Choosing early delivery for babies can be harmful to health

Thanks to overwhelming medical evidence of the important development that takes place in a baby's brain and lungs during the last few weeks of gestation, most area hospitals have changed their policies on early elective deliveries.

The change was prompted by the American College of Obstetricians and Gynecologists, ACOG, which in mid-2008, issued a recommendation that women should wait until the 39th week of completed pregnancy before opting for delivery. Other groups concerned with maternal and fetal health, including the March of Dimes, also endorsed the recommendation.

Locally, the three major health systems rapidly brought their policies on nonmedical elective inductions in line with ACOG's recommendation. Prior to that, choosing to deliver between 37 and 39 weeks for convenience had become commonplace, resulting in more C-section deliveries, more babies being admitted to neonatal intensive care units and a greater likelihood of their having lifelong health problems.

The latest report by the hospital watchdog group, The Leapfrog Group, shows that the changes effected by local hospitals have already reversed the trend of early elective deliveries, largely reducing the numbers below its 2010 target of 12 percent. (In 2011, the target will drop to 5 percent.) The one exception was Chesapeake Regional Medical Center, which had not considered the issue, and scored a glaring 61 percent.

Chief Medical Officer Cynthia Romero attributed the high number to the hospital being unaware of the problem with more than 2,700 deliveries annually and 21 active physicians delivering babies; since the hospital started tracking the numbers, prompted by the Leapfrog Group, and realized it was outside the state and national norms, it has alerted physicians to the issue and started a dialog on how to bring the numbers down, she says. "We're a freestanding, independent hospital and we allow patients to be part of the decision-making process; it's often requested by the patient."

Across the state, 35 Virginia hospitals volunteered their numbers (with just as many declining to respond); of those, 11 failed to meet the 12 percent target. Not only did all Hampton Roads' hospitals report their numbers, but most scored well: Bon Secours hospitals rated zero (or perfect) for Mary Immaculate in Newport News, 1.7 percent at DePaul in Norfolk, and 27.3 percent at Maryview Medical Center in Portsmouth. Administrators explained that incorrect numbers were submitted for Maryview, mixing elective and nonelective early deliveries and that 5.9 percent reflected the true number for electives, with none recorded since July 2010.

Riverside Regional Medical Center in Newport News recorded a 4 percent rate and Sentara Williamsburg Regional Medical Center, 10.5 percent. Other Sentara locations in Hampton Roads had rates between zero and 2.5 percent.

How it happened

There are many reasons for how early elective births became an accepted norm. "Full-term has been considered 37 weeks for 20 years," says Jeff Henke, chief of women's health services for Riverside Health System. While the definition hasn't changed, he says, the awareness of ensuing health problems has. Henke also notes that mothers who have not received early prenatal care may not be accurate as to their due date. An ultrasound at eight weeks can pinpoint age accurately within 2 to 3 days; beyond the first trimester, though, you can be off by up to three weeks, he says. "As little as four days can make a big difference in a baby's development and health," he adds.

In this area, several doctors and hospital administrators cite the large military presence and deployments as a factor in dictating the timing of births.

For most, though, early delivery is just a convenience, whether wanting to avoid discomfort in the later stages of pregnancy, helping with child-care provisions, or accommodating a family visit.

"Social inductions had become very much the norm. We live in a very busy time. People want to plan their delivery," says Nikki Dame Downs, Riverside service line administrator for services that impact women and children. It took intensive efforts across the board to move away from early deliveries, she says.

Implementing change

After learning of ACOG's recommendation and its supporting medical evidence, the region's three major health systems launched reviews of their practices followed by intensive education programs for physicians, hospital administrators and patients to reverse the risky practice of early elective deliveries. At Sentara. The OB Right program was already in existence to address patient safety issues; it ran an early pilot program in establishing 39 weeks as the delivery norm. By late 2008, Williamsburg Sentara voted to adopt the standard. Over two years of staff working together and in concert with patients, it has subsequently reduced its Leapfrog-reported 10.5 percent to just 3.1 percent of its more than 1,000 annual deliveries, according to Beth J. Carlson, vice-president for patient care services. "It's a lot of work to educate patients about why it's important… it's promoting quality of life."

The Riverside Medical Group started informal tracking as soon as ACOG issued its recommendation. It spent 2009 educating physicians and staff to the dangers of the practice. "It's a huge culture change. You have to work really hard with physicians and patients. It's very challenging," says Downs, even though babies at 38 weeks have immature lungs and therefore can suffer respiratory difficulties, as well as feeding issues, swallowing problems and difficulty maintaining their temperature.

Riverside formed a Maternal Child Operating Council, comprised of ob-gyns and pediatricians, and implemented a policy of no elective deliveries before 39 weeks. It was able to identify the physicians — most of whom are hospital employees — in need of education about the new standards and follow up quickly. Also, by instituting a system-wide policy, it helped doctors withstand pressure from patients. "It makes it easy when you can tell a patient that there's a policy of no inductions before 39 weeks," says Henke. The result has been immediately apparent in a 1 percent reduction in admissions to the hospital's neonatal intensive care unit. "It may be a stretch to attribute them all, but that's 35 babies that didn't need special care," he says.

Bon Secours has also implemented a policy not to induce for non-medical reasons before 39 weeks. "When the evidence came in that this is safer for the baby, it trumped everything else," says Warren Austin, vice-president of medical affairs. Since mid-2010, there have been no early elective deliveries performed, he says. "Now we're at zero, we want to stay there."

Reasons mothers choose early delivery:

• Uncomfortable, tired of being pregnant

• Family visit

• Scheduling issue

• Military deployments

• Child care considerations

• Want a specific birth date

• Want a certain physician

Health problems from early elective delivery:

Immature lungs and respiratory difficulties

Difficulty swallowing, feeding

Difficulty maintaining temperature

Increased number of C-sections

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