Alan Fleischman, M.D. Senior Vice President and Medical Director

1. October 4, 2011 Statewide strategies to improve birth outcomes through timely deliveries Alan Fleischman, M.D. Senior Vice President and Medical Director

2. 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. Alan Fleishman 2

3. March of Dimes • From its beginning, the March of Dimes has carried out its mission through research, community intervention programs, education, and advocacy Alan Fleishman

4. 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. Alan Fleishman

5. 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 Alan Fleishman

6. Consequences of Preterm Birth Long-term: Chronic Respiratory Problems Re-hospitalization Neurodevelopmental Problems Cerebral Palsy Cognitive Deficits Hearing and Vision Impairment Autistic Symptomatology Alan Fleishman

7. Institute of Medicine Report: Preterm Birth: Causes, Consequences, and Prevention, 2006 United States cost per year: $26.2 Billion Total costs $26.2 Billion Alan Fleishman

8. Average Expenditure for Newborn Care (privately insured through employer) Thomson Reuters for the March of Dimes, 2009 8 Alan Fleishman

9. Peak Shifted: 40 to 39 weeks Changing Distribution of Singleton Live Births United States, 1992, 1997, 2002, 2006 Over 4 million babies born per year Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2009 Alan Fleishman

10. 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 Alan Fleishman

11. Definitions • Weeks of Pregnancy Preterm Term Late Preterm 22 37 41 Alan Fleishman

12. Definitions • Weeks of Pregnancy Preterm Term Late Preterm 22 34 37 41 Alan Fleishman

13. Definitions • Weeks of Pregnancy Preterm Term Late Preterm Early Term Full Term 22 34 37 39 41 Alan Fleishman

14. Definitions • Weeks of Pregnancy Preterm Term Late Preterm Early Term Full Term 22 34 37 39 41 Alan Fleishman

15. Preterm Birth Rates by Gestational Age U. S., 1990, 2000, 2005-2009* Percent *2009, provisional -- Source: National Vital Statistics Reports Alan Fleishman

16. U.S. Preterm Birth Rates 12.3 11.6 11.0 10.6 71% Late Preterm % Alan Fleishman

17. 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 Alan Fleishman 17

18. Why are non-medically indicated (elective inductions and scheduled cesarean deliveries) increasing in frequency? Alan Fleishman 18

19. Sounds like a good idea… Advanced planning Convenience Delivered by her doctor Maternal intolerance to late pregnancy Excess edema, backache, indigestion, insomnia Prior bad pregnancy And, it’s okay right? Alan Fleishman Source: Clinical Obstetrics and Gynecology2006;49:698-704 19

20. Complications of Non-medically Indicated Deliveries Between 37 and 39 Weeks *See Toolkit for more data and full list of citations Source: Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997 Alan Fleishman 20 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 Increased suspected or proven sepsis Increased newborn feeding problems and other transition issues

21. What Motivates SomeObstetricians? Physician convenience Guarantee attendance at birth Avoid potential scheduling conflicts Reduce being woken at night … what’s the harm? Amnesia due to rare occurrence. The NICU can handle it. And… Source: Clinical Obstetrics and Gynecology 2006;49:698-704 Alan Fleishman 21

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23. Women’s Perceptions Regarding the Safety of Birth at Various Gestational Ages When is a baby full term? 34-36 weeks is full term 24.0% 37-38 weeks is full term 50.8% What is the earliest point in pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery? 34-36 weeks 51.7% 37-38 weeks 40.7% 39-40 weeks 7.6% Source: Goldenberg RL, et al. Obstet Gynecol 2009; 114:1254-1258. Alan Fleishman 23

24. 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 Alan Fleishman 24

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26. Eliminate Non-Medically Indicated Deliveries Before 39 Weeks Available at: marchofdimes.com or cmqcc.org Alan Fleishman 26

27. Table of Contents • Making the Case • Implementation Strategy • Data Collection/QI Measurement • Clinician Education • Patient Education • Appendices Alan Fleishman 27

28. Key Change Components • Identify Physician Champion • Create (Rewrite) Hospital Policy • Establish Professional Consensus on: “Indications for Early Delivery” Alan Fleishman 28

29. 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) Alan Fleishman 29

30. 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. Alan Fleishman 30

31. % Non-medically Indicated Deliveries<39 Weeks January 1999 – December 2005 Source: Oshiro, B. et al. Obstet Gynecol 2009;113:804-811. Alan Fleishman 31

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33. Summary: Reasons to Eliminate Non-medically Indicated Deliveries Before 39 Weeks • Reduction of neonatal complications • No harm to mother if no medical or obstetrical indication for delivery • Substantial cost savings • Now a national quality measure: • National Quality Forum (NQF) • Leapfrog Group • The Joint Commission (TJC) Alan Fleishman 33

34. The Big 5 States What are the unique opportunities for the Big 5 States to accomplish something significant... Alan Fleishman 34

35. Big 5 States - Total Together, the Big 5 States account for: Source: National Center for Health Statistics Alan Fleishman 35

36. 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 Alan Fleishman 36

37. Toward Improving the Outcome of Pregnancy III: Enhancing Perinatal Health Through Quality, Safety, and Performance Initiatives December, 15, 2010 Alan Fleishman 37

38. 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 38 Alan Fleishman

39. Patient Brochures Alan Fleishman

40. Patient Brochures Alan Fleishman 40

41. 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. Alan Fleishman 41

42. New TV PSA • Television public service ad featuring Julie Bowen (30-seconds) Alan Fleishman 42

43. Can We Improve Birth Outcomes Through Timely Deliveries? YES!!!! Alan Fleishman 43

44. Thank You!!! Alan Fleishman 44