Many physicians think it's no big deal to schedule elective deliveries before 39 weeks' gestation—contrary to guidelines—but their minds and practices can be changed with concerted effort, according to a study at nine hospitals.
In a 5-year program, reeducation of physicians and nurses on the hazards of early-term elective delivery, combined with policing of their practices, reduced the rate of early elective deliveries from 28% of all elective deliveries in 1999–2000 to less than 10% within 6 months of program initiation. After 6 years with the program in place, the near-term elective delivery rate remained less than 3%, Dr. Bryan T. Oshiro and his associates reported (Obstet. Gynecol. 2009;113:804–11).
Those improvements did not come easily. It wasn't enough to remind physicians of American College of Obstetricians and Gynecologists guidelines recommending that elective deliveries not be performed before 39 weeks' gestation. Nor were their minds changed by national data showing greater perinatal morbidity in infants delivered before 39 weeks, including 8- to 23-fold higher incidences of severe respiratory distress syndrome with deliveries at 38 or 37 weeks, respectively.
The medical staff argued that their local patients were healthier than those reported in the literature. The physicians wanted to maintain autonomy in managing the timing of delivery. Nursing staff did not want to be responsible for enforcing a policy against early elective deliveries, which would put them in adversarial relationships with the doctors. “It was not until internal or local neonatal morbidity data were presented that significant initial buy-in by the medical staff was seen,” reported Dr. Oshiro of Loma Linda (Calif.) University.
The team who developed and administered the program within the Intermountain Healthcare network of hospitals in Utah and Southeast Idaho collected and presented data showing that their rate of neonatal ICU admissions for normal pregnancies increased from 3.3% for deliveries at 39 weeks to 4.5% for elective deliveries at 38 weeks and 8.9% for deliveries at 37 weeks. The rate of ventilator use for deliveries without complications increased from 0.3% for deliveries at 39 weeks to 0.5% for deliveries at 38 weeks and 1.4% for deliveries at 37 weeks. The in-hospital data were key to obtaining staff buy-in.
Concerns that delaying elective deliveries might increase morbidity were allayed by follow-up data showing significant declines in the rates of postpartum anemia, meconium aspiration, Apgar scores less than 5 at 1 minute, and cesarean deliveries due to fetal distress in infants delivered at 39–41 weeks' gestation in the period after the program was started, compared with the pre-program era. The rate of preeclampsia increased slightly, the study found.
Intermountain Healthcare is a vertically integrated health care system with 21 hospitals. The nine hospitals in the study use an electronic records system that allows identification and tracking of elective deliveries.
To overcome strong initial opposition to the program, the program managers conducted extensive education of the staff at each hospital. Physicians who wanted to schedule an early-term elective delivery were required to obtain permission from their hospital's ob.gyn. department chair or the attending perinatologist so that nursing staff would not have to be the ones enforcing the new policy. A new brochure helped explain the policy on early-term elective deliveries to patients.
Clinical program leaders monitor performance systemwide, at each facility, and for each practitioner, and regularly discuss the results with each hospital and sometimes with individual physicians. Hospital administrators were motivated to help the program succeed because part of their compensation depended on meeting the goal of decreasing early-term elective deliveries.
“They've done a really nice job showing that if you do bring attention to it, you can improve your rates” of elective delivery at appropriate gestational ages, Dr. Catherine Spong of the National Institute of Child Health and Human Development commented in an interview.
Requiring physicians to get permission for early elective deliveries “would make it more difficult for someone to just go ahead and deliver early,” she added.
The proportion of U.S. deliveries of live infants that occur between 37 and 38 weeks' gestation has increased to nearly 18% in the past decade. Separate data have shown that approximately one-third of elective repeat cesarean deliveries are performed before 39 weeks. The rate of late preterm deliveries (between 34 and 37 weeks' gestation) and the indications for those deliveries also have changed, Dr. Spong said. All of these “probably should be more closely evaluated.”
The majority of obstetric providers in the Intermountain Healthcare system are community physicians, most of whom could choose to do deliveries at nearby competing hospitals. “Thus we feel that this program could work in other hospitals and in other areas of the country,” the investigators concluded.