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Strengthening the evidence base for maternal and child health programs

New: MCH Best strategies database for sample ESMs

Evidence Tools
MCH Best. NPM 2: Low-Risk Cesarean Delivery

MCH Best Logo pregnant woman reviewing a chart with a doctor

Strategy. Multicomponent: Active Management of Labor + Chart Audit and Feedback + State/National Guidelines

Approach. Support providers in active management of labor using oxytocin infusion + support the development of an elective induction policy + develop state goal for low-risk cesarean section rate.

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Overview. Implementation of a "nine-item list" including obstetrical skills training, improved teamwork, and public promotion of the strategy, decreased cesarean section rates for nulliparous women by 9% over a 9 year period.1

Evidence. Emerging. Adding population-based components to interventions (such as state/jurisdictional/national guidelines) may support the effectiveness of local interventions, as compared to interventions implemented in those categories alone. This strategy has been tested more than once and results trend positive overall. Access the peer-reviewed evidence for active management of labor through the MCH Digital Library. Access evidence for chart audit and feedback. Access evidence for state/national guidelines. (Read more about understanding evidence ratings).

Target Audience. Provider + hospital + state/national.

Outcome. Reduction of primary cesarean delivery rates among nulliparous women. For detailed outcomes related to each study supporting this strategy, click on the peer-reviewed evidence link above and read the "Intervention Results" for each study.

Examples from the Field. There are currently XXX ESMs across all states/jurisdictions that use this strategy directly or intervention components that align with this strategy. Access descriptions of these ESMs through the MCH Digital Library. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Using the approach “Support providers in active management of labor using oxytocin infusion + support the development of an elective induction policy + develop state goal for low-risk cesarean section rate,” here are sample ESMs you can use as a model for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies):

Quadrant 1:
Measuring Quantity of Effort
("What/how much did we do?")

  • Number of women receiving oxytocin in active labor in a hospital that meets state goals and utilizes an elective induction policy that includes chart audit.

Quadrant 2:
Measuring Quality of Effort
("How well did we do it?")

  • Percentage of women receiving oxytocin in active labor in a hospital that meets state goals and utilizes an elective induction policy that includes chart audit.

Quadrant 3:
Measuring Quantity of Effect
("Is anyone better off?")

  • Number of women who deliver vaginally after receiving oxytocin in active labor in a hospital that meets state goals and utilizes an elective induction policy that includes chart audit.

Quadrant 4:
Measuring Quality of Effect
("How are they better off?")

  • Percentage of women who deliver vaginally after receiving oxytocin in active labor in a hospital that meets state goals and utilizes an elective induction policy that includes chart audit.

Note. ESMs become stronger as they move from measuring quantity to measuring quality (moving from Quadrants 1 and 3, respectively, to Quadrants 2 and 4) and from measuring effort to measuring effect (moving from Quadrants 1 and 2, respectively, to Quadrants 3 and 4):

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.


Reference:

1 Blomberg M. Avoiding the first cesarean section-results of structured organizational and cultural changes. Acta Obstet Gynecol Scand.2016;95(5):580-586. doi:10.1111/aogs.12872.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.