UC Health West Chester — Mama Certified

Location
7759 University Drive
West Chester OH 45069

Certified Since
2023

UC Health - West Chester Hospital

At UC Health, your journey through pregnancy, childbirth, and beyond is our priority. Our compassionate, innovative approach means our experienced team works closely with you to create a birth experience that specially fits you and your baby’s needs. Plus, as the only academic health system in the region, we incorporate the latest research and breakthroughs so that you are receiving the newest treatments and therapies. From high-risk pregnancy management and Neonatal Intensive Care to childbirth education and breastfeeding support, we’re committed to providing unparalleled support and care every step of the way. 

Maternal Care
- High-Risk Pregnancy 
- Breastfeeding Support Services 
- Postpartum Care 
- Perinatal Treatment Services 
- Childbirth Education
- Centering Pregnancy 

Infant Care
- Level II Special Care Nursery

Mama Certification

Infant Care

Hospitals are awarded points for their certification based on guidelines that assign each metric a point value, which is split into parts based on the sub-questions in each metric. Hospitals receive points by sharing some or all of the metrics data.

View Full Report

METRICS	FINDINGS	PROGRESS
Health Equity on Race & Ethnicity Infant mortality rates are substantially higher for Black infants than for White infants in the United States. In 2021, Black babies were nearly 5 times more likely to die than White babies. Health disparities are preventable poor health outcomes experienced by populations disadvantaged by their social or economic status, geographic location, and environment. By monitoring health outcomes by race and ethnicity, hospital facilities can adapt processes and policies to provide more equitable quality care and improve the health outcomes of their patient populations.	The hospital facility has tracking, policies, and procedures in place to address racial and ethnic disparities in health outcomes related to infant care. Breastfeeding and breastmilk are tracked by racial and ethnic disparities. UC Health's standard practice is to collect root cause analysis (RCA) data stratified by race and ethnicity, and this is reported to the Patient Safety Organization (PSO). UC West Chester Hospital engages in a mortality and morbidity review committee to evaluate care inequities within the hospital facility and with the Butler County Health Department. Education and practice of safe sleep curriculum is also in place to address Black sleep-related deaths.
Breastfeeding Breastfeeding boosts the immune system and brain development, reduces the risk of infection, and reduces the risk of infant mortality. Racial disparities in breastfeeding rates can have a significant impact on infant health outcomes. Studies have found that Black mothers are less likely to initiate breastfeeding than their White counterparts and are more likely to stop breastfeeding before their infant is six months old. The national rate of exclusive breastfeeding in 2019 is 62.6%. Ohio’s rate of exclusive breastfeeding in 2021 is 51.7%.	The percentage of babies exclusively breastfed or fed breast milk while the newborn is at the hospital facility lower than the 2021 Ohio Rate of 51.7%.  The hospital tracks race and ethnicity disparities specific to exclusive breast milk feeding. The hospital facility has received four stars from Ohio First Steps for Healthy Babies breastfeeding program. The hospital facility promotes, protects and supports breastfeeding in their organization through providing pump friendly mother conditions, initiating pumping within 30 minutes of delivery, skin to skin, providing lactation consultants, Baby Café for follow-up and support.
Unexpected Complications in Term Newborns The most important childbirth outcome for families is bringing home a healthy baby. While there have been measures developed to assess clinical practices and outcomes in preterm infants, there is a lack of metrics that assess the health outcomes of term infants who represent over 90% of all births. No existing national or Ohio baseline data exists yet for this metric as it is defined by the Joint Commission. The overall local rate for newborns with severe complications and moderate complications from eight hospital-based birthing facilities in Butler and Hamilton County in 2021 is 2.59%.	Newborn complications at this hospital facility are slightly higher than the 2021 Hamilton and Butler County average of 2.59%. This hospital facility has the ability to track disparities by race and ethnicity in this category.
Safe Sleep Safe sleep is important because it helps to reduce the risk of sudden unexplained infant death (SUID). It is recommended that babies sleep on their back, in a crib or bassinet that meets current safety standards and is free of loose bedding, pillows, and stuffed animals. Sudden infant death syndrome (SIDS) is a well-known category of SUID. Racial disparities in sleep-related infant deaths are significant and contribute to the overall disparity in infant mortality rates. Black infants are more than twice as likely to die from a SUID as White infants.	The hospital facility participates in Cribs for Kids and Cradle Cincinnati safe sleep program.   This hospital facility connects parents with community organizations who provide infants with a safe crib, provide safe sleep education to healthcare providers and families, and implements quality improvement initiatives.
Mama Certified Promotion The Mama Certified badge is a symbol of commitment and trust that should be present during a mom’s entire birthing journey, from prenatal care to postpartum support. For bringing about change, visibility and repetition is key. These visual reminders are not only important for moms but also for staff.	The hospital facility demonstrates its public commitment to Mama Certified through the distribution of physical, digital and portable communication tools. Clinical staff may provide paper communication, flyers, etc. directly to patients for information and/or as part of discharge packets.  Clinicians and staff to wear lapel/lanyard pins to promote program. Clinicians and staff will wear lapel/lanyard pins to promote the program.   Mama Certified messages will also be displayed on electronic monitors throughout the hospital facility and OB service areas and on table tents in clinics.
Training & Staff Engagement Training helps hospital staff recognize that biases exist and helps them take steps to reduce the impact of those biases on workplace interactions and decisions.	The hospital facility has actively participated in training and engagement of staff as it relates to Mama Certified. The majority (>50%) of Women's Health and OBGYN staff will participate in the online ‘Intro to Mama Certified’ training offered by Cradle Cincinnati.   85% of Women's Health and OB GYN staff participated in unconscious bias training starting in 2021 through summer 2023. Staff completed UCH implicit bias training in 2022 ("Diversity Equity and Inclusion") - more than half of staff completed training and it is still available for internal learners to help with onboarding new staff.  Additionally, 100% of physicians completed a 4 hour implicit bias training through Cradle Cincinnati in 2018; physician turnover has remained low since so training has been retained within the culture.   One member of the hospital facility leadership will be joining the Cradle Cincinnati Learning Collaborative Circle of Advisors.
Center the Voices of Patients with Lived Experiences with Queens Village Centering the voices of those with lived experiences is essential for creating a more inclusive, equitable, and empathetic society. It fosters a culture of listening, learning, and empathy, ultimately leading to better outcomes for all members of society.	The hospital facility is actively working with Queens Village to center the voices of patients with lived experiences.  The hospital system has met with Cradle Cincinnati and Queens Village representatives to outline opportunities to co-create strategies supporting equitable maternal and infant care. The hospital facility will participate in quarterly dialogue meetings with a facility-specific Queens Village Hospital Advisory Board with community representative and staff.   As ideas and issues are raised, feedback will be routed through the Women's Health Clinical Domain to be addressed and communicated. The Clinical Domain structure includes a leadership team comprised of physician, nursing, and operations representatives and includes managers and bedside staff from Labor and Delivery, Obstetrics, Gynecology, and outpatient and inpatient operational areas. Active work in the domain is inclusive of operations, clinical, and financial projects and priorities. This provides adequate infrastructure for sharing feedback, creating clear and direct communication pathways, and turning ideas into improvements where needed.
Pathways to Improvement Crafting strategies to improve maternal and infant health is essential for driving systemic change by enabling targeted interventions, fostering collaboration and engagement, facilitating learning and adaptation, and building momentum for sustained impact. It provides a structured approach to addressing complex systemic issues and achieving meaningful and lasting transformation.	The hospital facility has outlined the following strategies to improve maternal and infant health. Building data and analytics infrastructure to evaluate key (White House Survey) WHS performance measures by race and ethnicity Work is underway to assess all Joint Commission core measures and severe maternal morbidity by race. Existing charts analyzed by race and ethnicity include prenatal access, adherence to postpartum care/visits, and postpartum hemorrhage. Analyzing data in this manner allows transparent identification of care inequities to trigger root cause analyses and improvement work.  Active/ongoing projects to address maternal health and equity.  Statewide AIM collaborative to increase compliance for Hypertension intervention bundle. Hypertension collaborative with Butler County to provide BP cuffs  Actively improving access to new OB visits. Postpartum hemorrhage compliance to safety bundle/interventions.  Reducing preventable general anesthesia (unscheduled c-section communication improvement, failed epidural), anesthesia safety (unintentional dural puncture during c-section, improvement of labor epidural analgesia). Infection reduction/prevention improvement work. Compliance for decision to incision for emergent c-section Pain assessment compliance  Neonatal Butler County infant death case reviews  Data stratified by race, reported to county to identify next steps for maternal and infant health education for county. PRIM with Butler Co Health District Babysteps (mom/baby visit between admission and outpatient follow-up to provide continuity of care)   Safe Sleep initiatives Partnerships with Cincinnati Children's Hospital, Cribs for Car Seats with Butler Co Health District Additional work includes infection reduction/prevention improvement work; reduction of chronic lung disease (regional collaborative); and the readmission reduction project. The Hospital Facility participates in the following initiatives:  Ohio Perinatal Quality Collaborative (OPQC) Magnet Accreditation
	The hospital facility received 92.5% of the measurable points for the Infant Care Focus Area.	92.5%

Maternal Care

Hospitals are awarded points for their certification based on guidelines that assign each metric a point value, which is split into parts based on the sub-questions in each metric. Hospitals receive points by sharing some or all of the metrics data.

View Full Report

METRICS	FINDINGS	PROGRESS
Health Equity on Race & Ethnicity Black mothers die at more than two and half times the rate of other mothers in Ohio (Ohio Department of Health, 2020) regardless of their parents´ socio-economic status or health behaviors. Multiple factors contribute to these disparities, such as variations in quality healthcare, underlying chronic conditions, structural racism, and implicit bias. Health disparities are preventable disparate outcomes to optimal health experienced by populations disadvantaged by their social or economic status, geographic location, and environment. By doing so, hospitals can adapt processes and policies to provide more equitable quality care and improve the health outcomes of their patient populations.	The hospital facility has tracking, policies, and procedures in place to address racial and ethnic disparities in health outcomes related to maternal care.  UC Health's standard practice is to collect root cause analysis (RCA) data stratified by race and ethnicity, and this is reported to the Patient Safety Organization (PSO). This hospital facility evaluates key maternal outcomes by race to determine inequities in care - examples include postpartum hemorrhage safety bundle compliance, hypertension intervention compliance, access to prenatal and postpartum visits, and c-section prevalence and outcomes. Interventions or workflows are revised accordingly to incorporate equity evaluations in the process and standard work.
Scheduled Early Delivery (Elective Delivery) The Center for Medicare & Medicaid Services has identified this measure as a key area to improve maternal and infant health. By providing care to pregnant individuals that follows best practices that advance health care quality, safety, and equity, hospitals and doctors can improve chances for a safe delivery and a healthy baby. Guidelines developed by doctors and researchers say it’s best to wait until the 39th completed week of pregnancy to deliver the baby because important fetal development takes place in the baby’s brain and lungs during the last few weeks of pregnancy. The national average rate of elective deliveries in 2022 is 2%. The Ohio average rate of elective deliveries in 2022 is 2%.	The hospital facility has higher-than-average elective deliveries.  This hospital facility has the ability to track disparities in this area by race and ethnicity.
Low-Risk Cesarean Births Cesarean deliveries place birthing individuals and infants at higher risk for adverse outcomes. Reducing the rate of cesarean births for individuals at low risk from a vaginal birth provides an opportunity to improve both maternal and infant health.	The rate of low-risk cesareans is lower than the 2021 Ohio Average Rate of 26.3%.*  This hospital facility has the ability to track disparities in this area by race and ethnicity.
Birthing-Friendly Hospital The Center for Medicare & Medicaid Services has identified this measure as a key area to improve maternal and infant health. Perinatal Quality Improvement Collaborative programs can help reduce racial disparities in maternal health outcomes by promoting access to evidence-based practices, providing education and training on racial disparities and health disparities, and engaging with communities to create culturally sensitive care models.	The hospital facility has met the criteria to be recognized as Birthing-Friendly.   This hospital facility participates in the Ohio Perinatal Quality Collaborative - Alliance for Innovation on Maternal Health Hypertension statewide project and Care Innovation and Community Improvement Program - Ohio Department of Health statewide project.  This hospital facility has implemented patient safety practices or bundles related to maternal morbidity to address complications including postpartum hemorrhage safety, hypertension safety/intervention bundle.
Smoking Cessation Support Smoking cessation is important to maternal health because smoking can cause serious health risks for pregnant people and their babies. Smoking during pregnancy increases the risk of premature birth, low birth weight, stillbirth, and birth defects. Additionally, smoking can lead to a host of other health problems including increased risk of miscarriage, increased risk of ectopic pregnancy, and increased risk of placenta previa. Quitting smoking before or during pregnancy can help reduce these risks and ensure a healthier pregnancy.	The hospital facility provides smoking cessation resources for women and birthing people.  Treatment options include nicotine replacement therapy (NRT) patch and lozenge, referral to Ohio Quitline, Baby and Me Tobacco Free, and Tobacco Treatment Specialists.
Postpartum Mental Health Perinatal depression, which includes major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery, is one of the most common medical complications during pregnancy and the postpartum period, affecting one in seven women. The American College of Obstetricians and Gynecologists recommends that obstetrician–gynecologists and other obstetric care providers screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. Postpartum depression (PPD) affects one in eight women; however, the risk is 1.6 times higher for Black women than White women. Black women are less likely to receive help due to factors such as financial barriers, stigma associated with mental health struggles, structural racism and a historical mistrust of the health care system. Maternal mental health symptoms and issues among Black women are often overlooked and under-addressed.	The hospital facility provides perinatal depression screening and referral services.  Patients are screened for depression multiple times throughout care using the validated Edinburgh Depression Scale.
Postpartum Family Planning Postpartum family planning is the process of planning for the future of a family after the birth of a child. This includes discussing and deciding on contraception, spacing of pregnancies, and other family planning options. Postpartum family planning is important for maternal health because it helps to reduce the risk of unintended pregnancies and the associated health risks. It also helps to ensure that women have the time and resources to recover from childbirth and to bond with their newborns. Additionally, postpartum family planning can help to reduce the risk of maternal mortality and morbidity, as well as to improve the overall health of mothers and their families.	The hospital facility provides options for family planning and contraceptive counseling.  Multiple options are offered for all patients for all known forms of contraception.
Access to Early Prenatal Care Early prenatal care can reduce risks for complications related to pregnancy or birth. Early identification can ensure that women with complex problems, chronic illnesses, or other risks are connected to appropriate specialists. Early high-quality prenatal care is critical to improving pregnancy outcomes.	The hospital facility collects information on early prenatal care.  59.86% of women who gave birth at this facility received a prenatal care visit at this facility in their first trimester.  This facility regularly receives patients for delivery who did not receive prenatal care at this facility. If a patient received prenatal care at another facility, they were included in total deliveries but not in the 59.86%.
Patient Satisfaction By collecting patient feedback, hospitals can identify areas of improvement and make necessary changes to ensure the delivery experience is as positive as possible. Collecting patient satisfaction related to the experience of care during labor and delivery can help reduce racial disparities by providing insights into the quality of care received by people from different racial backgrounds, allowing hospitals to identify and address disparities. By understanding the unique challenges faced by different racial groups, hospitals can better tailor their services and create a more equitable healthcare system.	The hospital facility collects patient satisfaction data during a labor and delivery stay and postpartum care for all patients.  Rounds are routinely conducted with patients during inpatient stays to collect verbal qualitative data and feedback on stay, needs, etc. Surveys from third parties, Press Ganey and HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), are completed after discharge to collect patient feedback. Internal Care teams review Press Ganey survey results on internal dashboards. Women's Health teams review these in monthly Labor and Delivery management and Hospital Administration meetings, and results are continually monitored within the Women's Health Clinical Domain.   If an unsatisfactory result and survey is identifiable, care teams may call patients to discuss the issue or identify learnings for what could be improved. Results are also available on CMS, Press Ganey website for patient review.
Mama Certified Promotion The Mama Certified badge is a symbol of commitment and trust that should be present during a mom’s entire birthing journey, from prenatal care to postpartum support. For bringing about change, visibility and repetition is key. These visual reminders are not only important for moms but also for staff.	The hospital facility demonstrates its public commitment to Mama Certified through the distribution of physical, digital and portable communication tools. Clinical staff may provide paper communication, flyers, etc. directly to patients for information and/or as part of discharge packets.  Clinicians and staff to wear lapel/lanyard pins to promote program. Clinicians and staff will wear lapel/lanyard pins to promote the program.   Mama Certified messages will also be displayed on electronic monitors throughout the hospital facility and OB service areas and on table tents in clinics.
Training & Staff Engagement Training helps hospital staff recognize that biases exist and helps them take steps to reduce the impact of those biases on workplace interactions and decisions.	The hospital facility has actively participated in training and engagement of staff as it relates to Mama Certified. The majority (>50%) of Women's Health and OBGYN staff will participate in the online ‘Intro to Mama Certified’ training offered by Cradle Cincinnati.   85% of Women's Health and OB GYN staff participated in unconscious bias training starting in 2021 through summer 2023. Staff completed UCH implicit bias training in 2022 ("Diversity Equity and Inclusion") - more than half of staff completed training and it is still available for internal learners to help with onboarding new staff.  Additionally, 100% of physicians completed a 4 hour implicit bias training through Cradle Cincinnati in 2018; physician turnover has remained low since so training has been retained within the culture.   One member of the hospital facility leadership will be joining the Cradle Cincinnati Learning Collaborative Circle of Advisors.
Center the Voices of Patients with Lived Experiences with Queens Village Centering the voices of those with lived experiences is essential for creating a more inclusive, equitable, and empathetic society. It fosters a culture of listening, learning, and empathy, ultimately leading to better outcomes for all members of society.	The hospital facility is actively working with Queens Village to center the voices of patients with lived experiences.  The hospital system has met with Cradle Cincinnati and Queens Village representatives to outline opportunities to co-create strategies supporting equitable maternal and infant care. The hospital facility will participate in quarterly dialogue meetings with a facility-specific Queens Village Hospital Advisory Board with community representative and staff.   As ideas and issues are raised, feedback will be routed through the Women's Health Clinical Domain to be addressed and communicated. The Clinical Domain structure includes a leadership team comprised of physician, nursing, and operations representatives and includes managers and bedside staff from Labor and Delivery, Obstetrics, Gynecology, and outpatient and inpatient operational areas. Active work in the domain is inclusive of operations, clinical, and financial projects and priorities. This provides adequate infrastructure for sharing feedback, creating clear and direct communication pathways, and turning ideas into improvements where needed.
Pathways to Improvement Crafting strategies to improve maternal and infant health is essential for driving systemic change by enabling targeted interventions, fostering collaboration and engagement, facilitating learning and adaptation, and building momentum for sustained impact. It provides a structured approach to addressing complex systemic issues and achieving meaningful and lasting transformation.	The hospital facility has outlined the following strategies to improve maternal and infant health. Building data and analytics infrastructure to evaluate key (White House Survey) WHS performance measures by race and ethnicity Work is underway to assess all Joint Commission core measures and severe maternal morbidity by race. Existing charts analyzed by race and ethnicity include prenatal access, adherence to postpartum care/visits, and postpartum hemorrhage. Analyzing data in this manner allows transparent identification of care inequities to trigger root cause analyses and improvement work.  Active/ongoing projects to address maternal health and equity.  Statewide AIM collaborative to increase compliance for Hypertension intervention bundle. Hypertension collaborative with Butler County to provide BP cuffs  Actively improving access to new OB visits. Postpartum hemorrhage compliance to safety bundle/interventions.  Reducing preventable general anesthesia (unscheduled c-section communication improvement, failed epidural), anesthesia safety (unintentional dural puncture during c-section, improvement of labor epidural analgesia). Infection reduction/prevention improvement work. Compliance for decision to incision for emergent c-section Pain assessment compliance  Neonatal Butler County infant death case reviews  Data stratified by race, reported to county to identify next steps for maternal and infant health education for county. PRIM with Butler Co Health District Babysteps (mom/baby visit between admission and outpatient follow-up to provide continuity of care)   Safe Sleep initiatives Partnerships with Cincinnati Children's Hospital, Cribs for Car Seats with Butler Co Health District Additional work includes infection reduction/prevention improvement work; reduction of chronic lung disease (regional collaborative); and the readmission reduction project. The Hospital Facility participates in the following initiatives:  Ohio Perinatal Quality Collaborative (OPQC) Magnet Accreditation
	The hospital facility received 100% of the measurable points for the Maternal Care Focus Area.	100%

UC Health - West Chester Hospital

Mama Certification

Infant Care

The hospital facility has received four stars from Ohio First Steps for Healthy Babies breastfeeding program.

Building data and analytics infrastructure to evaluate key (White House Survey) WHS performance measures by race and ethnicity

Active/ongoing projects to address maternal health and equity.

Neonatal Butler County infant death case reviews

PRIM with Butler Co Health District

Safe Sleep initiatives

The Hospital Facility participates in the following initiatives:

Maternal Care

Building data and analytics infrastructure to evaluate key (White House Survey) WHS performance measures by race and ethnicity

Active/ongoing projects to address maternal health and equity.

Neonatal Butler County infant death case reviews

PRIM with Butler Co Health District

Safe Sleep initiatives

The Hospital Facility participates in the following initiatives:

Active/ongoing projects to address maternal health and equity. 

Neonatal Butler County infant death case reviews 

The Hospital Facility participates in the following initiatives: 

Active/ongoing projects to address maternal health and equity. 

Neonatal Butler County infant death case reviews 

The Hospital Facility participates in the following initiatives: 