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Relationship Between Labor and Delivery Unit Management Practices and Maternal Outcomes

Plough, Avery C. BA; Galvin, Grace MPH; Li, Zhonghe MS; Lipsitz, Stuart R. ScD; Alidina, Shehnaz ScD, MPH; Henrich, Natalie J. PhD, MPH; Hirschhorn, Lisa R. MD, MPH; Berry, William R. MD, MPH; Gawande, Atul A. MD, MPH; Peter, Doris PhD; McDonald, Rory PhD, MBA; Caldwell, Donna L. PhD; Muri, Janet H. MBA; Bingham, Debra DrPH, RN; Caughey, Aaron B. MD, PhD; Declercq, Eugene R. PhD; Shah, Neel T. MD, MPP

doi: 10.1097/AOG.0000000000002128
Contents: Original Research

OBJECTIVE: To define, measure, and characterize key competencies of managing labor and delivery units in the United States and assess the associations between unit management and maternal outcomes.

METHODS: We developed and administered a management measurement instrument using structured telephone interviews with both the primary nurse and physician managers at 53 diverse hospitals across the United States. A trained interviewer scored the managers' interview responses based on management practices that ranged from most reactive (lowest scores) to most proactive (highest scores). We established instrument validity by conducting site visits among a subsample of 11 hospitals and established reliability using interrater comparison. Using a factor analysis, we identified three themes of management competencies: management of unit culture, patient flow, and nursing. We constructed patient-level regressions to assess the independent association between these management themes and maternal outcomes.

RESULTS: Proactive management of unit culture and nursing was associated with a significantly higher risk of primary cesarean delivery in low-risk patients (relative risk [RR] 1.30, 95% CI 1.02–1.66 and RR 1.47, 95% CI 1.13–1.92, respectively). Proactive management of unit culture was also associated with a significantly higher risk of prolonged length of stay (RR 4.13, 95% CI 1.98–8.64), postpartum hemorrhage (RR 2.57, 95% CI 1.58–4.18), and blood transfusion (RR 1.87, 95% CI 1.12–3.13). Proactive management of patient flow and nursing was associated with a significantly lower risk of prolonged length of stay (RR 0.23, 95% CI 0.12–0.46 and RR 0.27, 95% CI 0.11–0.62, respectively).

CONCLUSION: Labor and delivery unit management varies dramatically across and within hospitals in the United States. Some proactive management practices may be associated with increased risk of primary cesarean delivery and maternal morbidity. Other proactive management practices may be associated with decreased risk of prolonged length of stay, indicating a potential opportunity to safely improve labor and delivery unit efficiency.

The management of labor and delivery units across the United States varies dramatically and appears to be independently associated with maternal outcomes.

Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and the Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; the Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Harvard Medical School, Boston, Massachusetts; the Health Ratings Center, Consumer Reports, Yonkers, New York; the Technology and Operations Management Unit, Harvard Business School, Boston, Massachusetts; the National Perinatal Information Center, Providence, Rhode Island; the Institute for Perinatal Quality Improvement, Silver Spring, Maryland; the University of Maryland School of Nursing, Baltimore, Maryland; the Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; and the Department of Community Health Sciences, Boston University School of Public Health, and the Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Corresponding author: Neel T. Shah, MD, MPP, 401 Park Drive, Landmark Center, Floor 3 East, Boston, MA 02215; email:

Supported by the Rx Foundation.

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

Presented at the Society for Maternal-Fetal Medicine's 36th Annual Pregnancy Meeting, February 1–6, 2016, Atlanta, Georgia; and at the Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists, May 6–9, 2017, San Diego, California.

The authors thank the Rx Foundation for funding this study, the National Perinatal Information Center for supporting hospital recruitment and providing administrative data and member survey data for all participating hospitals, and Sarah Hodin for supporting the development of our survey instrument.

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

© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.