face-to-face visit from a BFC in the third trimester for more personalized and comprehensive support. WHS collaborates with the largest delivering hospital in the service area, a safety-net provider, to improve the breastfeeding environment and systems of care.

Intervention Results: In the year our model was implemented, 44.6% (49/110) of prenatal WHS participants reported that they planned to breastfeed, and 67.0% (183/273) of delivered partici- pants initiated. Among participants reaching 6 months postpartum, 10.5% (9/86) were breastfeeding. WHS also had 2667 encounters with women delivering at our partner hospital during breastfeeding rounds, with 65.1% of contacts initiating. Community data was not available to assess the efficacy of our model at the local level. However, WHS participants fared better than all delivering patients at our partner hospital, where 65.0% initiated in 2015.

Conclusion: Healthy Start programs are a promising vehicle to improve breastfeeding initiation at the individual and community level. Additional evaluation is necessary to understand barriers to duration and services needed for this population.

Study Design: Evaluation data

Setting: Westside Healthy Start program located in Chicago, IL

Population of Focus: Low-income, African-American women who are pregnant

Sample Size: 652 women

Age Range: Women <17 to 45 years old

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Elective Induction Policy

Intervention Description: A retrospective cohort in a single institution was used to investigate the difference in the cesarean delivery rate between induction of labor and spontaneous labor among nulliparous, term, singleton, and vertex-presenting (NTVS) women. Of the 5,997 deliveries analyzed, 2,283 were spontaneous labor deliveries and 2,017 were labor inductions (446 were elective and 1,571 were medically indicated). The 7-year study took place between January 2012 and December 2018.

Intervention Results: A statistically significant difference was found in cesarean delivery rate between those women whose labor was induced and those whose labor began spontaneously, at each term gestational age of labor initiation (P < 0.001). The proportion of indications for induction was described (i.e. elective vs. medically-indicated), and no difference was found for neonatal morbidity between the groups analyzed, using the 5-minute Apgar score as the perinatal outcome measure.

Conclusion: A comparison was made between spontaneous and induced labor regarding the resultant cesarean delivery rate, and a significant difference was found favoring spontaneous labor. This should be considered when electing to deliver using an induction methodology for nulliparous women, especially when there are no medical indications for it.

Setting: Advocate Aurora Health Illinois Masonic Medical Center

Population of Focus: Nulliparous, term, singleton, and vertex-presenting women

Intervention Components (click on component to see a list of all articles that use that intervention): Elective Induction Policy HOSPITAL

Intervention Description: The purpose of this study was to compare the cesarean birth rate for women with pregnancies at 39.0 weeks’ gestation or later admitted for spontaneous labor or medically indicated induction of labor (IOL) with that of women receiving elective IOL at term.

Intervention Results: A total of 1528 women were included in this study. Among these, 158 received elective IOL, and 1370 did not. The cesarean birth rates (31.0% vs 23.9%, elective induction of labor vs expectant management, respectively, P = .048), neonatal intensive care admissions (9.5% vs 7.6%, P = .41), and Apgar scores were similar among women in both management groups, respectively (P = .08). Accounting for other potential risk factors, the odds of having cesarean birth were not statistically different between management groups (adjusted odds ratio, 0.73; 95% CI, 0.5-1.1; P = .09). There were 2 fetal deaths among women whose labor was not electively induced. In the total cohort, women who were older, who had higher body mass index (BMI), and who identified as non-Hispanic Black had an increased odds of experiencing a cesarean birth. The associations between women in management groups and cesarean birth were not modified by age, BMI, race, or ethnicity (P = .33, .67, and .87, respectively).

Conclusion: Elective IOL was not associated with lower cesarean rates in this study. Further research is needed before implementing clinical practice changes that encourage more use of IOL

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination Telemedicine Systems (Inter-Hospital Systems) Quality Improvement Targeting Interventions to Focused Groups

Intervention Description: N/A

Intervention Results: Those with No USC and Facility USCs increased 10 and 18 percent, respectively, while those with Person USCs decreased by 43 percent. Compared to those in the lowest income bracket, those in the highest income bracket were less likely to have a Facility USC. Among those with low incomes, individuals with No USC, Person, in Facility, and Facility USCs were more likely to have ED visits than those with Person USCs.

Conclusion: A growing number are reporting facilities as their USCs or none at all. The impact of these trends is uncertain, although we found that some USC types are associated with ED visits and hospital admissions. Tracking USCs will be crucial to measuring progress toward enhanced care efficiency.

Study Design: We stratified each USC category, by age, region, gender, poverty, insurance, race/ethnicity, and education and used regression to determine the characteristics associated with USC types, ED visits, and hospital admissions.

Setting: 1996-2014 Medical Expenditure Panel Surveys

Population of Focus: Low income individuals, those with no USC

Sample Size: 559762

Age Range: All ages, five categories

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Hospital Policies Baby Friendly Hospital Initiative

Intervention Description: The environment in which a women gives birth may be an important determinant of breastfeeding initiation. The impact of the Baby-Friendly Hospital Initiative (BFHI) is not well characterized in the southeastern region of the US where significant breastfeeding disparities persist. The study aimed to evaluate the impact of the BFHI on breastfeeding initiation in North Carolina, with special attention to rural areas.

Intervention Results: Birth at a Baby-Friendly hospital was associated with increased odds of breastfeeding initiation, adjusted odds ratio = 1.7, 95% confidence interval [1.65, 1.89]. Model residuals showed significant clustering by county, with some rural areas’ rates systematically overestimated. Whereas presence of a Baby-Friendly hospital in a mother’s community of residence was not associated with increased initiation, birth at a Baby-Friendly hospital was associated with smaller disparities in initiation between rural and urban births.

Conclusion: Birth at a Baby-Friendly hospital is associated with improved breastfeeding initiation and reduced disparities in initiation between rural and urban counties in North Carolina.

Study Design: Secondary data analysis

Setting: Hospitals in North Carolina

Population of Focus: Mothers with North Carolina residence delivering in a hospital

Sample Size: 137,738 women

Age Range: Mothers older than 18 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): Maternal/In-Utero Transport Systems INTER-HOSPITAL SYSTEMS POPULATION-BASED SYSTEMS Consultation Systems (Inter-Hospital Systems) Perinatal Committees/Councils NICU Bed Registry/Electronic Bulletin Board

Intervention Description: The goal was to evaluate the impact of statewide coordinated changes in perinatal support and retrieval services on the outcomes of extremely premature births occurring outside perinatal centers in the state of New South Wales, Australia.

Intervention Results: There were 25% fewer nontertiary hospital live births (19.7% vs 14.9%) and more prenatal steroid use. Despite an 11.4% average annual increase in NICU admissions between the 2 epochs, fewer infants were outborn (12.0% vs 9.3%) and outborn mortality rates decreased significantly (39.4% vs 25.1%), particularly for those between 27 and 28 weeks of gestation. The overall improvement was equivalent to 1 extra survivor per 16 New South Wales births. There were also significantly fewer serious outcome morbidities in outborn infants during epoch 2, over the improvements in inborn infants.

Conclusion: Statewide coordinated strategies in reducing nontertiary hospital births and optimizing transport of outborn infants to perinatal centers have improved considerably the outcomes of extremely premature infants. These findings have vital implications for health outcomes and resource planning.

Study Design: QE: pretest-posttest

Setting: New South Wales, Australia hospitals Seven perinatal centers

Population of Focus: Infants born between 23+0 and 28+6 weeks GA who did not die before or during retrieval.

Data Source: Baseline population data for all births between 23 and 28 weeks GA obtained from the New South Wales Midwives Data Collection.

Sample Size: Pretest (n= 1,778) Posttest (n= 3,099)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Provider Training/Education HOSPITAL Quality Improvement Policy/Guideline (Hospital) Sleep Environment Modification CAREGIVER Education/Training (caregiver)

Intervention Description: This project assessed the change in infant safe sleep practices within 6 children's hospitals after the implementation of a statewide quality improvement program.

Intervention Results: At baseline, only 279 (32.6%) of 856 of the sleeping infants were observed to follow AAP recommendations, compared with 110 (58.2%) of 189 (P < .001) at the project's conclusion. The presence of empty cribs was the greatest improvement (38.1% to 67.2%) (P < .001). Removing loose blankets (77.8% to 50.0%) (P < .001) was the most common change made. Audits also showed an increase in education of families about safe sleep practices from 48.2% to 75.4% (P < .001).

Conclusion: Multifactorial interventions by hospitalist teams in a multi-institutional program within 1 state's children's hospitals improved observed infant safe sleep behaviors and family report of safe sleep education. These behavior changes may lead to more appropriate safe sleep practices at home.

Study Design: QE: pretest-posttest

Setting: Six children’s hospitals without internal maternity centers or wellbaby nurseries (academic tertiary or quaternary care institutions) in OH

Population of Focus: Infants ≤1 year of age admitted to the general medical/surgical units who were not awake during the audit (excluding those in the ICUs, with tracheostomies, ventilator or noninvasive ventilator dependence, recent spinal surgeries, or upper airway anatomic abnormalities)

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=856) Follow-up (n=189)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Training/Education PROFESSIONAL_CAREGIVER Education/Training (caregiver) HOSPITAL Quality Improvement Promotional Event Audit/Attestation (Provider)

Intervention Description: Physicians from various units within the hospital system created and led multidisciplinary safe sleep teams. After attending a kickoff event to learn more about infant mortality and sleep related deaths, safe sleep champions from four teams were encouraged to work with their teams to tailor interventions, both specific to the needs of their areas and to address the global aim of county-wide sleep-related death reduction. The teams collaborated and produced a hospital-wide key driver diagram, highlighting the importance of screening, family education, staff education, and hospital reporting interventions. They were encouraged to complete as many Plan-Do-Study-Act (PDSA) cycles as necessary to improve safe sleep practices in both hospital and home settings.

Intervention Results: Our teams have significantly increased compliance with safe sleep practices in the inpatient and neonatal intensive care unit settings (P < 0.01). We have also increased screening and education on appropriate safe sleep behaviors by ED and primary care providers (P < 0.01). Our county's sleep-related death rate has not significantly decreased during the collaborative.

Conclusion: Our collaborative has increased American Academy of Pediatrics-recommended safe sleep practices in our institution, and we decreased sleep-related deaths in our primary care network. We have created stronger ties to our community partners working to decrease infant mortality rates. More efforts will be needed, both within and outside of our institution, to lower our community's sleep-related death rate.

Setting: Nationwide Children’s Hospital and delivery hospitals throughout Columbus Ohio

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Provider Training/Education Audit/Attestation (provider) PROFESSIONAL_CAREGIVER Education/Training (caregiver) HOSPITAL Quality Improvement

Intervention Description: This study evaluates a quality improvement program to improve compliance with appropriate safe sleep practices in both children’s and birthing hospitals. Hospitalists from both settings were recruited to join the Ohio American Academy of Pediatrics’ EASE (Education and Sleep Environment) injury prevention collaborative to increase admitted infant safe sleep behaviors. The collaborative leadership team required hospitalist physician champions at each institution to form and lead multidisciplinary groups composed of other physicians and trainees, nursing leadership, hospital administrators, child life specialists, and other health care providers as deemed necessary. The leadership team educated participating hospital teams about safe sleep evidence-based guidelines, local statistics, quality improvement principles, and the use of Plan Do-Study-Act cycles within their institutions via interactive exercises. Multidisciplinary interventions in the areas of physician and/or nursing staff education, environmental management strategies, policy creation/revisions, and parental support and education were among the interventioned encourages. The Ohio AAP chapter instructed teams to collect data by conducting random audits, using a standardized tool (available by request).

Intervention Results: A total of 37.0% of infants in children's hospitals were observed to follow the current American Academy of Pediatrics recommendations at baseline; compliance improved to 59.6% at the project's end (P < .01). Compliance at birthing centers was 59.3% and increased to 72.5% (P < .01) at the collaborative's conclusion.

Conclusion: This study demonstrates that a quality improvement program in different hospital settings can improve safe sleep practices. Infants in birthing centers were more commonly observed in appropriate sleep environments than infants in children's hospitals.

Setting: 3 Children's hospitals and 6 birthing hospitals in Ohio

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Hospital Policies

Intervention Description: The purpose of this study was to evaluate the effects on breastfeeding rates of a private-sector early discharge program and a subsequent government mandate guaranteeing 48 hours of hospital coverage.

Intervention Results: Rate of breastfeeding increased over time, from 70.1% in the fourth quarter of 1990 to 81.9% in the first quarter of 1998, but there was no change after either intervention

Conclusion: Early postpartum discharge with outpatient breastfeeding support and a home visitor program has no adverse effects on initiation or continuation of breastfeeding.

Study Design: QE: interrupted time series analysis

Setting: Harvard Vanguard Medical Associates (HVMA), which includes 14 health centers in eastern MA

Population of Focus: HVMA/Harvard Pilgrim Health Care (HPHC) mother-infant pairs between Oct 1990-March 1998

Data Source: Harvard Vanguard Medical Associates Automated Medical Records System

Sample Size: Total (n=20,366) N=mother-infant pairs

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Provider Training/Education Active Management of Labor Labor Support HOSPITAL STATE Quality Improvement Policy/Guideline (State) Collaboratives Policy/Guideline (Hospital)

Intervention Description: California hospitals whose nulliparous, term, singleton, vertex cesarean delivery rates were above the Healthy People 2020 goal of 23.9% in 2015 were invited to participate in the Supporting Vaginal Birth collaborative led by the California Maternal Quality Care Collaborative (CMQCC). The participating hospitals were organized into small teams of six to eight hospitals each led by a physician and a nurse mentor who provided clinical expertise and quality-improvement coaching. The mentors were from other hospitals and had experience in prior CMQCC quality collaboratives. The collaborative focused on implementation of ACOG–SMFM guidelines for labor management and on increasing nursing labor support. A modified Institute for Healthcare Improvement Breakthrough Series collaborative model was used with monthly team check-in phone calls and sharing of implementation ideas and materials. Hospitals received training materials, Grand Rounds for physicians and nurses, educational webinars, and on-site assistance from their mentors.

Intervention Results: Among collaborative hospitals, the nulliparous, term, singleton, vertex cesarean delivery rate fell from 29.3% in 2015 to 25.0% in 2017 (2017 vs 2015 adjusted OR [aOR] 0.76, 95% CI 0.73-0.78). None of the six safety measures showed any difference comparing 2017 to 2015. As a sensitivity analysis, we examined the tercile of hospitals with the greatest decline (31.2%-20.6%, 2017 vs 2015 aOR 0.54, 95% CI 0.50-0.58) to evaluate whether they had greater risk of poor maternal and neonatal outcomes. Again, no measure was statistically worse, and the severe unexpected newborn complications composite actually declined (3.2%-2.2%, aOR 0.71, 95% CI 0.55-0.92).

Conclusion: Mothers and neonates participating in a large-scale Supporting Vaginal Birth collaborative had no evidence of worsened birth outcomes, even in hospitals with large cesarean delivery rate reductions, supporting the safety of efforts to reduce primary cesarean delivery using American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine guidelines and enhanced labor support.

Setting: 56 California hospitals

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We aimed to evaluate the effects of the implementation of the Baby-Friendly Hospital Initiative for a proportion of mothers who exclusively breastfed during a 6-month period, including breastfeeding problems, and maternal breastfeeding attitudes.

Intervention Results: The implementation of the Baby-Friendly Hospital Initiative had no effect on the proportion of mothers who exclusively breastfed, and we found no significant differences in exclusive breastfeeding at 6 months (41.3 % vs 52.9 %, p =.435). The intervention did not influence the reported number of breastfeeding problems (p =.260) or maternal breastfeeding attitudes (p =.354). More favourable breastfeeding attitudes (p <.001) and less problematic breastfeeding (p <.001) were associated positively with exclusive breastfeeding.

Conclusion: Exclusive breastfeeding rates did not increase after the intervention; however, the rates at baseline were already high. Ensuring the Baby-Friendly Hospital Initiative practices through pre- and postnatal periods and preparing mothers to manage common breastfeeding problems might improve breastfeeding rates.

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: To determine healthcare professionals’ breastfeeding attitudes and hospital practices before and after the implementation of the Baby-Friendly Hospital Initiative.

Intervention Results: The healthcare professionals’ breastfeeding attitude scores increased significantly after the implementation of the Baby-Friendly Hospital Initiative, difference = 0.16, (95% CI [0.13, 0.19]) and became breastfeeding favorable among all professional groups in each study unit. Positive changes in breastfeeding-supportive hospital practices were achieved. The infants had significantly more frequent immediate and uninterrupted skin-to-skin contact with their mothers. The rate of early breastfeeding, as well as the number of exclusively breastfed infants, increased.

Conclusion: After the Baby-Friendly Hospital Initiative and Baby-Friendly Hospital Initiative for neonatal wards (Neo-BFHI) interventions were concluded, we found significant improvements in the breastfeeding attitudes of healthcare professionals and in breastfeeding-related care practices.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE Provider Training/Education Hospital Policies Baby Friendly Hospital Initiative HOSPITAL Policy/Guideline (Hospital)

Intervention Description: The Baby-Friendly Hospital Initiative (BFHI), developed by the World Health Organization (WHO) and United Nations Children's fund, is a global program aimed at promoting, protecting, and supporting breastfeeding. Hospitals in the BFHI community must develop clear policies related to staff training and breastfeeding promotion from pregnancy until hospital discharge following childbirth. The aim of this study was to compare women in non-BFHI-accredited hospitals in a socio-economically homogeneous region of southern Italy (Campania region) with a "baby-friendly hospital," as recognized by UNICEF, in Verbania in the Piedmont region of northern Italy (Castelli Hospital) in terms of 1) breastfeeding in the days following childbirth; 2) the information provided by health personnel before and after childbirth; 3) knowledge about breastfeeding before and during hospitalizations; and 4) participation in antenatal classes.

Intervention Results: In general, both groups showed good basic knowledge about different aspects of breastfeeding. In both regions, about 90% reported that the information received during the antenatal classes simplified the breastfeeding experience.

Conclusion: Our study confirms the importance of systematic promotion of breastfeeding and subsequent delivery of adequate support to maternity departments, in accordance with international guidelines.

Study Design: Evaluation data

Setting: Ten accredited and non-accredited hospitals in the Piedmont region of northern Italy

Population of Focus: Women receiving care at the ten participating hospitals

Sample Size: 786 women (580 in Campania + 206 women in Piedmont)

Age Range: Not reported

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL Development/Improvement of Services Continuing Education of Hospital Providers POPULATION-BASED SYSTEMS INTER-HOSPITAL SYSTEMS Maternal/In-Utero Transport Systems Consultation Systems (Inter-Hospital Systems) Consultation Systems (Hospital) STATE Policy/Guideline (State) Funding Support

Intervention Description: This report summarizes the evaluation of a national demonstration program of such regionalization that was funded by the Robert Wood Johnson Foundation (RWJF) in 1975.

Intervention Results: In both funded regions and comparison areas, the neonatal mortality rates decreased sharply over the decade of the 1970s. This decline was linked to shifts in the hospital of delivery that indicated antepartum risk identification and transfer of management of high-risk pregnancies to tertiary centers for delivery, a change in service pattern consistent with some aspects of regionalization. The centralization of high-risk deliveries appeared so widespread that the special effect of the RWJF program could not be detected.

Conclusion: Surveys of surviving 1-year-old infants showed that the decrease in neonatal mortality was accompanied by a decrease in selected morbidity.

Study Design: QE: pretest-posttest nonequivalent control group

Setting: Eight regions and eight comparison regions

Population of Focus: Infants born weighing ≤1500

Data Source: Data from reproduced computer tapes of births and matched infant death and birth certificates obtained from state and local health offices in several states.

Sample Size: Intervention group: Pretest (n≈ 4080) Intervention (n≈ 3416) Posttest: (n≈ 4033) Comparison: Pretest: (n≈ 5221) Intervention: (n≈ 4297) Posttest: (n≈ 4596)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Provider Training/Education Provision of Safe Sleep Item HOSPITAL Quality Improvement Policy/Guideline (Hospital) Crib Card Visual Display (Hospital) Sleep Environment Modification Promotional Event CAREGIVER Education/Training (caregiver) Educational Material (caregiver) Attestation (caregiver) HEALTH_CARE_PROVIDER_PRACTICE Audit/Attestation

Intervention Description: The purpose of this quality improvement project was to promote the AAP safe sleep recommendations and provide appropriate role modeling of these recommendations for hemodynamically stable infants throughout their hospital stay.

Intervention Results: Observations noted an improvement from 70% to 90% (p< 0.01) of infants in a safe sleep position when comparing pre- and postintervention results. There were some improvements in knowledge of and agreement with the AAP guidelines after the educational intervention, but not as much as expected.

Conclusion: There was inconsistency between nursing knowledge and practice about safe infant sleep. Nurses were aware of the AAP recommendations, but it took time to achieve close to full compliance in changing clinical practice. Observation was an important part of this initiative to reinforce knowledge and role model best practice for parents.

Study Design: QE: pretest-posttest

Setting: Golisano Children’s Hospital at the University of Rochester in NY

Population of Focus: Hemodynamically stable infants less than 1 year of age in the mother-baby unit and nine pediatric units

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=65) Follow-up (n=60)

Age Range: Not specified