Call to Action: Limit Early Elective Deliveries, Improve Outcomes

By Megan M. Krischke, contributor

February 7, 2011 - Could patient or physician convenience be threatening patient safety and driving up costs in your L&D and NICU wards? If so, policy changes regarding scheduled deliveries could make all the difference.

CPOE LBinder
Leah Binder, CEO, The LeapFrog Group, urges hospital executives to take a look at their early elective delivery rates and to take action.

In January, The LeapFrog Group, an employer-driven hospital watchdog group, issued a call to action for hospitals to reduce the number of non-medically indicated Cesarean sections (C-sections) and inductions before the completion of 39 weeks of pregnancy based on the findings of its annual hospital survey. While delaying elective deliveries until 39 weeks has been the recommendation of the American College of Obstetricians and Gynecologists (ACOG) for nearly three decades, the LeapFrog Group is the first national organization to publicly report the data by hospital.

The LeapFrog survey revealed that in 2010, nearly 57,000 babies were delivered for non-medical reasons before 39 completed weeks of gestation. Of interest is that the percentage of early elective inductions varied widely from nearly zero to over 40 percent of births, even among hospitals in the same city or region.

Alan Fleischman, MD
Alan Fleischman, M.D., medical director at March of Dimes, said that insurance companies are rethinking reimbursement policies that create a financial incentive for physicians to offer early elective deliveries.

“We are always on the lookout for how we can measure the quality and safety of maternal/child care, so we began including this element in our survey after the Joint Commission added it to their measures of quality of care,” commented Leah Binder, CEO, The LeapFrog Group.

When it comes to why there are so many early elective deliveries, Alan Fleischman, M.D., medical director for the March of Dimes, offers several reasons: women are uncomfortable and want the pregnancy to be over; physicians are reluctant to argue with their patients who are requesting early deliveries; people are used to being able to schedule their lives; women want their own practitioner to deliver them; and practitioners face a financial disincentive for not delivering their own patients.

“While all early deliveries carry risks, the fact of the matter is that there are very few interventions, other than delivery, that are beneficial to the fetus if there is a complication with the pregnancy,” explained Fleischman. “There is, however, some debate about what the appropriate indications are for early delivery.”

“The last few weeks of pregnancy are critical to a baby’s health because important organs, including the brain and lungs, are not completely developed until then,” he said in the LeapFrog press release.

Limiting elective deliveries until after 39 weeks results in better outcomes for mothers and babies, decreased NICU admissions, shorter maternal hospital stays, fewer lawsuits, more available space in labor and delivery units (induced labors generally last longer), reduced numbers of C-sections, and reduced costs overall.

In fact, a study published by the American Journal of Obstetrics and Gynecology in 2010 estimated that nearly $1 billion could be saved each year in the United States if the rate of early elective deliveries was reduced to 1.7 percent.

“Implementing a policy that elective deliveries will not be scheduled between 37 and 39 weeks is something hospital executives can do to immediately impact the quality and safety of patient care. If they pass that policy today, tomorrow they will have fewer admissions to their NICU,” emphasized Binder. “Hospital executives should be ensuring that unsafe practices are not happening in their hospitals.”

For hospital leaders looking to limit early elective deliveries, The March of Dimes offers their 39 Week Toolkit free of charge. The Toolkit includes educational programs for health professionals, the forms a provider must fill out to justify scheduling an early delivery, tools for collecting data, defining problems and creating and implementing solutions. Additionally, there are consumer education materials that teach women about the importance of the final weeks of pregnancy and local March of Dimes chapters are available for assistance.

Ralph Steiger, MD
Ralph Steiger, M.D., medical director of maternal-fetal medicine, said that policy changes at Desert Regional Medical Center eliminated early elective inductions.

In 2005, Desert Regional Medical Center (DRMC) in Palm Springs, Calif., instituted a policy that they will not allow any non-medically indicated deliveries before 39 completed weeks of pregnancy and almost immediately reduced their number of elective early inductions to zero.

“In the beginning we got some push-back, with providers threatening to go to other hospitals. But I would advise them to review the ACOG guidelines and to tell me if I wasn’t simply holding them to our professional society’s recommendations,” reflected Ralph Steiger, M.D., the medical director of maternal-fetal medicine at DRMC.

“If you admit someone for an elective induction, you get a call back saying you can’t do that because it is in the rules and regulations,” he continued. “The nursing staff won’t give the medication for the induction. We won’t allow deliveries even one day early to avoid the slippery slope.”

Teri Kiehn
Teri Kiehn, MS, RNC, at Intermountain Healthcare was able to show their providers that the data proved better delivery outcomes after 39 weeks of pregnancy.

Steiger added that the charge nurse is often the one who becomes the gatekeeper, which can be quite stressful, so they need to know that the hospital leadership is behind them and will take the call if things get too stressful.

Intermountain Healthcare, a group of hospitals based primarily in Utah, reduced their rate of elective deliveries from 30-35 percent in the early 2000s, to under 5 percent since 2005. Intermountain, after providing clear information on the risks of early inductions, will still allow patients to choose a non-medically indicated early delivery.

Intermountain Healthcare’s Teri Kiehn, MS, RNC, data manager for women and newborns clinical programs, admitted that asking providers to not schedule elective deliveries before 39 weeks was a big change.

“They felt like they should have a choice, but after we showed them the data that reflected better patient outcomes if inductions were delayed until after 39 weeks, they were much more willing to comply.”

“We have a very robust electronic medical record that showed that elective deliveries prior to 39 weeks had more complications, resulted in more C-sections and that newborns were more likely to have to be separated from their mothers, have feeding problems and need oxygen,” explained Kiehn.

For other organizations desiring to reduce their early elective deliveries, Kiehn suggests sitting down with a multi-disciplinary team, including some consumers, and taking a look at the data. Determine the easiest places to initiate a change and decide what you want to accomplish and how you go about implementing the changes.