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A Note to the Speaker DELETE THIS SLIDE BEFORE PRESENTATION

The following slides have been developed to support presentations on the elimination of non-medically indicated deliveries <39 weeks gestational age and should be tailored to meet the needs of the audience.

When adapting the slide deck, the following guidelines must be considered: The slide deck is copyrighted by the State of California. Slides contained in this deck should not be changed or amended. Additional slides can be added, but new slides must not contain the

CMQCC logo, March of Dimes logo or the State of California copyright.



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Eliminating Non-medically Indicated (Elective) Delivery Before 39 Weeks in Our Hospital:

Difficult Q&A



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Difficult Q&A

1. Physician autonomy

2. Medical leadership

3. Consensus

4. Absolute refusers

5. Data collection

6. Stillbirths



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Physician Autonomy

• Outdated thinking • Reflective of underlying anxiety about loss of control and

autonomy• Lack of understanding that standardization of care

improves patient outcomes



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Medical Leadership

• Most “Hard Stop” reports in the literature have involved a hospital-based physician who can “take the heat”

• Many other specialties have standardized protocols Protocol examples include:• Door-to-cardiac catheterization time• Stroke• ICU - for prevention of ventilator associated pneumonia

and central line infections



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Consensus

• Use logic and literature to build a consensus among hospital providers

• An outlier may conform to guidelines if data demonstrating their practice patterns vs. their colleagues is presented, instead of forcing a doctor to follow new rules



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Absolute Refusers (1)

• Important to not allow a few physicians to affect the majority

• Physician level data can be very persuasive • Accurate data are critical - if data are wrong everyone

loses credibility• A few months of using “Scouts’ Honor” (“Soft Stop”) can

show the entire department how a few refusers can spoil the outcomes



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• Require every physician upon admission to write a full note in the chart describing why they plan to perform a non-medically indicated cesarean or induction before 39 weeks

• Require that all patients sign a full consent that describes the neonatal risks before undergoing induction/cesarean before 39 weeks without medical indication

• Require all cases be reviewed in Perinatal Committee and require that formal letters be returned and placed in their Medical Staff file

• The department Chair can use physician-level data on this measure for Ongoing Professional Practice Evaluation (JC requirement)



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• A key influence in many hospitals has been the Director of the Nurseries and/or Director of the NICU (Neonatologist or Pediatrician)• They are part of the team of champions for babies• They can illustrate examples of poor outcomes and hopefully

some statistics• It is much harder to challenge the “baby’s doctor’s” reasons

for eliminating non-medically indicated deliveries than those of another obstetrician



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Data Collection

• Data collection on non-medically indicated deliveries <39 weeks can be onerous

• Variety of methods used to calculated rates of elective deliveries <39 weeks

• A number of organizations have made collecting data and calculating the rates of elective deliveries <39 weeks easier: • The Joint Commission• California Maternal Quality Care Collaborative (CMQCC) • March of Dimes



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What About the Risk of Stillbirths?

• Even one day longer “in-utero” does increase the risk for stillbirth, but it is extremely low.

• What is the reported risk of stillbirth during the 38th week? • U.S. data (NCHS)1 = 0.36/1,000 births• Population rate - includes all risk categories

1MacDorman MF, Kirmeyer SE, Wilson EC. Fetal and perinatal mortality, United States, 2006. National vital statistics reports; vol 60 no 8. Hyattsville, MD: National Center for Health Statistics. 2012.



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What Have Intervention Studies Observed for the Risk of Stillbirth?

Intervention Study Total Population Studied

Stillbirth Rate Findings

Oshiro (2009)1

(large health system)160,394 Decline during

intervention period

Clark (2010)2

(large health system)433,551 No change during the

intervention period

Ehrenthal (2011)3

(single hospital)24,028 (>37 wk only) Increase noted at 37 and

38 wks

Benedetti (2012)4

(state of Washington)505,445 (>37wk only) No change during the

intervention period

1Obstet Gynecol 2009;113:804–112Am J ObstetGynecol 2010;203:449.e1-63Obstet Gynecol 2011;118:1047–554Obstet Gynecol 2012;119:656-7



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Increased Infant Mortality (birth to 1 year)for Babies Born at 37/38wks Gestation

Compared to 39wks or Greater Study Relative Risk

compared to 39 wksAbsolute Increase

per 1,000 births

Zhang (2009)1

(US cohort, 1995-2001)37wk: 1.7538wk: 1.25

37wk: 1.038wk: 0.3

Donovan (2010)2

(Ohio 2003-2005)37wk: 1.938wk: 1.4

37wk: 1.838wk: 0.8

Reddy (NICHD)(2011)3

(NCHS US 1995-2001)37wk: 1.938wk: 1.4

37wk: 2.038wk: 0.5

Altman (2012)4

(Sweden 1983-2006)37wk: 2.138wk: 1.4

37wk: 1.638wk: 0.5

1J Pediatric 2009;154:358-622Am J ObstetGynecol 2010;203:583Obstet Gynecol 2011;117:1279-874BMJ Open 2012;2:e001152

Results are quite consistent and show higher rates of observed infant mortality at 37/38

weeks than predicted for fetal mortality.



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For More Information, Contact:

Barbara [email protected]

Leslie Kowalewski [email protected]

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