1. Nevada Medicaid Looks at Increased Cesarean Section Rates and Early Induction of Labor Marti Coté, RN 1

2. Increased C/Section Rates As of 2007, the national cesarean section rate was 32% -- meaning about 1 in 3 moms gave birth by cesarean delivery. (National Center for Health Statistics Data Brief, March 2010) Some of the reasons cited for the increase are maternal request, medical necessity and/or provider convenience. (Declercq, et al. 2006a). In Nevada, roughly 32.3% of births are cesarean section. (National Center for Health Statistics Data Brief, No. 35 March 2010.) 2

3. Early Induction of Labor (EIOL) Of further concern is the rate of early induction of labor. In July 2009, the American Congress of Obstetricians and Gynecologists (ACOG) issued a Revision of Labor Induction Guidelines, stating, “The rate of labor induction in the US has more than doubled since 1990. In 2006, more than 22% (roughly 1 out of every 5) of all pregnant women had their labor induced. “ The revision further states, “... the ACOG recommendations say the gestational age of the fetus should be determined to be at least 39 weeks or, that fetal lung maturity must be established before induction.” 3

4. March of Dimes Toolkit The March of Dimes, the California Maternal Quality Care Collaborative, and the California Department of Public Health, Maternal, Child and Adolescent Health Division joined forces to develop a healthcare toolkit to address deliveries before 39 weeks gestation. The aim of the toolkit is to offer guidance and support to OB/GYN providers, clinical staff, hospitals and healthcare organizations in order to develop quality improvement programs which will help to eliminate elective deliveries <39 weeks gestation. 4

5. Division of Health Care Financing and Policy Response The Division of Health Care Financing and Policy (DHCFP) is dedicated to creating awareness of the latest findings regarding elective Cesarean sections and Early Induction of Labor for both healthcare providers and recipients. 5

6. DHCFP Proposed Solution Reduce the number of primary Cesarean sections Reduce the number of elective Cesarean section Reduce the number of early inductions of labor Reduce the number of infants requiring care in the NICU by creating awareness of the recent findings for both healthcare providers and recipients. 6

7. DHCFP Objectives Reduce the number of primary and elective Cesarean sections  As of March 2012, Nevada Medicaid will pay the lower rate of vaginal delivery for any elective C/sections.  Elective C/sections will be determined according to diagnosis code and/or records review.  Recipients will be given information regarding elective C/sections. 7

8. Nevada Medicaid Objectives, cont. Reduce the number of early inductions of labor (EIOL)  Providers will be given information (i.e. March of Dimes toolkit) on the risks of EIOL.  Recipients who are pregnant will be given information regarding the risks of EIOL and the importance of discussing with their health care provider. 8

9. Nevada Medicaid Objectives, cont. Reduce the number of infants requiring care in the NICU as a result of the above.  Through education, information and outreach to providers (physicians and hospitals) and recipients regarding elective C/sections and early induction of labor, Nevada Medicaid will see a decrease in the number of infants requiring neonatal intensive care. 9

10. Nevada Medicaid Review Approximately a year from the start of implementation of the new policy, Nevada Medicaid will gather data and review the findings. Policy will be updated and/or amended according to those findings. 10