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Rate of babies delivered early at U.S. hospitals drops sharply

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U.S. hospitals are making major strides at clamping down on early deliveries of babies and instead letting Mother Nature take its course in response to growing pressure from employers, government officials and patient-safety advocates.

The Leapfrog Group, an employer-backed organization that tracks hospital safety and quality, published data Monday showing a sharp decrease in early-elective deliveries since 2010 nationwide and in California.

The rate of deliveries before 39 weeks without a medical reason fell to 4.6% last year compared with 17% in 2010 among nearly 1,000 U.S. hospitals that reported results. California hospitals showed similar progress, going from 14.7% in 2010 to 3% last year.

"This is a remarkable reduction," said Edward McCabe, chief medical officer at the March of Dimes, which has pushed hospitals to address the issue. "It involves changing the culture of the hospital and that is always very hard to do."

In early-elective deliveries, the potential complications to the baby range from breathing and feeding problems to infections. The rate of infant mortality, or death in the first year, rises by 50% for those early births compared to babies who reach full-term, research shows.

Scheduling for convenience also boosts the likelihood of a cesarean section, which raises the risk of complications for the mother. It's estimated these unnecessary early deliveries increase healthcare costs by as much as $1 billion annually.

There are still hospitals where the rate of early deliveries is still relatively high, at 20% and 30% of all births. About a third of the 969 hospitals that reported data are still above Leapfrog's target rate of 5%.

But the swift improvement overall stands out compared to efforts to fix other long-standing quality and cost problems inside hospitals. Despite public attention and industry efforts, the incidence of medical errors, preventable infections and readmissions often remains stubbornly high.

"Healthcare takes a long time to change," said Leah Binder, chief executive of Leapfrog, a nonprofit group in Washington. "This is one of the most extraordinary examples of progress in healthcare that I've seen in my career."

Leapfrog began publicly reporting this maternity data four years ago, and health-policy experts credit that exposure for spurring change. The Obama administration has just begun collecting this data from hospitals nationwide as part of patient-safety efforts under the Affordable Care Act.

In response to the heightened scrutiny, many hospitals have recently adopted "hard-stop" policies, banning doctors from scheduling deliveries prior to 39 completed weeks without a medical reason.

Some health insurers and government health programs have sought to hit hospitals and doctors in the wallet. In South Carolina, the state's Medicaid program and the BlueCross BlueShield health plan there stopped paying for early-elective deliveries.

South Carolina had one of the country's highest rates of early-elective deliveries in 2010, at 27.3%. Last year, the statewide average was under 5%, according to Leapfrog.

Binder said some hospitals have been reluctant to tackle the issue because admissions to the neonatal-intensive-care unit and longer stays are good for the bottom line. Leapfrog's data on individual hospitals is available at the group's website.

"It does populate the NICU and that is a profit center for hospitals," Binder said. "Unfortunately, we still don't have the right payment incentives to make this easy for hospitals to do."

St. Francis Medical Center of Lynwood said it saw a drop in those intensive-care admissions after adopting tougher rules about a year ago. Doctors must now get approval from the department chairman for an early delivery.

The hospital's rate of early-elective deliveries went from 24% in 2012 to less than 9% last year, according to Leapfrog's data.

Dr. Wilburn Durousseau, chairman of the obstetrics and gynecology department at St. Francis, said he usually reviews one or two requests each week. He said it can be an adjustment for doctors who were taught that delivering at 37 weeks was acceptable.

For three decades, the American College of Obstetricians and Gynecologists has advised against early-elective deliveries. But just last year, it redefined a full-term birth as 39 to nearly 41 weeks to reflect recent research that shows the importance each week can have on the health of a newborn.

"You came up believing what you were doing was correct," Durousseau said. "There is a certain amount of intellectual resistance to change."

Dr. Parissa Moradi, an ob-gyn at L.A. County's Martin Luther King Jr. Ambulatory Care Center, said up to 20% of her expectant mothers ask for early "social" deliveries.

"It's mostly because they get tired of being pregnant," Moradi said. "I personally don't like to do social deliveries before full term. I tell them all the risks involved and they can go somewhere else."

Dignity Health, one of the nation's largest hospital chains, adopted a "hard-stop" policy in 2012 and drove its rate of early-elective deliveries from 7% in 2011 to less than 1% in 2012. Before the policy change there were about 70 early-elective deliveries each month at 29 Dignity hospitals that offer maternity services, and now it's down to one or two cases per month.

Dr. Robert Wiebe, Dignity's chief medical officer, said obstetricians aren't generally involved in care for the newborn so many "don't always know the consequences of early-elective delivery or they underestimate the risk."

Wiebe said it had been common for doctors to move up delivery because they were going out of town for a vacation or conference. Patients often welcomed the idea after forging a strong bond with that doctor.

"They are all seemingly legitimate reasons on the surface," Wiebe said, "but if you understand the risk to the baby it's not the right thing to do."

Riverside County resident Jennifer Loza said she was offered an early delivery for her baby son, Steven, in 2002. She had suffered from migraines and morning sickness for much of her pregnancy so the idea was tempting. But she opted to wait, feeling it was better for her son.

"Moms tend to listen to doctors," Loza said. "But you have to follow your gut and trust your own instincts."

chad.terhune@latimes.com

Twitter: @chadterhune

Copyright © 2014, Los Angeles Times
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