Some hospital obstetric units have reduced their rate of early elective deliveries between 37 and 39 weeks, according to the third annual report card from the Leapfrog Group, but the practice remains risky for both patients and babies.
While 75 hospitals curbed early deliveries between 2011 and 2012, some 54% of the 773 reporting hospitals still failed to meet the target of no more than 5% early elective births without medical necessity. "There's work that still must be done," said Leapfrog Group president Leah Binder.
The Leapfrog Group, a 13-year old organization founded by employers who demanded better measures of quality for their healthcare premium dollars, added labor and delivery risk factors to its public reports three years ago.
That was because of emerging concerns that their employees' babies were being put at risk of long-term and expensive medical and developmental problems, with longer lengths of stay in costly neonatal units, whenever doctors and/or their patients demanded pre-term scheduled births. Leapfrog provides the only rating of this practice that scores each participating hospital.
"Early elective deliveries represent a significant cost of healthcare, with one study estimating that nearly $1 billion could be saved annually in the U.S. if the rate were reduced" to 1.7%, Binder said during a media conference to announce the latest survey results from 2012.
Binder noted that in the last two years, the national average of hospitals' early elective delivery rates without medical necessity dropped from 14% in 2011 to 11.2% in 2012.
Again, as in previous years, hospital rates of early elective deliveries without medical necessity are varied, with six hospitals performing more than 90% of their deliveries as elective inductions or Cesarean sections between 37 and 39 weeks of pregnancy, and some doing none. "Lots of variation is the big story every year we do this survey," Binder said.
Variation is also stark among states. For example, New York and Massachusetts share the lowest rates of 5.9%, but Texas tops the list with rates of 18.3%, followed by Tennessee and Florida at 18.2%.
This year, however, there is evidence that more hospitals are adopting practices that prohibit obstetricians from scheduling premature deliveries in the absence of evidence that without it, the baby or mother would be medically harmed.
For example, John Nash, MD, chairman of the Geisinger Health System's OBGYN department and medical director of women's health, says his system has reduced dangerous deliveries in this fragile period down to zero through rigorous electronic medical record systems to track their physicians practices "and identify when protocols are not being followed.
"There has got to be at some point in the organization, what is termed a 'hard stop.' In other words, if a physician or patient is requesting a delivery before 39 weeks, which is associated with a two-fold increase in morbidity risk to the neonate... we have a tracking system."
When a problematic delivery has been scheduled, "we talk with them personally, and if we don't get an answer that it is in fact medically indicated, than this C-section will not be done in our system," he said.
Geisinger's vice president of operations for Women's Health, Kerri Potsko, added that her healthcare system now uses "behavioral interviewing" to make sure clinicians who work there "are a good cultural and clinical fit.
"During the interview process, we might ask a candidate, 'I'm sure in the past you might have had a patient who expressed a strong desire to deliver on a particular date, for example, her father's birthday, but that would be 38.6 weeks. Describe the conversation you had with that patient.'
"This has been extremely helpful (because) we find out what type of physician we may or may not be hiring."
Nash pointed to an article in the March Journal of the American College of Obstetrics and Gynecology that points to much higher neonatal morbidity and mortality, including unexplained stillbirths, in women who previously gave birth by Cesarean, and choose to schedule a second Cesarean prior to 39 weeks.
Nash added that for mothers who have elective inductions or C-sections "there's a 50% decrease in maternal morbidity if they wait until 39 weeks."
"The medicalization of women's healthcare is something that should be avoided and done only when necessary," Nash said, adding that programs such as Geisinger's lower-risk, midwife-centric experience, "have been a resounding success. So we encourage spontaneous labor as long as there's not a medical complication that would prevent that."
Asked why it has taken obstetricians and the hospitals where they deliver babies so long to recognize the problem, and adjust their practices, Nash explained that for many years, the phrase "carried to term" meant to 37 weeks.
Now, he said, there's much more awareness of the dramatic changes in the neonate between 37 and 39 weeks, especially in the neurologic development of the infant. "One argues that neurologic development could take place in the neonatal intensive care unit as well as in utero," he said. "But believe me, over and over again, we have found out that the best place for the neonate to develop normally, with the best advantage, is in utero."
"It's been an accumulation of evidence of neonatal harm that gave us the wakeup call."
While more hospitals are providing data to Leapfrog's obstetric report, Binder laments that not enough hospitals are willing to be transparent. She says only about one-third of hospitals offering obstetric services now report their rates of early elective deliveries. The other two-thirds just don't want to, she said, or complain that they think the 40 to 80 hours of staff time it takes to compile the survey data is too much.
"That's a lot less than any other reporting instrument we know of, a lot less, but for many hospitals it's more than they wish to commit to."
"I have to be frank," she continued. "We have good evidence behind the scenes that for many hospitals, the issue of transparency is a hard one. They are not accustomed to publicly reporting data, like early elective deliveries, for all to see.
"But I think hospitals are entering a new era of transparency, which is why we're seeing more interest." Binder advises patients and community members to "be assertive in saying that 'we do expect to hear this information from our hospitals before we entrust our lives in their care.' "
See also:
Reducing Early Elective Births Could Save $1B Annually
Rates of Early Elective Births 'Disturbing,' Says Watchdog Group