Can differences in obstetric outcomes be explained by differences in the care provided? The MFMU Network APEX study

Am J Obstet Gynecol. 2014 Aug;211(2):147.e1-147.e16. doi: 10.1016/j.ajog.2014.03.017. Epub 2014 Mar 12.


Objective: The purpose of this study was to determine whether hospital differences in the frequency of adverse obstetric outcomes are related to differences in care.

Study design: The Assessment of Perinatal EXcellence cohort comprises 115,502 women and their neonates who were born in 25 hospitals in the United States between March 2008 and February 2011. Hierarchical logistic regression was used to quantify the amount of variation in postpartum hemorrhage, peripartum infection, severe perineal laceration, and a composite adverse neonatal outcome among hospitals that is explained by differences in patient characteristics, hospital characteristics, and obstetric care provided.

Results: The study included 115,502 women. For most outcomes, 20-40% of hospital differences in outcomes were related to differences in patient populations. After adjusting for patient-, provider-, and hospital-level factors, multiple care processes were associated with the predefined adverse outcomes; however, these care processes did not explain significant variation in the frequency of adverse outcomes among hospitals. Ultimately, 50-100% of the interhospital variation in outcomes was unexplained.

Conclusion: Hospital differences in the frequency of adverse obstetric outcomes could not be explained by differences in frequency of types of care provided.

Keywords: obstetrics; quality care; quality measures.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Cohort Studies
  • Delivery, Obstetric / statistics & numerical data
  • Female
  • Hospitals / statistics & numerical data*
  • Humans
  • Infant, Newborn
  • Infections / epidemiology
  • Labor, Induced / statistics & numerical data
  • Lacerations / epidemiology
  • Logistic Models
  • Maternal Health Services / statistics & numerical data*
  • Outcome Assessment, Health Care*
  • Perineum / injuries
  • Postpartum Hemorrhage / epidemiology
  • Pregnancy
  • Pregnancy Complications / epidemiology*
  • Pregnancy Outcome*
  • Quality of Health Care
  • United States / epidemiology
  • Venous Thromboembolism / epidemiology
  • Young Adult

Grant support