Ask any mom, and especially a new mom: 40 weeks is a long time.
Amid the excitement – not to mention the physiological challenges – of the late days of a pregnancy, it used to be fairly common for expectant mothers to request a delivery prior to the full 40 weeks’ gestation. Doctors often complied, trying to accommodate the wishes and schedules of their patients – or themselves.
Now, as new understanding emerges of the potential short- and long-term health risks to babies delivered preterm, clinicians at Baystate Medical Center are taking part in a national collaborative to help moms and babies reap the benefits of a full-term pregnancy whenever possible.
More than 500,000 infants are born prematurely in the United States each year, and about 10 percent of all deliveries are scheduled before 39 weeks, according to the U.S. Department of Health and Human Services.
Furthermore, a recent study by The Leapfrog Group, a hospital quality watchdog, showed U.S. hospitals varied widely in their rates of elective preterm deliveries, ranging from less than 5 percent to more than 40 percent.
Of course, some of those early births are unavoidable. Complications of pregnancy and other challenges to the health of mom or baby can require an early delivery out of medical necessity.
Other preterm deliveries occur spontaneously without any known cause. And such preterm births – defined as delivery prior to 37 weeks gestation – unfortunately are still the leading cause of newborn deaths.
It is increasingly clear, though, that even without prenatal complications, delivering even a couple of weeks early can have implications for neonatal and long-term health.
The March of Dimes, a leading advocate for healthy pregnancy and neonatal health, is urging mothers not to elect for an early delivery for convenience before 39 weeks’ gestation, when fetal development is complete.
A baby’s brain and lungs are still growing in the last weeks of pregnancy, and as a result, babies born just a few weeks early are more likely to develop breathing problems, cerebral palsy, intellectual and developmental disabilities or other health challenges.
In addition to these life-changing or even life-threatening challenges, early deliveries prior to 37 weeks costs the already financially strained U.S. health-care system more than $26 billion each year, according to the Centers for Disease Control and Prevention.
“Early deliveries should only be an option for medical reasons, when the life or health of mother or baby is in jeopardy,” said Dr. Glenn Markenson, chief of Maternal Fetal Medicine at Baystate Medical Center, in a submitted interview.
Under Markenson’s leadership, Baystate Medical Center has been working to establish strong guidelines to prevent unnecessary preterm deliveries by induction or Caesarean section, and last year the hospital instituted a “hard stop” for any non-medically required elective delivery prior to 39 weeks, and all elective inductions in first-time mothers.
“We need to remind obstetricians and gynecologists, midwives and physician and nursing leaders everywhere about the risks of elective preterm deliveries, as well as helping expectant parents to understand that those last couple of weeks of pregnancy really do make a difference,” Markenson said about the half-million babies being born too soon each year in the United States.
“This is something that can be fixed, but it’s going to take even more education.”
The March of Dimes grades states by comparing their rate of premature births to the March of Dimes 2020 goal of 9.6 percent.
According to the recent 2012 Premature Birth Report Card, while the U.S. preterm birth rate dropped for the fifth consecutive year in 2011 to 11.7 percent, the lowest in a decade, the country still earned a disappointing “C” grade and has a long way to go in reducing the country’s rate of premature births.
Three states and Puerto Rico earned an “F,” and only four states – Maine, New Hampshire, Oregon and Vermont – were graded an “A.” Twenty-two states, including Massachusetts, received a “B” grade and are one step away from achieving the goal.
In addition to working with other Massachusetts hospitals to help the state achieve an “A” grade in the March of Dimes rankings, Baystate is helping lead a statewide initiative called the Massachusetts Perinatal Quality Collaborative.
More than 100 representatives from the state’s 47 birthing hospitals have been studying ways to standardize and improve maternity care throughout Massachusetts. The group has made it a priority to focus on reducing early elective deliveries.
“Our hope is that other hospitals will be able to learn from our experience at Baystate in order to design quality improvement measures that will reduce the rate of elective deliveries that are not medically necessary,” said Markenson, who is serving as chair of the statewide initiative.
“Dr. Markenson has been very instrumental from the beginning in our efforts with the American College of Gynecologists and the March of Dimes. His sharing of information about Baystate’s experience has been extremely helpful, and has already spurred some of our members to implement similar policies at their institutions,” said Dr. Lauren Smith, interim commissioner, Massachusetts Department of Public Health.
As a state representative of the American Congress of Obstetricians and Gynecologists, for which he serves as chair of the Committee on Patient Safety and Quality Improvement, and also as chair of the Western Massachusetts Chapter of the March of Dimes, Markenson stresses that the only motivation behind the hospital’s strong stance on elective preterm deliveries is the safety and health of mother and baby.
“It really comes down to the quality of care we provide: Do we have processes in place to ensure that our deliveries follow the absolute highest standards for quality and safety? Reducing early electives is a key part of that,” said Markenson.
“We have been carefully looking at early elective deliveries for the past couple of years at the hospital,” said Dr. Andrew Healy, medical director of Obstetrics at Baystate Medical Center.
“In fact, we began seeing a decrease in the number of early term babies (37-38 weeks) being admitted to our Davis Neonatal Intensive Care Unit for complications even before introducing a formal policy with a hard stop.”
Molly Gray, registered nurse at the master's level, director of Baystate Children’s Hospital and Women’s Services, also confirmed the hospital is seeing fewer admissions to its NICU, which she attributed directly to the hospital’s new policy and efforts to educate caregivers and families alike.
“Our nurses have been very involved in this important team effort to reduce the number of preterm births at Baystate and are working closely to help families understand that our new policy is in their best interest, especially for their baby,” she said.
“We understand that people live very complicated lives today and feel the need to schedule everything, but some things such as childbirth – a natural physiological process – are best left unscheduled.”
According to Markenson, some obstetricians and gynecologists became complacent before the new efforts got under way, with their skill in successful inductions and Caesareans.
“For women asking, it was simply a matter of convenience, such as wanting relief from the discomforts of pregnancy during a hot summer. And it became convenient for physicians, too, who might have been going on vacation and wanted to fit the birth in before leaving,” he said.
Markenson said the practice of elective preterm birth finally caught many healthcare quality officials’ attention when more and more studies were published showing its potential harm, including a recent March of Dimes report showing that babies born in the 37th or 38th week have a higher risk of dying in their first year than a baby born after 39 weeks.
Further evidence in a study published in July in the journal Pediatrics noted that even for infants born full term (37 weeks is considered full term), some extra weeks in utero can make a difference in their future academic achievement.
“In the wake of all of these new studies coming out saying that babies born at 37 or 38 weeks are at an increased risk for complications – complications which are not common, but increased nonetheless – we ask, why subject a baby to risk without any benefits?” Markenson asked.
Healy said he and his fellow providers recognize the importance of communication with moms-to-be about the Baystate policy, the reasons it exists, and its benefits for babies. “We encourage providers to discuss the policy up front with their pregnant patients, so that they are aware of it and there won’t be any unnecessary stress at 37 weeks if a woman is uncomfortable and requesting delivery,” he said.