1. 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

2. The March of Dimes mission is to improve the health of babies by preventing birth defects, premature birth and infant mortality.

3. Stronger, healthier babies: 75 years in the making

4. 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.

5. 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

6. 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

7. 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

8. What is the Big 5?

9. Big 5 States In the U.S., the Big 5 States account for: Source: National Center for Health Statistics, 2010 final natality data Births38.0% Hispanic Births63.7% Non-Hispanic Black Births32.5% Preterm Births37.1% Late Preterm Births37.3% C-Sections39.8%

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11. 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 15 th of the following month. Data quality checks performed for entry errors and inconsistency.

12. 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

13. Dating Indication(s) Cervical Exam Scheduling Info

14. 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

15. 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

16. 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 Characteristics of Hospitals Big 5 Hospital Network, 2011

17. 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.

18. Source: Big 5 Hospital Network, <39 Weeks Elective Delivery pilot project. Prepared by March of Dimes Perinatal Data Center. Singleton deliveries, by gestational age Big 5 Hospital Network, 2011 Gestational age groupQ1Q2Q3Q4p-value 37-38 completed weeks27.3%26.7%25.4%25.9%<0.01 39-41 completed weeks61.7%61.4%63.3% <0.01

19. 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.

20. 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.

21. 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

22. Limitations Lack of comparable baseline data or outcomes among comparable hospitals not participating in initiative. Long term sustainability yet to be determined.

23. 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

24. 39+ Weeks Quality Improvement Service Package WA OR CA NV ID MT WY CO UT NM AZ TX OK KS NE SD ND MN WI IL IA MO AR LA AL TN MI PA NY VT GA FL MS KY SC NC MD OH DE IN WV NJ CT MA ME VA Michigan (upper peninsula) Alaska Hawaii NH RI DC PR

25. 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

26. 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

27. 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 co- branding of March of Dimes advertising and educational materials by HHS and ACOG 27

28. “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.”

29. 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

30. Contact: Becky Russell rrussell@marchofdimes.com 914.997.4207 Thank you!