Institute for Healthcare Improvement, Boston, Massachusetts; Departamento Materno Infantil, Sociedade Beneficente Israelita Brasileira Albert Einstein, São Paulo, and Agencia Nacional de Saude Suplementar, Rio de Janeiro, Brazil; Harvard Medical School, Boston, Massachusetts; the Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland; and the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Obstet Gynecol. 2020 Feb;135(2):415-425. doi: 10.1097/AOG.0000000000003619.
To evaluate a quality improvement (QI) initiative designed to increase the frequency of vaginal delivery in Brazilian hospitals.
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.
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.
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.
Key interventions implemented with QI methods were associated with increased vaginal delivery. This approach may help address the global cesarean delivery epidemic.
评估一项旨在提高巴西医院阴道分娩率的质量改进（QI）计划。
28 家医院参与了为期 20 个月（2015 年 5 月至 2016 年 12 月）的突破性系列协作，该协作使用 QI 方法来增加具有增加阴道分娩可能性的产科方法的实施。所有医院都为迭代重新设计提供了定性数据。13 家有完整数据的干预医院对目标人群中阴道分娩的时间变化进行了分析。来自圣保罗地区的医院（5 家干预医院和 8 家非干预医院）对所有分娩中阴道分娩的时间变化进行了比较分析。
大多数医院针对初产妇的低风险妊娠，由医院雇用的产科医生分娩或通过急诊部门入院，一些医院还包括所有孕妇。该协作测试了四项增加阴道分娩的干预措施：1）建立有共同目标的利益相关者联盟，确保“适当分娩”；2）赋予孕妇选择自己喜欢的分娩方式的权力；3）实施有利于生理分娩的新护理模式；4）改进医疗保健提供者的持续学习信息系统。
在 13 家干预医院的 119378 例目标分娩（占所有分娩的 36%）中，阴道分娩率从 2014 年的 21.5%上升到 2016 年的 34.8%，相对增加了 1.62（95%CI 1.27-2.07，P<.001）。在比较分析中，圣保罗 5 家干预医院所有分娩中阴道分娩率从 16.1%上升到 23%（RI 1.43，P<.001），从 11.0%上升到 13.0%（相对率比 1.18，P<.001）圣保罗的 8 家非干预医院。圣保罗干预组和非干预组之间阴道分娩的相对增加率为 1.21（95%CI 1.05-1.41，P=.01）。在观察期间，新生儿体重至少为 2500 克的产妇不良事件和新生儿重症监护病房入院率无显著差异。
实施质量改进方法的关键干预措施与阴道分娩率的增加有关。这种方法可能有助于解决全球剖宫产率过高的问题。
