Background/Objectives: Previous literature has described that non-white pregnant patients are at increased risk of severe morbidity from obstetric hemorrhage (OBH). Here, we investigate whether such disparities are secondary to delay in the administration of postpartum oxytocin for non-white patients compared to white patients. Methods: This is a retrospective cohort study of all deliveries from 2018 to 2019, comparing (1) Hispanic white or non-white race (HW/NWR) pregnant people and (2) non-Hispanic white (NHW) pregnant people. Our primary outcome was the time from delivery to the first dose of postpartum oxytocin, and our secondary outcome was the frequency of other hemorrhage interventions. Results: Out of 3832 patients with self-identified race and ethnicity recorded in their patient record, 644 patients identified as NHW, and 3188 patients identified as HW/NWR. We found no difference in time to first dose of postpartum oxytocin (p = 0.51), and there was also no difference in the frequency of other hemorrhage-related interventions. Conclusions: Our study found no delay in the administration of postpartum oxytocin for non-white patients.

Aims and ObjectivesOur goal is to describe the association between total quantitative blood loss (QBL) and risk of obstetric haemorrhage-related morbidity (OBH-M) to assess the utility of the current definition of obstetric haemorrhage (OBH). MethodsThis was a retrospective cohort study completed of all patients who had a live delivery at the only urban safety-net hospital over a 2-year period from 2018 to 2019. We categorized deliveries into 10 equally sized deciles based on QBL and compared the proportion with OBH-M in each. Among the two deciles with the highest proportions of OBH-M, we stratified deliveries into seven groups of ascending intervals of 250cc QBL. Finally, we compared the positive predictive value (PPV) of the standard definition of OBH (QBL >= 1000cc) to a definition extrapolated from our stratified analysis. The primary outcome was proportion of deliveries within each QBL decile affected by OBH-M. The secondary outcome was PPV. ResultsWe found a significant increase in OBH-M from decile 9 (895-1201cc QBL) to decile 10 (1205-8325cc QBL) (p < 0.001). In our stratified analysis, we found QBL of 1500cc to be an inflection point for an increased proportion of OBH-M. Our secondary analysis showed an increased PPV for OBH-M using QBL of 1500cc (20.5%) compared with that of QBL 1000cc (9.8%). ConclusionsOur findings suggest that a higher QBL threshold than the currently accepted definition of OBH is more predictive of OBH-M.

Objective The aim of this study was to assess whether inclusion of intrapartum risk factors improves our obstetric hemorrhage risk stratification tool in predicting obstetric hemorrhage, transfusion, and related severe morbidity.Study Design This is a retrospective cohort study using all live deliveries at a single institution over a 2-year period ( n = 5,332). Obstetric hemorrhage risk factors, hemorrhage burden, and severe maternal morbidity index outcomes were assessed through chart abstraction. Hemorrhage risk was assessed at (1) "time of admission " through chart abstraction and (2) "predelivery " by calculation after inclusion of all abstracted intrapartum risk factors. Admission high risk was compared with predelivery high risk for sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio in predicting obstetric hemorrhage, obstetric hemorrhage requiring transfusion, and obstetric hemorrhage-related severe morbidity. Significance levels were calculated using descriptive statistical methods including chi-squared tests and McNemar's tests.Results The sensitivities of the risk assessment tool using admission risk classification for high-risk patients is 25% for obstetric hemorrhage, 37% for obstetric hemorrhage requiring transfusion, and 22% for obstetric hemorrhage-related severe morbidity. After intrapartum factor inclusion, the sensitivities increase to 55% for obstetric hemorrhage, 59% for obstetric hemorrhage requiring transfusion, and 47% for obstetric hemorrhage-related severe morbidity. This "predelivery " risk assessment is significantly more sensitive across all three end points ( p < 0.001 for all three outcomes). While the positive likelihood ratios for obstetric hemorrhage are equal on admission and predelivery (2.10 on admission and predelivery), they increase after intrapartum factor inclusion for obstetric hemorrhage requiring transfusion and obstetric hemorrhage-related severe morbidity (on admission, 2.74 and 1.6, respectively, and predelivery: 4.57 and 3.58, respectively).Conclusion Inclusion of intrapartum risk factors increases the accuracy of this obstetric hemorrhage risk stratification tool in predicting patients requiring hemorrhage management with transfusion and obstetric hemorrhage-related severe morbidity.

OBJECTIVE: The PNQIN (Perinatal-Neonatal Quality Improvement Network of Massachusetts) sought to adapt the Reduction of Peripartum Racial and Ethnic Disparities Conceptual Framework and Maternal Safety Consensus Bundle by selecting and defining measures to create a bundle to address maternal health inequities in Massachusetts. This study describes the process of developing consensus-based measures to implement the PNQIN Maternal Equity Bundle across Massachusetts hospitals participating in the Alliance for Innovation on Maternal Health Initiative. METHODS: Our team used a mixed-methods approach to create the PNQIN Maternal Equity Bundle through consensus including a literature review, expert interviews, and a modified Delphi process to compile, define, and select measures to drive maternal equity-focused action. Stakeholders were identified by purposive and snowball sampling and included obstetrician-gynecologists, midwives, nurses, epidemiologists, and racial equity scholars. Dedoose 9.0 was used to complete an inductive analysis of interview transcripts. A modified Delphi method was used to reach consensus on recommendations and measures for the PNQIN Maternal Equity Bundle. RESULTS: Twenty-five interviews were completed. Seven themes emerged, including the need for 1) data stratification by race, ethnicity and language; 2) performance of a readiness assessment; 3) culture shift toward equity; 4) inclusion of antiracism and bias training; 5) addressing challenges of nonacademic hospitals; 6) a life-course approach; and 7) selection of timing of implementation. Twenty initial quality measures (structure, process, and outcome) were identified through expert interviews. Group consensus supported 10 measures to be incorporated into the bundle. CONCLUSION: Structure, process, and outcome quality measures were selected and defined for a maternal equity safety bundle that seeks to create an equity-focused infrastructure and equity-specific actions at birthing facilities. Implementation of an equity-focused safety bundle at birthing facilities may close racial gaps in maternal outcomes.

Introduction: We examined severe maternal morbidity (SMM) among birthing people with opioid use disorder (OUD) and evaluated the extent to which differences in SMM exist by race and ethnicity. Methods: We performed a retrospective cohort study using hospital discharge data for all Massachusetts births between 2016 and 2020. SMM rates for all SMM indicators, except transfusions, were computed for those diagnosed with and without OUD. Multivariable logistic regression was used to examine the association between OUD and SMM after adjusting for patient and hospital characteristics, including race and ethnicity. Results: Among 324,012 childbirths, the SMM rate was 148 (95% confidence interval [CI]. 115-189) per 10,000 childbirths among birthing people with OUD compared with 88 (95% CI, 85-91) for those without. In adjusted models, both OUD and race/ethnicity were significantly associated with SMM. Birthing people with OUD had 2.12 (95% CI, 1.64-2.75) times the odds of experiencing an SMM event compared with those without. Non-Hispanic Black and Hispanic birthing people were at 1.85 (95% CI, 1.65-2.07) and 1.26 (95% CI, 1.13-1.41) higher odds of experiencing SMM compared with non Hispanic White birthing people. Among birthing people with OUD, the odds of SMM were not significantly different between birthing people of color and non-Hispanic White individuals. Conclusions: Birthing people with OUD are at an elevated risk of SMM, underscoring the need for improved access to OUD treatment and increased support. Perinatal quality improvement collaboratives should measure SMM in bundles aimed at improving outcomes for birthing people with OUD. Published by Elsevier Inc. on behalf of Jacobs Institute of Women's Health, George Washington University.

Purpose Venous thromboembolism (VTE) accounts for a significant proportion of pregnancy-related mortality. In response to a series of VTEs at our institution and in accordance with mounting medical evidence for increased assessment, we implemented a universal, standardized obstetric VTE risk assessment process during antepartum and postpartum admissions and corresponding pharmacological thromboprophylaxis, which extends into the postdischarge period to prevent pregnancy-associated VTE in our urban, safety-net population. This quality improvement (QI) project used the Institute for Healthcare Improvement's Model for Improvement. We analyzed data from chart audits, patient and pharmacy outreach, and electronic reports using statistical process control charts. A review of 407 charts showed an increase in the proportion of patients undergoing documented risk assessment from 0% to 80% (average of 61%) from July 2015 to June 2016. The average risk assessment rate increased from 61% to 98% from July 2016 through March 2021 after the screening was integrated into the electronic health record (EHR). Rate of receipt of recommended thromboprophylaxis during admission increased from an average of 85% before EHR integration to 94% after integration. The proportion of high-risk patients receiving prescriptions upon discharge increased from 7% before EHR integration to 87% after integration. We interviewed 117 patients by telephone, of whom 74% continued the medications at home. Conclusion An interprofessional team can achieve high rates of obstetric inpatient VTE risk assessment, pharmacological thromboprophylaxis initiation, and outpatient continuation using QI methodology.

BACKGROUND This quality improvement project aimed to create a decision aid for labor induction in healthy pregnancies at or beyond 39 weeks that met the needs of pregnant people least likely to experience shared decision-making and to identify and test implementation strategies to support its use in prenatal care. METHODS We used quality improvement and qualitative methods to develop, test, and refine a patient decision aid. The decision aid was tested in three languages by providers across obstetrics, family medicine, and midwifery practices at a tertiary care hospital and two community health centers. Outcomes included patients' understanding of their choices, pros and cons of choices, and the decision being theirs or a shared one with their provider. RESULTS Patient interview data indicated that shared decision-making on labor induction was achieved. Across three Plan-Do-Study-Act cycles, we interviewed a diverse group of 24 pregnant people: 20 were people of color, 16 were publicly insured, and 15 were born outside the United States. All but one (23/24) reported feeling the decision was theirs or a shared one with their provider. The majority could name induction choices they had along with pros and cons. Interviewees described the decision-making experience as empowering and positive. Nine medical providers tested the decision aid and gave feedback. Providers stated the tool helped improve the quality of their counseling and reduce bias. CONCLUSION This project suggests that using an evidence-based and well-tested decision aid can help achieve shared decision-making on labor induction for a diverse group of pregnant people.

INTRODUCTION: The Perinatal Neonatal Quality Improvement Network (PNQIN) of Massachusetts engaged hospital teams in a statewide improvement initiative to address maternal morbidity from obstetric hemorrhage (OB HEM) through support of implementation and adherence to best practices in screening for and diagnosis of OB HEM. METHODS: The Alliance for Innovation on Maternal Health (AIM) OB HEM bundle was adapted and implemented across hospitals in Massachusetts from June to December 2021. Each month, participating hospital teams joined educational webinars, learned quality improvement strategies, received access to resources for the intervention, and submitted data on six structure and five process measures. Severe maternal morbidity rates were provided using state hospital discharge data. Reliability of implementation was monitored by structure and process measure submission. Aggregate data were shared statewide. RESULTS: Fifty-three percent of birthing hospitals in the state (21 of 40) voluntarily participated. Baseline risk screening for OB HEM was 93% and quantitative blood loss measurement (QBL) was 60% in aggregate for all teams. Six participating hospitals reported all 11 measures monthly across the 6-month period. Half of these sites had all six structure measures in place at baseline and 83% reported completion of structure measures by the end of the study period. Among these six sites, the cumulative proportion QBL utilization increased 178% from 28% to 78% and documented OB HEM risk assessment during labor admission increased 8.4% from 83% to 90%. CONCLUSION: Implementation of the OB HEM bundle was effective in increasing adherence to evidence-based care among participating birth hospitals through a collaborative, quality improvement approach.

OBJECTIVE:To standardize the preprocedure process for urgent, unscheduled cesarean deliveries to decrease the time from decision to skin incision to improve maternal and fetal outcomes.METHODS:In our quality-improvement project, we selected indications that require urgent cesarean deliveries, created a standard algorithm, then implemented a multidisciplinary process intended to reduce decision-to-incision time. This initiative was conducted from May 2019 to May 2021, with a preimplementation period from May 2019 to November 2019 (n=199), implementation period from December 2019 to September 2020 (n=283), and postimplementation period from October 2020 to May 2021 (n=160). An interrupted time series calculation was performed, with stratification by patient race and ethnicity. The primary process measure was mean decision-to-incision time. The secondary outcomes were neonatal status as measured by 5-minute Apgar score and quantitative blood loss during the cesarean delivery.RESULTS:We analyzed 642 urgent cesarean deliveries; 199 were preimplementation of the standard algorithm, and 160 were postimplementation. The mean decision-to-incision time improved from 88 minutes (95% CI 75-101 min) to 50 minutes (95% CI 47-53 min) from the preimplementation period to the postimplementation period. When stratified by race and ethnicity, the mean decision-to-incision time among Black non-Hispanic patients improved from 98 minutes (95% CI 73-123 min) to 50 minutes (95% CI 45-55 min) (t=3.27, P<.01); it improved from 84 minutes (95% CI 66-103 min) to 49 minutes (95% CI 44-55 min) among Hispanic patients (t=3.51, P<.001). There was no significant improvement in decision-to-incision time among patients in other racial and ethnic groups. When the cesarean delivery was performed for fetal indications, Apgar scores were significantly higher in the postimplementation period compared with the preimplementation period (8.5 vs 8.8 beta=0.29, P<.01).CONCLUSION:Development and implementation of a standard algorithm to expedite decision-to-incision time for unscheduled, urgent cesarean deliveries led to a significant decrease in decision-to-incision time.

Purpose of the article Cesarean rates and maternal morbidity increase with the duration of the second stage of labor. We studied the effect of hourly evaluation and documentation during the second stage of labor on maternal and fetal outcomes. Materials and methods We performed a retrospective cohort study of all women who delivered at our urban, tertiary care hospital and underwent a second stage of greater than 60 min between 1 June 2016 and 31 May 2019. There were 1498 patients with complete data. Four hundred forty patients had hourly evaluation and documentation throughout the second stage and 1058 did not. We performed t-tests, Chi-squared, and regression analyses to compare cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage and blood transfusion rates, and fetal outcomes. We performed regression analyses to evaluate for independent effect of this intervention on each outcome. Results Patients with hourly evaluation and documentation had a decreased likelihood of cesarean delivery (8.2% vs. 20.3%, p < .001), shorter second-stage of labor (98.1 min vs. 177.5 min, p < .001), decreased quantitative blood loss (514.4 mL vs. 667.7 mL, p < .001), and hemorrhage rate (12.5% vs. 19.9%, p < .001). Hourly evaluation was associated with decreased transfusion rates (3.2% vs. 5.6%, p = .05) but was not related to the number of units transfused. Regression analyses confirmed the impact of hourly documentation when potential confounders were included. These differences in outcomes were also noted when evaluation was performed and documented within every 75 min. Hourly second-stage evaluation and documentation did not affect other maternal or infant morbidities. Conclusion Hourly evaluation and documentation in the second stage was associated with decreased cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage, and transfusion.

Obstetric hemorrhage is the leading cause of maternal mortality worldwide. There are emerging risk assessment tools with labor factors to guide prenatal pre-transfusion testing. In this study, we describe a dynamic risk assessment tool that includes antepartum and intrapartum risk factors, and assess its efficacy in predicting obstetric hemorrhage and hemorrhage requiring transfusion in an urban safety-net hospital. This is a retrospective cohort study using all deliveries at Boston Medical Center over a two-year period (n = 5,332). Risk factors were assessed through chart abstraction. Hemorrhage risk classification was calculated twice: once on admission using antepartum risk factors, and once pre-delivery using antepartum and intrapartum risk factors. We found that including intrapartum risk factors increased detection of both obstetric hemorrhage and hemorrhage requiring transfusion. Only 25% of those who hemorrhaged and 37% of those who required a transfusion were identified as high-risk on admission using antepartum factors. In contrast, 55% of those who hemorrhaged and 59% of those who required a transfusion were identified as high-risk at delivery, after including intrapartum factors. Both the difference in detection rate hemorrhage and hemorrhage requiring transfusion were statistically significant at p < 0.001. The incidence of obstetric hemorrhage using intrapartum risk factors to re-classify patients at delivery was: 0.7% of low, 10.6% of medium, and 28% of high risk groups. High included an increase that was statistically significant (p < 0.001). The incidence of transfusion in each group was: low (0.7%) medium (1.2%), high (4%). High included an increase that was statistically significant (p < 0.001). Our dynamic risk assessment tool increased the detection of high-risk pregnant individuals who ultimately required hemorrhage management with transfusion due to inclusion of intrapartum factors. We recommend that providers assess both antepartum and intrapartum risk factors in determining prenatal pre-transfusion testing.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

OBJECTIVE: Our goal is to describe the association between total quantitative blood loss (QBL) and risk of obstetric hemorrhage-related morbidity (OBH-M) in order to assess utility of the current definition of obstetric hemorrhage (OBH). DESIGN: Retrospective cohort study. SETTING: Urban safety-net hospital in Boston, Massachusetts. POPULATION or SAMPLE: Deliveries at our institution over a two-year period. METHODS: We categorized deliveries into ten equally sized deciles based on QBL and compared the proportion with OBH-M in each. Among the two deciles with the highest proportions of OBH-M, we stratified deliveries into seven groups of ascending intervals of 250cc QBL. Finally, we compared the positive predictive value (PPV) of the standard definition of OBH (QBL ≥ 1000cc) to a definition extrapolated from our stratified analysis. MAIN OUTCOME MEASURES: The primary outcome was proportion of deliveries within each QBL decile affected by OBH-M. The secondary outcome was PPV. RESULTS: We found a significant increase in OBH-M from decile 9 (895-1201cc QBL) to decile 10 (1205-8325cc QBL) (p<0.001). In our stratified analysis, we found QBL of 1500cc to be an inflection point for an increased proportion of OBH-M. Our secondary analysis showed an increased PPV for OBH-M using QBL of 1500cc (20.5%) compared to that of QBL 1000cc (9.8%). CONCLUSIONS: Our findings suggest that a higher QBL threshold than the currently accepted definition of OBH is more predictive of OBH-M.

The primary objective of this study was to implement a same-day discharge pathway for patients undergoing minimally invasive gynecologic surgery at an urban, safety-net hospital. Prior to implementation, patients routinely spent one to two nights in the hospital postoperatively. This project was implemented on December 3, 2018. We utilized a screening tool to identify eligible patients for same-day discharge. The primary outcome measure was the percentage of patients discharged the same day of the surgery. We compared data between patients discharged home same day versus patients admitted to the hospital, as well as patients who underwent benign minimally invasive gynecologic surgery prior to and after project implementation. Of the 237 patients undergoing minimally invasive gynecologic surgery, 209 were eligible for same-day discharge. More than half (111, 53.1%) of the eligible patients were discharged home on the same day. Same-day discharge was not found to be associated with an increased risk of adverse events compared to patients who were not discharged same day. Same-day discharge after minimally invasive gynecologic surgery is safe and feasible in an urban safety-net hospital, especially with the addition of a screening tool to identify social determinants of health prior to surgery.

Background Most women who have had previous caesareans are eligible to have labour after caesarean (LAC), but only 11.9% do so. Studies show the majority of women have already decided about future mode of birth (FMOB) before a subsequent pregnancy. Hence, providing women with LAC counselling soon after birth may help women plan for future pregnancies. Prior to our intervention, our hospital had no method of ensuring that women received LAC counselling after caesarean section. The purpose of this QI initiative was to assess whether formal LAC documentation on labour and delivery (L&D) improves rates of LAC counselling post partum. Methods Our three-part intervention included: (1) surgeon's assessment of LAC feasibility in the operative note, (2) written LAC education for women in discharge paperwork and (3) documentation of LAC counselling in the discharge summary. We implemented these changes on L&D in January 2019. We conducted phone surveys of 40 women after caesarean preintervention and postintervention. Surveys included questions regarding three primary outcomes: whether or not they had received LAC counselling either in the hospital or at a postpartum visit, and whether or not they would pursue LAC as FMOB. Surveys also assessed two secondary outcomes: (1) women's understanding of the indications for surgery and (2) their involvement in the decision process. We used a chi(2) analysis to assess primary outcomes and a Fisher's exact test to assess secondary outcomes. We also surveyed providers about the culture of LAC counselling at our hospital. Results After our intervention, there was a significant difference between the number of women reporting LAC postpartum counselling (30.77% vs 53.8%, p=0.04). There was also a significant difference in the number of women feeling involved in the decision-making process (68% vs 95%, p=0.03). Providers reported improved knowledge/confidence around LAC counselling (58%-100%). Providers universally stated that LAC counselling has become more ingrained in the culture on L&D. Conclusions Documentation of LAC counselling improved the consistency with which providers incorporated LAC counselling into postpartum care. Addressing FMOB at the time of pLTCS and documenting that counselling may be an effective first step in empowering women to pursue LAC in future pregnancies.

OBJECTIVE To implement a standardized universal substance use screening process in an outpatient prenatal clinic at an urban tertiary care hospital. METHODS Using a quality-improvement framework that involved process modeling, stakeholder analyses, and plan-do-study-act cycles, we implemented universal substance use screening for prenatal patients using a modified 5Ps screening tool (Parents, Peers, Partner, Past, Present). Implementation included an operational workflow based on the SBIRT (Screening, Brief Intervention, Referral to Treatment) model. The primary outcome measure was percentage of patients who were screened for substance use, with a goal of 90% screened. Secondary outcome measures were percentage who screened positive and percentage of the time a positive screen resulted in documentation of a brief intervention by a health care practitioner. RESULTS Over a 19-month implementation period, 733 patient encounters were sampled. A substance use screen was completed in 618 (84%). We exceeded our goal of screening 90% of eligible patients for the final 6 months of data collection. Of the 618 completed screens, 124 (20%) screened positive. Health care practitioner documentation of brief interventions for patients with a positive screen reached 80% in the final phase of implementation, but then declined to 50% by the completion of the study period. CONCLUSION A sustainable and generalizable process to carry out substance use screening within a large prenatal practice is feasible, and assisted with identification of patients not known to be at risk. Further efforts are needed to evaluate how to sustain health care practitioner documentation of intervention in response to positive screens.

Objective The study aimed to compare the quantitative blood loss (QBL) and hemorrhage-related outcomes of pregnant women with and without a coronavirus disease 2019 (COVID-19) diagnosis. Study Design This retrospective cohort study of all live deliveries at Boston Medical Center between April 1, 2020 and July 22, 2020 compares the outcomes of pregnant women with a laboratory-confirmed COVID-19 positive diagnosis and pregnant women without COVID-19. The primary outcomes are QBL and obstetric hemorrhage. The secondary outcomes analyzed were a maternal composite outcome that consisted of obstetric hemorrhage, telemetry-level (intermediate care unit) or intensive care unit, transfusion, length of stay greater than 5 days, or intraamniotic infection, and individual components of the maternal composite outcome. Groups were compared using Student's t-test, Chi-squared tests, or Fisher's exact. Logistic regression was used to adjust for confounding variables. Results Of 813 women who delivered a live infant between April 1 and July 22, 2020, 53 women were diagnosed with COVID-19 on admission to the hospital. Women with a COVID-19 diagnosis at their time of delivery were significantly more likely to identify as a race other than white (p = 0.01), to deliver preterm (p = 0.05), to be diagnosed with preeclampsia with severe features (p < 0.01), and to require general anesthesia (p < 0.01). Women diagnosed with COVID-19 did not have a significantly higher QBL (p = 0.64). COVID-19 positive pregnant patients had no increased adjusted odds of obstetric hemorrhage (adjusted odds ratio [aOR]: 0.41, 95% confidence interval [CI]: 0.17–1.04) and no increased adjusted odds of the maternal morbidity composite (aOR: 0.98, 95% CI: 0.50–1.93) when compared with those without a diagnosis of COVID-19. Conclusion Pregnant women with COVID-19 diagnosis do not have increased risk for obstetric hemorrhage, increased QBL or risk of maternal morbidity compared with pregnant women without a COVID-19 diagnosis. Further research is needed to describe the impact of a COVID-19 diagnosis on maternal hematologic physiology and pregnancy outcomes. Key Points

Background The rate of induction of labor in the U.S. has risen from 9.6% in 1990 to 25.7% in 2018, including 31.7% of first-time births. Recent studies that have examined inductions have been small qualitative studies or relied on either medical records or administrative data. This study examines induction from the perspective of those women who experienced it, with a particular focus on the prevalence and predictors of inductions for nonmedical indications, women’s experience of pressure to induce labor and the relationship between the attempt to medically initiate labor and cesarean section. Methods Study data are drawn from the 2119 respondents to the Listening to Mothers in California survey who were planning to have a vaginal birth in 2016. Mothers were asked if there had been an attempt to medically initiate labor, if it actually started labor, if they felt pressured to have the induction, if they had a cesarean and the reason for the induction. Reasons for induction were classified as either medically indicated or elective. Results Almost half (47%) of our respondents indicated an attempt was made to medically induce their labor, and 71% of those attempts initiated labor. More than a third of the attempts (37%) were elective. Attempted induction overall was most strongly associated with giving birth at 41+ weeks (aOR 3.28; 95% C.I. 2.21–4.87). Elective inductions were more likely among multiparous mothers and in pregnancies at 39 or 40 weeks. The perception of being pressured to have labor induced was related to higher levels of education, maternal preference for less medical intervention in birth, having an obstetrician compared to a midwife and gestational ages of 41+ weeks. Cesarean birth was more likely in the case of overall induction (aOR 1.51; 95% C.I. 1.11–2.07) and especially following a failed attempt at labor induction (aOR 4.50; 95% C.I. 2.93–6.90). Conclusion Clinicians counselling mothers concerning the need for labor induction should be aware of mothers’ perceptions about birth and engage in true shared decision making in order to avoid the maternal perception of being pressured into labor induction.

This survey study assesses patients’ self-reported communication experiences with their maternity care clinicians and examines the association of these experiences with women’s reports of feeling pressure to have interventions during delivery.

Objectives. To examine the extent to which differences in medication for opioid use disorder (MOUD) in pregnancy and infant neonatal opioid withdrawal syndrome (NOWS) outcomes are associated with maternal race/ethnicity. Methods. We performed a secondary analysis of a statewide quality improvement database of opioid-exposed deliveries from January 2017 to April 2019 from 24 hospitals in Massachusetts. We used multivariable mixed-effects logistic regression to model the association between maternal race/ethnicity (non-Hispanic White, non-Hispanic Black, or Hispanic) and prenatal receipt of MOUD, NOWS severity, early intervention referral, and biological parental custody at discharge. Results. Among 1710 deliveries to women with opioid use disorder, 89.3% (n = 1527) were non-Hispanic White. In adjusted models, non-Hispanic Black women (AOR = 0.34; 95% confidence interval [CI] = 0.18, 0.66) and Hispanic women (AOR = 0.43; 95% CI = 0.27, 0.68) were less likely to receive MOUD during pregnancy compared with non-Hispanic White women. We found no statistically significant associations between maternal race/ethnicity and infant outcomes. Conclusions. We identified significant racial/ethnic differences in MOUD prenatal receipt that persisted in adjusted models. Research should focus on the perspectives and treatment experiences of non-Hispanic Black and Hispanic women to ensure equitable care for all motherinfant dyads.

Background: This study aims to implement an enhanced recovery pathway (ERP) for patients undergoing gynecologic surgery and to track clinical outcomes, including perioperative opioid use and adverse events. Methods: Patients undergoing gynecologic surgery with a planned overnight stay were eligible. The primary outcome measure was perioperative opioid use in oral morphine milligram equivalents. Secondary outcome measures included bundle completion and length of stay. Balancing measures included rates of total and specific adverse events. Data were stratified by route of surgery and univariate analyses were performed between pre- and post-ERP groups to compare demographic factors and outcome measures. Linear regression analyses were run to assess mean differences in perioperative opioid use and length of stay when adjusting for route of surgery, age, body mass index (BMI), American Society of Anesthesiologists (ASA) status, surgical subspecialty, and postoperative hemoglobin change, and/or bundle completion score. Results: The ERP was implemented in 16 weeks and selected in 63 eligible patients from February 1 to April 30, 2017. ERP bundle completion was significantly higher for all surgical categories following formal pathway implementation. Compared to the pre-ERP cohort, the ERP cohort demonstrated significantly decreased total opioid use in laparotomies (175.5 mg vs. 209.8 mg, P = 0.03) and minimally invasive surgeries (125 mg vs. 170.3 mg, P = 0.018). Additionally, significantly decreased intraoperative opioids were used in both laparotomies (95 mg vs. 105 mg, P = 0.03) and minimally invasive surgeries (75 mg vs. 108.5 mg, P < 0.0001), as well as significantly decreased postoperative opioid use in minimally invasive surgeries (15 mg vs. 45 mg, P = 0.04). A one-point increase in ERP bundle completion score was associated with a 9.2 mg decrease in total opioid used (P = 0.0375) as well as a 4.8 h decrease in length of stay (P < 0.0001) when adjusting for route of surgery, age, BMI, ASA status, surgical subspecialty, and case length. There were no significant differences in adverse events when ERP was used. Conclusions: ERP implementation was rapidly accomplished at our urban, safety-net hospital. The pathway reduced perioperative opioid use without increasing adverse events. Continued monitoring of enhanced recovery quality improvement measures, including bundle completion, is essential to ensure adherence, safety, and effectiveness. J Clin Gynecol Obstet. 2020;9(3):43-52 doi: https://doi.org/10.14740/jcgo666