Transforming Maternity Care Blueprint for Action:

1. Transforming Maternity Care Blueprint for Action: Steps Toward a High Quality, High Value Maternity Care System Opportunities for Quality Collaboratives NJHA, June 22, 2010 R. Rima Jolivet, CNM, MSN, MPH Transforming Maternity Care Project Director Associate Director of Programs Childbirth Connection

2. Childbirth Connection Mission To improve the quality of maternity care through research, education, advocacy, and policy.

3. US Maternity Care Facts… • 4.3 million births in 2007, the most ever recorded • Maternal-newborn care is the most common reason for hospitalization, and accounts for 25% of all discharges • 6 out of 10 most common hospital procedures are maternity-related • The most common operating room procedure is cesarean section • The national cesarean rate is 32% (another record high) • Cesarean rates vary by payer: • private = 33.7%, Medicaid = 29.8%, uninsured = 25.4% References at http://www.childbirthconnection.org/article.asp?ck=10621

4. …and Figures • Combined maternal/newborn facility charges were $86 billion in 2006 • In 2006, 42% of all births billed to Medicaid • In 2007, 53% of all hospital discharges billed to Medicaid were maternity-related • Similarly, half of all births billed to private insurers • 35% of all hospital discharges billed to private insurers were maternity-related References at http://www.childbirthconnection.org/article.asp?ck=10621

5. New Jersey DoH data • In NJ, the rate of cesarean with no trial of labor has risen significantly since the late 90’s while the rate of vaginal birth has declined steadily • From 1999-2004, the annual growth in cesarean rates was greater than 5% for primary NTSV (standard), primary multip standard, primary singleton preterm, and repeat standard • The nulliparous cesarean rate following induction rose 6%/yr from 1997-2008 for a cumulative increase of 102%, and the nulliparous CS rate with no trial of labor rose 14% for a cumulative increase of 368% over the same period Denk, 2009

6. Much of the care women receive is not consistent with the best evidence The 2008 Milbank report reveals: • A pattern of wide practice variation, unwarranted by health status or women’s preferences • Overuse of many practices that entail harm and waste for mothers, babies, and the system at large • Other effective, high-value practices that are systematically underused Sakala & Corry, 2008 (available at: www.childbirthconnection.org)

8. The full reports are available at: www.childbirthconnection.org and www.whijournal.com

9. Transforming Maternity Care 2020 Vision for a High Quality, High Value Maternity Care System • Fundamental values and principles that apply across the whole continuum of maternity care • Goals for each phase and for providers and settings for maternity care • Attributes of the larger system that can reliably provide high quality, high value care to all childbearing women, their newborns and families

10. Blueprint for Action:Steps Toward a High Quality, High Value Maternity Care System • Five stakeholder workgroups developed detailed sector-specific reports • Actionable strategies in 11 critical focus areas • Synthesized into a comprehensive Blueprint for Action by the Symposium Steering Committee • Full stakeholder reports are published online at: www.childbirthconnection.org/workgroups

11. Blueprint for Action:Steps Toward a High Quality, High Value Maternity Care System 11 Critical Focus Areas: • Performance measurement and leveraging of results • Payment reform to align incentives with quality • Disparities in access and outcomes of maternity care • Improved functioning of the liability system

12. Blueprint for Action:Steps Toward a High Quality, High Value Maternity Care System 11 Critical Focus Areas: • Scope of covered services for maternity care • Coordination of maternity care across time, settings, and disciplines • Clinical controversies (home birth, VBAC, vaginal breech and twin birth, elective induction, and maternal demand cesarean section) • Decision making and consumer choice • Scope, content, and availability of health professions education • Workforce composition and distribution • Development and use of health information technology (IT)

13. Transforming Maternity Care: Looking Forward with Shared Perspective Blueprint for Action:Steps Toward a High Quality, High Value Maternity Care System ‘‘Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?’’

14. Blueprint for Action:Selected Recommendations and Strategies Performance Measurement and Leveraging of Results • Develop, test, and submit to NQF measures to address crucial topical gaps, including informed decision making, VBAC, comfort measures and pain relief, postpartum hospital practices that impact attachment and breastfeeding, and persistent physical and emotional problems that arise in the postpartum period. • Identify a core subset of national consensus measures for rapid reporting. Begin implementation with pilots to identify barriers that may result due to administrative variation across and within systems, and scale up. • Develop state or regional quality collaboratives that bring hospitals, clinicians, consumers, and payors together to test the impact of performance measures on P4P, audit and feedback, QI indicators.

15. Blueprint for Action:Selected Recommendations and Strategies Payment Reform to Align Incentives with Quality Build a better bundled payment system for maternity care, adapting “From Volume to Value” model to maternity care (Miller, 2008) Pilot the model through regional demonstration projects involving all payors and providers to decide on indicators and targets, to design mechanisms for cost- and revenue-sharing and incentives for value-based care coordination, and to test the outcomes of alternative payment models based on these determinants Encourage state Medicaid programs to use policy levers to coordinate implementation

16. Blueprint for Action:Selected Recommendations and Strategies Disparities in Access and Outcomes of Maternity Care • Form quality collaboratives and community-based partnerships to evaluate and implement programs to close disparities in maternity care outcomes. • Carry out comparative effectiveness research and apply disparities-sensitive criteria from the National Voluntary Consensus Standards for Ambulatory Care: part 2 (NQF, 2009) when collecting quality improvement data • Test effect on outcomes and cost of preventive programs such as Centering Pregnancy, language translation, care coordination, doulas, nurse home visitation, and comprehensive breastfeeding promotion

17. Blueprint for Action:Selected Recommendations and Strategies Improved Functioning of the Liability System • Widely adopt system-oriented patient safety and quality improvement programs, and measure and report experiences with malpractice claims and payments. • Evaluate the impact on reduction of adverse events and liability experiences, and satisfaction of women and providers, of: the laborist model, various team models and mechanisms for community coordination, regular team training and emergency drills, evidence-based checklists, and policies that provide better rest for maternity care providers • Pilot, evaluate, and share results of ‘‘enterprise liability’’ programs that relocate responsibility from individuals to systems.

18. Blueprint for Action:Selected Recommendations and Strategies Coordination of Maternity Care Across Time, Settings, and Disciplines • Develop local and regional QI initiatives designed to improve coordination at the community level • Establish mechanisms for 24-hour open access to MFM specialists by community providers for consultation, co-management , or referral • Convene an inclusive, interdisciplinary team of FP, OB, MFM and midwives, and use actual community patient safety data on near misses and reportable adverse events to develop community-specific consensus risk criteria for level of care including settings and providers, replicating Intermountain’s model • Conduct multi-disciplinary periodic review of all transfers and complications from community to higher levels of care to engage in joint problem solving

19. The potential to improve maternity care is within our reach, but none of us can do it alone.

20. Transforming Maternity Care: Looking Forward with Shared Perspective The TMC Partnership: www.childbirthconnection.org/Partnership • Outreach and dissemination to decision makers, including policy makers and legislators • Joint Blueprint implementation projects of a significant scope, undertaken with organizations that have the capacity and resources to accelerate health system change • The TMC Action Community: A forum for community-level partners to show support for the Vision and Blueprint, and get ideas and resources for ways to independently engage in this work within their own communities and practice settings

21. Thank You! R. Rima Jolivet, CNM, MSN, MPH Transforming Maternity Care Project Director Associate Director of Programs Childbirth Connection jolivet@ childbirthconnection.org