Strategy-Specific Measures
Elective Deliveries
Aim Statement: Reduce the proportion of non-medically indicated deliveries <39 weeks by 33% in Region IV and VI states, by December 2013.
Team Data Lead for Measure Detail, SAS Code, and Questions: Bill Sappenfield wsappenf@health.usf.edu
Measure
Numerator
Denominator
Percent of nonmedically
indicated* early
term (37 or 38
weeks) singleton
live births among
all term singleton
live births 37-41
weeks.
Inductions or cesareans without
trial of labor and without indication
(fetal distress, prolonged labor,
PROMS) among singleton deliveries
at 37, 38 weeks (clinical estimate)2
Singleton term deliveries
37-41 weeks (clinical
estimate)1
Percent of early
term (37 or 38
weeks) singleton
live births among
all term singleton
live births 37-41
weeks.
Singleton term deliveries at 37, 38
weeks (clinical estimate)2
Singleton term deliveries
37-41 weeks (clinical
estimate)2
Data Sources
Baseline
Frequency
State Vital Statistics
Birth File
2011
Quarterly
2011
Quarterly
In-state births to state
residents; delete nonhospital births and those
in military hospitals if
not included in state QI
efforts
State Vital Statistics
Birth File
In-state births to state
residents; delete nonhospital births and those
in military hospitals if
not included in state QI
efforts
Excluding women with conditions prior to or during pregnancy (e.g., chronic or gestational hypertension or diabetes, eclampsia, non-vertex
presentation, certain congenital anomalies, and previous poor birth outcome), following The Joint Commission list of conditions possibly
justifying delivery <39 weeks.
1
Coding for Non-Medically Indicated (NMI) Early Term Singleton Births
Developed by Bill Sappenfield (wsappenf@health.usf.edu) and Lindsay Womack (lwomack1@health.usf.edu)
Steps:
1.) Delete Multiple Births
2.) Delete Non-Resident Births
3.) Delete Out-of-State Births to Residents
4.) Delete Births Not in “Delivery Hospitals”
5.) Delete Military Hospitals (if state quality improvement efforts do not include these hospitals)
6.) Method of Delivery
Induced labor and cesarean deliveries are treated as mutually exclusive variables. The outcome
categories are defined based on the reason for initiating delivery and not how the delivery actually
occurred. Births that were induced and then delivered by cesarean are defined as inductions.
7.) Medical Indications for Early Term Delivery Available from Birth Certificate Data
The Joint Commission (TJC) Conditions Possibly Justifying Delivery <39 Weeks Gestation1 are
identified from birth certificate elements. Inclusion of additional recommended criteria by other
sources was found to have limited impact on study finding and are not included.2,3,4 Most
importantly, this includes most of the conditions identified from the lists on the birth certificate.
8.) Delete Medical Indications Present Prior to or During Pregnancy
Medical conditions present prior to or during pregnancy that might require early delivery are
deleted. Births with the mother or infant having medical conditions present prior to or during
pregnancy are not at risk for a NMI delivery.
9.) Gestational Age and Non-Medically Indicated Deliveries
Gestational age is defined using the clinical estimate of completed weeks from the birth certificate.
Clinical estimate of gestational age was found to be more accurate than gestational age using last
menstrual period based on a medical chart review of late preterm cesarean delivery (unpublished).
NMI inductions are induced labor without any indication for delivery. NMI cesareans are cesarean
deliveries without any indication for delivery and no attempt of labor.
10.) Number of NMI Early Term Singleton Births
This is limited to NMI live births of 37 and 38 weeks gestation based on clinical estimate.
11.) Number of Early Term Singleton Deliveries
This is limited to live births of 37 and 38 weeks gestation based on clinical estimate.
12.) Number of Term Singleton Deliveries
This is limited to live births of 37 or more weeks of gestation based on clinical estimate.
References:
1. TJC. Specifications Manual for Joint Commission National Quality Core Measures (2011a); Perinatal Care Core Measure Set.
2011 [cited July 27, 2011]; Available from:
http://manual.jointcommission.org/releases/TJC2011A/AppendixATJC.html#Table_Number_11_07_Conditions_Po
2. Donovan EF, Lannon C, Bailit J, et al. A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7)
weeks’ gestation. American Journal of Obstetrics and Gynecology 2010;202:603.
3. ACOG. Clinical management guidelines for obstetricians-gynecologists: Induction of labor. American College of
Obstetricians and Gynecologists Practice Bulletin Number 107 August, 2009.
4. LFG. 2010 Leapfrog Hospital Survey Reference Book. 2010 [cited 2010 September 24]; Available from:
https://www.leapfroghospitalsurvey.org/survey_downloads/reference.pdf
SAS CODE
data NMID;
/* DELETE MULTIPLE BIRTHS */
if _PLURALITY_CODE ne 1 then delete;
/*Delete Multiples*/
/* METHOD OF DELIVERY */
/*Inductions*/
if _CHAR_INDUCTION='Y' then induction=1; /* YES Induction */
else induction=0; /* NO Induction */
/*Cesareans*/
if _BIRROUTE_CODE=4 then cesarean=1; /* YES Cesarean */
else cesarean=0; /* NO Cesarean */
/*Induction and Cesarean Mutually Exclusive*/
if induction=1 then cesarean=0;
/*If YES Induction then NO Cesarean*/
/* MEDICAL INDICATIONS FOR EARLY TERM DELIVERY AVAILABLE FROM BIRTH
CERTIFICATE DATA*/
/*Hypertension/Prepregnancy*/
if _MR_HYPERT_CHRONIC='Y' then chrhyper=1;
else chrhyper=0;
/*Hypertension/Gestational*/
if _MR_HYPERT_PREG='Y' then gesthyp=1;
else gesthyp=0;
/*Hypertension/Eclampsia*/
if _MR_HYPERT_ECLAMPSIA='Y' then eclamp=1;
else eclamp=0;
/*Diabetes/Prepregnancy*/
if _MR_DIAB='Y' then diabetes=1;
else diabetes=0;
/*Diabetes/Gestational*/
if _MR_DIAB_GEST='Y' then gestdiab=1;
else gestdiab=0;
/*Non-Vertex Presentation or Other - Fetal Presentation at Birth*/
if (_CHAR_NON_VERTEX='Y' or _BIRPRESENT_CODE='3') then unstablelie=1;
else unstablelie=0;
/*Anencephaly or Meningomyelocele/Spina Bifida*/
if (_ANOM_ANENCEP='Y' or _ANOM_SPINA='Y') then cnsmalf=1;
else cnsmalf=0;
/*Down Syndrome or Suspected Chromosomal Disorder*/
if (_ANOM_DOWNS='Y' or _ANOM_CHROM='Y') then chromab=1;
else chromab=0;
/*Cyanotic Congenital Heart Disease or Diaphragmatic Hernia or Omphalocele or
Gastroschisis*/
if (_ANOM_HEART='Y' or _ANOM_DIAPH_HERNIA='Y' or _ANOM_OMPHAL='Y' or
_ANOM_GASTRO='Y') then fetalab=1;
else fetalab=0;
/*Fetal Intolerance of Labor*/
if _CHAR_FETAL_INTOLERANCE='Y' then fetaldistress=1;
else fetaldistress=0;
/*Premature Rupture of the Membranes*/
if _CLD_PREMATURE_ROM='Y' then preROM=1;
else preROM=0;
/*Prolonged Labor*/
if _CLD_PROLONG_LABOR='Y' then proROM=1;
else proROM=0;
/*Chorioamnionitis*/
if _CHAR_CHORIOAMNIO='Y' then chorio=1;
else chorio=0;
/*Other Previous Poor Pregnancy Outcome*/
if _MR_PREV_POOR_OUTCOME='Y' then poorhist=1;
else poorhist=0;
/*
if
if
if
if
if
if
if
if
if
if
DELETE MEDICAL INDICATIONS PRESENT PRIOR TO OR DURING PREGNANCY */
chrhyper=1 then delete;
gesthyp=1 then delete;
eclamp=1 then delete;
diabetes=1 then delete;
gestdiab=1 then delete;
unstablelie=1 then delete;
cnsmalf=1 then delete;
chromab=1 then delete;
fetalab=1 then delete;
poorhist=1 then delete;
/* GESTATIONAL AGE AND NON-MEDICALLY INDICATED DELIVERIES */
/* 37 through 41 Completed Weeks Gestation = Term*/
if _GESTATION_WEEKS in ('37','38','39','40','41') then term=1;
else term=0;
/* 37 or 38 Completed Weeks Gestation = Early Term*/
if _GESTATION_WEEKS in ('37','38') then earlyterm=1;
else earlyterm=0;
/* Delete Preterm and Post-term Births */
if term=0 then delete;
/* Indication = Any Condition from the TJC List Available on the Birth
Certificate*/
if (fetaldistress=1 or preROM=1 or proROM=1 or chorio=1) then indication=1;
else indication=0;
/* Non-Medically Indicated Induction = Induction without Indication */
if (induction=1 and indication=0) then NMIinduction=1;
else NMIinduction=0;
/*Cesarean with Attempt of Labor*/
if (_MD_CES_LABOR_ATTEMPT='Y' and cesarean=1) then attempt=1; /*Attempt of
Labor = YES Attempt of Labor and YES Cesarean*/
else attempt=0;
/* Non-Medically Indicated Cesarean = Cesarean without Indication and without
an Attempt of Labor*/
if (cesarean=1 and indication=0 and attempt=0) then NMIcesarean=1;
else NMIcesarean=0;
/* Non-Medically Indicated Delivery = Non-Medically Indicated Induction or
Non-Medically Indicated Cesarean */
if (NMIinduction=1 or NMIcesarean=1) then NMID=1;
else NMID=0;
/* Non-Medically Indicated Early Term Delivery = Early Term Delivery and NonMedically Indicated Delivery */
if (earlyterm=1 and NMID=1) then earlyNMID=1;
else earlyNMID=0;
run;
/* NUMBER OF NMI EARLY TERM SINGLETON BIRTHS */
proc freq data=NMID;
tables earlyNMID;
run;
/* NUMBER OF EARLY TERM SINGLETON DELIVERIES */
proc freq data=NMID;
tables earlyterm;
/* NUMBER OF TERM SINGLETON BIRTHS */
proc freq data=NMID;
tables term;
run;