# Factors that influence the implementation and effectiveness of a patient safety bundle to reduce low-risk cesarean deliveries

> **NIH NIH R03** · UNIVERSITY OF MARYLAND BALTIMORE COUNTY · 2020 · $80,450

## Abstract

High rates of cesarean delivery in the United States are a cause of urgent concern as cesarean delivery is
associated with increased risks for maternal morbidity and mortality. Women with a first cesarean are at
increased risk for serious complications such as uterine rupture, unplanned hysterectomy, and endometritis.
The risk of severe maternal morbidity and poor neonatal outcomes increases with each subsequent cesarean
delivery. The rise in cesarean delivery rates during the past two decades is a suspected driver of overall
increases in maternal mortality and morbidity in the same time period. To reduce cesarean delivery rates
among first-time mothers with low-risk pregnancies, the Health Resources and Services Administration is
currently supporting implementation of a “patient safety bundle” through state perinatal collaboratives.
The proposed study will leverage a real world implementation of the cesarean bundle through the Maryland
Perinatal Collaborative (MPC), which is one of the first state collaboratives to implement the bundle and
includes 31 of the state’s 32 birthing hospitals. Our research team, with expertise in implementation science,
obstetric care quality, and mixed-methods and qualitative research, will conduct a mixed-methods case study
of bundle implementation at hospitals participating in the MPC. The proposed research will be the first
implementation study of the cesarean bundle, and will address important gaps in the literature on guideline
implementation in obstetric care. For our first aim, we will conduct qualitative interviews with MPC leaders and
stakeholders to describe and categorize each hospital’s implementation approach and to identify barriers and
facilitators for implementing the bundle. Interviews will address the five domains of the Consolidated
Framework for Implementation Research (CFIR), and will contribute to building the evidence base for guideline
implementation in obstetric care. Under our second aim, we will conduct Comparative Qualitative Analysis to
assess which implementation factors are common to hospitals with high adoption of the bundle (>70% of
bundle practices) and low adoption (<40% of practices), and hospitals with higher cesarean rates (>30 per 100
live births) and lower rates (<20 per 100). For our third aim, we will assess the maintenance of bundle EBPs,
and any new adoption of EBPS, through a survey of MPC leaders one year after the collaborative ends. The
results of this study will contribute to the development of an R01 proposal to test an implementation support
package designed to improve implementation of the bundle and reduce cesarean delivery rates.

## Key facts

- **NIH application ID:** 9978865
- **Project number:** 5R03HD096397-02
- **Recipient organization:** UNIVERSITY OF MARYLAND BALTIMORE COUNTY
- **Principal Investigator:** Loren Henderson
- **Activity code:** R03 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $80,450
- **Award type:** 5
- **Project period:** 2019-07-16 → 2022-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9978865

## Citation

> US National Institutes of Health, RePORTER application 9978865, Factors that influence the implementation and effectiveness of a patient safety bundle to reduce low-risk cesarean deliveries (5R03HD096397-02). Retrieved via AI Analytics 2026-05-22 from https://api.ai-analytics.org/grant/nih/9978865. Licensed CC0.

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