In 2018, Michigan was facing a concerning reality: nearly one in three births in the state occurred by cesarean delivery, a rate that exceeded the national average and signaled opportunities to improve the safety, experience, and value of childbirth care. Behind every data point were real families navigating some of the most important moments of their lives and clinicians striving to deliver the best possible care within a complex maternity landscape. The need for change was personal, urgent, and increasingly difficult to ignore.
As such, patients, clinicians, and employers began voicing concerns about rising cesarean rates affecting patients’ recoveries, long-term health, and trust in the healthcare system. Recognizing the scope of the problem and the opportunity to address it, Blue Cross Blue Shield of Michigan (BCBSM) turned to clinician leaders at University of Michigan to help design a statewide response, which leveraged Michigan Value Collaborative (MVC) claims data on childbirth episodes. In 2018, this collaboration laid the groundwork for what would become a dedicated effort to transform maternity care in Michigan.
Formally launched in 2019, the Obstetrics Initiative (OBI) emerged as one of BCBSM’s 21 Collaborative Quality Initiatives (CQIs). At that time more than 70 hospitals joined together under OBI’s vision to support safer deliveries, reduce unnecessary cesarean deliveries, use resources more wisely, and improve the overall culture of care. Today, OBI continues to build on that foundation by ensuring that every birth in Michigan is supported by the best evidence, the best practices, and a shared commitment to healthier beginnings.
Services and Benefits for OBI Members
To support its members in successfully implementing quality improvement (QI) initiatives, OBI supports its members using four primary offerings (Figure 1). One of those offerings is OBI’s robust, real-time benchmarking data that enables actionable insights. OBI’s registry is a best-in-class source of clinically credible data and compelling data stories that inspire change. A second core offering is direct support and expertise on specific QI interventions, including the development of best practice protocols and resources that advance evidence-based care. A third core offering is the transformational learning that occurs at OBI’s collaborative-wide meetings and other activities that are key to networking, partnership building, and collective learning across maternity units in Michigan. Finally, a fourth core offering is the intentional collection and incorporation of patient stories and experiences in all ongoing activities.
Figure 1: OBI Member Service Offerings
OBI Program Director Michelle Moniz, MD, MSc, recognizes how OBI’s tailored approach to QI support helps sites achieve a shared purpose of high-quality perinatal care that improves the lives of current and future generations. In her words:
“Every large-scale QI initiative faces a vexing unsolved problem: how best to support hospitals and clinicians who aren’t responding. Our routine QI support approaches—group meetings, webinars, online toolkits, performance incentives—can fall short for sub-optimally responding sites/clinicians, and leave patients vulnerable to low-quality, low-value healthcare. OBI imagines a future where CQIs deliver the right support, to the right hospital/clinician, at the right time, to achieve highest-quality care across all CQI members. This vision—which we call Precision QI—leverages scarce resources most efficiently to achieve evidence-based healthcare at scale for all patients.”
OBI’s "precision QI” offers personalized QI support for each hospital. Just as precision medicine accounts for individual patient differences in developing a treatment plan, OBI’s precision QI support model (Figure 2) is adaptive, diagnosing and responding to the unique needs of each OBI member and may include:
- Performance Measurement: Offering observed, risk-adjusted, and peer-comparative data
- Performance Feedback: Incorporating individualized goal setting and data for hospitals and individual providers
- Outreach: Offering augmented support when performance deteriorates or is stably poor
- Engagement: Offering a suite of resources for key target audiences, including hospital leadership, QI leader, bedside clinicians, and patients
Figure 2. Mechanisms for OBI’s Precision QI Support Model
OBI’s Key Initiatives and Achievements
OBI is now a unique asset for quality improvement in Michigan and beyond. Having built a vibrant community of multidisciplinary teams at currently 65+ hospitals across Michigan, OBI generates the evidence base needed for more effective, transformational quality improvement in obstetrics.
Putting that framework into action, OBI achieved noteworthy successes over the years. Since OBI’s inception, their flagship initiative, Safely Averting Cesarean Births, has focused on safely lowering the primary cesarean rate in Michigan. In 2023, OBI launched Patient Voices, a statewide survey to assess childbirth experiences and patient-reported outcomes related to birth. OBI then launched another statewide initiative, Bringing Our Patients COMFORT, in 2024, to promote best practices for managing pain after childbirth.
To reduce first-birth term cesareans – also known as nulliparous term singleton vertex (NTSV) cesareans, OBI’s Safely Averting NTSV Cesarian Births initiative successfully reduced the statewide cesarean rate from a historic high of 28.9% in 2023 to 26.9% as of September 2025. This improvement reflects years of effort to increase compliance with national diagnostic criteria for labor arrest disorders (which increased from 37.9% in 2020 to 77.1% in 2025). Increased compliance was aided using an algorithm to guide fetal management in labor, resulting in significant improvement from 47.3% compliance in 2022 to 93.2% in 2025.
Pain management is another area where OBI has made meaningful progress. Successful promotion of the use of scheduled nonopioid prescribing after cesarean births through OBI’s Bringing Our Patients COMFORT quality initiative boosted a compliance rate of 86.1% in 2024 to 96.8% compliance in 2025. Analyses are ongoing to evaluate corresponding reductions in opioid prescribing rates and amounts.
OBI’s third quality initiative Better Births for All aims to ensure that every OBI member has the tools and support to consistently implement evidence-based obstetric practices while fostering psychological safety and respectful, person-centered care for all during labor and birth. The path to accomplish that is threefold. First, OBI partners with a Patient and Community Action Board (PCAB) to center patient and community experiences in its QI initiatives. The OBI PCAB reviews patient-facing materials and has decision-making power over OBI’s selection of QI initiatives and operationalization of initiative measures in OBI’s incentive packages. OBI further centers patients’ perspectives in its work by measuring and improving collection of patient-reported outcomes and experience data to ensure that patients’ voices are embedded in daily QI work. OBI also educates and trains clinicians on patient-centered approaches and practices they can bring to their own daily work.
What’s Next for OBI?
In 2026, OBI will launch a new Induction of Labor initiative to promote evidence-based management of induction of labor (IOL), the procedure to start labor before it begins on its own. This procedure occurs in more than 30% of all births, and yet the use of evidence-based techniques occurs in less than 10% of all inductions with wide variation across sites in Michigan (Figures 3 and 4).
Figure 3. Pathways for Evidence-Based Induction of Labor
OBI is incredibly proud to be a part of the 25+ year history of the Value Partnership portfolio in Michigan, including its long-standing partnership with MVC. OBI and MVC are currently collaborating on several analyses to drive quality improvement, such as evaluating statewide variation in complications and expenditures for different patient groups and modes of delivery, improving the timeliness and quality of prenatal care, evaluating the association between social vulnerability and surgical management of early pregnancy loss. MVC is also working with OBI to estimate the impact and associated cost savings of OBI’s efforts to safely reduce cesarean birth rates in Michigan as well as the impact of OBI’s opioid management work on prescribing rates and costs in Michigan.
The BCBSM-funded CQIs play a crucial role in driving healthcare quality improvement in Michigan. MVC is excited to continue highlighting the innovative contributions of individual CQIs and the ways in which MVC’s data are supporting high-value care initiatives across the portfolio. Please reach out to MVC by email [LINK] if you are interested in learning more.