The issue of unnecessary elective early-term deliveries of babies is receiving increasing attention in patient care organizations nationwide. This attention is not happening in a vacuum: an increasing number of reports and policy statements is backing up what has long been quietly understood among many clinicians: that many of the early-term deliveries are not only not medically indicated with regard to their timing, they can be detrimental to the health of babies and mothers.
For example, in June, the federal Centers for Disease Control and Prevention (CDC) reported that the total U.S. cesarean delivery rate reached a high of 32.9 percent of all births in 2009, having risen 60 percent from a rate of 20.7 percent of all births in 1996. Since 2009, though, that rate has remained unchanged.
Averting early-term births is a best practice that is actively being advocated by professional organizations involved in obstetrics, most notably the American College of Obstetrician Gynecologists (ACOG). Indeed, a joint March 2013 press release from ACOG and the Society for Maternal-Fetal Medicine (SMFM), noted that “The College and SMFM have long recommended that doctors not induce labor or perform cesareans before 39 weeks of pregnancy without a clear medical reason. A full-term pregnancy lasts 40 weeks. ‘Early-term’ deliveries are those that occur between 37 and 39 weeks of gestation.”
The March 21 press release noted that “Reducing the number of non-medically indicated early-term births and improving newborn outcomes is possible, according to The College and SMFM. Hospitals around the country have successfully lowered their rates of non-medically indicated early-term births by implementing policies to prevent them.”
One patient care organization in which active work to make such changes has been taking place is the four-hospital, Springfield-based Baystate Health.There, Andrew Healy, M.D., medical director of obstetrics, Daniel Grow, M.D., chair of the department of obstetrics and gynecology, and Peter St. Marie, the organization’s clinical research director, have been involved in groundbreaking work in this area. They have been leveraging PeriBirth EHR [electronic health record] solution from the Princeton, N.J.-based PeriGen, and have been using that data to optimize infant delivery at Baystate Health, where 45 physicians and 25 midwives perform 4,200 infant deliveries every year. Below are excerpts from the interview that Drs. Healy and Grow and Mr. St. Marie gave recently to HCI Editor-in-Chief Mark Hagland.
Can you share with me your overall strategy in pursuing this initiative?
Andrew Healy, M.D.: The background is that we certainly observed that babies were being delivered without a valid medical indication prior to 39 weeks; we also saw babies delivered after 39 weeks were being induced electively who weren’t favorable for induction, meaning that the mother’s cervix was closed. So often, the inductions of those patients would take more than one day—sometimes even three days—and many would fail, and they would have a cesarean section. And many of us have observed problems with the increase in c-sections across the country. And we’re also a teaching hospital, with both residents and medical students, so that element plays into the overall situation.
Daniel Grow, M.D.: And the problems with that are babies being born before they’re 39 weeks, and some of those babies go into the NICU [neonatal intensive care unit]. Furthermore, patients who are induced after 39 weeks’ gestation without a favorable cervix, spend a long time following induction, in labor, and often end up having a c-section. We found all those things unacceptable; so our goal was to eliminate uncalled-for inductions.
Healy: And in terms of process, we brought our faculty physicians and many community doctors into the process as well. And there have been statements from ACOG for more than 20 years, and evidence from recent publications around morbidity and mortality for these babies.
One of the things I’ve heard for years is that there is also a somewhat-hidden convenience factor for some of the physicians in this, having to do with disturbing their off-time with call or delivery.
Grow: You’re right about that, but some physicians will say, I’ve bonded with my patient and she wants me to be delivering while I’m on call or available. And sometimes there’s a reimbursement issue there, too, in terms of who gets paid for the cover delivery. So it’s complicated. But as the March of Dimes and ACOG and Leapfrog [the Leapfrog Group] have shown, babies are best delivered at term or when Mother Nature puts the mother into labor.
How did you reach consensus among all the physicians at Baystate for how to move forward with this?
Grow: Consensus is a strong word, right? So we had to show the doctors the data, and we showed that there were discrepancies in the induction rate between individual physicians and groups of physicians. So we shared the information with each group. There are four or five bigger groups, averaging about eight to 10 physicians each, here.
So you showed them the data in those groups, and got everyone to see what was going on?
Healy: Yes, and there were marked differences between the groups.
So you had a discussion of the differences?