Supporting Vaginal Birth in Illinois: the Role of Unit Culture

摘要 如果使用得当，剖腹产(剖腹产)可以挽救生命。然而，研究表明，使用 在美国，剖腹产的比例已经远远超过了必要的水平，并已成为一种 导致产妇发病率和死亡率的因素。剖腹产患者面临更高的严重风险 羊水栓塞、大出血、胎盘异常等并发症 怀孕和死亡。剖腹产婴儿患呼吸道并发症的风险增加， 新出现的研究表明，慢性病。出于这些原因，健康人2020的目标是减少 第一次怀孕的母亲的剖腹产率与≤之比为23.9%。目前，超过三分之一的妇女在美国分娩 美国通过剖腹产分娩。全美医院的剖腹产率从6%到69%不等， 即使在控制了患者的临床因素和医院和患者的情况下，仍存在显著差异 人口统计数据。患者要求剖腹产的比例不到全国剖腹产的1%，因此， 无法解释这种变化。我们先前的工作发现，实践中的这种变化与劳动有关 和分娩单位培养，而且，剖腹产过度使用的成功减少与特定的 单位文化的方方面面，例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，并相信孕产妇机构的重要性。组织文化有 已被证明是减少其他临床领域医院结果差异的关键因素；以及， 强调其重要性的是，解决剖腹产过度使用问题的国家安全捆绑包向医院收取 “发展一种支持阴道分娩的单位文化。”不幸的是，有证据表明，这方面的质量 参与减少剖宫产倡议的医院对改进措施的关注最少 过度使用。在加州全州范围内的倡议实施了两年后，大约42%的医院的剖腹产率仍然超过 2020年健康人口目标。这并不令人惊讶，因为几乎没有工具，也没有经过严格设计的用户- 以中心为中心的工具可以帮助医院实施文化变革。这项建议充分利用了 在实施的不同阶段支持多个州级围产期质量协作， 不断完善劳动文化调查工具。我们将致力于以用户为中心的全面设计 创建、调整和实施“文化变革工具集”的过程，用于以医院为基础的、组织的 努力提高文化素质，减少剖宫产的过度使用。此外，我们还将纳入患者 作为设计和适应过程中的关键利益攸关方的观点和反馈。根据我们之前的数据， 支持阴道分娩的单位培养每提高1个百分点，剖腹产就会转化为331,773例 每年27%的美国剖腹产和9%的美国出生是通过阴道分娩和低风险的初级 剖宫产率将从28%下降到19%，从而实现2020年健康人口目标并有所改善 孕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.