New FPQC initiative aims to increase vaginal deliveries

| CFH, Chiles Center, COPH Office of Research, Departments, FPQC, Monday Letter, Our Research, Programs, Take Note!

The Florida Perinatal Quality Collaborative (FPQC) at the USF College of Public Health has launched a new statewide project aimed at reducing primary cesarean section deliveries in low-risk first-time mothers.

“This is an important maternal health issue for Florida mothers and babies as we have one of the highest cesarean rates in the nation,” said Dr. William Sappenfield, director of the FPQC and director of the Lawton and Rhea Chiles Center for Healthy Mothers and Babies in the Department of Community and Family Health.

Delivery by C-section has been increasing in Florida from a low of 21.9 percent in 1996 to a high of 38.1 percent in 2012; Florida’s provisional 2016 rate is 37.4 percent.

The U.S. has also seen a rise in the total C-section rate, while cerebral palsy and neonatal seizure rates have not changed since 1980.

While C-sections are essential for maternal and neonatal health, most experts agree that the current rates are too high.

The new quality improvement initiative is called the Promoting Primary Vaginal Deliveries Initiative—PROVIDE.

The project will include working 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 PROVIDE is to improve maternal and newborn outcomes by applying evidence-based interventions to promote primary vaginal births at Florida delivery hospitals and ultimately reduce Nulliparous, Term, Singleton, Vertex (NTSV) cesareans.

NTSV represents babies born at or beyond 37 weeks gestation to women in their first pregnancy that are singleton (no twins or beyond) and in the vertex presentation (no breech or transverse positions), via cesarean birth.

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 percent; in Florida, it was 31 percent, the second highest in the U.S.

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.

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 ‘Initiative Kick-Off’ meeting, held Oct. 5, 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.

Health care providers were energized about the new PROVIDE initiative. (Photo courtesy of Emily Bronson)

Among the partners and supporters of the initiative was Dr. Karen Harris, American Congress of Obstetricians and Gynecologists (ACOG) district 12 chair, who recognized the group of leaders responsible for initiating C-sections as 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.

At the training, it was shared that only about one-fifth of Florida hospitals meet the Healthy People 2020 national goal for NTSV C-section deliveries of 23.9 percent or less.

The risk of a nulliparous, low risk pregnant woman at term with a singleton in the vertex position 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 percent, depending on the hospital.

Six of the 10 hospitals in the U.S. with the highest cesarean rates are in Florida.

Sappenfield also presented the latest data and health concerns related to low-risk primary C-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.

“This new initiative in promoting safe vaginal birth and reducing low risk cesareans has the largest number of Florida delivery hospitals ever participating in an FPQC quality improvement initiative,” Sappenfield said. “This would not be possible if it were not for the strong statewide partnership efforts of agencies, organizations, providers, health plans and others.”

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.

Annette Phelps led a panel including Jessica Brumley, Ellen French, Nancy Travis, and Jason James at the PROVIDE Initiative Kick-Off meeting. (Photo courtesy of Emily Bronson)

COPH’s Dr. Linda Detman and Emily Bronson, shared early data findings from qualitative research on the knowledge, beliefs and behaviors associated with NTSV C-sections from physicians, nurses, and patients from the Miami-Dade area, an area of the state with a particularly high rate.

This research will inform the development of patient education materials and is funded by the Florida Blue Foundation.

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.

Lee Health Team at the PROVIDE Initiative Kick-Off. (Photo courtesy of Nancy Travis)

For more information on the PROVIDE Initiative, visit


Story by Emily Bronson, Florida Perinatal Quality Collaborative