Clinical and Health Affairs
Preventing Elective Induction before 39 Weeks
By Trudy Ohnsorg, M.P.H., and Jeff Schiff, M.D., M.B.A.
Abstract
Induction of labor has become a common practice in Minnesota and elsewhere in the United States during the last three decades. Yet a review of the research shows that elective induction has no medical benefit and, in fact, is associated with risks to both the mother and infant, particularly if labor is induced before 39 weeks gestation. This article reports the recommendations of a Minnesota Department of Human Services advisory group on perinatal practices and labor induction. The recommendations include having hospitals establish new policies on elective induction and encouraging medical providers to educate patients about the risks of early-term induction.
In 1990, women across the United States were induced into labor about 9.5% of the time on average.1 By 2006, the percentage of deliveries that were induced had increased to between 22.5% and 31.1%. A recent report at one large hospital showed that in 2010, induction was used in 43.6% of births and that 39.9% of those inductions were elective.2
The increase in the number of inductions does not appear to be because there is a medical benefit. In fact, there are risks. Labor induction at all gestational ages has been associated with a two-fold increase in the risk of cesarean delivery.2 An additional 3.1% of newborns need NICU care for 4.5 days after an elective induction at 37 weeks as compared with infants who were born at full term.1 Infants born at 37 weeks have a risk of respiratory distress syndrome that is three times greater than that for babies born at 38 weeks; infants born at 38 weeks have a rate of respiratory distress syndrome that is 7.5 times higher than that for babies born between 39 and 41 weeks.3 In addition, the interventions associated with elective induction such as placement of an intravenous line; continuous use of electronic fetal monitoring; confinement of the mother to bed; amniotomy; and the use of pharmacologic labor stimulating agents, pain medications, and regional anesthesia have their own potential for complications and risk of iatrogenic harm.4
Learn More about Reducing the Number of Elective Inductions
Health care providers and administrators can learn more about best practices related to induction of labor, strategies for implementing induction policies and quality programs, and the state’s proposed policy changes at a November 17 seminar cosponsored by the Minnesota Hospital Association, the March of Dimes, and the Minnesota Department of Human Services.
The seminar will take place at the John Nasseff Medical Conference Center at Children’s Hospitals and Clinics of Minnesota, 333 North Smith Avenue, St. Paul, and will run from noon to 4:30 p.m. CME credit will be offered. To learn more or register, go to www.marchofdimes.com/minnesota.
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So how do we interpret the steady increase in the rate of induction? Are mothers and their doctors simply taking advantage of induction as a convenience? Are women not aware of the potential risks to themselves and their babies?
Research has shown that many women may be confused about when a pregnancy is considered “full term.” In a recent study of insured women who had recently given birth, 24% of respondents believed that a baby of 34 to 36 weeks gestation was full term, 50.8% believed full term occurred at 37 to 38 weeks, while only 25.2% considered full term to occur only at 39 to 40 weeks gestation.5 The American College of Obstetrics and Gynecology has stated that elective induction should not occur before 39 weeks gestation.6
In Minnesota, about 27,000 births each year (approximately 38% of all births) are covered by the state’s public health insurance programs.7 Because of this, a 2009 law recommended that the Minnesota Department of Human Services’ (DHS) Health Services Advisory Council review best practices for perinatal services. The council formed an ad hoc group, the Perinatal Practices Advisory Group (PPAG), in November of that year to study labor induction and make policy recommendations regarding elective induction before 39 weeks. The group issued a report in July of 2010.7
Induction Policies in the United States and Minnesota
The PPAG surveyed national and local initiatives related to reducing the rate of induction before 39 weeks gestation and conducted a comprehensive review of the medical literature on the topic. The group found that across the country, many organizations and facilities have been working to reduce their elective induction rates. At McGee Women’s Hospital in western Pennsylvania, for example, the rate of induction performed at less than 39 weeks dropped 64% in two years after an intensive institutional effort involving peer monitoring and enforcement to facilitate adherence to practice guidelines.8 A statewide collaborative in Ohio reduced the rate of elective induction before 39 weeks from 25% to 5% in one year by changing hospital policies and processes and giving feedback to providers.9 At Intermountain Health Care in Salt Lake City, the rate of early term (37 to 38 6/7 weeks) elective induction fell from 28% of all deliveries to less than 3% after they implemented guidelines that discouraged the use of elective induction.10
In Minnesota, an initiative by Park Nicollet Health Services that involved the use of patient educational materials, as well as the creation of hospital policies and order sets for induction, saw the number of elective inductions before 39 weeks fall to nearly zero. Other initiatives are currently underway within the Fairview, HealthEast, and Allina health systems. Other hospitals around the state are also in various stages of developing and implementing strategies for reducing their elective induction rates.
The PPAG also conducted a survey of hospitals in the state asking about their policies regarding elective induction as well as statistics related to births and inductions (Figure 1).11 The survey captured responses from 54 out of 97 facilities. The PPAG found that the hospitals that had induction policies tended to have both fewer inductions and fewer elective inductions.
In addition, the hospitals that had induction policies tended to have more than 300 births per year (Figure 2). However, several small hospitals that had policies also had low induction rates, showing that the size of the facility was not a limiting factor. One strategy commonly used to ensure compliance with these policies was to give a physician leader the authority to approve elective inductions when they were requested. Another strategy was to have a peer-review process.
Reducing Inductions
After a review of the literature, the PPAG was convinced that births before 39 weeks gestation put mothers and babies at greater risk for complications ranging from prolonged and more painful labor for mothers to respiratory distress, difficulty feeding, hypoglycemia, jaundice, temperature instability, and neonatal mortality for infants. They also were convinced that a program to reduce the number of inductions would lead to better health outcomes for both women and their babies. In addition, members noted that a program to reduce the number of early-term inductions could also reduce costs, as was seen in the Intermountain Health Care study, where hospitals decreased their per-delivery costs by $300.10
With that in mind, the PPAG made a number of policy recommendations to the Health Services Advisory Council about how to reduce the number of elective inductions. They include the following:
- Having Minnesota hospitals develop policies that prohibit the use of elective induction and/or cervical ripening without medical indication for pregnancies at less than 39 weeks gestation;
- Having Minnesota hospitals develop quality-review processes for elective induction;
- Having Minnesota hospitals identify gestational age in patients who present for prenatal care by 20 weeks gestation and inform expectant mothers of the risks of early-term induction; and
- Encouraging the Minnesota medical community to make patient education regarding the risks of early-term induction pervasive.
Changing Practice
The Minnesota Department of Human Services is now encouraging hospitals that deliver babies covered by Medical Assistance to adopt the PPAG’s recommendations. To assist them, DHS officials are working with the March of Dimes, which will soon be releasing a tool kit for perinatal policy implementation and which offers assistance and grants to organizations trying to make the changes necessary to affect perinatal practices and outcomes.
In addition, DHS officials will develop a way to track the use of and reasons for induction. They have proposed that hospitals be required to submit this data annually starting in 2012. Providers at facilities that do not have induction policies would be required to submit this data with all deliveries as a condition of payment for deliveries covered by Medical Assistance. Department officials also are pursuing payment policy changes that will target both the fee-for-service and managed-care sides of Medical Assistance.
A number of details still need to be worked out about how to encourage hospitals to adopt policies aimed at preventing early inductions. However, human services officials hope that by providing incentives and assistance with implementation, they can create a climate for change that will result in fewer early-term elective inductions.
Reducing the number of elective inductions will decrease the risks and costs associated with early-term births. Policies regarding early induction will go a long way toward improving the health of the next generation of Minnesotans. MM
Trudy Ohnsorg is staff to the Minnesota Health Services Advisory Council and Jeff Schiff is medical director for Minnesota’s Health Care Programs at the Minnesota Department of Human Services.
The authors are grateful to the following members of the Perinatal Practices Advisory Group, who worked tirelessly over a seven-month period in 2009 and 2010 to provide clinical and policy guidance to the Department of Human Services on perinatal issues: Carol Busman, M.S., R.N., RNC-LRN; Dee Ann Frodl; Janette Strathy, M.D.; Kathleen Macken, M.D.; Kathryn Zuspan, M.D.; Kitty Haight; Laurel Briske; Mark Bergeron, M.D., M.P.H.; Marianne Keuhn; Mary Goering, N.P.; Mary Rossi, C.N.M.; Stan Davis, M.D.; Thomas Satre, M.D.; Vince Laporte, M.D.; and Virginia Lupo, M.D.
References
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11. Perinatal Practices Advisory Group. Hospital Survey Results, 2010. Available at: www.dhs.state.mn.us/main/groups/healthcare/documents/pub/dhs16_151146.pdf. Accessed October 8, 2010.