The latest Leapfrog data are consistent with what other efforts that are aimed at reducing early elective deliveries have been able to show, said Dr. Donald Dudley, professor and vice chair for research in the department of ob.gyn. at the University of Texas Health Sciences Center in San Antonio.
Dr. Dudley also has been active in the March of Dimes Big 5 Prematurity Collaborative, which has been working to reduce preterm births through evidence-based quality improvement projects.
The Big 5 Prematurity Collaborative worked with 25 hospitals in California, Florida, Illinois, New York, and Texas to implement a policy of not performing elective deliveries before 39 weeks unless they are medically indicated. They found that hospitals – regardless of their size or location – were able to rapidly reduce early elective deliveries. The key, Dr. Dudley said, was making physicians and nurses aware of the data on complications from early deliveries.
Dr. Dudley said some physicians are skeptical that those last few weeks make that big a difference. He had been one of them. But once he read through the studies, it became clear that deliveries before 39 weeks were not the safest path for mothers and babies. "You’ll come away saying it is really not a good idea to do elective deliveries at less than 39 weeks," he said.
Once the buy-in from providers is there, making the change is fairly simple and relatively cheap, Dr. Dudley said. Hospitals can take advantage of free toolkits like the one from the California Maternal Quality Care Collaborative and the March of Dimes.
The most costly and time-intensive part of any effort to reduce early elective deliveries is the data collection, he said. Hospitals need to know how they doing at the start, but many community hospitals don’t routinely collect those data.
Dr. Dudley cautioned hospitals to be careful not to push the policy so hard that they discourage physicians from exercising their clinical judgment. "One of the things we have to be really careful about is not to swing the pendulum so far the other way that we disengage our brains."
If there’s a reason for a patient to be delivered at less than 39 weeks, then the delivery is indicated, not elective, he said. And there is a long list of appropriate indications for an early delivery.
For example, Dr. Dudley said he recently had a patient whom he had been monitoring and hoping to deliver after 39 weeks, but at 38 and a half weeks her blood pressure began creeping up enough that it was necessary to do the delivery early. The patient had a history of hypertension, and the risk of waiting outweighed the risks of early induction, he said. "You don’t want to delay acting when there’s an acceptable indication."
Policies aimed at reducing early elective deliveries can introduce a reluctance to induce (either by the physician or the patient) that may result in delaying an induction that is actually indicated, said Dr. William H. Barth Jr., chief of the division of maternal-fetal medicine at Massachusetts General Hospital, Boston, where the early elective newborn delivery rate has declined from 8% to 4% between 2010 and 2011. "Recommending an induction is a complex decision," he said. "The recent push to decrease elective inductions is sort of one more factor in the mix of that complex decision."
But the other issue is simple math, Dr. Barth said. If more inductions are delayed – indicated or not – there will be more stillbirths. He pointed to a retrospective cohort study published last year in Obstetrics & Gynecology that looked at the effect of a policy limiting elective delivery before 39 weeks’ gestation. The researchers found a significant decrease in admissions to the neonatal ICU, but they also detected an increase in stillbirths at 37 and 38 weeks (Obstet. Gynecol. 2011;118:1047-55).
Dr. Barth advised hospitals considering formal policies to reduce early elective deliveries to track not only the number of elective deliveries, but also stillbirths. "Shared decision making between patients and physicians is best conducted with all of the information – good and bad," he said.