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Avoiding Early, Elective Deliveries

By Carolyn Davis Cockey, MLS

Avoiding Early, Elective Deliveries

Could where you plan to birth put you and baby at risk for delivering early, even risking prematurity for baby? It could, if you’re planning to birth in a hospital or facility that doesn’t restrict early, elective births—especially before 39 weeks.

Birthing the way nature intended is healthy best for most pregnant women. No doubt if you’re reading Healthy Mom&Baby you’ve likely seen the “Don’t Rush Me . . . Go the Full 40” weeks of pregnancy campaign (GoTheFull40.com) from the Association of Women’s Health, Obstetric & Neonatal Nurses (AWHONN), the nursing association that produces this magazine. At the heart of this effort is advice and encouragement from experts to help you know why it’s healthy best to let your pregnancy go full term, to wait for your labor to naturally start on its own, and to have a normal, vaginal birth when all is well.
Allowing your pregnancy to go full term is best for your health. While being done with pregnancy may seem tempting, especially during those last few weeks, inducing labor is associated with increased risks including prematurity, cesarean surgery, hemorrhage and infection.
Non-medically related choices—called “elective”—include inducing labor without cause, as well as birthing via cesarean without a medical reason for surgical delivery. When these choices are made without cause before your pregnancy is term, they’re called “elective, early deliveries.” They’re also called “dangerous” for the many immediate and life-long risks documented in research for both you and your baby.

Know Your Hospital’s Numbers

One group that’s trying to drive down these interventions by reporting elective, early birth practices at hospitals is the hospital quality watchdog, The Leapfrog Group. Through a voluntary annual hospital survey, Leapfrog reports elective, early delivery rates at www.LeapfrogGroup.org. When we spoke with Leapfrog Group CEO Leah Binder, she explained why she’s celebrating recent declines in early, elective interventions across the country, and why there’s still more work needed.

How is Leapfrog Group pressuring hospitals to curb early, elective deliveries, which you and many other experts call “dangerous?”

We started publicly reporting, hospital by hospital, 2 years ago on early, elective delivery rates, and that quickly changed the conversation. Groups like AWHONN, the March of Dimes and the American College of Obstetricians and Gynecologists have been trying to reduce the rates of early, elective deliveries for years. But those efforts really didn’t see the kind of traction they deserved until we put the numbers out there. Many hospitals didn’t even realize how high their rates were.
Since we started drawing attention to the issue, our data shows 75% of hospitals improved this year, and the national average for these deliveries dropped from 14% to 11.2%—evidence to the commitment many hospitals are making to put babies and mothers first.
Our simply shining a light on the practice has had an enormous impact. I’ve talked to hospital executives who until they looked at this data said they had no idea that this was a problem at their facility. For example, I spoke with one director of obstetrics who, after reporting to Leapfrog and looking at the data, completely revamped his hospital’s practices. He created a PowerPoint presentation for the entire staff entitled, “What Were We Thinking?” I give credit to nurses and physicians who have been fighting this for a long time. Now, they have the momentum for change.

How do you measure what the hospitals report?

We’re looking at all the deliveries that take place between 37 and 39 completed weeks of pregnancy, and of all of those births, we’re measuring the percentage of those births between 37 and 39 weeks that were done electively—for no medical reason. So, when a woman looks up her hospital’s rates on our website and sees an 80% or a 100%, that means that 80% or 100% of those deliveries between 37 and 39 weeks were for no medical reason—they were elective, by choice, for convenience or whatever other reason, such as when the physician is on call.

Leapfrog’s goal is to get early, elective deliveries to 5% or less; should it be 0%?

There are some cases where there may be a particular non-medical related issue that affects a woman under a particular circumstance that may not be accounted for in the broad ways we classify medical need. Since there are exceptions to medical need for these circumstances, we account for those exceptions by allowing up to 5%.

So, what should happen if a pregnant mom looks at www.LeapfrogGroup.org and can’t find her hospital in your survey?

We would encourage women to approach their local hospital and ask them to please report to Leapfrog. Currently, about 1/4 of all birthing hospitals are reporting. Second, call you doctor or midwife and ask about their views on preventing early, elective deliveries. If your provider says, “we schedule them a lot,” then you may want to reconsider your choice of obstetrician or midwife. If they’re strongly opposed to early, elective deliveries, ask if the whole practice feels the same way and practices likewise.
Often, we don’t want to challenge [our providers] because they know better than we do, it’s scary for us, or we don’t want to get on the wrong side of our physician. But you are entitled to ask these questions of the person with whom you’re entrusting your life, and the life of your family. Not all doctors and hospitals are the same. You have to be picky. We find big variation in the early, elective delivery rates for one hospital compared to another that might be literally down the street. You have to think of yourself as a consumer of health care; you have to shop.

How can an army of pregnant moms make a difference in their community?

It’s important for women to reach out to their legislators in their states. Medicaid pays for about half of all childbirths in this country, so your state should be actively engaged in using that leverage to influence the way births take place. States can certainly insist that hospitals make every effort to avoid early, elective deliveries.
I need to mention something a little bit cynical: When hospitals reduce their rate of early, elective deliveries, their neonatal intensive care unit admissions go down—some have reported by as much as half after implementing these policies. So, while these policies are great for babies, for moms and for our country as a whole, they’re not so great for the hospital’s bottom line because the NICU is a high-profit center.
There is a problem in our whole [healthcare] payment system where we have created this horribly perverse incentive that results in suffering babies, which is truly not excusable. We need the payment system to force hospitals to do what’s right for these babies and these moms. It’s going to take all of us to really push that agenda.

Avoiding Dangerous Deliveries

Early, elective deliveries come with considerable risks:

For moms, risks increase for:

  • Birth by cesarean, including the risks of uncontrolled bleeding (hemorrhage)
  • Longer hospital stays and longer recovery
  • Anemia
  • Endometriosis
  • Urinary tract infections
  • Sepsis

For babies, risks increase for:

  • Prematurity
  • Low or lower birth weight
  • NICU admission
  • Health complications, now and life-long
  • Death, especially in the first year of life

Carolyn Davis Cockey, MLS, is editor of Healthy Mom&Baby and director of publications for AWHONN. Follow her Momalogues blog at www.Health4Mom.org.

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