Preemie worry: Induced labor rules tightened
WASHINGTON – Hoping to schedule your baby’s birth while your mother’s in town, or before the doctor goes on vacation? Labor is becoming less of a late-night surprise, but some hospitals are starting to tighten the rules for elective deliveries because some babies are being delivered too early.
More hospitals are expected to crack down as regulators begin new quality measurements next spring that aim to reduce too-early elective inductions and first-time cesareans.
Induced labor is on the rise for lots of reasons, some medical and some not. But recent research shows a troubling link between elective inductions and these so-called “late preemies.” These aren’t the dire too-small babies that the word premature conjures, but near-term babies who nonetheless are at higher risk of breathing disorders and other problems than babies who finish their very last weeks in the womb.
“It was an ‘aha’ moment for me,” recalls Dr. Bryan Oshiro of his visit to a Utah intensive care nursery several years ago, where neonatologists pointed to babies there simply because they’d been induced too soon.
National guidelines from the American College of Obstetricians and Gynecologists have long discouraged elective deliveries before the 39th week of pregnancy. But some hospitals that took a close look were surprised. At Utah’s Intermountain Healthcare, for example, 28 percent of elective deliveries were breaking ACOG’s rule in 2001, Oshiro told a March of Dimes meeting on preventable prematurity this month.
Most were being induced in week 37, such a small difference that local obstetricians argued it wasn’t a problem. So Oshiro pulled the medical charts and found those near-term babies had more than double the risk of ending up in neonatal ICU, suffering respiratory distress, even needing a ventilator.
It took several years of policing: Inductions now are allowed only after meeting a checklist of requirements. But today, only about 3 percent of Intermountain’s elective deliveries occur before 39 weeks and infant hospitalizations have dropped, saving money, too, says Oshiro, now a maternal-fetal medicine specialist at Loma Linda University in California. He’s about to pilot a similar program at hospitals in that area.
“If there’s no need to intervene, please don’t intervene,” is Oshiro’s message.
Labor is induced in more than one in five births, double the rate in 1990, according to the Centers for Disease Control and Prevention. Many cases are for clear health reasons, such as a problem with the fetus or a sick mom or a pregnancy that has dragged well beyond the woman’s due date.
There’s little data on how many are elective. But a Hospital Corporation of America study of nearly 18,000 births at 27 of its hospitals around the country suggests 10 percent of all births are performed electively before the 39-week mark. (That date is considered the point at which doctors can be sure a pregnancy has reached full-term, typically defined as 40 weeks give or take about a week.)
There are many reasons to perform an elective induction, such as if mom lives two hours from a hospital, notes Dr. John Fisch of the University of Pittsburgh Medical Center’s Magee-Women’s Hospital.
Patient and doctor preference helped drive the rise in inductions, such as women timing grandma’s arrival to take care of the siblings, or minimizing 3 a.m. deliveries. Then there’s defensive medicine, where doctors worried about litigation induce for minor reasons like a slight uptick of the mother’s blood pressure.
So Pittsburgh also had “a little bit of a hard sell” after discovering nearly 12 percent of elective deliveries broke the 39-week rule in 2004, Fisch says. “It was perceived to be a safe and effective way in delivering a baby and it is, as long as it meets certain criteria.”
After Magee began strict enforcement requiring that a mother’s cervix be nearly ready for natural labor, and limiting the beds available for elective inductions too-early inductions dropped to 4 percent by 2007 and are “effectively zero” today, Fisch says. Overall, elective inductions dropped 30 percent.
More hospitals are expected to start enforcing those criteria this spring, when the Joint Commission that regulates health quality will require hospitals to report all elective deliveries and the gestational age to its public database, providing peer pressure for improvement. Hospitals also will have to report cesareans for first-time mothers, too often a result of a failed induction.
“That’s not a good outcome for the baby or the mom,” says Joint Commission President Dr. Mark Chassin. “We believe this will be a very important driver of improvement in perinatal care.”
EDITOR’S NOTE Lauran Neergaard covers health and medical issues for The Associated Press in Washington.