Supporting Vaginal Birth in Illinois: the Role of Unit Culture

总结 如果使用得当，剖腹产可以挽救生命。研究表明，使用 在美国，剖腹产的数量已经远远超过了必要的水平，并已成为一个 是导致产妇发病率和死亡率的主要因素。剖腹产的患者面临严重的风险增加 并发症，如羊水栓塞，灾难性出血，未来胎盘异常 怀孕和死亡。剖腹产婴儿面临呼吸系统并发症的风险增加， 新的研究表明，慢性病。因此，《2020年健康人》的目标是减少 第一次分娩的剖宫产率降至≤ 23.9%。目前，超过三分之一的妇女在 美国通过剖腹产分娩。美国的医院剖宫产率从6%到69%不等， 即使在控制患者临床因素以及医院和患者时， 人口统计。要求剖腹产的患者占全国剖腹产人数的不到1%，因此， 无法解释这种变化。我们先前的工作已经发现，这种变化在实践中与劳动力有关 和分娩单位文化，而且，成功减少剖宫产过度使用与特定的 单位文化的各个方面，如减少对阴道分娩的恐惧，医生接受监督，同意 以证据为基础的做法，并相信母亲机构的重要性。组织文化具有 已被证明是减少其他临床领域医院结局差异的关键因素;以及， 强调其重要性，国家安全捆绑解决剖宫产过度使用收费医院， "发展一种支持顺产的单位文化"不幸的是，有证据表明，这方面的质量 参与减少剖腹产手术的医院对改善的关注最少 过度使用经过两年的加州全州范围内的倡议，约42%的医院仍然有剖宫产率超过 2020年健康人目标。这并不奇怪，因为很少有工具，也没有严格设计的用户- 中心化的工具可以帮助医院实施文化变革。该提案利用了 支持多个国家级围产期质量协作在不同阶段的实施和新的， 不断完善劳动文化调查工具。我们将进行全面的以用户为中心的设计 创建、调整和实施“文化变革工具集”的过程，用于医院、组织 努力提高文化素质，减少剖宫产过度使用。此外，我们还将患者 作为设计和适应进程中的关键利害关系方，根据我们之前的数据， 支持阴道分娩的单位文化提高1分，将使331,773例剖腹产分娩转变， 每年27%的美国剖腹产和9%的美国分娩为阴道分娩， 剖宫产率将从28%下降到19%，从而实现2020年健康人的目标， 产妇和新生儿发病率和死亡率。

SUMMARY Cesarean deliveries (cesareans), when used judiciously, save lives. However, research indicates that the use of cesareans in the United States (US) has risen well above the level of necessity and has become a contributor to maternal morbidity and mortality. Patients who have cesareans face increased risk of serious complications such as amniotic fluid embolism, catastrophic hemorrhage, placental abnormalities in future pregnancies, and death. Babies born by cesarean face increased risk of respiratory complications, and, emerging research suggests, chronic disease. For these reasons, the Healthy People 2020 goal is to reduce cesarean rates to ≤ 23.9% for first-time mothers. Currently, over one-third of all women giving birth in the United States deliver via cesarean. Hospital cesarean rates across the US range from 6% to 69%, and significant variation remains even when controlling for patient clinical factors and hospital and patient demographics. Patient request for a cesarean make up less than 1% of cesareans nationwide, and, thus, cannot explain this variation. Our prior work has found that this variation in practice is associated with labor and delivery unit culture and, moreover, that successful reduction in cesarean overuse correlates with specific aspects of unit culture, such as decreased fear of vaginal birth, physician acceptance of oversight, agreement with evidence-based practices, and belief in the importance of maternal agency. Organizational culture has been shown to be a key element in reducing variation in hospital outcomes in other clinical areas; and, underscoring its importance, the national safety bundle addressing cesarean overuse charges hospitals to “develop a unit culture that supports vaginal birth.” Unfortunately, there is evidence that this aspect of quality improvement receives the least attention from hospitals that participate in initiatives to reduce cesarean overuse. After 2 years of a California statewide initiative, about 42% of hospitals still had cesarean rates over the Healthy People 2020 goal. This is not surprising given that few tools and no rigorously designed user- centered tools exist to help hospitals implement culture change. This proposal leverages the strength and support of multiple state-level perinatal quality collaboratives at different stages of implementation and a novel, continually improving Labor Culture Survey tool. We will engage in a comprehensive user-centered design process to create, adapt, and implement a “Culture Change Toolset” for use in hospital-based, organizational culture quality improvement efforts to reduce cesarean overuse. Furthermore, we will incorporate patient perspectives and feedback as key stakeholders in the design and adaptation process. Based on our prior data, a 1-point improvement in unit culture supportive of vaginal birth would convert 331,773 cesarean deliveries or 27% of US cesarean births and 9% of all US births each year to vaginal deliveries and the low-risk, primary cesarean rate would decrease from 28% to 19%, thus achieving the Healthy People 2020 goal and improving maternal and newborn morbidity and mortality.