What better time to go public about healthcare quality than at the start of life?
That's what The Leapfrog Group is trying to do with an annual survey that reveals by name those hospitals with unacceptably high (more than 5%) rates of elective inductions and Cesarean sections performed "for no medical reason" between 37 and 39 weeks.
No reason, that is, except that it was more convenient for the obstetrician, for the hospital, or perhaps for the patient, and draws more revenue in fee-for-service payment systems. Rates of these elective early births, or "social" deliveries involving medical interventions, have skyrocketed over the last decade.
It's not just about the money, although childbirth mishaps linked to these early births add $1 billion to healthcare costs. Evidence has accumulated in the last two years about significant harm, including neurodevelopmental problems, rates of disability, brain size, and sleep behaviors, in babies born just a few weeks too soon.
Organizations tracking this trend attribute it to the fact that pregnant women haven't been informed about the terrible consequences associated with some elective inductions or C-sections performed before 40 weeks. If expectant mothers knew, they would certainly wait.
Now, data is accumulating to better document the harm obstetricians and hospitals can cause mothers and their babies when providers give assurances that a 37 to 39-week old fetus is good to go. A stay in an expensive NICU is not the same thing as longer gestation.
"Until recently, the late preterm infant has been overlooked because of assumptions that most of these infants have little to no risk for long-term morbidities," said Steven Benjamin Morse, MD, and colleagues in a 2009 paper published in the journal Pediatrics.
"However, several recent studies for late preterm, term infants have documented increased short-term medical risks during their birth hospitalization (e.g., respiratory distress, hypoglycemia, temperature instability, hyperbilirubinemia) and higher rates of readmission to the hospital after the birth hospitalization compared with term infants," he wrote.
The human toll of developmental problems that come to these babies aside, money of course is a big issue. "For the commercial (insured) population, the non-governmental payers and employers, (labor and delivery care) constitutes about 20% of the cost," says Barbara Rudolph, the Leapfrog Group's senior science director.
"This issue, childbirth, is one that's specifically a working person's issue," as opposed to a government payer's, although Medicaid is taking steps to include provider reporting of 37-39 week elective deliveries as well.
Now, however, awareness campaigns are underway, like those from the Childbirth Connection and the March of Dimes, which are attempting to correct the pervasive myth that a fetus is full-term, more or less, at 37 weeks. Proponents of awareness make the crucial point that the date of conception can be off by a few weeks, so fetal development believed to be 39 weeks might really be 37.
Across the country, many hospitals are launching their own campaigns modeled after the March of Dimes', with names like "Worth the Wait," targeted for pregnant women, or instituting policies like "Hard Stop," which means a hospital's labor and delivery unit receiving a physician's request for an early elective delivery without documented medical necessity will just say no.
"A baby's brain at 35 weeks weighs only two-thirds of what it will weigh at 39 to 40 weeks," says the website of the Oregon and Washington state chapter of the March of Dimes.
Leapfrog, an effort launched 11 years ago by large employers to measure hospital quality to aid consumers and plan contractors make wise healthcare purchasing decisions, isn't stopping with the delivery process. Leapfrog is adding several metrics to monitor quality of care for newborns and their mothers, and is investigating the idea of adding more measures for prenatal care.
For example, the group is looking at practices for newborns and deliveries beyond whether gestation is allowed for 40 weeks, including:
• Episiotomy rates, which vary widely in vaginal births across the country, will be added to hospital reports as of April 1, Rudolph says.
Leapfrog is adding the measure because of "clear research that routine episiotomies do not help prevent more extensive vaginal tears during childbirth than natural tears, and that episiotomies can result in a variety of lasting morbidities for the mother (e.g., incontinence after childbirth, the mother’s bladder and rectum drooping into her vagina, pain during sex)," the group explains on its Website.
The incidence rate of episiotomies in vaginal births in 2008 and 2009 was slightly over 12%, but vary dramatically across providers and hospitals. It should be closer to zero, according to the National Perinatal Information Center/Quality Analytic Services database.
• DVT prophylaxis, rates of which also vary widely, should be assured for women undergoing Cesarean section. Leapfrog adopted this measure in 2009 to encourage hospitals to strive to assure that at least 80% of patients receive this preventive care, such as fractionated or unfractionated heparin or pneumatic compression devices prior to surgery.
• Jaundice and encephalopathy prevention should include routine bilirubin testing to prevent abnormal levels, and in extreme cases, a condition called Kernicterus. Leapfrog wants hospitals to achieve testing rates of 80% or better.
"A fair number of Leapfrog participant hospitals meet the goals, but sometimes women leave the hospital early, and hospital providers say they should be responsible to watch out for symptoms on their own," Rudoph says. Under this measure, the hospital should make that monitoring routine.
And by the way, Leapfrog Group is not the only organization drilling into public reporting of perinatal quality measures. The Joint Commission is getting ready to roll out five public reports, covering not just rates of elective delivery, but also Cesarean sections, antenatal steroids, healthcare associated bloodstream infections in newborns and exclusive breast milk feeding.
Some success, but more to do
In one year, Leapfrog's survey has shown a measured decrease in the number of women who were persuaded to have early elective inductions or Cesarean without medical indication. For example, 65% of participating hospitals improved; but the numbers are still poor.
As we reported last week, of the 757 hospitals that agreed to participate and disclose their rates, inappropriate early scheduled births averaged 14% – much higher than the National Quality Forum-endorsed threshold of 5%, which was achieved by 39% of the hospitals reporting.
About 140 hospitals had rates of 20% or higher and 32 had rates so high, the spreadsheet just said "greater than 40%."
Another major challenge is to encourage more hospitals, especially those with major maternal care programs, to respond to the survey.
Rudolph says there are many reasons why so many hold back. Sometimes, she says, "the chief medical officer doesn't agree with the measure or decides it's not fair or that it doesn't include everything it should.