Dramatic gains by California hospitals in reducing early deliveries
Citing dangers for both mother and child, these hospitals are prohibiting doctors from scheduling deliveries between weeks 37 and 39 of pregnancy unless there are medical reasons to do so.
Care for premature babies has so improved that some mothers schedule early births simply because they are tired of pregnancy and some doctors do it to avoid a night call.
“People are beginning to understand that there’s an increased risk of complications to the babies at 37 and 38 weeks, particularly if it’s the baby who isn’t the one deciding to be born,” said Elliott Main, medical director of the California Maternal Quality Care Collaborative.
These scheduled deliveries occur by C-section or when doctors induce labor.
Complications to the baby range from breathing and feeding problems to blood infections. Inducing labor also increases the likelihood of having a cesarean-section with its greater chance of complications for the mother, he said.
Main, who is also chairman of the ob-gyn department at San Francisco’s California Pacific Medical Center, is overseeing a campaign to reduce early elective births at 20 Sutter Health hospitals in Northern California.
Among them, Alta Bates Summit Medical Center in Berkeley has seen its rate of elective deliveries between weeks 37 and 39 plummet from 17 percent of all deliveries during that timeframe to 6 percent since early last year, said Katarina Lannér-Cusin, medical director for women’s services.
“This is better for the family and most of all for the baby,” she said.
The Sutter hospitals are part of a growing movement, said Leslie Kowalewski, associate state director of California’s March of Dimes. The organization has joined with the Care Collaborative and the state Public Health Department to help hospitals set policies.
The state has 93 hospitals “actively working to eliminate elective deliveries” before 39 weeks, she said.
Advocates say the change is good for the health of mother and child and may help tame health-care costs by shortening hospital stays and curtailing use of neonatal intensive care units.
“It’s thousands and thousands of dollars difference per day,” said Tracy Flanagan, director of women’s health, Kaiser Permanente Northern California.
In recent months, she said, Kaiser’s 14 Northern California hospitals that offer obstetrics have reduced their early elective deliveries to 5 percent or less, compared to 10 to15 percent in 2010.
Even though pregnancies at 37 and 38 weeks are considered “term pregnancies,” the fetus may not be fully developed, said John Wachtel, a clinical professor of obstetrics and gynecology at Stanford University Medical School and a Care Collaborative leader.
The optimal time to deliver is between 39 and 41 weeks, he said.
But in the past two decades, the average gestation has fallen by more than a week as doctors and patients increasingly scheduled deliveries during weeks 37 and 38, Wachtel said.
Some scheduled deliveries are for medical conditions such as maternal diabetes or hypertension that could endanger either mother or child. Others are elective, often done as a matter of convenience for the doctor or patient.
“We have gotten so much better at taking care of premature newborns and early birth that both obstetricians and patients believe it’s safe to deliver before 39 weeks, which is not always accurate,” Wachtel said.
Women ask to deliver before 39 weeks because they’re tired of being pregnant or want the baby home by the time grandma arrives to help, for instance.
Doctors may schedule deliveries before 39 weeks to avoid being paged in the middle of the night or because they want to go on vacation.
“It’s a desire to do what’s tongue-in-cheek called ‘daylight obstetrics’,” Main said.
But there are consequences.
Data show that babies born between 37 and 39 weeks have higher rates of respiratory distress syndrome, blood infections, difficulty regulating temperature and other problems than those born after 39 weeks. They may also have more trouble sucking and swallowing.
“If you compare babies that are born between 37 and 39 weeks and babies born 39 weeks on, there’s almost two times higher risk of having any of those complications,” Flanagan said.
Inducing labor before 39 weeks also doubles some women’s chances of having a C-section, which makes complications more likely than if they delivered vaginally, Wachtel said.
Some of the hospitals taking action are trying persuasion first. They share data with physicians and urge them to stop early elective deliveries.
Others get tough.
Sutter Medical Center in Sacramento started sharing elective birth data with doctors a little more than a year ago, said William Gilbert, medical director for women’s services in Sutter Health’s Sacramento Sierra region.
Next, the hospital posted each physician’s rate in the doctor’s lounge.
Finally, as some doctors still resisted, the hospital programmed computers to flag scheduled early deliveries lacking appropriate medical explanations.
When that occurs, Gilbert asks the doctors to confirm a medical necessity. If there isn’t one, they are not permitted, he said.
The hospital’s rate of these early elective deliveries fell to 5.5 percent last year, about one-third the rate in late 2010.
“Some doctors said ‘Well, I’m taking my patients to another hospital where they don’t make me do this’,” Gilbert said. “We said, ‘That’s OK, we want to provide the best evidence-based quality care’.”