BackgroundValue-based health care aims to optimize the balance of patient outcomes and health care costs. To improve value in perinatal care using this strategy, standard outcomes must first be defined. The objective of this work was to define a minimum, internationally appropriate set of outcome measures for evaluating and improving perinatal care with a focus on outcomes that matter to women and their families.MethodsAn interdisciplinary and international Working Group was assembled. Existing literature and current measurement initiatives were reviewed. Serial guided discussions and validation surveys provided consumer input. A series of nine teleconferences, incorporating a modified Delphi process, were held to reach consensus on the proposed Standard Set.ResultsThe Working Group selected 24 outcome measures to evaluate care during pregnancy and up to 6 months postpartum. These include clinical outcomes such as maternal and neonatal mortality and morbidity, stillbirth, preterm birth, birth injury and patient-reported outcome measures (PROMs) that assess health-related quality of life (HRQoL), mental health, mother-infant bonding, confidence and success with breastfeeding, incontinence, and satisfaction with care and birth experience. To support analysis of these outcome measures, pertinent baseline characteristics and risk factor metrics were also defined.ConclusionsWe propose a set of outcome measures for evaluating the care that women and infants receive during pregnancy and the postpartum period. While validation and refinement via pilot implementation projects are needed, we view this as an important initial step towards value-based improvements in care.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3732-3) contains supplementary material, which is available to authorized users.

Objective To examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital. Methods This was a retrospective cohort study of 9,381 singleton live births at one community hospital, where women were provided labor and delivery care under one of two distinct practice models: a traditional “private” practice model and a midwife-physician “laborist” practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the chi square test and multivariable logistical regression. Results Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%, p<0.001; adjusted odds ratio [aOR] 2.11, 95% confidence interval [CI] 1.73-2.58). Women with nulliparous, term, singleton, vertex (NTSV) gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% versus 15.9%, p<0.001; aOR 1.86, 95% CI 1.33-2.58) as were women who had a prior cesarean delivery (71.3% versus 41.4%, p<0.001; aOR 3.19, 95% CI 1.74-5.88). Conclusion In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.

Objective: To determine interest in and barriers to video visits in safety-net patients with diverse age, racial/ethnic, or linguistic background. Materials and methods: We surveyed patients in an urban safety-net system to assess: interest in video visits; ability to successfully complete test video visits; and barriers to successful completion of test video visits. Results: Among 202 participants, of which 177 (87.6%) were persons of color and 113 (55.9%) preferred non-English languages, 132 (65.3%) were interested in and 109 (54.0%) successfully completed a test video visit. Younger age, non-English preference, and prior smartphone application use were associated with interest. Over half (n=112) reported barriers to video visits; Internet/data access was the most common barrier (n=50, 24.8%). Conclusion: Safety-net patients are interested in video visits and able to successfully complete test visits. Internet or mobile data access is a common barrier in even urban safety-net settings and may impact equitable telemedicine access.

Objective To examine the association between expanded access to collaborative midwifery and laborist services and cesarean delivery rates. Methods This was a prospective cohort study at a community hospital between 2005 and 2014. In 2011, privately insured women changed from a private practice model to one that included 24-hour midwifery and laborist coverage. Primary cesarean delivery rates among nulliparous, term, singleton, vertex women and vaginal birth after cesarean delivery (VBAC) rates among women with prior cesarean were compared before and after the change. Multivariable logistic regression models estimated the effects of the change on the odds of primary cesarean and VBAC; an interrupted time series analysis estimated the annual rates before and after the expansion. Results There were 3,560 nulliparous term singleton vertex deliveries and 1,324 deliveries with prior cesarean during the study period; 45% were among privately insured women whose care model changed The primary cesarean rate among these privately insured women decreased after the change, from 31.7% to 25.0% (p=0.005, adjusted odds ratio (aOR) 0.56 (95% CI 0.39 – 0.81). The interrupted time series analysis estimated a 7% drop in the primary cesarean rate in the year after the expansion, and a decrease of 1.7% per year thereafter. The VBAC rate increased from 13.3% before to 22.4% afterward; aOR 2.03 (95%CI 1.08 – 3.80). Conclusion The change from a private practice to a collaborative midwifery–laborist model was associated with a decrease in primary cesarean rates and an increase in VBAC rates.

Background Extreme disparities in access, experience, and outcomes highlight the need to transform how pregnancy care is designed and delivered in the United States, especially for low-income individuals and people of color. Methods We used human-centered design (HCD) to understand the challenges facing Medicaid-insured pregnant people and design interventions to address these challenges. The HCD method has three phases: Inspiration, Ideation, and Implementation. This study focused on the first and second. In the Inspiration phase we conducted semi-structured interviews with a purposeful sample of stakeholders who had either received or participated in the care of Medicaid-insured pregnant people within our community, with a specific emphasis on representation from marginalized communities. Using a general inductive approach to thematic analysis, we identified themes, which were then framed into design opportunities. In the Ideation phase, we conducted structured brainstorming sessions to generate potential prototypes of solutions, which were tested and iterated upon through a series of community events and engagement with a diverse community advisory group. Results We engaged a total of 171 stakeholders across both phases of the HCD methodology. In the Inspiration phase, interviews with 23 community members and an eight-person focus group revealed seven insights centered around two main themes: (1) racism and discrimination create major barriers to access, experience, and the ability to deliver high-value pregnancy care; (2) pregnancy care is overmedicalized and does not treat the pregnant person as an equal and informed partner. In the Ideation phase, 162 ideas were produced and translated into eight solution prototypes. Community scoring and feedback events with 140 stakeholders led to the progressive refinement and selection of three final prototypes: (1) implementing telemedicine (video visits) within the safety-net system, (2) integrating community-based peer support workers into healthcare teams, and (3) delivering co-located pregnancy-related care and services into high-need neighborhoods as a one-stop shop. Conclusions Using HCD methodology and a collaborative community-health system approach, we identified gaps, opportunities, and solutions to address perinatal care inequities within our urban community. Given the urgent need for implementable and effective solutions, the design process was particularly well-suited because it focuses on understanding and centering the needs and values of stakeholders, is multi-disciplinary through all phases, and results in prototyping and iteration of real-world solutions.

Telemedicine in perinatal care has the potential to reduce disparities in maternal and perinatal health outcomes if implemented in an equitable manner.

Background: Extreme disparities in access, experience, and outcomes highlight the need to transform how pregnancy care is designed and delivered in the United States, especially for low-income individuals and people of color. Methods: We used human-centered design (HCD) to understand the challenges facing Medicaid-insured pregnant people and design interventions to address these challenges. The HCD method has three phases: Inspiration, Ideation, and Implementation. This study focused on the first and second. In the Inspiration phase we conducted semi-structured interviews with a purposeful sample of stakeholders who had either received or participated in the care of Medicaid-insured pregnant people within our community. Using a general inductive approach to thematic analysis, we identified themes, which were then framed into design opportunities. In the Ideation phase, we conducted structured brainstorming sessions to generate potential prototypes of solutions, which were tested and iterated upon through a series of community events. Results: We engaged a total of 171 stakeholders across both phases of the HCD methodology. In the Inspiration phase, interviews with 23 community members and an eight-person focus group revealed seven insights centered around two main themes: (1) racism and discrimination create major barriers to access, experience, and the ability to deliver high-value pregnancy care; (2) pregnancy care is overmedicalized and does not treat the pregnant person as an equal and informed partner. In the Ideation phase, 162 ideas were produced and translated into eight solution prototypes. Community scoring and feedback events with 140 stakeholders led to the progressive refinement and selection of three final prototypes: (1) implementing telemedicine (video visits) within the safety-net system, (2) integrating community-based peer support workers into healthcare teams, and (3) delivering co-located pregnancy-related care and services into high-need neighborhoods as a one-stop shop. Conclusions: Using HCD methodology and a collaborative community-health system approach, we identified gaps, opportunities and solutions to address perinatal care inequities within our urban community. Given the urgent need for implementable and effective solutions, the design process was particularly well-suited because it focuses on understanding the needs and values of stakeholders, is multi-disciplinary through all phases, and results in prototyping and iteration of real-world solutions.

Background The COVID-19 pandemic triggered unprecedented expansion of outpatient telemedicine in the United States in all types of health systems, including safety-net health systems. These systems generally serve low-income, racially/ethnically/linguistically diverse patients, many of whom face barriers to digital health access. These patients’ perspectives are vital to inform ongoing, equitable implementation efforts. Methods Twenty-five semi-structured interviews exploring a theoretical framework of technology acceptability were conducted from March through July 2020. Participants had preferred languages of English, Spanish, or Cantonese and were recruited from three clinics (general medicine, obstetrics, and pulmonary) within the San Francisco Health Network. Both deductive and inductive coding were performed. In a secondary analysis, qualitative data were merged with survey data to relate perspectives to demographic factors and technology access/use. Results Participants were diverse with respect to language (52% non-English-speaking), age (range 23-71), race/ethnicity (24% Asian, 20% Black, 44% Hispanic/Latinx, 12% White), & smartphone use (80% daily, 20% weekly or less). All but 2 had a recent telemedicine visit (83% telephone). Qualitative results revealed that most participants felt telemedicine visits fulfilled their medical needs, were convenient, and were satisfied with their telemedicine care. However, most still preferred in-person visits, expressing concern that tele-visits relied on patients’ abilities to access telemedicine, as well as monitor and manage their own health without in-person physical evaluation. Conclusions High satisfaction with telemedicine can co-exist with patient-expressed hesitations surrounding the perceived effectiveness, self-efficacy, and digital access barriers associated with a new model of care. More research is needed to guide how healthcare systems and clinicians make decisions and communicate about visit modalities to support high-quality care that responds to patients’ needs and circumstances.