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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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On Our Radar…Tocophobia and its Consequences

September 26th, 2011 by avatar

The Research
Several interesting studies have recently been published in the Scandinavian journal, Acta Obstetricia et Gynecologica Scandinavica (some of which I will cover in a subsequent post)The greatest one of interest, which has garnered much media attention lately is the study about fear of childbirth which, according to researchers, has a drastic affect on increasing instrumental deliveries (51%), labor inductions (17%), and requests for elective cesarean deliveries (30%) when compared to women not suffering from this intense form of childbirth-based fear termed “tocophobia.”

The results of this relatively small study (cases=353, controls =579) out of  University Hospital in Linköping, Central Sweden, are not necessarily surprising to many of us, but reiterate what many having been talking about for decades: fear has a very real affect on the process of labor and birth.  In fact,  in the most extreme cases, tocophobia may result in avoidance of pregnancy all together.  But for our purposes, as childbirth professionals, we need to be thinking about how we approach the topic of fear pertaining to birth in our interactions with our students/patients/clients.

Take the cascade of interventions, for example: For the woman who is increasingly anxious about what will happen during labor and birth–who asks for an elective labor induction to “just get it over with,” some of the difficulties she may be most afraid of, become a self-fulfilling prophecy when her labor is complicated by the effects of labor induction (increased pain, intensity and frequency of contractions…potential negative effects of epidural analgesia when assistance with her intense pain is requested…fetal heart rate concerns…maternal blood pressure concerns…potential advancement to cesarean surgery).

Application for Childbirth Educators
Carefully and sensitively bringing up the topic of fear related to childbirth is imperative for childbirth educators:  it gives our students the opportunity to express concerns which they might otherwise keep to themselves–thinking they are “the only ones” harboring such anxiety.   It is not about inducing or encouraging fear, rather it is about presenting the opportunity and encouraging dialogue on this topic–offering positive perspectives and coping strategies that the woman/couple may not have come up with on their own.

Don’t be Afraid to Refer
In the event we find ourselves interacting with a woman whose fear pertaining to pregnancy and/or birth is deeper than that which we feel poised to handle in class (or in clinic), referring the woman locally to a trained professional adept at counseling her through this challenge becomes a must.  Tocophobia is a very real phenomena.  This study published in Clinical Obstetrics and Gynecology, 2004 (47:3) describes tocophobia as occurring in 20% of pregnancies with disabling fear occurring in 6%.

As childbirth educators and maternity care professionals, we may not have the training or skill set to appropriately handle and solve every challenge that faces an expectant woman.  And when we don’t immediately posses those skill sets, we must invite the assistance of other professionals trained to do so.  In the mean time, proactively delivering evidence-based information that empowers (rather than frightens or degrades) expectant women can go a long way toward building confidence and reducing fear.

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

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