Quality in obstetric care: measuring what matters.

Quality measures allow providers, payers, and patients to assess and compare the performance of medical teams. The ideal quality measure is easy to define and observe, important to patients and physicians, and identifies areas ripe for improvement. There are several challenges unique to obstetrics that complicate quality measurement. Nationally available data are flawed and limited. Adverse outcomes are rare and difficult to compare between groups. An appropriate emphasis on teamwork makes assigning outcomes to individuals improper and impractical. We suggest some strategies that address these challenges and may improve obstetric measures: applying measures to teams rather than individuals, using sentinel events for internal root cause analysis rather than comparisons between groups, devising measures that account for alternatives, and developing data-collection fields that address important quality metrics directly. We highlight four measures that meet these criteria: 1) elective delivery before 39 weeks of gestation, 2) prophylactic antibiotic use for cesarean delivery, 3) the Adverse Outcome Index, and 4) the nulliparous term singleton vertex cesarean delivery rate. We suggest that each institution evaluate local priorities, select a measure, then continue to refine measures based on feedback from frontline clinicians.