Maternal Morbidity and Birth Satisfaction After Implementation of a Validated Calculator to Predict Cesarean Delivery During Labor Induction
Authors: Rebecca F. Hamm, Jennifer McCoy, Amal Oladuja, Hilary R. Bogner, Michal A. Elovitz, Knashawn H. Morales, Sindhu K. Srinivas, Lisa D. Levine
Journal: JAMA Network Open (2020)

<h3>Importance</h3> A previously created and validated calculator provides an individualized cesarean delivery risk score for women undergoing labor induction. A higher predicted risk of cesarean delivery on the calculator has been associated with increased maternal and neonatal morbidity regardless of ultimate delivery mode. The effect of this calculator when implemented in clinical care has yet to be evaluated. <h3>Objective</h3> To determine whether implementation of a validated calculator that predicts the likelihood of cesarean delivery at the time of labor induction is associated with maternal morbidity and birth satisfaction. <h3>Design, Setting, and Participants</h3> This prospective cohort study used medical record review to compare the 1 year before calculator implementation (July 1, 2017, to June 30, 2018) with the 1 year after implementation (July 1, 2018, to June 30, 2019) at a US urban, university labor unit. Women admitted for labor induction with singleton gestation in cephalic presentation, intact membranes, and an unfavorable cervix were included. Data were analyzed from August 1, 2019, to September 13, 2020. <h3>Exposures</h3> Patient and clinician knowledge of the calculated cesarean delivery risk score based on the validated calculator. <h3>Main Outcomes and Measures</h3> The primary outcomes were (1) composite maternal morbidity defined by at least 1 of the following within 30 days of delivery: endometritis, postpartum hemorrhage (estimated or quantitative blood loss &gt;1000 mL), blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and readmission and (2) patient satisfaction assessed via Birth Satisfaction Scale–Revised (BSS-R) scores. Secondary outcomes included rate of cesarean delivery and neonatal morbidity. <h3>Results</h3> A total of 1610 women were included in the analysis (788 in the preimplementation and 822 in the postimplementation periods) with a median age of 29 (interquartile range [IQR], 24-34) years. There were no significant baseline differences between groups except fewer inductions at a gestational age of 40 weeks or later in the postimplementation period (256 [31.1%] vs 298 [37.8%]). Calculator implementation was associated with decreased maternal morbidity overall, even when adjusting for confounders (141 [17.9%] vs 95 [11.6%]; adjusted absolute risk difference [aARD], −6.3%; 95% CI, −9.7% to −2.8%). Although there was no difference in birth satisfaction overall, calculator implementation was associated with improvements on items pertaining to quality of care provision (median BSS-R score, 19 [IQR, 16-20] vs 19 [IQR, 17-20];<i>P</i> = .006). Calculator implementation was also associated with a decrease in cesarean delivery rate (228 [28.9%] vs 167 [20.3%]; aARD, −8.5% [95% CI, −12.6% to −4.5%]). There were no significant differences in neonatal morbidity. <h3>Conclusions and Relevance</h3> These findings suggest that implementation of a validated calculator to predict risk of cesarean delivery in clinical care is associated with reduced maternal morbidity. Implementation should occur broadly to determine whether calculator use improves national maternal outcomes.