AHRQ Report Helps Alabama Medicaid Improve Maternity Care

Comparative Effectiveness
May 2009

After attending the AHRQ-sponsored Medicaid Medical Directors Learning Network meeting held in February 2008, the Alabama Medicaid Agency drew upon the AHRQ Evidence Report/Technology Assessment, No. 133, Cesarean Delivery on Maternal Request, in developing a performance improvement project for its maternity care program.

The meeting featured the research findings from the evidence report. The report highlights the incidence of cesarean delivery in the United States and discusses the factors affecting the magnitude and scope of neonatal and maternal benefits and harms associated with cesarean delivery on maternal request.

The findings raised the awareness level of Robert Moon, MD, medical director for the Alabama Medicaid Agency, regarding the growing trends in elective cesarean deliveries. A review of Alabama Medicaid claims data confirmed that state-specific increases in cesarean delivery rates aligned with national trends, but there was a paucity of data detailing the specific clinical indications for these pre-term cesarean births.

Given these safety concerns, Moon and colleagues wanted to measure more accurately occurrences of cesarean delivery on maternal request in Alabama at 39 weeks or shorter gestation. Moon states, "This report helped me raise awareness with providers and other stakeholders about the importance of this issue."

The evidence report also helped him justify that this "is not just an issue for Alabama Medicaid, but is a broader issue. Cesarean delivery on maternal request is neither a well-recognized clinical entity, nor an accurately reported indication for diagnostic coding or reimbursement."

One of the goals of Alabama's new performance improvement project is to reduce the number of deliveries occurring before 39 weeks of gestation. Alabama Medicaid created a quality measure to record delivery at fewer than 39 weeks' gestation. This new measure resulted in part from the awareness generated by the AHRQ evidence report.

The American College of Obstetricians and Gynecologists recommends in its Practice Bulletin 10, Induction of Labor, that elective delivery not occur before 39 weeks due to increased rates of newborn respiratory complications. Studies have found that the risk of complications doubles if an elective cesarean section is performed at 37 weeks; at 38 weeks, the risk of complications is 50 percent higher.

Moon notes that due to the evidence report, Alabama Medicaid knew to list cesarean delivery on maternal request as one of the indications under the measure for early delivery. He says, "One of the things I appreciated about this report is that it demonstrates how hard it is to define the circumstances around early delivery, especially when it's occurring because of maternal request."

Data for Alabama's performance improvement project will be collected for each Medicaid patient delivering between January 1, 2010 and June 31, 2010. State officials will review the impact of this new measure in the third quarter of 2010.

The evidence report was prepared by the RTI International-University of North Carolina Evidence-Based Practice Center.

Impact Case Study Identifier: 
AHRQ Product(s): Evidence Report, Medicaid Medical Directors Learning Network
Topics(s): Policy, Women's Health, Pediatrics
Geographic Location: Alabama
Implementer: Alabama Medicaid Agency
Date: 05/01/2009

Cesarean Delivery on Maternal Request. Evidence Report/Technology Assessment No. 133. March 2006. AHRQ Publication No. 06-E009. Agency for Healthcare Research and Quality, Rockville, MD. Contract No. 290-02-0016. http://www.ahrq.gov/clinic/tp/cesarreqtp.htm

Page last reviewed October 2014