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March of Dimes Big 5 Project: Reducing Non-Medically Indicated Deliveries (NMID) <39 Weeks

More than 30 years ago, the American Congress of Obstetricians and Gynecologists (ACOG) created guidelines advising obstetricians against elective deliveries without medical indications before 39 weeks gestation in order to improve the health outcomes of babies. According to ACOG, the last few weeks of a healthy pregnancy are necessary for the full development of some vital organs, such as the brain and lungs. Despite these guidelines, NMID <39 weeks gestational age steadily had been increasing in the United States by 2010 – with variability in the rates of such deliveries ranging from 5 - 40+%. At that time, the March of Dimes (MOD) decided to create a national collaborative comprised of the five most populous states – Florida, California, Texas, New York and Illinois – and to focus the Big 5 Collaborative’s first quality improvement (QI) initiative on eliminating NMID <39 weeks.

With a seed grant from the MOD to represent Florida, the FPQC focused its efforts on recruiting hospitals and educating practitioners. The FPQC and the MOD partnered to aid the efforts of six Florida hospitals in the Big 5 Hospital QI Project, a year-long pilot test of the “California Maternal Quality Care Collaborative Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age” toolkit. The goal of the project was to change hospital policies and procedures to avoid scheduling these types of inductions or cesareans. To monitor project outcomes, data were collected on live births that were singleton, Florida residents and “term” pregnancies (370/7 – 386/7) with no medical conditions prior to or during pregnancies.

Each hospital was responsible for gathering together a QI team with a physician champion, nurse leader, scheduler and staff member. Without existing protocols in place, the hospitals’ QI teams were trained by the FPQC with the MOD on how to implement the California toolkit. Training included:
  1. Establishing consistent policies and procedures for scheduling guidelines
  2. Creating a uniform scheduling form
  3. Applying a “Hard Stop” policy process
  4. Collecting and inputting data accurately into the MOD national web data portal

The FPQC also coordinated Grand Rounds and other educational and promotional opportunities to help gain more staff buy-in.

Between January and December 2011: The hospitals input their de-identified data from the scheduling forms into the data portal. Improvement was monitored by each hospital through monthly and quarterly reports as well as monthly phone calls with the MOD and the FPQC to check individual progress, compare status against others, share new ideas for enhancements and discuss challenges and opportunities.

The project was extremely effective, and the results were published by the MOD at the national level. To access the abstract for "A Multistate Quality Improvement Program to Decrease Elective Deliveries Before 39 Weeks Gestation," please click here.

The success of the project attracted the interest of the Florida Hospital Association (FHA) and others. With continued funding from the MOD and new funding from the FHA, the FPQC has started a current project expanding the initiative on eliminating early elective deliveries (EED) through the Health Engagement Network (HEN) to more Florida hospitals.

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