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PURPOSE: Large-scale efforts to reduce cesarean deliveries have shown varied levels of impact; yet understanding factors that contribute to hospitals’ success are lacking. We aimed to characterize unit culture differences at hospitals that successfully reduced their cesarean rates compared with those that did not. METHODS: A mixed methods study of California hospitals participating in a statewide initiative to reduce cesarean delivery. Participants included nurses, obstetricians, family physicians, midwives, and anesthesiologists practicing at participating hospitals. Hospitals’ net change in nulliparous, term, singleton, and vertex cesarean delivery rates classified them as successful if they achieved either a minimum 5 percentage point reduction or rate of fewer than 24%. The Labor Culture Survey was used to quantify differences in unit culture. Key informant interviews were used to explore quantitative findings and characterize additional cultural barriers and facilitators. RESULTS: Out of 55 hospitals, 37 (n = 840 clinicians) meeting inclusion criteria participated in the Labor Culture Survey. Physicians’ individual attitudes differed by hospital success on 5 scales: best practices (P = .003), fear (P = .001), cesarean safety (P = .014), physician oversight (P

Background Rates of maternal mortality and severe maternal morbidity (SMM) are higher in the United States than in other high-resource countries and are increasing further. Objective To examine the association of maternal comorbid conditions, age, body mass index, and previous cesarean birth with occurrence of SMM. Design Population-based cohort study using linked delivery hospitalization discharge data and vital records. Setting California, 1997 to 2014. Patients All 9 179 472 mothers delivering in California during 1997 to 2014. Measurements SMM rate, total and without transfusion-only cases; 2019 maternal comorbidity index. Results Total SMM increased by 160% during this time, and SMM excluding transfusion-only cases increased by 53%. Medical comorbid conditions were associated with an increasing portion of SMM occurrences. Medical comorbid conditions increased over the study period by 111%, and obstetric comorbid conditions increased by 30% to 40%. Identified medical comorbid conditions had high relative risks ranging from 1.3 to 14.3 for total SMM and even higher relative risks for nontransfusion SMM (to 32.4). The obstetric comorbidity index that is most often used may be undervaluing the degree of association with SMM. Limitations Hospital discharge diagnosis files and birth certificate records can have misclassifications and may not include all relevant clinical data or social determinants. The period for analysis ended in 2014 to avoid the transition to the International Classification of Diseases, 10th Revision, Clinical Modification, and therefore missed more recent years. Conclusion Obstetric and, particularly, medical comorbid conditions are increasing among women who develop SMM. The maternal comorbidity index is a promising tool for patient risk assessment and case-mix adjustment, but refinement of factor weights may be indicated. Primary funding source National Institutes of Health.

OBJECTIVE To evaluate the use of administrative data for identification of labor induction and to estimate the variation in cesarean delivery rates among low-risk women who underwent labor induction. METHODS A cross-sectional study was performed examining live births in California hospitals during 2016 and 2017 using birth certificate data linked with maternal patient discharge records. Initially, eight hospitals performed medical record reviews by using reVITALize definitions on 46,916 deliveries to assess the validity of induction identification by birth certificate or discharge diagnosis records or both. Hospital-level variation in cesarean delivery rates was then assessed among all California hospitals for women with low-obstetric-risk first births before and after further risk adjustment and after the exclusion of potential medical and obstetric indications for induction. Variation in physician-level cesarean delivery rates after induction at four large hospitals also was examined. The relationships between cesarean delivery rates among women with induced labors compared with noninduced labors and with the hospital rate of induction also were explored. RESULTS Identifying induction by a combination of discharge diagnosis codes and birth certificate data had the highest accuracy (92.9%, 95% CI 92.7-93.2). Among 917,225 births at 238 birthing hospitals, there were 99,441 nulliparous women with term, singleton, vertex pregnancies who were induced. The median cesarean delivery rate after labor induction for nulliparous women with term, singleton, vertex pregnancies was 32.2%, with a range of 18.5-84.6%. This wide variation was not reduced after risk adjustment or after exclusion of all women with induction indications. A similar wide variation was noted within geographic regions, neonatal intensive care levels, and among individual physicians in the same facility. Only very weak associations were found for the cesarean delivery rate after labor induction and either the rate after noninduced labor (R

Objective To assess whether there is a relationship between evening, night, and weekend births and severe unexpected neonatal morbidity in low-risk term singleton births. Methods We conducted a population-based, cross-sectional analysis. Severe unexpected neonatal morbidity as defined by the National Quality Forum specification 0716 was derived from linked birth certificate and hospital discharge summaries for 1,048,957 low-risk singleton term Californian births during 2011 through 2013. The association between the nursing shift (7 am-3 pm vs 3-11 pm and 11 pm -7 am) and weekday compared with weekend birth and the risk of severe unexpected neonatal morbidity was estimated using mixed effects logistic regression models. Results Severe unexpected neonatal morbidity was higher among births during the 3-11 pm evening shift (2.1%) and the 11 pm-7 am night shift (2.1%), compared with those during the 7 am-3 pm day shift (1.8%). The adjusted odds ratios (ORs) were 1.10 (95% CI 1.06-1.13) for the evening shift and 1.15 (1.11-1.19) for the night shift. The adjusted ORs of severe unexpected neonatal morbidity were increased only on Sunday, as compared with other days (adjusted OR 1.08, 95% CI 1.02-1.14). When our analysis was by perinatal region, the increase was seen in four of the nine perinatal regions. Conclusion After risk adjustment, the risk of severe unexpected morbidity in the low-risk singleton California birth cohort was significantly increased on Sundays and births during evening and night shifts. These elevations were detected in only four of California's nine perinatal regions. Further analysis at the individual hospital level is warranted.

To estimate racial and ethnic differences in rates of hospital-based care associated with postpartum depression. This is a retrospective cohort study using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes within data from the Office of Statewide Planning and Development in California. We included primiparous women who underwent delivery hospitalization from 2008 to 2012. The primary outcome was the first postpartum hospital encounter with a ICD-9-CM code for depression over a 9-month period after delivery. We examined the cumulative incidence of hospital-based care for postpartum depression by race/ethnicity. Logistic regression was used to estimate relative risk. The study cohort consisted of 984,167 primiparous women: 314,037 (32%) were non-Hispanic White; 59,754 (6%) were non-Hispanic Black; 150,855 (15%) were non-Hispanic Asian; 448,770 (46%) were Hispanic; and 10,399 (1%) were other races. The cumulative incidence of hospital-based care for postpartum depression was highest for Black women (39; 95% CI = 34–44 per 10,000 deliveries) and lowest for Asian women (7; 95% CI = 5–8 per 10,000 deliveries). Compared with White women, hospital-based care for postpartum depression was more likely to be provided to Black women (OR = 2.3; 95% CI = 1.9–2.7), whereas care was less likely for Asians (OR = 0.4; 95% CI = 0.3–0.5) and Hispanics (OR = 0.8; 95% CI = 0.7–1.0). Similar findings were observed after excluding women with antepartum depression, adjusting for sociodemographic and clinical variables, and stratifying according to care settings. Compared with White women, hospital-based care for postpartum depression more frequently impacts Black women. Identifying and improving inequities in access to and utilization of mental health care for postpartum women should be a maternal health priority.

Severe hypertension in pregnancy is a medical emergency. Although expeditious treatment within 30 to 60 minutes is recommended to reduce the risk of maternal death or severe morbidity, treatment is often delayed by more than 1 hour. In this statement, we propose a quality metric that facilities can use to track their rates of timely treatment of severe hypertension. We encourage facilities to adopt this metric so that future reports from different facilities will be based on a uniform definition of timely treatment.

The experience of childbirth and its outcomes in the United States varies by race: Black and Hispanic infants face higher risks of neonatal morbidity and mortality even after accounting for clinical risk. Although perinatal disparities are rooted in a complex set of causes, there is increasing recognition that differential quality of care contributes to disparities.1–3 This has been most clearly demonstrated among preterm infants receiving care in the NICU. Minority infants and families are more likely to receive care in poor quality NICUs3,4 and within a NICU are more likely to receive worse care.1 In this issue of Pediatrics , Glazer et al5 found that in New York City, compared with white infants, Black and Hispanic term infants had increased risk of complications. The study confirms the grim reality of racial and ethnic disparities in infant outcomes in a low-risk population that accounts for 90% of all births. Disparities within individual hospitals were attenuated when adjusted for sociodemographic factors. However, the disparities measured across hospitals were significant. Prevalence of complications differed by race and ethnicity and by hospital. Infection rates demonstrated the widest variation: a sixfold difference between highest- and lowest-performing tertile of hospitals. Although other factors, such as data validity, case mix, and obstetric and neonatal practice variation may account for observed disparities between hospitals, and further investigation into underlying drivers of disparity is needed, this study adds to a growing body … Address correspondence to Ravi Dhurjati, PhD, Perinatal Health Systems, Department of Pediatrics, School of Medicine, Stanford University, 1265 Welch Rd, x1C31, Stanford CA 94035-5415. E-mail: dhurjati{at}stanford.edu

What are the key features of hospitals that consistently deliver safe care on labour and delivery? This is the primary question posed by Liberati and colleagues in this issue of BMJ Quality & Safety .1 The authors propose a framework distilled from observations on a group of high-performing units in the UK participating in a training activity to improve patient safety. This study combined ethnography with individual interviews and focus groups and involved over 400 hours of total observations at six different maternity care sites. The seven features in their resulting For Us framework correspond well to existing theoretical as well as applied quality improvement strategies. While we agree that their framework describes features that every labour and delivery unit should strive to include, this approach has some limitations in terms of generalisability. Specifically, Liberati and colleagues studied maternity units that are high performing, but their sample included only large-volume hospitals in what appear to be well-resourced settings. What is potentially missing is observations on underperforming units, and how these findings may or may not apply to smaller, lower resourced settings. Additionally, the structure of the UK’s National Health Service (NHS) also limits generalisability. For example, this is most analogous to employed physician models in the USA, with the potential advantage of a more organisationally oriented provider workforce. Given that most US hospitals do not have an employed provider model, we can’t assume that these factors will have the same impact in other models of care. In the USA, the Agency for Healthcare Research and Quality (AHRQ) developed a Culture of Safety framework that delineates four key features: (1) organisations recognise that their primary activities are inherently high risk and make it their goal to operate in a reliably safe manner; (2) organisations create a safe and blame-free reporting …

Importance: Safe reduction of the cesarean delivery rate is a national priority. Objective: To evaluate the rates of cesarean delivery for nulliparous, term, singleton, vertex (NTSV) births in California in the context of a statewide multifaceted intervention designed to reduce the rates of cesarean delivery. Design, Setting, and Participants: Observational study of cesarean delivery rates from 2014 to 2019 among 7 574 889 NTSV births in the US and at 238 nonmilitary hospitals providing maternity services in California. From 2016 to 2019, California Maternal Quality Care Collaborative partnered with Smart Care California to implement multiple approaches to decrease the rates of cesarean delivery. Hospitals with rates of cesarean delivery greater than 23.9% for NTSV births were invited to join 1 of 3 cohorts for an 18-month quality improvement collaborative between July 2016 and June 2019. Exposures: Within the collaborative, multidisciplinary teams implemented multiple strategies supported by mentorship, shared learning, and rapid-cycle data feedback. Partnerships among nonprofit organizations, state governmental agencies, purchasers, and health plans addressed the external environment through transparency, award programs, and incentives. Main Outcomes and Measures: The primary outcome was the change in cesarean delivery rates for NTSV births in California and a difference-in-differences analysis was performed to compare cesarean delivery rates for NTSV births in California vs the rates in the rest of the US. A mixed multivariable logistic regression model that adjusted for patient-level and hospital-level confounders also was used to assess the collaborative and the external statewide actions. The cesarean delivery rates for NTSV births at hospitals participating in the collaborative were compared with the rates from the nonparticipating hospitals and the rates in the participating hospitals prior to participation in the collaborative. Results: A total of 7 574 889 NTSV births occurred in the US from 2014 to 2019, of which 914 283 were at 238 hospitals in California. All California hospitals were exposed to the statewide actions to reduce the rates of cesarean delivery, including the 149 hospitals that had baseline rates of cesarean delivery greater than 23.9% for NTSV births, of which 91 (61%) participated in the quality improvement collaborative. The rate of cesarean delivery for NTSV births in California decreased from 26.0% (95% CI, 25.8%-26.2%) in 2014 to 22.8% (95% CI, 22.6%-23.1%) in 2019 (relative risk, 0.88; 95% CI, 0.87-0.89). The rate of cesarean delivery for NTSV births in the US (excluding California births) was 26.0% in both 2014 and 2019 (relative risk, 1.00; 95% CI, 0.996-1.005). The difference-in-differences analysis revealed that the reduction in the rate of cesarean delivery for NTSV births in California was 3.2% (95% CI, 1.7%-3.5%) higher than in the US (excluding California). Compared with the hospitals and the periods not exposed to the collaborative activities, and after adjusting for patient characteristics and time using a modified stepped-wedge analysis, exposure to collaborative activities was associated with a lower odds of cesarean delivery for NTSV births (24.4% vs 24.6%; adjusted odds ratio, 0.87 [95% CI, 0.85-0.89]). Conclusions and Relevance: In this observational study of NTSV births in California from 2014 to 2019, the rates of cesarean delivery decreased over time in the setting of the implementation of a coordinated hospital-level collaborative and statewide initiatives designed to support vaginal birth.

INTRODUCTION Despite evidence supporting the safety of low-interventional approaches to intrapartum care, defined by the American College of Obstetricians and Gynecologists as "practices that facilitate a physiologic labor process and minimize intervention," little is known about how frequently such practices are utilized. We examined hospital use of low-interventional practices, as well as variation in utilization across hospitals. METHODS Data came from 185 California hospitals completing a survey of intrapartum care, including 9 questions indicating use of low- versus high-interventional practices (eg, use of intermittent auscultation, nonpharmacologic pain relief, and admission of women in latent labor). We performed a group-based latent class analysis to identify distinct groups of hospitals exhibiting different levels of utilization on these 9 measures. Multivariable logistic regression identified institutional characteristics associated with a hospital's likelihood of using low-interventional practices. Procedure rates and patient outcomes were compared between the hospital groups using bivariate analysis. RESULTS We identified 2 distinct groups of hospitals that tended to use low-interventional (n = 44, 23.8%) and high-interventional (n = 141, 76.2%) practices, respectively. Hospitals more likely to use low-interventional practices included those with midwife-led or physician-midwife collaborative labor management (adjusted odds ratio [aOR], 7.52; 95% CI, 2.53-22.37; P < .001) and those in rural locations (aOR, 3.73; 95% CI, 1.03-13.60; P = .04). Hospitals with a higher proportion of women covered by Medicaid or other safety-net programs were less likely to use low-interventional practices (aOR, 0.96; 95% CI, 0.93-0.99; P = .004), as were hospitals in counties with higher medical liability insurance premiums (aOR, 0.53; 95% CI, 0.33-0.85; P = .008). Hospitals in the low-intervention group had comparable rates of severe maternal and newborn morbidities but lower rates of cesarean birth and episiotomy compared with hospitals in the high-intervention group. DISCUSSION Only one-quarter of hospitals used low-interventional practices. Attention to hospital culture of care, incorporating the midwifery model of care, and addressing medical-legal concerns may help promote utilization of low-interventional intrapartum practices.

OBJECTIVE:To describe the clinical characteristics of stroke and opportunities to improve care in a cohort of preeclampsia-related maternal mortalities in California.METHODS:The California Pregnancy-Associated Mortality Review retrospectively examined a cohort of preeclampsia pregnancy-related death

Creating change at scale within a short time frame poses multiple challenges. Using the experience of the California Maternal Quality Care Collaborative, the authors illustrate how state perinatal quality collaboratives have been able to achieve this goal using a series of key steps: engage as many disciplines and partner organizations as possible; mobilize low-burden data to create a rapid-cycle data center to support the quality improvement efforts; provide up-to-date guidance for implementation using safety bundles and tool kits; and make available coaching and peer learning to support implementation through multihospital quality collaboratives. There are now multiple national resources available to support these efforts.

Objective To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from obstetric hemorrhage by the California Pregnancy-Associated Mortality Review Committee. Design Qualitative descriptive using thematic analysis. Sample A total of 159 QIOs identified from 33 cases of pregnancy-related deaths from obstetric hemorrhage in California from 2002 to 2007. Methods We coded and thematically organized the 159 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. Results Thematic findings indicated that facility Readiness would be improved through practice standardization, better organization of equipment to treat hemorrhage, and planning for care of women with risk factors for hemorrhage. Recognition of hemorrhage by health care providers could be improved through accurate assessment of blood loss, risk factors, and early clinical signs of deterioration. Provider Response could be improved through reducing delays in administering blood, seeking consultations, transferring women to higher levels of care within or outside of the facility, and moving on to other treatments if a woman does not respond to current treatment. Conclusion Hemorrhage is the most preventable cause of maternal death in California. Morbidity and mortality from hemorrhage can be prevented if birth facilities and maternity care clinicians align local practices with national safety guidelines.

Purpose Racial/ethnic disparities in severe maternal morbidity (SMM) are substantial, but little is known about whether these disparities are changing over time or the role of maternal and obstetric factors. Methods We examined disparities in SMM prevalence and trends using linked birth certificate and delivery discharge records from Californian births during 1997–2014 (n = 8,252,025). Results The prevalence of SMM was highest in non-Hispanic (NH) Black women (1.63%), lowest in NH White women (0.84%), and increased from 1997 to 2014 by approximately 170% in each racial/ethnic group. The magnitude of SMM disparities remained consistent over time. Compared with NH White women, the adjusted risk of SMM was higher in women who identified as Hispanic (RR 1.14; 95% CI 1.12, 1.16), Asian/Pacific Islander (RR 1.23; 95% CI 1.20, 1.26), NH Black (RR 1.27; 95% CI 1.23, 1.31), and American Indian/Alaska Native (RR 1.29; 95% CI 1.15, 1.44), accounting for comorbidities, anemia, cesarean birth, and other maternal characteristics. Conclusions The prevalence of SMM varied considerably by race/ethnicity but increased at similarly high rates among all racial/ethnic groups. Comorbidities, cesarean birth, and other factors did not fully explain the disparities in SMM, which remained persistent over time.

Objective To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from venous thromboembolism (VTE) by the California Pregnancy-Associated Mortality Review Committee. Design Qualitative, descriptive design using thematic analysis. Sample A total of 108 QIOs identified from 29 cases of pregnancy-related deaths from VTE in California from 2002 to 2007. Methods We coded and thematically organized the 108 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. Results Women's lack of awareness of the significance of severe VTE symptoms and the lack of a standardized approach to recognize and respond to VTE signs and symptoms were the most prevalent themes in the Readiness domain. Missing the signs and symptoms of VTE and the resultant missed or delayed diagnosis were predominant themes in the Recognition domain. For Response, issues related to lack of VTE prophylaxis were most frequently noted, along with other themes, including timing of treatment and appropriate follow-up after hospital discharge. Conclusion To decrease the occurrence of maternal death from VTE in the United States, consistent and thorough education regarding VTE signs and symptoms must be given to all women and their families during pregnancy and the postpartum period. Maternity care facilities and providers should implement preventive measures, including standardized use of VTE prophylaxis, improved methods to recognize the signs and symptoms of VTE, and improved follow-up after hospital discharge.

Objective To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from sepsis by the California Pregnancy-Associated Mortality Review Committee. Design Qualitative descriptive design using thematic analysis. Sample A total of 118 QIOs identified from 27 cases of pregnancy-related deaths from sepsis in California from 2002 to 2007. Methods We coded and thematically organized the 118 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. Results Women's delay in seeking care was the central theme in the Readiness domain. In the Recognition domain, health care providers missed the signs and symptoms of sepsis, including elevated temperature, elevated white blood cell count, increased heart rate, decreased blood pressure, mottled skin, preterm labor, headache, and pain. For Response, late antibiotic administration was a central theme; multiple emergent themes included administration of the wrong antibiotics, failure to investigate women's complaints of pain, lack of nurse/provider communication, and lack of follow-up care after hospital discharge. Conclusion To reverse the contribution of sepsis to the rising rate of maternal mortality in the United States, health care facilities and providers need to reduce barriers for women who seek care, recognize early symptoms, and respond with appropriate treatment. This could be achieved by implementation of the Maternal Early Warning Criteria, standardized guidelines such as those from the Surviving Sepsis campaign, and comprehensive discharge education.

To evaluate maternal and neonatal safety measures in a large-scale quality improvement program associated with reductions in nulliparous, term, singleton, vertex cesarean delivery rates.This is a cross-sectional study of the 2015-2017 California Maternal Quality Care Collaborative (CMQCC) statewide collaborative to support vaginal birth and reduce primary cesarean delivery. Hospitals with nulliparous, term, singleton, vertex cesarean delivery rates greater than 23.9% were solicited to join. Fifty-six hospitals with more than 119,000 annual births participated; 87.5% were community facilities. Safety measures were derived using data collected as part of routine care and submitted monthly to CMQCC: birth certificates, maternal and neonatal discharge diagnosis and procedure files, and selected clinical data elements submitted as supplemental data files. Maternal measures included chorioamnionitis, blood transfusions, third- or fourth-degree lacerations, and operative vaginal delivery. Neonatal measures included the severe unexpected newborn complications metric and 5-minute Apgar scores less than 5. Mixed-effect multivariable logistic regression model was used to calculate odds ratios (Ors) and 95% CIs.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).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.

Objective To assess hospital unit culture and clinician attitudes associated with varying rates of primary cesarean delivery. Data Sources/Study Setting Intrapartum nurses, midwives, and physicians recruited from 79 hospitals in California participating in efforts to reduce cesarean overuse. Study Design Labor unit culture and clinician attitudes measured using a survey were linked to the California Maternal Data Center for birth outcomes and hospital covariates. Methods Association with primary cesarean delivery rates was assessed using multivariate Poisson regression adjusted for hospital covariates. Principal Findings 1718 respondents from 70 hospitals responded to the Labor Culture Survey. The “Unit Microculture” subscale was strongly associated with primary cesarean rate; the higher a unit scored on 8‐items describing a culture supportive of vaginal birth (eg, nurses are encouraged to spend time in rooms with patients, and doulas are welcomed), the cesarean rate decreased by 41 percent (95% CI = −47 to −35 percent, P

Background Severe maternal morbidity – life-threatening childbirth complications – has more than doubled in the United States over the past 15 years, affecting more than 50,000 women (1.4% of deliveries) annually. During this time period, maternal age, obesity, comorbidities, and cesarean delivery also increased and may be related to the rise in severe maternal morbidity. We sought to evaluate: (1) the association of advanced maternal age, pre-pregnancy obesity, pre-pregnancy comorbidities, and cesarean delivery with severe maternal morbidity, and (2) whether changes in the prevalence of these risk factors affected the trend of severe maternal morbidity. Methods This population-based cohort study used linked birth record and patient discharge data from live births in California during 2007–2014 (n = 3,556,206). We used multivariable logistic regression models to assess the association of advanced maternal age (≥35 years), pre-pregnancy obesity (body mass index ≥30 kg/m2), pre-pregnancy comorbidity (index of 12 conditions), and cesarean delivery with severe maternal morbidity prevalence and trends. Severe maternal morbidity was identified by an index of 18 diagnosis and procedure indicators. We estimated odds ratios, predicted prevalence, and population attributable risk percentages. Results The prevalence of severe maternal morbidity increased by 65% during 2007–2014. Advanced maternal age, pre-pregnancy obesity, and pre-pregnancy comorbidity also increased during this period, but cesarean delivery did not. None of these risk factors affected the increasing trend of severe maternal morbidity. However, the pre-pregnancy risk factors together were estimated to contribute to 13% (95% confidence interval: 12, 14%) of severe maternal morbidity cases in the study population overall, and cesarean delivery was estimated to contribute to 37% (95% confidence interval: 36, 38%) of cases. Conclusions Pre-pregnancy health and cesarean delivery are important risk factors for severe maternal morbidity but do not explain an increasing trend of severe maternal morbidity in California during 2007–2014. Investigation of other potential contributors is needed in order to identify ways to reverse the trend of severe maternal morbidity. Electronic supplementary material The online version of this article (10.1186/s12884-018-2169-3) contains supplementary material, which is available to authorized users.

OBJECTIVE: To assess maternal and neonatal healthcare workers (HCWs) perspectives on well-being and patient safety amid the COVID-19 pandemic. STUDY DESIGN: Anonymous survey of HCW well-being, burnout, and patient safety over the prior conducted in June 2020. Results were analyzed by job position and burnout status. RESULT: We analyzed 288 fully completed surveys. In total, 66% of respondents reported symptoms of burnout and 73% felt burnout among their co-workers had significantly increased. Workplace strategies to address HCW well-being were judged by 34% as sufficient. HCWs who were "burned out" reported significantly worse well-being and patient safety attributes. Compared to physicians, nurses reported higher rates of unprofessional behavior (37% vs. 14%, p = 0.027) and difficulty focusing on work (59% vs. 36%, p = 0.013). CONCLUSION: Three months into the COVID-19 pandemic, HCW well-being was substantially compromised, with negative ramifications for patient safety.

Severe maternal morbidity (SMM) is a composite outcome measure that indicates serious, potentially life-threatening maternal health problems. There is great interest in defining SMM using administrative data for surveillance and research. In the United States, one common way of defining SMM at the population level is an index developed by the Centers for Disease Control and Prevention. Modifications to this index (e.g., exclusion of maternal blood transfusion) have been proposed; some research defines SMM using an index introduced by Bateman et al. (Obstet Gynecol. 2013;122(5):957–965). Birth certificate data are also increasingly being used to define SMM. We compared commonly used US definitions of SMM among all California births (2007–2012) using the kappa (κ) statistic and other measures. We also evaluated agreement between maternal morbidity fields on the birth certificate as compared with health insurance claims data. Concordance between the 7 definitions of SMM analyzed was generally low (i.e., κ

Objective To develop and validate an expanded obstetric comorbidity score for predicting severe maternal morbidity that can be applied consistently across contemporary U.S. patient discharge data sets. Methods Discharge data from birth hospitalizations in California during 2016-2017 were used to develop the score. The outcomes were severe maternal morbidity, defined using the Centers for Disease Control and Prevention index, and nontransfusion severe maternal morbidity (excluding cases where transfusion was the only indicator of severe maternal morbidity). We selected 27 potential patient-level risk factors for severe maternal morbidity, identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used a targeted causal inference approach integrated with machine learning to rank the risk factors based on adjusted risk ratios (aRRs). We used these results to assign scores to each comorbidity, which sum to a single numeric score. We validated the score in California and national data sets and compared the performance to that of a previously developed obstetric comorbidity index. Results Among 919,546 births, the rates of severe maternal morbidity and nontransfusion severe maternal morbidity were 168 and 74 per 10,000 births, respectively. The highest risk comorbidity was placenta accreta spectrum (aRR of 30.5 for severe maternal morbidity and 54.7 for nontransfusion severe maternal morbidity) and the lowest was gestational diabetes mellitus (aRR of 1.06 for severe maternal morbidity and 1.12 for nontransfusion severe maternal morbidity). Normalized scores based on the aRR were developed for each comorbidity, which ranged from 1 to 59 points for severe maternal morbidity and from 1 to 36 points for nontransfusion severe maternal morbidity. The overall performance of the expanded comorbidity scores was good (C-statistics were 0.78 for severe maternal morbidity and 0.84 for nontransfusion severe maternal morbidity in California data and 0.82 and 0.87, respectively, in national data) and improved on prior comorbidity indices developed for obstetric populations. Calibration plots showed good concordance between predicted and actual risks of the outcomes. Conclusion We developed and validated an expanded obstetric comorbidity score to improve comparisons of severe maternal morbidity rates across patient populations with different comorbidity case mixes.

Objective The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy. Study design This population-based study used linked birth record and maternal hospital discharge data from live births in California during 2007 to 2012 (n = 2,548,380). All women who had a diagnosis of peripartum cardiomyopathy during the childbirth hospitalization or who were diagnosed with peripartum cardiomyopathy during a postpartum hospital readmission within 5 months of birth were identified as cases. Pre-pregnancy body mass index (BMI, kg/m2) was classified as normal weight (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (≥40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities. Results The overall prevalence of peripartum cardiomyopathy during hospital admissions was 1.3 per 10,000 live births (n = 320). Unadjusted ORs were 1.32 (95% CI: 1.01-1.74) for women with overweight BMI and 2.03 (95% CI: 1.57-2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95-1.66) for overweight women and 1.38 (95% CI: 1.04-1.84) for women with obesity. The ORs suggested a dose-response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00. Conclusion Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period. Key points · Pre-pregnancy obesity affects maternal health.. · Effects may extend to peripartum cardiomyopathy.. · The risk includes peripartum cardiomyopathy that emerges postpartum..

Background Cesarean delivery rates in the United States vary widely between hospitals, which cannot be fully explained by hospital or patient factors. Cultural factors are hypothesized to play a role in cesarean overuse, yet tools to measure labor culture are lacking. The aim of this study was to revise and validate a survey tool to measure hospital culture specific to cesarean overuse. Methods A panel of clinicians and researchers compiled an item bank from validated surveys, added newly created items, and performed four rounds of iterative revision and consolidation. Obstetricians, family physicians, midwives, anesthesiologists, and labor nurses were recruited from 79 hospitals in California. Exploratory factor analysis was used to reduce the number of survey items and identify latent constructs to form the basis of subscales. Confirmatory factor analysis examined reliability in 31 additional hospitals. Poisson regression assessed associations between hospitals' mean score on each individual item and cesarean rates. Results A total of 1718 individuals from 70 hospitals were included in the exploratory factor analysis. The final Labor Culture Survey (LCS) consisted of 29 items and six subscales: "Best Practices to Reduce Cesarean Overuse," "Fear of Vaginal Birth," "Unit Microculture," "Physician Oversight," "Maternal Agency," and "Cesarean Safety." Conclusions The revised LCS is a valid and reliable tool to measure constructs shown to be associated with cesarean rates. These findings support prior research that has shown that hospital culture is measurable, and that clinician attitudes are predictive of clinician behaviors. Unique to our survey is the construct of labor and delivery unit microculture.

Perinatal complications linked to maternal comorbidities contribute to increased healthcare utilization through an extended postpartum length of stay (LOS). Understanding factors influencing postpartum LOS may minimize the adverse effects associated with comorbidities and complications. The purpose of this study was to identify risk factors with the greatest odds of increasing postpartum LOS. Linked 2008-2009 hospital discharge and birth certificate data were used to examine comorbidities and complication codes in 1 015 424 births. The overall rate for an extended LOS (vaginal: >5 days/cesarean: >6 days) was 3.63 per 1000 live births. Complications were present in 17% of pregnancies; multiple complications were seen in 1%. Chronic hypertension was associated with an extended stay for both vaginal and cesarean births (odds ratio [OR] = 5.89 [95% CI, 4.39-7.88]; OR = 3.57 [95% CI, 3.05-4.17], respectively). Puerperal infections (OR = 6.86 [95% CI, 5.73-8.21]), eclampsia (OR = 17.07 [95% CI, 13.76-21.17]), and transfusions (OR = 11.66 [95% CI, 9.20-14.75]) occurred most frequently and conferred the highest odds of an extended stay for vaginal births. Cerebrovascular conditions (OR = 15.32 [95% CI, 11.90-19.60]) and infection (OR = 15.35 [95% CI, 10.11-23.32]) conferred the highest odds of an extended LOS for cesarean births. The earlier risk factors are recognized, the sooner processes can be initiated to optimize organizational preparation, thus decreasing adverse maternal outcomes and extended hospital stays.

State Perinatal Quality Collaboratives (PQCs) represent a major advance for scaling up quality improvement efforts for reducing maternal mortality and severe maternal morbidity. The critical roles of partners, rapid-cycle low-burden data systems, and linkage to maternal mortality review committees are reviewed. The choice of measures is also explored. California's experience with its PQC, data center, quality improvement efforts, and promising results for reduction of maternal mortality and morbidity from hemorrhage are presented. Early data from other states is also shared.

Background Obstetric safety bundles, consisting of action steps shown to improve outcomes, have been developed to address the most common and preventable causes of maternal morbidity and mortality. Implementing these best practices across all birthing facilities remains an important and challenging clinical and public health priority. Methods The California Maternal Quality Care Collaborative (CMQCC) developed an innovative external mentor model for large-scale collaborative improvement in which participating organizations were subdivided into small teams of six to eight hospitals, led by a paired dyad of physician and nurse leaders. The mentor model preserves the active sharing that enhances improvement across a large group of facilities working on the same project while enabling individualized attention to teams. The mentor model was tested by implementing the obstetric hemorrhage safety bundle (which consists of 17 key practices in four domains) in multiple California hospitals. Results A total of 126 hospitals were engaged to simultaneously implement the safety bundle. The adoption rates for the recommended practices in the four action domains were (1) Readiness, 78.9%; (2) Recognition and Prevention, 76.5%; (3) Response, 63.1%; and (4) Reporting and Systems Learning, 58.7%. Mentors (31/40) and participating teams (48 responses from 39/126 hospitals) provided feedback in an exit survey. Among the respondents, 64.5% of mentors and 72.9% of participants agreed that compared to a traditional collaborative structure, the mentor model was better suited for quality improvement at scale. Conclusion The mentor model was successful in providing individualized support to teams and enabled implementation of the hemorrhage safety bundle across a diverse group of 126 hospitals.

Background High and low prepregnancy BMI are risk factors for severe maternal morbidity (SMM), but the contribution of gestational weight gain (GWG) is not well understood. Objectives We evaluated associations between GWG and SMM by prepregnancy BMI group. Methods We analyzed administrative records from 2,483,684 Californian births (2007-2012), utilizing z score charts to standardize GWG for gestational duration. We fit the z scores nonlinearly and categorized GWG as above, within, or below the Institute of Medicine (IOM) recommendations after predicting equivalent GWG at term from the z score charts. SMM was defined using a validated index. Associations were estimated using multivariable logistic regression models. Results We found generally shallow U-shaped relations between GWG z score and SMM in all BMI groups, except class 3 obesity (≥40 kg/m2), for which risk was lowest with weight loss. The weight gain amount associated with the lowest risk of SMM was within the IOM recommendations for underweight and class 2 obesity, but above the IOM recommendations for normal weight, overweight, and class 1 obesity. The adjusted risk ratios (RRs) and 95% CIs for GWG below the IOM recommendations, compared with GWG within the recommendations, were the following for underweight, normal weight, overweight, class 1 obesity, class 2 obesity, and class 3 obesity: 1.13 (0.99, 1.29), 1.09 (1.04, 1.14), 1.10 (1.01, 1.19), 1.07 (0.95, 1.21), 1.03 (0.88, 1.22), and 0.89 (0.73, 1.08), respectively. For GWG above the recommendations, the corresponding RRs and 95% CIs were 0.99 (0.84, 1.15), 1.04 (0.99, 1.08), 0.98 (0.92, 1.04), 1.03 (0.95, 1.13), 1.07 (0.94, 1.23), and 1.08 (0.91, 1.30), respectively. Conclusions High and low GWG may be modestly associated with increased risk of SMM across BMI groups, except in women with class 3 obesity, for whom low weight gain and weight loss may be associated with decreased risk of SMM.

The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.

Background An association between prepregnancy body mass index (BMI) and severe maternal morbidity (SMM) has been reported, but evidence has been mixed and potential explanations have not been examined. Objective To evaluate the association between prepregnancy BMI and SMM in a large, diverse birth cohort and assess potential mediation by obesity-related co-morbidities and caesarean birth. Methods This cohort study used linked birth certificate and hospitalisation discharge records from Californian births during 2007-2012. We assessed associations between prepregnancy BMI and SMM, and used inverse probability weighting for multiple mediators to estimate relative and absolute natural direct and indirect effects accounting for mediation by co-morbidities (hypertensive conditions, diabetes, asthma) and caesarean birth. Results Among 2 650 182 births, the prevalence of SMM was 1.42%. Adjusted risk ratios for the total association between prepregnancy BMI category and SMM were 1.12 (95% confidence interval [CI] 1.07, 1.18) for underweight, 1.02 (95% CI 0.99, 1.04) for overweight, 1.04 (95% CI 1.00, 1.07) for obesity class 1, 1.14 (95% CI 1.09, 1.20) for obesity class 2, and 1.28 (95% CI 1.22, 1.36) for obesity class 3 compared to women with normal weight. After accounting for mediation by co-morbidity and caesarean birth, the risk ratios were 1.19 (95% CI 1.14, 1.26) for underweight, 0.91 (95% CI 0.89, 0.94) for overweight, 0.86 (95% CI 0.84, 0.89) for obesity class 1, 0.88 (95% CI 0.84, 0.92) for obesity class 2, and 0.89 (95% CI 0.83, 0.95) for obesity class 3. Conclusions Co-morbidities and caesarean birth explained an association between high prepregnancy BMI and SMM. These findings suggest that promotion of healthy prepregnancy weight, along with management of co-morbidities and support of vaginal birth in pregnant women with high BMI, could reduce the risk of SMM. However, these mediators did not reduce the elevated risk of SMM observed in women with low BMI.

Objective To describe quality improvement opportunities (QIOs) associated with the five leading causes of pregnancy-related death in California and the methods by which the QIOs were collected by the California Pregnancy-Associated Mortality Review committee. Design Qualitative, descriptive design using thematic analysis. Sample A total of 907 QIOs identified from 203 cases of pregnancy-related deaths from cardiovascular disease, preeclampsia/eclampsia, hemorrhage, venous thromboembolism, and sepsis that occurred in California from 2002 to 2007. Methods We coded and thematically organized QIO data using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. We refer to the domains collectively as the 4R Framework. Results We identified key themes across the five leading causes of death. In the Readiness domain, themes were related to overall facility readiness and helping women be prepared and knowledgeable about pregnancy and childbirth. Themes that emerged as central in the Recognition domain addressed the need for clinicians to better recognize risk factors and women’s signs and symptoms to ensure an accurate diagnosis. In the Response domain, three themes were predominant, and they were related to the coordination of care, timing of treatment, and follow-up care. Conclusion Results from our study show the utility and transferability of the first three domains of the 4R Framework as applied to quality improvement data from a large statewide maternal mortality review. Nursing leadership is necessary to support and guide national, statewide, and local efforts to improve the quality of maternity care through the implementation of quality improvement at the system, facility, clinician, and patient levels.

Background Value-based health care aims to optimize the balance of patient outcomes and health care costs. To improve value in perinatal care using this strategy, standard outcomes must first be defined. The objective of this work was to define a minimum, internationally appropriate set of outcome measures for evaluating and improving perinatal care with a focus on outcomes that matter to women and their families. Methods An interdisciplinary and international Working Group was assembled. Existing literature and current measurement initiatives were reviewed. Serial guided discussions and validation surveys provided consumer input. A series of nine teleconferences, incorporating a modified Delphi process, were held to reach consensus on the proposed Standard Set. Results The Working Group selected 24 outcome measures to evaluate care during pregnancy and up to 6 months postpartum. These include clinical outcomes such as maternal and neonatal mortality and morbidity, stillbirth, preterm birth, birth injury and patient-reported outcome measures (PROMs) that assess health-related quality of life (HRQoL), mental health, mother-infant bonding, confidence and success with breastfeeding, incontinence, and satisfaction with care and birth experience. To support analysis of these outcome measures, pertinent baseline characteristics and risk factor metrics were also defined. Conclusions We propose a set of outcome measures for evaluating the care that women and infants receive during pregnancy and the postpartum period. While validation and refinement via pilot implementation projects are needed, we view this as an important initial step towards value-based improvements in care. Electronic supplementary material The online version of this article (10.1186/s12913-018-3732-3) contains supplementary material, which is available to authorized users.

Background Birth hospital has recently emerged as a potential key contributor to disparities in severe maternal morbidity, but investigations on its contribution to racial and ethnic differences remain limited. Objective We leveraged statewide data from California to examine whether birth hospital explained racial and ethnic differences in severe maternal morbidity. Study Design This cohort study used data on all births at ≥20 weeks gestation in California (2007–2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least 1 of the 21 diagnoses and procedures (eg, eclampsia, blood transfusion, hysterectomy). Mixed-effects logistic regression models (ie, women nested within hospitals) were used to compare racial and ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, comorbidities, and hospital characteristics. We also estimated the risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percentage reduction in severe maternal morbidity if each group of racially and ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic white women. Results Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian and Pacific Islander; 1.1% white; 1.6% American Indian and Alaska Native, and Mixed-race referred to as Other). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, the odds of severe maternal morbidity were greater among nonwhite women than white women in a given hospital (Black: odds ratio, 1.25; 95% confidence interval, 1.19–1.31); US-born Hispanic: odds ratio, 1.25; 95% confidence interval, 1.20–1.29; foreign-born Hispanic: odds ratio, 1.17; 95% confidence interval, 1.11–1.24; Asian and Pacific Islander: odds ratio, 1.26; 95% confidence interval, 1.21–1.32; Other: odds ratio, 1.31; 95% confidence interval, 1.15–1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of white women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared with 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and white women and accounted for 16.1% to 24.2% of the differences for all other racial and ethnic groups. Conclusion In California, excess odds of severe maternal morbidity among racially and ethnically minoritized women were not fully explained by birth hospital. Structural causes of racial and ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.

Summary In high-income countries, medical interventions to address the known risks associated with pregnancy and birth have been largely successful and have resulted in very low levels of maternal and neonatal mortality. In this Series paper, we present the main care delivery models, with case studies of the USA and Sweden, and examine the main drivers of these models. Although nearly all births are attended by a skilled birth attendant and are in an institution, practice, cadre, facility size, and place of birth vary widely; for example, births occur in homes, birth centres, midwifery-led birthing units in hospitals, and in high intervention hospital birthing facilities. Not all care is evidenced-based, and some care provision may be harmful. Fear prevails among subsets of women and providers. In some settings, medical liability costs are enormous, human resource shortages are common, and costs of providing care can be very high. New challenges linked to alteration of epidemiology, such as obesity and older age during pregnancy, are also present. Data are often not readily available to inform policy and practice in a timely way and surveillance requires greater attention and investment. Outcomes are not equitable, and disadvantaged segments of the population face access issues and substantially elevated risks. At the same time, examples of excellence and progress exist, from clinical interventions to models of care and practice. Labourists (who provide care for all the facility's women for labour and delivery) are discussed as a potential solution. Quality and safety factors are informed by women's experiences, as well as medical evidence. Progress requires the ability to normalise birth for most women, with integrated services available if complications develop. We also discuss mechanisms to improve quality of care and highlight areas where research can address knowledge gaps with potential for impact. Evaluation of models that provide woman-centred care and the best outcomes without high costs is required to provide an impetus for change.

Objective To assess frequency of very low birth weight (VLBW) births at non-level III hospitals. Study design Retrospective cohort study using linked California birth certificate and discharge data of 2008 to 2010 for deliveries of singleton or first-born infant of multiple gestations with birth weight 400 to 1500 g. Delivery rates by neonatal level of care were obtained. Risk of delivery at non-level III centers was estimated in univariable and multivariable models. Results Of the 1 508 143 births, 13 919 (9.2%) were VLBW; birth rate at non-level III centers was 14.9% (8.4% in level I and 6.5% in level II). Median rate of VLBW births was 0.3% (range 0 to 4.7%) annually at level I and 0.5% (range 0 to 1.6%) at level II hospitals. Antepartum stay for >24 h occurred in 14.0% and 26.9% of VLBW births in level I and level II hospitals, respectively. Conclusion Further improvement is possible in reducing VLBW infant delivery at suboptimal sites, given the window of opportunity for many patients.

Appropriate use of health care resources is a priority for improving the quality of care. Overutilization affects almost all specialties including obstetrics and gynecology. Initiatives such as the Choosing Wisely campaign and the Joint Commission Perinatal Care Measures have brought attention to issues of overuse. The decision of these campaigns to focus on eliminating nonmedically indicated inductions before 39 weeks of gestation is an example of how more appropriate health care use can reduce complications and save millions of dollars. Cesarean delivery, hysterectomy, and prophylactic oophorectomy are procedures with high levels of variation in utilization, and the use of an intrauterine device is an example of underutilization. Efforts to promote adherence to best practices such as those directed at nonmedically indicated inductions could lead to more appropriate use of these interventions and improve women's health care.

Objective Independent and joint impacts of maternal race/ethnicity and obesity on adverse birth outcomes, including pre-eclampsia, low birth weight, and macrosomia, were characterized. Methods Retrospective cohort study of all 2007 California births was conducted using vital records and claims data. Maternal race/ethnicity and maternal body mass index (BMI) were the key exposures; their independent and joint impact on outcomes using regression models was analyzed. Results Racial/ethnic minority women of normal weight generally had higher risk as compared with white women of normal weight (e.g., African-American women, pre-eclampsia adjusted odds ratio [aOR] 1.60, 95% confidence interval [CI]: 1.48-1.74 vs. white women). However, elevated BMI did not usually confer additional risk (e.g., pre-eclampsia aOR comparing African-American women with excess weight with white women with excess weight, 1.17, 95% CI: 0.89-1.54). Obesity was a risk factor for low birth weight only among white women (excess weight aOR, 1.24, 95% CI: 1.04-1.49 vs. white women of normal weight) and not among racial/ethnic minority women (e.g., African-American women, 0.95, 95% CI: 0.83-1.08). Conclusions These findings add nuance to our understanding of the interplay between maternal race/ethnicity, BMI, and perinatal outcomes. While the BMI/adverse outcome gradient appears weaker in racial/ethnic minority women, this reflects the overall risk increase in racial/ethnic minority women of all body sizes.

Background Eliminating persistent racial/ethnic disparities in maternal mortality and morbidity is a public health priority. National strategies to improve maternal outcomes are increasingly focused on quality improvement collaboratives. However, the effectiveness of quality collaboratives for reducing racial disparities in maternity care is understudied. Objective To evaluate the impact of a hemorrhage quality-improvement collaborative on racial disparities in severe maternal morbidity from hemorrhage. Study Design We conducted a cross-sectional study from 2011 to 2016 among 99 hospitals that participated in a hemorrhage quality improvement collaborative in California. The focus of the quality collaborative was to implement the national maternal hemorrhage safety bundle consisting of 17 evidence-based recommendations for practice and care processes known to improve outcomes. This analysis included 54,311 women from the baseline period (January 2011 through December 2014) and 19,165 women from the postintervention period (October 2015 through December 2016) with a diagnosis of obstetric hemorrhage during delivery hospitalization. We examined whether racial/ethnic-specific severe maternal morbidity rates in these women with obstetric hemorrhage were reduced from the baseline to the postintervention period. In addition, we conducted Poisson Generalized Estimating Equation models to estimate relative risks and 95% confidence intervals for severe maternal morbidity comparing each racial/ethnic group with white. Results During the baseline period, the rate of severe maternal morbidity among women with hemorrhage was 22.1% (12,002/54,311) with the greatest rate observed among black women (28.6%, 973/3404), and the lowest among white women (19.8%, 3124/15,775). The overall rate fell to 18.5% (3553/19,165) in the postintervention period. Both black and white mothers benefited from the intervention, but the benefit among black women exceeded that of white women (9.0% vs 2.1% absolute rate reduction). The baseline risk of severe maternal morbidity was 1.34 times greater among black mothers compared with white mothers (relative risk, 1.34; 95% confidence interval, 1.27–1.42), and it was reduced to 1.22 (1.05–1.40) in the postintervention period. Sociodemographic and clinical factors explained a part of the black–white differences. After controlling for these factors, the black–white relative risk was 1.22 (95% confidence interval, 1.15–1.30) at baseline and narrowed to 1.07 (1.92–1.24) in the postintervention period. Results were similar when excluding severe maternal morbidity cases with transfusion alone. After accounting for maternal risk factors, the black–white relative risk for severe maternal morbidity excluding transfusion alone was reduced from a baseline of 1.33 (95% confidence interval, 1.16–1.52) to 0.99 (0.76–1.29) in the postintervention period. The most important clinical risk factor for disparate black rates for both severe maternal morbidity and severe maternal morbidity excluding transfusion alone was cesarean delivery, potentially providing another opportunity for quality improvement. Conclusion A large-scale quality improvement collaborative reduced rates of severe maternal morbidity due to hemorrhage in all races and reduced the performance gap between black and white women. Improving access to highly effective treatments has the potential to decrease disparities for care-sensitive acute hospital-focused morbidities.

In 2006, noting a rise in maternal deaths and complications, the California Department of Public Health launched efforts to investigate maternal deaths. In that year, the California Maternal Quality Care Collaborative was formed as a public-private partnership to lead maternal quality improvement activities. Key steps undertaken over the next decade included linking public health surveillance to actions, mobilizing a broad range of public and private partners, developing a rapid-cycle Maternal Data Center to support and sustain quality improvement initiatives, and implementing a series of data-driven large-scale quality improvement projects. While US maternal mortality has worsened in the 2010s, by 2013 California's rate had been cut in half to a three-year average of 7.0 maternal deaths per 100,000 live births. The state's rate had become comparable to the average rate in Western Europe (7.2 per 100,000). In this article we describe the key steps undertaken by the California Department of Public Health and the California Maternal Quality Care Collaborative that supported change at large scale. Special challenges for implementation are also discussed.

Background When used judiciously, cesarean sections can save lives; but in the United States, prior research indicates that cesarean birth rates have risen beyond the threshold to help women and infants and become a contributor to increased maternal mortality and rising healthcare costs. Healthy People 2020 has set the goal for nulliparous, term, singleton, vertex (NTSV) cesarean birth rate at no more than 23.9% of births. Currently, cesarean rates vary from 6% to 69% in US hospitals, unexplained by clinical or demographic factors. This wide variation in cesarean use is also seen among individual providers of intrapartum care. Previous research of birth attitudes found providers of intrapartum care hold widely differing views, which may be a key underlying factor influencing practice variation; however, further study is needed to determine if differences in attitudes are associated with differences in clinical outcomes. The purpose of this study was to estimate the association between individual provider attitudes towards birth and their low-risk primary cesarean rate. Methods Four hundred providers were drawn from a stratified random sample of all California providers of intrapartum care in 2013 and surveyed for their attitudes towards various aspects of labor and birth. Providers’ NTSV cesarean birth rates were obtained for 2013 and 2014. Covariates included gender, years of experience, practice location, and primary hospital’s NTSV cesarean rate. We used adjusted multivariate Poisson regression to compare cesarean rates and linear regression to compare attitude scores of providers meeting versus not meeting the Healthy People 2020 (HP2020) goal. Results Two hundred nine total participants (obstetricians, family physicians, and midwives) completed surveys, of which 109 perform cesareans. Providers’ NTSV cesarean rate was significantly associated with their composite attitudes score [IRR for each one-point increase 1.21 (95% CI 1.002–1.45)]. Physicians meeting the HP2020 goal held attitudes which were significantly more favorable towards vaginal birth: mean 2.70 (95% CI 2.58–2.83) versus 2.91 (95% CI 2.82–3.00), p

State Perinatal Quality Collaboratives (PQCs) are networks of multidisciplinary teams working to improve maternal and infant health outcomes. To address the shared needs across state PQCs and enable collaboration, Centers for Disease Control and Prevention, in partnership with March of Dimes and perinatal quality improvement experts from across the country, supported the development and launch of the National Network of PQCs National Network of Perinatal Quality Collaboratives (NNPQC). This process included assessing the status of PQCs in this country and identifying the needs and resources that would be most useful to support PQC development. National representatives from 48 states gathered for the first meeting of the NNPQC to share best practices for making measurable improvements in maternal and infant health. The number of state PQCs has grown considerably over the past decade, with an active PQC or a PQC in development in almost every state. However, PQCs have some common challenges that need to be addressed. After its successful launch, the NNPQC is positioned to ensure that every state PQC has access to key tools and resources that build capacity to actively improve maternal and infant health outcomes and healthcare quality.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.