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Preventing Cesarean Delivery – What is the Nurses’ Role?

January 8th, 2013 by avatar

By Christine H. Morton, PhD

 ”Experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.” 

Today, on Science & Sensibility, Christine Morton, PhD takes a look at a study examining the role of nurses in helping to achieve a vaginal birth for patients under their care.  No surprise from my point of view, my professional experience as a doula has demonstrated that L&D nurses play a critical role in the birth, and can really help a mother to achieve the outcome she desires.  Please enjoy Christine’s synopsis and interview with one of the study authors.- Sharon Muza, Community Manager

© 2013 Patti Ramos Photography

Readers of this blog are well aware of the 50% increase in cesarean delivery rates over the past decade, and are likely aware that the high US cesarean delivery rate is on the maternal quality and patient safety agendas for many organizations.  More attention will soon be focused on hospital rates (the Joint Commission recently expanded its performance measurement requirements such that as of January 1, 2014, all hospitals with more than 1100 annual births will be REQUIRED to report on the Perinatal Care Measure Set, which was the subject of a past blog post).  The Perinatal Care Measure Set includes a measure on the first birth cesarean among low risk women (nulliparous women who have cesareans at term, with singleton, vertex babies).  Furthermore, Centers for Medicare and Medicaid Services (CMS) is requiring that all states report rates of Elective Deliveries <39 Weeks as of 1/1/13 and it is likely that a similar requirement for the NTSV (Nulliparous Term Singleton Vertex) Cesarean measure is not far behind.

One indicator of this trend was the February 2012 symposium on preventing the first cesarean held jointly by National Institute of Child Health and Human Development (NICHD), the Society for Maternal Fetal Medicine (SMFM) and American Congress of Obstetricians and Gynecologists (ACOG.)  A comprehensive summary of the proceedings of that symposium was published in the November 2012 issue of Obstetrics and Gynecology, which is well worth reading but is available only with a subscription.  That same issue had a commentary on how to create a public agenda for reducing cesarean delivery, written by me and my California Maternal Quality Care Collaborative colleagues, which is free to all, thanks to our funder.

The attention to the detrimental health impact of our country’s cesarean rate for women and their babies is a good sign, coming as it does from powerful organizations with interests in providing care and paying for it.  Most of the focus on quality measurement reporting on cesarean delivery has been directed at hospital level (i.e., Leapfrog and The Joint Commission), though there is interest among payers and consumers for public reporting of provider-specific rates.  Virginia is one example where obstetric outcomes (cesarean, episiotomy) are publicly reported at the hospital and provider levels.  However, it is complicated to attribute outcome rates in obstetrics, which is increasingly a ‘team sport’ with multiple clinicians (physicians, midwives and nurses) involved in the care of a woman throughout her pregnancy and birth.

Yet, in all these domains (institutional, measurement, quality improvement), the role of nurses on cesarean delivery decisions and outcomes has been barely mentioned.  Neglecting the labor & delivery nurse’s role is unfortunately all too typical in public discourse around quality reporting, shared decision-making and improving outcomes in birth. I have become very interested in the nursing perspective as the more I learn about hospital birth, the more I realize that nurses are central to the management of labor & delivery units, and in measuring and reporting outcomes.  Thus, it was with great delight that I saw a new study, Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes in the January 2013 issue of JOGNN

Nurse-researchers Joyce K. Edmonds and Emily J. Jones conducted a semi-structured interview study with 13 nurses who were employed at a hospital with about 2000 births a year and overall cesarean rate of 36%.  These nurses work within a “nurse-managed labor model” which is characterized by a relatively autonomous nursing role, with intermittent communication with an off-site obstetrician.  Most nurses in the US practice within this type of model.  Nationally less than 10% of hospitals that do births are teaching hospitals, which have 24/7 access to physician consultation.  Other hospitals with 24/7 physicians on staff include HMOs like Kaiser Permanente, or those who have hospitalists.  In California, about half of all birthing facilities do not have an OB available onsite 24/7.

Shockingly few studies have looked at nurses’ role on the mode of delivery.   This is more striking when one considers the many specific nursing clinical practice responsibilities that may affect cesarean rates.  Nurses are largely responsible for assessing women during triage for admission, monitoring and assessing the health of mother/baby after hospital admission.  Nurses manage and administer oxytocin, assess and assist with labor pain, and are primary managers of second stage labor.  These practices occur within the administrative context of each hospital’s policies on admission in early labor, rates of interventions such as inductions (especially those for no medical indication), cesarean (especially those among the low risk population) and availability and rates of Vaginal Birth After Cesarean (VBAC).

Data for this study were drawn from semi-structured interviews with nurses who had a range of 10-40 years clinical experience in L&D.  Questions were specifically designed to elicit active practice and interaction with physicians (interactions with women were not addressed).  An example of a question asked of respondents, “Can you tell me about a time when you intervened to promote vaginal delivery or avoid a cesarean?”

The overarching theme in this study was how nurses described their efforts to ‘negotiate for more time’ during labor, to positively impact the likelihood of a vaginal delivery.   Negotiating for more time was defined in this study as “a form of nurse-physician interaction and an action taken to create the temporal space in which nursing interventions thought to affect delivery mode decisions operate”.    The authors found that nurses’ ability to negotiate for more time was based on their knowledge of labor and birth over their many years of experience, as well as their knowledge of individual physician practice patterns.  Furthermore, nurses’ awareness of physician and institutional-imposed time constraints was a key factor in negotiating for more time.

The important conclusion reached by the authors was that “experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.”  Despite the known limitations of this study – small sample of highly experienced nurses working at a single institution – I was intrigued and excited by the practice implications and the potential to develop quality improvement strategies for reducing cesarean deliveries that are specific to nurses.  So often, the labor & delivery nurses’ role is overlooked in this area and this study is an important contribution to our understanding of nurses’ influence in cesarean outcomes.   There is clearly more research and work to be done, and one of the authors, Joyce K. Edmonds, graciously responded to questions I had about the study and future directions for this research and quality improvement initiatives:

CHM: It was interesting that the range of experience represented in your study was 10-40 years – do you think your sample was more weighted toward the more experienced nurses?  Do you have any theories for why the lower end of the range was so high?  Were there nurses in that hospital with 2-3 years of experience?  Any thoughts about why they did or did not participate?

JKE:  Our sample was without doubt weighted to the experienced nurse, and we used the term experienced as a qualifier throughout the paper. This particular hospital staff was highly experienced, although, there were nurses with less than < 5 years experience. We think the sample was a self-selecting group of nurses who felt strongly about birth mode and the influence they had on birth mode decisions. Perhaps, less experienced nurses’ perspectives on birth mode were not as clearly developed as those who participated. It could also be that those who volunteered to participate were more supportive of promoting vaginal deliveries than those who did not participate. It could also be that scheduling conflicts with less experienced nurses prohibited them from participating.

Joyce Edmonds

CHM: I think the fluid nature of ‘time’ and the constraints on physician time bear further exploration.  In this regard, it would have been helpful have analyses of accounts where nurses felt they were ‘unsuccessful’ in buying more time for labor.  The counter-factual example can sometimes shed light on the dynamics – what didn’t work in this case? Do you have any unsuccessful stories in your data and/or did you analyze those?   It seemed as though all the nurses in your study DID negotiate for time, or at least provided you with accounts of when they did.  Were there any nurses who did NOT have a story to share about negotiating for more time?

JKE: All the nurses did talk about negotiating for time, which is the reason it emerged as the overarching theme.  Nurses did talk about not being able to negotiate for more time when cesareans were scheduled because the course of labor management was already established. They also seemed to have less influence when inductions were scheduled because again the labor management plan was established prior to their involvement in the care. I’d have to look back at the interviews with an eye toward specific counter-factual examples.

CHM: I also found it fascinating to read the quote that begins, “It almost feels like you’re working against the machine.” I was curious to know more about the justifications for that taboo of not being able to talk or confront the physician with the ‘agenda.’   In my interviews with OB nurses, I also came across this and think it is an important factor to explore further.  I imagine that nurses with less clinical experience are even less able to identify or recognize this ‘agenda’ and that comes with its own set of practice and policy issues for nursing training.  

JKE: I think the nurse physician relationship shapes the day-to-day work environment of the nurse. It is a long-term relationship relative to the nurse-patient relationship. It is likely that talking about or confronting a particular physician about the potential of an agenda could negatively disrupt the work environment, which is significantly related to nurses’ job satisfaction. Nurses want to be seen as team players and discussing the potential of physician ‘hidden agendas’ is like being a whistle blower. In addition to not wanting to disrupt the power balance, they may not want to invite scrutiny into their own practice patterns.

CHM: I was struck in particular by the account on page 5 of your paper that ends with the quote, “There are certainly situations where the baby needs to come out via C-section, but it is not as many as we do by any stretch.”  What situations?  What factors influence those decisions?  Where do nurses feel they lost power to bargain /buy more time?  

JKE: In this quote, the nurse is referring to medically indicated versus potentially unnecessary cesareans. I believe when nurses speak about cesareans they are not only focused on unplanned, intrapartum cesareans but also scheduled cesareans or scheduled inductions, which can result in a cesarean. It was clear from the interviews that nurses felt less invested in the decision-making process when women came in for scheduled cesareans or planned inductions. Nurses also spoke of how women are set up for failure during pregnancy—by way of unfavorable media messages, lack of unbiased childbirth education, and lack of risk reduction information from prenatal care providers.

CHM: I was intrigued that in this study you did not appear to ask about nurses’ views toward physiological birth (vaginal) and cesarean, or other indicators of their philosophy of birth.  The comment from the nurses who viewed themselves as a ‘dying breed’ begin to capture some sense of that – whether it is experience, knowledge, or philosophy of birth that unites them against this perceived different group of newer nurses.

JKE:  Great question, although it assumes that nurses’ personal philosophy of birth impacts their practice, which it likely does according to Reagan et al. In an attempt to keep the data focused on our main aim we did not ask nurses directly about their personal philosophy of birth. I believe the nurses in the study were united in their knowledge of childbirth–without the now pervasive assessment and intervention technology–knowledge borne out of experience.

CHM: How do you plan to follow up with this research and what are your future projects?    

JKE: Locally, we want to continue the discussion about the influence of nursing care and knowledge on cesarean rates that started with our interviews. Due to the sensitive nature of the topic and hospital policies, we have not had much success with direct follow-up where the study was conducted. However, we are very interested in presenting and discussing the results with other interested audiences. With regard to future projects, we are currently initiating a study to document the degree of nursing influence on cesarean rates at the level of the individual nurse, at an academic medical center and at a community hospital, building on the sentinel, yet dated, work of Radin et. al.  If the results are significant, we foresee the development of a quality improvement strategy directed at providing individual nurses routine (e.g., bi-monthly or quarterly) feedback on standard measures, such as risk adjusted primary cesarean section rates, cervical dilation at cesarean, and cesarean indication, based on the cohort of women in their care. Clearly, although not without great effort, such a strategy would need to be interdisciplinary and have adequate IT infrastructure and support. I also think nurses, as part of a team, should be involved in giving feedback about physician practice patterns in accordance with obstetric standards.

Are you an L&D nurse?  Can you comment on your experiences and how you feel your actions can influence the mode of birth.  If you are a doula, what has been your observation.  Doctor or midwife?  How do you view the role of the L&D nurse?  I look forward to a robust discussion. – SM

References

Edmonds, J. K. and Jones, E. J. (2013), Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42: 3–11. doi: 10.1111/j.1552-6909.2012.01422.x

Main, E.K., Morton, C.H, Hopkins, D., Giuliani, G.,  Melsop, K., and Gould, J.B (2012), Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery, Obstetrics and Gynecology, November 2012; 120 (5):1194-1198.

Radin TG, Harmon JS, Hanson DA. Nurses’ Care During labor: Its Effect on the Cesarean Birth Rate of Healthy, Nulliparous Women. Birth. 1993;20(1):14-21.

Regan M, Liaschenko J. In the Mind of the Beholder Hypothesized Effect of Intrapartum Nurses’ Cognitive Frames of Childbirth Cesarean Section Rates. Qualitative Health Research. 2007;17(5):612-624.

Spong, C. Y. MD; Berghella, V. MD; Wenstrom, K. D. MD; Mercer, B. M. MD; Saade, G. R. MD (2012), Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop, Obstetrics & Gynecology, Volume 120(5), November 2012, p 1181–1193

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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)

    References

 

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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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