Getting to Zero: Sustained Efforts Needed to Eliminate Early Elective Births Among Medicaid Beneficiaries

by | Dec 15, 2014 | Maternal Health

Early elective delivery (EED) — defined as a delivery before 39 weeks of gestation without medical necessity — places women and babies at risk for harm, offers no benefits to either, and increases costs for taxpayers and for women and their families. Recent efforts to reduce EED rates to five percent or less of all deliveries have been largely successful, yet there is more work to be done as some hospitals and states are still struggling to reduce their rates.

Childbirth Connection Programs at the National Partnership for Women & Families congratulates Mary Applegate, MD, and Jeff Schiff, MD, Medicaid Medical Directors in Ohio and Minnesota respectively, and colleagues at AcademyHealth for their new study. It reports results of the first multi-state perinatal quality improvement project led by Medicaid Medical Directors to reduce the rates of non-medically indicated inductions and cesarean sections before 39 weeks’ gestation among Medicaid beneficiaries. With Medicaid paying for more than 48 percent of births in the United States each year, including 1.8 million births in 2010, this study is a huge contribution to the field, providing important information to Medicaid agencies, the Centers for Medicare and Medicaid (CMS), hospitals, policymakers and others committed to continuing efforts to improve birth outcomes for women and babies and reduce costs.

Twenty-two states representing about half of births covered by Medicaid participated in the study. This work was funded by the Agency for Healthcare Research and Quality, CMS, and the Health Resources and Services Administration, all of which have prioritized efforts to reduce EEDs. Key findings include:

  • In the participating states, 32.3 percent of Medicaid singleton births in 2011 (or the most recent year with available data) were elective, and 8.9 percent were early elective deliveries. These results suggest that nationally about 160,000 births covered by Medicaid were EEDs.
  • EED rates among participating states ranged from 2.8 percent to 13.7 percent, although individual state rates were not identified.
  • Elective cesarean deliveries were more common than elective inductions before 39 weeks of gestation.
  • Babies who experienced EEDs were more likely to be transferred or admitted to neonatal intensive care units than babies electively born at 39 weeks or beyond.
  • Of the 22 participating states, 18 had implemented programs and policies to reduce EEDS, including quality improvement initiatives, consumer and clinician education, financial disincentives, and “hard stop” policies developed in partnership with hospitals that prohibit scheduling of EEDs without documentation of medical need.

Despite sustained efforts over many years to reduce the rate of EEDs, they still occur too frequently, including among Medicaid beneficiaries. Statewide variation in EEDs, and an average rate well above the aim of zero, point to the need for concerted efforts to eliminate early elective deliveries to improve the health of mothers and babies.

This year’s multi-stakeholder Maternity Action Team, convened by the National Quality Forum to support the Partnership for Patients, issued a timely Playbook for the Successful Elimination of Early Elective Deliveries with proven strategies and resources to help bring the national EED rate close to zero.

The campaign to eliminate EEDs has given many in the maternity care community the experience and satisfaction of successful work to improve the quality of maternity care. Following this year’s consensus recommendations on Safe Prevention of the Primary Cesarean Delivery from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, consensus appears to be building about the next big maternity care QI (quality improvement) focus: reining in the unwarranted runaway cesarean rate — a longstanding goal of the advocacy community. Childbirth Connection Programs at the National Partnership for Women & Families stands ready to support this work and has many cesarean reduction resources for women and others.