Online Program

Reducing C-sections through Payment Reform and Data-Driven Quality Improvement

Tuesday, November 3, 2015 : 5:15 p.m. - 5:30 p.m.

Brynn Rubinstein, MPH, Transform Maternity Care, Pacific Business Group on Health, San Francisco, CA

Increasing costs, rising C-section rates, and worsening health outcomes plauge maternity care in the US. To address the costs and risks of avoidable C-sections, in May 2012 the Pacific Business Group on Health (PBGH) and the California Maternal Quality Care Collaborative (CMQCC) launched the Maternity Bundled Payment Pilot Project. The pilot integrates existing research on evidence-based best practices, variation data about hospital cesarean rates in California, and effective quality improvement techniques into a multi-pronged intervention.


Through a multi-stakeholder effort, the pilot deployed three levers to reduce low-risk (NTSV) C-sections:

  1. Payment change that creates one blended episode-based payment for delivery (vaginal or cesarean) allowing for shared savings;
  2. Data and measurement support from the California Maternal Data Center (CMDC);
  3. Quality improvement guidance from CMQCC for participating hospitals and medical groups to align labor management practices with current national guidelines.


In 2014, all three components of the pilot were implemented at four California hospitals (representing over 9,000 deliveries annually) and with two health plans. Preliminary data is very promising and has yielded a 20% reduction at three hospitals in 10 months. At one hospital, the intervention brought the NTSV C-section rate to below 30% for the first time in over three years.

In January 2015, a third hospital system with four additional sites agreed to participate pending health plan contracts.


The combination of payment reform, data measurement, and physician led quality improvement can effectively reduce hospital C-section rates. This approach should be replicated and scaled for further validation.

Learning Areas:

Clinical medicine applied in public health

Learning Objectives:
Demonstrate effectiveness of a multi-prong approach to improving obstetric care. Identify challenges and barriers to implementation and discuss strategies to overcome them. Explain process for formulating and adopting one maternity blended case rate for cesarean and vaginal births. Name data, partners, and resources required to successfully implement data-driven quality improvement.

Keyword(s): Quality Improvement, Maternal and Child Health

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I currently manage the RWJF grant for the Maternity Bundled Payment Pilot and direct the Maternity program at the Pacific Business Group on Health. I worked closely with the plans, hospitals, purchasers, and data centers to coordinate this project. My MPH Masters’ thesis examined evidence-based strategies for cesarean reduction, which I presented her findings at APHA’s 2012 Annual Conference
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.