Bio

Academic Appointments


Administrative Appointments


  • Medical Director, California Maternal Quality Care Collaborative (2006 - Present)

Publications

All Publications


  • Low-Interventional Approaches to Intrapartum Care: Hospital Variation in Practice and Associated Factors. Journal of midwifery & women's health Lundsberg, L. S., Main, E. K., Lee, H. C., Lin, H., Illuzzi, J. L., Xu, X. 2019

    Abstract

    INTRODUCTION: Despite evidence supporting the safety of low-interventional approaches to intrapartum care, defined by the American College of Obstetricians and Gynecologists as "practices that facilitate a physiologic labor process and minimize intervention," little is known about how frequently such practices are utilized. We examined hospital use of low-interventional practices, as well as variation in utilization across hospitals.METHODS: Data came from 185 California hospitals completing a survey of intrapartum care, including 9 questions indicating use of low- versus high-interventional practices (eg, use of intermittent auscultation, nonpharmacologic pain relief, and admission of women in latent labor). We performed a group-based latent class analysis to identify distinct groups of hospitals exhibiting different levels of utilization on these 9 measures. Multivariable logistic regression identified institutional characteristics associated with a hospital's likelihood of using low-interventional practices. Procedure rates and patient outcomes were compared between the hospital groups using bivariate analysis.RESULTS: We identified 2 distinct groups of hospitals that tended to use low-interventional (n = 44, 23.8%) and high-interventional (n = 141, 76.2%) practices, respectively. Hospitals more likely to use low-interventional practices included those with midwife-led or physician-midwife collaborative labor management (adjusted odds ratio [aOR], 7.52; 95% CI, 2.53-22.37; P < .001) and those in rural locations (aOR, 3.73; 95% CI, 1.03-13.60; P = .04). Hospitals with a higher proportion of women covered by Medicaid or other safety-net programs were less likely to use low-interventional practices (aOR, 0.96; 95% CI, 0.93-0.99; P = .004), as were hospitals in counties with higher medical liability insurance premiums (aOR, 0.53; 95% CI, 0.33-0.85; P = .008). Hospitals in the low-intervention group had comparable rates of severe maternal and newborn morbidities but lower rates of cesarean birth and episiotomy compared with hospitals in the high-intervention group.DISCUSSION: Only one-quarter of hospitals used low-interventional practices. Attention to hospital culture of care, incorporating the midwifery model of care, and addressing medical-legal concerns may help promote utilization of low-interventional intrapartum practices.

    View details for DOI 10.1111/jmwh.13017

    View details for PubMedID 31502407

  • National Partnership for Maternal Safety: Consensus Bundle on Obstetric Care for Women With Opioid Use Disorder. Obstetrics and gynecology Krans, E. E., Campopiano, M., Cleveland, L. M., Goodman, D., Kilday, D., Kendig, S., Leffert, L. R., Main, E. K., Mitchell, K. T., O?Gurek, D. T., D?Oria, R., McDaniel, D., Terplan, M. 2019

    Abstract

    The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.

    View details for DOI 10.1097/AOG.0000000000003381

    View details for PubMedID 31306323

  • Creating Change at Scale Quality Improvement Strategies used by the California Maternal Quality Care Collaborative OBSTETRICS AND GYNECOLOGY CLINICS OF NORTH AMERICA Markow, C., Main, E. K. 2019; 46 (2): 317-+
  • Creating Change at Scale: Quality Improvement Strategies used by the California Maternal Quality Care Collaborative. Obstetrics and gynecology clinics of North America Markow, C., Main, E. K. 2019; 46 (2): 317?28

    Abstract

    Creating change at scale within a short time frame poses multiple challenges. Using the experience of the California Maternal Quality Care Collaborative, the authors illustrate how state perinatal quality collaboratives have been able to achieve this goal using a series of key steps: engage as many disciplines and partner organizations as possible; mobilize low-burden data to create a rapid-cycle data center to support the quality improvement efforts; provide up-to-date guidance for implementation using safety bundles and tool kits; and make available coaching and peer learning to support implementation through multihospital quality collaboratives. There are now multiple national resources available to support these efforts.

    View details for PubMedID 31056133

  • Systolic Hypertension, Preeclampsia-Related Mortality, and Stroke in California. Obstetrics and gynecology Judy, A. E., McCain, C. L., Lawton, E. S., Morton, C. H., Main, E. K., Druzin, M. L. 2019; 133 (6): 1151?59

    Abstract

    OBJECTIVE: To describe the clinical characteristics of stroke and opportunities to improve care in a cohort of preeclampsia-related maternal mortalities in California.METHODS: The California Pregnancy-Associated Mortality Review retrospectively examined a cohort of preeclampsia pregnancy-related deaths in California from 2002 to 2007. Stroke cases were identified among preeclampsia deaths, and case summaries were reviewed with attention to clinical variables, particularly hypertension. Health care provider- and patient-related contributing factors were also examined.RESULTS: Among 54 preeclampsia pregnancy-related deaths that occurred in California from 2002 to 2007, 33 were attributed to stroke. Systolic blood pressure exceeded 160 mm Hg in 96% of cases, and diastolic blood pressure was 110 or higher in 65% of cases. Hemolysis, elevated liver enzymes, and low platelet count syndrome was present in 38% (9/24) of cases with available laboratory data; eclampsia occurred in 36% of cases. Headache was the most frequent symptom (87%) preceding stroke. Elevated liver transaminases were the most common laboratory abnormality (71%). Only 48% of women received antihypertensive treatment. A good-to-strong chance to alter outcome was identified in stroke cases 66% (21/32), with delayed response to clinical warning signs in 91% (30/33) of cases and ineffective treatment in 76% (25/33) cases being the most common areas for improvement.CONCLUSION: Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia. All but one patient in this series of strokes demonstrated severe elevation of systolic blood pressure, whereas other variables were less consistently observed. Antihypertensive treatment was not implemented in the majority of cases. Opportunities for care improvement exist and may significantly affect maternal mortality.

    View details for DOI 10.1097/AOG.0000000000003290

    View details for PubMedID 31135728

  • Cesarean overuse and the culture of care. Health services research White VanGompel, E., Perez, S., Datta, A., Wang, C., Cape, V., Main, E. 2019

    Abstract

    OBJECTIVE: To assess hospital unit culture and clinician attitudes associated with varying rates of primary cesarean delivery.DATA SOURCES/STUDY SETTING: Intrapartum nurses, midwives, and physicians recruited from 79 hospitals in California participating in efforts to reduce cesarean overuse.STUDY DESIGN: Labor unit culture and clinician attitudes measured using a survey were linked to the California Maternal Data Center for birth outcomes and hospital covariates.METHODS: Association with primary cesarean delivery rates was assessed using multivariate Poisson regression adjusted for hospital covariates.PRINCIPAL FINDINGS: 1718 respondents from 70 hospitals responded to the Labor Culture Survey. The "Unit Microculture" subscale was strongly associated with primary cesarean rate; the higher a unit scored on 8-items describing a culture supportive of vaginal birth (eg, nurses are encouraged to spend time in rooms with patients, and doulas are welcomed), the cesarean rate decreased by 41 percent (95% CI=-47 to -35 percent, P<0.001). Discordant attitudes between nurses and physicians were associated with increased cesarean rates.CONCLUSIONS: Hospital unit culture, clinician attitudes, and consistency between professions are strongly associated with primary cesarean rates. Improvement efforts to reduce cesarean overuse must address culture of care as a key part of the change process.

    View details for PubMedID 30790273

  • The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity BMC Pregnancy and Childbirth Leonard, S. A., Main, E. K., Carmichael, S. L. 2019; 19 (16)
  • Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Annals of epidemiology Leonard, S. A., Main, E. K., Scott, K. A., Profit, J., Carmichael, S. L. 2019

    Abstract

    Racial/ethnic disparities in severe maternal morbidity (SMM) are substantial, but little is known about whether these disparities are changing over time or the role of maternal and obstetric factors.We examined disparities in SMM prevalence and trends using linked birth certificate and delivery discharge records from Californian births during 1997-2014 (n = 8,252,025).The prevalence of SMM was highest in non-Hispanic (NH) Black women (1.63%), lowest in NH White women (0.84%), and increased from 1997 to 2014 by approximately 170% in each racial/ethnic group. The magnitude of SMM disparities remained consistent over time. Compared with NH White women, the adjusted risk of SMM was higher in women who identified as Hispanic (RR 1.14; 95% CI 1.12, 1.16), Asian/Pacific Islander (RR 1.23; 95% CI 1.20, 1.26), NH Black (RR 1.27; 95% CI 1.23, 1.31), and American Indian/Alaska Native (RR 1.29; 95% CI 1.15, 1.44), accounting for comorbidities, anemia, cesarean birth, and other maternal characteristics.The prevalence of SMM varied considerably by race/ethnicity but increased at similarly high rates among all racial/ethnic groups. Comorbidities, cesarean birth, and other factors did not fully explain the disparities in SMM, which remained persistent over time.

    View details for PubMedID 30928320

  • Measuring labor and delivery unit culture and clinicians' attitudes toward birth: Revision and validation of the Labor Culture Survey. Birth (Berkeley, Calif.) White VanGompel, E., Perez, S., Wang, C., Datta, A., Cape, V., Main, E. 2018

    Abstract

    BACKGROUND: Cesarean delivery rates in the United States vary widely between hospitals, which cannot be fully explained by hospital or patient factors. Cultural factors are hypothesized to play a role in cesarean overuse, yet tools to measure labor culture are lacking. The aim of this study was to revise and validate a survey tool to measure hospital culture specific to cesarean overuse.METHODS: A panel of clinicians and researchers compiled an item bank from validated surveys, added newly created items, and performed four rounds of iterative revision and consolidation. Obstetricians, family physicians, midwives, anesthesiologists, and labor nurses were recruited from 79 hospitals in California. Exploratory factor analysis was used to reduce the number of survey items and identify latent constructs to form the basis of subscales. Confirmatory factor analysis examined reliability in 31 additional hospitals. Poisson regression assessed associations between hospitals' mean score on each individual item and cesarean rates.RESULTS: A total of 1718 individuals from 70 hospitals were included in the exploratory factor analysis. The final Labor Culture Survey (LCS) consisted of 29 items and six subscales: "Best Practices to Reduce Cesarean Overuse," "Fear of Vaginal Birth," "Unit Microculture," "Physician Oversight," "Maternal Agency," and "Cesarean Safety."CONCLUSIONS: The revised LCS is a valid and reliable tool to measure constructs shown to be associated with cesarean rates. These findings support prior research that has shown that hospital culture is measurable, and that clinician attitudes are predictive of clinician behaviors. Unique to our survey is the construct of labor and delivery unit microculture.

    View details for PubMedID 30407646

  • Addressing Maternal Mortality And Morbidity In California Through Public-Private Partnerships. Health affairs (Project Hope) Main, E. K., Markow, C., Gould, J. 2018; 37 (9): 1484?93

    Abstract

    In 2006, noting a rise in maternal deaths and complications, the California Department of Public Health launched efforts to investigate maternal deaths. In that year, the California Maternal Quality Care Collaborative was formed as a public-private partnership to lead maternal quality improvement activities. Key steps undertaken over the next decade included linking public health surveillance to actions, mobilizing a broad range of public and private partners, developing a rapid-cycle Maternal Data Center to support and sustain quality improvement initiatives, and implementing a series of data-driven large-scale quality improvement projects. While US maternal mortality has worsened in the 2010s, by 2013 California's rate had been cut in half to a three-year average of 7.0 maternal deaths per 100,000 live births. The state's rate had become comparable to the average rate in Western Europe (7.2 per 100,000). In this article we describe the key steps undertaken by the California Department of Public Health and the California Maternal Quality Care Collaborative that supported change at large scale. Special challenges for implementation are also discussed.

    View details for PubMedID 30179538

  • Do provider birth attitudes influence cesarean delivery rate: a cross-sectional study BMC PREGNANCY AND CHILDBIRTH VanGompel, E., Main, E. K., Tancredi, D., Melnikow, J. 2018; 18: 184

    Abstract

    When used judiciously, cesarean sections can save lives; but in the United States, prior research indicates that cesarean birth rates have risen beyond the threshold to help women and infants and become a contributor to increased maternal mortality and rising healthcare costs. Healthy People 2020 has set the goal for nulliparous, term, singleton, vertex (NTSV) cesarean birth rate at no more than 23.9% of births. Currently, cesarean rates vary from 6% to 69% in US hospitals, unexplained by clinical or demographic factors. This wide variation in cesarean use is also seen among individual providers of intrapartum care. Previous research of birth attitudes found providers of intrapartum care hold widely differing views, which may be a key underlying factor influencing practice variation; however, further study is needed to determine if differences in attitudes are associated with differences in clinical outcomes. The purpose of this study was to estimate the association between individual provider attitudes towards birth and their low-risk primary cesarean rate.Four hundred providers were drawn from a stratified random sample of all California providers of intrapartum care in 2013 and surveyed for their attitudes towards various aspects of labor and birth. Providers' NTSV cesarean birth rates were obtained for 2013 and 2014. Covariates included gender, years of experience, practice location, and primary hospital's NTSV cesarean rate. We used adjusted multivariate Poisson regression to compare cesarean rates and linear regression to compare attitude scores of providers meeting versus not meeting the Healthy People 2020 (HP2020) goal.Two hundred nine total participants (obstetricians, family physicians, and midwives) completed surveys, of which 109 perform cesareans. Providers' NTSV cesarean rate was significantly associated with their composite attitudes score [IRR for each one-point increase 1.21 (95% CI 1.002-1.45)]. Physicians meeting the HP2020 goal held attitudes which were significantly more favorable towards vaginal birth: mean 2.70 (95% CI 2.58-2.83) versus 2.91 (95% CI 2.82-3.00), p 

    View details for PubMedID 29843622

  • Improving Maternal Safety at Scale with the Mentor Model of Collaborative Improvement JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Main, E. K., Dhurjati, R., Cape, V., Vasher, J., Abreo, A., Chang, S., Gould, J. B. 2018; 44 (5): 250?59

    Abstract

    Obstetric safety bundles, consisting of action steps shown to improve outcomes, have been developed to address the most common and preventable causes of maternal morbidity and mortality. Implementing these best practices across all birthing facilities remains an important and challenging clinical and public health priority.The California Maternal Quality Care Collaborative (CMQCC) developed an innovative external mentor model for large-scale collaborative improvement in which participating organizations were subdivided into small teams of six to eight hospitals, led by a paired dyad of physician and nurse leaders. The mentor model preserves the active sharing that enhances improvement across a large group of facilities working on the same project while enabling individualized attention to teams. The mentor model was tested by implementing the obstetric hemorrhage safety bundle (which consists of 17 key practices in four domains) in multiple California hospitals.A total of 126 hospitals were engaged to simultaneously implement the safety bundle. The adoption rates for the recommended practices in the four action domains were (1) Readiness, 78.9%; (2) Recognition and Prevention, 76.5%; (3) Response, 63.1%; and (4) Reporting and Systems Learning, 58.7%. Mentors (31/40) and participating teams (48 responses from 39/126 hospitals) provided feedback in an exit survey. Among the respondents, 64.5% of mentors and 72.9% of participants agreed that compared to a traditional collaborative structure, the mentor model was better suited for quality improvement at scale.The mentor model was successful in providing individualized support to teams and enabled implementation of the hemorrhage safety bundle across a diverse group of 126 hospitals.

    View details for DOI 10.1016/j.jcjq.2017.11.005

    View details for Web of Science ID 000432378500003

    View details for PubMedID 29759258

  • Reducing Maternal Mortality and Severe Maternal Morbidity Through State-based Quality Improvement Initiatives. Clinical obstetrics and gynecology Main, E. K. 2018

    Abstract

    State Perinatal Quality Collaboratives (PQCs) represent a major advance for scaling up quality improvement efforts for reducing maternal mortality and severe maternal morbidity. The critical roles of partners, rapid-cycle low-burden data systems, and linkage to maternal mortality review committees are reviewed. The choice of measures is also explored. California's experience with its PQC, data center, quality improvement efforts, and promising results for reduction of maternal mortality and morbidity from hemorrhage are presented. Early data from other states is also shared.

    View details for PubMedID 29505420

  • The National Network of State Perinatal Quality Collaboratives: A Growing Movement to Improve Maternal and Infant Health JOURNAL OF WOMENS HEALTH Henderson, Z. T., Ernst, K., Simpson, K., Berns, S., Suchdev, D. B., Main, E., McCaffrey, M., Lee, K., Rouse, T., Olson, C. K. 2018; 27 (3): 221?26

    Abstract

    State Perinatal Quality Collaboratives (PQCs) are networks of multidisciplinary teams working to improve maternal and infant health outcomes. To address the shared needs across state PQCs and enable collaboration, Centers for Disease Control and Prevention (CDC), in partnership with March of Dimes and perinatal quality improvement experts from across the country, supported the development and launch of the National Network of Perinatal Quality Collaboratives (NNPQC). This process included assessing the status of PQCs in this country and identifying the needs and resources that would be most useful to support PQC development. National representatives from 48 states gathered for the first meeting of the NNPQC to share best practices for making measurable improvements in maternal and infant health. The number of state PQCs has grown considerably over the past decade, with an active PQC or a PQC in development in almost every state. However, PQCs have some common challenges that need to be addressed. After its successful launch, the NNPQC is positioned to ensure that every state PQC has access to key tools and resources that build capacity to actively improve maternal and infant health outcomes and healthcare quality.

    View details for PubMedID 29634446

  • The Impact of Maternal Obesity and Race/Ethnicity on Perinatal Outcomes: Independent and Joint Effects OBESITY Snowden, J. M., Mission, J. F., Marshall, N. E., Quigley, B., Main, E., Gilbert, W. M., Chung, J. H., Caughey, A. B. 2016; 24 (7): 1590?98

    Abstract

    Independent and joint impacts of maternal race/ethnicity and obesity on adverse birth outcomes, including pre-eclampsia, low birth weight, and macrosomia, were characterized.Retrospective cohort study of all 2007 California births was conducted using vital records and claims data. Maternal race/ethnicity and maternal body mass index (BMI) were the key exposures; their independent and joint impact on outcomes using regression models was analyzed.Racial/ethnic minority women of normal weight generally had higher risk as compared with white women of normal weight (e.g., African-American women, pre-eclampsia adjusted odds ratio [aOR] 1.60, 95% confidence interval [CI]: 1.48-1.74 vs. white women). However, elevated BMI did not usually confer additional risk (e.g., pre-eclampsia aOR comparing African-American women with excess weight with white women with excess weight, 1.17, 95% CI: 0.89-1.54). Obesity was a risk factor for low birth weight only among white women (excess weight aOR, 1.24, 95% CI: 1.04-1.49 vs. white women of normal weight) and not among racial/ethnic minority women (e.g., African-American women, 0.95, 95% CI: 0.83-1.08).These findings add nuance to our understanding of the interplay between maternal race/ethnicity, BMI, and perinatal outcomes. While the BMI/adverse outcome gradient appears weaker in racial/ethnic minority women, this reflects the overall risk increase in racial/ethnic minority women of all body sizes.

    View details for PubMedID 27222008

  • The Goldilocks Quandary of Health Care Resources Too Little, Too Much, or Just Right? OBSTETRICS AND GYNECOLOGY Morgan, D. M., Main, E., Gee, R. E. 2016; 127 (6): 1039?44

    Abstract

    Appropriate use of health care resources is a priority for improving the quality of care. Overutilization affects almost all specialties including obstetrics and gynecology. Initiatives such as the Choosing Wisely campaign and the Joint Commission Perinatal Care Measures have brought attention to issues of overuse. The decision of these campaigns to focus on eliminating nonmedically indicated inductions before 39 weeks of gestation is an example of how more appropriate health care use can reduce complications and save millions of dollars. Cesarean delivery, hysterectomy, and prophylactic oophorectomy are procedures with high levels of variation in utilization, and the use of an intrauterine device is an example of underutilization. Efforts to promote adherence to best practices such as those directed at nonmedically indicated inductions could lead to more appropriate use of these interventions and improve women's health care.

    View details for PubMedID 27159743

  • Measuring severe maternal morbidity: validation of potential measures AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Main, E. K., Abreo, A., McNulty, J., Gilbert, W., McNally, C., Poeltler, D., Lanner-Cusin, K., Fenton, D., Gipps, T., Melsop, K., Greene, N., Gould, J. B., Kilpatrick, S. 2016; 214 (5)

    Abstract

    Both maternal mortality rate and severe maternal morbidity rate have risen significantly in the United Sates. Recently, the Centers for Disease Control and Prevention introduced International Classification of Diseases, 9th revision, criteria for defining severe maternal morbidity with the use of administrative data sources; however, those criteria have not been validated with the use of chart reviews.The primary aim of the current study was to validate the Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria for the identification of severe maternal morbidity. This analysis initially required the development of a reproducible set of clinical conditions that were judged to be consistent with severe maternal morbidity to be used as the clinical gold standard for validation. Alternative criteria for severe maternal morbidity were also examined.The 67,468 deliveries that occurred during a 12-month period from 16 participating California hospitals were screened initially for severe maternal morbidity with the presence of any of 4 criteria: (1) Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, diagnosis and procedure codes; (2) prolonged postpartum length of stay (>3 standard deviations beyond the mean length of stay for the California population); (3) any maternal intensive care unit admissions (with the use of hospital billing sources); and (4) the administration of any blood product (with the use of transfusion service data). Complete medical records for all screen-positive cases were examined to determine whether they satisfied the criteria for the clinical gold standard (determined by 4 rounds of a modified Delphi technique). Descriptive and statistical analyses that included area under the receiver operating characteristic curve and C-statistic were performed.The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria had a reasonably high sensitivity of 0.77 and a positive predictive value of 0.44 with a C-statistic of 0.87. The most important source of false-positive cases were mothers whose only criterion was 1-2 units of blood products. The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria screen rate ranged from 0.51-2.45% among hospitals. True positive severe maternal morbidity ranged from 0.05-1.13%. When hospitals were grouped by their neonatal intensive care unit level of care, severe maternal morbidity rates were statistically lower at facilities with lower level neonatal intensive care units (P < .0001).The Centers for Disease Control and Prevention International Classification of Diseases, 9th revision, criteria can serve as a reasonable administrative metric for measuring severe maternal morbidity at population levels. Caution should be used with the use of these criteria for individual hospitals, because case-mix effects appear to be strong.

    View details for DOI 10.1016/j.ajog.2015.11.004

    View details for Web of Science ID 000375452100025

    View details for PubMedID 26582168

  • Pregnancy-Related Cardiovascular Deaths in California: Beyond Peripartum Cardiomyopathy OBSTETRICAL & GYNECOLOGICAL SURVEY Hameed, A. B., Lawton, E. S., McCain, C. L., Morton, C. H., Mitchell, C., Main, E. K., Foster, E. 2016; 71 (2): 63?65
  • Clues for understanding hospital variation among obstetric services AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Main, E. K. 2015; 213 (4): 443?44

    View details for PubMedID 26410202

  • National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage OBSTETRICS AND GYNECOLOGY Main, E. K., Goffman, D., Scavone, B. M., Low, L., Bingham, D., Fontaine, P. L., Gorlin, J. B., Lagrew, D. C., Levy, B. S. 2015; 126 (1): 155?62
  • The National Partnership for Maternal Safety: A Call to Action for Anesthesiologists ANESTHESIA AND ANALGESIA Scavone, B. M., Main, E. K. 2015; 121 (1): 14?16

    View details for DOI 10.1213/ANE.0000000000000784

    View details for Web of Science ID 000356669300006

    View details for PubMedID 26086504

  • Pregnancy-Related Mortality in California Causes, Characteristics, and Improvement Opportunities OBSTETRICS AND GYNECOLOGY Main, E. K., McCain, C. L., Morton, C. H., Holtby, S., Lawton, E. S. 2015; 125 (4): 938-947

    Abstract

    To compare specific maternal and clinical characteristics and contributing factors among the five leading causes of pregnancy-related mortality to develop focused clinical and public health prevention programs.California pregnancy-related deaths from 2002-2005 were identified with enhanced surveillance using linked birth and death certificates. A multidisciplinary committee reviewed medical records, autopsy reports, and coroner reports to determine cause of death, clinical and demographic characteristics, chance to alter outcome, contributing factors (at health care provider, facility, and patient levels), and quality improvement opportunities. The five leading causes of death were compared with each other and with the overall California birth population.Among the 207 pregnancy-related deaths, the five leading causes were cardiovascular disease, preeclampsia or eclampsia, hemorrhage, venous thromboembolism, and amniotic fluid embolism. Among the leading causes of death, we identified differing patterns for race, maternal age, body mass index, timing of death, and method of delivery. Overall, there was a good-to-strong chance to alter the outcome in 41% of deaths, with the highest rates of preventability among hemorrhage (70%) and preeclampsia (60%) deaths. Health care provider, facility, and patient contributing factors also varied by cause of death.Pregnancy-related mortality should not be considered a single clinical entity. Reducing mortality requires in-depth examination of individual causes of death. The five leading causes exhibit different characteristics, degrees of preventability, and contributing factors, with the greatest improvement opportunities identified for hemorrhage and preeclampsia. These findings provide additional support for hospital, state, and national maternal safety programs.

    View details for DOI 10.1097/AOG.0000000000000746

    View details for Web of Science ID 000351595200026

    View details for PubMedID 25751214

  • Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy. American journal of obstetrics and gynecology 2015

    Abstract

    Maternal mortality rates rose markedly from 2002 to 2006 in California, prompting an in-depth maternal mortality review in a state that comprises one twelfth of the US birth cohort. Cardiovascular disease has emerged as the leading cause of pregnancy-related death in the United States. The primary aim of this analysis was to describe the incidence and type of cardiovascular disease as a cause of pregnancy-related mortality in California. The secondary aims were to describe racial/ethnic and socioeconomic disparities, risk factors, birth outcomes, timing of death and diagnosis, and signs and symptoms of cardiovascular disease and identify contributing factors.The California Pregnancy-Associated Mortality Review retrospectively examined a case series of 64 cardiovascular pregnancy-related deaths from 2002 through 2006. Two cardiologists independently reviewed complete inpatient and outpatient medical records including laboratory, radiology, electrocardiogram, chest X-ray, echocardiograms, and autopsy findings for each cardiovascular death and classified cause of death by type of cardiovascular disease. Demographic data, racial disparities, risk factors, signs and symptoms, timing of diagnosis and death, birth outcomes, and contributing factors were analyzed using bivariate comparisons with noncardiovascular pregnancy-related deaths and population-based data.Among 2,741,220 California women who gave birth, 864 died while pregnant or within 1 year of pregnancy; 257 of the deaths were deemed pregnancy related, and of these, 64 (25%) were attributed to cardiovascular disease. There were 42 deaths caused by cardiomyopathy, and the pregnancy-related mortality rate from cardiomyopathy was 1.54 per 100,000 births. Dilated cardiomyopathy existed in 29 cases, of which 15 met the definition of peripartum cardiomyopathy. Women with cardiovascular disease were more likely than women who died from noncardiovascular causes to be African-American (39.1% vs 16.1%; P < .01) and more likely to use illicit substances (23.7% vs 9.4%; P < .01). Thirty-seven percent were obese and 20% had a concomitant diagnosis of hypertension or preeclampsia during pregnancy. Health care decisions in the diagnosis or treatment of cardiovascular disease during and after pregnancy contributed to the fatal outcomes.African-American race, substance use, and obesity were risk factors for pregnancy-related cardiovascular disease mortality. Chronic disease prevention and better recognition and response to cardiovascular disease during pregnancy are needed to reduce maternal mortality.

    View details for PubMedID 25979616

  • Executive Summary of the reVITALize Initiative Standardizing Obstetric Data Definitions OBSTETRICS AND GYNECOLOGY Menard, M., Main, E. K., Currigan, S. M. 2014; 124 (1): 150?53

    Abstract

    Precision in language has become critically important with the evolution of the electronic medical record and proliferation of measurement in vital statistics and health care. Taking the opportunity to standardize clinical definitions is a fundamental step in building a robust national data infrastructure that is useful and useable for clinicians and patients. The reVITALize Initiative leads and coordinates a national multidisciplinary movement to standardize obstetric data definitions for written and verbal clinical communication, electronic health record data capture, vital statistics and public health surveillance, measurement, quality improvement, reporting, and research.

    View details for PubMedID 24901267

  • California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings MATERNAL AND CHILD HEALTH JOURNAL Mitchell, C., Lawton, E., Morton, C., McCain, C., Holtby, S., Main, E. 2014; 18 (3): 518-526

    Abstract

    After several decades of declining rates, maternal mortality climbed in California from a three-year moving average of 9.4 deaths per 100,000 live births in 1999-2001 to a high of 14.0 deaths per 100,000 live births in 2006-2008 (p < 0.001). The Maternal, Child and Adolescent Health Division of the California Department of Public Health developed a mixed method approach to identify and investigate maternal deaths to inform prevention strategies. This paper describes the methodology of the California Pregnancy-Associated Mortality Review (CA-PAMR) and its advantages for improved surveillance, cause of death analysis, and translation of findings. From 2002 to 2004, 1,598,792 live births occurred in California and 555 women died while pregnant or within one year of pregnancy. A screening algorithm identified cases for review that were likely to be pregnancy-related. Medical records were then abstracted and reviewed by a multidisciplinary committee to determine cause of death, contributing factors, and opportunities for quality improvement. Mixed methods were used to analyze, synthesize and translate Committee recommendations for improved care. Of 211 cases selected for review, 145 deaths were determined to be pregnancy-related. CA-PAMR methods corrected misclassification of cases and more accurately identified the leading causes of death. Cardiovascular disease emerged as the leading cause of pregnancy-related deaths (20%), and African-American women were disproportionately represented among cardiovascular deaths. Overall, the chance to prevent the fatal outcome appeared good or strong in 40% of cases reviewed. The CA-PAMR methodology resulted in additional case finding, improved accuracy of the causes of pregnancy-related deaths, and evidence to guide development of prevention and quality improvement efforts.

    View details for DOI 10.1007/s10995-013-1267-0

    View details for Web of Science ID 000333026600002

    View details for PubMedID 23584929

  • Maternal Mortality Time for National Action OBSTETRICS AND GYNECOLOGY Main, E. K., Menard, M. 2013; 122 (4): 735?36

    View details for PubMedID 24084528

  • Quality and Safety Programs in Obstetrics and Gynecology. Clinical obstetrics and gynecology Main, E. K. 2019

    View details for DOI 10.1097/GRF.0000000000000482

    View details for PubMedID 31305486

  • Measuring labor and delivery unit culture and clinicians' attitudes toward birth: Revision and validation of the Labor Culture Survey BIRTH-ISSUES IN PERINATAL CARE VanGompel, E., Perez, S., Wang, C., Datta, A., Cape, V., Main, E. 2019; 46 (2): 300?310

    View details for DOI 10.1111/birt.12406

    View details for Web of Science ID 000468219400011

  • Systolic Hypertension, Preeclampsia-Related Mortality, and Stroke in California. Obstetrics and gynecology Judy, A. E., McCain, C. L., Lawton, E. S., Morton, C. H., Main, E. K., Druzin, M. L. 2019

    Abstract

    OBJECTIVE: To describe the clinical characteristics of stroke and opportunities to improve care in a cohort of preeclampsia-related maternal mortalities in California.METHODS: The California Pregnancy-Associated Mortality Review retrospectively examined a cohort of preeclampsia pregnancy-related deaths in California from 2002 to 2007. Stroke cases were identified among preeclampsia deaths, and case summaries were reviewed with attention to clinical variables, particularly hypertension. Health care provider- and patient-related contributing factors were also examined.RESULTS: Among 54 preeclampsia pregnancy-related deaths that occurred in California from 2002 to 2007, 33 were attributed to stroke. Systolic blood pressure exceeded 160 mm Hg in 96% of cases, and diastolic blood pressure was 110 or higher in 65% of cases. Hemolysis, elevated liver enzymes, and low platelet count syndrome was present in 38% (9/24) of cases with available laboratory data; eclampsia occurred in 36% of cases. Headache was the most frequent symptom (87%) preceding stroke. Elevated liver transaminases were the most common laboratory abnormality (71%). Only 48% of women received antihypertensive treatment. A good-to-strong chance to alter outcome was identified in stroke cases 66% (21/32), with delayed response to clinical warning signs in 91% (30/33) of cases and ineffective treatment in 76% (25/33) cases being the most common areas for improvement.CONCLUSION: Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia. All but one patient in this series of strokes demonstrated severe elevation of systolic blood pressure, whereas other variables were less consistently observed. Antihypertensive treatment was not implemented in the majority of cases. Opportunities for care improvement exist and may significantly affect maternal mortality.

    View details for PubMedID 31083120

  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Cardiovascular Disease JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING VanOtterloo, L. R., Morton, C. H., Seacrist, M. J., Main, E. K. 2019; 48 (3): 263?74

    Abstract

    To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from cardiovascular disease (CVD) by the California Pregnancy-Associated Mortality Review committee.Qualitative descriptive design using thematic analysis.A total of 269 QIOs identified from 87 pregnancy-related deaths from CVD in California from 2002 to 2007.We coded and thematically organized the 269 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.The most prevalent theme within the Readiness domain was the care of women in a facility or a department within a facility that was not equipped to handle the severity of their CVD conditions. For Recognition, a common theme was an underappreciation of the severity of illness, including high-risk factors and clinical warning signs, which led to inaccurate diagnoses, such as anxiety or asthma, and missed diagnoses of CVD. The lack of recognition of CVD led to delays in treatment or inaccurate treatment, the leading themes in the Response domain.Identification of CVD or its risk factors during pregnancy can lead to timely, multidisciplinary approaches to management and birth in facilities that offer appropriately trained health care professionals and appropriate equipment. Maternal mortality can be reduced if signs and symptoms of CVD in women are recognized early and treatment modalities are implemented quickly during pregnancy, childbirth, and the postpartum period.

    View details for DOI 10.1016/j.jogn.2019.03.001

    View details for Web of Science ID 000467251700003

    View details for PubMedID 30998902

  • Racial and ethnic disparities in severe maternal morbidity prevalence and trends ANNALS OF EPIDEMIOLOGY Leonard, S. A., Main, E. K., Scott, K. A., Profit, J., Carmichael, S. L. 2019; 33: 30?36
  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Preeclampsia/Eclampsia JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Morton, C. H., Seacrist, M. J., VanOtterloo, L. R., Main, E. K. 2019; 48 (3): 275?87

    Abstract

    To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from preeclampsia/eclampsia by the California Pregnancy-Associated Mortality Review Committee.Qualitative descriptive design using thematic analysis.A total of 242 QIOs identified from 54 cases of pregnancy-related deaths from preeclampsia/eclampsia in California between 2002 and 2007.We coded and thematically organized the 242 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.Standardized Policies and Protocols to manage severe hypertension and respond to obstetric emergencies was the main theme identified in the Readiness domain. For Recognition, issues related to Missed Clinical Warning Signs of worsening preeclampsia/eclampsia were predominant. In the Response domain, the themes Inadequate Assessment and Treatment of severe hypertension and Coordination of Care were most frequently noted.Findings from our study suggest numerous opportunities to improve care and outcomes for women who died of preeclampsia/eclampsia in California from 2002 to 2007. Facilities need to adopt and implement standardized policies and protocols about the diagnosis and treatment of preeclampsia/eclampsia. Clinician education about key warning signs is critical, as is ensuring that women understand the signs and symptoms that warrant immediate clinical attention. Death from preeclampsia/eclampsia is very preventable, and efforts to reduce maternal mortality and morbidity from this serious condition of pregnancy are needed at all levels.

    View details for DOI 10.1016/j.jogn.2019.02.008

    View details for Web of Science ID 000467251700004

    View details for PubMedID 30980787

  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Sepsis JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Seacrist, M. J., Morton, C. H., VanOtterloo, L. R., Main, E. K. 2019; 48 (3): 311?20

    Abstract

    To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from sepsis by the California Pregnancy-Associated Mortality Review Committee.Qualitative descriptive design using thematic analysis.A total of 118 QIOs identified from 27 cases of pregnancy-related deaths from sepsis in California from 2002 to 2007.We coded and thematically organized the 118 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.Women's delay in seeking care was the central theme in the Readiness domain. In the Recognition domain, health care providers missed the signs and symptoms of sepsis, including elevated temperature, elevated white blood cell count, increased heart rate, decreased blood pressure, mottled skin, preterm labor, headache, and pain. For Response, late antibiotic administration was a central theme; multiple emergent themes included administration of the wrong antibiotics, failure to investigate women's complaints of pain, lack of nurse/provider communication, and lack of follow-up care after hospital discharge.To reverse the contribution of sepsis to the rising rate of maternal mortality in the United States, health care facilities and providers need to reduce barriers for women who seek care, recognize early symptoms, and respond with appropriate treatment. This could be achieved by implementation of the Maternal Early Warning Criteria, standardized guidelines such as those from the Surviving Sepsis campaign, and comprehensive discharge education.

    View details for DOI 10.1016/j.jogn.2019.02.007

    View details for Web of Science ID 000467251700007

    View details for PubMedID 30974075

  • Translating Maternal Mortality Review Into Quality Improvement Opportunities in Response to Pregnancy-Related Deaths in California JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Morton, C. H., VanOtterloo, L. R., Seacrist, M. J., Main, E. K. 2019; 48 (3): 252?62

    Abstract

    To describe quality improvement opportunities (QIOs) associated with the five leading causes of pregnancy-related death in California and the methods by which the QIOs were collected by the California Pregnancy-Associated Mortality Review committee.Qualitative, descriptive design using thematic analysis.A total of 907 QIOs identified from 203 cases of pregnancy-related deaths from cardiovascular disease, preeclampsia/eclampsia, hemorrhage, venous thromboembolism, and sepsis that occurred in California from 2002 to 2007.We coded and thematically organized QIO data using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. We refer to the domains collectively as the 4R Framework.We identified key themes across the five leading causes of death. In the Readiness domain, themes were related to overall facility readiness and helping women be prepared and knowledgeable about pregnancy and childbirth. Themes that emerged as central in the Recognition domain addressed the need for clinicians to better recognize risk factors and women's signs and symptoms to ensure an accurate diagnosis. In the Response domain, three themes were predominant, and they were related to the coordination of care, timing of treatment, and follow-up care.Results from our study show the utility and transferability of the first three domains of the 4R Framework as applied to quality improvement data from a large statewide maternal mortality review. Nursing leadership is necessary to support and guide national, statewide, and local efforts to improve the quality of maternity care through the implementation of quality improvement at the system, facility, clinician, and patient levels.

    View details for DOI 10.1016/j.jogn.2019.03.003

    View details for Web of Science ID 000467251700002

    View details for PubMedID 30981725

  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Obstetric Hemorrhage JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Seacrist, M. J., VanOtterloo, L. R., Morton, C. H., Main, E. K. 2019; 48 (3): 288?99

    Abstract

    To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from obstetric hemorrhage by the California Pregnancy-Associated Mortality Review Committee.Qualitative descriptive using thematic analysis.A total of 159 QIOs identified from 33 cases of pregnancy-related deaths from obstetric hemorrhage in California from 2002 to 2007.We coded and thematically organized the 159 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.Thematic findings indicated that facility Readiness would be improved through practice standardization, better organization of equipment to treat hemorrhage, and planning for care of women with risk factors for hemorrhage. Recognition of hemorrhage by health care providers could be improved through accurate assessment of blood loss, risk factors, and early clinical signs of deterioration. Provider Response could be improved through reducing delays in administering blood, seeking consultations, transferring women to higher levels of care within or outside of the facility, and moving on to other treatments if a woman does not respond to current treatment.Hemorrhage is the most preventable cause of maternal death in California. Morbidity and mortality from hemorrhage can be prevented if birth facilities and maternity care clinicians align local practices with national safety guidelines.

    View details for DOI 10.1016/j.jogn.2019.03.002

    View details for Web of Science ID 000467251700005

    View details for PubMedID 30981726

  • Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Venous Thromboembolism JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING VanOtterloo, L. R., Seacrist, M. J., Morton, C. H., Main, E. K. 2019; 48 (3): 300?310

    Abstract

    To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from venous thromboembolism (VTE) by the California Pregnancy-Associated Mortality Review Committee.Qualitative, descriptive design using thematic analysis.A total of 108 QIOs identified from 29 cases of pregnancy-related deaths from VTE in California from 2002 to 2007.We coded and thematically organized the 108 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.Women's lack of awareness of the significance of severe VTE symptoms and the lack of a standardized approach to recognize and respond to VTE signs and symptoms were the most prevalent themes in the Readiness domain. Missing the signs and symptoms of VTE and the resultant missed or delayed diagnosis were predominant themes in the Recognition domain. For Response, issues related to lack of VTE prophylaxis were most frequently noted, along with other themes, including timing of treatment and appropriate follow-up after hospital discharge.To decrease the occurrence of maternal death from VTE in the United States, consistent and thorough education regarding VTE signs and symptoms must be given to all women and their families during pregnancy and the postpartum period. Maternity care facilities and providers should implement preventive measures, including standardized use of VTE prophylaxis, improved methods to recognize the signs and symptoms of VTE, and improved follow-up after hospital discharge.

    View details for DOI 10.1016/j.jogn.2019.02.006

    View details for Web of Science ID 000467251700006

    View details for PubMedID 30986370

  • Risk of severe maternal morbidity in relation to prepregnancy body mass index: Roles of maternal co-morbidities and caesarean birth. Paediatric and perinatal epidemiology Leonard, S. A., Carmichael, S. L., Main, E. K., Lyell, D. J., Abrams, B. 2019

    Abstract

    An association between prepregnancy body mass index (BMI) and severe maternal morbidity (SMM) has been reported, but evidence has been mixed and potential explanations have not been examined.To evaluate the association between prepregnancy BMI and SMM in a large, diverse birth cohort and assess potential mediation by obesity-related co-morbidities and caesarean birth.This cohort study used linked birth certificate and hospitalisation discharge records from Californian births during 2007-2012. We assessed associations between prepregnancy BMI and SMM, and used inverse probability weighting for multiple mediators to estimate relative and absolute natural direct and indirect effects accounting for mediation by co-morbidities (hypertensive conditions, diabetes, asthma) and caesarean birth.Among 2 650 182 births, the prevalence of SMM was 1.42%. Adjusted risk ratios for the total association between prepregnancy BMI category and SMM were 1.12 (95% confidence interval [CI] 1.07, 1.18) for underweight, 1.02 (95% CI 0.99, 1.04) for overweight, 1.04 (95% CI 1.00, 1.07) for obesity class 1, 1.14 (95% CI 1.09, 1.20) for obesity class 2, and 1.28 (95% CI 1.22, 1.36) for obesity class 3 compared to women with normal weight. After accounting for mediation by co-morbidity and caesarean birth, the risk ratios were 1.19 (95% CI 1.14, 1.26) for underweight, 0.91 (95% CI 0.89, 0.94) for overweight, 0.86 (95% CI 0.84, 0.89) for obesity class 1, 0.88 (95% CI 0.84, 0.92) for obesity class 2, and 0.89 (95% CI 0.83, 0.95) for obesity class 3.Co-morbidities and caesarean birth explained an association between high prepregnancy BMI and SMM. These findings suggest that promotion of healthy prepregnancy weight, along with management of co-morbidities and support of vaginal birth in pregnant women with high BMI, could reduce the risk of SMM. However, these mediators did not reduce the elevated risk of SMM observed in women with low BMI.

    View details for DOI 10.1111/ppe.12555

    View details for PubMedID 31106879

  • In Reply. Obstetrics and gynecology Judy, A. E., McCain, C. L., Lawton, E. S., Morton, C. H., Main, E. K., Druzin, M. L. 2019; 134 (4): 880?81

    View details for DOI 10.1097/AOG.0000000000003494

    View details for PubMedID 31568351

  • The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity. BMC pregnancy and childbirth Leonard, S. A., Main, E. K., Carmichael, S. L. 2019; 19 (1): 16

    Abstract

    Severe maternal morbidity - life-threatening childbirth complications - has more than doubled in the United States over the past 15?years, affecting more than 50,000 women (1.4% of deliveries) annually. During this time period, maternal age, obesity, comorbidities, and cesarean delivery also increased and may be related to the rise in severe maternal morbidity. We sought to evaluate: (1) the association of advanced maternal age, pre-pregnancy obesity, pre-pregnancy comorbidities, and cesarean delivery with severe maternal morbidity, and (2) whether changes in the prevalence of these risk factors affected the trend of severe maternal morbidity.This population-based cohort study used linked birth record and patient discharge data from live births in California during 2007-2014 (n?=?3,556,206). We used multivariable logistic regression models to assess the association of advanced maternal age (?35?years), pre-pregnancy obesity (body mass index ?30?kg/m2), pre-pregnancy comorbidity (index of 12 conditions), and cesarean delivery with severe maternal morbidity prevalence and trends. Severe maternal morbidity was identified by an index of 18 diagnosis and procedure indicators. We estimated odds ratios, predicted prevalence, and population attributable risk percentages.The prevalence of severe maternal morbidity increased by 65% during 2007-2014. Advanced maternal age, pre-pregnancy obesity, and pre-pregnancy comorbidity also increased during this period, but cesarean delivery did not. None of these risk factors affected the increasing trend of severe maternal morbidity. However, the pre-pregnancy risk factors together were estimated to contribute to 13% (95% confidence interval: 12, 14%) of severe maternal morbidity cases in the study population overall, and cesarean delivery was estimated to contribute to 37% (95% confidence interval: 36, 38%) of cases.Pre-pregnancy health and cesarean delivery are important risk factors for severe maternal morbidity but do not explain an increasing trend of severe maternal morbidity in California during 2007-2014. Investigation of other potential contributors is needed in order to identify ways to reverse the trend of severe maternal morbidity.

    View details for PubMedID 30626349

  • The National Network of State Perinatal Quality Collaboratives: A Growing Movement to Improve Maternal and Infant Health. Journal of women's health (2002) Henderson, Z. T., Ernst, K., Simpson, K. R., Berns, S. D., Suchdev, D. B., Main, E., McCaffrey, M., Lee, K., Rouse, T. B., Olson, C. K. 2018; 27 (2): 123?27

    Abstract

    State Perinatal Quality Collaboratives (PQCs) are networks of multidisciplinary teams working to improve maternal and infant health outcomes. To address the shared needs across state PQCs and enable collaboration, Centers for Disease Control and Prevention, in partnership with March of Dimes and perinatal quality improvement experts from across the country, supported the development and launch of the National Network of PQCs National Network of Perinatal Quality Collaboratives (NNPQC). This process included assessing the status of PQCs in this country and identifying the needs and resources that would be most useful to support PQC development. National representatives from 48 states gathered for the first meeting of the NNPQC to share best practices for making measurable improvements in maternal and infant health. The number of state PQCs has grown considerably over the past decade, with an active PQC or a PQC in development in almost every state. However, PQCs have some common challenges that need to be addressed. After its successful launch, the NNPQC is positioned to ensure that every state PQC has access to key tools and resources that build capacity to actively improve maternal and infant health outcomes and healthcare quality.

    View details for PubMedID 29389242

  • TIME OF BIRTH AND THE RISK OF SEVERE UNEXPECTED COMPLICATIONS IN TERM SINGLETON NEWBORNS Gould, J. B., Abreo, A., Main, E. K. WILEY. 2017: 13
  • Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Main, E. K., Cape, V., Abreo, A., Vasher, J., Woods, A., Carpenter, A., Gould, J. B. 2017; 216 (3)

    Abstract

    Obstetric hemorrhage is the leading cause of severe maternal morbidity and of preventable maternal mortality in the United States. The California Maternal Quality Care Collaborative developed a comprehensive quality improvement tool kit for hemorrhage based on the national patient safety bundle for obstetric hemorrhage and noted promising results in pilot implementation projects.We sought to determine whether these safety tools can be scaled up to reduce severe maternal morbidity in women with obstetric hemorrhage using a large maternal quality collaborative.We report on 99 collaborative hospitals (256,541 annual births) using a before-and-after model with 48 noncollaborative comparison hospitals (81,089 annual births) used to detect any systemic trends. Both groups participated in the California Maternal Data Center providing baseline and rapid-cycle data. Baseline period was the 48 months from January 2011 through December 2014. The collaborative started in January 2015 and the postintervention period was the 6 months from October 2015 through March 2016. We modified the Institute for Healthcare Improvement collaborative model for achieving breakthrough improvement to include the mentor model whereby 20 pairs of nurse and physician mentors experienced in quality improvement gave additional support to small groups of 6-8 hospitals. The national hemorrhage safety bundle served as the template for quality improvement action. The main outcome measurement was the composite Centers for Disease Control and Prevention severe maternal morbidity measure, for both the target population of women with hemorrhage and the overall delivery population. The rate of adoption of bundle elements was used as an indicator of hospital engagement and intensity.Compared to baseline period, women with hemorrhage in collaborative hospitals experienced a 20.8% reduction in severe maternal morbidity while women in comparison hospitals had a 1.2% reduction (P < .0001). Women in hospitals with prior hemorrhage collaborative experience experienced an even larger 28.6% reduction. Fewer mothers with transfusions accounted for two thirds of the reduction in collaborative hospitals and fewer procedures and medical complications, the remainder. The rate of severe maternal morbidity among all women in collaborative hospitals was 11.7% lower and women in hospitals with prior hemorrhage collaborative experience had a 17.5% reduction. Improved outcomes for women were noted in all hospital types (regional, medium, small, health maintenance organization, and nonhealth maintenance organization). Overall, 54% of hospitals completed 14 of 17 bundle elements, 76% reported regular unit-based drills, and 65% reported regular posthemorrhage debriefs. Higher rate of bundle adoption was associated with improvement of maternal morbidity only in hospitals with high initial rates of severe maternal morbidity.We used an innovative collaborative quality improvement approach (mentor model) to scale up implementation of the national hemorrhage bundle. Participation in the collaborative was strongly associated with reductions in severe maternal morbidity among hemorrhage patients. Women in hospitals in their second collaborative had an even greater reduction in morbidity than those approaching the bundle for the first time, reinforcing the concept that quality improvement is a long-term and cumulative process.

    View details for DOI 10.1016/j.ajog.2017.01.017

    View details for Web of Science ID 000397089700033

    View details for PubMedID 28153661

  • Leading Change on Labor and Delivery: Reducing Nulliparous Term Singleton Vertex (NTSV) Cesarean Rates JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Main, E. K. 2017; 43 (2): 51?52

    View details for DOI 10.1016/j.jcjq.2016.11.009

    View details for Web of Science ID 000424157800001

    View details for PubMedID 28334562

  • Relationship of Hospital Staff Coverage and Delivery Room Resuscitation Practices to Birth Asphyxia. American journal of perinatology Tu, J. H., Profit, J., Melsop, K., Brown, T., Davis, A., Main, E., Lee, H. C. 2017; 34 (3): 259-263

    Abstract

    Objective?The objective of this study was to assess utilization of specialist coverage and checklists in perinatal settings and to examine utilization by birth asphyxia rates. Design?This is a survey study of California maternity hospitals concerning checklist use to prepare for delivery room resuscitation and 24-hour in-house specialist coverage (pediatrician/neonatologist, obstetrician, and obstetric anesthesiologist) and results linked to hospital birth asphyxia rates (preterm and low weight births were excluded). Results?Of 253 maternity hospitals, 138 responded (55%); 59 (43%) indicated checklist use, and in-house specialist coverage ranged from 38% (pediatrician/neonatologist) to 54% (anesthesiology). In-house coverage was more common in urban versus rural hospitals for all specialties (p?

    View details for DOI 10.1055/s-0036-1586505

    View details for PubMedID 27487231

  • Rapid reduction of the NTSV CS rate in multiple community hospitals using a multi-dimensional QI approach Lagrew, D. C., Mills, M., Mikes, K., Chan, K., Trial, J., Deeds, T., Rubinstein, B., Main, E. MOSBY-ELSEVIER. 2017: S471?S472
  • Opportunities for maternal transport for delivery of very low birth weight infants JOURNAL OF PERINATOLOGY Robles, D., Blumenfeld, Y. J., Lee, H. C., Gould, J. B., Main, E., Profit, J., Melsop, K., Druzin, M. 2017; 37 (1): 32-35

    Abstract

    To assess frequency of very low birth weight (VLBW) births at non-level III hospitals.Retrospective cohort study using linked California birth certificate and discharge data of 2008 to 2010 for deliveries of singleton or first-born infant of multiple gestations with birth weight 400 to 1500?g. Delivery rates by neonatal level of care were obtained. Risk of delivery at non-level III centers was estimated in univariable and multivariable models.Of the 1?508?143 births, 13?919 (9.2%) were VLBW; birth rate at non-level III centers was 14.9% (8.4% in level I and 6.5% in level II). Median rate of VLBW births was 0.3% (range 0 to 4.7%) annually at level I and 0.5% (range 0 to 1.6%) at level II hospitals. Antepartum stay for >24?h occurred in 14.0% and 26.9% of VLBW births in level I and level II hospitals, respectively.Further improvement is possible in reducing VLBW infant delivery at suboptimal sites, given the window of opportunity for many patients.Journal of Perinatology advance online publication, 29 September 2016; doi:10.1038/jp.2016.174.

    View details for DOI 10.1038/jp.2016.174

    View details for Web of Science ID 000391517000007

  • Confirmed severe maternal morbidity is associated with high rate of preterm delivery. American journal of obstetrics and gynecology Kilpatrick, S. J., Abreo, A., Gould, J., Greene, N., Main, E. K. 2016; 215 (2): 233 e1-7

    Abstract

    Because severe maternal morbidity (SMM) is increasing in the United States, affecting up to 50,000 women per year, there was a recent call to review all mothers with SMM to better understand their morbidity and improve outcomes. Administrative screening methods for SMM have recently been shown to have low positive predictive value for true SMM after chart review. To ultimately reduce maternal morbidity and mortality we must better understand risk factors, and preventability issues about true SMM such that interventions could be designed to improve care.Our objective was to determine risk factors associated with true SMM identified from California delivery admissions, including the relationship between SMM and preterm delivery.In this retrospective cohort study, SMM cases were screened for using International Classification of Diseases, Ninth Revision codes for severe illness and procedures, prolonged postpartum length of stay, intensive care unit admission, and transfusion from all deliveries in 16 hospitals from July 2012 through June 2013. Charts of screen-positive cases were reviewed and true SMM diagnosed based on expert panel agreement. Underlying disease diagnosis was determined. Women with true-positive SMM were compared to SMM-negative women for the following variables: maternal age, ethnicity, gestational age at delivery, prior cesarean delivery, and multiple gestation.In all, 491 women had true SMM and 66,977 women did not have SMM for a 0.7% rate of true SMM. Compared to SMM-negative women, SMM cases were significantly more likely to be age >35 years (33.6 vs 23.8%; P < .0001), be African American (14.1 vs 7.9%; P < .0001), have had a multiple gestation (9.7 vs 2.1%; P < .0001), and, for the multiparous women, have had a prior cesarean delivery (58 vs 30.2%; P < .0001). Preterm delivery was significantly more common in SMM women compared to SMM-negative women (41 vs 8%; P < .0001), including delivery <32 weeks (18 vs 2%; P < .0001). The most common underlying disease was obstetric hemorrhage (42%) followed by hypertensive disorders (20%) and placental hemorrhage (14%). Only 1.6% of women with SMM had cardiovascular disease as the underlying disease category.An extremely high proportion of women with severe morbidity (42.5%) delivered preterm with 17.8% delivering <32 weeks, which underscores the importance of access to appropriate-level care for mothers with SMM and their newborns. Further, the extremely high rate of preterm delivery (75%) in women with placental hemorrhage in combination with their 63% prior cesarean delivery rate highlights another risk of prior cesarean delivery: subsequent preterm delivery. These data provide a reminder that a cesarean delivery could be a contributing factor to not only hemorrhage-related SMM, but also to increased subsequent preterm delivery, more reason to continue national efforts to safely reduce initial cesarean deliveries.

    View details for DOI 10.1016/j.ajog.2016.02.026

    View details for PubMedID 26899903

  • Severe maternal morbidity is associated with high rate of preterm delivery Kilpatrick, S., Abreo, A., Lanner-Cusin, K., Main, E. MOSBY-ELSEVIER. 2016: S28
  • Relationship between ICU Admissions and Severe Maternal Morbidity McNulty, J., Kilpatrick, S., Arbreo, A., Fenton, D., Main, E. MOSBY-ELSEVIER. 2016: S129?S130
  • Variation in transfusion rates and Maternal Levels of Care: Implications for quality indicators and the measurement of Severe Maternal Morbidity (SMM) Gilbert, W., Abreo, A., McNally, C., Poeltler, D., Main, E. MOSBY-ELSEVIER. 2016: S275?S276
  • National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Main, E. K., Goffman, D., Scavone, B. M., Low, L., Bingham, D., Fontaine, P. L., Gorlin, J. B., Lagrew, D. C., Levy, B. S. 2015; 44 (4): 462?70

    View details for DOI 10.1111/1552-6909.12723

    View details for Web of Science ID 000357898600003

    View details for PubMedID 26058596

  • National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage JOURNAL OF MIDWIFERY & WOMENS HEALTH Main, E. K., Goffman, D., Scavone, B. M., Low, L. K., Bingham, D., Fontaine, P. L., Gorlin, J. B., Lagrew, D. C., Levy, B. S. 2015; 60 (4): 458-464

    Abstract

    Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

    View details for DOI 10.1111/jmwh.12345

    View details for Web of Science ID 000359355400015

    View details for PubMedID 26059199

  • National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage ANESTHESIA AND ANALGESIA Main, E. K., Goffman, D., Scavone, B. M., Low, L. K., Bingham, D., Fontaine, P. L., Gorlin, J. B., Lagrew, D. C., Levy, B. S. 2015; 121 (1): 142-148

    Abstract

    Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

    View details for DOI 10.1097/AOG.0000000000000869

    View details for Web of Science ID 000356671400001

    View details for PubMedID 26091046

  • Pregnancy Outcomes in the Super Obese, Stratified by Weight Gain Above and Below Institute of Medicine Guidelines OBSTETRICS AND GYNECOLOGY Swank, M. L., Marshall, N. E., Caughey, A. B., Main, E. K., Gilbert, W. M., Melsop, K. A., Chung, J. H. 2014; 124 (6): 1105?10

    Abstract

    To examine the association of antenatal weight gain above and below the 2009 Institute of Medicine (IOM) guidelines in the super-obese population (body mass index [BMI] of 50 or higher) on the maternal and neonatal morbidities of gestational hypertension or preeclampsia (pregnancy-induced hypertension), gestational diabetes mellitus, cesarean delivery, birth weight more than 4,000 g and more than 4,500 g, low birth weight, and preterm birth.The effect of gestational weight gain was assessed in this retrospective cohort study using California birth certificate and patient discharge diagnosis data. Unconditional logistic regression was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) as a function of antenatal weight gain. Weight gain within 2009 IOM guidelines (11-20 pounds) served as the reference group.The study population consisted of 1,034 women. Women gaining below, within, and above IOM guidelines accounted for 38.3, 23.5, and 38.2%, respectively. Weight gain below IOM guidelines was not associated with a statistically increased odds of preterm birth (OR 1.82, 95% CI 0.60-5.59) or low birth weight (OR 1.20, 95% CI 0.57-2.49); however, birth weight more than 4,000 g was significantly reduced (OR 0.50, 95% CI 0.32-0.77). Excessive weight gain statistically increased the odds of pregnancy-induced hypertension (OR 1.96, 95% CI 1.26-3.03) and cesarean delivery (OR 1.40, 95% CI 1.00-1.97) while not appearing to protect against the delivery of low-birth-weight neonates (OR 0.84, 95% CI 0.40-1.78).Weight gain below the current guidelines in the super-obese cohort is not associated with an increase in maternal or neonatal risk while decreasing the odds of delivering a macrosomic neonate. Women with BMIs of 50 or higher may warrant separate gestational weight gain recommendations.

    View details for PubMedID 25415161

  • The Impact of Change in Pregnancy Body Mass Index on Macrosomia OBESITY Swank, M. L., Caughey, A. B., Farinelli, C. K., Main, E. K., Melsop, K. A., Gilbert, W. M., Chung, J. H. 2014; 22 (9): 1997?2002

    Abstract

    To examine the impact of change in body mass index (BMI) during pregnancy on the incidence of macrosomia.This is a retrospective cohort study using 2007 linked birth certificate and discharge diagnosis data from the state of California. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated for the outcome of macrosomia, as a function of a categorical change in pregnancy BMI: BMI loss (<-0.5), no change (-0.5 to 0.5), minimal (0.6 to 5), moderate (5.1 to 10), and excessive (>10). The impact of pregnancy change in BMI was determined for the entire cohort and then stratified by prepregnancy BMI category. Minimal BMI change served as the reference group.The study population consisted of 436,414 women. Overall, women with moderate and excessive BMI changes had aORs of 1.66 and 3.21, respectively, for macrosomia, when compared with women with minimal BMI change. When stratified by prepregnancy BMI, normal (aOR 3.85) and overweight women (aOR 2.96) with antenatal BMI change greater than 10 had the highest odds of macrosomia.Excessive change in pregnancy BMI results in an increased odds of macrosomia. This finding was most pronounced in the normal and overweight women.

    View details for DOI 10.1002/oby.20790

    View details for Web of Science ID 000341578000012

    View details for PubMedID 24890506

  • The impact of change in pregnancy body mass index on cesarean delivery JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE Swank, M. L., Caughey, A. B., Farinelli, C. K., Main, E. K., Melsop, K. A., Gilbert, W. M., Chung, J. H. 2014; 27 (8): 795?800

    Abstract

    To examine the impact of pregnancy changes in body mass index (BMI) on the incidence of cesarean delivery.This is a retrospective cohort study using linked birth certificate and discharge diagnosis data from the year 2007. Adjusted odds ratios (aOR) were calculated for the outcome of cesarean delivery, as a function of a categorical change in pregnancy BMI (kg/m(2)): BMI loss (BMI change<-0.5), no change (-0.5 to 0.5), minimal (0.6 to 5), moderate (5.1 to 10) and excessive (>10). The impact of pregnancy change in BMI was determined for the entire cohort and then stratified by prepregnancy BMI category.The study population consisted of 436?414 women with singleton gestations. When compared to women with no net change in BMI, women with excessive BMI changes collectively had a 80% increased incidence of cesarean delivery (aOR?=?1.78). By prepregnancy obesity class, the aOR for cesarean delivery in women with excessive BMI change were: normal weight (aOR?=?2.25), overweight (aOR?=?2.39), obese class I (aOR?=?2.23), obese class II (aOR?=?2.56) and obese class III (aOR?=?2.08).The odds of cesarean delivery were uniformly increased in all prepregnancy BMI categories as net BMI change increased. These data illustrate that all women, not just the overweight and obese, are at significantly increased risk of cesarean delivery with excessive BMI change during pregnancy.

    View details for DOI 10.3109/14767058.2013.845657

    View details for Web of Science ID 000334738800005

    View details for PubMedID 24047475

  • The impact of change in pregnancy body mass index on the development of gestational hypertensive disorders JOURNAL OF PERINATOLOGY Swank, M. L., Caughey, A. B., Farinelli, C. K., Main, E. K., Melsop, K. A., Gilbert, W. M., Chung, J. H. 2014; 34 (3): 181?85

    Abstract

    To examine the impact of change in body mass index (BMI) during pregnancy on the incidence of gestational hypertension/preeclampsia.This is a retrospective cohort study using linked California birth certificate and discharge diagnosis data from the year 2007. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated for the outcome of gestational hypertension/preeclampsia, as a function of a categorical change in pregnancy BMI: BMI loss (<-0.5), no change (-0.5 to 0.5), minimal (0.6 to 5), moderate (5.1 to 10) and excessive (>10). The impact of change in pregnancy BMI was evaluated for the entire cohort and then as a function of prepregnancy BMI category. Women with no change in pregnancy BMI served as the reference group.The study population consisted of 436?414 women with singleton gestations. Overall, women with excessive BMI change had a nearly twofold increased odds of gestational hypertension/preeclampsia (aOR=1.94; 95% CI=1.72 to 2.20). By prepregnancy BMI class, overweight and obese women who had a moderate change in pregnancy BMI also had increased odds of developing gestational hypertension/preeclampsia with aOR ranging from 1.73 to 1.97.Regardless of prepregnancy BMI category, women with excessive BMI change have a higher chance of developing gestational hypertension/preeclampsia. Overweight and obese women with moderate BMI change may also be at increased risk.

    View details for PubMedID 24384780

  • Maternal Mortality: Time for National Action Reply OBSTETRICS AND GYNECOLOGY Menard, M., Main, E. 2014; 123 (2): 362?63

    View details for PubMedID 24451666

  • Maternal height and perinatal outcomes in normal weight women Marshall, N., Snowden, J., Darney, B., Main, E., Gilbert, W., Chung, J., Caughey, A. MOSBY-ELSEVIER. 2014: S252
  • The impact of pre-pregnancy body mass index and gestational weight gain on failed trial of labor after cesarean Chung, J., Swank, M., Main, E., Melsop, K., Gilbert, W., Caughey, A. MOSBY-ELSEVIER. 2014: S309?S310
  • Influence of Fetal Sex, Maternal Obesity, and Gestational Weight Gain on Perinatal Outcomes. Marshall, N. E., Snowden, J. M., O'Tierney-Ginn, P. F., Melsap, K., Chung, J., Main, E., Gilbert, W., Caughey, A. B. SAGE PUBLICATIONS INC. 2013: 309A?310A
  • The impact of gestational change in body mass index (BMI) on adverse pregnancy outcomes among women with gestational diabetes 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Chung, J., Swank, M., Main, E., Melsop, K., Gilbert, W., Caughey, A. MOSBY-ELSEVIER. 2013: S122?S123
  • The impact of change in pregnancy body mass index on gestational hypertension/preeclampsia 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Swank, M., Caughey, A., Farinelli, C., Main, E., Melsop, K., Gilbert, W., Chung, J. MOSBY-ELSEVIER. 2013: S274?S274
  • Impact of gestational weight gain by BMI class on cesarean delivery in nulliparous women 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Marshall, N., Halloran, D., Chung, J., Snowden, J., Cheng, Y., Melsap, K., Main, E., Gilbert, W., Caughey, A. MOSBY-ELSEVIER. 2013: S303?S304
  • The impact of change in pregnancy body mass index on cesarean delivery 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Swank, M., Caughey, A., Farinelli, C., Main, E., Melsop, K., Gilbert, W., Chung, J. MOSBY-ELSEVIER. 2013: S339?S339
  • The impact of change in pregnancy body mass index on macrosomia 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Swank, M., Caughey, A., Farinelli, C., Main, E., Melsop, K., Gilbert, W., Chung, J. MOSBY-ELSEVIER. 2013: S190?S190
  • The impact of change in pregnancy body mass index on preterm birth and low birthweight 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Swank, M., Caughey, A., Farinelli, C., Main, E., Melsop, K., Gilbert, W., Chung, J. MOSBY-ELSEVIER. 2013: S191?S191
  • Prevalence of non-medically indicated induction of labor among women of varying body mass index in California 33rd Annual Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM) Snowden, J., Cheng, Y., Darney, B., Marshall, N., Chung, J., Main, E., Gilbert, W., Melsop, K., Caughey, A. MOSBY-ELSEVIER. 2013: S299?S300
  • Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery OBSTETRICS AND GYNECOLOGY Main, E. K., Morton, C. H., Melsop, K., Hopkins, D., Giuliani, G., Gould, J. B. 2012; 120 (5): 1194-1198

    Abstract

    Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at www.cmqcc.org/white_paper). All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.

    View details for DOI 10.1097/AOG.0b013e31826fc13d

    View details for Web of Science ID 000310512500027

    View details for PubMedID 23090538

  • Neonatal Outcomes After Implementation of Guidelines Limiting Elective Delivery Before 39 Weeks of Gestation OBSTETRICS AND GYNECOLOGY Oshiro, B., Branch, W., Main, E. 2012; 119 (3): 656

    View details for DOI 10.1097/AOG.0b013e318248a84a

    View details for Web of Science ID 000300637400025

    View details for PubMedID 22353967

  • Decisions Required for Operating a Maternal Mortality Review Committee: The California Experience SEMINARS IN PERINATOLOGY Main, E. K. 2012; 36 (1): 37?41

    Abstract

    Maternal mortality is a current and important issue for obstetrics. The challenge is to structure case reviews so that they develop real data that can inform and direct quality improvement activities. In this article, we describe a series of decisions we have made in California to organize and run our maternal mortality review committee. These include defining the goal of the reviews, selection of cases, composition of the committee, basic review issues, and the definitions used for analysis (eg, cause of death, contributing factors, role of cesarean delivery, preventability, identifying quality improvement opportunities). It is expected that each maternal mortality review committee will have somewhat different approaches based on local resources and case mix.

    View details for DOI 10.1053/j.semperi.2011.09.008

    View details for Web of Science ID 000299860900008

    View details for PubMedID 22280864

  • A State-Wide Obstetric Hemorrhage Quality Improvement Initiative MCN-THE AMERICAN JOURNAL OF MATERNAL-CHILD NURSING Bingham, D., Lyndon, A., Lagrew, D., Main, E. K. 2011; 36 (5): 297-304

    Abstract

    The mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and to promote equitable maternity care in California. This article describes California Maternal Quality Care Collaborative's (CMQCC's) statewide multistakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success. PROJECT DESIGN AND APPROACH: In partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multidisciplinary, multistakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage. PROJECT DESCRIPTION: The OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multilevel strategy to disseminate the guideline, including an open access toolkit, a minimal support-mentoring model, a county partnership model, and a 30-hospital learning collaborative.In participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 (or greater) hemorrhage, hosting skills stations for measuring blood loss, and running obstetric (OB) hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the statewide initiative in which nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a difference in the quality of care that can be achieved. Nurses provide significant leadership in multidisciplinary, multistakeholder quality projects in California. Ensuring that nurses have the opportunity to participate in formal leadership of these teams and are represented at all workgroup levels is critical to the overall initiative. Nurses brought key understanding of operational issues within and across departments, mobilized engagement across the state through the regional perinatal programs, and developed innovative approaches to solving clinical problems during implementation. Nursing leadership and integrated participation was especially critical in considering the needs of lower-resource settings, and was essential to the toolkit's enthusiastic adoption at the unit/service level in facilities across the state.

    View details for DOI 10.1097/NMC.0b013e318227c75f

    View details for Web of Science ID 000294047700006

    View details for PubMedID 21857200

    View details for PubMedCentralID PMC3203841

  • Excess gestational weight gain is associated with gestational hypertension/preeclampsia and cesarean birth 31st Annual Scientific Meeting of the Society-of-Maternal-Fetal-Medicine (SMFM) Melsop, K., Main, E., Caughey, A. B., Gilbert, W., Walker, C., Chung, J. MOSBY-ELSEVIER. 2011: S232?S232
  • Interrelationship between race/ethnicity and obesity on perinatal outcomes 31st Annual Scientific Meeting of the Society-of-Maternal-Fetal-Medicine (SMFM) Main, E., Melsop, K., Caughey, A. B., Gilbert, W., Walker, C., Chung, J. MOSBY-ELSEVIER. 2011: S313?S313
  • Interrelationship between gestational weight gain and race/ethnicity on perinatal outcomes 31st Annual Scientific Meeting of the Society-of-Maternal-Fetal-Medicine (SMFM) Main, E., Melsop, K., Caughey, A. B., Gilbert, W., Walker, C., Chung, J. MOSBY-ELSEVIER. 2011: S50?S50
  • Increasing maternal body mass index is strongly associated with gestational diabetes, gestational hypertension/preeclampsia and cesarean delivery 31st Annual Scientific Meeting of the Society-of-Maternal-Fetal-Medicine (SMFM) Melsop, K., Main, E., Caughey, A. B., Gilbert, W., Walker, C., Chung, J. MOSBY-ELSEVIER. 2011: S231?S232
  • Effective Implementation Strategies and Tactics for Leading Change on Maternity Units JOURNAL OF PERINATAL & NEONATAL NURSING Bingham, D., Main, E. K. 2010; 24 (1): 32-42

    Abstract

    Change implementation within organizations is a complex and dynamic process that is not always successful. Tailoring the implementation strategies and tactics to address the identified barriers to change is one method that has been shown to be effective. Examples of 3 broad types of interrelated strategies used by frontline leaders when implementing quality improvement (QI) projects are (1) discourse (communication), (2) education (formal and informal), and (3) data (audit). Examples of common barriers to implementation are leaders' and clinicians' knowledge, attitudes, and practices, the QI topic characteristics, and the implementation climate. External pressures from national organizations such as the National Quality Forum, the Leapfrog Group, and The Joint Commission likely facilitate change. Knowledgeable, tenacious, and creative frontline physician and nurse leaders may have the greatest impact on QI implementation effectiveness because they are the individuals who decide how the strategies and tactics will be tailored.

    View details for DOI 10.1097/JPN.0b013e3181c94a24

    View details for Web of Science ID 000275333600008

    View details for PubMedID 20147828

  • Cesarean delivery rates and neonatal morbidity in a low-risk population OBSTETRICS AND GYNECOLOGY Gould, J. B., Danielsen, B., Korst, L. M., Phibbs, R., Chance, K., Main, E., Wirtschafter, D. D., Stevenson, D. K. 2004; 104 (1): 11-19

    Abstract

    To estimate the relationship between case-mix adjusted cesarean delivery rates and neonatal morbidity and mortality in infants born to low-risk mothers.This retrospective cohort study used vital and administrative data for 748,604 California singletons born without congenital abnormalities in 1998-2000. A total of 282 institutions was classified as average-, low-, or high-cesarean delivery hospitals based on their cesarean delivery rate for mothers without a previous cesarean delivery, in labor at term, with no evidence of maternal, fetal, or placental complications. Neonatal mortality, diagnoses, and therapeutic interventions determined by International Classification of Diseases, 9th Revision, Clinical Modification codes, and neonatal length of stay were compared across these hospital groupings.Compared with average-cesarean delivery-rate hospitals, infants born to low-risk mothers at low-cesarean delivery hospitals had increased fetal hemorrhage, birth asphyxia, meconium aspiration syndrome, feeding problems, and electrolyte abnormalities (P <.02). Infused medication, pressors, transfusion for shock, mechanical ventilation, and length of stay were also increased (P <.001). This suggests that some infants born in low-cesarean delivery hospitals might have benefited from cesarean delivery. Infants delivered at high-cesarean delivery hospitals demonstrated increased fetal hemorrhage, asphyxia, birth trauma, electrolyte abnormalities, and use of mechanical ventilation (P <.001), suggesting that high cesarean delivery rates themselves are not protective.Neonatal morbidity is increased in infants born to low-risk women who deliver at both low- and high-cesarean delivery-rate hospitals. The quality of perinatal care should be assessed in these outlier hospitals.III

    View details for DOI 10.1097/01.AOG.0000127035.64602.97

    View details for PubMedID 15228995

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