The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Category: Value Coalition Campaigns

Improving Maternal and Neonatal Outcomes through the Obstetrics Initiative

Nina Bobowski, MPH is the Obstetrics Initiative Project Manager

One in three women who give birth in the United States deliver by cesarean. Cesarean delivery can reduce morbidity and be life-saving for mother and baby, but it is associated with higher rates of complications and higher costs than vaginal delivery. Rates of cesarean delivery, both nationally and in Michigan, increased 50% between 1997 and 2008[1]. High rates of cesarean delivery are an increasingly recognized patient safety concern. Blue Cross Blue Shield of Michigan (BCBSM) has invested in this effort through a statewide initiative to safely reduce the use of cesarean delivery where appropriate.

At the November 2017 collaborative-wide meeting, MVC hospitals were introduced to the new Obstetrics Initiative (OBI). OBI is part of BCBSM’s Value Partnership collaborative quality initiative (CQI) program and is closely partnered with MVC. OBI is a physician-led initiative quality improvement project addressing variation in obstetric care, specifically supporting vaginal birth and safely reducing cesarean delivery.

OBI was established to help Michigan become a national leader in improving the quality of maternity care.  Cesarean delivery rates are an important quality issue for patients and maternity clinicians alike.  OBI’s first initiative is safely lowering the cesarean section rate among low-risk patients.

How can your hospital benefit from joining the Obstetrics Initiative?

OBI provides the framework to leverage the data available in MVC to determine your hospital’s cesarean delivery and vaginal delivery rates for “low”[2] and “non-low” risk groups, and to assess maternal and fetal outcomes with proper risk adjustment. There is no one strategy to address all practice patterns around the use of cesarean delivery but engaging in discussion regarding these data is a critical step in understanding why such variation exists and how we can respond. The significant variation in cesarean delivery rates across hospitals suggests that there is an opportunity to reduce use of cesarean section.

OBI catalyzes quality improvement efforts in three key ways.

  1. OBI provides an Obstetrics Report ( to help you understand how your hospital’s vaginal and cesarean delivery rates compare to peer hospitals across the state.
  2. OBI will offer technical support to help your hospital implement strategies to safely lower the cesarean rate.
  3. OBI will engage hospitals in peer-to-peer quality improvement efforts, so we can all benefit from each other’s successes.

Based on prior successes in state-wide obstetric quality collaboratives[3], we are confident that these three activities can help us improve the quality of obstetric care for the women and families we serve.

What does the Obstetrics Report show my hospital?

OBI is excited to provide resources to support your obstetric quality improvement efforts.  The OBI Reports ( provide rich data to understand your hospital’s cesarean delivery and vaginal delivery rates for “low” and “non-low” risk groups of patients[4], and to assess maternal and fetal outcomes after adjusting for your patient population. These reports can also help hospitals monitor maternal and neonatal outcomes after implementing interventions to improve maternity care quality and support vaginal birth.

How can your hospital participate in the Ob Initiative?

Become an obstetric champion at your hospital for the Ob Initiative. Both nursing and physician champions are core components of successful implementation and leading culture change. Nursing champions play a central role in testing, implementing, coordinating, and disseminating clinical practice refinement and changes. Physicians and midwife champions are particularly important as they make the definitive diagnostic and treatment decisions.

Supported by OBI, these champions will enable peer-to-peer Michigan hospital efforts regarding rates of vaginal and cesarean delivery as well as maternal and neonatal outcomes. OBI will engage these champions and hospital stakeholders in understanding and effectively utilizing their Obstetrics Report to improve safe birth practices.

OBI will:

  • Engage champions and hospital stakeholders in understanding and effectively utilizing their Obstetrics Report to improve safe birth practices;
  • Initiate hospital site visits and workgroups to identify root causes of variation and opportunities for improvement in obstetric care;
  • Support hospitals to develop their own site-specific goals with regards to obstetric care, specifically around safely reducing cesarean births and supporting vaginal births; and
  • Identify and support dissemination of strategies shown to promote vaginal births and reduce cesarean delivery rates for low-risk births while working toward the goal of safe delivery practices with continued good outcomes for infants and women.

Please join us as we work together to improve safe delivery practices across the state.

If you would like more information about OBI or are interested in participating, please contact the OBI Project Manager, Nina Bobowski at


[1] E.L. Barber, L.S. Lundsberg, K. Belanger, C.M. Pettker, E.F. Funai, J.L. Illuzzi. Indications contributing to the increasing cesarean delivery rate Obstet Gynecol, 118 (2011), pp. 29-38

[2] Armstrong JC, Kozhimannil KB, McDermott P, Saade GR, Srinivas SK. ; Society for Maternal-Fetal Medicine Health Policy Committee. Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures. Am J Obstet Gynecol 2016; 214 (02) 153-163


[4] Armstrong JC, Kozhimannil KB, McDermott P, Saade GR, Srinivas SK. ; Society for Maternal-Fetal Medicine Health Policy Committee. Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures. Am J Obstet Gynecol 2016; 214 (02) 153-163


MVC Goals and Mission for 2018: Value Coalition Campaigns

Jim Dupree

Jim Dupree, MD, MPH is the Director of MVC

At the start of the new year, I would like to share with you our thoughts and discuss our collaborative goals for 2018. As always, the Michigan Value Collaborative (MVC) Coordinating Center will continue to support MVC hospitals in their missions to improve patient care, and in 2018, we aim to achieve even more.

We discussed our 2018 goals at the November 3rd collaborative-wide meeting. We referred to these targeted goals as the Value Campaign Coalitions (VCCs) since they aim to increase health care value in Michigan.  We updated these VCC in response to your subsequent feedback, and you will be hearing more about them during our April 20th, 2018 collaborative-wide meeting.

Here, I would like to take a moment to explain what the VCCs are, why these goals were chosen, and how we hope to move forward.

What are the 2018 VCCs?   

  1. Optimizing post-discharge care utilization after joint replacement surgery. Most patients can be safely discharged home after elective lower extremity joint replacement, yet the use of inpatient post-acute care after arthroplasty varies widely around the state. The goals of this campaign are to identify opportunities to reduce low-value care after discharge and learn from hospitals that have safely identified patients who do not require inpatient rehabilitation and skilled nursing.
  2. Improving population-based disease management for chronic conditions.  After the November meeting, many MVC hospitals expressed strong interest in population-based disease management.  Chronically-ill patients often have high episode payments and require complex treatment.  Many hospitals are already focusing on improving in-hospital CHF care. Bringing these concepts together, MVC aims to help hospitals identify high-use CHF patients and better manage CHF in their population.
  3. Supporting vaginal birth and safely reducing cesarean delivery for low-risk pregnancies. The development and persistence of high cesarean delivery rates are important safety and quality issues. While sometimes absolutely necessary for the health of mother or child, cesarean delivery is associated with higher costs and increased rates of complications. The Obstetric Initiative’s first program is to safely lower the cesarean delivery rate among low-risk patients by improving safe birth practices.

Why these three focused areas were chosen?

Over the past several years, we have developed intellectual engagement and performed impactful work around MVC’s mission. To further drive change, these three VCCs were selected because they represented areas of strength for MVC and high value targets for quality improvement. In addition, these three VCCs are closely related to MVC hospitals’ current quality initiatives.

The VCCs are also connected to previous work at MVC and will therefore be supported with our resources, including analytical expertise and hospital engagement efforts. Our past collaborative-wide meetings have highlighted best-practice sharing around “post-discharge care” (April 2017), “episodes of hospital-based care” (November 2016), and “reducing ED utilization and unnecessary hospital readmissions” (November 2017). MVC’s synergies with other Collaborative Quality Initiatives (CQIs) will provide additional strengths. For example, the Michigan Arthroplasty Registry Collaborative Quality Initiative (MACQI), the Integrated Michigan Patient-centered Alliance in Care Transitions (I-IMPACT), and the Obstetrics Initiative (OBI) are all leaders in their fields.

How will we move forward?

Although MVC will continue our other work with hospitals, CQIs, and BCBSM, the Collaborative’s 2018 emphasis will be on these VCCs. In the short term, we hope to learn about hospitals’ best practices in these areas and share their stories. In the long term, we look forward to using claims data to evaluate hospitals’ spending trends.

If you have any questions, please do not hesitate to contact the MVC Coordinating Center or directly comment on this article. We welcome your comments and feedback.

Happy New Year, and we look forward to a great 2018 together.