Last April, the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question carefully. Today, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Association of Family Physicians (AAFP) have joined the campaign, drawing national attention to the overuse and misuse of induction of labor. ACOG and AAFP are telling women and their maternity care providers:
1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.
2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.
(“Favorable” means the cervix is already thinned out and beginning to dilate, and the baby is settling into the pelvis. Another word for this is “ripe,” and doctors and midwives use a tool called the Bishop Score to give an objective measurement of ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally.)
Much work has already been done to spread the first message. Although ACOG has long advised against early elective deliveries, the practice has persisted. But a confluence of recent reforms has made it increasingly difficult for providers to perform elective deliveries before 39 weeks. Quality collaboratives have supported hospitals to implement “hard stops” that prevent these deliveries. Payers have used carrots and sticks to disincentivize them. CMS has funded a national public awareness campaign to reduce consumer demand.
New data released today suggest these efforts are working. The Leapfrog Group, an employer-driven hospital watchdog, announced the results of their latest hospital survey, which showed progress toward eliminating non-medically indicated delivery before 39 weeks. This year, 46% of the 773 reporting hospitals met Leapfrog’s early elective deliveries target rate of less than 5%, an increase from 39% in 2011.
But as the public and the health care community increasingly accept the “39 weeks” directive, concern about unintended consequences has grown. Christine Morton, a researcher at the California Maternal Quality Care Collaborative, sums up concerns shared by many, including Childbirth Connection:
It is possible that this measure may sensitize stakeholders to the wrong issue: timing of birth rather than the fact that it is generally best when labor begins on its own. Additionally, is it possible that 39 weeks could become the new “ideal” gestational age, because it will be assumed that 39 completed weeks is the best time to be born?
The second Choosing Wisely statement aims to mitigate these unintended consequences. Inducing with an unripe cervix significantly increases the chance of a c-section and its many associated harms. Women considering induction for a non-medical reason deserve to know about these excess risks, and should question whether it is worth any non-medical benefits of elective delivery they perceive or expect.
By cautioning against elective induction with an unripe cervix, doctors are making a bold and public statement against another practice that is common in obstetrics. But we cannot assume that the “39 weeks” success story will repeat itself with this practice. The apparently falling rates of early elective induction announced by Leapfrog today represent intense multi-stakeholder efforts to rein in the problem. To see meaningful reductions in elective deliveries with an unripe cervix, we need to treat this practice with the same diligence as early elective delivery and use all of the tools in our toolbox. Data-driven performance improvement, public reporting, payment reforms, consumer advocacy, and public awareness can all get at the problem in different ways.
Meanwhile, the risk of unintended consequences remains. Will the new message lead women and care providers to think that delivery is indicated once a woman’s cervix is ripe or she reaches 41 weeks? Anytime we intervene with the timing of birth we have to weigh the potential benefits and harms of overriding the complex natural process in the context of the fully informed preferences and values of women. Reaching a certain date on the calendar or achieving a certain dilation shouldn’t flip the elective delivery switch from “off” to “on.” It should trigger a process of shared decision making to engage women as partners in choosing, based on the best available evidence and in the context of their own values, how and when to give birth.
Amy Romano, MSN, CNM, is the Project Director of the Transforming Maternity Care Partnership coordinated by Childbirth Connection.