The Near-Term (Scheduled, Elective,

Convenient)(Indicated?)

Birth Controversy and the OPQC

Christopher T. Lang MDColumbus, Ohio

Disclosures: None

Objectives…

Audience members will be able to: List reasons for current concerns.

Counsel women and families about the risks and benefits of near-term birth.

Adopt care practices to reduce inappropriate scheduled births.

Percent change in gestational age distribution in US (1990-2006)

Martin JA, Hamilton BE, Sutton PD, et al. Natl Vital Stat Rep. 2009.

Causes and consequences of the rise in late preterm birth

A culture of “interventional obstetrics” Medical and obstetric benefit

Rising rates of scheduled births after 37 wks Rising rates of cesarean births

Obstetric complacency Obstetricians work in Labor & Delivery Unit Pediatricians work in the NICU

Unhappy patients and colleagues Happy parents until they are unhappy in NICU Unhappy AAP, March of Dimes, others Unhappy obstetricians (?)

Late-preterm and near-term infants

occupy most NICU beds

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30000

23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

Estimated Gestational Age (wks)

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Clark R et al. Pediatrix Database. 2005.

Increased public awareness of the risks of near-term birth

Morbidity at 37 and 38 wks greater than at 39 wks National conferences – Surgeon General, IOM, NIH Recent literature

March of Dimes State preterm birth “report cards” – Ohio got an F The “Brain Card” The “Fertility Care Card”

Health departments and hospital systems

Hospital Performance Public ReportingPerinatal Measures (March, 2009 Ohio

HB 197)Measure Title Source

Cesarean rate for low-risk first birth women (NTSV CS rate)

California Maternal Quality Care Collaborative

Elective delivery prior to 39 completed wks gestation

HCA - St Mark’s Perinatal Center

Appropriate use of antenatal steroids

Providence St. Vincent’s Hospital/Council of Women

and Infants' Specialty Hospitals (CWISH)

Infants < 1500g not delivered at appropriate level of care

California Maternal Quality Care Collaborative (CMQCC)

Tita ATN, Landon MB, Spong CY, et al. NEJM. 2009.

Timing of elective repeat cesarean delivery at termand neonatal outcomes

Clark SL, Miller DD, Belfort M, et al. AJOG. 2009.

Timing of elective delivery at termand neonatal outcomes

Yoder BA, Gordon MC, and Barth W. Obstet Gynecol. 2008.

Timing of delivery anddiagnosis of clinically significant

respiratory morbidity

411,089 births, 35 – 41 weeks gestational age

Infant mortality rates in Ohio by gestational age at birth1999-2001 (423,803 births)

Infant Mortality RateOhio, 1999-2001

423,803 births, 35-41 weeks gestational age

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35 36 37 38 39 40 41

Gestational Age (weeks)

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ive b

irth

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Obstetrical factors contributing to a culture of scheduled birth

More indicated inductions

Better induction techniques

Confidence in NICU care

Better dates

Antenatal tests not perfect

Liability No suit for doing a

cesarean

Time management

Need to satisfy patients

Competition for OR slots

Cesarean on demand

Availability of anesthesia The tough case

ACOG Guidelines: Indications for induction of labor

(ACOG Practice Bulletin No. 10, 1999) Examples = Abruption, preeclampsia, etc… “Labor may also be induced for logistic reasons,

for example, risk of rapid labor, distance from hospital, or psychosocial indications. In such circumstances, at least 1 of the criteria [for being at least 39 weeks gestation] should be met or fetal lung maturity should be established.”

ACOG Guidelines: Confirming 39 wks gestation

(ACOG Practice Bulletin No. 10, 1999) Fetal cardiac activity documented

x 20 wks without electronic fetoscope or x 30 wks with Doppler

36 wks since positive beta-hCG by reliable lab Ultrasound at 6 - 12 wks 39 wks or greater Ultrasound at less than 20 wks confirms

history and exam IOM Preterm Birth Report early scan for all

patients

As Babies are Born Earlier, They Risk Problems Later

The average U.S. pregnancy has shortened from 40 weeks to 39, driven by social and medical trends, e.g. older mothers, fertility treatments and more

women’s decision to choose when they will deliver. At the same time, medical advances enable doctors

to detect problem pregnancies earlier and to improve care for premature babies, prompting them

to deliver babies early when something threatens their lives or those of their mothers.

The Washington Post May 21, 2006 (1)

As Babies are Born Earlier, They Risk Problems Later

Some question whether the increase in Caesareans and inductions is the reason for the drop in

stillbirths. They worry that much of the increase may be due to women hastening delivery for non-medical reasons — they want to make sure their mother will

be in town, their husband has a business trip pending, or they are just fed up with being pregnant. An obstetrician in San Ramon, Calif. routinely honors such requests for the wives of professional athletes

so their husbands can be present. “I have no problem with that. We never compromise the

mother or baby’s safety.”

The Washington Post May 21, 2006 (2)

The pediatric perspective (summary of the NICHD

Late Preterm Workshop):

Do some health care providers use “soft” indications for induction of labor in late-preterm pregnancies?

Have the improved standards of neonatal care led to a sense of complacency concerning late-preterm births?

Do some patients request early labor inductions (and their obstetricians oblige) for the sake of mutual conveniences? If so, how common are such practices?

Are there variations in standards of care for late-preterm birth?

Obstetrics Elective = not emergent Denominator: all fetuses Measure: gestational age

“Good dates”: hx = US < 20 wks

Pediatrics Elective = convenient

Denominator: live born Measure: birth weight

“Good dates”: Ballard score

Pediatricians do not speak the same language

as obstetricians

Late-preterm birth = not term = not 39 wks386 wks = late-preterm

Scheduled = elective = convenient A scheduled birth between 340 and 386 = elective

Perinatal mortalityUS (1990-2004)

Mathews TJ, MacDorman MF. Natl Vital Stat Rep. 2008.

Non-stress test ≠ Crystal ball

Placenta previa Prior classical cesarean delivery Cholestasis of pregnancy Mild preeclampsia Preterm premature rupture of membranes

Oshiro BT, Henry E, Wilson J, et al. Obstet Gynecol. 2009.

“Institutional commitment” and the feasibility ofdecreasing elective deliveries (1)

Oshiro BT, Henry E, Wilson J, et al. Obstet Gynecol. 2009.

“Institutional commitment” and the feasibility ofdecreasing elective deliveries (2)

A collaborativecollaborative effort by Ohio care providers, hospitals, payers, parents

and policy makers to identify and apply effective improvement effective improvement

methodsmethods to reduce preterm birth and morbidity and mortality for preterm

infants in Ohio.

1

2

Preterm birth is the leading cause of infant mortality in Ohio.  Among states, we rank 35th in 35th in

infant mortality and 31st in prematurityinfant mortality and 31st in prematurity. Effective interventions such as antenatal

corticosteroids, surfactant, regionalized care, and CPAP are variably used throughout Ohio.  Thus,

there are opportunities to improve our care before and after birth.

3

OPQC has received a contract from the Ohio Department of Job and Family Services (ODJFSODJFS) for 2 years of funding from the Centers for Medicare & Medicaid Services (CMSCMS)

to further develop a quality improvement quality improvement collaborativecollaborative including setting up a data system and

supporting optimal systems of care throughout Ohio. The Ohio Department of Health (ODHODH) is also a partner.

March of Dimes, National Initiative for Children’s March of Dimes, National Initiative for Children’s Healthcare Quality (NICHQ), AAP, ACOGHealthcare Quality (NICHQ), AAP, ACOG

4

Ohio’s opportunity to be a national model…1)Large and diverse population

2)Cooperative and collegial institutions and professionals

3)Regionalized care

Document method of pregnancy dating Document reason for scheduled delivery < 39

wks Document discussion with patient regarding

risks and benefits of delivery < 39 wks Scheduled delivery form Communicate with pediatricians directly Promote early ultrasound Data tracking

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Gestational age distribution of births at OPQC member hospitals, by month, January 2006 to July 2009

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Full term (39-41 weeks) Near term (36-38 weeks)

2% decrease in births 36-38 wks and 2% increase in

births 39-41 wks; approximately 1000 births

moved to term

Ohio births at 36-38 weeks gestation following induction, with no apparent medical indication for delivery, by OPQC member status September 2008 to June 2009

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Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09

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Non-member Member Linear (Non-member ) Linear (Member )

Non-member hospitals = 0.1% decrease/mo

Member hospitals = 0.3% decrease/mo

% charts with risksand benefits of

scheduledbirth documented

% charts with methodof EDC determination

documented

% charts with optimalcriteria for gest age

determination

July 2008 February 2009

Obstetrical best practices

Establish dates early with ACOG criteria (1999 PB) Patient education Establish hospital policies for scheduled births

The Labor & Delivery front desk Document benefits and risks of scheduled births

Signed consent in chart Improve communication with pediatricians

Physician-to-physician before and after birth Expand schedule to weekends