Baysinger Curtis L, Pujic Borislava, Velickovic Ivan, Owen Medge D, Serafin Joanna, Shotwell Matthew S, Braveman Ferne
Division of Obstetric Anesthesia, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, United States.
Klinika za Ginekologiju I Akuserstvo, Klinickog Centra Vojvodine, Novi Sad, Serbia.
Front Public Health. 2017 Jun 9;5:134. doi: 10.3389/fpubh.2017.00134. eCollection 2017.
Many low- and middle-income countries (LMICs) report low rates of regional anesthesia (RA) use for cesarean delivery (CD), despite its association with lower maternal major morbidity and mortality. Also, the prevalence of neuraxial analgesia for labor (NAL) is often low in LMICs. We report on the results of a collaboration in clinical education over a multi-year period between Kybele Inc., an international non-profit organization, and Klinicki Centar Vojvodine (CCV), a teaching hospital in Novi Sad, Serbia, to increase RA use for CD and NAL at CCV. From late 2011 through 2015, teams from Kybele participated in annual to biannual didactic conferences and week-long bedside teaching efforts involving obstetric and anesthesia staff from CCV and surrounding hospitals. Ongoing contact occurred at least weekly between Kybele and the host to discuss progress. De-identified quality improvement data on total deliveries, numbers of elective and non-elective CDs, number of vaginal deliveries, type of anesthesia for CD, and the number of NALs were collected. RA use for CD increased to 25% in year 2015 versus 14% in base year 2011 [odds ratio (OR): 2.05; 95% confidence interval (CI): 1.73,2.42; < 0.001]. NAL increased to 10.5% of laboring women in 2015 versus 1.2% in 2011 (OR: 9.6; 95% CI: 7.2, 12.8; < 0.001). Greater increases for RA use during non-elective CD were observed between 2011 and 2015 (1.4 versus 7.5% of total CD; OR: 5.52; 95% CI: 2.63, 8.41; < 0.001) relative to elective CD (12.5 versus 17.5% of total CD; OR: 1.48; 95% CI: 1.23, 1.77; < 0.001). Overall, RA for CD increased during the 4 year collaboration but was not as great as reported in other countries with similar health-care demographics utilizing a similar program. Detailed descriptions of program interventions and barriers to change at CCV are presented.
许多低收入和中等收入国家（LMICs）报告称，剖宫产（CD）时区域麻醉（RA）的使用率较低，尽管其与较低的孕产妇严重发病率和死亡率相关。此外，LMICs中分娩时神经轴镇痛（NAL）的普及率通常也较低。我们报告了国际非营利组织Kybele Inc.与塞尔维亚诺维萨德的一家教学医院——伏伊伏丁那临床中心（CCV）在多年临床教育合作中的成果，旨在提高CCV剖宫产时RA的使用率以及NAL的普及率。从2011年末到2015年，Kybele的团队参加了年度至半年一次的理论研讨会以及为期一周的床边教学活动，参与人员包括CCV及周边医院的产科和麻醉科工作人员。Kybele与主办方之间至少每周进行一次沟通，讨论进展情况。收集了关于总分娩量、择期和非择期剖宫产数量、阴道分娩数量、剖宫产麻醉类型以及NAL数量的匿名质量改进数据。2015年剖宫产时RA的使用率增至25%，而2011年基准年为14%[优势比（OR）：2.05；95%置信区间（CI）：1.73,2.42；P＜0.001]。2015年，分娩妇女中NAL的使用率增至10.5%，而2011年为1.2%（OR：9.6；95%CI：7.2,12.8；P＜0.001）。2011年至2015年期间，非择期剖宫产时RA使用率的增幅更大（占总剖宫产的比例从1.4%增至7.5%；OR：5.52；95%CI：2.63,8.41；P＜0.001），相比之下，择期剖宫产时RA使用率的增幅较小（占总剖宫产的比例从12.5%增至17.5%；OR：1.48；95%CI：1.23,1.77；P＜0.001）。总体而言，在为期4年的合作期间，剖宫产时RA的使用率有所增加，但不如其他具有类似医疗保健人口统计学特征且采用类似项目的国家所报告的增幅大。本文还介绍了CCV项目干预措施的详细情况以及变革的障碍。
