The latest salvo in the battle to eliminate unnecessary deliveries before 39 weeks gestation is a Web site that lets expectant mothers compare individual hospital rates of early elective deliveries.
An annual survey by the Leapfrog Group found 57,000 early deliveries by induction or scheduled C-section for nonmedical reasons at 773 U.S. hospitals that provided data. Rates varied between hospitals by more than 100-fold. In Ohio, for example, early elective delivery rates ranged from 0.3% to 32% among the 36 hospitals reporting.
The Leapfrog Group is a project of employers that buy health insurance for employees, such as General Motors and the Boeing Company. View the survey findings.
"This is a matter of great national concern," Leapfrog chief executive officer Leah Binder said in a telephone press conference. "There are thousands of babies in neonatal intensive care units who shouldn’t be there today."
Babies need at least 39 weeks of gestation to fully develop the brain and lungs. Babies delivered before term (40 weeks or later) for nonmedical reasons are more likely to need intensive care and breathing assistance, to develop infections, and to die, previous studies have shown. Elective C-sections increase risks for mothers and affect options for future deliveries. Delivery before 39 weeks is not justified unless there is a medical indication for early delivery, Dr. Alan R. Fleischman said in the teleconference.
"Gestational dating can be grossly inaccurate, even off by as much as 2 weeks, so unindicated inductions and scheduled cesarean sections can have serious consequences, even possibly resulting in a premature birth – a baby born before 37 weeks," said Dr. Fleischman, medical director of the March of Dimes. "Every week counts," since a third of fetal development occurs in the last 5 weeks of pregnancy.
He and Barbara Rudolph, Ph.D., Leapfrog’s senior science director, will host two free national webinars in February for health care workers to promote a quality improvement toolkit for eliminating early elective deliveries; they are scheduled for Feb. 15 from noon to 1 p.m., Eastern time, and Feb. 17 from 3 p.m. to 4 p.m. For more information, contact Leapfrog’s Melissa Danforth at mdanforth@leapfroggroup.org.
The "Less than 39 weeks toolkit," developed by the March of Dimes with the California Department of Health and the California Maternal Quality Care Collaborative, is available for free online. It includes a literature review about the risks of early elective delivery, a step-by-step guide for hospital leaders who want to eliminate early elective deliveries, a guide for measuring and tracking quality improvement, sample forms and case studies, and educational tools for clinicians, staff, and patients.
The Leapfrog data comprised a minimum of 100 births from each hospital that reported, with early elective deliveries ascertained from those. The methodology was developed by the Joint Commission and does not cover all births in 2010 at each hospital.
Rates of elective deliveries between 37 and 39 full weeks of gestation ranged from less than 5% to more than 40% at individual hospitals. There is no national benchmark for an acceptable rate of early elective delivery, so Leapfrog tapped an expert panel to say that 12% or less would be acceptable. Half of the reporting hospitals in the survey hit that benchmark and 29% reported rates below 5%, so Leapfrog will lower its acceptable rate for 2011 to 5%, Ms. Binder said.
Not all hospitals were surveyed, and many who were did not respond. In Alabama, for example, 101 hospitals declined to respond and 5 said the survey did not apply to them. The four hospitals that responded reported early elective delivery rates of 13%-24%. Rates can vary greatly on local levels too. At Los Angeles hospitals, rates ranged from 4% to 29%, and in Boston, from less than 1% to 27%.
Women need to demand that hospitals disclose their early elective delivery rate in order to make informed decisions about where to give birth, Maureen Corry of the advocacy group Childbirth Connection said in the teleconference.
Her organization commissioned a poll of 1,573 women delivering in U.S. hospitals in 2005 (the Listening to Mothers II survey) and found that 1 in 3 mothers reported labor induced by artificial means. Reasons reported for induction were caregiver concern that they were overdue (25%), maternal health problems (19%), the mother’s desire to finish the pregnancy (19%), and caregiver concern about the size of the baby (17%), Ms. Corry said.
Guidelines by the American College of Obstetricians and Gynecologists have long opposed elective early deliveries and say that a large size is not an indication for early elective delivery, Dr. Fleishman said. "It’s more than just education that’s needed. It is a commitment on the part of the hospital to set up specific guidelines and policies to empower those people who are taking the requests of doctors who are initiating inductions or scheduling cesareans to question, to have forms and a peer review process," he said.