The Near-Term
(Scheduled, Elective, Convenient)
(Indicated?)
Birth Controversy
and the OPQC
Christopher T. Lang MD
Columbus, 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



Happy parents until they are unhappy in NICU
Unhappy AAP, March of Dimes, others
Unhappy obstetricians (?)
Unhappy patients and colleagues
Late-preterm and near-term infants
occupy most NICU beds
Number of Patients
30000
25000
20000
15000
10000
5000
0
23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Estimated Gestational Age (wks)
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



March of Dimes




National conferences – Surgeon General, IOM, NIH
Recent literature
State preterm birth “report cards” – Ohio got an F
The “Brain Card”
The “Fertility Care Card”
Health departments and hospital systems
Hospital Performance Public Reporting
Perinatal 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)
Timing of elective repeat cesarean delivery at term
and neonatal outcomes
Tita ATN, Landon MB, Spong CY, et al. NEJM. 2009.
Timing of elective delivery at term
and neonatal outcomes
Clark SL, Miller DD, Belfort M, et al. AJOG. 2009.
Timing of delivery and
diagnosis of clinically significant
respiratory morbidity
Yoder BA, Gordon MC, and Barth W. Obstet Gynecol. 2008.
Infant mortality rates in Ohio by gestational age at birth
1999-2001 (423,803 births)
411,089 births, 35 – 41 weeks gestational age
Infant Mortality Rate
Ohio, 1999-2001
423,803 births, 35-41 weeks gestational age
Infant Deaths
per 1000 live births
12.0
10.0
8.0
6.0
4.0
2.0
0.0
35
36
37
38
39
Gestational Age (weeks)
40
41
Obstetrical factors contributing
to a culture of scheduled birth

More indicated inductions
 Time management

Better induction techniques
 Need to satisfy patients

Confidence in NICU care

Better dates

Antenatal tests not perfect

Liability

No suit for doing a cesarean
 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
The Washington Post May 21, 2006 (1)
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 (2)
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 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 latepreterm birth?
Pediatricians do not speak the same language
as obstetricians
 Late-preterm birth = not term = not 39 wks
386 wks = late-preterm
 Scheduled = elective = convenient
A scheduled birth between 340 and 386 = elective

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
Perinatal mortality
US (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
“Institutional commitment” and the feasibility of
decreasing elective deliveries (1)
Oshiro BT, Henry E, Wilson J, et al. Obstet Gynecol. 2009.
“Institutional commitment” and the feasibility of
decreasing elective deliveries (2)
Oshiro BT, Henry E, Wilson J, et al. Obstet Gynecol. 2009.
A collaborative effort by Ohio care
providers, hospitals, payers, parents and
policy makers to identify and apply
effective improvement methods to
reduce preterm birth and morbidity and
mortality for preterm infants in Ohio.
1
Preterm birth is the leading cause of infant mortality
in Ohio. Among states, we rank 35th in infant
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.
2
OPQC has received a contract from the Ohio Department of
Job and Family Services (ODJFS) for 2 years of funding from
the Centers for Medicare & Medicaid Services (CMS) to
further develop a quality improvement collaborative including
setting up a data system and supporting optimal systems of
care throughout Ohio. The Ohio Department of Health (ODH)
is also a partner.
March of Dimes, National Initiative for Children’s
Healthcare Quality (NICHQ), AAP, ACOG
3
Ohio’s opportunity to be a national model…
1) Large and diverse population
2) Cooperative and collegial institutions and
professionals
3) Regionalized care
4







5
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
Gestational age distribution of births at OPQC member hospitals, by month,
January 2006 to July 2009
65
60
55
2% decrease in births 36-38
wks and 2% increase in births
39-41 wks; approximately 1000
births moved to term
Percent
50
45
40
35
30
25
20
Jan- Feb- Mar- Apr- May- Jun07
07
07
07
07
07
Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun07
07
07
07
07
07
08
08
08
08
08
08
Full term (39-41 weeks)
Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun08
08
08
08
08
08
09
09
09
09
09
09
Near term (36-38 weeks)
Jul09
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
Non-member hospitals = 0.1% decrease/mo
20
18
16
14
Percent
12
10
8
Member hospitals = 0.3% decrease/mo
6
4
2
0
Sep-08
Oct-08
Nov-08
Dec-08
Non-member
Jan-09
Member
Feb-09
Mar-09
Apr-09
Linear (Non-member )
May-09
Linear (Member )
Jun-09
Jul-09
Aug-09
% charts with risks
and benefits of scheduled
birth documented



% charts with method
of EDC determination
documented
% charts with optimal
criteria 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