Michigan launches statewide curb on early deliveries

A decade ago, it wasn't unusual for doctors at Oakwood Hospital and Medical Center in Dearborn, Mich., to induce labor or perform elective cesarean sections on women who had not yet reached the 39th week of pregnancy.

The reasons for those early elective deliveries varied, including physician convenience, patient preference and a poor understanding of the serious medical risks involved, said Dr. Charles Cash, medical director of women's services for four-hospital Oakwood Healthcare, based in Dearborn. “We experienced a number of occasions where babies were delivered early and developed lung complications and needed to be transferred to the ICU,” he said.

The tipping point for Cash, then Oakwood Hospital's chief of obstetrics and gynecology, came when Children's Hospital in Detroit said it would no longer accept transferred newborns from Oakwood if they had been induced or delivered before 39 weeks without a good medical reason. “They said we were filling their ICU with babies delivered at 36 and 37 weeks,” he said. “We realized we needed to intervene and develop criteria so these babies had time to develop.”

Organizations such as March of Dimes sounded the alarm for decades about high complication rates associated with elective deliveries before 39 weeks, including breathing problems, feeding issues and higher mortality rates. Still, the number of these deliveries held stubbornly steady until about four years ago, after the release of several compelling studies and an aggressive improvement effort led by organizations such as the Leapfrog Group.

Since then, early elective deliveries have fallen sharply across the country, with many states now reporting rates of less than 10%, according to Leapfrog data released this year. Rates at some hospitals, however, are still higher than 30%, Leah Binder, Leapfrog CEO, said in a news release. “There is still work that needs to be done,” she said.

Oakwood Hospital took steps to curb early elective deliveries long before the issue was on most hospitals' radar, Cash said. In 2005, the hospital adopted a “hard-stop” policy that forbade elective inductions and C-sections before 39 weeks. The entire Oakwood system soon implemented the same policy.

Oakwood experienced some pushback from a few physicians at the outset, but addressed it with an approach combining physician education and shaming, mainly by turning away patients referred before 39 weeks. “If a patient showed up for an induction at 38 weeks, six days, they were sent home and the physician was called and counseled,” Cash said.

Those early efforts caught the attention of the Michigan Health and Hospitals Association. The association had achieved dramatic results reducing central-line associated bloodstream infections and ventilator-associated pneumonia, and it was looking to tackle other patient-safety issues.

In 2009, the association launched MHA Keystone: Obstetrics, a 15-hospital pilot aimed at promoting perinatal safety practices and improving outcomes for mothers and babies. The participating hospitals, including Oakwood, were provided with educational tools and received regular feedback. Over the course of the yearlong program, elective inductions fell 62% and elective C-sections dropped 68%, according to results published in the Joint Commission Journal on Quality and Patient Safety.

The program since has been expanded to include 65 Michigan hospitals, accounting for 80% of all births statewide, said Sam Watson, the hospital association's senior vice president who heads the MHA Keystone Center for Patient Safety and Quality. Hospitals have reduced early elective deliveries by 68%, from 4.75% in 2010 to 1.53% in 2012, and neonatal ICU admissions fell 35%. Watson credits the project's success to the use of evidence-based practices and to culture change among clinical staff.

Practices like hard-stops for early deliveries and appropriate use of the labor-inducing drug pitocin are now standard at Oakwood, Cash said. “The medical staff understands what they can and can't do,” he said. “It's evidence-based care—it's as simple as that.”

The number of early elective labor inductions across Oakwood Healthcare's hospitals fell from three in 2009 to zero for 2010, 2011 and 2012. There have been no early elective C-sections since 2011, said Nancy Gray, Oakwood's administrator of women's services.

Watson praised the work of Cash and others at Oakwood. “They were a strong voice in encouraging their colleagues, and they set the example of that desire to seek improvement,” he said.

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