July/Aug. 2011 - Why Babies Need 39 Weeks: The Case Against Induced Labor
If you’re having a baby, you’ve read a lot about what to expect during delivery – a lot. But when the baby doesn’t come ‘on time’ – on the due date – many moms begin to wonder about having labor induced. In the U.S., the rate of labor inductions has climbed significantly over the past 20 years. But many question whether the increase is for medical reasons or for personal convenience – of the patient or the doctor.
There are certainly sound reasons for your doctor to suggest inducing labor. But a recently published study by a large group of hospitals in Utah provides some of the most up-to-date information on the complications than can arise from inducing labor.
“Utah has the highest birthrate in the nation, so it may not be surprising that close to 30,000 babies are delivered every year at Intermountain Healthcare, a Salt Lake City-based system of nonprofit hospitals and clinics,” writes Janie Wilson, M.S., R.N.of Intermountain Hospitals. Here’s her recent article ‘Designing Best Practices through Data Mining’ that explains what her hospital system found about induced labor. Her article was about the hospital’s practice of collecting data about medical procedures, but her research focused on a particular trend they discovered – induced labor.
“Since the 1970s, Intermountain has pioneered the use of EMRs to improve patient care.
Intermountain’s record system gives clinicians a complete medical history for individual patients, but it also serves as a giant research tool. For more than 30 years, these records – including medical details about every birth – have been compiled in a database, much like large, clinical data warehouse.
The database collects medical information from certain data fields in order to track trends and best practice care models across Intermountain’s entire patient population. This means that unlike some other EMR systems that are focused only on individual records, Intermountain’s clinical database allows statisticians to statistically evaluate treatment methods such as the benefits of various interventions or the efficacy of different medications. Using a rigorous statistical analysis of millions of patient records, statisticians can identify trends and make evidence-based decisions about best practices that can improve quality, saving lives and money across the system.
As an outgrowth of the clinical database, Intermountain was one of the first health care organizations to implement continuous quality improvement techniques to manage care.
These techniques – used for many years in other industry sectors like manufacturing and education – consist of thinking about complex organizations as systems with processes that can be continually improved using objective data.
Analyzing statistics from the database, Intermountain has developed best care models or protocols that continually improve medical outcomes in several clinical programs including cardiovascular, oncology, surgical services, primary care, intensive medicine, pediatric specialties, preventive medicine, and behavioral health along with programs for women and newborns.
Spotlight on Elective Inductions
A few years ago, Intermountain noticed a striking trend that was part of a larger national phenomenon. Women and their doctors were more frequently choosing to induce labor and increasingly, those inductions were happening at 37 or 38 weeks gestational age.
Intermountain’s statisticians and obstetric medical experts were concerned that early inductions might have negative health consequences for babies and moms. When they analyzed the data from births at Intermountain’s hospitals, they found that women who deliver before babies reach 39 weeks gestational age tend to have longer and more complicated deliveries. The statisticians also found a statistically significant increase in the number of newborns with medical complications.
Specifically, the data showed that of babies delivered at 37 weeks gestational age, 8.85 percent were admitted to the neonatal intensive care unit. The number dropped to 4.51 percent of babies delivered at 38 weeks and then bottomed out to 3.34 percent at 39 weeks. The percentage of NICU admissions climbs slowly for babies born at 40 weeks gestational age and beyond.
So according to Intermountain’s statistics, hitting the magic 39-week mark seemed to significantly cut the chances of a baby being sent to the NICU. But that wasn’t all the research found. Babies also were more likely to struggle with respiratory distress syndrome if physicians electively induced labor before 39 weeks.
The data showed that if delivery occurs at 37 weeks, 1.92 percent of babies were affected. At 38 weeks the percentage drops to .68 percent and bottoms out at .42 percent at 39 weeks, before slightly climbing again at 40 weeks. The need for newborns to be on a ventilator was also significantly reduced if delivery occurred at 39 weeks gestational age.
Armed with statistical information from their own hospitals and using standards from the American College of Obstetrics and Gynecologists, Intermountain instituted a new guideline to limit labor inductions before 39 weeks unless a consulting physician agreed that an earlier induction was medically necessary.
Making the Case
Working with leading obstetric providers throughout Utah, Intermountain’s statisticians and medical experts began to make their case for waiting until 39 weeks to induce labor.
Many physicians said that in their experience, inducing labor at 38 or even 37 weeks did not result in memorable problems for moms or babies. They also said that that early inductions were being driven by patient demand.
But when the Intermountain team showed Utah physicians the composite data indicating that when birth occurred at 37 weeks the risks to babies were up to three times higher than waiting two more weeks, the number of elective inductions dropped. Early adopters helped to encourage their medical colleagues to follow the 39-week guideline. Today there is strong support for the best practice protocol throughout all of Intermountain’s labor and delivery units.
In 1999, approximately 28 percent of all inductions at Intermountain’s hospitals occurred before 39 weeks. Today, that percentage is only 3.4 percent. And with the significant drop in early elective inductions, Intermountain has also seen a 90-minute drop in the average length of labor in electively induced patients, with fewer emergency cesarean sections and other medical complications associated with deliveries. The guidelines benefit new babies and their moms. And as icing on the cake, the protocol also saved patients approximately $2 million since the program began.
Janie Wilson, M.S., R.N., is operations director for the Women and Newborn Clinical Program, Intermountain Healthcare, Salt Lake City.