Title V Transformation Tools
Recommendations to Support NPM 2 – Low-risk Cesarean Delivery
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Significance. The Title V Maternal and Child Health Services Block Grant to States Program guidance1 defines the significance of this NPM as follows:
Cesarean delivery can be a life-saving procedure for certain medical indications. However, for most low-risk pregnancies, cesarean delivery poses avoidable maternal risks of morbidity and mortality, including hemorrhage, infection, and blood clots— risks that compound with subsequent cesarean deliveries.
Much of the temporal increase in cesarean delivery (over 50% in the past decade), and wide variation across states, hospitals, and practitioners, can be attributed to first-birth cesareans. Moreover, cesarean delivery in low-risk first births may be most amenable to intervention through quality improvement efforts. This low-risk cesarean measure, also known as nulliparous term singleton vertex (NTSV) cesarean, is endorsed by the ACOG, The Joint Commission (PC-02), National Quality Forum (#0471), Center for Medicaid and Medicare Services (CMS) - CHIPRA Child Core Set of Maternity Measures, and the American Medical Association-Physician Consortium for Patient Improvement.
Background. The Maternal and Child Health Bureau (MCHB) Title V Maternal and Child Health Services Block Grants to States Program has established 15 National Performance Measures (NPMs) for the 2015-2017 grant cycle. In order to effectively address the NPMs, MCH professionals need to think about not only the evidence and strategies to make change, but also the capacity of the workforce to carry out these activities. These lists identify online learning materials, resources, and evidence-based strategies and programs to support the knowledge sets and skills needed to advance each NPM.
Introduction. Six skill sets have been identified by the National MCH Workforce Development Center to support implementation of this NPM: (1) population health; (2) strategic planning and program design; (3) strategic alliances and effective partnerships; (4) consumer engagement and cultural and linguistic brokering; (5) policy and program implementation; and (6) communication.
In addition, a knowledge areas specific to the NPM topic area have been highlighted that are keyed to the evidence base and promising practices: cesarean delivery background, recommendations, and guidelines.
The MCH Navigator, in collaboration with the Center, has developed this crosswalk to guide MCH professionals to online learning opportunities and implementation resources to support these skill sets.
Please click on the Read More buttons below for additional information, learning materials, and implementation resources. You can also email us with suggestions for additions.
Six skill sets have been identified to support implementation of this NPM:
1. Population Health
A renewed focus on MCH population health is key to achieving the NPMs in the era of health transformation. These skills enable Title V professionals to analyze how program interventions and their related health outcomes are distributed among a state’s MCH population. Population health skills complement all of Title V’s work, including program design and implementation, strategic partnerships and communication.
- Ability to conduct surveillance of low-risk cesarean delivery first births that allows public health practitioners to understand and respond to disparities in trends regarding cesarean deliveries among low-risk first births
2. Strategic Planning & Program Design
Effective strategic planning and program design require the ability to base programs on defined goals and desired outcomes. Strategic planning should include a monitoring and evaluation system to track and monitor progress and inform program alterations as needed. Program design skills must ultimately be coupled with implementation, where program design is carried out.
- Skills to implement evidence-based “train the trainer” models that use clinician champions to train other providers
- Skills in quality improvement to support providers and health systems to make data-informed decisions
- Skills to effectively align Title V initiatives related to low-risk cesarean deliveries and perinatal regionalization activities
3. Strategic Alliances & Effective Partnerships
The wide array of stakeholders and partners in the field of MCH, from providers and insurers to women and children, require a set of skills in strategically aligning Title V goals with those of their partners. In the Title V world, there is an increasing interest in engaging unlikely or nontraditional partners to achieve the NPMs. The skills in this category take that into account and include unique partner groups linked to this measure.
- Ability to effectively collaborate with March of Dimes and state/territory perinatal quality collaboratives to decrease rates of low-risk cesarean deliveries
- Ability to provide public health support for health systems to conduct quality improvement initiatives designed to decrease low-risk cesarean deliveries
- Ability to align low-risk cesarean delivery activities with perinatal regionalization initiatives
- Ability to foster collaboration between public and private health care providers in low-risk cesarean delivery
4. Consumer Engagement/Cultural & Linguistic Brokering
Consumers are arguably the most important stakeholders in MCH work, thus skills in consumer engagement and cultural and linguistic brokering are essential to moving the needle for each NPM. In some cases, consumer engagement includes negotiating with other stakeholders on behalf of MCH populations. Closely linked with this skills category are skills in communication and strategic alliances.
- Skills to identify and involve women of childbearing age in development of program and policy efforts
- Ability to engage women and their families as advocates for policy change
- Skills to empower women and those that influence them to make decisions about their deliveries
5. Policy & Program Implementation
These skills ensure that MCH priorities are integrated into all aspects of policy and program implementation, as well as ensuring that policies and programs selected are well-aligned with NPMs and other MCH program goals. Implementing policies and programs with fidelity also requires skills in the implementation science drivers: technical and adaptive leadership; selection; training; coaching; systems intervention; facilitative administration; and decision support data systems.
- Skills to set up new agreements that include the minimum of what each agreement should include from a Title V perspective
- Ability to determine legal authority behind existing memoranda of understanding with governmental agencies
- Skills to develop memoranda of understanding with Medicaid and other payers to develop policies that address use of cesarean deliveries in low-risk first deliveries
- Ability to understand options available to draw down Medicaid administrative match for Title V programs
- Skills to negotiate health system and payer incentives to align with cesarean delivery goals
- Skills to develop or edit delivery protocols for medical indications for hospital systems
- Skills to ensure evidence-based regulations and guidelines are disseminated to health systems and physician practices
Communication skills support the creation and delivery of effective messages between MCH professionals, professional and community partners, and populations served by Title V. Effective communication ensures the delivery of appropriate messages to audiences in the way that they were intended and is key to all aspects of MCH work. These skills are linked closely with skills in strategic partnerships and cultural and linguistic brokering.
- Ability to effectively communicate the risks of cesarean delivery to pregnant women so they can make fully informed delivery decisions
- Ability to communicate with professional associations to ensure best practices are communicated to physician groups
In addition to skills, each NPM requires a knowledge base that will help Title V progress effectively in the measure. Knowledge should be considered at the foundation of achieving all measures.
1. Cesarean Delivery Background & Guidelines
- Knowledge of definition of low-risk first birth
- Knowledge of low-risk first birth prevalence
- Knowledge of cesarean birth prevalence
- Knowledge of prevalence and trends of cesarean deliveries among low-risk first births
- Knowledge of health risks and costs of cesarean delivery among low-risk first time births
- Knowledge of risk factors for early labor induction
- Knowledge of current guidelines for cesarean delivery among low-risk first births
See other online learning resources related to health transformation, collected in the Health Transformation Learning Laboratory.
1 Health Resources and Services Administration. 2014. Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, Appendix F, p. 75.