The purpose of this article was to describe a continuous quality improvement project in a family medicine residency practice based research network to improve the rates of delivery of several recommended maternal care interventions. We found that there was evidence for a range of effects of this intervention on provider behaviors. Interventions with high rates of adherence in the baseline phase of the study (90+%) did not increase significantly following the initiation of the intervention probably reflecting a ceiling effect for these interventions. Three interventions were initially low and had significant increases following the initiation of the CQI program. These interventions span three distinct domains of maternal health (emotional distress, smoking cessation, and contraception planning) suggesting that the CQI approach can be effective across thematic areas within maternal care. Interestingly screening for postpartum depressive symptomatology had low initial rates of delivery and which did not increase following the CQI program suggesting that additional attention must be paid to this intervention.
The differences identified in care delivery rates could in part be explained by how well established a certain practice is. For instance, screening for asymptomatic bacteriuria has an “A” level recommendation from the US Preventive Health Service Panel and has long been part of prenatal care. However smoking cessation interventions generally focus only on the initial prenatal period despite the fact that portions of women who smoke in early pregnancy continue through gestation [15
]. Given this fact it was hopeful to see that the CQI intervention was able (though not initially) to modify provider behavior and increase screening for smoking late in pregnancy. Depressive symptomatology screening has only recently been widely recommended in the maternal care setting and is complicated by issues of treatment options during pregnancy [16
]. Interestingly we found an increase in prenatal but not in postpartum screening suggesting that additional efforts are needed in the later period.
The data presented here expose the limitations of our perinatal care routines and point the way to areas of improvement. This is exactly why the CQI phase of this project has the potential to be successful in increasing rates of maternal care delivery. Through continual feedback on our performance and re-engineering of care processes through stakeholder discussions, we believe there is potential to improve perinatal care.
This study has several limitations; foremost of which is the non-randomized design. We chose to include all network residency programs because of the nature of the CQI process. Also, although many aspects of the project are standardized, it is critical for the site teams to develop site-specific implementation processes and there was an inherent variability in this approach. However we believe that this is a critical component of the network as each site must deal with a unique context with distinct real life challenges that must be addressed. There is no “one size fits all” approach to overcoming obstacles to care delivery. This variability also provides an opportunity for innovation which is shared among members of the network. Data quality measures are also somewhat limited. Each site was asked to implement a random assessment of the accuracy of data submitted to the network and the details of these assessments varied from one site to another. Finally the generalizability of our findings is unknowm. The data are from family medicine residency programs; this may not reflect how prenatal care processes are carried out in private office or community health center sites. Further work is needed to determine if a similar approach can be successful in these settings. Despite these limitations we feel that this work provides important initial support for the use of a CQI approach to increase the rates of delivery of maternal care interventions.