NU684 Unit 10 Equity Improvement Proposal Example

Twenty-Two Percent for Some, Thirty-One for Others: A Unit 10 Equity Improvement Proposal on First-Birth Cesarean Rates

[Student Name]

Purdue University Global

NU684: Obstetrical Care

Unit 10 Equity Improvement Proposal

[Instructor Name]

[Date]

The hospital, its data and staff are composite and illustrative; the studies and figures cited from them are real.

The Measure and the Gap

The nulliparous, term, singleton, vertex cesarean rate, known as the NTSV rate, counts cesareans among first-time mothers at 37 weeks or more with one baby in the head-down position. Because it removes many differences in medical risk, it is widely used to compare labor care between hospitals and over time.

The hospital's overall NTSV rate last year was 25.1 percent, close to the state target of 23.9 percent. Stratifying the same data showed rates of 22 percent for White patients, 31 percent for Black patients, 27 percent for English-speaking Hispanic patients, 29 percent when Spanish was the language a patient asked to use, and 26 percent for Asian patients. Most of the difference came from cesareans recorded as arrest of dilation.

What the Evidence Says About Such Gaps

Other hospitals see the same split. In a cohort of more than 16,000 NTSV births in an integrated health system, Black, Asian, Hispanic and multiracial women all had higher adjusted odds of cesarean than White women, with Black women at the highest odds, about 1.7 times. Among women whose cesareans were for failure to progress, Black, Hispanic and Asian women were less likely than White women to have reached full dilation before the decision (Okwandu et al., 2021). That last finding points to the timing of decisions in labor, which is something a unit can change.

If the decision to stop labor comes earlier for some patients than others, the gap begins at the bedside.

What Has Worked Elsewhere

California's maternal quality collaborative offers a model. Between 2014 and 2019, the state's NTSV cesarean rate fell from 26.0 to 22.8 percent even as the national rate outside California held at 26.0 percent, and hospitals that joined the collaborative saw greater reductions than those that did not (Rosenstein et al., 2021). The collaborative's work combined data feedback to clinicians, standard definitions of labor progress and arrest, labor support and attention to hospital culture.

The standard definitions come from the joint ACOG and Society for Maternal-Fetal Medicine consensus on preventing the first cesarean. It recommends that active labor be considered to begin at 6 centimeters for most patients, and that arrest of dilation be diagnosed only at 6 centimeters or more, with ruptured membranes and no cervical change despite adequate contractions for at least four hours, or inadequate contractions with oxytocin for at least six hours (Caughey et al., 2014). Applying these definitions consistently is one way to ensure that every patient is given the same time in labor.

Proposed Changes

Stratified data, shared monthly. The NTSV rate is reported every month by race, ethnicity and preferred language, by attending clinician group and by indication. The data go to all labor clinicians, not only leaders, because feedback is a core element of the collaborative's success. Small numbers in some groups mean rolling twelve-month rates are used to avoid overreacting to single months.

A standard arrest checklist. Before a cesarean for arrest of dilation or descent, the clinician completes a brief checklist confirming that the consensus criteria are met, reviewed with the charge nurse. This creates the same pause for every patient regardless of who she is or what language she speaks.

Case review of early arrest decisions. Every cesarean for arrest before 6 centimeters is reviewed monthly by a small team that includes a midwife, an obstetrician and a nurse, with feedback framed as learning rather than blame.

Interpreter access in labor. Audit data showed that a qualified interpreter was documented in fewer than half of labor admissions for Spanish-speaking patients. The proposal requires a video interpreter at triage, admission, every decision point and the discussion before any cesarean, so that patients can take part in decisions about continuing labor.

Labor support. The hospital will pilot a volunteer doula program aimed first at patients without a support person, and train nurses in positioning and comfort measures that help labor progress.

Measures

The primary measure is the stratified NTSV rate, with the goal of halving the distance between the group with the highest rate and the group with the lowest inside two years while keeping the overall rate at or below 23.9 percent. Process measures include the percentage of arrest cesarean cases with a completed checklist, interpreter use at each decision point and doula coverage. Balancing measures, which check for unintended harm, include rates of severe perineal laceration, postpartum hemorrhage, chorioamnionitis and low Apgar scores, also stratified.

Patient Voice

Numbers alone will not show whether patients felt respected. A short postpartum survey asking whether patients felt their wishes were heard during labor goes to every patient in her preferred language, and its results will be reviewed alongside the clinical data. Two community members who gave birth at the hospital will be invited to join the quality committee.

Timeline and Ownership

The first three months build the data system and train staff on the checklist, led by the unit's quality nurse and the obstetric medical director. Stratified reports begin in month four, and the case review team meets monthly from then on. The interpreter requirement starts at once, since it needs no new equipment, only a change to the admission and decision workflow, and the nurse manager owns its audit. The doula pilot, which needs volunteer recruitment and training, starts in month six with the community liaison as its lead. The quality committee reviews all measures quarterly and reports to hospital leadership and to the community members on the committee at the end of each year.

Risks and Responses

Clinicians may feel that stratified data accuse them of bias. The proposal presents the data as a description of systems and decision timing, shares the published evidence that similar gaps exist widely and focuses on standard processes rather than individual blame. Monthly counts for smaller groups swing widely, so rolling rates and case review are used together.

Conclusion

An overall rate near the target concealed a gap of nine percentage points between groups at this hospital. Published evidence suggests such gaps often reflect earlier decisions to end labor for some patients, and California's experience shows that data feedback, standard definitions and labor support can lower rates. This proposal applies those lessons, adds interpreter access and patient voice, and measures progress by group so that improvement reaches everyone.

References

Caughey, A. B., Cahill, A. G., Guise, J.-M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology, 210(3), 179-193. https://doi.org/10.1016/j.ajog.2014.01.026

Okwandu, I. C., Anderson, M., Postlethwaite, D., Shirazi, A., & Torrente, S. (2021). Racial and ethnic disparities in cesarean delivery and indications among nulliparous, term, singleton, vertex women. Journal of Racial and Ethnic Health Disparities, 9(4), 1161-1171. https://doi.org/10.1007/s40615-021-01057-w

Rosenstein, M. G., Chang, S.-C., Sakowski, C., Markow, C., Teleki, S., Lang, L., Logan, J., Cape, V., & Main, E. K. (2021). Hospital quality improvement interventions, statewide policy initiatives, and rates of cesarean delivery for nulliparous, term, singleton, vertex births in California. JAMA, 325(16), 1631-1639. https://doi.org/10.1001/jama.2021.3816