Singleton Births by Gestational Age and Method of Delivery, (U.S. 1996 – 2004) 25 Between 1996 and 2004: Vaginal • 10% increase in preterm 20 singleton births • 36% increase in C-section rate Percent 15 for singleton preterm births 10 C-section 5 0 28 30 32 34 36 38 40 42 44 Gestation in weeks 1996 C-section 1996 Vaginal 2004 C-section 2004 Vaginal Bettegowda VR, et al . The Relationship Between Cesarean Delivery and Gestational Age Among U.S. Singleton Births. Clinics in Perinatology, May, 2008.
Contemporary Cesarean Delivery Practice in the United States (2002-2008) Induction Rates: • Attempt Vaginal Delivery 43.8% (21.1% C-Section) C-Section Rates: • Overall 30.5% • Nulliparous: 31.2% • Prelabor: 30.9% Vaginal Birth After C-Section: • 28.8% of women with prior c-section had trial of labor – 57.1% of these women delivered vaginally Zhang,et al. Amer J. Obstet Gynecol, Oct 2010.
Accuracy of Gestational Dating (Guidelines for Perinatal Care 6 th Edition, October, 2007) “ Management of pregnancy requires establishing an estimated date of delivery.” An ultrasound examination is most accurate when performed before 20 weeks of gestation – 6-10 weeks +/- 3 days – 10-14 weeks +/- 5 days – 14-20 weeks +/- 7 days - >20 weeks +/- 7-14 days
Definitions Weeks of Pregnancy Preterm Term Late Preterm 22 37 41
Definitions Weeks of Pregnancy Preterm Term Late Preterm 22 34 37 41
Definitions Weeks of Pregnancy Preterm Term Late Preterm Early Term Full Term 22 34 37 39 41
Definitions Weeks of Pregnancy Preterm Term Late Preterm Early Term Full Term 22 34 37 39 41
Preterm Birth Rates by Gestational Age U. S., 1990, 2000, 2005-2009* Percent 14 12.8 12.7 12.7 12.3 12.2 11.6 12 10.6 10 9.14 9.09 9.03 8 8.77 8.22 LPTB (34-36 wks) 7.30 32-33 wks 6 VLBW (<32 wks) 4 1.60 1.62 1.59 1.57 1.49 1.40 2 2.03 2.04 2.04 1.92 1.93 1.99 0 1990 2000 2005 2006 2007 2008 2009* *2009, provisional -- Source: National Vital Statistics Reports
U.S. Preterm Birth Rates 14 12.3 11.6 12 11.0 10.6 10 71% Late 8 8.8 8.2 % 7.7 7.3 Preterm 6 4 2 3.5 3.4 3.3 3.3 0 1990 1995 2000 2008 Year less than 34 weeks Late Preterm (34-36 6/7 weeks)
Change in preterm birth rates, by state: U.S., 2006 - 2008 -7.2% -1.0% -2.7% -3.4% -8.3% NH: -7.7% -4.8% -1.7% -3.2% MA: -4.4% -1.9% +1.6% RI: -11.1% -15.5% -2.6% -6.3% CT: 0% -12.5% NJ: -3.1% -0.9% -6.1% DE: -5.8% -5.6% -6.3% -5.3% -2.1% MD: -3.7% -4.5% -4.3% VA: -5.8% -6.6% -1.9% -5.1% -7.3% -3.9% -3.1% -5.1% -8.8% -3.6% -7.1% -2.3% -1.5% -12.8% -8.8% -4.3% -5.0% -2.9% -7.1% 0% -6.1% +5.8% Source: Martin JA, Osterman MJK, Sutton PD. Are preterm births on the decline in the United States? Recent data from the National Vital Statistics System. NCHS Data Brief, No 39. Hyattsville, MD: National Center for Health Statistics. 2010. Percent change prepared by the March of Dimes Perinatal Data Center, May 2010.
Risk Factors for Preterm Labor & Delivery • Behavioral • Tobacco, AlcoholNutrition – Under-nutrition and Obesity • Illicit Drug Use • Psychosocial • Stress – Severe Acute, Chronic Unremitting • Social Supports – Resources, Human Interactions • Intendedness of Pregnancy and inter-pregnancy interval
Risk Factors for Preterm Labor & Delivery • Sociodemographic • African-American Race • Maternal Age-- <16 and >35 • Poverty • Medical • Uterine, cervical, placental abnormalities • Prior Preterm Birth-- Genetic Predisposition • Chronic Illness (Hypertension, diabetes, etc.) • Assisted Reproduction – Singleton or Multiples • Twins and Higher Order Multiples
Risk Factors for Preterm Labor & Delivery • Groups at highest risk: • History of preterm labor/delivery • Current multifetal pregnancy • African-American • Non-medically indicated Iatrogenic intervention
Eliminate Non-Medically Indicated Deliveries Before 39 Weeks Available at: marchofdimes.com or cmqcc.org
Toolkit Authors: Elliott Main, MD Bryan Oshiro, MD Brenda Chagolla, RN, MSN, CNS Debra Bingham, Dr.PH, RN Leona Dang-Kilduff, RN, MSN Leslie Kowalewski Click to edit Master title style Author Organizations: California Maternal Quality Care Collaborative (CMQCC) California Pacific Medical Center Loma Linda University School of Medicine Click to edit Master subtitle style Catholic Healthcare West California Perinatal Quality Care Collaborative (CPQCC) March of Dimes Funders Federal Title V block grant--California Department of Public Health March of Dimes 36
Letters of Support • American Congress of Obstetricians and Gynecologists District II (New York) • American Congress of Obstetricians and Gynecologists Illinois Section (District VI) • American Congress of Obstetricians and Click to edit Master title style Gynecologists District IX (California) • American Congress of Obstetricians and Gynecologists FACOG (Florida) Click to edit Master subtitle style • American Congress of Obstetricians and Gynecologists District XI (Texas) • Association of Women’s Health Obstetric and Neonatal Nurses (National) and (California) 37
Why are non-medically indicated (elective Click to edit Master title style inductions and scheduled cesarean deliveries) Click to edit Master subtitle style increasing in frequency? 38
Sounds like a good idea… Advanced planning Convenience Click to edit Master title style Delivered by her doctor Maternal intolerance to late pregnancy Excess edema, backache, indigestion, Click to edit Master subtitle style insomnia Prior bad pregnancy And, it’s okay right? 39 Clin Obstet Gynecol 2006;49:698-704
Complications of Non-medically Indicated Deliveries Between 37 and 39 Weeks Increased NICU admissions (and separation from mother) Click to edit Master title style Increased respiratory illness--transient tachypnea of the newborn (TTN) and respiratory distress syndrome (RDS) Click to edit Master subtitle style Increased jaundice and readmissions Increased suspected or proven sepsis Increased newborn feeding problems and other transition issues See Toolkit for more data and full list of citations 40 Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997
What Motivates Some Obstetricians? Physician convenience Guarantee attendance at birth Click to edit Master title style Avoid potential scheduling conflicts Reduce being woken at night … what’s the harm? Click to edit Master subtitle style Amnesia due to rare occurrence. The NICU can handle it. And… 41 Clin Obstet Gynecol 2006;49:698-704
Click to edit Master title style Click to edit Master subtitle style 42
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% Click to edit Master title style • What is the earliest point in pregnancy that it is safe to deliver the baby, should Click to edit Master subtitle style 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. Obstet Gynecol 2009; 114:1254-1258. 43 11
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 13
Click to edit Master title style Click to edit Master subtitle style 45
Table of Content s Making the Case Implementation Strategy Click to edit Master title style Data Collection/QI Measurement Clinician Education Click to edit Master subtitle style Patient Education Appendices 46
Key Change Components Identify Physician Champion Click to edit Master title style Create (Rewrite) Hospital Policy Establish Professional Consensus on: Click to edit Master subtitle style “Indications for Early Delivery” 47
Key Change Components Develop Scheduling Form and Process Establish Medical Leadership “Hard Click to edit Master title style Stop” Process Secure Buy-In Click to edit Master subtitle style Collect Data to Drive Change Review Progress Serially 48
What do we need to get started? MAP-IT Mobilize Assess Plan Implement Track Guidry, M., Vischi, T., Han, R., & Passons, O. Healthy people in healthy communities: A community planning guide using healthy people 2010. Washington, D.C.: U.S. Department of Health and Human Services. The Office of Disease Prevention and Health Promotion.
Examples of Successful Programs to Reduce Non-medically Indicated Deliveries Before 39 week of Gestation Magee Women’s Hospital (Pittsburgh) Intermountain Healthcare (Utah) Ohio Perinatal Quality Collaborative (State Department of Health)
Common Themes Started with professional education to obstetricians regarding ACOG guidelines and best practices. Modest change at most, until physicians were held accountable, nurses were empowered, and guidelines were enforced (“Hard stop”). Medical leadership critically important.
Magee Women’s Experience with Guidelines Baseline Voluntary Enforced 3mos 3mos 14mos 2004 2005 2006-7 Deliveries 2,139 2,260 10,895 Elective Inductions <39wks (rate) 11.8% 10.0% 4.3% (p<0.001) Elective Nullip Inductions =>C/S (rate) 35.7% 15.2% 13.8% (p<0.01) Total Induction Rate 24.9% 20.1% 16.6% Fisch et al Obstet Gynecol 2009;113:797
% Non-medically Indicated Deliveries <39 Weeks January 1999 – December 2005 Oshiro, B. et al. Obstet Gynecol 2009;113:804-811 .
Results (1): Fewer Births at 36 0/7 -38 6/7 Weeks Without Documented Medical or Obstetrical Indications Click to edit Master title style Click to edit Master subtitle style OPQC Project Am J Obstet Gynecol 2010; 202:243.e1-243.e8 54
Results (2): Fewer Births at 36 0/7 -38 6/7 Weeks Induced Without Medical or Obstetric Indication Click to edit Master title style (arrow indicates OPQC startup) Click to edit Master subtitle style OPQC Project Am J Obstet Gynecol 2010; 202:243.e1-243.e8 55
Results (3): Fewer Total Births at 36-38 Weeks (and More Births at 39-41 Weeks) (arrow indicates OPQC startup) Click to edit Master title style Click to edit Master subtitle style 2% decrease in births 36-38 weeks and 2% increase in births 39-41 weeks; Approximately 1,000 births moved to >39 0/7 OPQC Project Am J Obstet Gynecol 2010; 202:243.e1-243.e8 56
Obstetricians Voice Concerns: Click to edit Master title style Do These Programs Increase Perinatal Mortality and Maternal Morbidity? Click to edit Master subtitle style 57
Stillbirths Before and After Implementation of Guidelines Intermountain Healthcare 1999-2000 July 2001 to June 2006 Weeks of Stillbirths Deliveri % Stillbir Deliveries % Odds 95% CI Click to edit Master title style Gestation es ths Ratio 37 17 4,117 0.41 22 13,077 0.17 0.406 0.22-0.77 38 19 9,954 0.19 21 28,209 0.07 0.390 0.21-0.72 Click to edit Master subtitle style 39 10 13,752 0.07 28 51,721 0.05 0.744 0.36-1.53 40 10 7,925 0.13 14 24,140 0.06 0.459 0.20-1.03 41 2 1,938 0.10 3 5,571 0.05 0.522 0.09-3.12 All 58 37,686 0.15 88 122,718 0.07 0.466 0.33-0.65 Oshiro, B. et al. Obstet Gynecol 2009;113:804-811. 58
Summary: Reasons to Eliminate Non-medically Indicated Deliveries Before 39 Weeks • Reduction of neonatal complications • No harm to mother if no medical or Click to edit Master title style obstetrical indication for delivery • Substantial cost savings • Now a national quality measure: Click to edit Master subtitle style • National Quality Forum (NQF) • Leapfrog Group • The Joint Commission (TJC) 59
The Big 5 States Wh What are the uni niqu que e opportunitie rtunities for the Big g 5 St 5 States es to accomplis lish something ing signific ifican ant... t...
Big 5 States - Total Together, the Big 5 States account for: Births 1,629,521 38.2% Hispanic Births 665,313 64.0% Non-Hispanic Black Births 202,823 32.9% Preterm Births 199,806 36.8% Late Preterm Births 142,834 36.8% C-Sections 528,018 40.0% Source: National Center for Health Statistics
Current Big 5 Collaboration <39 Weeks Toolkit – < 39 Weeks input, review and local Toolkit endorsements Elimination of Elective Deliveries Implementation – 5x5 QI Hospital Network Data – outlining the March of Dimes Consumer Awareness population-based data to Big 5 Implementation - Why the Last -QI Hospital support the initiative Weeks of Network Pregnancy Count CA, FL, IL, NY , TX Consumer Awareness – Why the Last Weeks of Pregnancy Count, Prematurity Awareness Population- based Data Day
Big 5 Hospital Network Goal: To eliminate non-medically indicated deliveries <39 weeks in 25 network hospitals by conducting a proof of concept of the toolkit. A minimum of 5 hospitals from each Big 5 state selected Hospital QI teams carrying out change components outlined in the toolkit Hospital teams participate on monthly conference calls Baseline data and post-implementation data collected, analyzed and given back to the hospitals Tools and lessons learned will support a national rollout Network Timeline 9/1/2010 – 12/31/2011
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
Toward Improving the Outcome of Pregnancy III: Enhancing Perinatal Health Through Quality, Safety, and Performance Initiatives December, 15, 2010
TIOP III: Table of Contents Chapter 1: History of the Quality Improvement Movement Chapter 2: Evolution of Quality Improvement in Perinatal Care Chapter 3: Epidemiologic Trends in Perinatal Care Chapter 4: The Role of Patients and Families in Improving Perinatal Care Chapter 5: Quality Improvement Opportunities in Preconception and Interconception Care Chapter 6: Quality Improvement Opportunities in Prenatal Care Chapter 7: Quality Improvement Opportunities in Intrapartum Care Chapter 8: Applying Quality Improvement Principles in Caring for the High Risk Infant Chapter 9: Quality Improvement Opportunities in Postpartum Care Chapter 10: Quality Improvement Opportunities to Promote Equity in Perinatal Health Outcomes Chapter 11: Systems Change Across the Continuum of Care Chapter 12: Policy Dimensions of Systems Change in Perinatal Care Chapter 13: Opportunities for Action and Summary of Recommendations
NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights March 8 – 10, 2010, Bethesda, Maryland
NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights Conclusions: • A trial of labor after a previous c- section is “reasonable.” • There are substantial barriers that women face in accessing clinicians and facilities that are able and willing to offer a trial of labor. • Medico-legal considerations add to and exacerbate these barriers. • Healthcare organizations and clinicians should make public their policies about VBAC so women can make informed choices about their healthcare provider and where they wish to deliver.
Patient Brochures
Patient Brochures
Summary: Reasons to Eliminate Non-medically Indicated Deliveries before 39 Weeks
New Media Campaign Babies aren’t fully developed until at least 39 weeks in the womb…… If your pregnancy is healthy, wait for labor to begin on it’s own.
New TV PSA Television public service ad featuring Julie Bowen (30-seconds)
Can We Prevent Non-Medically Indicated Early Deliveries? YES!!!!
Thank You!!!
Elective Deliveries Scheduled Early: Report from the Leapfrog 2010 Survey Leah Binder June 22, 2011
A Market-Driven Approach to Safety and Quality 1. Competitive Transparency 2. Apples to Apples Measurement 3. Customers Tie Payment to Value 2010 Leapfrog Hospital Survey (Run 3/31/11)
A Regional Approach to National Participation 2000+ Purchasers • Regions Drive Survey Data Collection • 43 Regional Roll Outs invite hospitals to complete the survey • Use various incentives and recognition to drive further improvements
The Leapfrog Hospital Survey: The Gold Standard in Competitive Transparency Shows contrasts Measures what matters to consumers Reported through a neutral or consumer oriented source Broad spectrum of competitive highs and lows
Hospital Compare
Example of State “Public Reporting”: South Carolina Reporting of Infection Rates
Leapfrog Reporting
Deliveries Scheduled Too Early • Measure: The proportion of a hospital ’ s newborns delivered with a gestational age between the 37 th and 39 th completed week, that were delivered electively • Measure introduced to Leapfrog Hospital Survey in 2009 • Fully aligned with Joint Commission and CDC • 782 hospitals reported nationally
Too Early Deliveries: State Results Average Rate of Elective Deliveries Between the 37th and 39th Completed Week: State Results (Leapfrog Hospital Survey Data 2/28/11) 30% Average Rate of Elective Deliveries 25% 20% 2010 National Average: 15% 10% 2010 Leapfrog Target: 12% 5% 0% CO GA ME MI MA OH NV WA CA NJ WI NC TX IL TN VA FL NY MN SC IN AZ State With More Than 10 Reporting Hospitals
Too Early Deliveries: Variation! National Average: 17 % Illinois Average: 17.8% 2010 Leapfrog Hospital Survey (Run 3/31/11)
Deliveries in Illinois • 165 targeted hospitals; 87 hospitals participate • 66 hospitals reported an early elective delivery rate to Leapfrog • Best hospital reported a rate of 0 • 3 hospitals with rates over 60%
Illinois Results
Collaborating to Make Change • March of Dimes • Childbirth Connection • 4 National Health Plans: Wellpoint, Cigna, Aetna, United • Hospitals, Physicians, Policymakers
Contact Us Leah Binder, CEO The Leapfrog Group 1150 17 th Street NW Ste. 600 Washington, DC 20036 (202)292-6713
Steps Toward a High- Quality, High-Value Maternity Care System Summit on Preventing Early Deliveries Midwest Business Group on Health Chicago, Illinois June 22, 2011 Maureen Corry, MPH, Executive Director Childbirth Connection transform.childbirthconnection.org/ www.childbirthconnection.org
Childbirth Connection • Mission is to improve the quality of maternity care through research, education, advocacy, and policy. transform.childbirthconnection.org/ www.childbirthconnection.org
Overview of Presentation • Share selected findings from Listening to Mothers national survey of women’s childbearing experiences and Milbank Report Provide overview of “ 2020 Vision ” and “ Blueprint • for Action: Steps Toward a High-Quality, High- Value Maternity Care System ” • Share selected Blueprint recommendations to improve maternity care quality and value transform.childbirthconnection.org/ www.childbirthconnection.org
transform.childbirthconnection.org/ www.childbirthconnection.org
Reasons for Choosing Maternity Caregiver • Provider in my insurance plan 47% • Past experience with provider/group 42% • Friend or family recommendation 26% • Office location convenient 26% • Wanted female provider 26% • Provider’s style/care options fit my views 18% • Provider attends birth at preferred hospital 17% transform.childbirthconnection.org/ www.childbirthconnection.org
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% transform.childbirthconnection.org/ www.childbirthconnection.org
Interventions by Vaginal Birth • Continuous EFM 90% • Epidural or spinal analgesia 71% • Attempted induction 49% • Caregiver induced labor 34% • Ruptured membranes 59% • Pitocin to speed labor 55% • Synthetic oxytocin to induce/speed labor 57% • Bladder catherization 43% • Episiotomy 25% transform.childbirthconnection.org/ www.childbirthconnection.org
Cesarean Birth and VBAC • 32% cesarean rate: 16% primary, 16% repeat • Among mothers with previous cesarean, 11% had a VBAC for most recent birth • Of women with previous cesarean, 45% interested in option of VBAC, but 57% denied that option • Most common reasons for denial: caregiver unwillingness (45%) or hospital unwillingness (23%) transform.childbirthconnection.org/ www.childbirthconnection.org
Listening to Mothers II : In Her Own Words “ I feel I was railroaded into labor, pain medication and subsequently a cesarean section. The baby then had to be protected by my husband from a spinal tap immediately after birth. I did not get to hold my baby for hours after birth. It was not enjoyable, only interfered with by my health care workers ” . transform.childbirthconnection.org/ www.childbirthconnection.org
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% transform.childbirthconnection.org/ www.childbirthconnection.org
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