The Florida Perinatal Quality Collaborative (FPQC) launched a new statewide project aimed at reducing primary Cesarean section delivery in low-risk first-time mothers.
Delivery by cesarean section has been increasing in Florida from a low of 21.9% in 1996 to a high of 38.1% in 2012; Florida’s provisional 2016 rate is 37.4%.
The US has seen a relentless rise in the total cesarean rate without realizing maternal or neonatal benefit. The cerebral palsy and neonatal seizure rates are unchanged since 1980. While cesareans are essential for maternal and neonatal health, most experts agree that the current rates are too high.
It is likely NTSV cesareans are driving the increasing cesarean rate as virtually all subsequent births by NTSV women will be delivered by cesarean due to limited opportunity for vaginal delivery after cesarean. In 2014, the national rate of primary cesareans was 26%; in Florida, it was 31%, the 2nd highest in the U.S.
The new quality improvement initiative is called the Promoting Primary Vaginal Deliveries Initiative, or PROVIDE. The purpose of this project is to work with Florida stakeholders and hospitals to improve readiness, recognition, response, and reporting with the ultimate goal of promoting intended primary vaginal deliveries. The goal of the PROVIDE Initiative is to improve maternal and newborn outcomes by applying evidence-based interventions to promote primary vaginal deliveries at Florida delivery hospitals and ultimately reduce NTSV cesareans.
Forty-five participating hospitals across the state will utilize a variety of quality improvement techniques and processes to address focus areas identified as a priority by their facility.
At the October 5, 2017 Initiative Kick-Off meeting, 185 hospital champions were educated on the background and significance of the issue, as well as an overview of the key drivers for Cesarean delivery and key recommendations.
Among the partners and supporters of the initiative was Dr. Karen Harris, ACOG District 12 Chair, who recognized the forward thinking group of leaders who initially proposed that Cesarean section was an important area for FPQC to address. Additionally, CDC representatives Dr. Zsakeba Henderson from the Division of Reproductive Health and Dr. Dave Goodman from the CDC maternal mortality project attended; it was Dr. Goodman’s original research as an epidemiology fellow with the Florida Department of Health that provided an impetus to work on this issue.
About one-fifth of Florida hospitals meet the Healthy People 2020 national goal for Nulliparous Term Singleton Vertex (NTSV) cesarean section deliveries of 23.9% or less. The risk of a nulliparous low risk pregnant woman at term with a singleton in the vertex position (NTSV) having a cesarean is directly dependent on which hospital she walks into. The range of primary cesarean in this group ranges from 12.6% to 66.3% depending on the hospital. Six of the ten hospitals in the US with the highest cesarean rates are in Florida.
Dr. William Sappenfield presented on the latest data and the health concerns related to low-risk primary Cesarean sections in Florida. The PROVIDE Initiative’s clinical co-leads, Dr. Julie DeCesare and Dr. Karen Bruder, provided information about clinical concerns. Other initiative expert advisors including Dr. John Caravello, Dr. Jessica Brumley, Margie Boyer, and Dr. Jason James shared clinical considerations and algorithms that will be used in the initiative.
The day’s training also included a panel presentation by PROVIDE expert nurses, midwives, and physicians who have begun implementing some of the PROVIDE key recommendations in their hospitals. They shared implementation process lessons, potential barriers and solutions, and solicited input from the attendees about these issues. Attendees found the interactive discussion where they could hear from other hospitals and learn from one another to be very helpful in beginning to work through the issues as a collaborative.
Dr. Linda Detman and Emily Bronson, shared early data findings from qualitative research on the knowledge, beliefs and behaviors associated with NTSV Cesarean sections from physicians, nurses, and patients from the Miami-Dade area (an area of the state with particularly high rates of Cesareans). This research will inform the development of patient education materials and is funded by the Florida Blue Foundation. The early information provided participants with additional information on the issues and drivers of primary cesareans, in particular those related to patients.
Each hospital has assembled a quality improvement team including physician, nurse, and administrative champions. Over the course of the 18-month initiative, the FPQC will provide monthly quality improvement data reports for each hospital, a toolkit and an online toolbox with resources and tools, and technical assistance to assist hospitals in implementing process changes and improving documentation.
The FPQC plans to conduct on-site technical assistance visits coupled with Grand Rounds presentations, and webinar learning sessions to further assist initiative hospitals with implementation. Regional labor support skills workshops will be offered to participating hospitals with a focus on promoting physiologic births and labor management to promote vaginal delivery.
Funding for PROVIDE is provided by the Florida Department of Health’s Title V Block Grant, and the national Alliance for Innovation on Maternal Health (AIM) program. For more information on the PROVIDE Initiative, visit FPQC.org.