A greater willingness by hospitals to not schedule early elective deliveries without documented medical necessity is a major reason for the drop cited in The Leapfrog Group's latest survey findings.
At long last, policy changes made by hospitals have resulted in plummeting numbers of women undergoing medically unnecessary C-sections and inductions before 39 weeks of pregnancy, according to the latest Leapfrog Group survey, released Monday.
In 2010, the first year the watchdog group conducted this survey, 793 hospitals reported rates of early elective deliveries that averaged 17%, although many were more than 50%.
For 2013, nearly 1,000 hospitals reported rates that averaged 4.6%, just below Leapfrog's target rate of 5%, and almost none over 50%. As of the 2013 report, 71% of hospitals reporting to Leapfrog fell below 5%, a sharp contrast to 46% of hospitals in 2012.
Leah Binder, President and CEO of The Leapfrog Group, called the reduction "very impressive.
"When you're advocating for change in healthcare, you get accustomed to seeing a very slow pace of change; and even 1% is a cause for celebration. So when we see over a four-year period this kind of massive shift in performance, it's extraordinary. I've never seen anything like it in my career," she says.
Today women eager to deliver and physicians looking to organize their delivery schedules are more likely to be encouraged to wait for the natural process to evolve for both the health of the baby and the mother. Waiting reduces the risk that a newborn will require expensive and risky care in the neonatal intensive care unit, or other developmental problems as the child grows up.
Binder cites two major reasons for the change:
1. Greater transparency through the disclosure of hospitals' rates of early elective deliveries by individual facility name and by state, which Leapfrog began with the first report in an annual series in 2011 for volunteering hospitals.
2. More widespread use of obstetric unit "hard-stop" policies, by which hospitals refuse to schedule any woman's delivery prior to 39 weeks without documented medical necessity.
On transparency, Binder says, "the amount of attention that (the 2011) announcement received was unprecedented for Leapfrog. We did nothing more than report these numbers, but transparency has a big motivational impact."
Binder says that "a lot of quality improvement projects are done with no transparency and are not nearly as successful at changing the culture and the practice. This is not a minor point. So often we start improvement projects in healthcare and we say we're not going to release the data or we hide the data because we don't want anyone to be embarrassed."
The second major influence, hard stop policies in the obstetric units, has changed the culture of obstetrician gynecologists. "At least in hospitals we've spoken with where we see massive improvement, they've made it more difficult to schedule these deliveries," she says.
"When they put in place a policy that these deliveries can not be scheduled without a medical reason—and if a physician wants to schedule a delivery, they need to go through a process to get it approved—that pretty much lowers the rate pretty quickly."
The Leapfrog program encourages hospitals with at least 50 births a year to voluntarily report to the organization, and the list of those that do continues to climb, with 200 more hospitals reporting for 2013 than reported for 2010.
Other Efforts
In recent years, several researchers have published findings showing that women who give birth before 39 weeks or pregnancy run a higher risk of delivering babies with developmental disabilities and neurocognitive problems. Other reports suggest that the mother herself is at greater risk of complications, such as excessive bleeding, when babies are delivered before they're ready.
In early 2012, the U.S. Department of Health and Human Services launched "Strong Start," which received broad support from the American Hospital Association, the March of Dimes, and numerous medical specialty groups such as the American Academy of Pediatrics and the American College of Nurse Midwives.
Also in 2012, the federal Partnership for Patients' Hospital Engagement Networks (HENs) effort included reduction of early elective deliveries as one of 11 quality improvement goals for more than 3,000 hospitals.
Last month, the American Hospital Association's HEN reported results from its first two years saying that among its 1,500 participating hospitals, interventions prevented 13,340 babies from being electively delivered prior to 39 weeks, and 640 babies "did not have to go to the neonatal intensive care unit." That saved the healthcare system $3.13 million.
The Centers for Medicare and Medicaid Services recently began posting on Hospital Compare rates of medically unnecessary early elective deliveries either vaginally or by C-section under 39 weeks.
And in some states, such as California and South Carolina, payers are tying rates of hospital payment to reducing early elective delivery rates, Binder says.
Length of Stay in NICUs
An important provocation was the anecdotal observation within the healthcare industry that hospitals that had high rates of early elective deliveries without medical justification also had higher numbers and long lengths of stay for babies in their neonatal intensive care units, which often is a hospital profit center.
"We were hearing quite a lot of information about NICUs being populated by these babies," Binder says. "And there's very little in the world that's more heartbreaking than a baby in the NICU for no good reason. What this comes down to is that hospitals head true north for the good of the patient."
Binder notes that the momentum of change picked up between 2012 and 2013, "with the rate of early elective deliveries cut in half from 2012 alone," from 11.2% in 2012 to 4.6% in 2013.
Leapfrog Group was not the first organization to be concerned about the problem, Binder says. The March of Dimes and the American College of Obstetrics and Gynecology had been talking about this for decades, she says. "But these got very little attention and no traction.
"We put out the data. We said here's the problem, and here's where it is, which hospitals are doing what," Binder says.
Binder says that there is still work to be done for the 280 reporting hospitals that still have rates over 5%. "We hope to see them join their colleagues in preventing these deliveries in the future," she says.