published Thursday, June 13th, 2013

Hospitals working harder to cut the number of early deliveries

A baby lies in a crib at Erlanger hospital.
A baby lies in a crib at Erlanger hospital.
Photo by Angela Lewis /Chattanooga Times Free Press.
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EARLY ELECTIVE DELIVERY RATES

To find these rates, Leapfrog Group collects numbers for all elective deliveries that occur between 37 and 39 completed weeks of gestation. From that denominator, it excludes any early deliveries that are medically justifiable. These are the remaining elective deliveries.*

The target is 5 percent.

Erlanger Baroness Hospital

2011 -- 34.3 percent

2012 -- 42.8 percent

Erlanger East Hospital

2011 -- Data unavailable

2012 -- 52.9 percent

Parkridge East Hospital

2011 -- 9.5 percent

2012 -- 29.5 percent

*Hutcheson does not report this data

Source: Leapfrog Group

REDUCING RATES

Tennessee rates of early elective births out of all births.

May 2012 -- 14.1 percent

Dec. 2012 -- 3.5 percent

Source: Tennessee Hospital Association

The descriptions of week 37 and week 38 of pregnancy aren't pretty.

"Your back aches. You can't breathe. You can't eat because of the pressure on your diaphragm. You become more and more exhausted. You just become miserable," says Traci Josephsen, a mother and clinical resources specialist with women and infant services at Erlanger hospital.

Over the last decade, it became common for doctors to schedule inductions and Caesarean sections for the convenience of patients or themselves.

But hospitals are fighting harder than ever to make sure mothers endure the agony until week 39 -- the number experts say is the gold standard for ensuring a baby is delivered healthy and more fully developed.

Within seven months last year, a group of 37 Tennessee hospitals saw their elective delivery rate reduced by 75 percent -- from 14 percent of all births to just 3.5 percent, according to a Wednesday announcement from the Tennessee Hospital Association.

The steep reduction "is the result of a lot of hard work and focus on the part of physicians and other providers across our state," said Dr. David Adair, director of maternal-fetal medicine at Erlanger, in a THA statement.

He added that cutting that number means "fewer health and developmental complications in the short and long term."

Nationally, hospitals have made notable strides in reducing early elective births. It initially has appeared to be more of a struggle in Tennessee, which had one of the highest rates for early preventable deliveries among surveyed states, according to the Leapfrog Group, a national nonprofit organization run by employers and other large purchasers of health insurance. Georgia's rates also surpass the national average.

Local hospital numbers also depicted an ongoing battle: At both of Erlanger's maternity campuses and at Parkridge East, the rates of early elective deliveries spiked between 2011 and 2012.

But last year, the state launched "Healthy Tennessee Babies are Worth the Wait," a partnership of state health care organizations aimed at improving awareness about the issue among hospitals, doctors and patients.

"We really started the full-court press of this work at the end of last year," said Phil Martin, spokesman for the hospital association. "This is the first wave of new results. It's exciting because this collaborative has been getting national recognition."

Within the past several months, both Erlanger and Parkridge have created new policies to crack down on the problem. They're also focusing on patient education.

"Perhaps the biggest challenge that we face as providers is awareness," said Lisa Wallace, Parkridge East Hospital Associate Chief Nursing Officer. "Many women don't fully understand the importance of carrying a pregnancy to 39 weeks when possible. Those last few weeks are very important for the development of the baby."

9 MONTHS ... PLUS

Most people think of pregnancy as a nine-month ordeal.

"No woman really wants to hear this, but [full gestation] is really nine months plus four weeks," said Erica Mobley, communications manager for Leapfrog Group.

Babies born before the 39-week mark are more likely to have breathing, feeding and developmental problems than full-term babies, experts say.

"Early elective deliveries are associated with increased maternal and neonatal complications for both mothers and newborns, compared to deliveries beyond 39 weeks," explained Adair.

And due dates can be off -- meaning babies may be delivered dangerously early.

Every year, an estimated 10 to 15 percent of U.S. babies are delivered early without medical cause, the Department of Health and Human Services has found.

The trend of scheduling early inductions didn't just grow because mothers were eager to give birth, Mobley says. It was more convenient for doctors, too.

"We looked into one study that showed the vast majority of babies are born between Tuesday and Thursday," Mobley said.

Some doctors' scheduling reasons seem justifiable -- like rural providers who want to ensure a patient who lives in a remote area is in safe hands when she gives birth.

And patients may have emotionally delicate arguments for wanting an early delivery: A mother may have lost a previous baby very late in pregnancy. A military father may want to meet his child before he is deployed. A couple may want their child to be born on a beloved relative's birthday.

Though these may be "humanitarian" reasons for scheduling an early birth, Josephsen stresses they may not align with the hospital's two chief goals in maternity care:

"A healthy mom, healthy baby," she says. "That's what we want."

NEW STRATEGIES

If hospitals want real results, it will require drawing a line in the sand, Mobley said.

In South Carolina, the state's Medicaid program stopped reimbursing hospitals for deliveries that didn't meet the standard, and BlueCross BlueShield of South Carolina followed suit.

Similar standards could be implemented through health care reform, hospital officials say.

That's why states have launched initiatives like "Healthy Tennessee Babies are Worth the Wait."

"Prevention is the most effective use of our precious health resources," said Craig Becker, president of the THA, in a statement on Tennessee's reduction.

Mobley said providers can make big dents in their own numbers if they simply implement strict policies.

In March, Erlanger did just that.

"This is a hardstop," describes Josephsen, holding up a white sheet of paper with 28 boxes. Each box lists a medical condition such as diabetes, pre-eclampsia, or fetal malformation. A doctor must check one of the boxes and schedule the procedure through a single office before an early birth procedure is approved.

Parkridge East has a similar new practice.

"Requests for scheduled inductions before 39 weeks are reviewed by the Women's Services director and may be granted if there is a pressing medical need," Wallace said.

The plans seem to be working.

Parkridge reports that it has not had any scheduled inductions before the 39-week mark in 2013. Erlanger is also seeing dramatic results. In May, only one birth fell outside of requirements -- a "huge new record," Josephsen said.

Adhering to the new requirements will mean a culture change, she said. But doctors have been receptive.

As for the miserable mothers-to-be, Josephsen says to hang in there.

"Once you pass that 39-week mark, you can schedule your day," she said. "No one would blame you."

Contact staff writer Kate Harrison at kharrison@timesfreepress.com or 423-757-6673.

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