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Program cuts medically unnecessary scheduled births

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A quality improvement program can cut by 60 percent the number of deliveries scheduled a few weeks before the due date, according to a new study.

"To me this (study) is a success story on how to do it," said Dr. Kenneth Leveno, the chair in obstetrics and gynecology at UT Southwestern Medical Center, who was not involved in the research.

According to the Leapfrog Group, a nonprofit that represents healthcare employers, among U.S. hospitals that reported their rates of early elective deliveries in 2011, 14 percent of births were early elective deliveries.

That was a drop from 2010's 17 percent, but still higher than the Leapfrog Group's target of five percent. In Australia, numbers seem to be on the rise (see Reuters Health report of July 26, 2012:.)

In some cases, there are medical reasons whose risks far outweigh the potential danger to the baby. In other cases, there might not be a clear medical necessity, or some families and physicians might be scheduling births out of convenience, said Dr. Jennifer Bailit, the lead author of the study and an associate professor at Cleveland's Case Western Reserve University School of Medicine.

"I think part of this has to do with the fact that we've had such great strides in the last 20 years or so on making premature babies better that people have gotten a little cavalier about babies who are just a little bit early," she said.

The hope is that letting babies finish out the pregnancy could reduce the chances that they will suffer any health problems associated with being born early.

These include breathing and feeding issues, keeping their temperature regulated and liver problems.

"While they're rare, they're significant enough where they shouldn't be taken lightly," said Bailit.

A steady drop

Four years ago, a group called the Ohio Perinatal Quality Collaborative brought together 20 hospitals across the state to try and address the issue of scheduling deliveries early when there is no medical need.

All the hospitals were asked to collect information on scheduled births and to submit it to a common database, so the hospitals could compare their performance to the others.

In addition, each hospital decided on its own approach to reducing unnecessary deliveries, such as by requiring the delivering physician to get approval from another nurse or doctor, or having a patient sign a form acknowledging the risks of the procedure.

"It's hard to say what it was that worked, but all those things combined" contributed to a 60 percent drop in medically unnecessary early deliveries, said Bailit.

The researchers first reported their results in 2010, but there was some concern that the reductions had more to do with how doctors were classifying their patients, rather than actually avoiding the unnecessary deliveries.

In other words, doctors perhaps became better at properly documenting when moms had a medical necessity to deliver the baby early.

In their latest report, published in the medical journal Obstetrics & Gynecology, the researchers went back through the medical records of all deliveries that had been scheduled between 37 and 39 weeks of pregnancy. Typically, a pregnancy lasts 40 weeks.

They looked for the reasons why the delivery was scheduled, and categorized them as medically necessary - such as if the mother is carrying multiple babies or if the placenta has detached from the uterus - and medically unnecessary - such as if the mom has herpes, Crohn's disease or is older.

Of more than 23,000 deliveries from October 2008 to December 2009, close to 6,700 were scheduled early - many for established medical reasons.

Deliveries for which doctors gave medically unnecessary indications declined over time.

During the first four months of the study, for instance, there were 145 more unnecessary deliveries scheduled than during the last four months of the study.

This translated to a steady drop in these births from about seven percent of all deliveries at the beginning of the study to about three percent at the end.

At the same time, the percentage of births that required an early delivery did not change throughout the course of the study.

Bailit said the results show that unnecessary scheduling were not simply being recorded as necessary, but were actually avoided.

"This paper puts that rumor to sleep," she told Reuters Health.

Leveno said that letting hospitals choose their own method for policing unnecessary deliveries was an important strategy.

"I've always been an advocate of local, hospital-based (efforts). Physicians should group together and they should meet and make decisions among themselves about what they think they should have as practice guidelines," Leveno told Reuters Health.

"And if all the physicians agree on it, it will work. If you try to impose it on them from the outside, it's not going to work," he added.

Leveno said the only thing he would like to have seen is whether the reductions in unnecessarily early births had any impact on the babies' health.

Bailit encouraged women to talk to their doctors about why their delivery is being scheduled before 39 weeks.

"We strongly discourage people for doing them just for convenience's sake," she said.