Association between hospital-level obstetric quality indicators and maternal and neonatal morbidity

Abstract

Importance: In an effort to improve the quality of care, several obstetric-specific quality measures are now monitored and publicly reported. The extent to which these measures are associated with maternal and neonatal morbidity is not known.

Objective: To examine whether 2 Joint Commission obstetric quality indicators are associated with maternal and neonatal morbidity.

Design, setting, and participants: Population-based observational study using linked New York City discharge and birth certificate data sets from 2010. All delivery hospitalizations were identified and 2 perinatal quality measures were calculated (elective, nonmedically indicated deliveries at 37 or more weeks of gestation and before 39 weeks of gestation; cesarean delivery performed in low-risk mothers). Published algorithms were used to identify severe maternal morbidity (delivery associated with a life-threatening complication or performance of a lifesaving procedure) and morbidity in term newborns without anomalies (births associated with complications such as birth trauma, hypoxia, and prolonged length of stay). Mixed-effects logistic regression models were used to examine the association between maternal morbidity, neonatal morbidity, and hospital-level quality measures while risk-adjusting for patient sociodemographic and clinical characteristics.

Main outcomes and measures: Individual- and hospital-level maternal and neonatal morbidity.

Results: Severe maternal morbidity occurred among 2372 of 115,742 deliveries (2.4%), and neonatal morbidity occurred among 8057 of 103,416 term newborns without anomalies (7.8%). Rates for elective deliveries performed before 39 weeks of gestation ranged from 15.5 to 41.9 per 100 deliveries among 41 hospitals. There were 11.7 to 39.3 cesarean deliveries per 100 deliveries performed in low-risk mothers. Maternal morbidity ranged from 0.9 to 5.7 mothers with complications per 100 deliveries and neonatal morbidity from 3.1 to 21.3 neonates with complications per 100 births. The maternal quality indicators elective delivery before 39 weeks of gestation and cesarean delivery performed in low-risk mothers were not associated with severe maternal complications (risk ratio [RR], 1.00 [95% CI, 0.98-1.02] and RR, 0.99 [95% CI, 0.96-1.01], respectively) or neonatal morbidity (RR, 0.99 [95% CI, 0.97-1.01] and RR, 1.01 [95% CI, 0.99-1.03], respectively).

Conclusions and relevance: Rates for the quality indicators elective delivery before 39 weeks of gestation and cesarean delivery performed in low-risk mothers varied widely in New York City hospitals, as did rates of maternal and neonatal complications. However, there were no correlations between the quality indicator rates and maternal and neonatal morbidity. Current quality indicators may not be sufficiently comprehensive for guiding quality improvement in obstetric care.

Figure 1

Risk adjusted maternal (A and B) and neonatal morbidity (C and D) by quality indicators. Hospitals ranked in the top 10 on the quality measures (lowest rate for elective and cesarean deliveries) are shown as black circles, hospital ranked in the bottom 10 on these quality measures (highest rate for elective and cesarean deliveries) are shown as black triangles.