Delivering Progress. Choosing Wisely.

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.

12 replies »

  1. “The courts will get to this one soon, too.” Actually, hospital systems that have implemented hard stops to prevent elective deliveries, as part of comprehensive quality improvement and risk management programs, have seen plummeting malpractice costs. In particular, HCA, a leader in the hard stop movement, reduced the obstetric malpractice claim rate by two-thirds, and brought its cost of claims below the level of the category “accidents on hospital grounds” over the first decade of this system-wide QI program. See “Substantive Interventions” chapter of http://transform.childbirthconnection.org/wp-content/uploads/2013/02/Maternity-Care-and-Liability.pdf

  2. Oh, yeah – lawsuits. Great way to regulate health care. I guess we’re going to turn this post back into one more burn-all-HIT-in-effigy rally?

  3. JDK said: “Might it not be easier, cheaper and more effective to educate women directly, and have THEM agitate and advocate for the use of better, smarter, more evidence-based medicine.”

    Lawsuits are the best remedy for this v the hospitals, the insurance plans, and lastly, the doctors whose judgments are corrupted by big business.

    Leapfrog is hardly a purveyeor of safe practices, despite its claims. It trumpeted CPOE at the behest of its corporate sponsors as a leap to transform health care, but that device is being shown to cause as many overall deaths and errors as it may prevent. The courst will get to this one soon, too.

  4. It is all about money and convenience in our rushed, hyper extended, media driven, multi tasked society, that is getting dumber and more contrived as more control and decision making is ceded to the care governing machines, computers, and politicians.

    Wonderful post.

  5. We would be better off if Medicaid just sent block grants of money to public hospitals and safety net clinics.

    The public providers would do what they could with the resources that they have.

    There would be no claims at all. The Medicaid patient goes to the public hospital or safety net clinic, pays nothing, and gets what is offered.

    This does mean that some Medicaid patients will have undetected cancers, fatal heart attacks, and insufficient medications.

    However, and this is the key point, they will have better health care than 99% of the human race over 99.9% of human history.

    Calvin Coolidge’s son died of an infected blister in 1925, and he had the best medical care in the country. We forget how far we have come.

  6. Though I have to admit that using an employer group to move the needle only this far, after such a huge effort, may not be the best way to get there. Might it not be easier, cheaper and more effective to educate women directly, and have THEM agitate and advocate for the use of better, smarter, more evidence-based medicine?

  7. Great summary of a complex and important topic.

    Thanks to Leapfrog, we really are finally starting to move – and setting the induction bar at a less dangerous date, even if it’s still not a clinically complete picture – means at least we’re moving in the right direction. Worse than the clinical incompleteness is the fact that we are all cheering all of 46% of hospitals getting this right – because it’s better than 39%! Argh! But hey – it was lots worse before on the inductions, and let’s hope Leapfrog keesp pushing, so to speak, and also hammers down hard on the c-section, while they have birth providers’ attention.

    As for the unintended consequences, these are trivial compared to other versions of same as we try to break inertia in health care. An induction at 42 weeks is still better than at 37, and as long as there are not MORE of them, this is still directionally positive. In an ideal world, we have a multi-dimensional set of guidelines for all of these clinical factors.

    In the meanwhile…I’ve had this argument a thousand times about hospital ratings, physician quality assessment, data at the point of care, and all the other proxy wars about health care that are really about power and authority….and I still stand by my oversimplistic aphorism: a 40 watt light bulb is still better than the dark.

    Leapfrog’s progress – Leapcrawl? – is like all other guidelines in medicine – one step forward but not one step back, and no, we’re still not there – but at least we’re trying. And as the other reader noted, it’s nothing less than a miracle that ACOG is even at the table – something unimaginable a few years ago.

  8. @maithri – There is certainly a component of women asking for elective delivery, but the little research that does exist suggests that the role of patient preferences is overestimated while the role of clinician preference is underestimated. We’ve done some focus groups with women who had elective inductions and inductions for unsupported indications (e.g. suspected macrosomia) and many of our participants described being offered or pressured into induction (or even c-section). We’ve seen this in our Listening to Mothers national surveys as well. There is a lot of work to do to educate both clinicians and women on these matters.

    In my role at Childbirth Connection we are launching a national maternity care shared decision making initiative in partnership with the Informed Medical Decisions Foundation. The first three decision aids we will launch with this summer relate to elective delivery. Elective induction at or beyond 41 weeks is not one of these but is in the hopper for the next phase. We’re working with various partners from hospital systems to payers to consumer advocates to develop models for implementing SDM and engaging women as care partners. More to come on all of this!

  9. ACOG addition to Choosing Wisely is such a bold (and wonderful) statement.

    Multi-pronged efforts necessary, as mentioned, and as often is the case.

    But: Seems like accepting the complexity of birth is a hard pill to swallow for the modern woman who lives life on a schedule. If not 39, 41 is such an EASY thing to go by. What are effective ways to convey this message so that shared decision making is actually a reality (and more of a priority) for the patient? I wonder if more personalized advocacy/an incentive system directed toward patient is necessary.