Archive for December, 2011

The Maternal Quality Landscape–Part Three, Segment Five: How do we measure AND achieve it?

December 30th, 2011 by avatar

[Editor’s Note:  In this final segment of Christine Morton and Kathleen Pine’s series on the Maternal Quality Care landscape in the United States, the post authors look at where the <39 weeks elective deliveries bans have been effective, and where such attempts may have some unintended outcomes.  Finally, Morton and Pine offer a feasible list of actions childbirth educators and doulas can take in their own communities.  To read this entire series from the beginning, go here.]


Unintended consequences

We would like to now draw your attention to some of the unintended consequences of quality measurement.

 There has been strong support for this initiative among many stakeholders, including ACOG, the March of Dimes, and several National Quality organizations, such as NQF, TJC and Leapfrog.  Many states or major hospital systems have convened collaboratives, such as Ohio and Intermountain HealthCare in Utah, and several more are in the works, such as North Carolina, Oregon, Oklahoma and Illinois.  State Medicaid programs are expressing interest, especially in payment reforms and commercial insurance companies have launched initiatives, such as Anthem Blue Cross Patient Safety First initiative in California.  This type of support from a wide range of stakeholders is impressive, and positive.  Yet, some stakeholders promoting the <39 weeks measure assumed its adoption would lead to a significant reduction in the overall cesarean section rate.   Unfortunately, this assumption is largely unwarranted since only about 4-10% of all births are elective deliveries between 37 and 39 weeks, and most of these are scheduled repeat cesareans.

 Another unintended consequence is that this measure may affect the way elective inductions are scheduled.  At the micro-level, it is possible that schedulers may simply schedule inductions so as to not negatively impact the hospital’s statistics (for example, by scheduling inductions automatically for 39 weeks and 1 day gestation).  However, this brings up a big-picture question: If we focus on 39 weeks, what are we doing to prevent elective inductions at any gestational age, which may arguably be the bigger issue?  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?  While the measure does not state that 39 weeks is ideal for all inductions, providers and the general public may not understand that selecting 39 weeks as an upper limit is not an endorsement of this age as the ideal age to be born.



The last unintended consequence we discuss has to do with how the public message is conveyed via the media, such as the recent NPR story with the title, “Doctors to Pregnant Women: Wait at Least 39 Weeks.”  Some reports, like the one in the Portland Tribune, cover the issue in a balanced way, and note that there are pressures/drivers from both women and physicians in early term deliveries.  Yet, others, with headlines like “More hospitals banning elective C-sections” convey the message that women have been the driving force behind this trend in early deliveries and hospitals/providers are finally drawing the line in the sand.   Data from Listening to Mothers II doesn’t support such claims, but while it’s true some women seek early elective deliveries there are also physicians who recommend or ‘lead women’ to that decision.   After all, women can’t schedule a cesarean or an induction – only hospital staff can, upon orders from a provider.   The result of this framing is that public comments on such stories often take women to task for being selfish and unthinking, unfit mothers. There are a few who provide the other side, however, citing providers as drivers, and hospitals as willing partners, of the increase in early deliveries.


What can childbirth educators and doulas do?

  • Take advantage of education resources, including the March of Dimes’ “brain card” which illustrates the differences in brain development at 35 and 40 weeks of pregnancy, and can be used to help women understand the importance of waiting.
  • Share this excellent article by Kathleen Rice Simpson and colleagues on the success of an educational intervention to decrease the rate of elective labor indication among nulliparous women at a community hospital with hospital staff in your community, and implement in your own classes.
  • Make sure your local hospital maternity nursing staff is aware of AWHONN’s new education campaign: “40 Reasons to Go the Full 40 Weeks.”
  • Reach out to a local March of Dimes organization to partner with them on a public education seminar- this is an issue for the general public as much as for pregnant women.  March of Dimes chapters tend to have good relationships with hospitals and may be a new ally in your community for promoting optimal birth practices.
  • Set up Google Alerts for key words (“Elective Deliveries” “cesarean”) so that you are notified by email when new content appears online (news or blogs).  Then monitor the public comments pages and offer your perspective as a childbirth educator/doula and be sure to include information on your services or cite Lamaze as a place for people to get evidence based information.
  • Ask the perinatal nurse manager at your local hospital(s) whether the facility is going to report on TJC perinatal measure set.  If not, ask when they plan to, and who in the hospital is the decision maker.   But understand it may be a struggle for hospitals to report on this measure set, and the process might be slower than advocates would like.
  •  Reach out to non-mainstream audiences, especially among those who are not likely to attend typical childbirth classes but who may be at greater risk for elective deliveries –Latinas, African American women, younger and non-native English speaking women and those without partners.

    Posted by:  Christine Morton, PhD and Kathleen Pine (University of California, Irvine)



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The Maternal Quality Landscape–Part Three, Segment Four: How do we measure AND achieve it?

December 29th, 2011 by avatar

[Editor’s note:  Continuing with Christine Morton and Kathleen Pine’s review of U.S. maternal quality care measures assessment this week, and in completion of their three-part series, today they discuss methods of data collection and the problems that sometimes occur in accurate documentation.]

Reporting the Measure
The <39 Weeks measure is a good example of why accuracy in data collection and reporting of measures is important. The Leapfrog Group (a patient safety group that conducts self-selected patient safety and quality surveys with participant hospitals and makes the results public) adopted the measure after its NQF endorsement, and incorporated it into the 2010 Leapfrog survey. When the results of the measure were made public, some hospitals had extremely high ED <39 weeks rates and some had extremely low rates. Such wide variation can indicate true differences in incidence of a procedure, or it can reflect challenges in measurement.  Quality advocates pay close attention to how a measure is calculated, because if the data is challenged as inaccurate, hospitals will not acknowledge they have a quality improvement issue.  In this case, at least some of the variation seen in the Leapfrog data may have been due to hospitals not reporting just those elective deliveries within the specified time frame. Correct measurement is crucial not just to improve quality but to the quality improvement endeavor as a whole.  Hospitals and providers must understand how a measure is correctly executed and have the time and resources to prepare data.  As hospitals and initiatives move forward on this issue, specifications for this measure have been refined.  In the 2011 Leapfrog survey, the measurement specifications were adapted to match those of TJC.  It will be interesting to compare the results in the next survey with those reported in 2010.

Obtaining accurate data
In order to trust that the information being reported by a measure reflects the actual practices in a hospital and their outcomes, the data that the quality measures are built on must be accurate.  <39 weeks presents several potential problems with data accuracy, chief among them:

1) Gestational age.  Although ACOG provides criteria for confirming gestational age (ACOG, 2009), it can be difficult to gauge gestational age effectively, and the further a pregnancy progresses, the more difficult it is. There are two issues: the accuracy of gestational age and consistency in using a particular method to assess it.  Women may not know when their last menstrual period before pregnancy was, and menstrual cycles vary in length.  Ultrasound used in early pregnancy provides a more accurate estimate, but some women do not seek early prenatal care or receive a first trimester ultrasound.  The medical record may indicate gestational age as calculated by last menstrual period, by ultrasound or some other means.   In addition, hospitals vary in terms of which department and what level of staff are assigned to fill in the data required by the birth certificate.  In some cases, birth clerks are assigned this task and may not receive adequate training to ensure they select the most accurate gestational age, if there is more than one estimate in various places throughout the chart.

2) Documentation.  Accurate and complete documentation of the data elements required to make the measurement is crucial.  If something is charted wrong at the bedside, it may be impossible to catch the error in later calculations.  Good documentation practice often requires extensive education of providers from quality analysts and educators.  <39 weeks, for instance, requires providers to accurately record whether a patient was induced, and this becomes an ICD-9 procedure code.  A common mistake in documentation on the part of providers is to note that a patient was augmented with Pitocin when they were actually induced or vice versa.  Definitions of induction can be confusing, it may be difficult to determine whether or not labor started on its own, and those collecting the data often must do extensive “detective work” when one piece of information does not match up with another to create a clear picture of what happened.  The chart review component of this measure can be time consuming.

3) Sampling issues. TJC specifications allow for hospitals use sampling methods to select a random subset of births to calculate the measure. The problem with this is that hospitals with small numbers of births may select a random sample of cases in which there are few elective deliveries < 39 weeks, thus under-reporting the issue.  If instead, obstetric departments work with their medical records or quality department and screen cases (less the excluded ICD-9 codes) for the desired time period, they then use the delivery logbook (electronic or paper) to identify all births occurring between 37-39 weeks.  Those births coded with a cesarean or induction will need to undergo a chart review to ascertain whether the woman had rupture of membranes or was in labor to exclude those cases.  Sampling seems simpler, but has the potential to be the victim of the law of small numbers, leaving hospitals with nothing to report but not necessarily accurate.  Doing chart review can be time-consuming – for a hospital with about 100 births a month, this simplified approach would result in about 8-10 births needing a chart review.  At an estimated 15-20 minutes per chart review, this entails 2-3 hours per month to collect the data for the <39 weeks measure.

4) Redefining the issue.  It may be that by adopting a hard stop policy, hospitals will be successful in reducing early inductions.  However, rather than charting the intervention as an ‘induction,’ hospital staff may instead chart the intervention as an ‘augmentation,’ with a concomitant rise in augmentations.  It is important for quality measure advocates to develop mechanisms to ensure that focused attention on reducing one practice do not result in increasing the incidence of another, related practice.  It also means that a set of ‘balancing’ measures can be helpful to avoid certain processes/outcomes being relabeled.

[Tomorrow, Christine and Kathleen will complete this series with a look at the unintended consequences that sometimes coincide with <39 weeks messaging, as well as a call to action for childbirth educators and doulas.  To read segment one go here.  To read this series from the beginning, go here.]


Posted by:  Chritine Morton PhD and Kathleem Pine, University of California, Irvine

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The Maternal Quality Landscape–Part Three, Segment Three: How do we measure AND achieve it?

December 28th, 2011 by avatar

How Hospitals Measure ED < 39 Weeks


Next we discuss how hospitals actually compile the data elements needed to calculate their rate of elective deliveries occurring between 37 and 39 completed weeks gestation.  It is crucial to remember that successful quality measurement depends on the local practices of collecting data, making calculations, and reporting data to quality improvement organizations.  Each hospital and unit presents a different configuration of personnel, technology, documentation practices, and other resources, thus conducting measurements in practice may look quite different from one context to the next.  As we noted in our first post, maternal quality measures are fairly recent.  Hospitals have long reported on measures but obstetrics departments may not have the staff or training to do the work necessary to accurately collect and report on the newer maternal quality measures.  Obstetrics has long been considered an “island” in the hospital, with little crossover in terms of staff or patient population, and thus may not have much experience working with the quality department.  To further complicate the situation, it turns out that there are several dilemmas faced by hospitals, providers, and quality analysts as they perform the local practices of quality measurement.


Measure Specifications
The Joint Commission publishes the specifications
for calculating the perinatal quality measures.  The premise of the <39 weeks measure is to calculate a percentage by dividing the number of women who had elective deliveries between 37 and 39 weeks (the numerator) by the total number of women who had elective deliveries (the denominator).  One basic sequence of steps in calculating the measure is:

1) Identify births to all mothers between 8 and 65 years old who were not part of clinical trials;

2) Exclude all mothers with an ICD-9 code on the exclusion list (see box);

3) Exclude all mothers where the birth occurred at less than 37 or more than 39 completed weeks’ gestation;

4) Of those identified so far, include those mothers who had a cesarean section or induction of labor by ICD-9 code.

5) By chart review, exclude those labor inductions or cesarean deliveries done after spontaneous rupture of membranes and/or active labor.

Five steps doesn’t seem so bad!  However, calculating the measure in practice can be quite tricky.  In most hospitals, the data elements needed for each step are found in the patient discharge database containing ICD-9 codes, the birth certificate and/or the delivery logbook and the actual medical chart.  Assembling all these sources of information can be challenging, as we describe below.


Deciding on exclusions
There are a number of reasons that elective delivery between 37 and 39 weeks may be medically indicated.  The Joint Commission lists such “exclusions” in its specifications manual and the most recent of these are noted in the box.  These cases are “exclusions” to the denominator- they must be pulled out before the calculation is made.  Although it is possible to identify and list a number of likely scenarios that would be appropriate to exclude, it is impossible to account for every possible scenario that may make early delivery an appropriate choice.  This is acknowledged as an issue by the authors of the <39 Weeks Toolkit:


For the purposes of creating a quality measure that was not overly labor intensive to collect, TJC chose to utilize diagnoses that had ICD-9 codes no matter if some codes were over-inclusive (gestational diabetes) or simply not available (prior vertical cesarean section scar). TJC has noted during private conversations with CMQCC leaders that the list of codes is not exhaustive and anticipates that every hospital will have some cases of medically justified elective deliveries prior to 39 weeks that are not on the TJC list. Therefore, each hospital, hospital system or perinatal region should, based on the available evidence, set their own internal medical standards for conditions that justify a scheduled delivery prior to 39 weeks. Note that too loose an internal standard will become apparent once hospitals are publically compared (Main et al, 2010).


Thus, it is up to hospitals to develop their own list of exclusions and decide in unusual cases whether early elective delivery was justified or not.  Quality advocates work under the assumption that sloppy or inaccurate measurement practices will be reflected in the data but not until the measure is collected and rates publically reported will it become obvious if a hospital has set too loose a standard for medically-justified elective delivery.


[Tomorrow’s post will look at data collection and reporting, and the pitfalls that sometimes occur in the process.  To read segment one go here.  To read from the beginning of this series, go here.]


Posted by:  Christine Morton, PhD and Kathleen Pine, University of California, Irvine

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The Maternal Quality Landscape–Part Three, Segment Two: How do we measure AND achieve it?

December 27th, 2011 by avatar

Perinatal Measure Case Study:  Elective Deliveries <39 Weeks

The <39 weeks measure is designed to capture the percentage of elective vaginal or cesarean deliveries at greater than or equal to 37 and less than 39 completed weeks of gestation.   Elective in this sense means “scheduled and having no medical indication.”

Background: How did <39 Weeks become an Issue?
The seeds of the <39 weeks measure were planted over a decade ago.  One early alarm bell was the finding in 2002 that average length of gestation was shifting downward, with 39 weeks becoming the most common gestational age among babies rather than 40 weeks (Davidoff et al., 2002). Figure 1 shows how the distribution of singleton live births in the US has shifted since 1992 (Fleishman 2011).  At the same time, research was emerging which showed that babies born at ‘term’ but at less than 39 weeks’ gestation, had poor outcomes.

Effects of ED<39 Weeks on Babies and Mothers
Researchers have demonstrated significant variation in the health of babies born during the five-week window considered “full term” (Fleischman, Oinuma, & Clark, 2010).  And, as Amy Romano writes in a recent S&S blog post, new research suggests these early term births may be associated with emotional health costs for mothers.

Most providers do not see a lot of bad outcomes in infants who are born during this time, so many had been unaware of the growing literature suggesting a problem.  However, overall, there has been an increase in NICU admissions of infants that are considered “term” but are born prior to 40 weeks (Clark 2009; Morrison 1995; Madar 1999; Tita 2009).  Anecdotally, lactation consultants note that babies born less than 40 weeks seem to have an increased risk of breastfeeding problems.  They are called “imposter babies,” because they have difficulty nursing like a full term infant despite having the appearance of one.

To address the growing concern about these avoidable harms to babies born prior to 39 weeks, a public awareness campaign was spearheaded by the March of Dimes, which included a re-definition of preterm births.

Shifting definitions of “term” and “preterm”

Definitions of prematurity have a complex history.  In 1948, the World Health Assembly adopted a definition of “prematurity” that tied birth weight to gestational age; an infant was considered premature IF it weighed less than 2500 grams (~5.5lbs) AND/OR estimated gestational age was less than 38 weeks (Drillien, 1974).  However, many (healthy) babies were classified as premature who were not actually born prior to 38 weeks, and babies who were less than 38 weeks but over 2500 grams were misclassified as not premature.  Researchers recognized that although there was a relationship between gestational age and newborn weight, these two categories did not map directly onto each other. Subsequently, new classification schemes were developed that subdivided infants into separate categories based on prematurity and weight.  Definitions for pre-term (less than 37 weeks); term (37 through 41 and 6/7 weeks); and post-term (42 weeks or more) were developed and became well-established in obstetric practice.   Additionally, in recent years researchers have proposed new sub-categories.  In particular, there was a further distinction among the pre-term births for those occurring between 34-36 completed weeks (previously referred to as near-term): “Late preterm” (Engle, 2006) and those occurring between 37 and 39 completed weeks:  “Early term ” (Fleischman et al., 2011)  (See Table 1).  The observed rise in births occurring in the time frame that was technically considered “term” – births occurring in the 37-39 week range – can be seen in Figure 2.




How the Upper Limit was Defined as 39 Weeks
Selecting gestational ages between 37 and 39 completed weeks as a target for a quality measure was based on research briefly outlined above as well as clinical consensus that babies born at less than 39 completed weeks have worse outcomes than those born after; but it was never designed to be a prescribed or recommended delivery goal for all babies.

A large body of literature, summarized in the California Maternal Quality Care Collaborative (CMQCC)/March of Dimes Toolkit (Main et al. 2010), shows that babies born before 39 weeks are at increased risk for NICU admission and sepsis and are more likely to need a ventilator, among other problems.

However, research also suggests that babies born after a certain point may be more likely to be stillborn.  In particular, the mortality rate increases for babies born after 42 weeks gestation, although the causes of this phenomenon are still unclear.  Mortality in post-term infants has not been linked definitively to prolonged pregnancy itself but may be linked to fetal growth restriction and fetal deformities. Currently, there is debate about whether or not elective induction at 42 weeks is better than expectant management (Mandruzatto et al., 2010).

It is important to remember that 39 weeks was not chosen because it is the optimal time for a baby to be born; indeed it seems that very few pregnancies last long enough to enter a time that may be sub-optimal.  Instead, 39 weeks was chosen because research has shown it is the point at which the baby appears to suffer little additional harm from being outside the uterus as opposed to inside of it. There is some evidence to suggest that for scheduled repeat cesareans, delivery between 39-40 weeks is optimal for neonatal outcomes.


[Tomorrow’s post explores how hospitals identify and document <39 weeks births including use of The Joint Commission’s specifications for calculating perinatal quality measures To read segment one, go here.  To read this series from the beginning, go here.]

Posted by:  Christine Morton, PhD and Kathleen Pine (University of California, Irvine)


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The Maternal Quality Landscape–Part Three, Segment One: How do we measure AND achieve it?

December 26th, 2011 by avatar

Quality measures, transparency, and quality improvement –these “buzz words” are proliferating in the blogosphere, reflecting increased activity and interest around improving the quality of health care in the United States.  How does maternity care fit into this picture?  This blog post series contains three parts: Part 1 provides an introduction to the history of the general quality measure landscape.  Part 2 deconstructs and demystifies the alphabet soup of indicators, measures and organizations involved and explains their relationship to one another. This week, in Part 3, we review the current National Quality Forum (NQF) perinatal measures and discuss The Joint Commission (TJC) Perinatal Core Measure Set, describe how these measures are being used by various organizations and/or states, and discuss their limitations as well as their potential.  We conclude with suggestions on how maternity care advocates can engage with maternal quality improvement efforts on national and local levels.

The Joint Commission Measure Set

In 2007, The Joint Commission (TJC) recommended replacing the previous pregnancy and related conditions measure set.  NQF began an extensive process of soliciting measures from experts, vetting measures, and creating a set of high-quality measures related to perinatal care that other quality organizations and state Medicaid programs could then use.  In October 2008, NQF unveiled 17 perinatal measures which were endorsed through their expert panel review process.  From this set, TJC selected five measures for their new Perinatal Core Measure Set (see Table 1 below).  Hospitals had the option to report on these measures as of April 1, 2010


Maternal quality advocates are excited about this new TJC set of perinatal quality measures, because it brings renewed focus to maternity care and it also incorporates a new process measure focusing on a major problem with obstetrical practice: over-utilization of elective induction and elective cesarean section prior to 39 completed weeks gestation (referred to here as the <39 weeks measure).  Tomorrow, we will examine this measure in-depth to explain the justification, development, selection process, and actual practices of measuring data at the level of individual hospitals.

[Tomorrow Dr. Morton and Ms. Pine discuss the concept of limiting elective deliveries prior to 39 completed weeks gestation–and how those measures have come about in various U.S. hospital locales in recent years.  To read this series from the very beginning, go here.]


Posted by:  Christine Morton, PhD (CMQCC) and Kathleen Pine (University of California, Irvine)



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