Reducing Early Elective Deliveries

[elleng]

How do institutions change their practices? In medicine, the usual answer is “slowly.” Clinical trials can show the efficacy of a new practice — yet, decades later, many physicians still haven’t gotten the message.

Until four years ago, it seemed like early elective delivery was a textbook example of evidence widely ignored. These are induced or cesarean section deliveries after 37 completed weeks but before 39 completed weeks of gestation, when not medically necessary. The reason is usually convenience — the family is coming in for Christmas or the obstetrician will be off next week.

Delivery at 37 or 38 weeks was widely considered benign — but it is not. Infant mortality is at least 50 percent higher for babies at 37 or 38 weeks than at 39 or 40 (at 41 weeks the rate rises again). These babies are also more likely to suffer breathing, feeding and developmental problems.

The American College of Obstetricians and Gynecologists had been warning against early elective delivery since 1979. The March of Dimes, one of the most respected advocacy groups in America, had long campaigned to discourage the practice.

http://opinionator.blogs.nytimes.com/2014/03/12/reducing-early-elective-deliveries/

[DreamGypsy]

1. Interesting to see South Carolina and Texas as "pioneers" in this infant health care improvement...

...but quite telling (and sad) that $$$$'s are what provides the real incentives for these kinds of changes.

A year later, there was good progress, but South Carolina had started with one of the country’s highest rates, and officials worried that progress had reached a plateau. Keck announced that the state would cut off payments the next year. The state’s program gradually prepared hospitals to make the switch.

On Jan. 1, 2013, payments stopped. Data from that quarter shows that early elective inductions dropped by more than 45 percent since 2011. (Since reasons for C-sections are harder to collect and interpret, the state doesn’t have good data for the program’s effects on early elective C-sections.) NICU admissions were down. The state saved $6 million that quarter — 25 percent of it from cheaper deliveries and 75 percent from fewer NICU admissions.

One might hope for an altruistic basis for improving health care outcomes; one might be wrong.

[kdmorris]

2. It was this study that upset me so much when I had my twins

My OB was willing to let us go to 40 weeks - almost unheard of with twins. Most doctors insist on delivering you at 37 weeks. But then I got pre-eclampsia and I ended up on bed rest at 32 weeks. I was allowed out of the house to go to twice weekly doctors' appts - one for a biophysical profile for the babies with the perinatalogist and one with the OB for protein/urine check and BP (it was 150/94 at first, but after a couple weeks of bedrest, came down to 142-138 over 85-89.

But the only cure for pre-eclampsia is delivery. They just compiled all the data each week and told me I could keep them in another week. But because things could go drastically, horribly wrong at any moment, they just would be happy if I got to 37 weeks. (my kidney function has still not returned to normal 9 months later!)

I was horrified, but I didn't have a death wish and I knew that my pregnancy was compromising my kidneys every day that it lasted. But I still wanted them to have the best chance possible. In the end, when my blood pressure started going back up, we had a c-section at 37w 5d... so 2 days shy of 38 weeks. I just knew there were going to be issues based on this study... basically, my sons were premature!

They didn't have any issues - one was 8lbs 1oz (21.5 in) and one was 8lbs 5oz (20 in). At almost 9 months old they are standing up and cruising around the furniture and hitting all their developmental milestones. They are still huge boys - the size of an average 12-15 month old. But, their father and I are tall (6'4 and 6'0), so I guess they will be too.

ETA: I also had a lot of feelings about "letting my boys down" when my body failed them and they had to be delivered early because of me. They were perfect... it was my blood pressure/kidney function that caused them to be "evicted". My OB was very helpful in making me feel better and said that they would do fine, but Dr. Google is not your friend... I had seen information like this and was very scared that they would end up in the NICU, too... of course, at the time, I still thought they would be "small because they are twins" HAHAHAHAHAHAHAHAHAHAHA

So I always kind of think that we just got lucky. I'm a firm believer in NOT delivering early, even with twins, unless there is some reason to do so. I do, however, think they should do a better job of calming the fears of mothers who DO have to deliver early... let them know it's not a guarantee that their baby(ies) will have problems.

[elleng]

3. Sorry you went through the added aggravation,

and HAPPY they're ' bouncing' around so nicely!

Pre-eclampsia would have horrified me. My older daughter appeared, briefly, at risk for it recently so I did a bit of study. She was fine, and delivered normally, at term, in December. My younger daughter is now expecting, due in July.

Google can be our friend, but also a really aggravating addition to our 21st Century lives.

OB/GYNs have recently re-defined 'term pregnancy.'

https://www.acog.org/About_ACOG/News_Room/News_Releases/2013/Ob-Gyns_Redefine_Meaning_of_Term_Pregnancy