Author: Rebekah E. Gee, MD, Secretary, Louisiana Department of Health
In an effort to create a generation of healthier women and children in Louisiana, our team at the Louisiana Department of Health initiated the Louisiana Birth Outcomes quality effort in 2010. The team, that included staff from Medicaid, the Office of Public Health, the Louisiana Perinatal Commission and other medical experts, began with the goal of eliminating medically unnecessary or elective deliveries prior to 39 weeks gestation as one of its major strategies. Specifically, this included cesarean deliveries or inducing labor through medication.
According to maternal health experts, elective deliveries before 39 weeks of gestation poses both short-term and long-term health risks for the newborn as there are key developmental processes that occur in the last several weeks of a full-term pregnancy. Early elective deliveries are also more expensive than standard deliveries.
In addition, we sought to create a culture of continuous quality improvement in hospitals in Louisiana that delivered babies, reduce costs and, ultimately, reduce the number of poor birth outcomes as measured by preterm birth, low and very low birth weight, C-section rate and infant mortality.
With the Louisiana Medicaid program paying for almost 70 percent of births in Louisiana (the second highest Medicaid birth rate in the nation), we had a great opportunity to make improvements.
For our effort to be successful, we recognized that we could not simply use the force of State government to effect this change. Instead, we identified people and teams from throughout the state to participate. The teams represented community partners, health care consumers, advocates, public health professionals, clinicians, hospital administrators and insurers. Including professionals from each of these disciplines allowed us to take into account the complex interplay of social, behavioral, biological and genetic factors that influence birthing decisions and outcomes.
By July 2011, 20 birthing hospitals in Louisiana had pledged to participate in this voluntary initiative. By January 2012, all of the state’s hospitals where babies are delivered had pledged to work toward that goal.
The 39-week standard is not a new one. For almost three decades, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have had in place a standard requiring 39 completed weeks gestation prior to elective delivery such as a cesarean delivery or medically inducing labor.
To achieve optimal birth outcomes, hospitals must implement evidence-based best practices. While poor birth outcomes are well-documented in Louisiana, performance measurement systems to monitor the success of initiatives to improve birth outcomes are often not available outside of hospital-level reporting. Now that birthing hospitals were implementing the 39-week initiative, we needed a system to monitor improvements in birth outcomes without burdening the hospitals.
The Birth Outcomes Initiative leadership partnered with the Louisiana Hospital Association; various LDH programs including the Bureau of Family Health, Office of Vital Records and Louisiana Medicaid; private physicians and health care quality experts to find a solution.
Through this partnership, it was decided to also make changes to Louisiana birth certificates to include reasons for deliveries prior to 39 weeks.
With several other researchers, I recently co-authored a study, published by the Journal of Maternal and Child Health, on the effectiveness of this birth certificate initiative. The study reviewed more than 4,300 births in Louisiana’s largest maternity hospital. Our study found that the medical reason for early delivery listed on the birth certificate matched the reason recorded by the hospital 99.8% of the time.
The most common reasons listed for early delivery were spontaneous active labor, gestational hypertensive disorders, gestational diabetes and premature rupture of membranes. The information now contained in the birth certificate shows the hospital has all but eliminated non-medically necessary preterm births. The full study, “Public Health Data in Action: An Analysis of Using Louisiana Vital Statistics for Quality Improvement and Payment Reform,” can be found here.
The 39-week initiative has resulted in an 85 percent decrease in elective preterm births, a corresponding 10 percent decrease in NICU admission, and has proven to reduce early elective deliveries without any medical indications.