Hospitals and their obstetricians must drastically reduce the number of pregnant women who – through pressure or lack of correct information – agree to undergo non-medically necessary labor induction before their 39th week because they are not safe.
That's the message from The Leapfrog Group, an employer-supported hospital quality watchdog group that receives voluntary information from some hospitals. In an effort to educate providers to change their practices, the group is making each facility's induction rates public for the first time to show the enormous variability and extent of potentially harmful early deliveries.
"This has been extremely disturbing (finding) to our members," Leapfrog CEO Leah Binder said in a news conference this week. "We are calling for hospitals to put policies in place that prevent (non-medically necessary) early elective delivery."
The group released its Call to Action: Protect Mothers and Babies from Unnecessary Harm" in conjunction with the March of Dimes and its senior vice president and medical director, Alan R. Fleischman, MD, and the advocacy group, Childbirth Connection. The Call to Action was prepared in a partnership with several of the largest health plans, including CIGNA, UnitedHealthcare and WellPoint, in a plan to improve quality and lower costs.
The 773 hospitals in Leapfrog's 2010 hospital survey reported 57,000 early elective deliveries by Cesarean section or induction during the reporting period, with varying rates as high as 100-fold from hospital to hospital and state-by-state, Binder said. In at least one hospital, nine in 10 births were delivered with unnecessary early induction, the report shows.
For example, Riverside Community Hospital Riverside, CA reported a 55.1% rate of early induction, while the University of California Ronald Reagan Medical Center reported its rate at 4%. Putnam Hospital Center Carmel NY reported a 94.3% rate.
Hospitals should have rates of elective induction no higher than 5%, Binder says.
"Leapfrog's release of 2010 data is the first real evidence that the practice of scheduling newborn deliveries before 39 weeks without a medical reason is common and varies among hospitals even in the same state or community," Binder said.
"We all know that there are clearly instances when an early delivery is medically necessary for the health of the mother or the baby," Fleishman said. But, as the American Congress of Obstetricians and Gynecologists makes clear in its guidelines, there should be no elective induction or scheduled Cesarean delivery before 39 weeks without clinical indication.
"Even a mature fetal lung test before 39 weeks in the absence of appropriate clinical circumstances is not an indication for delivery," Fleischman said. "Healthcare professionals and patients must continue to make those hard clinical choices while they remember that critical development occurs to a baby's brain, lungs, liver and other organs during the last weeks of pregnancy (and) one-third of fetal brain development occurs in the last five weeks of pregnancy.
"And there are significant increased problems for babies born just a few weeks early (such as) neonatal intensive care unit admissions, feeding problems, jaundice, inability to hold temperature, and tremendous increased costs. Every week counts."
Asked why medically unnecessary inductions are increasing, and why there is so much variability across the nation, Fleischman said that a "perfect storm" has increased the occurrence.
- First, often the mother is at the end of her pregnancy and feels that she's had enough.
- Second, the doctor wishes "for convenience to schedule his or her life...we have a much more interventionist practice these days....Obstetricians are in fact pretty anxious to deliver babies early."
- And third, women have misperceptions about the safety of earlier birth. According to a 2009 report, Fleischman said, one in four women believe that 34 to 36 weeks is full term and another 50% think 37-38 weeks is full term. "75% got it wrong. A true full term is 39-40 weeks and women think there are no medical complications for early delivery."
The Leapfrog report asked hospitals to submit the percentage of inductions and Cesarean sections between the 37th and the 39th week. These elective early procedures were classified as non-medically necessary if they were not done for any of the several dozen justifiable exclusions specified by the National Quality Forum, such as the women in labor had hypertension or diabetes or multiple gestation.
The Leapfrog Group suggests this web site as a resource for providers who want more information on guidance for the appropriateness of early induction procedures.
The site lists several reasons women are given for why they should have early induction that are not supported by rigorous research. Those reasons include:
- · Preterm pre-labor rupture of the membranes
- · Twin pregnancy
- · Gestational diabetes requiring insulin
- · Intrauterine growth restriction (IUGR) at term and
- · Oligohydramnios (too little amniotic fluid).
Asked why Leapfrog Group is targeting hospitals and not specifically physicians who perform the procedures, Binder replied that physicians are "key caregivers when these deliveries are scheduled to o early and obviously they have a critical role in that happening."
She said, however, that at Leapfrog, "we're looking at the outcomes, we're looking at the data. We want to know what's going on so our purchasers can make good decisions about insuring that employees are getting the best quality care."
Binder added that at Leapfrog "we do think that hospitals have a bottom-line responsibility for what goes on within their walls. As consumers, we need to trust that when we walk in the door of a hospital, that all precautions are taken to protect our health and safety and that of our babies."
“Hospitals must look to the recommendations of the ACOG and work with their physicians to end elective deliveries before 39 weeks," said Jack Ludmir, MD, chair, AHA Section for Maternal and Child Health and chair of obstetrics and gynecology at Pennsylvania Hospital. "Elective delivery prior to 39 weeks, that is deliveries without medical indication, is not an acceptable obstetrical practice.” Ludmir also is vice chair of obstetrics and gynecology and director of obstetrical services at the Hospital of the University of Pennsylvania in Philadelphia.