General Articles

New Endeavor in Michigan Hospitals Focuses on Evidence-Based Childbirth Practices to Improve Maternal and Infant Health Outcomes

Data reported in early November on a new Michigan project reveals promising results in the health outcomes of women and infants following childbirth in major hospitals around the state. The obstetrics portion of the Michigan Health and Hospital Association’s Keystone Project for Patient Safety and Quality has now been implemented in 65 hospitals in the state, with success in reducing elective caesarean sections (C-sections), improving scores on infant health measures, and curtailing the use of labor-induction drugs before the 39th week of pregnancy.[1]

Dr. Charles Cash, director of obstetrics at Oakwood Hospital and Medical Center in Dearborn, Michigan, has long focused on the reproductive health and well-being of Michigan’s mothers. Over three years ago, he suggested the Keystone obstetrics initiative to reel in the medical interventions performed and allow evidence-based practices to become the norm, trusting that women’s bodies are overwhelmingly capable of delivering babies successfully. While some women would prefer to have a baby before the due date because of factors like scheduling, fear of labor, discomfort, and predictability, best medical practices often preclude elective inductions. A recent article notes that families in the United States have access to excellent pediatric care, and because of this, “we’ve come to expect that babies born ‘a little bit early’ will be fine.”[2]

As the Michigan hospitals acknowledge, there are many cases in which C-sections are the best option for mothers and infants. Women who are carrying more than one baby are significantly overweight, have a chronic condition, or whose babies experience irregular growth typically require a C-section. Many other variables that lead to C-sections reflect more about the culture and philosophy of birth, as well as issues like fear of malpractice lawsuits and the convenience of scheduling a C-section.

In Michigan in 2008, 34% of women delivered their babies via C-sections, which was roughly two percent higher than the national average of 32.3 percent. In 2009, the caesarean delivery rate for women of all ages in the United States was 32.9 percent, up from 20.7 percent in 1996.[3] Maternal mortality in the U.S. nearly doubled to between 12 and 15 deaths per 100,000 live births from 2003­ to 2007. This places the United States—in a United Nations report released in September 2010—50th in the world for maternal mortality, a rank that is worse than that of most countries in Europe and a portion of countries in Asia and the Middle East. As a recent report from the Association of Reproductive Health Professionals notes, “For a country that spends more than any other country on health care and more on childbirth-related care than any other area of hospitalization — US$86 billion a year — this is a shockingly poor return on investment. Given that at least half of maternal deaths in the United States are preventable, this is not just a matter of public health, but a human rights failure.”[4]

Dr. Cash and his colleagues are now implementing a “culture of nonintervention” successfully in Michigan, and patient education is an essential component of the plan. He notes that natural birth “is the expectation of our department; it’s the expectation for the doctors, the nurses, and the patients. We tell them that from the onset.” Labor and delivery staff inform expectant parents about pain-relieving positions and equipment they can use throughout the birthing process and now provide more counseling with women to help laboring women relax and focus.[5] Nearly every major birthing center, in 65 of the state’s hospitals, is taking part in the Keystone project. While more data on patient outcomes will be published in December, hospitals have reported an 18 percent drop in elective C-sections before 39 weeks of gestation and a 13 percent drop in the use of labor-induction drugs between March 2010 and March 2011. Staff have also seen improved Apgar scores (newborn health measurements) and lower numbers of infants in intensive care.[6]


[1] Patricia Anstett, “Statewide Project Helps Mothers Avoid C-sections,” Detroit Free Press, 8 November 2011, accessed 8 November 2011, <>.

[2] Martha Bebinger, “Top Maternity Hospitals in Mass. Stop Early Elective Deliveries,” WBUR: Boston’s NPR News Source, 14 November 2011, accessed 16 November 2011, <>.

[3] Anstett, “Statewide Project Helps Mothers Avoid C-sections;” see also “Births: Final Data for 2008,” National Vital Statistics Report vol. 59 (Atlanta,: Centers for Disease Control and Prevention, December 2010), accessed 16 November 2011, <>, figure 1.

[4] Francine Coeytaux et al., “Maternal Mortality in the United States: A Human Rights Failure,” Contraception Journal: Association of Reproductive Health Professionals, March 2011, accessed 16 November 2011, <>.

[5] Anstett, “Statewide Project Helps Mothers Avoid C-sections.”

[6] Ibid.