Providing Safe and Appropriate Mode of Delivery: Decreasing Unnecessary Cesarean Sec:ons in Brazil 1
C- Sec)on rates Brazil private sector 85% 2
Yes, We have a problem In 2013 2100 women died Prematurity is increasing 3
The birth of the Collabora)ve Natural Birth Before 2012, 1 demonstra)on project to reduce CS rates private sector Public prosecutor sued ANS Brazilian Regulatory Agency for Health Private Sector First Pilot 2012 using Model of Improvement Unimed Jabo)cabal from 0% to 40% NB in 9 months 3 more ci)es with same results 4
Pilot Project 2012 Jabo)cabal City, SP No reimbursement for CS Empower women Nurses added to teams ShiVs NICU admissions 60% reduc)on Increasing the percentage of vaginal birth in the private sector in Brazil through the redesign of care model: Rev Bras Ginecol Obstet. 2015; 37(10):446-545 Borem P, Ferreira JB, Silva UJ, Valério Júnior J, Orlanda CM
IHI Breakthrough Series (18 Months Time Frame) Topic: Reduce C- section Expert Meeting Develop Framework & Changes Planning Group LS Learning Session AP Action Period Participants (10-100 Teams) Prework LS 1 A P S D A P S D LS 2 LS 3 LS 4 AP 2 Supports Email Phone Conferences Extranet Visits Assessments Sponsors AP 1 Monthly Team Reports A LS 5 P S *AP3 continue reporting data as needed to document success D AP3* Dissemination Publications, Congress, etc. Holding the Gains 6
Mission Projeto Parto Adequado - PPA (42 hospitals from private and public sector) AVer 18 months we expect 1. Reduce maternal and neonatal morbidity 2. Reduce the gap between scien:fic evidence and the obstetric prac:ce in Brazil safely increase the percentage of vaginal deliveries 3. Improve the experience of care (safety care, )meless, efficient, effec)ve, equitable and focused on the needs of families and community) 4. Implementa)on of best prac)ces to assist vaginal delivery 5. Reduce per capita costs of maternal and child care 7
The PPA Project Who are the 42 hospitals? Well distributed countrywide Some figures Hospital had to have CS rate > 75%. In average 80.9% The 42 hospitals represent 85.185 deliveries year and 6% in Brazil 8 8
Primary drivers Secondary drivers Change concepts Aim Promo:ng Healthier Moms and Babies by achieving 40% of Natural Child Birth by September 2016 1. Coali)on of major stakeholders aligned around primacy of safe mother, safe baby 2. Empower pregnant women and their families to choose the care that is right for them (ensure readiness for NB Leaders, champions, front line with the skills to do con)nuous improvement Educate senior leaders, providers, community and pa)ents about the benefits of normal physiologic birth. New contract between health plan/hospital crea)ng incen)ves for quality, safety and NB Protocols and standardiza)on for perinatal care Confident and competent caregivers who can support 3. New care model natural birth Physical space redesign (Adequate ambiance for NB) to accommodate Suppor)ve environment for clinicians promotes joy in 3. New care model to accommodate work Invest resources the to conquer longer healthy work environment )me the longer )me frame of normal physiologic birth 4. Data systems that support learning Alignment of financial incen)ves Hospitals and Health Plans 1. Coali)on of major stakeholders aligned around Drive change and remove barriers to create a learning and culture improvement quality and safety Shared care for each mother- child unit Well trained team to assist the deliveries frame of normal physiologic Team assist birth all pregnancy phases Reliable implementa)on of best clinical prac)ce, Protocols and standardiza)on for delivery and postpartum Select measures to reflect quality and safety New contract between payers and providers crea)ng incen)ves for quality and safety Engaged, ac)vated community expec)ng best, safest care Ac)vate the community 2. Empower Adequate pregnant informa)on, based on evidence women to support the Educate and instruct their families and pregnant families women to new care to best choice model Co- design and shared decision Public Campaigns choose the care that is right for them (ensure The intangible aspects of being a mother - deligh)ng the pregnant women Retake ownership of labor and families readiness for NB Perinatal redesigning Transparency Listening to mother and families Establish some quality and safety measures, report them to the providers 4. Data systems that support learning Establish some quality and safety measures, report them to the general public Create the capability to collect reliably informa)on to generate the measures and results 9
Change Package Leaders, champions, front line with the skills to do con)nuous improvement New contract between payers and providers crea)ng incen)ves for quality and safety Ac)vate the community Educate and instruct families and pregnant women to new care model Listening to mother and families Co- design and shared decision Physical space redesign (Adequate ambiance for NB) Well trained team to assist the deliveries Team assist all pregnancy phases Protocols and standardiza:on for delivery and postpartum Establish some quality and safety measures, report them to the providers Create the capability to collect reliably informa:on to generate the measures and results 10
Preliminary results Fom 18% to 28% in 4 months Percentage of Natural Birth 42 hospitals Gráfico de C ontrole: % partos vag inais g eral (totalizado) 0.30 2014 2015 Proportion 0.28 0.26 0.24 0.22 90% of hospitals increased NB 1 1 1 UCL= 0.2880 _ P= 0.2451 0.20 0.18 Project started 1 st LS LCL= 0.2022 0.16 jan/2014 mar/2014 mai/2014 jul/2014 set/2014 no v/2014 jan/2015 mar/2015 mai/2015 j ul/2015 set/2015 Tests performed with unequal sample sizes Mês 11
Learnings What s:ll needs to be done Too many changes Community engagement s)ll crawling Worked well: Collabora)ve model and a bold Aim Having the Regulatory body involved Right Coali)on Teams engagement 12
Next steps 2017 and beyond: A second wave of hospitals Improve community engagement Publish and Celebrate results As health system, we are s:ll in debt to our pregnant women and babies..but 13
there is hope 14