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

Borem, Paulo; Sánchez, Rebeca; Torres, Jacqueline Alves; Delgado, Pedro L.; Petenate, Ademir José; Peres, Daniel; Parry, Gareth; Betrán, Ana Pilar; Barker, Pierre

doi:10.1097/aog.0000000000003619

Cited by 25 publications

(61 citation statements)

References 23 publications

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“…111,292 women delivered in the period before the hard-stop policy (2008–2010), and 69,742 women delivered after the rollout of the policy (2012–2013). Baseline total CS rate: 26% Baseline early CS rate: 4% Outcomes assessed: CS, maternal morbidity, neonatal morbidity and mortality Borem 2020 [ 37 ] Interrupted time series (ITS) study Study period: 2014 to 2016 Baseline period: January to December 2014 to the year following the set-up period of Projeto Parto Adequado (PPA) or “Appropriate Birth” project; Full implementation period: January to December 2016 Country: Brazil Low risk women (nulliparous, term, singleton, vertex) in Brazilian hospitals. Twenty-eight hospitals enrolled in a 20-month quality improvement (QI) Collaborative that targeted low-risk pregnancies.…”

Section: Resultsmentioning

confidence: 99%

“…The study found no effect on elective CS (OR 1.00, 95% CI 0.97 to 1.03). An additional study (Brazil) [37] assessed the effect of a multifaceted quality improvement initiative ("Appropriate Birth"), that among other change packages, included new contracts between payers and providers and between health plan and hospital creating incentives for quality and safety. Vaginal births increased following implementation of the quality improvement initiative (relative increase of 1.62, 95% CI 1.27 to 2.07).…”

Section: Other Interventionsmentioning

confidence: 99%

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Reducing unnecessary caesarean sections: scoping review of financial and regulatory interventions

et al. 2020

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Background: Caesarean sections (CS) are increasing worldwide. Financial incentives and related regulatory and legislative factors are important determinants of CS rates. This scoping review examines the evidence base of financial, regulatory and legislative interventions intended to reduce CS rates. Methods: We searched MEDLINE, EMBASE, CINAHL and two trials registers in June 2019. Both experimental and observational intervention studies were eligible for inclusion. Primary outcome measures were: CS, spontaneous vaginal and instrumental birth rates. We assessed quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. Results: We identified 9057 articles and assessed 65 full-texts. We included 16 observational studies. Most of the studies were conducted in high-income countries. Three studies assessed payment methods for health workers: equalising physician fees for vaginal and caesarean delivery reduced CS rates in one study; however, little or no difference in CS rates was found in the remaining two studies. Nine studies assessed payment methods for health organisations: There was no difference in CS rates between diagnosis-related group (DRG) payment system compared to fee-forservice system in one study. However, DRG system was associated with lower odds for CS in another study. There was little or no difference in CS rates following implementation of global budget payment (GBP) system in two studies. Vaginal birth after caesarean section (VBAC) increased after implementation of a case-based payment system in one study. Caesarean section increased while VBAC rates decreased following implementation of a cap-based payment system in another study. Financial incentive for providers to promote vaginal delivery combined with free vaginal delivery policy was found to reduce CS rates in one study. Studied regulatory and legislative interventions (comprising legislatively imposed practice guidelines for physicians in one study and multi-faceted strategy which included policies to control CS on maternal request in another

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Section: Resultsmentioning

confidence: 99%

Section: Other Interventionsmentioning

confidence: 99%

Reducing unnecessary caesarean sections: scoping review of financial and regulatory interventions

et al. 2020

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“…The PPA is a quality improvement project of childbirth care implemented in Brazilian public and private hospitals, with the goal of increasing the percentage of vaginal deliveries and reducing the rate of hospitalization in a neonatal intensive care unit (NICU) [11][12][13] . It is an ongoing project, started in May 2015 and developed in three phases described in Fig.…”

Section: Methodsmentioning

confidence: 99%

“…In the rst phase of the project, managers and local leaders participated in ve face-to-face learning sessions in addition to monthly virtual learning sessions, focusing on training in the improvement model, initial tests of change to reduce the cesarean rate based on the four PPA components and sharing successful experiences and challenges in implementing changes. In addition, the project offered clinical training at realistic simulation centers, with a focus on assisting physiological vaginal delivery and managing obstetric complications 12 .…”

Section: Methodsmentioning

confidence: 99%

“…In Brazilian private hospitals, cesarean section rates reach 90% 9, 10 . In 2015, the National Supplementary Health Agency (ANS), responsible for regulating the supplementary health sector in the country, together with the Institute for Health Improvement (IHI) and Hospital Israelita Alberto Einstein, and with the support of the Brazilian Ministry of Health, implemented the Adequate Childbirth Project ("Projeto Parto Adequado-PPA"). This is a quality improvement project of childbirth care in Brazilian hospitals that aims to identify innovative and viable models of care, which value vaginal delivery and reduce the percentage of cesarean sections without clinical indication 11,12 .…”

Section: Introductionmentioning

confidence: 99%

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Cost-Effectiveness Analysis of A Quality Improvement Program to Reduce Cesarean Sections in Brazilian Private Hospitals: A Case Study

Domingues

Luz

Ayres

et al. 2020

Preprint

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Background: In 2015, a quality improvement project of childbirth care called Adequate Birth Project (“Projeto Parto Adequado”- PPA) was implemented in Brazilian public and private hospitals, aiming to improve the quality of childbirth care and to reduce cesarean sections without clinical indications. The objective of this study is to conduct an economic analysis of two models of care existing in a private Brazilian hospital - the model following the recommendations of the PPA and the standard of care model - in reducing the proportion of cesarean sections. Methods: We conducted a case study in one of the private hospitals included in the PPA project. The main outcome was the proportion of cesarean section. We used total cost of hospitalization for women and newborns, from the perspective of the health care provider, during the length of the observed hospital stay. We did not apply discount rates and inflation rate adjustments due to the short time horizon. We conducted univariate sensitivity analysis using the minimum and maximum costs observed in hospitalizations and variation in the probabilities of cesarean section and of maternal and neonatal complications. Results: 238 puerperal women were included in this analysis. The PPA model of care resulted in a 56.9 percentage point reduction in the cesarean section probability (88.6% vs 31.7%, p <0.001) and an increase in the total cost of US$ 67,346.25, which an incremental cost-effectiveness ratio of US$ 1,183.59 per avoided cesarean section. Women in the PPA model of care also had a higher proportion of spontaneous and induced labor and a lower proportion of early term births. There were no maternal, fetal or neonatal deaths and no significant differences in cases of maternal and neonatal nearmiss. The cost of uncomplicated vaginal births and cesarean sections was the parameter with the greatest impact on the cost-effectiveness ratio of the PPA model of care. Conclusion: The quality improvement project of childbirth care “PPA” was cost-effective in reducing cesarean sections in women assisted in a Brazilian private hospital, without increasing severe negative maternal and neonatal outcomes and reducing the frequency of early term births.

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Knowledge Gaps in Placenta Accreta Spectrum

et al. 2023

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Since its first description early in the 20th Century, placenta accreta and its variants have changed substantially in incidence, risk factor profile, clinical presentation, diagnosis and management. While systematic use of diagnostic tools and a multidisciplinary team care approach has begun to improve patient outcomes, the condition's pathophysiology, epidemiology, and best practices for diagnosis and management remain poorly understood. The use of large databases with broadly accepted terminology and diagnostic criteria should accelerate research in this area. Future work should focus on non-traditional phenotypes, such as those without placenta previa–preventive strategies, and long term medical and emotional support for patients facing this diagnosis. Key Points

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

Abstract: al. A quality improvement initiative to increase the frequency of vaginal delivery in Brazilian hospitals. Obstet Gynecol 2020;135. The authors provided this information as a supplement to their article.

Cited by 25 publications

References 23 publications

Reducing unnecessary caesarean sections: scoping review of financial and regulatory interventions

Reducing unnecessary caesarean sections: scoping review of financial and regulatory interventions

Cost-Effectiveness Analysis of A Quality Improvement Program to Reduce Cesarean Sections in Brazilian Private Hospitals: A Case Study

Knowledge Gaps in Placenta Accreta Spectrum

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