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Reducing Primary Cesareans Application Checklist

Below is a list of the items needed to complete the application for the American College of Nurse-Midwives, Healthy Birth Initiative: Reducing Primary Cesareans Quality Improvement (QI) multi-hospital learning collaborative. There is a link to a survey which must be completed at Survey Monkey, and all other application materials (Letter of Application and Participation Agreement) should be submitted via the ACNM portal at  (Note: you will have to log in to your ACNM account in order to access this page).

We expect to schedule telephone interviews with teams who are finalists during the weeks of August 7-15.

Timeline for Applications to Reducing Primary Cesareans Collaborative – 2018


Date Due

Application period opens

May 15, 2017

Applications accepted on a rolling basis

May 15-July 21, 2017

Final deadline for applications:

1. Survey completed on Survey Monkey

2. Letter of application (LOA) uploaded to ACNM portal

3. Participation agreement uploaded to ACNM portal

July 21, 2017

Interviews to be scheduled for finalists

August 7-15, 2017

Notification to accepted hospital teams

Early September 2017

SAVE THE DATE for Mandatory Kickoff meeting in Portland, OR

October 25, 2017

We will only review complete applications. Please double check that these three items are submitted as part of your application:

1. Survey on Survey Monkey:

2. Letter of Application (LOA) not more than 3 pages, 11 pt. font. Please upload your LOA to the ACNM portal:

Body of letter to include the following:

o Institution Name and Address

o Reasons you want to participate in ACNM’s Reducing Primary Cesareans Collaborative

o Brief description of your hospital’s experience in leading obstetric quality improvement efforts, including the topics for recent obstetric quality improvement projects

o Please list at least two people from your team who will be designated as co-leaders of this initiative, serve as the key points of contact to the RPC, and participate in required training from IHI as part of the collaborative. Please describe their experience and skills.

o What skills exist in your department to support quality improvement (QI)? What support will the team receive from your QI dept?

o Have you participated in the ACNM Benchmarking program? If so in which years?

o Describe how your OB department collects or obtains clinical statistics for quality improvement activities.

o What are the current strengths within the OB department that would support your success in the project?

o What are the current challenges within the OB department that would need to be addressed in order to change the current culture in the OB department?

List of your team members, including their role and contact information:




phone number


Staff Nurse

OB physician

Quality Improvement

3. Participation agreement (copy and paste from text below, sign, and then save as a PDF and upload to the ACNM portal) signed by appropriate Senior Hospital Leadership (for example, COO, VP for Quality, Chief Clinical or Nursing Officer. Agreement should be uploaded via ACNM portal:

Administrative Commitment to Participate in

ACNM’s Reducing Primary Cesareans Learning Collaborative, 2018


Nearly one third of births in the US are delivered by cesarean section each year. After a 60% increase in cesarean births from 1996 to 2009, reaching a high of 32.9%, there was a slight decline to 32.7% in 2013.[1] While cesarean birth can be a lifesaving procedure in situations when vaginal delivery is not a safe option, for most low-risk women giving birth for the first time, cesarean deliveries create more risk, including hemorrhage, uterine rupture, abnormal placentation, and respiratory problems for infants.[2] Furthermore, mothers who have had cesarean sections have increased chance of these risks in subsequent cesarean deliveries. In addition to these risks, mothers who undergo cesareans have longer recovery times, slower returns to productive activities, and difficulty breastfeeding.

This trend has received worldwide attention from various stakeholders as a maternal and child quality issue. In 2000, the American Congress of Obstetricians and Gynecologists (ACOG) published a report on the trend in cesarean births, with a proposed national goal of 15.5%. More recently, the federal Healthy People 2020 guideline established a target rate cesarean delivery rate of no more than 23.9% for low-risk women without a prior cesarean. These births to low risk, first time mothers are referred to as NTSV births[3].

Concern about high cesarean rates is driven by both quality concerns and costs. For example, national data shows that, on average, a cesarean birth costs $3,432 to $7,000 more than a vaginal birth.[4] [5] In response, a range of stakeholders, including professional societies and purchasers, have now focused attention on this issue.

ACNM and other midwifery organizations developed the Physiologic Birth Consensus statement aimed at supporting women to give birth without intervention, unless medically indicated. Recognizing the need for additional learning tools and support for clinicians seeking to promote healthy births, ACNM developed The Healthy Birth InitiativeTM (HBI), a long-term program led by ACNM and representatives from leading maternity care organizations. HBI provides the tools and resources to put the Physiologic Birth Consensus statement into practice. It focuses on promoting physiologic birth and avoiding unnecessary medical interventions, including cesareans, in order to achieve the best childbirth outcomes for mothers and babies. The program provides resources and tools to help women, their families and health care providers achieve healthy childbirth. In addition, HBI provides information about evidence-based research to hospital quality managers and policy leaders, which can drive quality improvement and support mandated reporting for national quality measurement programs.

The American College of Nurse-Midwives will be accepting applications for its third year of a multi-state, multi-hospital initiative aimed at reducing primary cesarean births in low risk women through the support of physiologic labor and birth. The collaborative is called Reducing Primary Cesareans, or “RPC.” Twenty two hospitals from across the U.S. participated in the first and second years of the collaborative during 2016 and 2017. These hospitals have already achieved reductions in their NTSV rates of up to 18%. At a median reduction of 6%, for the hospitals participating in the 2016 collaborative, this would represent savings of between $618,000 and $1.5 million.

Benefits of participation

Hospitals selected to participate in the learning collaborative work with a multi-disciplinary team of RPC quality improvement experts to identify areas of improvement and track process and outcome measures. Hospitals implement one of three change bundles that are designed to reduce NTSV cesareans by promoting key principles of physiologic birth. The three bundles are aimed at: promoting progress in labor; promoting comfort in labor; and implementing intermittent auscultation (fetal monitoring). More information about the bundles can be found at In addition, hospitals collect and submit data to the ACNM RPC Data Center, which produces key measures so hospitals can track their progress.

Hospitals participating in the collaborative will work with national experts to change clinical practice at your facility. They will:

· Participate in learning community and share best practices

· Receive coaching from our clinical experts

· Contribute data to and get access to reports from our data center that allow you to track key metrics

· Have access to materials and tools that have enabled others to succeed

Participation Agreement

Your hospital is applying to participate in the 2018 Collaborative. Please review the commitment required and indicate your support by signing this agreement.

Commitment required:

· Two co-leaders for this project who will serve as the primary points of contact to the broader collaborative, and who will complete some free online courses offered by IHI if they do not already have training and experience in quality improvement.

· Attendance by the co-leaders at a mandatory , full day initial kick-off meeting. This is being held in conjunction with Midwifery Works in the last week of October 2017 in Portland, OR.

· Attendance at quarterly training webinars, led by RPC faculty (1 hour per webinar)

· Attendance at monthly, mandatory coaching calls with several other hospitals who are implementing the same bundle as your team, facilitated by a RPC coach. (2 hours per call)

· Data collection and analysis activities. In 2017, there are 19 key data elements to be uploaded in the aggregate for your hospital’s NTSV deliveries (does not involve personal health information (PHI)) on a monthly basis. We are currently reviewing these data elements for parsimony, and will confirm any changes to the current data elements by October, 2017. Some data may be extracted from existing reports, and other data may require chart review to collect. (Time estimate of 4 hours per month; this will vary by hospital based upon how data is currently collected).

· Team meetings plus other interdisciplinary meetings at your hospital. (Time estimate of 2-5 hours/month)

Costs of participation:

In 2018, there will be a $7,500 annual fee for participants to defray ACNM’s costs of supporting this project. Each institution is responsible for all expenses related to travel to the kick off meeting.

Please review and sign the following agreement:

I, the undersigned, agree to provide the administrative support needed to participate in the 2018 cycle of the American College of Nurse-Midwives HBI Reducing Primary Cesareans Collaborative. This support includes ensuring adequate time and other resources are available to the team as described below:

1. Dedicated time for co-leaders to work with RPC coaches and other teams in the collaborative for the project period from January 1, 2018 through June 30, 2019

2. Attendance at by two co-leaders at the full day kickoff meeting on October 25, 2017 in Portland, OR

3. Formation of a clinical improvement team comprised of between 3 and 5 clinical staff to participate in the RPC collaborative throughout the project period. At a minimum, the team must include a clinical provider leader (nurse-midwife, physician, nurse practitioner or registered nurse), an administrative leader, and a representative from quality improvement. Provide an opportunity for all members of the improvement team to meet at least twice a month to engage in improvement activities. Practices that have previously participated suggest dedicating between 4-6 hours per month.

4. Working towards implementing the components of one of the three RPC change bundles

5. Participate in, and contribute to, the RPC Learning Collaborative, including practice representation at all quarterly webinars and monthly coaching sessions:

6. Provide information technology support for your team to connect via Go To Meeting for webinars

7. Provide support from Electronic Medical Records or other staff to automate (when possible) data extraction and uploading to the RPC Data Center

By signing below, the parties agree that they have reviewed this participation agreement. We acknowledge that failure to meet the participation requirements may result in failure of the team to achieve the goals they set and potentially your team being asked to leave the project.












[3] This measure refers to first-time pregnancies (Nulliparous) that have reached at least 37 weeks gestation (Term), with one fetus (Singleton) in the head-down position (Vertex).

[4], accessed 7/25/16



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