October 4, 2011
Statewide strategies to
improve birth outcomes
through timely
deliveries
Alan Fleischman, M.D.
Senior Vice President and
Medical Director
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March of Dimes Mission
The mission of the March of Dimes is to
improve the health of babies by
preventing birth defects, premature
birth and infant mortality.
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March of Dimes
From its beginning, the March of Dimes has
carried out its mission through research,
community intervention programs,
education, and advocacy
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Institute of Medicine Report: Preterm Birth:
Causes, Consequences, and Prevention, 2006
Preterm birth is a complex,
costly and serious public
health problem in the U.S.
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Consequences of Preterm Birth
Acute:
– Respiratory Distress Syndrome
– Cardiovascular Function
– Fluid and Electrolyte Balance
– Jaundice
– Nutrition and Growth
– Infection
– Necrotizing Enterocolitis
– Intraventricular Hemorrhage and
Periventricular Leukomalacia
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Consequences of Preterm Birth
• Long-term:
– Chronic Respiratory Problems
– Re-hospitalization
– Neurodevelopmental Problems
• Cerebral Palsy
• Cognitive Deficits
• Hearing and Vision Impairment
• Autistic Symptomatology
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Institute of Medicine Report: Preterm Birth:
Causes, Consequences, and Prevention, 2006
United States cost
per year:
$26.2 Billion
Total costs $26.2 Billion
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Average Expenditure for Newborn Care
(privately insured through employer)
Thomson Reuters for the March of Dimes, 2009
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Changing Distribution of Singleton Live Births
United States, 1992, 1997, 2002, 2006
Peak Shifted:
40 to 39 weeks
Over 4 million babies born per year
30%
Percent
25%
20%
15%
10%
5%
0%
28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
Gestational Age (weeks)
1992
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1997
2002
2006
Source: National Center for Health Statistics, final natality data
Prepared by March of Dimes Perinatal Data Center, 2009
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Accuracy of Gestational Dating
(Guidelines for Perinatal Care 6th 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
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Definitions
Weeks of Pregnancy
Preterm
Term
Late Preterm
22
37
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Definitions
Weeks of Pregnancy
Preterm
Term
Late Preterm
22
34
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41
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Definitions
Weeks of Pregnancy
Preterm
Term
Late Preterm
22
34
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Early Term
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Full Term
39
41
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Definitions
Weeks of Pregnancy
Preterm
Term
Late Preterm
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34
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Early Term
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Full Term
39
41
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Preterm Birth Rates by Gestational Age
U. S., 1990, 2000, 2005-2009*
14
12
Percent
11.6
12.7
12.8
12.7
12.3
9.09
9.14
9.03
8.77
12.2
10.6
10
8
6
7.30
8.22
32-33 wks
VLBW (<32 wks)
4
2
0
LPTB (34-36 wks)
1.40
1.49
1.60
1.62
1.59
1.57
1.92
1.93
2.03
2.04
2.04
1.99
1990 2000 2005 2006 2007 2008 2009*
*2009, provisional -- Source: National Vital Statistics Reports
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U.S. Preterm Birth Rates
14
12
10.6
11.6
11.0
12.3
10
%
8
6
7.3
7.7
8.2
8.8
3.3
3.3
3.4
3.5
1990
1995
2000
2008
71% Late
Preterm
4
2
0
Year
less than 34 weeks
Late Preterm (34-36 6/7 weeks)
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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
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Why are non-medically
indicated (elective
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inductions and scheduled
cesarean deliveries)
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increasing in frequency?
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Sounds like a good idea…

Advanced planning

Convenience
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Maternal intolerance to late pregnancy
 Excess
edema,
backache,
indigestion,
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insomnia

Prior bad pregnancy

And, it’s okay right?
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Source: Clinical Obstetrics and Gynecology 2006;49:698-704
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Complications of Non-medically Indicated
Deliveries Between 37 and 39 Weeks
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
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
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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
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Increased suspected or proven sepsis
Increased newborn feeding problems and other
transition issues
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*See Toolkit for more data and full list of citations
Source: Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997
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What Motivates Some
Obstetricians?

Physician convenience

Guarantee attendance at birth
Avoid potential scheduling conflicts
Reduce being woken at night
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
… what’s the harm?
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 Amnesia due to rare occurrence.


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The NICU can handle it.
And…
Source: Clinical Obstetrics and Gynecology 2006;49:698-704
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Women’s Perceptions Regarding the Safety
of Birth at Various Gestational Ages
•
When is a baby full term?
• 34-36 weeks is full term
• 37-38 weeks is full term
24.0%
50.8%
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•
What is the earliest point in pregnancy that it is
safe to deliver the baby, should there be no other
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medical
requiring
earlystyle
delivery?
 34-36 weeks
51.7%
 37-38 weeks
40.7%
 39-40 weeks
7.6%
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Source: Goldenberg RL, et al. Obstet Gynecol 2009; 114:1254-1258.
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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.
Source: ACOG Practice Bulletin No. 107, August, 2009
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Eliminate Non-Medically Indicated
Deliveries Before 39 Weeks
Available
at:
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or
cmqcc.org
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Table of Contents

Making the Case

Implementation
Strategy
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
Data Collection/QI
Measurement
 Clinician
Education
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
Patient Education

Appendices
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Key Change Components

Identify Physician
Champion
 Create (Rewrite)
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Hospital Policy
Establish Professional
Consensus
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“Indications for Early
Delivery”

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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)

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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.

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% Non-medically Indicated Deliveries
<39 Weeks January 1999 – December 2005
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Source: Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.
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Summary:
Reasons to Eliminate Non-medically
Indicated Deliveries Before 39 Weeks
• Reduction of neonatal complications
• No harm to mother if no medical or
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obstetrical indication for delivery
• Substantial cost savings
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Now atonational
quality
measure:
• National Quality Forum (NQF)
• Leapfrog Group
• The Joint Commission (TJC)
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The Big 5 States
What are the unique opportunities for the
Big 5 States to accomplish something
significant...
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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
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Big 5 Hospital Network
Goal: To eliminate non-medically indicated deliveries <39
weeks in 25 network hospitals by conducting a study of the
proof of concept that the toolkit can result in positive
change.
 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
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Toward Improving the Outcome of
Pregnancy III:
Enhancing
Perinatal Health
Through Quality,
Safety, and
Performance
Initiatives
December, 15, 2010
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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
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Patient
Brochures
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Patient
Brochures
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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.
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New TV PSA
Television public service ad featuring Julie Bowen (30-seconds)
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Can We Improve Birth Outcomes
Through Timely Deliveries?
YES!!!!
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Thank You!!!
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