Reduction in cesarean delivery rates following a state collaborative in Maryland

Abstract

Objective High rates of cesarean delivery in the United States are a cause of urgent concern as cesarean delivery is associated with increased risks for maternal morbidity and mortality. The national Alliance for Innovation in Maternal Health (AIM) program encourages state perinatal collaboratives (PQCs) to adopt a bundle of interventions to reduce cesarean deliveries. In June 2016, Maryland’s PQC became one of the first to implement the AIM cesarean bundle. The objectives of this study are to describe the implementation of bundle practices at Maryland hospitals and to evaluate the impact of the collaborative on cesarean delivery rates.

Study Design Thirty-one of the 32 birthing hospitals in the state participated in the 30-month collaborative. Quality improvement leaders from each hospital completed an endline survey reporting implementation status of 26 bundle practices. Differences in state-level cesarean rates at baseline (January to June 2016) and endline (January to June 2019) were calculated from vital statistics data for 30 hospitals and tested for significance using chi-squared tests.

Results On average, hospitals reported 8.2 bundle practices (range: 0, 23) in place prior to the collaborative and fully-implementing an average of 4.8 new practices (range: 0, 17) during the collaborative. The clinical practices with highest reported implementation were standardized assessment of fetal heart rate and standardized induction scheduling (80.6% of hospitals each); the lowest was integration of doulas into the care team (9.7%). There was a 4.8 percentage-point reduction in cesarean rates for induced nulliparous, term, singleton, vertex (NTSV) births between baseline and endline (p<0.001). Smaller significant reductions (p<0.05) in cesarean delivery rates were also observed for all births and all NTSV births (Figure 1).

Conclusion The majority of hospitals in the Maryland PQC implemented multiple new practices and the state saw a reduction in cesarean delivery rates. Few hospitals implemented all bundle practices, suggesting opportunities for further reductions with continued practice change.