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Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California

Lundsberg, Lisbet, S., PhD; Lee, Henry, C., MD; Dueñas, Grace, Villarin, MPH; Gregory, Kimberly, D., MD; Grossetta Nardini, Holly, K., MLS; Pettker, Christian, M., MD; Illuzzi, Jessica, L., MD; Xu, Xiao, PhD

doi: 10.1097/AOG.0000000000002437
Contents: Original Research

OBJECTIVE: To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices.

METHODS: Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests.

RESULTS: Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P≤.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04).

CONCLUSION: Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.

Hospitals engage in a range of quality assurance efforts in obstetric care; however, practices vary among hospitals, and several areas warrant improvement and further evaluation.

Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut; the Department of Pediatrics, Division of Neonatal & Developmental Medicine, Stanford University School of Medicine, Stanford, California; the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California; and Cushing/Whitney Medical Library, Yale University, New Haven, Connecticut.

Corresponding author: Lisbet S. Lundsberg, PhD, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 310 Cedar Street, FMB 328, New Haven, CT 06520; email:

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the AcademyHealth annual research meeting, June 25–27, 2017, New Orleans, Louisiana.

This project was supported by grant number R01HS023801 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

The authors thank the California Maternal Quality Care Collaborative and the California Perinatal Quality Care Collaborative for their assistance in coordination of the survey as well as Bat-Sheva Stein for her advice in designing the survey and assistance from Taylor Brown for implementing the survey. The authors also thank focus group members for their insights and help with the design of survey questionnaire and all survey respondents for their participation and the valuable information they provided.

Each author has indicated that he or she has met the journal's requirements for authorship.

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.