Public Comment: Support of MUC18-52 Cesarean Birth

Submitted to NQF Hospital MAP by Maternal Safety Foundation

January 10, 2018

The Maternal Safety Foundation, an NQF consumer member organization, supports the implementation of MUC18-52 Cesarean Birth (CB) in IQR and the CMS EHR Incentive Program. We are submitting this comment to address MAP’s concerns and fears of negative unintended consequences documented in the Hospital IQR Program final report.

MUC18-52 (also called the NTSV Cesarean Birth Measure or PC-02) measures a specific subset of patients (nulliparous patients with term, singleton, vertex pregnancies without a placenta previa) whose outcomes are shown to be largely influenced by physician factors, rather than patient characteristics or obstetric diagnoses. Over 60% of hospital variation in NTSV patients can be attributed to first birth labor induction rates and first birth early labor admission rates.

As a consumer/patient organization, we consider a robust measure that illuminates practice variation among providers and facilities to be very valuable for comparing hospitals and for holding providers accountable. The addition of Unexpected Newborn Complications (NQF #716) to The Joint Commission’s Perinatal Core Measure Set beginning January 1, 2019, will serve as a balancing measure to the current delivery measures. Whereas there is little further room for improvement in Early Elective Delivery rates, reducing unwarranted practice variation and curbing overuse of medically unnecessary cesarean births--both primary and repeat—as well as ensuring that patients have access to risk-appropriate care remain top public health priorities.

MAP’s question about whether or not measuring CB rates directly relates to improved maternal health outcomes seems to originate from a discussion that “some states” have seen “unintended consequences that may arise such as increased maternal mortality with decreased CB rates.”

Research shows that the NTSV cesarean rate can be quickly lowered with no adverse maternal or infant outcomes. In fact, they fared better in a 2015 California Maternal Quality Care Collaborative three-hospital pilot program. While implementing a quality improvement program to lower NTSV cesarean rates, data were collected for NTSV cesarean births and balancing measures, including the NQF Unexpected Newborn Complications measure (now TJC’s PC-06) and 3rd/4th degree maternal lacerations occurring in vaginal births. The hospitals in the pilot program averaged a 18.6% reduction in their NTSV. Newborn complications fell (significantly) by 24.5% and 3rd/4th degree lacerations dropped by 4.7%.

With regards to MAP’s suggestion that the NQF Scientific Methods Panel and Perinatal Standing Committee pay special attention to risk adjustment, exclusions, and unintended consequences (full-disclosure: I am a new member of the Perinatal and Women’s Health Standing Committee), the cesarean birth measure in question was just re-endorsed as one of NQF’s Perinatal and Women’s Health measures in 2016 with 96% of the committee supporting the measure, and The Joint Commission is now the steward of the measure. This measure and its exclusions have already undergone recent rigorous review by the appropriate NQF committees.

We apologize for late involvement with this, as we learned that CB was up for discussion by MAP just prior to the final meeting on December 11, 2018. In mid-2018, the same measure was being discussed by the MAP Rural Health Workgroup measure, with the committee recommending that it not be included due to concerns about low-volume in critical access and rural hospitals. We ran some numbers and found that the majority of rural hospitals with maternity services meet TJC’s reporting threshold of 300 births and asked that the committee please ensure that their decision was data-driven. PC-02 was changed to a “yes” for recommendation as a rural-relevant measure with a caveat that low volume should be taken into consideration.

The cesarean section is the most commonly performed surgery in the United States, and pregnancy accounts for almost 25 percent of all hospitalizations. Overuse of cesarean births is a significant contributor to both short-term and long-term maternal morbidity as well as maternal mortality and we as consumer/patient advocates strongly recommend the implementation of MUC18-52 Cesarean Birth (CB) in IQR and the CMS EHR Incentive Program.

Sincerely,

Jill Arnold

Executive Director, Maternal Safety Foundation

MAP Final Report published December 21, 2018

Public Comment: Healthy People MICH-2030-06

Submitted to U.S. Department of Health and Human Services (HHS) by Maternal Safety Foundation

January 8, 2018

MICH-2030-06: Reduce cesarean births among low-risk women with no prior births

Our organization is submitting a comment to recommend that Healthy People 2020’s MICH 7.2, or “Reduce cesarean births among low-risk women giving birth with a prior cesarean birth,” carries forward as a Healthy People 2030 objective. With sub-objectives not outlined in the proposed objectives, we wanted to express our support of including the low-risk repeat cesarean/VBAC objective for 2030.

This objective meets all five criteria required to continue as a Core Objective. The reliable, nationally representative data source is the Centers for Disease Control National Center for Health Statistics. The same effective, evidence-based interventions used to safely lower NTSV cesarean rates by promoting vaginal birth apply to any vaginal birth, even those occurring after a previous cesarean. Recently updated professional guidelines from the American College of Obstetricians and Gynecologists affirm that any hospital that can offer maternity services which include the capacity to perform an emergency cesarean are also capable of offering a trial of labor after previous cesarean (TOLAC) to most patients with one or two previous cesarean births.

Our organization’s preliminary analysis of hospital VBAC data for one-third of the country’s roughly 3000 hospitals with maternity services show that only half make VBAC routinely available, which disproportionately impacts patients in rural areas. Families with the financial means to do so may choose to stay in a hotel in a city where TOLAC is available to them until they go into labor. However, without safe, accessible, risk-appropriate options for vaginal birth accessible, most patients who want a vaginal birth are confronted with the decision to seek an alternative to medical care in a hospital for their TOLAC, such as a planned home birth, or to schedule a repeat cesarean. If repeat cesarean birth is the only option available, then these patients are being subjected to tacit coercion due to lack of safe options.

The Healthy People 2030 Advisory Committee should be made aware that the percentage of women giving birth annually is now 15.5 percent of the birthing population, or 600,000 of the 4 million births. CDC data show that the number of patients giving birth annually with a previous cesarean birth has tripled since 1980, when the estimated number was 184,000, or 5.5 percent.

Public health and quality improvement efforts have focused on preventing the first cesarean birth in first time mothers with low-risk deliveries and this rate has plateaued. However, continuing failure to provide systemic access to risk-appropriate care, inclusive of non-surgical birth options for the growing population of patients with a previous cesarean birth, leaves up to about 600,000 patients annually at risk for abnormal placentation and increased morbidity and mortality. The newly published SMFM-ACOG Obstetric Care Consensus document on Placenta Accreta Spectrum cites a 2016 study using National Inpatient Sample data which found that the overall estimated rate of placenta accreta in the United States was 1 in 272 for women with birth-related hospital discharge diagnosis.

Thank you in advance for including this objective for 2030.

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