Established Evidence Results

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): Organizational Changes

Intervention Description: To introduce uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care and that address maternal health needs, thereby reducing maternal morbidity and mortality in the United States. To develop standardized definitions and nomenclature for facilities that provide each level of maternal care. To provide consistent guidelines according to level of maternal care for use in quality improvement and health promotion. To foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate antepartum, intrapartum, and postpartum services.

Intervention Results: Implicit in the effort to establish levels of maternal care is the goal to provide the best possible maternal outcomes, as well as ongoing quality improvement. If levels of maternal care improve care, then ensuring that appropriate transfer of women occurs should be associated with a decrease in preventable maternal severe morbidities and mortality. There also should be a shift toward less severe morbidity in lower-level care facilities. Therefore, facilities and regional systems should develop methods to track severe maternal morbidity and mortality to assess the efficacy of utilizing maternal levels of care. Operational definitions are needed to compare data and outcomes between levels of maternal care. However, waiting for the precise measure before establishing tiered levels of care invites unnecessary delay. Therefore, two constructs to implement with the utilization of levels of maternal care are proposed: (1) identify women at extreme risk of morbidity and (2) identify severe morbidity outcomes that may improve with appropriate use of maternal levels of care. Some women at extreme risk of severe morbidities, such as stroke, cardiopulmonary failure, or massive hemorrhage, can be identified during the antepartum period and should give birth in the appropriate level hospital. Examples of such women include those with suspected placenta accreta or placenta percreta; prior cesarean birth and current anterior previa; severe heart disease such as complex cardiac malformations and pulmonary hypertension, coronary artery disease, or cardiomyopathy; severe preeclampsia with uncontrollable hypertension; and preterm HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). Outcome morbidities that may improve with appropriate use of levels of maternal care include stroke, returns to the operating room, massive transfusions, severe maternal morbidity, and potential ICU admissions. The incidence of these outcomes could decrease or be shifted from lower-level to higher-level hospitals. For example, known placenta accreta has the potential for massive blood loss and need for advanced surgical services, which are best available at facilities with a high designated level of care. Expectant management of severe early preeclampsia, septic shock, and pulmonary hypertension are other examples of conditions that require considerable resources likely best available at facilities with a high designated level of care. Although the development of comprehensive lists of what conditions comprise extreme morbidity risks and what outcomes ought to be measured currently is an evolving process, prospective measurement with continuous monitoring and evaluation of any regionalized maternal care system is critical to improvement in care processes and outcomes.

Conclusion: Many barriers to the implementation of levels of maternal care may need to be overcome. The development of the classification system is the first step; the next step, is the implementation of this concept in all facilities that provide maternal care. The questions of whether to have state-level or national-level accrediting bodies establish and set these proposed levels of maternal care, as well as how to provide the financing needed to run them, are unanswered. Follow-up interdisciplinary work groups are needed to further explore the implementation needs to adopt the proposed classification system for levels of maternal care in all facilities that provide maternal care. The determination of the appropriate level of care to be provided by a given facility should be guided by local and state health care regulations, national accreditation and professional organization guidelines, and identified regional perinatal health care service needs.6 State and regional authorities should work together with the multiple institutions within a region to determine the appropriate coordinated system of care.

Study Design: N/A

Setting: N/A

Data Source: N/A

Sample Size: N/A

Age Range: N/A

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

Intervention Description: The intervention in this study was the national organization of preventive health services for children, particularly the difference between countries where child vaccinations are administered by general practitioners (Denmark) and those where preschool children are vaccinated in "well-baby" clinics (Finland, Iceland, and Sweden).

Intervention Results: The study found that Denmark, where child vaccinations are administered by general practitioners, presented the lowest overall coverage of MMR at 83% and the greatest difference between subpopulations of low and high socioeconomic status (SES) at 14 percentage points. In contrast, Finland, Iceland, and Sweden, where preschool children are vaccinated in "well-baby" clinics, had a higher overall coverage at 91–94%, with a more equal distribution between SES groups at 1–4 percentage points.

Conclusion: This study suggests that the organisation of preventive health care in special units, 'well-baby' clinics, facilitates vaccine uptake among children with low SES in a Nordic welfare context.

Study Design: The study utilized a comparative design to investigate the socioeconomic patterns of MMR vaccine uptake in the four Nordic countries.

Setting: Denmark, Finland, Iceland, and Sweden.

Population of Focus: The target audience of the study includes children under the age of two years and their families, particularly those from socially disadvantaged backgrounds.

Sample Size: The study analyzed register data from Denmark, Finland, Iceland, and Sweden. Specific sample sizes for each country were not provided in the text.

Age Range: The study focused on the measles, mumps, and rubella (MMR) vaccine uptake before the age of two years.

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): Organizational Changes, Prenatal Care Access, Access, Telehealth/Virtual Care

Intervention Description: The OB Nest intervention involved a reduced-frequency prenatal care model enhanced with remote home monitoring devices and nursing support. Participants in the OB Nest group received 8 scheduled clinic appointments with an obstetrician or a certified nurse midwife, as well as 6 virtual (phone or online) connected care visits with an OB Nest registered nurse. These virtual visits consisted of home blood pressure and fetal heart rate evaluation. Additionally, the OB Nest model included home monitoring devices and an online prenatal community to support the pregnant women .

Intervention Results: The study found that participants in the OB Nest group had significantly higher satisfaction with care and lower prenatal-related stress compared to patients in the usual care group. Perceived quality of care was similar between groups. Adherence to the provision of American College of Obstetricians and Gynecologists prenatal services was similar in both arms. Maternal and fetal clinical outcomes were similar between groups. Total reported nursing time was higher in OB Nest. The study concluded that OB Nest is an innovative, acceptable, and effective reduced-frequency prenatal care model that resulted in higher patient satisfaction and lower prenatal stress while reducing the number of appointments with clinicians and maintaining care standards for pregnant women .

Conclusion: The study concluded that the OB Nest intervention is an innovative, acceptable, and effective reduced-frequency prenatal care model. It resulted in higher patient satisfaction and lower prenatal stress, while reducing the number of appointments with clinicians and maintaining care standards for pregnant women. The findings suggest that OB Nest is a step toward evidence-driven prenatal care that improves patient satisfaction .

Study Design: The study utilized a rigorous randomized controlled trial (RCT) design to compare the OB Nest prenatal care model with usual care. Participants were randomized to either OB Nest or usual care using a dynamic allocation system, with an algorithm minimizing imbalances in a 1:1 ratio across specific factors such as age, body mass index, and parity. The allocation sequence was concealed from the study nurse who enrolled and assessed the eligibility of participants. The study team nurses and clinicians were aware of the assigned arms after randomization occurred, and team members analyzing quantitative data were blinded to which intervention arm mothers were assigned to

Setting: The study was conducted as a single-center randomized controlled trial within the Outpatient Obstetric Division at Mayo Clinic, a tertiary care academic center in Rochester, Minnesota. The Mayo Clinic serves approximately 2400 pregnant women annually, and the trial took place between March 2014 and January 2015

Population of Focus: The target audience for the OB Nest prenatal care model and the study evaluating its effectiveness were low-risk pregnant women who were between 18 and 36 years old, at less than 13 weeks of gestation, and without a concurrent medical or obstetric complication, who had the ability to provide informed consent. The study aimed to evaluate the acceptability and effectiveness of the OB Nest model compared to traditional prenatal care for this specific population .

Sample Size: he study aimed to recruit 300 pregnant women, with 150 participants assigned to the OB Nest group and 150 participants assigned to the usual care group. The sample size was determined based on the power to detect differences in patient satisfaction, which was considered the most important endpoint for pregnant patients and caregiver representatives when creating the OB Nest bundle. The study was powered to detect differences in patient satisfaction with a 98% power to detect a difference of 7 points, based on a standard deviation of 14.4, with 10% attrition

Age Range: The study enrolled English-speaking pregnant women between 18 and 36 years old who were at less than 13 weeks of gestation. This age range was part of the enrollment criteria for the study .

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): 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): HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation, Organizational Changes, Quality Improvement

Intervention Description: Our purpose was to determine whether completion of the medical audit cycle in labor ward practice could safely reduce cesarean section rates.

Intervention Results: After management change the overall cesarean section rate was decreased (9.5% vs 12%, p < 0.0001). In our population spontaneously laboring nulliparous women with a singleton, cephalic, term pregnancy contributed a significant number of cesarean sections 1982 to 1988 (19.7% of all cesarean sections). Applying principles of early diagnosis and treatment of dystocia in these women resulted in a decrease in the cesarean section rate (2.4% vs 7.5%, p < 0.0001). This was primarily responsible for the overall decrease in the cesarean section rate.

Conclusion: Effective medical audit of labor management can reduce cesarean section rates.

Study Design: Prospective cohort

Setting: 1 private hospital

Population of Focus: Nulliparous women who gave birth between 1984 and 1988 and between September 1989 and August 1992

Data Source: Not specified

Sample Size: Total (n=9,207) 1984-1988 (n=5,622) 1989-1992 (n=3,585)

Age Range: Not Specified