A Quality Improvement Initiative to Increase the Frequency of Vaginal Delivery in Brazilian Hospitals

Abstract

Objective: To evaluate a quality improvement (QI) initiative designed to increase the frequency of vaginal delivery in Brazilian hospitals.

Methods: Twenty-eight hospitals enrolled in a 20-month (May 2015-December 2016) Breakthrough Series Collaborative that used QI methods to increase implementation of obstetric approaches with potential to increase the frequency of vaginal delivery. All hospitals contributed qualitative data for iterative redesign. Thirteen intervention hospitals with complete data contributed to an analysis of changes in vaginal delivery in a targeted population over time. Hospitals from the São Paulo region (five intervention and eight nonintervention) contributed to a comparator analysis of changes in vaginal delivery for all deliveries over time.

Intervention: Most hospitals targeted low-risk pregnancies in primiparous women, delivered by hospital-employed obstetricians or admitted through emergency departments, and some included all pregnant women. The collaborative tested four interventions to increase vaginal delivery: 1) coalition building of stakeholders with the common purpose of ensuring "appropriate delivery," 2) empowering pregnant women to choose their preferred mode of delivery, 3) implementation of new care models favoring physiologic birth, and 4) improved information systems for continuous learning by health care providers.

Results: For 119,378 targeted deliveries (36% of all deliveries) in 13 intervention hospitals, vaginal delivery increased from 21.5% in 2014 to 34.8% in 2016, a relative increase of 1.62 (95% CI 1.27-2.07, P<.001). In the comparator analysis, vaginal delivery for all deliveries in the five São Paulo intervention hospitals increased from 16.1% to 23% (RI 1.43, P<.001) and from 11.0% to 13.0% (relative rate ratio 1.18, P<.001) in the eight nonintervention São Paulo hospitals. The relative increase in vaginal delivery between the São Paulo intervention and nonintervention groups was 1.21 (95% CI 1.05-1.41, P=.01). The rate of maternal adverse events and neonatal intensive care unit admissions for newborns who weighed at least 2,500 g did not differ significantly during the observation period.

Conclusions: Key interventions implemented with QI methods were associated with increased vaginal delivery. This approach may help address the global cesarean delivery epidemic.

Fig. 1.. Selection and participation of hospitals in Project Appropriate Birth.

Borem. Quality Improvement for Cesarean Delivery in Brazil. Obstet Gynecol 2020.

Fig. 2.. U-chart of vaginal birth percentages in the target population of 13 hospitals in the Intensive group reporting continuously throughout the baseline, intervention, and follow-up periods. Learning session 1: hospitals introduced to the model for improvement. Hospitals introduced to more than 100 change concepts and ideas (from literature) to increase vaginal births. Hospitals began participation in clinical training for vaginal delivery practices after learning session 1. Learning session 2: hospitals shared their first experiences using the model for improvement. Hospitals introduced to specific concepts and ideas for patient and family engagement. Hospitals practiced “all teach, all learn” for the first time, exchanging experiences in the storyboard walkaround format. Learning session 3: health plans (insurance companies) formally invited to join the collaborative and to support participating hospitals in their transformation. Synthesized learning from testing and narrowed down the change package from more than 100 change concepts to 18 high-effect concepts and corresponding ideas. Learning session 4: hospitals introduced to methods and tools to promote physician engagement in improvement work and behavior change. Learning session 5: celebrated results and motivated hospitals. Selected hospitals shared their success stories on stage. Identified bright spot hospitals to lead subsequent phase. Set the vision for a national campaign in 2020. UCL, upper control limit; LCL, lower control limit.

Borem. Quality Improvement for Cesarean Delivery in Brazil. Obstet Gynecol 2020.

Fig. 3.. A. U-chart of vaginal birth percentages among total hospital births in five hospitals comprising the Intensive group (São Paulo). B. U-chart of vaginal birth percentages among total hospital births in eight hospitals comprising the Comparison group (São Paulo). UCL, upper control limit; LCL, lower control limit.

Borem. Quality Improvement for Cesarean Delivery in Brazil. Obstet Gynecol 2020.