Statewide Strategy to IMprove perinatal care and reduce early elective deliveries

city match abstract submission

Presenter/Author Information


Thomas Evans, MD
Iowa Healthcare Collaborative
Meg Nugent, MHA, RN
Director, Clinical Strategies
Iowa Healthcare Collaborative
100 E Grand Ave, Suite 360
Des Moines, IA 50309
(515) 283-9330
Ryan Meyer, MHA
Director, Operations
Iowa Healthcare Collaborative


Presentation Title:
Statewide Strategy to Improve Perinatal Care and Reduce Early Elective Deliveries

Induction of labor before 39 completed weeks poses serious risks compared to full term babies. Premature infants have an increased mortality risk, a higher chance of being admitted into neonatal intensive care units, increased need for ventilator support and higher risk of developing bloodstream infections.

In November 2011, the March of Dimes Premature Birth Report Card graded Iowa a C with a 11.3% preterm birth rate. During this time, Iowa experienced a rising cesarean section rate (18% in 1995 to 27% in 2011) and continued lack of improvement in other OB quality metrics.

In spring 2012, the Iowa Department of Public Health requested assistance from CDC to conduct an epidemiologic investigation. This investigation demonstrated the knowledge gap of Iowa clinicians related to current guidelines associated with EED.

Iowa’s healthcare system reflects its rural geography. Ninety of Iowa’s 118 community hospitals are classified by Medicare as Rural, with 82 licensed as Critical Access Hospitals.

By implementing this statewide strategy, the goal is to address safety concerns for mothers and babies.

IHC, in collaboration with partners, implemented a rapid improvement campaign on June 6, 2012. In committing to the Partnership for Patients (PfP), the 84 birthing HEN hospitals analyzed their current performance and conducted operational and leadership surveys. The campaign provided the structure for the hospitals and engaged providers to reduce non-medically indicated EED. Hospitals demonstrated improvement by implementing “hard stop” policy. This project focused on several tactics to achieve results:

  • Engaging physicians and leadership on the standard of care
  • Strategies to routinely collect and utilize data to drive change
  • Rapid deployment of tools and spread of best practices by utilizing the IHI Breakthrough Series model through conferences, web-based toolkits and webcasts
  • HEN Improvement Advisers worked on-site with hospitals to equip and coach through the improvement cycle
  • Led development of Iowa Statewide OB Task Force  


  • EED rate dropped from 7.55% in May 2012 to 0.71% in September 2013
  • 83 of 84 birthing hospitals currently have hard stop policy
  • Iowa State Wide Plan for Obstetrical Care approved
  • Development of hospital capability to collect and report monthly EED performance data to IHC through PfP Database and validated with IDPH NMI Early Term Delivery Reports. IHC utilizes State Inpatient Database to analyze claims and publicly report AHRQ PSIs 17, 18 and 19.


  • Physician engagement
  • Common messaging ? Rural access to OB care
  • Loss of rural physician work force

Lessons learned:
IHC has utilized the campaign model to be one of the most impactful rapid-cycle initiatives able to affect meaningful change. By combining this approach with education, deployment of best practice policies and collaboration of key stakeholders sharing common messaging, IHC has found significant results in EED reduction.

Information for Replication:
Development of key partnerships and common messaging from all agencies providing education and information on obstetrical care.

Key partners include:
Iowa Department of Public Health
Iowa Medicaid Enterprise
March of Dimes
Iowa Hospital Association
University of Iowa Healthcare

Presentation Date: August 2013 – Los Angeles, California