A PUBLICATION OF THE NATIONAL ACADEMY FOR STATE HEALTH POLICY September 2017

Case Study: Oklahoma’s Cesarean

Section Quality Initiative Promotes
Improved Birth Outcomes
Derica Smith

Introduction
Improving birth outcomes—including reducing infant mortality—is a priority of many state Medicaid
agencies, which finance nearly half of all births nationwide each year.1 Nearly 60 percent of births in
Oklahoma were financed by Medicaid in 2014.2 Over the last 20 years, the national cesarean section
(C-section) rate has continued to steadily increase without a corresponding improvement in maternal
or neonatal outcomes.3 Research suggests a correlation between early elective delivery and poor birth
outcomes, such as lower brain mass, low birth weight, feeding problems, and respiratory issues.4 Addi-
tionally, C-sections financed by Medicaid on average cost nearly $5,000 more than vaginal births, and
the average payment for maternal and newborn care, including
Oklahoma’s SoonerCare Medicaid neonatal intensive care unit stays, is about $6,100 higher for
program reduced medically C-sections than vaginal births.5
unnecessary C-sections between
2011-2013 among enrollees::
• Hospital claims declined from The incidence of early elective C-sections and its contribution to
19.75 percent to 17.83 percent the overall increase of C-section rates are not well known, but it
• Physician claims decreased
from 21.43 percent to 20.03 is estimated that 2.5 percent of all births in the United States are
percent elective C-sections.6 The rate of C‐sections increased almost 60
• The rate of C-sections per- percent between 1996 (when it was 20.7 percent) and 2009 (ris-
formed without medical indi-
cation decreased from 1.81 ing to 32.9 percent), and has remained steady since.7 The rate of
percent to 1.43 percent early deliveries occurring between 37 and 38 weeks increased
• The initiative resulted in a cost
savings of more than $1.2 almost 50 percent between 1990 (19.7 percent) and 2006 (28.9
million percent) but has since declined. The rate was 24.7 percent in
2012.8 Additionally, births at 39 weeks increased 17 percent from
2006 to 2012 (25.4 percent to 29.8 percent).9 The American College of Obstetricians and Gynecologists
(ACOG) has released clinical guidelines designed to reduce non-medically-indicated Cesarean delivery
and early induction of labor under 39 completed weeks.10

The following case study highlights Oklahoma Medicaid’s innovative and effective Cesarean Section
Quality Initiative. This case study is a companion to two other case studies of Tennessee and Wiscon-
sin and a 50-state environmental scan of state Medicaid performance measures, improvement projects
and incentives promoting women’s health services.

Overview of Cesarean Section Quality Initiative

OHCA created the Cesarean Section Quality Initiative in 2011 to reduce elective C-sections without
medical indication. The initiative was designed to decrease the primary C-section rate11 performed
without medical indication to 18 percent or less by encouraging providers and hospitals to follow medi-
cal best practice guidelines when performing C-sections on mothers in the SoonerCare program. (See
Overview of OHCA Pregnancy Services text box for more information about SoonerCare services). The
primary C-section rate reflects first births by SoonerCare mothers for whom C-sections were performed,
Case Study: Oklahoma’s Cesarean Section Quality Initiative Promotes Improved Birth Outcomes 2

as a percentage of all vaginal and primary C-section births among SoonerCare mothers. Oklahoma’s
initiative includes three main components: provider education, performance feedback, and reimburse-
ment reform (e.g., payment reduction for non-medically necessary C-sections).12

In 2011, OHCA sent letters to providers detailing the implementation process of the C-section initiative,
including reimbursement reform information.13, 14 The initiative
was implemented in two phases. Phase I started January 2011 Overview of OHCA Pregnancy
and included data collection, feedback to providers and hospitals, Services
and provider education. In collaboration with the University of The Oklahoma Health Care Authority
Oklahoma Quality Department, OHCA provided educational tools (OHCA) administers the SoonerCare
(Medicaid) program and determines fi-
and resources for providers and hospitals,15 including information nancial eligibility. It is the primary entity
about trends in Cesarean delivery in the United States, the March in Oklahoma charged with controlling
of Dimes’ Less than 39 Weeks Toolkit,16 and a link to the ACOG the costs of state-purchased health
care. Sooner Care’s goal is to improve
website that provides medical guidelines related to early elective access, quality, and utilization of health
deliveries. In addition, OHCA sent a letter to in-state contracted care for pregnant women and children.
OHCA offers a variety of pregnancy
providers and hospitals that highlighted their primary C-section services to women in Oklahoma with
rate and the total C-section rate.17 incomes at or below 133 percent of the
Federal Poverty Level (FPL) through the
SoonerCare program. Additionally, preg-
Phase II began September 2011 and continues today. It includes nant women with incomes between 134
medical chart reviews of all C-section claims for providers with and 185 percent of FPL are eligible for
pregnancy-related health care coverage
greater than 18 percent primary C-section rates to identify medi- through the Soon-to-be-Sooners Main-
cal necessity and reimbursement reform opportunities. If review- tenance (STBS-M) program. Pregnant
ers determine that a C-section was medically necessary, OHCA women who are not eligible for Sooner-
Care due to citizenship status may be
processes the payment at the established C-section payment eligible for pregnancy-related coverage
rate. Conditions indicating medical necessity include but are not through Soon-to-be-Sooners (STBS).
STBS coverage provides services ben-
limited to: previous C-section, uterine rupture, and multiple ges- eficial during pregnancy to promote
tation.18 If medical necessity is not established, the delivery claim healthy pregnancies and improve birth
is paid at the vaginal delivery rate. The Medicaid vaginal delivery outcomes. These services include, but
are not limited to, delivery services,
rate in Oklahoma is approximately $200 less than the C-section smoking cessation, high-risk obstetric
reimbursement rate for physicians and $1,600 less for hospitals. care, genetic counseling, and maternal
19 and infant health social work.

An independent evaluation assessed the effectiveness of the ini-

tiative for state fiscal years 2011 through 201320 by analyzing available claims data submitted by phy-
sicians and hospitals. It focused on the percentage of C-sections performed among the SoonerCare
population, C-sections without medical indication, and quality implications.

Results from the evaluation indicated the primary C-section rate among SoonerCare enrollees signifi-
cantly decreased over the evaluation period.
• Hospital claims declined from 19.75 percent to 17.83 percent over the two-year period;
• Physician claims decreased from 21.43 percent to 20.03 percent;21 and
• The rate of C-sections performed without medical indication also significantly decreased from
1.81 percent to 1.43 percent.22

While not a primary goal, the initiative also resulted in cost savings for the SoonerCare program. For
C-sections without medical indication, hospitals were paid at the lower vaginal delivery rate. This result-
ed in a more than $1.2 million savings for the SoonerCare program over two years.23 The average cost
of both methods of delivery significantly decreased over the initiative period too. In 2016, the primary
C-section without medical indication rate was 15.6 percent.24

NATIONAL ACADEMY FOR STATE HEALTH POLICY | Download this publication at www.nashp.org
Case Study: Oklahoma’s Cesarean Section Quality Initiative Promotes Improved Birth Outcomes 3

Partnerships to Improve Outcomes

OHCA partners with the Oklahoma Department of Public Health on a statewide initiative, Preparing for a
Lifetime, It’s Everyone’s Responsibility, funded by the state’s Title V Maternal and Child Health Services
Block Grant.25 The overarching goal is to reduce infant mortality and other adverse birth outcomes as
well as reduce racial disparities related to these outcomes.26 As part of the planning process, data anal-
ysis revealed the need for medical professionals and hospitals to implement interventions that focus on
both maternal and infant health.
• Maternal health issues include behaviors before and during pregnancy, maternal infections,
preterm birth, postpartum depression, and tobacco use.
• Infant health efforts focus on infant safe sleep, breastfeeding and childhood injury.

A key component of this partnership initiative is education around prevention of preterm birth, which
includes early elective inductions or C-sections that are not medically indicated.27

Additionally, early elective delivery is a national outcome measure for the federal Title V MCH Services
Block Grant28 tracked by Oklahoma through the state’s Pregnancy Risk Assessment Monitoring System
(PRAMS).29 This measure offers a potential opportunity for state Medicaid and Title V programs in Okla-
homa and across the country to collaborate and share data related to services and health outcomes of
shared interest.

Oklahoma is an active member of the Collaborative Improvement and Innovation Network to Reduce
Infant Mortality (IM CoIIN), led by the National Institute for Children’s Health Quality and supported by
the Maternal and Child Health Bureau in the Health Resource and Services Administration.30 IM CoIIN
promotes state efforts to prevent and reduce infant mortality and eliminate disparities in birth outcomes.
Following an IM CoIIN Infant Mortality Summit in 2012, OHCA implemented an Interconception Care (ICC)
case management31 project in 2013 for pregnant women ages 12 to 18 in counties with high infant mortal-
ity. The ICC case management project provides care coordination and relevant health education and life
planning assistance during the woman’s pregnancy and continues during the first year of a newborn’s life.

Conclusion
OHCA’s efforts to address C-sections without medical indication provide a model for other states that
are considering strategies to reduce infant mortality and improve birth outcomes. Overall, OHCA’s Ce-
sarean Section Quality Initiative has been successful in reducing C-sections without medical indication
among SoonerCare mothers. Additionally, the state’s experience to date demonstrates how state agen-
cies can partner to achieve shared goals for maternal and infant health.

Endnotes
1. George Washington University. (2013). “Medicaid Pays For Nearly Half of All Births in the United States,” accessed July 7, 2017, https://
publichealth.gwu.edu/content/medicaid-pays-nearly-half-all-births-united-states
2. Kaiser Family Foundation. (2016). “Births Financed by Medicaid,” accessed July 7, 2017, http://www.kff.org/medicaid/state-indicator/births-
financed-by-medicaid/?currentTimeframe=0&soKairtModel=%7B"colId":"Location","sort":"asc"%7D
3. Oklahoma Health Care Authority. (2017). “OHCA Cesarean Section Quality Initiative,” accessed July 7, 2017, http://www.okhca.org/providers.
aspx?id=12541
4. “Born Too Early: Improving Maternal & Child Health by Reducing Early Elective Deliveries,” National Institute for Health Care Management, 2014.
accessed July 7, 2017, https://www.nihcm.org/pdf/Early_Elective_Delivery_Prevention_Brief_2014.pdf
5. Ibid.
6. American Congress of Obstetricians and Gynecologists. (2017). “Cesarean Delivery on Maternal Request” accessed July 7, 2017, https://www.
acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Cesarean-Delivery-on-Maternal-Request
7. Centers for Disease Control and Prevention. (2017). “Recent Declines in Induction of Labor by Gestational Age” accessed July 7, 2017, https://
www.cdc.gov/nchs/data/databriefs/db155.htm

NATIONAL ACADEMY FOR STATE HEALTH POLICY | Download this publication at www.nashp.org
Case Study: Oklahoma’s Cesarean Section Quality Initiative Promotes Improved Birth Outcomes 4

8. Ibid.
9. Ibid.
10. Centers for Disease Control and Prevention. “Primary Cesarean Delivery Rates, by State: Results From the Revised Birth Certificate, 2006–
2012” accessed July 7, 2017, https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_01.pdf
11. Primary C-section rate is defined as the number of first births performed by C-section divided by the total number of vaginal deliveries and first
birth C-sections as defined by OHCA.
12. Oklahoma Health Care Authority. “OHCA Policies and Rules,” accessed July 7, 2017, https://www.okhca.org/xPolicySection.
aspx?id=6063&number=317:30-5-56.&title=Utilization%20review
13. “Cesarean Section Quality Initiative (Hospital Administrator).” Oklahoma Health Care Authority, 2011. http://www.okhca.org/WorkArea/
showcontent.aspx?id=12551
14. “Cesarean Section Quality Initiative (Provider).” Oklahoma Health Care Authority, 2011. http://www.okhca.org/WorkArea/showcontent.
aspx?id=12550
15. Oklahoma Health Care Authority. “OHCA Cesarean Section Resources,” accessed July 7, 2017, https://okhca.org/providers.aspx?id=12549
16. The toolkit provides hospitals with support in eliminating non-medically indicated (elective) deliveries before 39 weeks’ gestational age. The
toolkit can be found at the following link: http://www.marchofdimes.org/professionals/less-than-39-weeks-toolkit.aspx.
17. Phase I excluded providers and hospitals with less than six deliveries per quarter in a fiscal year, out-of-state providers and hospitals, and
assistant surgeons.
18. Conditions indicating medical necessity include: previous C-section delivery, previous uterine rupture, HIV positive, invasive cancer of cervix,
placenta abruption, uterine rupture, multiple gestation, cord around the neck with compression complicating labor and delivery, postdates
[greater than 41 weeks Estimated Gestational Age (EGA)], placenta previa, placenta accrete, transverse lie; or malpresentation.
19. “Evaluation of the Oklahoma Medicaid Cesarean Section Quality Initiative.” Oklahoma Health Care Authority, 2014. http://www.okhca.org/
research.aspx?id=87
20. Ibid.
21. Ibid.
22. Ibid.
23. Ibid.
24. Ibid.
25. “Title V MCH Block Grant Program Oklahoma State Snapshot,” Health Resource and Services Administration, 2016. https://mchb.tvisdata.hrsa.
gov/uploadedfiles/StateSubmittedFiles/2017/stateSnapshots/OK_StateSnapshot.pdf
26. Oklahoma State Department of Health. “Preparing for a Lifetime, It’s Everyone’s Responsibility,” accessed July 7, 2017, https://www.ok.gov/
health/Community_&_Family_Health/Improving_Infant_Outcomes/
27. “Facts about Preterm Birth,” Oklahoma State Department of Health, 2011. https://www.ok.gov/health2/documents/Prematurity.pdf
28. Health Resource and Services Administration. “National Outcome Measure,” accessed July 7, 2017, https://mchb.tvisdata.hrsa.gov/
PrioritiesAndMeasures/NationalOutcomeMeasures.
29. “Early Term and full term Births in Oklahoma,” Oklahoma State Department of Health, 2013. https://www.ok.gov/health2/documents/Early%20
Term%20PRAMS%20brief_Oct_2013.pdf
30. “Using Maternal and Child Health Quality Improvements Efforts to Advance State Health Agency Accreditation,” Association of State and
Territorial Health Officials, 2017. http://www.astho.org/Accreditation-and-Performance/CoIIN-Accreditation-QI-Issue-Brief/
31. Oklahoma Health Care Authority. “Population Care Management Descriptions,” accessed July 7, 2017, http://www.okhca.org/providers.
aspx?id=16533

Author’s Note:
“Case Study: Oklahoma’s Cesarean Section Quality Initiative Promotes Improved Birth Outcomes” is a joint publication of the National
Academy for State Health Policy (NASHP) and the National Institute for Children’s Health Quality (NICHQ). This case study was written
by Derica Smith of NASHP, with support and guidance from Karen VanLandeghem of NASHP, Carrie Hanlon of NASHP, Anisha Agrawal
of NASHP, Zhandra Levesque of NICHQ and Patricia Heinrich of NICHQ. The author would also like to thank the Oklahoma Health Care
Authority for their review and guidance on the case study.

Acknowledgement:
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 # UF3MC26524, Providing Support for the Collaborative Improvement and Innovation Network (CoIIN) to
Reduce Infant Mortality, $2,918,909, no NGO sources). 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.

About the National Academy for State Health Policy:

The National Academy for State Health Policy (NASHP) is an independent academy of state health policymakers working together to
identify emerging issues, develop policy solutions, and improve state health policy and practice. As a non-profit, nonpartisan organization
dedicated to helping states achieve excellence in health policy and practice, NASHP provides a forum on critical health issues across
branches and agencies of state government. NASHP resources are available at: www.nashp.org.

About the National Institute for Children’s Health Quality:

The National Institute for Children’s Health Quality (NICHQ) is a mission-driven nonprofit dedicated to driving dramatic and sustainable
improvements in the complex issues facing children’s health. Visit www.NICHQ.org to learn more.