Room for Improvement in Hospital Maternity Care

Rates of early induction of labor have declined in U.S. acute care and pediatric hospitals, but rates of episiotomies  remain unacceptably high in many hospitals, according to a 2014 survey released by the Leapfrog Group and developed by Castlight Health.  The survey results also reflected little change in the number of hospitals meeting Leapfrog’s standards for high-risk deliveries since 2013.  The American Congress of Obstetricians and Gynecologists (ACOG) has long advised limiting both elective inductions prior to 39 weeks’ gestation and the use of episiotomies.  Leapfrog has made suggestions for improvement to hospitals, and existing CMS programs seem to support the advice as far  as inductions are concerned.

Elective Inductions

Definitions of “full term” range from 39 weeks’ gestation to 40 weeks and six days.  However, according to Leapfrog, rates of elective inductions, those with no medical basis, prior to 39 weeks, increased from 9.5 percent in 1990 to 32.9 percent in 2009.  Providers and patients may choose early inductions for nonmedical reasons le convenience, perceived liability, or relief of pregnancy symptoms.  However, infants born at 36 to 38 weeks are more likely than full-term infants to have lung problems and other medical issues, often requiring treatment in the neonatal intensive care unit (NICU).  Long-term effects on academic achievement resulting from preterm birth may also be seen.  Mothers whose labor is induced are more likely to undergo cesarean sections (C-sections) than women who are not induced, and they may be at higher risk of other postpartum complications.  In addition, Leapfrog cited a study finding that the early deliveries cost up to 17.4 percent more than full term early deliveries.  If early term delivery were reduced to 1.7 percent, the report suggests, the U.S. could  save $1 billion annually, much of which results from a reduction in days spent in the NICU.

Leapfrog has defined its standard for early elective deliveries as a rate of scheduled C-sections or inductions before 39 weeks no greater than 5 percent.  In 2010, only 30 percent of hospitals responding to the survey met the standard.  The rate increased  over time, to 71 percent in 2013 and 78 percent in 2014.  The numbers are positive; however, significant variation exists among hospitals, with 17 hospitals reporting early elective delivery rates of 30 percent or more.

Recognizing the dangers of elective inductions, and perhaps the financial costs associated with them, CMS launched  the Strong Start for Mothers and Newborns initiative in  2012, which promotes awareness, spreads best practices, and promotes transparency.  In an August 2012 final rule, CMS added a measure to the Inpatient Quality Reporting (IQR) Program that is effective for fiscal year (FY) 2015: Elective delivery prior to 39 completed weeks of gestation, which will link quality of care with payment.  In December 2013, the agency updated its Hospital Compare website to include voluntary reports of the measure. CMS also created the Expert Panel on Improving Maternal and Infant Health Outcomes in Medicaid and CHIP to explore opportunities that could not only result in better care and outcomes, but reduce the cost of care for mothers and infants enrolled in Medicaid and the Children’s Health Insurance Program. The recommendations, in part, led to the creation of the Maternal and Infant Health Initiative.

Episiotomies

Episiotomies are incisions made in the perineum–the area between the vagina and the anus–during childbirth.  The procedure was formerly a routine part of childbirth intended to prevent worse tears of the perineum.  However, they have been linked to worse tears, bladder and fecal incontinence, pelvic floor defects, and painful recoveries.  The Mayo Clinic notes that episiotomies may be warranted in certain cases, such as when a physician anticipates “extensive vaginal tearing,” the baby is an abnormal position, or the baby needs to be delivered quickly. Leapfrog’s standard rate for episiotomies is less than or equal to 12 percent. Sixty-five percent of reporting hospitals achieved the standard in 2014 and the national average was 11.3 percent, down less than two percentage points from 2012. However, dramatic variations were seen.  Twenty-five hospitals reported rates of less than or equal to 1 percent, but 12 reported rates of 40 percent or greater. To further encourage a decrease in episiotomies, Leapfrog plans to lower its standard from less than or equal to 12 percent to less than or equal to 5 percent; only 27 percent of hospitals reporting in the 2014 survey would meet that standard.

High-Risk Deliveries

Infants who weigh less than 3 pounds, 4.91 ounces should be cared for in a NICU.  They have a higher likelihood of survival and better prognoses when they are born at hospitals with experienced, on-site NICUs. Leapfrog deems hospitals to meet standards for high-risk deliveries if they ensure that at least 80 percent of mothers receive antenatal steroids prior to delivery, which can reduce the incidence and severity of respiratory distress syndrome (RDS) in infants, as other well as other issues, including mortality; and either (1) deliver at least 50 “very low” birth weight babies each year or (2) maintain a lower than average morbidity/mortality rate for very low birth weight babies. In 2014, 24.4 percent of reporting hospitals met this standard, which is only an increase of 0.4 percent since 2013, although some hospitals are making “substantial progress.”  Hospitals in 24 states reported on this standard.  Strikingly, no hospitals in Georgia, Missouri, or South Carolina met Leapfrog’s high-risk delivery standard; only 4 percent of hospitals  reporting from New York met the standard.

Looking Forward

While the survey results reflect improvement, there is clearly room for improvement.  In addition, variations among suggest that standards are not being consistently achieved across hospitals.  Leapfrog will continue to assess hospitals’ compliance with its maternity standards and report again in 2016.