Perinatal Quality Improvement Research Articles

Strategies to Promote Maternal Health Equity: The Role of Perinatal Quality Collaboratives.

Perinatal quality improvement is a method to increase obstetric safety and promote health equity. Increasing trends of maternal deaths, life-threatening complications of pregnancy, and persistent racial inequities are unacceptable. This Narrative Review examines the role and strategies of perinatal quality initiatives and collaboratives to deliver safe and equitable maternity care and the evidence of demonstrated success. Key strategies to promote maternal equity through perinatal quality include communicating equity as a priority through leadership, leveraging data and enhancing surveillance, engaging in strategic partnerships, engaging community, educating clinicians, and implementing practice recommendations through collaboration.

Risk of Severe Maternal Morbidity in Birthing People With Opioid Use Disorder.

We examined severe maternal morbidity (SMM) among birthing people with opioid use disorder (OUD) and evaluated the extent to which differences in SMM exist by race and ethnicity. We performed a retrospective cohort study using hospital discharge data for all Massachusetts births between 2016 and 2020. SMM rates for all SMM indicators, except transfusions, were computed for those diagnosed with and without OUD. Multivariable logistic regression was used to examine the association between OUD and SMM after adjusting for patient and hospital characteristics, including race and ethnicity. Among 324,012 childbirths, the SMM rate was 148 (95% confidence interval [CI]. 115-189) per 10,000 childbirths among birthing people with OUD compared with 88 (95% CI, 85-91) for those without. In adjusted models, both OUD and race/ethnicity were significantly associated with SMM. Birthing people with OUD had 2.12 (95% CI, 1.64-2.75) times the odds of experiencing an SMM event compared with those without. Non-Hispanic Black and Hispanic birthing people were at 1.85 (95% CI, 1.65-2.07) and 1.26 (95% CI, 1.13-1.41) higher odds of experiencing SMM compared with non-Hispanic White birthing people. Among birthing people with OUD, the odds of SMM were not significantly different between birthing people of color and non-Hispanic White individuals. Birthing people with OUD are at an elevated risk of SMM, underscoring the need for improved access to OUD treatment and increased support. Perinatal quality improvement collaboratives should measure SMM in bundles aimed at improving outcomes for birthing people with OUD.

Expanding midwifery care in the United States: Implications for clinical outcomes and cost.

This study compared clinical and financial outcomes for low-risk birthing people between those attended by midwives and those attended by obstetricians during hospital births. We conducted a retrospective cohort analysis of births from January 1, 2016 to December 31, 2020 at hospitals participating in a perinatal quality improvement collaborative, Obstetrical Care Outcomes Assessment Program (OB COAP), in the Northwest region of the United States and estimated risk ratios using a multivariate regression approach with a modified Poisson binomial for mode of delivery, labor interventions, and newborn outcomes comparing midwife-led to obstetrician-led care. Using publicly available data on average costs of vaginal and cesarean births, we then extrapolated the cost differences in care between midwives and obstetricians. Births in the midwife group were less likely to be associated with induction (17.6% vs. 20.3% RR 0.74; 95% CI 0.70-0.78), epidural use (58.9% vs. 76.3% RR 0.78; 95% CI 0.77-0.80), and episiotomy (2.2% vs. 3.4% RR 0.68; 95% CI 0.58-0.81). Cesarean birth was also lower in the midwifery group (7.8% vs. 12.3% RR 0.68, 95% CI 0.62-0.73), without a corresponding increase in risk in adverse neonatal outcomes. We estimated that expanding midwifery care to 100% of low-risk births across the United States could save as much as $340 million per year. Midwifery care is associated with a lower risk of cesarean birth and other interventions versus care provided by obstetricians and is therefore likely lower-cost.

Promoting Best Practice in Obstetrics: Findings From a State-Based Perinatal Quality Collaborative Implementing the Obstetric Hemorrhage Maternal Safety Bundle [ID: 1377611

INTRODUCTION: The Perinatal Neonatal Quality Improvement Network (PNQIN) of Massachusetts engaged hospital teams in a statewide improvement initiative to address maternal morbidity from obstetric hemorrhage (OB HEM) through support of implementation and adherence to best practices in screening for and diagnosis of OB HEM. METHODS: The Alliance for Innovation on Maternal Health (AIM) OB HEM bundle was adapted and implemented across hospitals in Massachusetts from June to December 2021. Each month, participating hospital teams joined educational webinars, learned quality improvement strategies, received access to resources for the intervention, and submitted data on six structure and five process measures. Severe maternal morbidity rates were provided using state hospital discharge data. Reliability of implementation was monitored by structure and process measure submission. Aggregate data were shared statewide. RESULTS: Fifty-three percent of birthing hospitals in the state (21 of 40) voluntarily participated. Baseline risk screening for OB HEM was 93% and quantitative blood loss measurement (QBL) was 60% in aggregate for all teams. Six participating hospitals reported all 11 measures monthly across the 6-month period. Half of these sites had all six structure measures in place at baseline and 83% reported completion of structure measures by the end of the study period. Among these six sites, the cumulative proportion QBL utilization increased 178% from 28% to 78% and documented OB HEM risk assessment during labor admission increased 8.4% from 83% to 90%. CONCLUSION: Implementation of the OB HEM bundle was effective in increasing adherence to evidence-based care among participating birth hospitals through a collaborative, quality improvement approach.

The Ohio Maternal Safety Quality Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented during the COVID-19 pandemic

Hypertensive disorders of pregnancy are a leading cause of severe maternal morbidity (SMM) and mortality and studies have shown that more than 60% of cases are preventable. As part of a state-wide quality maternal safety quality improvement project (MSQIP), we adapted the Alliance for Innovation on Maternal Health (AIM) Severe Hypertension in Pregnancy bundle in a consortium of maternity hospitals in [REDACTED] to improve care processes and outcomes for patients with a severe hypertensive event during pregnancy or postpartum period. To report the first year of data from this MSQIP, including an assessment of the process measures by hospital level of maternal care designation, and provide perspective on the unique challenges of implementing a large-scale MSQIP during a global pandemic. This MSQIP engaged [REDACTED] Level I-IV maternity hospitals and provided multimodal QI support. Participating hospitals submitted monthly patient level data, which included all cases of new onset sustained severe hypertension. The primary process measure was the proportion of birthing persons in [REDACTED] with sustained severe hypertension who received treatment with appropriate acute antihypertensive therapy within 60 minutes. Secondary process measures included receipt of: a follow-up appointment after hospital discharge within 72 hours (if discharged on medication) or 10 days (if discharged without medication), a blood pressure cuff on hospital discharge, and education about urgent maternal warning signs. Data for primary and secondary process measures were plotted on a biweekly basis and statistical process control methods were used to identify special cause variation over time. Data were stratified by various demographic variables, including race/ethnicity, insurance status, and maternal level of care. To assess the impact of the COVID-19 pandemic on this MSQIP, process measure data was compared to COVID-19 case volume in [REDACTED] across the study epoch. Twenty-nine hospitals participated in the project from July 2020 through September 2021. Data was collected on 4,948 hypertensive events representing 4,678 unique patients. In aggregate, the primary process measure (timely and appropriate treatment) demonstrated a 19.3% increase (from baseline of 56.5% to 67.4%, p < 0.001). The secondary process measures demonstrated significant increases ranging 26.1% to 166.8% (all p < 0.001). Both non-Hispanic Black and White pregnant or postpartum people demonstrated shifts and sustained improvements in the treatment of severe hypertension, which did not differ by race across the study period. Notably, process measure improvements were achieved and sustained across peaks in the COVID-19 pandemic. This [REDACTED] MSQIP demonstrated meaningful changes in project process measures in the identification and treatment of severe hypertension in pregnancy and the postpartum period. Process measures improvements were achieved across all hospital levels of maternal care and differences were not observed by race or ethnicity. Our findings suggest that a robust and comprehensive QI initiative with appropriate support and resources can achieve meaningful gains in the setting of a global pandemic.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Bypassing of nearest labor & delivery unit is contingent on rurality, wealth, and race.

Patient decisions to bypass the closest labor & delivery (L&D) facility in favor of other birthing locations can have consequences for the provision of health care in rural and micropolitan areas as patient volumes decline and payer mixes change. Among 220 589 uncomplicated births in Iowa, we document characteristics of birth parents who bypass their closest birthing facility, show how this bypassing behavior results in changed travel times to delivery facilities across the rural/urban divide, and indicate the parts of the state where bypassing behavior is most prevalent. From 2013 to 2019, 55.2% of deliveries occurred in facilities that were further from birthing parents' residences than the closest L&D facility. Bypassing is associated with White, non-Hispanic race/ethnicity, and private insurance status. Although bypassing is least common among micropolitan birth parents, this group has the greatest travel burden to birthing facilities and exhibits increasing rates of bypassing over time. Perinatal quality improvement programs can target locations and populations where low-risk birthing parents can be encouraged to deliver close to home if medically appropriate, particularly in small towns and rural areas. This can potentially alleviate the risk of obstetric deserts by ensuring L&D units maintain patient volumes necessary to continue operations.

The 5D Cycle for Health Equity: Combining Black Feminism, Radical Imagination, and Appreciative Inquiry to Transform Perinatal Quality Improvement.

Too often, quality improvement initiatives are rooted in the health care system's oppressive structures and hierarchies. Transformative quality improvement models that embody the wisdom and liberatory potential of oppressed groups areneeded to address the alarming inequities within perinatal health. Inspired by experiences with Appreciative Inquiry, a possibility-focused change model, and frustrated by the limits of traditional quality improvement, the author sought new approaches to perinatal quality improvement. Inquiry into Black feminist recommendations for perinatal quality improvement and the principles of radical imagination led to the creation of the 5D Cycle for Health Equity, which grounds Appreciative Inquiry's 5D cycle (define, discover, dream, design, deliver/destiny) in Black feminism and radical imagination. The 5D Cycle for Health Equity is an innovative approach to addresshealth inequities by challenging oppressive quality improvement methods and health care structures. The cycle guides quality improvement collectives through a process that redefines harm and health equity; discovers new understandings of wellness across the past, present, and future; dreams of equitable care with the principles of antioppression and collectivity; designs solutions that embody the liberatory practices of oppressed groups; delivers solutions that strive to free everyone by freeing the most oppressed; and forges a new destiny. Midwives are well poised to use the 5D Cycle for Health Equity to disrupt structures of inequity and foster a health care system that supports the health and wellness of oppressed groups.

Validation of ICD-10-CM Diagnosis Codes for Gestational Age at Birth.

The International Classification of Diseases , 10th Revision, Clinical Modification (ICD-10-CM) introduced diagnosis codes for week of gestation. Our objective was to assess the validity of these codes among live births, which could have major utility in perinatal research and quality improvement. We used linked birth certificate and patient discharge data from births in California during 2016-2019 (N = 1,843,992). We identified gestational age using Z3A.xx ICD-10-CM diagnosis codes in birthing patient discharge data and compared it with the gold standard of obstetric estimate, as recorded on the birth certificate. We further assessed sensitivity and specificity of gestational age categories (≥37 weeks, <37 weeks, <32 weeks, <28 weeks), given these categories are frequently of interest, and evaluated differences in validity of preterm birth (<37 weeks' gestation) by patient characteristics. One-million seven-hundred seventy-thousand one-hundred three patients had a gestational age recorded in patient discharge and birth certificate data. When comparing gestational age in patient discharge data with birth certificate data, the concordance correlation coefficient was 0.96 (95% confidence interval [CI] = 0.96, 0.96) and the mean difference between the two measurements was 0.047 weeks (95% CI = 0.046, 0.047 weeks). Ninety-five percent of the differences between the two measurements were between -1.00 week and +1.09 weeks. Sensitivity and specificity were 0.94 to 1.00 for all gestational age categories and were 0.94 to 1.00 for preterm birth across sociodemographic groups. We found week-specific gestational age at delivery ICD-10-CM diagnosis codes in patient discharge data to have high validity when compared with the best obstetric estimate on the birth certificate.

An Initiative "that you do for one person": Identifying Barriers and Facilitators to Implementing an Immediate Postpartum LARC Initiative in Florida Hospitals.

In the United States (U.S.), perinatal quality improvement collaboratives have pursued implementing immediate postpartum long-acting reversible contraception (LARC) initiatives to increase people's access to contraception and support their fertility desires. This process evaluation aimed to identify barriers and facilitators to implementing an immediate postpartum LARC initiative in Florida. Data collection included in-depth qualitative assessments (i.e., interviews, small focus group discussions) with hospitals in pre- and early stages of the implementation process. Snowball sampling was used to recruit participants. Interviews were conducted in-person or via Zoom or phone and were audio-recorded and transcribed verbatim. Four of the five domains within the Consolidated Framework for Implementation Research (e.g., process, intervention characteristics, inner and outer settings) informed the study design and data collection/analysis. Fourteen staff of diverse job roles from five hospitals participated. Factors that facilitated implementation were the strength of the evidence, relative advantage, internal and external networks, and engaging staff. Barriers to implementation included billing and reimbursement and needing significant support from external networks to progress through implementation phases. Findings suggest that depending on the task or phase, multiple factors work in tandem to serve as implementation barriers and facilitators. Additionally, evaluating hospitals' progress at the pre- and early implementation phases was critical for quickly finding solutions and benefited other hospitals in different stages. As this initiative requires substantial support, health systems should create and sustain a culture of excellence and efficiency to facilitate implementing initiatives that improve care quality.

Birth Outcomes of Infants Born to Mothers With Disability: A Population at Risk.

Birth Outcomes of Infants Born to Mothers With Disability: A Population at Risk.

Rethinking Nursing Education and Curriculum Using a Racial Equity Lens.

Health educators are called on to dismantle health care inequities as they train future health care clinicians to deliver care that promotes equity, improves access to care, and actively addresses antiracism. Through an Advanced Nursing Workforce grant by the Health Resources and Services Administration, a partnership was established with the Institute for Perinatal Quality Improvement to provide training for health care clinicians and students on ways to SPEAK UP against implicit and explicit bias with an emphasis on maternal health. Dismantling racism is a continuous process. Activities included self-reflection, small group meetings, antiracism and bias training, and community engagement. Acknowledging that racism and health inequities exist and directly contribute to the rise in maternal and infant mortality is only the beginning. Rethinking nursing education, curriculum, and clinical care to train culturally responsive health care clinicians is required to address systemic and structural racism in health care. [J Nurs Educ. 2022;61(8):493-496.].

Effect of a perinatal care quality improvement package on patient satisfaction: a secondary outcome analysis of a cluster-randomised controlled trial

ObjectiveTo investigate the effect of a quality improvement (QI) package on patient satisfaction of perinatal care.DesignSecondary analysis of a stepped-wedge cluster-randomised controlled trial. Participating hospitals were randomised by size into...

Missed opportunities to improve food security for pregnant people: a qualitative study of prenatal care settings in Northern New England during the COVID-19 pandemic

BackgroundFood insecurity during pregnancy has important implications for maternal and newborn health. There is increasing commitment to screening for social needs within health care settings. However, little is known about current screening processes or the capacity for prenatal care clinics to address food insecurity among their patients. We aimed to assess barriers and facilitators prenatal care clinics face in addressing food insecurity among pregnant people and to identify opportunities to improve food security among this population.MethodsWe conducted a qualitative study among prenatal care clinics in New Hampshire and Vermont. Staff and clinicians engaged in food security screening and intervention processes at clinics affiliated with the Northern New England Perinatal Quality Improvement Network (NNEPQIN) were recruited to participate in key informant interviews. Thematic analysis was used to identify prominent themes in the interview data.ResultsNine staff members or clinicians were enrolled and participated in key informant interviews. Key barriers to food security screening and interventions included lack of protocols and dedicated staff at the clinic as well as community factors such as availability of food distribution services and transportation. Facilitators of screening and intervention included a supportive culture at the clinic, trusting relationships between patients and clinicians, and availability of clinic-based and community resources.ConclusionPrenatal care settings present an important opportunity to identify and address food insecurity among pregnant people, yet most practices lack specific protocols for screening. Our findings indicate that more systematic processes for screening and referrals, dedicated staff, and onsite food programs that address transportation and other access barriers could improve the capacity of prenatal care clinics to improve food security during pregnancy.

Validation of ICD-10-CM Diagnosis Codes for Gestational Age at Birth

The International Classification of Diseases Clinical Modification 10th Revision (ICD-CM-10) introduced diagnosis codes for week of gestation at delivery (8-42 weeks). Our objective was to assess the validity of these codes, which could have major utility in perinatal research and quality improvement. We used linked birth certificate and hospitalization discharge data from all live births in California during 2016-2019 (N = 1,843,992). Gestational age was identified using Z3A.xx ICD-10-CM diagnosis codes in maternal patient discharge data and compared with the gold standard of best obstetric estimate, as recorded on the birth certificate. We further assessed sensitivity and specificity of gestational age categories (< 37 weeks, < 32 weeks, < 28 weeks) given these categories are frequently of interest. We excluded records with gestational age < 20 or >42 weeks or if missing (3.9%). 1,771,527 patients had gestational age recorded on the birth certificate and in the hospitalization discharge data. When comparing gestational age in patient discharge data with birth certificate data, the mean of the difference was -0.32 days (SD=3.80) and the R2 value was 0.92. 95% of observed differences between pairs of gestational age measurements were between -7.14 to +7.77 days, and 99.3% of differences were within +/-14 days. The sensitivity, specificity, positive predictive value, and negative predictive value were all high for the three gestational age categories, although the positive predictive value did decrease with earlier gestational age category (Table). Week-specific gestational age at delivery diagnosis codes in patient discharge data were found to have high validity when compared with the gold standard of best obstetric estimate on the birth certificate. The introduction of these codes with the implementation of ICD-10-CM in 2015 is promising for research and quality improvement purposes.

The Virtual Perinatal Quality Improvement Prioritization By Affected Communities (V‐QPAC) Protocol

Research ObjectiveTo facilitate community participation in prioritizing perinatal improvement (QI) recommendations across six theorized domains of the Patient Reported Experience Measure of Obstetric Racism© (PREM‐OB Scale™) to mitigate obstetric racism during hospital‐based labor and birth. PREM‐OB Scale™ Domains Perinatal QI Priorities and Mitigations Safety &amp; Accountability Shame, Stigma, Love, Grace, and Dignity: Birthing While Black Patient/Community Feedback in EHR Language and Patient Handoff Autonomy &amp; Social Capital/Kinship Black Birthing Rights in Hospital Settings Black Women's/People's Autonomy: Asset vs Threat Communication &amp; Information Exchange Pre‐Escalation Steps Prior to Calling Hospital Security Use of Mediation with a Professional and Community Representative External to Hospital Racism Redesign and expansion of care team Anti‐Racism Community Advisory &amp; Accountability Board/Taskforce Empathy &amp; Humanity Human Resources Accountability Metric: What is your Why? and Empathy‐specific Competency Based Screening/Interviews SACRED Birth Assessment/Checklist for Black People Focused Care Dignity in Blackness &amp; Holistic Care Explicit Informed Consent/Refusal for Every Cervical Exam Racial Equity Caucus for Restoration of Dignity in Blackness for patients, community, clinicians, staff, and physicians with hospital privileges Study DesignThe Virtual Quality Improvement Prioritization by Affected Communities (V‐QPAC) is an adaptation of the Research Prioritization by Affected Communities (RPAC) protocol. V‐QPAC applies Black feminist ethnographic methodology to describe different forms of resistance and resilience that Black women community leaders adopt to mitigate the dimensions of obstetric racism and power inequities that emerge from supporting Black mothers and birthing people during hospital births. The V‐QPAC protocol is implemented using a web‐based video conferencing tool and presentation software for interactive real‐time input. The components include: 1) preparation; 2) facilitated group work to generate a list of potential techniques and topics (Session 1); 3) interim analysis by the same two Black women researchers; 4) facilitated group work to prioritize topics (Session 2); and 5) summary analysis using reflexive thematic analysis. We used both inductive coding and theoretical coding in this analytic approach.Population StudiedWe enrolled a total of 24 participants from 15 different Black women‐led community organizations across California, who support Black women and people experiencing pregnancy, birth, and lactation. Twenty participants completed the demographic survey and identified as Black women, ranging in age from 28 to 72 years, with prior perinatal QI experience (n = 7), other QI experience (n = 3), no prior QI experience (n = 10), previous hospital births in California (n = 13), and experience supporting a Black mother during a hospital birth in California (n = 15).Principal FindingsCommunity leaders identified 74 and prioritized 44 potential perinatal QI topics across the PREM‐OB Scale™ Domains. Then they further prioritized QI topics down to the top two mitigations for each domain.ConclusionsThe V‐QPAC protocol is a novel method for generating rapid, in‐depth knowledge of socio‐cultural QI priorities from Black women community leaders who support Black mothers and birthing people during hospital births.Implications for Policy or PracticeV‐QPAC offers potential mitigations against obstetric racism beyond pathology centered – risk reduction strategies described in existing QI safety bundles through the intellectual thought and political activism of Black women community leaders.Primary Funding SourceThe California Health Care Foundation.

A way forward in the maternal mortality crisis: addressing maternal health disparities and mental health.

Our objective was to review the role of maternal health disparities and mental health in the maternal mortality crisis in the USA, and discuss how perinatal care quality improvement in these areas is a critical lever for reducing maternal death. This paper summarizes content from a plenary talk delivered at the 2020 Biennial Meeting of the International Marcé Society for Perinatal Mental Health, in commemoration of the Society's 40th anniversary. The talk synthesized literature on two characteristics of the maternal mortality crisis in the US: (1) wide racial and ethnic disparities in maternal mortality and severe morbidity and (2) the impact of mental health and substance use disorders on maternal death, and introduced a framework for how health care quality gaps contribute to both of these issues. The US remains an outlier among similar nations in its alarmingly high rates of maternal mortality. Achieving significant progress on this measure will require confronting longstanding racial and ethnic disparities that exist throughout the pregnancy-postpartum continuum, as well as addressing the under-reported issue of maternal self-harm. Suicide and overdose are leading but under-recognized causes of death among pregnant and postpartum women in some states. Health care delivery failures, including inadequate risk assessment, care coordination, and communication, are identified in the literature on drivers of maternal health disparities and self-harm. Many of the same steps to improve quality of perinatal care can help to reduce health disparities and address the essential role of mental health in maternal well-being.

Vignettes Identify Variation in Antibiotic Use for Suspected Early Onset Sepsis.

There is widespread unwarranted antibiotic use and large individual provider variation in antibiotic use in NICUs. Vignette-based research methodology offers a unique method of studying variation in individual provider decisions. The objective with this study was to use a vignette-based survey to identify specific areas of provider antibiotic use variation in newborns being evaluated for early onset sepsis. This study was undertaken as part of a statewide multicenter neonatal antibiotic stewardship quality improvement project led by a perinatal quality improvement collaborative. A web-based vignette survey was administered to identify variation in decisions to start and discontinue antibiotics in cases of early onset sepsis. The largest variation was noted in 3 of the 6 vignette cases. These cases highlighted variation in (1) decisions to start antibiotics in a case describing a well-appearing newborn with risk factors and an elevated C-reactive protein, (2) decisions to start antibiotics in the case of a newborn with risk factors plus mild respiratory signs at birth, and (3) decisions to stop antibiotics in the case of the newborn with a history of sepsis risk factors and mild clinical respiratory signs that resolved after 72 hours. Clinical vignette assessment identified specific areas of variation in individual provider antibiotic use decisions in cases of suspected early onset sepsis. Vignettes are a valuable method of describing individual provider variation and highlighting antibiotic stewardship improvement opportunities in NICUs.

The Rise of Black Feminist Intellectual Thought and Political Activism in Perinatal Quality Improvement: A Righteous Rage about Racism, Resistance, Resilience, and Rigor

AbstractIn this description of her work in perinatal quality improvement, obstetrician and crunk public health scholar Dr. Karen A. Scott describes the ways in which perinatal quality improvement has typically prioritized the deaths or near deaths of Black women at the exclusion of the lived experiences of Black women and people as patient, community, and content experts. Drawn into the work to apply a Black women‐centered and liberatory analytic, Dr. Scott turned to Black feminist anthropology to transform perinatal quality improvement ethics and theories of change. The work of Leith Mullings, particularly her excursus on the Sojourner Syndrome, was at the center of Dr. Scott's approach to abating Black perinatal death and redesigning perinatal quality improvement.

680 Excess risk of preterm delivery in monochorionic diamniotic twins: a review of 1536 twin pregnancies

Twin pregnancies are associated with an excess risk of preterm birth compared to singletons. Monochorionicity further confers an excess risk of pregnancy complications, often related to placental vascular connections and unequal placental sharing. However, the excess risk of prematurity related to monochorionicity has not been well studied in a systematic fashion. This study is a retrospective cohort analysis of 23 0/7 - 42 6/7 week twin pregnancies from April 2016 through September 2019 utilizing clinical data from the Obstetrical Care Outcomes Assessment Program (OB COAP). OB COAP is a collaborative perinatal quality improvement initiative based in WA state. The 17 participating sites span all levels of care in urban, suburban and rural settings and provide population-based data including approximately 1/3 of all births in WA state. Data were available on 93,780 pregnancies, including 1536 twin pregnancies. Of the 1536 twin pregnancies, 1115 (72.6%) were dichorionic diamniotic (DIDI), 362 (23.5%) were monochorionic diamniotic (MODI), 22 (1.4%) were monoamniotic (MOMO), 37 (2.4%) did not have data on chorionicity. Data on patient characteristics are shown in Table 1. The rates of pre-eclampsia and gestational diabetes were similar between MODI and DIDI twins. However, the risk of preterm birth (<37 weeks) was significantly higher for MODI than DIDI twin pregnancies (81.5% vs 52.6%), p<0.001. This was largely due to an excess risk of preterm birth between 28 and 34 weeks (relative risk 1.9; 95% CI 1.6-2.2) (Table 2). The rate of cesarean birth, especially pre labor cesarean birth, was significantly higher in MODI vs DIDI (77.9% vs 68.7%; p=0.001). MODI twins have a significantly increased risk of prematurity, especially prematurity prior to 34 weeks. Determination of chorionicity early in pregnancy is crucial to allow for close surveillance and appropriate clinical management, as well as referral if needed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)