the modest growth in United States births (14.6 percent) between 1987 and 2008, compared to the significant growth in neonatal special care beds. Improvements in access and quality may not have mirrored this growth.3 Critical to any current discussion is a determination of what is the right volume and allocation of subspecialty resources, especially in a climate where outside scrutiny of outcomes and cost of care is likely to increase. Role of Professional Organizations Many tools, especially health information technology, have strengthened the ability of care providers and facilities to actively participate in quality improvement. Professional organizations representing the many disciplines in perinatal care, including obstetrics, pediatrics, family medicine, certified nurse midwifery and nursing, have been involved in QI through members and public education to affect change in provider behavior. While each organization has a separate governing structure, many have worked collaboratively to improve quality of care by continuing to publish evidence-based research studies and set the Evolution of Quality Improvement in Perinatal Care Figure 1: Trends in Neonatal Special Care Beds and United States Births4 Toward Improving the Outcome of Pregnancy III marchofdimes.com 13 standard of care through publications, such as the TIOP documents and Guidelines for Perinatal Care, jointly published by AAP and ACOG every 5 years since 1983. In addition, and in response to numerous hospital requests for peer-review services of their obstetrics and gynecology departments, ACOG established the Voluntary Review of Quality of Care Program (VRQC) in 1986. The VRQC program provides confidential peer-review consultation to OB/GYN departments on request and is completely voluntary. These comprehensive department reviews are intended to assess quality of care and patient safety and lead to extensive recommendations for improvement in patient care. By 2010, the VRQC program had completed more than 275 hospital reviews, representing nearly 10 percent of hospitals in the United States providing obstetrical services. A four-day site visit is scheduled with a five-person team consisting of three board-certified OB/GYNs in active practice who have experience and training in quality assessment and improvement, a nurse reviewer and a team administrator who is a professional writer. Following a comprehensive department review, including one full day of interviews and one full day of selected chart reviews, a very detailed, confidential final report is produced with findings and recommendations based upon ACOG published guidelines. This report is protected under appropriate state peer-review statutes. While almost every hospital surveyed has implemented many of the suggested process improvements, the VRQC program has been unable to capture data from the various hospitals documenting improved outcomes as a result of the changes.5 Figure 2 shows how the impact of a professional organization’s recommendations, in this case ACOG, can directly change provider behavior and improve quality. The graph depicts the vaginal birth after cesarean section (VBAC) rate (defined as the rate/100 women with a successful vaginal delivery after previous cesarean Evolution of Quality Improvement in Perinatal Care Figure 2: VBAC Rate by Year6-10 Name of Report Year 1 ACOG Committee Opinion No.17 1982 2 ACOG Committee Opinion No. 64 1988 3 ACOG Committee Opinion No. 143 1994 4 ACOG Practice Bulletin No. 2 1998 5 ACOG Practice Bulletin No. 5 1999 Name of Report Year 1 ACOG Committee Opinion No.17 1982 2 ACOG Committee Opinion No. 64 1988 3 ACOG Committee Opinion No. 143 1994 4 ACOG Practice Bulletin No. 2 1998 5 ACOG Practice Bulletin No. 5 1999 14 marchofdimes.com Toward Improving the Outcome of Pregnancy III Evolution of Quality Improvement in Perinatal Care delivery) from 1970 through 2005. The asterisks indicate when significant ACOG publications on the subject were released. The initial 1982 publication was the first to recommend the practice.6 By 1988, ACOG guidelines “encouraged” providers to allow labor for appropriate candidates.7 The 1994 publication reiterated that properly selected women be counseled and encouraged and that an obstetrician be “readily” available.8 By 1998, in response to evidence about potential complications, ACOG recommended that women “should be counseled and offered (not encouraged) a trial of labor.”9 In 1999, guidelines suggested that physicians be “immediately” available. By 2005, the VBAC rate again approximated the 1985 level.10 In 2010, ACOG published a further update to its prior recommendations about VBAC that relaxed some of the previous restrictions.11 It will be interesting to follow any subsequent changes to the national VBAC rates based on this update. Role of Government and Regulators in Perinatal Quality of Care Federal and state governments, especially after the release of TIOP I, were instrumental in guiding the evolution of the perinatal system and QI efforts. Many states readily adopted TIOP I’s level of care definitions in the context of regulations and guidelines, especially with regard to Certificate of Need (CON) applications, thereby driving the expansion of regional systems. Governmental stimulation and support