Audit and feedback is an effective implementation strategy to increase fidelity to a multi-component labor induction protocol designed to reduce obstetric inequities.

Background: Studies have demonstrated that standardizing labor induction (IOL), often with the use of protocols, may reduce racial inequities in obstetrics. IOL protocols are complex, multi-component interventions. To target identified implementation barriers, audit and feedback (A&F) was selected as an implementation strategy. Here, we aimed to understand the acceptability and effect of A&F on fidelity to this complex intervention through quantitative and qualitative approaches.

Methods: This secondary analysis of a type I hybrid effectiveness-implementation trial (10/2018-12/2022) compared 2 years before (PRE) to 2 years after (POST) implementation of an IOL protocol at two sites. Fidelity to each of 8 specific protocol components was collected via chart review. During the POST period, unit-aggregated A&F reports were distributed via email every 3 months to site clinicians. Reports tracked fidelity to protocol components over time. For this analysis, we compared component fidelity PRE to POST-implementation. Additionally, during the POST period, we compared fidelity by month after each A&F (Month#1 v. Month#2/3) to evaluate the effect of A&F over time. Acceptability of A&F reports was evaluated using qualitative interviews.

Results: 8509 labor inductions were included (PRE = 4214, POST = 4295). A&F reports were successfully distributed every 3 months for the 2-year POST period. PRE to POST-implementation, fidelity to 4 of the 8 components increased significantly (cervical Foley utilization, latent labor examination frequency, amniotomy timing, and intrauterine pressure catheter utilization), without change in the other 4 components. For 2 of those 4 components where improvement was noted, there was no difference in fidelity by month after A&F report; rather, there was sustained improvement across the POST-implementation period. On the other hand, for the remaining 2 components, fidelity peaked in the first month after each A&F report, with some decline in the following 2 months prior to the next A&F report. Qualitative analysis (n = 24) supported A&F acceptability, with A&F described as "motivating" and "helpful."

Conclusions: A&F was an effective implementation strategy to promote fidelity to certain components of this labor induction protocol. With some decline in effect after the first month POST-A&F report, increased A&F frequency should be considered in future work targeting obstetric outcomes, as well as health inequities.