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How Can Hospitals Curb Elective Early Deliveries?

Posted Aug 03 2010 1:16pm

Tuesday, August 3, 2010
  Reuters Health Information Logo

By Amy Norton

NEW YORK (Reuters Health) - Among women who choose when to deliver their babies, it has long been common practice to schedule delivery as soon as the fetus is considered "full-term," despite expert recommendations that say they should wait longer. Now a new study shows that tougher hospital policies can go a long way toward curbing the practice.

Normally, pregnancy lasts about 40 weeks, and any birth between the 37th and 41st weeks is considered full-term. (Pregnancies lasting 42 weeks or longer are considered "post-term.")

But even though babies born during the 37th or 38th week are usually healthy, they do have a higher risk of complications than infants born later. The earlier babies may, for example, have breathing problems because their lungs are not yet mature enough, requiring that they go on supplemental oxygen.

Because of the potential for problems, the American College of Obstetricians and Gynecologists (ACOG) recommends against electively having induced labor or C-section delivery before the 39th week of pregnancy.

By definition, elective deliveries have no underlying medical justification. They may be done for convenience, for example, or in cases where pregnancy is causing significant physical discomfort or when a woman wants to ensure that her own doctor is available to deliver the baby.

Despite the fact that elective delivery in the 37th or 38th week is considered to carry needless risks, the practice has remained common -- estimated to account for 10 percent to 15 percent of all deliveries in the U.S. -- because the absolute risk of complications for any one baby are low, explained Dr. Steven L. Clark, the lead researcher on the new study and medical director of Women's and Children's Clinical Services for the Hospital Corporation of America (HCA).

Many women may know someone who had an elective early-term delivery, and many obstetricians may have performed the procedure and never seen a complication. So the popular perception is that it is safe.

But on the national scale, even a small increase in the risk of newborn complications translates into an important public health issue, Clark said in an interview. He also pointed out that inducing labor in the 37th or 38th week increases the chances that a woman will end up needing a C-section -- since the cervix may not be ready to fully dilate at that point in pregnancy.

The current study, reported in the American Journal of Obstetrics & Gynecology, is the first to look at the question of how to best curb elective deliveries in the 37th and 38th week.

For the study, 27 HCA hospitals in 14 U.S. states chose one of three policies to address the issue: a "hard stop" approach where the hospital prohibited purely elective deliveries before the 39th week, enforced by designated staff empowered to refuse to schedule the procedures; a "soft stop" policy in which the early elective deliveries were prohibited but compliance was left to individual doctors; and an "education only" approach that included no formal ban on the deliveries and relied on doctors to change their practices themselves.

Over two years, the hard-stop policy proved most effective.

At the seven hospitals that adopted the policy, the rate of elective delivery in the 37th or 38th week fell from 8 percent of all deliveries to just below 2 percent.

In the soft-stop group, the rate dropped from just above 8 percent to roughly 3 percent. And at the education-only hospitals, the rate dipped from 11 percent to 6 percent -- a difference that was not statistically significant, which means it could have been due to chance.

"The message here is that there is a way that this practice can be reduced," Clark said, noting that the findings can serve as a model for other hospital systems that are now getting "serious" about curbing early-term elective deliveries.

Clark's team also found evidence of a benefit for newborns. Across all of the hospitals, the decline in elective deliveries was accompanied by a 16 percent reduction in the number of term infants admitted to the neonatal intensive care unit (NICU).

The researchers estimate that if the drop in elective deliveries achieved in the hard-stop policy hospitals could be accomplished nationally, a half-million NICU days could be avoided and close to $1 billion saved each year.

The bottom line for expectant parents, Clark said, is that they should realize that elective delivery in 37th or 38th week does carry risks. "It's simply not good for your baby to be born before the 39th week," he said.

Clark stressed, however, that the issue here is elective delivery only. There are a range of medical reasons that a doctor may recommend a planned delivery in the 37th or 38th week, such as dangerously high blood pressure in the mother, poor fetal growth or cases in which a woman's "water breaks" but labor does not begin spontaneously.

SOURCE: http://link.reuters.com/suk23n American Journal of Obstetrics & Gynecology, online July 9, 2010.

Reuters Health


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