Obstetric Quality Research Articles

Multicentre cross-sectional study on adverse events and good practices in maternity wards in Brazil and Mexico: same problems, different magnitude

ObjectiveTo evaluate the quality of delivery care in maternity wards in Brazil and Mexico based on good practices (GP) and adverse events (AE), in order to identify priorities for improvement.DesignA...

Malpractice litigation, quality improvement, and the University Hospitals Obstetric Quality Network

Objective A healthcare organization’s medical malpractice data can help identify patient safety risks and drive improvement. In most organizations, obstetric malpractice losses are assumed to be part of the risk of delivering obstetric care. We describe a systematic approach to mitigating risks for obstetric patients and their newborns while simultaneously improving patient outcomes and reducing obstetric litigation costs at University Hospitals, a northeast Ohio-based health system of 18 hospitals, including seven hospitals providing obstetric services and delivering approximately 8000 women per year. Methods From multiple data sources, including malpractice claims data, the team identified four key drivers of risk on the obstetric service: hypoxic ischemic encephalopathy, obstetric hemorrhage, hypertensive disorders of pregnancy, and shoulder dystocia. Collectively, these contributed to multiple adverse maternal and neonatal outcomes and accounted for 71% of obstetric litigation costs from 2009 to 2015. In response, the team built a regional obstetric quality network and implemented interventions to mitigate the four major risk areas. Results We achieved a substantial reduction in serious safety events from 2010 to 2018, defined as any event where the standard of care was not met and the level of harm to mother or baby was one (death) or two (severe permanent or temporary harm). We also achieved a reduction in obstetric litigation costs between 2009–2012 and 2015–2018. Discussion This multifaceted intervention was associated with decreased patient harm and reduced obstetric litigation costs. Application of this approach to other hospitals could result in improvements in obstetric patient safety and reduced obstetric litigation costs.

Positive Deviance to Address Health Equity in Quality and Safety in Obstetrics.

Racial/ethnic disparities persist in obstetrical outcomes. In this paper, we ask how research in obstetrical quality can go beyond a purely quantitative approach to tackle the challenge of health inequity in quality and safety. This overview debriefs the use of positive deviance and mixed methods in others areas of medicine, describes the shortcomings of quantitative methods in obstetrics and presents qualitative studies carried out in obstetrics as well as the insights provided by this method. The article concludes by proposing positive deviance as a mixed methods approach to generate new knowledge for addressing racial and ethnic disparities in maternal outcomes.

Contributors: Quality and Safety Programs in Obstetrics and Gynecology

Clinical Obstetrics and Gynecology 62(3):p x-xii, September 2019. | DOI: 10.1097/01.grf.0000577936.66599.3b

Foreword: Quality and Safety Programs in Obstetrics and Gynecology.

Foreword: Quality and Safety Programs in Obstetrics and Gynecology.

Evaluation of patient-reported outcome measures of functional recovery following caesarean section: a systematic review using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist.

We performed a systematic review using 'consensus-based standards for the selection of health measurement instruments' (COSMIN) criteria to identify and evaluate the quality of patient-reported outcome measures (PROM) instruments that have been utilised to assess functional recovery following caesarean section, and determine the optimal instrument for use in this setting. A literature search was performed using five databases. Studies were included if a psychometrically validated instrument was used to assess functional recovery following caesarean section. The COSMIN appraisal checklist was utilised to: assess the quality of included studies reporting PROMs; determine psychometric quality of instruments; and identify the most promising instruments for use after caesarean section. We identified 13 PROMs used to assess the quality of recovery after caesarean section in 20 studies that included 9214 patients. All PROMs contained between two and seven domains. Five out of the 13 PROMs were specific to postpartum recovery. Only two of these PROM instruments were specifically designed for use after caesarean section (Obstetric Quality of Recovery-11 and Recovery from Caesarean SectionScale). We found very few adequate measures of functional recovery following caesarean section. Overall, the Obstetric Quality of Recovery-11 achieved the highest COSMIN standards for any PROM. Future development of PROMs for use after caesarean section should include multiple domains, and undergo validation as outlined by the COSMIN criteria.

Quality of maternal obstetric and neonatal care in low-income countries: development of a composite index

BackgroundIn low-income countries, studies demonstrate greater access and utilization of maternal and neonatal health services, yet mortality rates remain high with poor quality increasingly scrutinized as a potential point of failure in achieving expected goals. Comprehensive measures reflecting the multi-dimensional nature of quality of care could prove useful to quality improvement. However, existing tools often lack a systematic approach reflecting all aspects of quality considered relevant to maternal and newborn care. We aim to address this gap by illustrating the development of a composite index using a step-wise approach to evaluate the quality of maternal obstetric and neonatal healthcare in low-income countries.MethodsThe following steps were employed in creating a composite index: 1) developing a theoretical framework; 2) metric selection; 3) imputation of missing data; 4) initial data analysis 5) normalization 6) weighting and aggregating; 7) uncertainty and sensitivity analysis of resulting composite score; 8) and deconstruction of the index into its components. Based on this approach, we developed a base composite index and tested alternatives by altering the decisions taken at different stages of the construction process to account for missing values, normalization, and aggregation. The resulting single composite scores representing overall maternal obstetric and neonatal healthcare quality were used to create facility rankings and further disaggregated into sub-composites of quality of care.ResultsThe resulting composite scores varied considerably in absolute values and ranges based on method choice. However, the respective coefficients produced by the Spearman rank correlations comparing facility rankings by method choice showed a high degree of correlation. Differences in method of aggregation had the greatest amount of variation in facility rankings compared to the base case. Z-score standardization most closely aligned with the base case, but limited comparability at disaggregated levels.ConclusionsThis paper illustrates development of a composite index reflecting the multi-dimensional nature of maternal obstetric and neonatal healthcare. We employ a step-wise process applicable to a wide range of obstetric quality of care assessment programs in low-income countries which is adaptable to setting and context. In exploring alternative approaches, certain decisions influencing the interpretation of a given index are highlighted.

Monitoring quality of obstetric care from hospital discharge databases: A Delphi survey to propose a new set of indicators based on maternal health outcomes.

ObjectivesMost indicators proposed for assessing quality of care in obstetrics are process indicators and do not directly measure health effects, and cannot always be identified from routinely available databases. Our objective was to propose a set of indicators to assess the quality of hospital obstetric care from maternal morbidity outcomes identifiable in permanent hospital discharge databases.MethodsVarious maternal morbidity outcomes potentially reflecting quality of obstetric care were first selected from a systematic literature review. Then a three-round Delphi consensus survey was conducted online from 11/2016 through 02/2017 among a French panel of 37 expert obstetricians, anesthetists-critical-care specialists, midwives, quality-of-care researchers, and user representatives. For a given maternal outcome, several definitions could be proposed and the indicator (i.e. corresponding rate) could be applied to all women or restricted to specific subgroup(s).ResultsOf the 49 experts invited to participate, 37 agreed. The response rate was 92% in the second round and 97% in the third. Finally, a set of 13 indicators was selected to assess the quality of hospital obstetric care: rates of uterine rupture, postpartum hemorrhage, transfusion incident, severe perineal lacerations, episiotomy, cesarean, cesarean under general anesthesia, post-cesarean site infection, anesthesia-related complications, postpartum pulmonary embolism, maternal readmission and maternal mortality. Six were considered in specific subgroups, with, for example, the postpartum hemorrhage rate assessed among all women and also among women at low risk of PPH.ImplicationsThis Delphi process enabled us to define consensually a set of indicators to assess the quality of hospital obstetrics care from routine hospital data, based on maternal morbidity outcomes. Considering 6 of them in specific subgroups of women is especially interesting. These indicators, identifiable through codes used in international classifications, will be useful to monitor quality of care over time and across settings.

Evaluation of the Obstetric Quality-of-Recovery score (ObsQoR-11) following non-elective caesarean delivery

BackgroundFew robust scoring tools exist to assess recovery following caesarean delivery (CD). We evaluated a new obstetric quality of recovery score (ObsQoR-11, initially formulated for elective CD) following non-elective CD. MethodsObsQoR-11 questionnaires were completed by women at day one post non-elective CD. Convergent validity was assessed by correlation of ObsQoR-11 with a 100 mm numerical rating scale (NRS) of general health status; discriminant validity by correlation with good vs poor recovery (NRS of ≥70 vs <70 mm, respectively); and content validity by correlation with length of stay (LOS), CD category, parity, gestation, previous CD, duration, blood loss, haemoglobin, age and body mass index. Cronbach’s alpha, inter-item, split-half and test–retest correlation assessed reliability. Feasibility was tested by recruitment rate and time for ObsQoR-11 completion. ResultsOne hundred women completed ObsQoR-11 at 24 h and 20 women repeated it at 25 h. ObsQoR-11 correlated strongly with NRS (r = 0.72 [95% CI 0.61 to 0.81], P <0.0001); discriminated well between good versus poor recovery (median [IQR] score 97 [86.5–101] vs 64 [50.5–78.5], P <0.0001); correlated to LOS (r = −0.24 [−0.42 to −0.04], P=0.02) and parity (r = 0.24 [0.04 to 0.42], P=0.02). Reliability was acceptable: Cronbach’s alpha 0.75; inter-item correlation >0.15; split-half reliability 0.96; and intra-class correlation >0.6; no floor or ceiling effects. One hundred percent completed the ObsQoR-11 (median [IQR] completion time 117 [89–156] s). ConclusionsObsQoR-11 is valid and reliable in assessing recovery after non-elective CD. Further research should assess generalisability and use following vaginal delivery.

In What Ways Might Stories and Anecdotes Impact upon the Quality of Small Group Teaching in Obstetrics and Gynecology?

Objectives:The aim of this study was to find out how stories and anecdotes might improve the quality of the daily morning obstetrics and gynecology (O and G) teaching and determine if the emotions generated by the stories and anecdote deepened the understanding of medical topics.Materials and Methods:The overarching approach to this study was action research. On two occasions, I told stories using PowerPoint presentation during the morning teaching in the O and G seminar room to 10 and 11 learners instead of the traditional factual presentation of a medical topic. The learners ranged from the 3rd-year medical students to 4th-year specialist trainees in O and G and a consultant anesthetist. Each learner completed a feedback questionnaire at the end of the teaching session. I noted the learners' comments and analyzed written feedback.Results:More than 90% of the learners agreed or strongly agreed that the stories were appropriate for their level of training, and on both occasions, every single learner agreed or strongly agreed that the stories improved the quality of the morning teaching. On both days all but one learner agreed or strongly agreed that the stories improved their understanding of the medical topics, and a senior O and G trainee wrote that the story was: “useful – improved my understanding of situation involved.” The stories generated a lot of emotion in the learners, emotions that deepened their understanding of the topic covered.Conclusion:Stories and anecdotes appear to improve the quality of teaching, and this was the case regardless of level of training and experience of the learner. Hence, stories and anecdotes may be an excellent teaching tool in a setting like the morning teaching where the learners are quite varied.

753: Quality and feasibility of obstetrics and gynecology performance metrics

753: Quality and feasibility of obstetrics and gynecology performance metrics

50: Hospital-level variation in term nicu admission rates

Neonatal intensive care unit (NICU) admissions are known to vary by hospital, and NICU admission rates among term, non-anomalous infants have been proposed as a metric of obstetric quality. The objective of this study was to determine what percentage of the variation was attributed to systemic differences between hospitals and their practices after accounting for a hospital’s patient case mix. This is a retrospective cohort study using data collected as part of the Consortium for Safe Labor study. Women who delivered term (≥37 weeks), vertex-presenting, singleton, non-anomalous, liveborn infants in hospitals with a NICU were included. The primary outcome was NICU admission. Multilevel mixed effect models were used and included a hospital-specific random effect. The total variance and the proportion of the variance attributed to the hospital was calculated before and after adjustment for maternal demographics (age, race, insurance status) and pregnancy characteristics (parity, gestational age, diabetes, hypertension, tobacco use, drug use, HIV, abruption, and birth weight). Adjusted odds ratios were obtained, controlling for demographics, pregnancy characteristics, and the random-effect of the hospital. 146,714 infants from 9 hospitals were included. Figure 1 shows the variation in NICU admission rates (range 3.0 – 9.8%). Prior to adjustment for patient case mix, 11.4% of the variation was attributed to the hospital. With the addition of maternal demographics, the hospital-level variation was slightly decreased at 10.7%. However, the majority of the variation was explained by the pregnancy characteristics of patients at each hospital. When these characteristics were added to the model, the residual hospital variation was only 2.0%. The adjusted odds ratios for the pregnancy characteristics associated with NICU admission are shown in Table 1. The term, non-anomalous NICU admission rate varied three-fold across the nine, geographically diverse hospitals that participated in the Consortium for Safe Labor. However, the residual variation attributed to hospital-specific practices was minimal (2.0%) after accounting for each hospital’s case mix. The lack of variation attributed to hospital-specific practices argues against this rate being used as a quality metric in obstetrics. Further research is needed to study NICU admission variation in more diverse settings to assess the generalizability of these findings.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Evaluation of cesarean delivery rate at tertiary general hospitals based on risk adjustment

Objective To calculate the standardized cesarean delivery rate by considering the individual characteristics of puerprae, and to evaluate the medical quality of obstetrics in the hospital. Methods Medical records of 69 406 puerprae from January to December in 2016 were collected from 33 tertiary general hospitals in Shanxi province. A logistic regression model was used to construct a maternal risk adjustment model of cesarean delivery, with the area under the ROC curve (AUC) used to evaluate the goodness of fit of the model. Results Of the 69 406 puerprae, 30 881 used caesarean delivery, accounting to 44.37%. The cesarean section rate difference was statistically significant among those of different age, nationality, conditions upon admission, whether to participate in a clinical pathway, fetus number, birth weight and maternal gestational age, as well as the severity of complications (P< 0.001). According to the logistic model, those of older age, history of cesarean delivery, twins or triplet births, neonatal overweight, malposition, placenta previa, and those with various pregnancy complications tend to use maternal cesarean section surgery, with a goodness-of-fit of 0.82. With risk adjusted, the ranking of actual cesarean section rate and standardized cesarean section rate varies among the hospitals. Conclusions With the factor of puerprae factor adjusted, the standardized cesarean delivery rate can eliminate risk factors of the puerprae, it is feasible to scientifically evaluate the cesarean delivery rate of the hospital′s obstetric department. Key words: Obstetric department; Cesarean delivery rate; Risk adjustment; Evaluation

Challenges to the improvement of obstetric care in maternity hospitals of a large Brazilian city: an exploratory qualitative approach on contextual issues

BackgroundMaternal morbidity and mortality are still serious public health concerns in Brazil, and access to quality obstetric care is one critical point of this problem. Despite efforts, obstetric care quality problems and sub-optimal/poor outcomes persist. The study aimed to identify contextual elements that would potentially affect the implementation of an obstetric care quality improvement intervention.MethodsA qualitative study was conducted in three public maternity hospitals of a large Brazilian city, with high annual volume of births and buy-in from high-level managers. Individual interviews with doctors and nurses were conducted from July to October 2015. Semi-structured interviews sought to explore teamwork, coordination and communication, and leadership, being open to capture other contextual elements that could emerge. Interviews were recorded and transcribed, and the categories of analysis were identified and updated based on the constant comparative method.ResultsTwenty-seven interviews were carried out. Extra-organizational context concerning the dependence of the maternity hospitals on primary care units, responsible for antenatal care, and on other healthcare organizations’ services emerged from interviews, but the main findings of the study centered on intra-organizational context with potential to affect healthcare quality and actions for its improvement, including material resources, work organization design, teamwork, coordination and communication, professional responsibility vis-à-vis the patient, and leadership. A major issue was the divergence of physicians' and nurses' perspectives on care quality, which in turn negatively affected their capacity to work together.ConclusionOverall, the findings suggest that care on the maternity hospitals was fragmented and lacked continuity, putting at risk the quality. Redesigning work organization, promoting conditions for multi-professional teamwork, better communication and coordination, improving more systemic accountability/lines of authority, and investing in team members’ technical competence, and fitness of organizational structures and processes are all imbricated actions that may contribute to obstetric care quality improvement.

A new typology for understanding context: qualitative exploration of the model for understanding success in quality (MUSIQ)

BackgroundThe importance of contextual factors in influencing quality improvement and implementation (QI&I) initiatives is broadly acknowledged. Existing treatments of context have primarily viewed it as static and distinct from interventions themselves. The objective of this study was to advance understanding of the complex and dynamic interaction between context, intervention, and implementation strategies. Using the Model for Understanding Success in Quality (MUSIQ), we aimed to better understand the roles of, and inter-relationships between, contextual factors within QI&I initiatives.MethodsSecondary analysis was performed on qualitative data collected as part of two studies: (1) an evaluation of a state-wide obstetrical quality improvement (QI) initiative, and (2) a study of the use of Plan-Do-Study-Act cycle method in QI projects. Electronic coding databases from each study were reviewed jointly. Data analysis was initiated deductively using MUSIQ as a template. Codes were added in an inductive manner.ResultsAll original factors in MUSIQ were observed to be important in the QI initiatives studied and new factors were identified. Three distinct types of context were identified; the setting(s) of care in which QI&I takes place (Type 1); the context of the team conducting a specific project (Type 2); and the wider context supporting general QI&I (Type 3). The picture of context emerging from this study is a dynamic one with multiple, closely-linked factors operating at different levels in a system that is constantly changing in response to QI&I initiatives. To capture this complexity, a revised model (MUSIQ v2.0) was created positioning use of structured QI&I approaches as the focal point and demonstrating how context influenced effective use of these approaches, and in turn, how these approaches supported teams in navigating context by adapting interventions to fit local settings.ConclusionsMUSIQ is a useful tool to explore the roles of, and inter-relationships between, contextual factors within QI&I initiatives. The revised model may help address some existing controversies about how context influences QI&I success and help ensure that future research efforts consider context not as static background, but as a complex system that is constantly changing, tightly-linked, and governed by feedback loops.

Caesarean Section Rates and Activity-Based Funding in Northern Norway: A Model-Based Study Using the World Health Organization's Recommendation.

Objective Caesarean section (CS) rates vary significantly worldwide. The World Health Organization (WHO) has recommended a maximum CS rate of 15%. Norwegian hospitals are paid per CS (activity-based funding), employing the diagnosis-related group (DRG) system. We aimed to document how financial incentives can be affected by reduced CS rates, according to the WHO's recommendation. Methods We employed a model-based analysis and included the 2016 data from the Norwegian Patient Registry (NPR) and the Medical Birth Registry of Norway (MBRN). The vaginal birth rate and CS rates of each hospital trust in Northern Norway were analyzed. Results There were 4,860 deliveries and a 17.5% CS rate (range 13.9–20.3%). The total funding of the deliveries was €16,351,335 (CS: €6,389,323; vaginal births: €9,962,012). The CS rate varied significantly and was lower in the southern region (P < 0.002). Consequently, the introduction of a cutoff at a 15% CS rate would gain the two southern hospital trusts by a budget increase of 0.2%. The two northern ones would experience 6.4% less resources. A total of €644,655 could be allocated to further quality and safety initiatives in obstetrics. Conclusion The economic consequences of the model-based financial incentive were low, but probably sufficient to get the necessary attention and influence on the CS rate. Recommendations A financial incentive for the reduction of CS rates should be tested as a supplement to other instruments.

Understanding of Key Obstetric Quality Terminology by Asian and Pacific Islander Subgroups: Implications for Patient Engagement and Health Equity.

Introduction Comprehension of healthcare terminology across diverse populations is critical to patient education and engagement. Methods Women in Oahu, Hawai'i with a recent delivery were interviewed about their understanding of ten common obstetric terms. Health literacy was assessed by the rapid estimate of adult literacy in medicine (REALM). Multivariable models predicted total terms comprehended by demographic factors. Results Of 269 participants, self-reported primary race was 20.5% Japanese, 19.0% Native Hawaiian, 19.0% White, 16.7% Filipino, 11.5% other Asian, 9.7% other Pacific Islander, and 3.7% other race/ethnicity; 12.7% had low health literacy. On average, participants understood 6.0 (SD: 2.2) of ten common obstetric terms. Comprehension varied by term, ranging from 97.8% for "Breastfeeding" to 27.5% for "VBAC routinely available." Models showed (1) being Filipino, Japanese, Native Hawaiian, or other Pacific Islander (vs. white); (2) having low (vs. adequate) health literacy; (3) having a high school (vs. a college) degree; and (4) being under 25-years-old (vs. 35 +) were significantly associated with less comprehension. Discussion Participants were unfamiliar with common obstetrics terminology. Comprehension struggles were more common among populations with maternal health disparities, including Asian and Pacific Islander subgroups, and those with low health literacy.

Clinical characteristics and etiological analysis of late fetal death

With the continuous improvement of obstetric quality, the death of the fetus caused by serious pregnancy complications showed a downward trend. However, the etiological analysis of late fetal death is still an urgent health problem and early detection is required to reduce the risk of stillbirth. This study aimed to investigate the clinical and pathological features of late fetal death, and to propose the intervention measures to reduce the incidence of perinatal mortality. This was a retrospective analysis with 131 cases of fetal death of more than 28 gestation weeks from February 2009 to December 2015 in International Peace Maternity and Child-health Hospital. The related factors of maternal and umbilical cord were analyzed by STATA software. Among the 131 cases of dead fetuses in the late stage, 71 (54.2%) cases died of umbilical cord factor. Maternal age of late fetal death usually occurred from 25~35 years (83.97%). History of hysteromyoma, syphilis, thyroid disease, diabetes or uterine abnormalities of pregnant women are risk factors contributed to fetal death. Most pregnant women had regular prenatal examination 107 (89.9%), among which the number of stillbirths with ultrasound screening abnormalities was 69 (58.0%), 47 (39.5%) cases with D-Dimer abnormal of blood coagulation function, and 32 (26.9%) cases with positive bacterial culture results of fetal death. There were no statistically significant differences in fetal death rate between fasting blood glucose, platelet counts, ultrasound of fetal biparietal diameter, and pregnancy age, with or without abortion history (all p > 0.05). Umbilical cord torsion, edema, necrosis, and funisitis were the most common factors associated with late fetal death. In conclusion, perinatal healthcare management and monitoring should be strengthened, and the umbilical cord length, diameter, spiral coil index, blood flow, with or without torsion, and other conditions should be classified as routine examination of fetal structural screening in the second trimester ultrasound.

Examining Trends in Obstetric Quality Measures for Monitoring Health Care Disparities.

Elective delivery (ED) before 39 weeks, low-risk cesarean delivery, and episiotomy are routinely reported obstetric quality measures and have been the focus of quality improvement initiatives over the past decade. To estimate trends and differences in obstetric quality measures by race/ethnicity. We used 2008-2014 linked birth certificate-hospital discharge data from New York City to measure ED before 39 gestational weeks (ED <39), low-risk cesarean, and episiotomy by race/ethnicity. Measures were following the Joint Commission and National Quality Forum specifications. Average annual percent change (AAPC) was estimated using Poisson regression for each measure by race/ethnicity. Risk differences (RD) for non-Hispanic black women, Hispanic women, and Asian women compared with non-Hispanic white women were calculated. ED<39 decreased among whites [AAPC=-2.7; 95% confidence interval (CI), -3.7 to -1.7), while it increased among blacks (AAPC=1.3; 95% CI, 0.1-2.6) and Hispanics (AAPC=2.4; 95% CI, 1.4-3.4). Low-risk cesarean decreased among whites (AAPC=-2.8; 95% CI, -4.6 to -1.0), and episiotomy decreased among all groups. In 2008, white women had higher risk of most measures, but by 2014 incidence of ED<39 was increased among Hispanics (RD=2/100 deliveries; 95% CI, 2-4) and low-risk cesarean was increased among blacks (RD=3/100; 95% CI, 0.5-6), compared with whites. Incidence of episiotomy was lower among blacks and Hispanics than whites, and higher among Asian women throughout the study period. Existing measures do not adequately assess health care disparities due to modest risk differences; nonetheless, continued monitoring of trends is warranted to detect possible emergent disparities.

Evaluation of Physician Communication Skills During Simulated Vacuum-Assisted Deliveries [29M

INTRODUCTION: The objective of this study was to determine if a targeted education program using a mannequin-simulated vacuum-assisted delivery could improve the communication skills of obstetricians. METHODS: This study involved a concurrent assessment of the performance of obstetricians during vacuum-assisted vaginal deliveries using synthetic models. All obstetricians within an existing Obstetric Quality Improvement Collaborative with operative vaginal delivery privileges were enrolled in the study. All evaluators underwent a rigorous training program to ensure uniformity. Demographic information including years in practice and simulation experience were recorded. Eight communication skills and an overall assessment were scored using a standardized checklist. Performance on all variables was evaluated before and after a targeted training session. RESULTS: 288 obstetricians participated across the 5 study hospitals. The majority (69%) of subjects was female, and most (70%) had greater than 10 years of training. For all 8 communication skills measured and for the overall performance, there were statistically significant improvements following the simulation and targeted education session. Communication skills did not vary by sex of the participant. Obstetricians with an intermediate level of experience (6-10 years) appeared to perform best across all parameters. CONCLUSION: Our data show that a simulation training program including a targeted education session in vacuum assisted-deliveries improves obstetrician communication skills.