SAFE PASSAGES Training Decreased the Incidence of Perineal Trauma During Childbirth

BACKGROUND: Active-duty women of childbearing potential comprise a significant portion of service members in the United States (US) Armed Forces. Obstetrical anal sphincter injuries have been associated with significant morbidity including anal incontinence, rectovaginal fistula, and pain. In the early 2000s, the US Air Force OB/GYN (obstetrics and gynecology) leadership championed the development of a novel education intervention that had the potential to standardize maternal obstetrical care across the DoD.

METHODS: This prospective cohort design focused on quality improvement of patient outcomes by implementing a regimented training program for obstetrical providers. Baseline rates of perineal trauma in spontaneous and operative vaginal deliveries for each of the Armed Services were established using delivery data from January to December 2010 (n = 272,161). While all three services were given grant funds and education materials, only the US Air Force (USAF) implemented a formal SAFE PASSAGES algorithm and training program from January to December 2012. All but one USAF hospital received on-site training. Perineal trauma rates were compared to post-implementation rates (January 2013-September 2014, with 451,446 deliveries).

RESULTS: The USAF hospitals showed a reduction in the rate of perineal trauma while the other two (Army, Navy) did not. Overall, there was a reduction in Patient Safety Indicator (PSI) 18 (lacerations after operative delivery, p < 0.01) and a statistically insignificant decrease for PSI 19 (lacerations after spontaneous delivery; 5.8%; p = 0.07) across the services. Again, USAF hospitals showed the greatest improvement (41.8%, p < 0.01). In USAF hospitals that received on-site training, PSI 18 rates decreased from 18.5/1000 to 6.0/1000, a 309% improvement (p = 0.012).

CONCLUSIONS: The USAF OB/GYN Leadership developed a training program and strategic intervention that is now well-recognized across the Department of Defense and the United States as the standard of care. Decades later, much evidence now supports the tenets of the SAFE PASSAGES training and its historic beginnings.