Quality Quest for Health Peoria, IL

Steps Toward a High-Quality, High-Value Maternity Care System
Preventing Elective Deliveries Before 39 Weeks
Quality Quest for Health,
Peoria, Illinois
August 10, 2011
Maureen Corry, MPH, Executive Director
Childbirth Connection

Mission is to improve the quality of maternity care through consumer engagement and health system transformation.

Evidence-Practice Gap in Maternity Care
Much of the care women receive is not consistent with the best evidence despite unprecedented body of comparative effectiveness research to guide practice and quality improvement
www.childbirthconnection.org/ebmc

Maternity Care is Procedure-Intensive and Costly
Milbank Report, Evidence-Based Maternity Care (2008) Deficiencies include:
Overuse of many practices that entail harm and waste for mothers, babies, and the system at large, (e.g. cesarean section, elective induction)
Underuse of effective, high-value practices that would improve outcomes, (smoking cessation, vaginal birth after cesarean)
Broad variations in care, outcomes, and costs across geographic regions, facilities, and providers unwarranted by health status or women’s preferences
www.childbirthconnection.org/ebmc

Maternity Care Variation
In 2007, cesarean rates ranged from less than 25% in AK, ID, NM, and UT, to over 35% in FL, LA, MI, NJ, and WV
Recent studies affirm WHO recommendations on optimal cesarean rates: best outcomes for women and babies appears to occur with rates of 5% to 10%. Rates above 15% seem to do more harm than good (Althabe and Belizan 2006)

Practice Variation Among 10 Largest Hospitals in Greater Peoria Area
Variation:
C-section rates range from 19-34%
VBAC rates range from 0-17%
Rates of early elective delivery range from 1-30%
All but 3 exceed The Leapfrog Group’s threshold of 12%
Sources: Illinois Hospitals Caring for You (http://www.illinoishospitals.org/iha/home) ,
The Leapfrog Group Hospital Survey, 2011, (http://www.leapfroggroup.org/tooearlydeliveries)

Birth Centers: Coming Soon to Illinois
New law authorizes 10 pilot birth centers
Hospital or FQHC owned
For low-risk women in labor at term
Evidence for birth centers for low-risk women
Higher spontaneous vaginal birth rate
Fewer interventions
No excess in perinatal or maternal morbidity/mortality
High satisfaction
Average charges for birth center vaginal birth = $1,872 (American Association of Birth Centers, Uniform Data Set, 2007)

Healthy Childbearing Women
Great majority of pregnant women in the U.S. are well and healthy and enter labor at “low risk” for problems
Maternity care system often treats pregnancy and birth in healthy women as medical conditions or disease states, rather than normal life processes
Limited attention given to ensuring that millions of healthy women receive appropriate care

Transforming Maternity Care Project
Multi-year collaboration with more than 100 health care leaders from across health system
Resulted in publication of two direction-setting papers in 2010:“2020 Vision for A High-Quality, High-ValueMaternity Care System” and “Blueprint for Action”

Coordination of Care
Scope of Covered Services
Performance Measurement
Development and Use of HIT
Clinical Controversies
11 Critical Blueprint for Action Focal Areas
Liability
Payment Reform
Disparities
Workforce Composition and Distribution
Decision Making and Consumer Choice
Health Professions Education

Blueprint for Action: Critical Focus Areas
Performance measurement and leveraging of results
Payment reform to align incentives with quality
Improved functioning of the liability system
Disparities in access and outcomes of care
Clinical controversies (home birth, VBAC, elective delivery, cesarean section)
Decision making and consumer choice

Peak Shifted: 40 to 39 weeks
Changing Distribution of Singleton Live Births United States, 1992, 1997, 2002, 2006
Over 4 million babies born per year
Source: National Center for Health Statistics, final natality data
Prepared by March of Dimes Perinatal Data Center, 2009, and used with permission.

Definitions
Weeks of Pregnancy
Preterm
Term
Late Preterm
Early Term
Full Term
22
34
37
39
41
Prepared by March of Dimes and used with permission.

Complications of Non-medically Indicated Deliveries Between 37 and 39 Weeks
Increased NICU admissions (and separation from mother)
Increased respiratory illness--transient tachypnea of the newborn (TTN) and respiratory distress syndrome (RDS)
Increased jaundice and readmissions
Increased suspected or proven sepsis
Increased newborn feeding problems and other transition issues
See CMQCC/MOD Toolkit for more data and full list of citations
Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997

Contemporary Cesarean Delivery Practice
in the United States (2002-2008)
C-Section Rates:
Overall 30.5% (variation from 20%-40%)
First time mother: 31.2%
Prelabor repeat: 30.9%
Vaginal Birth After C-Section:
28.8% of women with prior c-section had trial of labor– success rate was 57.1%. Overall, 83.6% w/ prior cesarean delivered by cesarean.
43.8% of women attempting VBAC were induced. Cesarean rate twice as high in induced women than in spontaneous labor in all pregnancies (21.1% vs 11.8%)
50% for cesareans for dystocia done before 6 cm dilation
Zhang,et al. Amer J. ObstetGynecol, Oct 2010.

Labor and Birth Charges
Source: U.S. Agency for Healthcare Research and Quality, HCUPnet, Healthcare Cost and Utilization Project. Rockville, MD: AHRQ. Available at: http://hcupnet.ahrq.gov/

Women’s Perceptions Regarding the Safety of Birth at Various Gestational Ages
When is a baby full term?
34-36 weeks is full term 24.0%
37-38 weeks is full term 50.8%
What is the earliest point in pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery?
34-36 weeks 51.7%
37-38 weeks 40.7%
39-40 weeks 7.6%
Goldenberg RL, et al. ObstetGynecol 2009; 114:1254-1258.
11

Attitudes on Medical Intervention in Birth Process
Giving birth is a process that should not be interfered with unless medically necessary:
Agree strongly 24%
Agree somewhat 26%
Neither agree or disagree 25%
Disagree somewhat 17%
Disagree strongly 8%

Mother’s Interest in Knowing About Complications for Decision Making
Necessary to know every or most complications before consenting to:
Labor induction 97%
Cesarean 98%

Mother’s Knowledge of Impact of Interventions
In no case did majority of mothers cite the correct response when given a series of statements on adverse effects of induction and cesarean section.
“not sure” was most common response
When mothers did respond they were as likely to be incorrect as correct
Having intervention did not increase proportion of correct answers

Pressure on Mothers to Accept Interventions
Felt pressure from any health professional to have:
Labor induction 7% all mothers, 17% with induction
Cesarean 2% w. vaginal birth, 25% with cesarean
Episiotomy 73% of mothers did not have choice
about it

Listening to MothersII:In Her Own Words
“My goal, this time, was to not get pressure about doing anything against my wishes because my first birth was a genuine nightmare with unnecessary induction, tons of drugs and medical students watching me push! I stayed home most of the labor to make sure I wouldn’t get any of that. And I didn’t, everything was perfect. It’s all in choosing the right doctor”.

Reasons for Rise in Elective Deliveries
Perception that elective delivery is convenient and cost-effective among women, caregivers, and hospital administrators
Scheduling and predictability appealing to women, providers, hospitals
Frequent use of screening tests at the end of pregnancy, despite lack of evidence that the use of such tests improves outcomes
The belief that the best way to manage risks in pregnancy is to deliver the baby

Elimination of Non-Medically Indicated Elective Deliveries Before 39 Weeks
Table of Contents
Making the Case
Implementation Strategy
Data Collection/QI Measurement
Clinician Education
Patient Education
Appendices
Available at:
marchofdimes.com
or
cmqcc.org

American College of Obstetricians and Gynecologists – Practice Bulletin, August, 2009
No elective induction or elective cesarean delivery before 39 weeks without clinical indication.
Even a mature fetal lung test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery.
ACOG Practice Bulletin No. 107, August, 2009

Examples of Successful Programs to Reduce Non-medically Indicated Deliveries Before 39 week of Gestation
Magee Women’s Hospital (Pittsburgh)
Intermountain Healthcare (Utah)
Magee Women’s and Intermountain Health found that strong leadership and strict policy enforcement were critical to success
Ohio Perinatal Quality Collaborative (State Department of Health)
multi-stakeholder efforts resulted in decrease of scheduled births at < 39 weeks from 25% to < 5% within14 months
Source: Elimination of Non-Medically Indicated Elective Deliveries Before 39 Weeks Toolkit

QI Programs to Eliminate Elective Deliveries Before 39 Weeks Do Not Increase Perinatal Mortality and Maternal Morbidity
QI programs do:
Improve maternal and neonatal outcomes
Reduce NICU admissions
Reduce primary cesarean rates
Reduce OB malpractice claims
Reduce costs

Strategies to Reduce Elective Deliveries
Hospital Corporation of America: 3 Approaches to Reducing Elective Births < 39 Weeks
“Hard stop” policy, not allowed; staff empowered to refuse schedule or perform;
“Soft stop” policy, compliance left up to individual doctors
Education only approach for providers re: current evidence, ACOG guidelines, facility policies
Elective delivery may be reduced to level of <2% using “hard stop” policy; cost savings of $1 billion annually. Correct patient misconceptions re harms to women and babies (Clark et al., AJOG, November 2010)

Successful QI Programs
Started with professional education to obstetricians regarding ACOG guidelines and best practices
Effective particularly when interventions are data-driven, involve multidisciplinary teams, and reference to specific guidelines that can be enforced
Modest change at most until physicians were held accountable, nurses were empowered, and guidelines were enforced (“Hard stop”)
Medical leadership critically important

More Strategies to Minimize Elective Labor Inductions
No elective births unless 41 weeks or cervical readiness without pharmacologic agents
Elimination of the time factor as a driving force
Performance measurement and public reporting
Source: Reconsideration of the Cost of Convenience, Quality, Operational, and
Fiscal Strategies to Minimize Elective Labor Induction,
Kathleen Rice Simpson, PhD, RNC, FAAN, J PerinatNeonatNurs,
Vol. 24, No. 1, pp. 43-52

More Strategies to Minimize Elective Labor Inductions
Re-evaluation of costs of care: cost of cesarean birth after failed labor induction are nearly double that of spontaneous vaginal birth due to longer intrapartum and postpartum length of stay
Reconsideration of provider reimbursement/patient payment: financial disincentives could be coming and should be strongly considered: increase co-pay, decreased reimbursement to provider
Source: Kathleen Rice Simpson, PhD, RNC, FAAN

Current March of Dimes Big 5 Collaboration
<39 Weeks Toolkit – input, review and local endorsements
Implementation – 5x5 QI Hospital Network
Data – outlining the population-based data to support the initiative
Consumer Awareness– Why the Last Weeks of Pregnancy Count, Prematurity Awareness Day
Source: March of Dimes with permission

Hospitals Participating in Illinois Big 5 QI Initiative
University of Illinois Medical Center -Chicago
Edward Hospital - Naperville
Katherine Shaw Bethea Hospital, Dixon
Decatur Memorial Hospital - Decatur
St. Joseph Hospital - Breese
St. Elizabeth Hospital – Belleville

March of Dimes PatientBrochures

March of Dimes New Media Campaign:
Healthy Babies are Worth the Wait
Babies aren’tfully developed until at least 39 weeks in the womb……
If your pregnancy is healthy, wait for labor to begin on it’s own.

Childbirth Connection Consumer Education Resources
Women need access to full, accurate and complete evidence-based information on harms and benefits of elective induction and cesarean section before 39 weeks, and at 40 or 41 weeks without a clear medical reason. childbirthconnection.org/induction.

Promising Consumer Engagement Strategy: Shared Decision Making
Collaboration between women and caregivers to come to an agreement about a health care decision:
Supports & encourages women to participate in their maternity care decisions
Fully informs them with accurate, unbiased & understandable information
Respects them by having their goals & preferences honored

FIMDM and Childbirth Connection: Shared Decision Making Maternity Initiative
Initiative aims to expand opportunities for SDM in maternity care and develop tools and resources to facilitate women’s informed choice.
Goals:
improved knowledge of care options, benefits,
harms
improved provider participation and satisfaction
with SDM process
reduced use of overused harmful interventions
increased use of underused interventions that
improve outcomes
improved maternity care quality and value

“How to Stop the Relentless Rise in Cesarean Deliveries”
“The rising cesarean rate is a threat to the profession and there’s no time for complacency.” John Queenan, MD
He calls for concerted action by his profession to confront the problem and commit to action to “curtail the runaway increase in cesarean deliveries.”
He offers two “complex” solutions:
“make VBAC more accessible and more desirable” and “prevent primary deliveries in the first place.”

“How to Stop the Relentless Rise in Cesarean Deliveries”
He offers many specific strategies, among them:
Implementing hospital quality improvement programs
Increasing utilization of midwives
Addressing problems in the liability system
Improving shared decision making

All of the great leaders have had one characteristic in common: it was the willingness to confront unequivocally the major anxiety of their people in their time. This, and not much else, is the essence of leadership.
- John Kenneth Galbraith

Rapid gains in maternity care quality, value and outcomes are within our reach, through multi-stakeholder, collaborative efforts.

Thank You!
Maureen Corry, Executive Director
corry@childbirthconnection.org
“2020 Vision”: transform.childbirthconnection.org/vision/
“Blueprint for Action”: transform.childbirthconnection.org/blueprint/

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Quality Quest for Health Peoria, IL

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