Friday, December 07, 2012

Did Childbirth Education Just Receive a Mandate?

A recent Bloomberg News Editorial came across my desk: Hospital Incentives Help Babies Determine Own Birth Dates.  In the editorial, a two year project in Washington State showed that hospitals could indeed reduce their elective induction/cesarean rates and subsequently the number of weak babies admitted to the NICU.  State health authorities studied health records and revealed that an astounding 15% of the 80,000 births were elective deliveries at 37 - 39 weeks; meaning that 12,000 elective early births took place in Washington State for no medical reason.

It is the assumption of many that health care providers are taught about physiologic birth during their years of training to become physicians or nurses.  Sadly, this is not the case.  Washington State legislature created a $10 million reward fund to be shared by hospitals that showed marked improvement on statistical data regarding early elective deliveries. Staff education was a part of the plan for many hospitals to reach the goal and partake in the reward.  Piggy backing the reward was a decrease in Medicaid payments that hospitals received for uncomplicated Cesareans. But why did it take money to be the incentive to respect human beings and facilitate health pregnancy outcomes?  

The evidence is clear and highly available.  Anyone now can access the CDC, Cochrane Database or National Institute of Health to find that the US infant and maternal mortality/morbidity rates are higher than ever before despite the fact that the US spends more on health care than many other countries whose statistics in this area are much better.  In a nearly 20 year period from 1990 to 2009, the number of near term babies (those born between 37-38 weeks) jumped 8% from 19% to 27% or more than 1/4 of the babies born.  Babies who are born at 37 weeks are more likely to die in their first year and are more likely to have health problems.

In the October issue of Seminars in Perinatology*, authors Chauhan and Ananth stated:

Approximately 1 in 4 women in the United States are induced, with up to 1 in 10-12 being induced for elective reasons. National guidelines by the American College of Obstetricians and Gynecologists, the Society of Obstetricians Gynaecologists of Canada, and the Royal College of Obstetricians and Gynaecologists list 21 indications for inductions; however, all 3 concur in only 14% women (3 of 21). An induction should be considered appropriate if it meets the following 4 criteria: (1) concordant with women's autonomous informed decisions and desideratum; (2) optimizes maternal-fetal outcomes, including psychological maternal well-being; (3) congruous with evidence-based medicine; and (4) cost-effective. A meta-analysis of 22 randomized trials noted that membrane sweeping reduces the likelihood of induction. Implementing policies to prevent elective induction at 37-38 weeks provides conflicting results about the rate of macrosomia and stillbirth at early term. We argue that a well-designed randomized controlled trial, with adequate power to demonstrate whether prohibiting elective induction increases the rate of stillbirth or complications such as macrosomia, is warranted. Patient education during their prenatal course is a promising strategy to decrease the rate of induction.

Were their efforts successful?  Yes!  Elective early deliveries were reduced 77%.This in conjunction with the statement that many hospitals in Washington reduced rates with patient and staff education demonstrates that education is the key to this entire dilemma.  

If this doesn't constitute a mandate for childbirth education involving both parents and professionals, I don't know what does. 

*Chauhan SPAnanth CV.  Induction of labor in the United States: a critical appraisal of appropriateness and reducibility. Seminars in Perinatology. 2012 Oct;36(5):336-43. 

photo credit: SantaRosa OLD SKOOL via photopin cc

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