"Choosing Wisely" in maternity care: ACOG and AAFP urge women to question elective deliveries.

pitocin iv cropped

http://flic.kr/p/4v3Zeh

Last April, the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question carefully. Today, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) have joined the campaigndrawing national attention to the overuse and misuse of induction of labor. ACOG and AAFP are telling women and their maternity care providers:

• Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.

• Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable. 

(“Favorable” means the cervix is already thinned out and beginning to dilate, and the baby is settling into the pelvis. Another word for this is “ripe,” and doctors and midwives use a tool called the Bishop Score to give an objective measurement of ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally.)  

Much work has already been done to spread the first message. Although ACOG has long advised against early elective deliveries, a confluence of quality improvement programs and public awareness campaigns have made it increasingly difficult for providers to perform non-medically indicated inductions or c-sections before 39 weeks.

But as the public and the health care community have accepted the “39 weeks” directive, concern about unintended consequences has grown. Christine Morton, a researcher at the California Maternal Quality Care Collaborative and regular contributor to Science & Sensibilitysums up concerns shared by many, including Childbirth Connection:

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?

The second Choosing Wisely statement aims to mitigate these unintended consequences. Inducing with an unripe cervix significantly increases the chance of a c-section and its many associated harms. Women considering induction for a non-medical reason deserve to know about these excess risks, and should question whether it is worth any non-medical benefits of elective delivery they perceive or expect. Lamaze International has spoken to the importance of letting labor begin on its own, as it is the first topic in the Six Healthy Birth Practices.

But will the new message lead women and care providers to think that delivery is indicated once a woman’s cervix is ripe? Through the Choosing Wisely campaign ACOG and AAFP have made powerful statements acknowledging that scheduled delivery is unwise if the baby or the woman might not be ready for birth. Although gestational age and the Bishop score are tools to estimate readiness for birth, the best indicator of readiness is still the spontaneous onset of labor at term, the culmination of an intricate interplay of hormonal signals between the fetus and the woman. Anytime we intervene with the timing of birth we have to weigh the potential benefits and harms of overriding that process in the context of the fully informed preferences and values of women.

This summer, our collaboration with the Informed Medical Decisions Foundation will culminate in the release of our first three Smart Decision Guides. These evidence-based, interactive decision support tools will help women learn the possible benefits and harms of scheduled delivery versus waiting for labor to start on its own and to weigh these based on what is most important to them. These tools help women choose wisely – to identify when an option is not appropriate or safe for them, and to thoughtfully weigh options when there are both pros and cons to consider.

Interested in learning more about shared decision making in maternity care? Sign up for a free webinar on March 13 sponsored by the Informed Medical Decisions Foundation to hear more about what clinicians, consumers, employers, and others thinking about the importance of maternity care shared decision making.

18 Comments

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Ten Month Mamas
Kamila asks: Hi! I'm 39w5d, 90% effaced and 1cm dilated -- first time mom. Doctor brought up use of Cytotec if I don't dilate further by early-next week. Anyone have success with it? I'm planning on natural hospital birth therefore attempting every natural induction method possible if anyone has sure fire ideas on what worked so I can buy time, would greatly appreciate. TIA!

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Robin Elise Weiss
I'm so glad to see this information making it to the main stream. This is a huge boon for pregnant mothers.

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Dr. Poppy
@acognews and @aafp join forces to educate against elective inductions before 39 wks. But @midwifeamy highlights an excellent point. Will we now be fixated on "39 wks, favorable cervix" as the equivalent of the button popping out of the turkey? http://www.scienceandsensibility.org/?p=6256

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Dani Long Bbci
http://www.scienceandsensibility.org/?p=6256

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Jasmine Nicholas
I really need to stop inquiring about people's due dates and getting the story about how doc won't "let" them go past 39 wks bc Omgzbigbaby. Just depresses me.

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Michele L Deck, RN, MEd, BSN, LCCE, FACCE
Even though this seems basic to us, I'm so glad OBs and Family practice doctors are making this part of defining good practice.

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Deena H. Blumenfeld, ERYT, RPYT, LCCE, FACCE
It's about time... I'm glad ACOG finally came out and said it, but I'd like to see the OB's follow the guidelines now.

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Bay Area Midwifery Center
http://www.scienceandsensibility.org/?p=6256

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by I return to the new family blog!! ta da.. « Between The Gates
[...] up is an article on the wisdom of NOT electing when to have birth. There are mechanisms at work in the baby and your body that are not well understood. Many many [...]

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Swell Bellies Doula Care
Progress is being made. Medical Caregivers are remembering the benefits of patience, and hopefully more and more of them will acknowledge the inherent wisdom of women's bodies. http://www.scienceandsensibility.org/?p=6256

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Better Beginnings: Childbirth Education & Support
We say, "Don't schedule elective, non-medical inductions EVER." Your doctors' professional association today announced that they do not support elective induction prior to 39 weeks or even 41 weeks if your cervix is not "favorable." Next question, can you depend on your care provider to advise you when you and baby are safer with induction, than staying as is? http://www.scienceandsensibility.org/?p=6256

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 21, 2013 07:00 AM by Birth Services
http://www.scienceandsensibility.org/?p=6256&utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+science-sensibility+%28Science+%26+Sensibility%29

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 22, 2013 07:00 AM by Capital City Doulas
?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries. -- http://www.scienceandsensibility.org/?p=6256

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 22, 2013 07:00 AM by Oklahoma Birth Network
Via Science & Sensibility: ACOG & AAFP urge women to question elective induction/c-section! http://www.scienceandsensibility.org/?p=6256

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 22, 2013 07:00 AM by Midwifery Care - North Don River Valley
http://www.scienceandsensibility.org/?p=6256&utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+science-sensibility+%28Science+%26+Sensibility%29

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

February 23, 2013 07:00 AM by In Due Time Doula Services
http://www.scienceandsensibility.org/?p=6256

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

March 5, 2013 07:00 AM by Jessie Valenzuela, LCCE
I'm really glad that this information is shown. Where I live in Culiacan, Mexico, induction before 39 weeks is a regular activity. The general question between moms there is "ok, so when are you going to be induced? ". I personally think that there's a reason why birth has its own time, women bodies are wise, and babies too. Hope this regulations are truly followed by OB'S and that moms use this info to question more and to stop saying YES to everything "just because".

?Choosing Wisely? in maternity care: ACOG and AAFP urge women to question elective deliveries

March 10, 2013 07:00 AM by Carolyn Gall AAHCC
How about a woman who is 2 weeks overdue and is healthy and low risk with a vigorously kicking fetus? That is technically only 1 week over due if you use the Harvard Medical School Study which says due dates are 41weeks and one day. Thanks

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