Preterm Delivery

Childbirth by its very nature carries potential risks for the woman and her baby, regardless of the route of delivery. Cesarean birth can be life-saving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of associated decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, non-reassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. In 2011, one in three women who gave birth in the United States did so by cesarean delivery.

Guidelines from the American Congress of Obstetricians and Gynecologists (ACOG) indicate that births should not be induced or delivered via cesarean section prior to 39 weeks gestation for first time mothers, unless there is medical indication that necessitates delivery. In a study published by the Centers for Disease Control and Prevention titled, Trends in Low-risk Cesarean Delivery in the United States, 1990–2013, West Virginia demonstrated a statistically significant decline of 5 percent (from 30.9 to 29.3) in low risk cesarean delivery. This rate has further decreased to 27.2 in 2015 as demonstrated by the Federally Available Data, a 14% decline since 2009.

To address this concern, the WV Perinatal Partnership (OMCFH and DPWH are active participants), WV Chapter of the March of Dimes, WV Health Care Authority, and the WV Improvement Institute embarked on a collaborative quality improvement (QI) project in 2009 to eliminate non-medically indicated elective deliveries prior to 39 weeks gestation. All 30 birthing hospitals (four hospitals have since discontinued delivering babies) were invited to participate, but only 14 accepted. However, these hospitals represented 70% of total births in WV. Both participating and non-participating hospitals experienced substantial declines in elective deliveries during the project period. Between January and June 2009, total elective deliveries prior to 39 weeks gestation decreased from 11.8% to 4.7% of all births occurring in WV. This decrease was mostly attributed to a decline in elective labor inductions. Labor induction is more likely to result in the need for a C-section particularly if the woman has never given birth before and her cervix has not already begun to thin, soften, and dilate (unfavorable cervix). Labor inductions prior to 39 weeks gestation with no documented medical risk factor or congenital anomaly decreased significantly from 8.2% in January 2009 to 2.7% in June 2009. Cesarean section deliveries prior to 39 weeks with no documented medical risk factor, congenital anomaly or complications decreased from 3.6% to 2.0% for all births during the six-month project period.

The momentum created by the success of this collaborative quality improvement project encouraged perinatal partners to continue and expand efforts to improve birth outcomes. In 2011, the WV Perinatal Partnership (OMCFH and DPWH are active participants), WV Chapter of the March of Dimes, WV Health Care Authority, and the WV Health Statistics Center partnered on the “First Baby Initiative” QI project to reduce cesarean section deliveries among WV’s first-time mothers. This QI project focused on reducing the rate of cesarean deliveries in first-time mothers by implementing nursing strategies, such as increased active labor support, increased labor support techniques explained in childbirth classes, and implementation of medical criteria. These strategies were identified as most successful, very successful, and somewhat successful.

The results of this QI project showed that cesarean deliveries had remained stable over the previous six years (2006 -2011), with nearly one-third of first time mothers delivered by cesarean section. There was no significant change in the statewide cesarean section rate among nulliparous women before and after this study (31.6% pre-project vs. 32.4% post project). Although no hospital experienced a significant decline during the project, 13 of the participating hospitals did reduce the percentage of nulliparous births that were delivered by cesarean section. Many smaller community

hospitals experienced a decrease in cesarean section deliveries. In 2011, two of the smaller birthing hospitals had a cesarean section delivery rate among nulliparous singleton births that was less than 16% (half of the statewide rate of 32%). Unfortunately, the same results were not seen by larger hospitals. Changing processes and practice to influence more staff at larger hospitals takes longer and requires sustained effort. Also, the larger hospitals (three tertiary care hospitals) that treat high-risk maternity patients will likely have a higher cesarean section rate compared to hospitals that do not provide care for high-risk pregnancies.

The DPWH supported collaborative projects to address low risk first-time cesarean births during the next five-year grant period. Working with the WV Perinatal Partnership (statewide partnership of over 300 health care professionals and public and private organizations working to improve perinatal health) and the WV Chapter of the March of Dimes, evidence-based activities will be implemented to bring hospital administrators, physicians, nurses and other health care professionals together to address changes in practice and sustained education.

After a review of available literature, the Office has based strategies on the “Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age, A California Toolkit to Transform Maternity Care.” This resource was developed collaboratively with the March of Dimes and the California Department of Public Health, Maternal, Child, and Adolescent Health Division. The Office supports clinician and patient education through labor support education for nurses, promotion of childbirth education for first time mothers, providing Lamaze childbirth education courses, and providing best practice updates for maternity care providers. In addition, the Office provides public education messages to maternity care providers, home visitors, and childbirth educators.

The OMCFH, the WV Perinatal Partnership, and the March of Dimes also promotes the March of Dimes Banner Program. The March of Dimes Banner Program recognizes hospitals that for their efforts to reduce early elective deliveries (EED) to less than 5% (national goal). All delivering hospitals in the state were asked to review their rates of elective deliveries prior to 39 weeks gestation and submit an application, copies of policies, procedures, and forms supporting the practice of no EED before 39 weeks gestation to the Perinatal Partnership and the March of Dimes. Fourteen hospitals completed the application process and were awarded their EED Banner. Several hospitals found documentation, coding, and data submission process errors that were impacting their outcome measures. The Centers for Medicaid/Medicare has included the PCO1 measure into the Value Based Purchasing program. Beginning this year, hospitals will be penalized to having deliveries that are scheduled or induced prior to 39 weeks gestation without a medical indication. The OMCFH will continue to support these efforts.

Provide evidence-based labor support education for nurses in birth facilities.

Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support. A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery. Given that there are no associated measurable harms, this resource may be underutilized.

Support during labor provides reassurance that what's happening during labor is normal and healthy and to get feedback about the progress of labor. Research shows that women having labor support are 28% less likely to have a cesarean section delivery. Women with continuous one-on-one labor support were more likely to have a spontaneous vaginal birth and have slightly shorter labor. 

Childbirth education can help reduce the use of unnecessary interventions and improve overall outcomes for mothers and babies. Knowing that pregnancy and childbirth can be demanding on a woman’s body and mind, Lamaze childbirth education serves as a resource for information about what to expect and what choices are available during the childbirth. The number one tenant of Lamaze childbirth education is, “Let labor begin on its own”. Lamaze childbirth education empowers women to make informed choices in healthcare, take responsibility for their health and to trust their innate ability to give birth. These education and practices are based on the best, most current medical evidence available. An 8-hour workshop was held at two hospitals for labor and delivery nurses representing five hospitals.  The participants expressed increased confidence and additional skills following the workshop. 

The OMCFH provided funding to the WV Perinatal Partnership to conduct best practice updates in multiple locations and the annual 2018 Perinatal Summit for maternity care providers to share the new guidelines of the American Congress of Obstetrics and Gynecologists (AGOC) and Society for Maternal Fetal Medicine. This education included a post session evaluation. The target audience included physicians, nursing staff, childbirth educators, and medical and nursing students.

Provide Lamaze childbirth education courses to increase the number of childbirth instructors.

The DPWH provided funding to the WV Perinatal Partnership to conduct statewide Lamaze childbirth education workshop. The target audience was uncertified childbirth educators, nurses, and others interested in providing childbirth education. It is expected that a minimum of 50% of participants will pass the certification exam and 90% will conduct childbirth classes. Attempts are being made to track the number of participants that passed the final exam and the number that are teaching childbirth education. Individuals trained will be strongly encouraged to share their knowledge by providing childbirth education.

Childbirth education can help reduce the use of unnecessary interventions and improve overall outcomes for mothers and babies. Knowing that pregnancy and childbirth can be demanding on a woman’s body and mind, Lamaze childbirth education serves as a resource for information about what to expect and what choices are available during the childbirth. The number one tenant of Lamaze childbirth education is, “Let labor begin on its own”. Lamaze childbirth education empowers women to make informed choices in healthcare, take responsibility for their health, and to trust their innate ability to give birth. These education and practices are based on the best, most current medical evidence available.  There were six nurses trained in May 2019 on Lamaze Childbirth education. 

Promote childbirth education for first-time mothers statewide.

To increase the number of pregnant women participating in childbirth education, DPWH will continue promoting education services to all pregnant women enrolled in home visitation programs. Some home visitors are certified childbirth educators and can provide the education during the home visit.

Fewer pregnant women are participating in childbirth education. Many are unprepared for the physical and emotional stress of childbirth. This often leads to medical interventions that influence labor and often leads to cesarean deliveries. Childbirth education offers the woman’s partner or labor coach the chance to understand the labor and birth process and how to best provide support once labor begins.

Childbirth classes help expectant parents learn about and prepare for labor and birth. Childbirth education promotes a natural, healthy, and safe approach to pregnancy, childbirth, and early parenting. Childbirth classes that explain labor support techniques have been effective in reducing medical interventions, such as cesarean deliveries. Participants learn how to identify the signs of labor and the changes in a woman’s body as the baby is born. Participants also have opportunities to share their concerns and fears with each other and the instructor can dispel myths and provide reassurance.

Provide increased public awareness about the risks of labor induction and cesarean section deliveries that are not medically indicated.

The DPWH provided public education materials to maternity care providers, home visitors and childbirth educators. Materials stressed that if the pregnancy is healthy, it’s best to wait the full 40 weeks for delivery. The DPWH provides the March of Dimes brain development to all maternity care providers to give to all maternity clients to illustrate the importance of waiting for labor to begin. The card shows brain development at 35 weeks and at 39-40 weeks gestation to encourage waiting until at least 39 weeks to deliver their baby.

Increasing labor support, encouraging childbirth education, and increasing the number of childbirth educators were identified in the “First Baby Initiative” and leading research as successful strategies to decrease the percentage of cesarean section deliveries in low-risk first-time mothers. However, the first step is educating the pregnant woman and the general public about the risks associated with unnecessary medical interventions such as labor induction and scheduled cesarean deliveries. Having the first cesarean section is a very good indicator the woman’s next birth will also be a cesarean delivery. These messages and literature will be shared in childbirth classes and by home visitation programs serving prenatal clients.

Conduct best practice updates for maternity care providers on the recommendations of ACOG and the Society for Maternal Fetal Medicine.

The OMCFH provided funding to the WV Perinatal Partnership to conduct best practice updates in multiple locations and the annual Perinatal Summit for maternity care providers to share the new guidelines of the American Congress of Obstetrics and Gynecologists (AGOC) and Society for Maternal Fetal Medicine. This education included a post session evaluation. The target audience included physicians, nursing staff, childbirth educators, and medical and nursing students.

The first stage of labor has been historically divided into the latent phase and the active phase based on the work by Friedman in the 1950s and beyond. The latent phase of labor is defined as beginning with maternal perception of regular contractions and is considered prolonged when exceeds 20 hours in nulliparous women and 14 hours in multiparous women. The active phase of labor has been defined as the point at which the rate of change of cervical dilation significantly increases. Active phase arrest traditionally has been defined as the absence of cervical change for two hours or more in the presence of adequate uterine contractions and cervical dilation of at least 4 cm.

However, more recent data from the Consortium on Safe Labor have been used to revise the definition of contemporary normal labor progress. The data highlights two important features of contemporary labor progress. First, from 4–6 cm, nulliparous and multiparous women dilated at essentially the same rate, and more slowly than historically described. This is the latest evidence-based information on labor management. Beyond 6 cm, multiparous women dilated more rapidly. Second, the maximal slope in the rate of change of cervical dilation over time (i.e., the active phase) often did not start until at least 6 cm. The Consortium on Safe Labor data suggests that neither latent phase nor active phase of labor should be diagnosed before 6 cm of dilation.

Oral Health

Continue oral health surveillance of perinatal population through Basic Screening Survey to inform program policy and development.

The mouth is our primary connection to the world. It serves to nourish our bodies as we take in water and nutrients to sustain life. It is our primary means of communication, the most visible sign of our mood and greatly influences how we are perceived by others. Oral refers to the whole mouth: teeth, gums, hard and soft palate, linings of the mouth and throat, tongue, lips, salivary glands, chewing muscles, and upper and lower jaws. Therefore, the mouth is an integral part of the human anatomy and plays a major role in our overall physiology, making oral health intimately related to the health of the rest of the body.

Manifested in poor nutrition, school absences, missed workdays, and increasing public and private expenditures for dental care, the burden of oral disease is overwhelming. Caries experience and untreated decay are monitored in WV as consistent with the National Oral Health Surveillance System (NOHSS), which allows for comparisons with other states and with the nation. According to the most recent Basic Screening Survey (BSS) conducted among WV Pre-K students (aged three-five years) during the 2011-2012 school year, 34% had a history of caries, which is about 4% higher than the Healthy People 2020 target (30%). In contrast, WV succeeded in surpassing both, the national status and Healthy People 2020 targets for Pre-K children with untreated decay, with 21% of the Pre-K population in WV having active decay present.

According to the Centers for Disease Control and Prevention (CDC), the second leading cause of infant mortality is the combination of premature birth and low birthweight. These two factors are also the most significant predictors of infant health and survival. Over the past 25 years, there has been a growing body of research supporting an association between poor oral health/chronic oral infection to the increased incidence of preterm labor and low birthweight babies. Dental maladies ranging from bleeding gums to dental-related abscesses have special significance during pregnancy.

Other factors contributing to poor oral health status during pregnancy include changes in diet and oral hygiene directly resulting in higher decay (cavity) rates, tooth erosion from esophageal reflux and vomiting and pregnancy gingivitis. According to the National Institutes of Health, “as many as 18 percent of the 250,000 premature low birthweight infants born in the US each year may be attributed to infectious oral disease.”

The Oral Health Program has worked to maintain the core infrastructure that has been developed over the last eight years. This infrastructure includes a State Dental Director with over ten years of public health experience, an oral health epidemiologist/evaluator, a program director, leadership expertise in policy analysis and health communications and an experienced Research, Evaluation and Planning Division to assist with monitoring, accountability and evaluation. The Oral Health Program now employs two registered dental hygienists (RDHs) with public health certifications.

Oral health surveillance was completed through a partnership with Marshall University School of Medicine on the adult population in West Virginia. This surveillance activity is in alignment with the 2013-2018 Oral Health Surveillance Plan.

Provide education to medical and dental care providers on national consensus statement 2012.

In addition to surveillance efforts, the Oral Health program also made efforts to address the needs of pregnant women. Key efforts include working with the Health Resources and Services Administration to increase the number of pregnant women who receive dental exams during pregnancy. One of the most significant barriers for women is the lack of dental coverage, especially among Medicaid-eligible pregnant women. The State Dental Director has engaged in numerous meetings with MCOs to begin addressing this issue. As a result, all four of the state’s MCOs now offer dental checkups as a value-added service for their eligible customers during pregnancy through 56 days postpartum. The Oral Health Program also worked with the West Virginia University School of Dentistry and the WV Dental Association to educate dentists on the importance of providing dental care to pregnant women. Lack of dental coverage combined with the fact that many dentists are uncomfortable providing care to pregnant women makes this a challenging area for WV.

Smoking

Offer evidence-based training to maternity care providers to promote tobacco cessation during each prenatal visit.

Maternal smoking during pregnancy can result in multiple adverse consequences for the neonate such as small for gestational age, which itself is a risk factor for numerous diseases throughout the lifespan. According to Vital Statistics, WV has the highest smoking rate for pregnant women in the US. The rate of smoking during pregnancy in WV for 2015 was 25.3%. Alarming rates of Medicaid insured pregnant smokers were 40.3% and this rate does not seem to be decreasing. The non-Medicaid insured pregnant smokers rate was 9.6%.

The Maternal Risk Screening Instrument asks women about cigarette use and tobacco smoke exposure during their first prenatal visit. In 2016, 25.9% of women indicated that they currently smoke cigarettes, 48.9% reported that they had ever smoked cigarettes, 33% reported that their partner smokes cigarettes, and 27.8% reported that they are exposed to 2nd or 3rd hand smoke. Of those women that currently smoke 32.5% reported they smoke one-five cigarettes per day, 46.1% smoke six-10 cigarettes per day, 19% smoke 11-20 cigarettes per day, 2,4% smoke 21-40 cigarettes per day, and 1.9% smoke 41 or more cigarettes per day. None of the women included in the PRSI data reported smoking more than 40 cigarettes per day.

The three leading causes of infant death in WV in line with the leading causes of infant death in the US are: medical conditions occurring during the perinatal period, birth defects, and sudden unexpected infant death. Leading risk factors of the unexpected infant deaths indicated 81% of the infant deaths were exposed to smoking.

A much higher percentage of births have a high birth score when maternal tobacco use is indicated on the WV Birth Score – Developmental Risk Screen and Newborn Hearing Screen. Fifty percent of infants born to mothers who reported tobacco use had a high score. Tobacco use alone will not cause an infant to have a high birth score, but a high score may result when combined with low birth weight, low maternal age, gender, intention to use formula, number of previous pregnancies, and low maternal education.

Although smoking is one of public health’s top priorities, it is also one of the most difficult problems to address. West Virginia invested over $5 million per year since the Master Settlement Agreement until fiscal Year 2017 to reduce tobacco use. As a result of this investment, youth smoking rates reduced dramatically, but adult smoking

rates have not dropped at the same rate, despite implementation of a statewide tobacco quit line and targeted media campaigns. The area of smoking during pregnancy has also been a priority area for the State since 2001, and this data is also decreasing at slower rates than youth.

The OMCFH and the Division of Tobacco Prevention continue to partner with the WV Perinatal Partnership to address smoking during pregnancy through the Smoking During Pregnancy Project. The primary focus of the project is to develop training and intervention programs using evidence-based strategies targeted to prenatal and pediatric providers to reduce smoking during and after pregnancy. The trainings are taken to the physicians and are conducted by physician champions. The Perinatal Partnership first looked at birthing hospitals and identified those with the highest number of births, maternal smoking rates, and pre-term delivery rates. The initial training efforts were targeted at those facilities which have more than 50% of births in the state. During the past year, only 44 healthcare providers received training on the 5 A's and 5 R's due to a delay of receipt of grant funds. Providers also received tools to assist with promotion of smoking cessation. Providers that were trained prior to October 2018 were recognized at the 2018 Perinatal Summit.

A survey was distributed to prenatal providers in April 2015. The purpose of the survey was to understand training needs, use of the Five A's Method, current interventions and use of pharmacology, including nicotine replacement therapy. The survey was developed and reviewed by OMCFH, Division of Tobacco Prevention, physician champions, and members of the Tobacco Free Pregnancy Advisory Council (TFPAC). Results of the survey indicated most maternity care providers knew the importance of counseling patients to reduce smoking, many did not understand the billing and reimbursement procedure or have the tools needed for their patients. The provider training has given them the tools needed to conduct tobacco cessation counseling.

In addition, Partnership staff drafted curriculum materials, including a PowerPoint presentation that will be used when working with obstetrical providers and their staffs. Additional information from the Tobacco Cessation for Health Care Provider Trainings sponsored by the Division of Tobacco Prevention was incorporated into the current Help2Quit curriculum materials. Physician leaders serve as faculty for the provider training.

In 2018, the Help2Quit program was expanded to include pediatric providers.  Women may not return for postpartum visits or seek healthcare for themselves, but most do take their infants for well-child and sick visits.  This is an opportune time for healthcare providers to offer tobacco cessation education and support.

The OMCFH will monitor tobacco cessation on the 7 providers sites that participated in the Certified Tobacco Treatment Specialist (CTTS) training in May 2019.  An evaluation of the success of a CTTS within the provider sites increases tobacco cessation by patients.

Offer evidence-based cessation curriculums to pregnant women via home visitation services.

All home visitation programs provide evidence-based tobacco cessation to pregnant women and their families. The Right From The Start Program uses Smoking Cessation Reduction In Pregnancy Treatment (SCRIPT) with all pregnant women. The other home visitation programs use curricula based on their specific national model.

The Office used evidence-based cessation and prevention programs to reduce the number of pregnant women who smoke and to protect children from secondhand smoke. Between January 1, 2017 and September 30, 2017, WV HVP and RFTS programs served 857 prenatal participants. Of those women, 384 or 44.1% indicated smoking during program enrollment. For prenatal participants who indicated smoking at enrollment, 47% were provided and accepted a referral for smoking cessation services, including SCRIPT.

Continue to seek out innovative evidence-based strategies to support women in quitting tobacco products before, during and after pregnancy.

The Department of Health and Human Services is partnering with WV on a multifaceted effort that includes both individual level and population level actions that target women of childbearing age and the broader population in order to have the greatest impact on prenatal smoking rates. The WV Management of Maternal Smoking (WV MOMS) held an action planning summit in December 2015. There were multiple domains identified that need addressed, three were highlighted as the most pressing areas for action. They are: Policy and Public Health - to implement a tobacco tax increase to the national average of $1.60 per pack, engage advocates for tobacco tax and support the tobacco tax; Medicaid - use the managed care organizations contracting with Medicaid Health plans to offer consistent and robust tobacco cessation benefit for pregnant women, evaluate existing MCO cessation services and connect with Kentucky and Michigan to determine their best practices; Systems Change - all healthcare boards and agencies should require mandatory tobacco cessation training for certifications. In the last year, the workgroups have combined into one workgroup because many of the same individuals were serving on each separate workgroup.

The workgroup has developed a Tobacco Cessation Guide for providers. This Guide contains all the insurance payers, what type counseling is covered, reimbursement rates, NRT, and CPT codes. A letter to all healthcare related Boards was sent by Commissioner and State Health Officer Dr. Rahul Gupta suggesting they add continuing education on tobacco cessation to the required annual continuing education requirements. None of the Boards have adopted this measure yet. The workgroup has partnered with the National Health Institute and promoting SmokeFreeMom.gov to pregnant smokers through all the home visitation programs. Through a Memorandum of Understanding with the National Health Institute data was reported bi-monthly on the number of WV users utilizing the website and phone app.

Follow-up with maternity care providers after receipt of evidence-based training to assess increase of tobacco cessation with pregnant women.

The OMCFH and the Division of Tobacco Prevention continue to partner with the WV Perinatal Partnership to address smoking during pregnancy through the Smoking During Pregnancy Project. The primary focus of the project is to develop training and intervention programs using evidence-based strategies targeted to prenatal and pediatric providers to reduce smoking during and after pregnancy. The trainings are offered in provider offices and conducted by physician champions. Follow-up with trained provider sites will assess the impact on smoking cessation education offered by the clinician, decreased quit rate and any suggestions for future trainings.