March of Dimes
Efforts to Reduce Early
Elective Deliveries
2013 NAPHSIS/NCHS
Joint Meeting
Phoenix, AZ
June 6, 2013
Rebecca Russell, MSPH
Director, Perinatal Data Center
March of Dimes Foundation
The March of Dimes mission is to
improve the health of babies by
preventing birth defects, premature
birth and infant mortality.
Stronger, healthier babies:
75 years in the making
Perinatal Data Center Roles & Goals
• Secure relevant and timely perinatal data.
• Develop and disseminate products and publications to
support the March of Dimes mission.
• Provide technical assistance to help March of Dimes
staff and volunteers effectively interpret perinatal data.
• Support mission-relevant, data-driven projects of the
Foundation.
• Lead national-scope evaluation projects.
Quality Improvement
The March of Dimes is working to ensure that perinatal
quality measures are developed and incorporated, as
appropriate, in a consistent way into various measure sets
and initiatives.
• National Quality Forum Maternity Action Team
• AHRQ Subcommittee on Quality Measures for Children’s Healthcare
(SNAC)
• CMCS Expert Panel on Improving Maternal and Infant Health
Outcomes
• ReVITALize conference (August 1-2, 2012)
• MACPAC Expert Panel on Medicaid Implications of Trends in Induction
of Labor and Cesarean Deliveries
Healthy Babies Are Worth the Wait:
Quality Improvement Initiative
Table of Contents:
• Making the Case
• Implementation Strategy
• Data Collection/QI
Measurement
• Clinician Education
• Patient Education
• Appendices
Available at: marchofdimes.com
Toolkit Components
Reduce Demand for Non-medically Indicated Deliveries
• Provider/staff Education
• Patient Education
• Public Awareness
Key Change Tactics
• Adoption of a policy on non-medically indicated deliveries
• Implementation of a scheduling process
• Increase Physician Leadership
QI Data Collection and Monitoring over time
What is the Big 5?
Big 5 States
• In the U.S., the Big 5 States account for:
•
•
•
•
•
•
Births
38.0%
Hispanic Births
63.7%
Non-Hispanic Black Births
32.5%
Preterm Births
37.1%
Late Preterm Births
37.3%
• C-Sections
•
39.8%
Source: National Center for Health Statistics, 2010 final natality data
10
Methods
• Scheduling form implemented in all participating hospitals.
• Data collected at the time of scheduling, with limited follow-up
to determine actual outcome and NICU admission
• De-identified data for each singleton delivery scheduled at 34
weeks 0 days and greater were submitted monthly through a
web-based data entry system.
• Gestational age at scheduled delivery date assigned by clinician
based on the best clinical estimate.
• Data entry completed on a monthly basis by the 15th of the
following month. Data quality checks performed for entry
errors and inconsistency.
Data Collection
• Data collected:
• A count of singleton live births and fetal deaths by
gestational age in weeks for each month of the project
period
• Individual delivery and outcome data on scheduled
deliveries ≥ 34 0/7 weeks gestation.
– Scheduling data from the scheduling form
– Outcome data from L&D log
SCHEDULING FORM FOR INDUCTIONS AND CESAREAN SECTIONS
Call (XXX) XXX-XXXX or Fax (XXX) XXX-XXXX
Name _____________________________________ Phone _______________________
OB Provider ________________________________________ G/P _________________
Type of Delivery Planned: Induction; C/S Desired Date/Time: _________________
DATING ..................................................................................................................................
EDC: __________ Gestational Age at Date of Induction or C/S: ____________ (week+day)
EDC Based on: US <20 weeks; Doppler FHT+ for 30 weeks; +hCG for 36 weeks
Other dating criteria: ______________________________________________ (details)
By ACOG Guidelines, women should be 39 wks or greater before initiating an elective (no indication) delivery. ACOG
also states that a mature fetal lung test in the absence of clinical indication is not considered an indication for delivery.
Scheduling Info
Dating
Fetal Lung Maturity test result: _______________ Date: ________________
INDICATION................................................................................................................................
Obstetric and Medical Conditions (OK if <39 weeks)
(need to deliver <39 weeks dependent on severity of condition)
Abruption
Previa
Preeclampsia
Gestational HTN
GDM with insulin
PROM
Fetal Demise (current)
Fetal Demise (prior)
Oligohydramnios
Polyhydramnios
IUGR
Non-reassuring fetal
status
Isoimmunization
Fetal malformation
Multiples w/
complications
Heart disease
Liver disease (e.g.
cholestasis of preg.)
Chronic HTN
Diabetes (Type I or II)
Renal disease
Coag/Thrombophilia
Pulmonary disease
HIV infection
Prior classical C/S
Prior myomectomy
Other: _____________
_____________________
Perinatology consult
obtained and agrees
with plan:
________________
Scheduled 41+0 wks
Scheduled C/S (39 wks)
Prior C/S
Breech presentation
Other malpresentation
Patient choice
Other: _____________
Twin w/o complication
(ok 38 wks)
Indication(s)
Elective Induction
(39wks)
Patient choice/social
Macrosomia
Distance
Other: _____________
(consultant name)
Description/Details: _________________________________________________________
CERVICAL EXAM (for inductions).............................................................................................
Date of Exam: _____________ (within 7 days of date of induction)
Bishop Score: circle each element of the exam below and add:
Total Score: _________
Score_ Dilation__ Effacement__Station___Consistency __Position
0
Closed
0-30%
-3
Firm
Posterior
1
1-2
40-50%
-2
Medium
Midposition
2
3-4
60-70%
-1, 0
Soft
Anterior
3
5-6
80%
+1, +2
-----------------
This section is used only
by those hospitals using
cervical exam criteria for
scheduling inductions.
SCHEDULING OFFICE USE .................................................................. Procedure not scheduled: 
Scheduled? by Confirmed Date/Time
Referred to Dept Chair? 
Prenatal
presenting
Yes
Cervical Exam
Data Portal to Monitor Scheduled Deliveries
• Secure, web-based system
• Data entry across multiple
hospitals
• User friendly, intuitive
• Report monthly and quarterly
progress to eliminate elective
deliveries < 39 weeks
• Comparison data for state and
Big 5
Reporting
•
Purpose: to inform hospitals
about their progress towards
eliminating NMI deliveries <39
weeks
•
Frequency:
– Monthly and Quarterly
with benchmarking
– Optional Provider report
quarterly
– Ad hoc reporting done by
request
Characteristics of Hospitals
Big 5 Hospital Network, 2011
•
•
•
•
•
Diverse group of hospitals, with a majority:
Located in large Metropolitan Counties (66.7%)
2,000-4,999 annual deliveries (62.5%)
Designated Level III NICU/Regional Perinatal Center (70.8%)
Nonprofit (75%)
In 2011:
• 65,123 singleton deliveries
• 29,030 scheduled singleton deliveries ≥34 weeks 0 days
Early term is 37 0/7 to 38 6/7 weeks gestation.
For each delivery type, the numerator is the number of scheduled singleton early term non-medically
indicated inductions and cesarean deliveries and the denominator is the number of scheduled singleton
early term deliveries.
Source: Oshiro BT et al. A Multistate Quality Improvement Program to Decrease Elective Deliveries Before
39 Weeks of Gestation. Obstet Gynecol. May, 2013.
Singleton deliveries, by gestational age
Big 5 Hospital Network, 2011
Gestational age group
Q1
Q2
Q3
Q4
37-38 completed
weeks
27.3%
26.7%
25.4%
25.9%
<0.01
39-41 completed
weeks
61.7%
61.4%
63.3%
63.3%
<0.01
Source: Big 5 Hospital Network, <39 Weeks Elective Delivery pilot project.
Prepared by March of Dimes Perinatal Data Center.
p-value
Other Clinical Outcomes
• NICU Admissions
• Among scheduled singleton early term deliveries, NICU
admissions declined from 1.5 per 100 singleton term
deliveries to 1.2 (p=0.024).
• Fetal Mortality
• The fetal morality rate among deliveries at 37-41
weeks fluctuated over the four quarters of 2011 with
no discernible trend.
• Similar fluctuations when stratified into 37-38 weeks
and 39-41 weeks.
Conclusions
• Rate of non-medically indicated scheduled early term
deliveries decreased 83% over the 12 month pilot period.
• Significant declines observed for both inductions (72%,
p=0.002) and cesarean deliveries (84%, p<0.001).
• No change in medically indicated or unscheduled early
term deliveries.
• Project demonstrated a successful model for
implementation of a multi-hospital, multi-state quality
improvement initiative.
Additional Outcomes
 Increased consistency among practitioners in defining what is
medically and non-medically necessary
 Nurses empowered to call into question deliveries that were not
medically necessary
 Hospitals reported shift in staffing needs and an increase in babies
being born at night and on the weekends
•
Limitations
• Lack of comparable baseline data or outcomes among
comparable hospitals not participating in initiative.
• Long term sustainability yet to be determined.
March of Dimes 39+ Weeks
Quality Improvement Service Package
• Professional Education: Grand Rounds
• Online Services
• Webinars
• Access to Experts in the Field
• Public Education: March of Dimes Materials
• Web Based Data Portal
39+ Weeks Quality Improvement
Service Package
VT
ME
Michigan
(upper peninsula)
WA
MT
MN
ND
NH
NY
OR
WI
RI
MI
SD
ID
PA
WY
IA
NE
WV
VA
UT
CO
KY
MO
KS
NC
TN
AZ
OK
NM
SC
AR
Alaska
MS
TX
AL
GA
LA
FL
PR
Hawaii
NJ
CT
DE
OH
IN
IL
NV
CA
MA
MD
DC
Strong Start Components
1. An initiative to reduce the rate of preterm births for
women who are at-risk for preterm birth and covered
by Medicaid by testing enhanced prenatal care models
2. A test of a nationwide public-private partnership and
awareness campaign (Healthy Babies Are Worth the
Wait™) to spread the adoption of best practices that
can reduce the rate of early elective deliveries prior to
39 weeks for all populations
25
Strong Start Initiative
• U.S. HHS is working in partnership with other organizations
nationwide, including:
—March of Dimes
—American Congress of Obstetricians and Gynecologists
—National Partnership for Women and Families
—Society for Maternal and Fetal Medicine
—American College of Nurse Midwives
—Childbirth Connections
—Leapfrog Group
—National Priorities Partners
—National Quality Forum
26
Healthy Babies Are Worth the Wait™
• HHS has become a national partner in the March of
Dimes Healthy Babies are Worth the Wait™ education
and awareness campaign
• This campaign aims to reduce elective induction and
cesarean section prior to 39 completed weeks of
pregnancy
• The March of Dimes campaign, which was launched in
June 2011, was expanded
• Expansion included advertising placement and cobranding of March of Dimes advertising and educational
materials by HHS and ACOG
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“Babies aren’t fully
developed until at least
39 weeks in the womb……
If your pregnancy is
healthy, wait for labor
to begin on its own.”
ASTHO Challenge
In 2011, ASTHO President David Lakey challenged all state
health officials to reduce their state’s preterm birth rate by
8% by 2014
• MOD joined ASTHO in issuing the challenge
• MOD chapters are working with state health officials to
offer assistance and resources
• 50 states (DC & Puerto Rico) have joined
• MOD has created a new award for states who meet the
challenge
Thank you!
Contact:
Becky Russell
rrussell@marchofdimes.com
914.997.4207