Nursing News

Early Elective Deliveries on the Decline

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By Jennifer Larson, contributor 

March 1, 2013 - Early elective deliveries seem to be on the decline, but there’s still a great deal of room for improvement. And children’s health advocates say that nurses can continue making a positive difference in the rate of preterm births.

The Leapfrog Group announced last week that their annual hospital survey data shows that the national rate of early elective deliveries has declined for the second consecutive year. The watchdog group reported that 46 percent of 773 hospitals hit the early elective delivery target rate of less than 5 percent in 2012, an increase from 39 percent in 2011. Early elective deliveries are defined as deliveries that are scheduled or induced before 39 weeks of gestation without a medical indication.

The news was met with delight by many women’s and children’s health experts, who have been concerned about the issue of preterm births for many years.

“It’s exciting news,” said Diane Ashton, MD, MPH, deputy medical director of the March of Dimes, which is dedicated to improving the health of babies by preventing birth defects, premature birth and infant mortality.

And Catherine Ruhl, CNM, MS, director of women's health programs at the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), agreed. But she and Ashton noted that the progress can’t stop now.

“There is a lot of education to be done,” Ruhl said.

Organizations work to educate 

Organizations such as AWHONN, March of Dimes and Childbirth Connection have been laboring to educate both health care professionals and the public about the need to reduce the number of early elective deliveries.

The American Congress of Obstetricians and Gynecologists (ACOG) has cautioned against them since 1979, citing a lengthy list of potential complications associated with elective inductions between 37 and 39 weeks. These complications include an increased risk of respiratory distress syndrome, increased ventilator support and increased feeding problems.

The March of Dimes collaborated with the California Maternal Quality Care Collaborative and the California Department of Health to create a quality improvement toolkit entitled “Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age.”

Nurses, including nurse practitioners and nurse midwives, are well-positioned to educate both their own patients and the general public about the importance of waiting on labor, said Ashton. They can communicate the risks that can result from inducing labor and answer questions, too.

“And let them know early,” she added.

Meanwhile, AWHONN has its own educational campaign: Go the Full 40, which urges women to go at least the full 40 weeks of pregnancy and also allow for spontaneous labor, instead of inducing labor.

“Women need to not only be thinking, ‘Oh, I want my baby to be ready’ but also, ‘I want my body to be the most ready it could be,’” said Ruhl.

And she agreed that nurses have great potential to educate people, or continue educating them, on the matter. Labor and delivery nurses, by virtue of the fact that they spend more time with women in labor than anyone else, can really make a difference.

“They need to own that role,” she said.

The Midwest Business Group on Health (MBGH) was specifically mentioned by Leapfrog as a coalition that has made a significant difference in reducing early elective deliveries in Illinois, where the state’s rate dropped from 13.7 percent in 2011 to 7.2 percent in 2012.

The MBGH worked to publicize the issue from a safety and quality standpoint--and also to make it clear that increased cost is also involved with high rates of early elective deliveries. As ACOG has long emphasized, early inductions are also associated with increased neonatal intensive care unit (NICU) admissions, which contributes to higher costs for hospitals and health insurers.

MBGH has been promoting the March of Dimes’ campaign and working to get toolkits into the workplace, said Larry Boress, president and CEO of the Midwest Business Group on Health. And MBGH is now also promoting a “hard-stop” policy for hospitals in Illinois--to require medical approval for any elective deliveries done before 39 weeks.

Boress is optimistic about the progress his state has made and thinks that more is on the horizon. A handful of Illinois hospitals have already hit the zero mark for early elective deliveries, and many more are below the target 5 percent mark. It will just take continued education and communication, he said.

More efforts to drive the decline in preterm births 

There may be more information available soon that could help the cause, based on the decision by the Joint Commission in November 2012 to expand its performance measurement requirements from four to six. For hospitals with 1,100 or more births per year, that includes the perinatal care measure set, which means they will be required to start reporting this data on January 1, 2014; among other data collected will be a hospital’s rate of first-birth C-sections among low-risk women.

ACOG also recently addressed the issue with its “Five Things Physicians and Patients Should Question,” its most recent contribution to the Choosing Wisely campaign, which is led by the American Board of Internal Medicine (ABIM) Foundation.

Two of ACOG’s five priorities specifically caution against scheduling a delivery, either a non-medically indicated induction of labor or cesarean delivery, before 39 weeks. ACOG also recommended that providers let a woman go into labor on her own; the second of the five priorities also noted that non-medically indicated inductions should not be scheduled between 39 weeks 0 days and 41 weeks 0 days “unless the cervix is deemed favorable.”

“We will be using that (information) as we communicate more with physicians and with health plans,” said Boress.



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