Caroline Helwick

December 04, 2014

NEW ORLEANS — A campaign that includes professional education and limitations on insurance coverage can help reduce the potentially harmful practice of delivering babies early for no medical reason, according to new research.

This practice has become common in Mississippi, but efforts to reverse the trend are working, Amy Radican-Wald, MPH, from the Center for Mississippi Health Policy in Jackson said here at the American Public Health Association 142nd Annual Meeting.

Early elective deliveries are deliveries scheduled before 39 weeks of gestation that are not medically necessary. There are no proven health benefits related to this practice, but the documented harms include breathing problems, feeding problems, low body temperatures, life-threatening infections, and increased risks for cesarean delivery and neonatal death.

These problems come at a cost; the Institute of Medicine estimates that $51,600 per infant could be saved by reducing early-term deliveries.

There are some encouraging signs. From 1990 to 2006, rates of elective inductions in the United States increased from 9.5% to 22.4%. However, after coordinated efforts to address the problem, these rates declined to 17.0% in 2010 and 11.2% in 2012, according to a previous report by Radican-Wald and colleagues (Journal of the Mississippi State Medical Association. 2014;LV[8]:252-255).

"Nevertheless, wide variation among the states is still observed, ranging from less than 5% to 25%," she said. According to the March of Dimes, early elective delivery rates below 5% are considered acceptable.

A number of state and national initiatives and partnerships are now in place to discourage early elective delivery, and The Joint Commission, which accredits and certifies healthcare organizations and programs, has added early elective delivery rates as a quality indicator for delivery hospitals.

Policy Making Changes

In 2011, five states collaborated on a rapid-cycle improvement program that succeeded in reducing early deliveries from 27.8% to 4.8% in a 12-month time frame (Obstet Gynecol. 2013;121:1025-1031). And South Carolina, through its Birth Outcomes Initiative partnership, announced a 45.0% reduction, with an estimated savings of $6 million to state Medicaid in the first quarter of 2013.

"These are very impressive outcomes, and they are findings that speak to policy makers," said Radican-Wald.

In Mississippi, which has one of the highest rates of infant mortality, state leaders are targeting practices known to increase neonatal risk, such as early elective delivery. And in 2013, the Department of Health partnered with the Center for Mississippi Health Policy to examine the impact of early elective deliveries in the state.

Early elective deliveries increased from 8.5% in 2001 to 17.8% in 2008, and then declined slightly in 2011, to 16.5%. "We showed that this had been a growing practice in Mississippi," Radican-Wald said.

Neonatal death rates in Mississippi from 2007 to 2011 were 2.8 per 1000 babies born at 37 weeks of gestation, 1.1 per 1000 babies born at 38 weeks, and 0.6 per 1000 babies born at 39 weeks. According to Mississippi vital statistics data, nearly one of four infants who died were born preterm or had a low birth weight.

"This practice of early elective deliveries at 37 and 38 weeks was driving the increase in death rates within the first 28 days of life," Radican-Wald explained. "The potential impact was very big. If we could alter the common practice of early elective deliveries in a state with one of the highest infant mortality rates in the nation, we could improve birth outcomes."

Radican-Wald and colleagues found that policies such as payment reforms and scheduling policies that require a medical indication for planned deliveries before 39 weeks can curtail the practice of early elective delivery.

Impact of Early Delivery

Those findings "were used by the Mississippi State Department of Health and their partners to engage providers and policymakers in dialogue about the issue," said Radican-Wald. "For example, they sent letters to all delivery hospitals about the impact of early elective delivery. The letter also requested that facilities pledge to reduce the practice, and in return for their efforts they would be recognized publicly for reductions at or below the 5% target rate recommended by health experts."

Blue Cross and Blue Shield of Mississippi, the state's largest insurer, announced that, effective January 1, 2015, they would provide benefits only for induced early-term deliveries deemed medically necessary.

"It helps that private payers will no longer support this practice," she added.

Although outcomes data are just emerging, the project appears to be working. "We were at nine early elective deliveries per 100,000, and now — within the last 2 years — we are at 8.1," said Radican-Wald.

The work was praised by Ruth Perou, PhD, from the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention.

 
It helps that private payers will no longer support this practice.
 

"They gathered data, utilized it to understand the problem, found evidence-based strategies, and used those to implement a program and evaluate outcomes. This is a great public health model for utilizing data to inform action," Dr Perou told Medscape Medical News.

In a separate presentation, efforts to uncover reasons for the practice of early elective delivery, to educate hospital management and providers, and to discourage early elective deliveries in Illinois were reported.

Rates declined from 29.6% in 2010 to 25.0% in 2012, said Mary Driscoll, RN, from the Division of Patient Safety and Quality at the Illinois Department of Public Health in Chicago.

Driscoll and her colleagues found that rates were higher in non-Hispanic white women, women with insurance, and hospitals in rural counties. Rates did not differ according to level of hospital care, but did vary — from 13.7% to 32.4% — among regional perinatal networks.

There was no commercial funding for these studies. Ms Radican-Wald, Dr Perou, and Ms Driscoll have disclosed no relevant financial relationships.

American Public Health Association (APHA) 142nd Annual Meeting: Abstracts 297109 and 306626. Presented November 18, 2014.

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