1. 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

3. 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

4. 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)

5. 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)

6. 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)

9. 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

10. 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

11. 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.

12. 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.

13. 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

14. 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.

15. 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/

17. 34-36 weeks is full term 24.0%

18. 37-38 weeks is full term 50.8%

19. 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

21. 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%

22. 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%

23. 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

24. 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

25. 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”.

26. 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

27. 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

29. 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

30. 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

32. Reduce NICU admissions

33. Reduce primary cesarean rates

34. Reduce OB malpractice claims

35. Reduce costs Source: Elimination of Non-Medically Indicated Elective Deliveries Before 39 Weeks Toolkit

36. 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) Source: Elimination of Non-Medically Indicated Elective Deliveries Before 39 Weeks Toolkit

37. 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 Source: Elimination of Non-Medically Indicated Elective Deliveries Before 39 Weeks Toolkit

38. 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

39. 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

41. Implementation – 5x5 QI Hospital Network

42. Data – outlining the population-based data to support the initiative

43. Consumer Awareness– Why the Last Weeks of Pregnancy Count, Prematurity Awareness Day Source: March of Dimes with permission

44. 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 Source: March of Dimes with permission

45. March of Dimes PatientBrochures Source: March of Dimes with permission

46. 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. Source: March of Dimes with permission

48. 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.

49. 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

52. “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.”

54. Increasing utilization of midwives

55. Addressing problems in the liability system

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

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