Washington state has seen dramatic progress in a statewide effort to convince doctors, hospitals and pregnant women that scheduling deliveries even a few weeks early can heighten risks for newborns. There's still work to be done, because hospital culture, doctors' longstanding practices and patient expectations are difficult to change.
Change, in the health-care world, typically comes slowly. The rule of thumb is that an innovation or best practice, even after proven, takes 10 to 15 years to be adopted.
Babies, by contrast, are on a fast-moving assembly line, metaphorically speaking, with one produced in the U.S. every eight seconds.
In Washington state, those two timelines have begun to merge, as doctors and hospitals reap results from a campaign to ensure babies don’t arrive at the end of the production line before they’re fully assembled.
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Under new protocols, doctors at many hospitals won’t induce labor before 39 weeks unless there’s a medical reason. Even Antoinette Lindberg, of West Seattle, whose son was found in utero to have an umbilical-cord problem, had to wait until she hit the target. Last Thursday night, Beckett, calm and alert, made his first appearance at Swedish Medical Center.
This particular effort isn’t about prematurity. Everybody knows that’s bad for babies. Their lungs and other parts aren’t fully functional, often requiring expensive interventions.
But for many years, doctors thought “early term” births a few weeks shy of the 40-week full-term mark were OK, even when the due date was arranged by mom and doctor — not the baby.
“Ever since most of us were trained, the definition of ‘term’ was 37 weeks,” said Dr. Tom Benedetti, University of Washington professor of obstetrics and gynecology and specialist in maternal-fetal medicine. “I think a lot of us got a sort of misplaced comfort with 37 weeks, even 34 or 35 weeks.”
Over the years, a culture took root in most hospitals that permitted, even encouraged, “elective inductions,” medically induced deliveries scheduled a week or two early. Doctors and midwives who had cared for a patient all through pregnancy wanted to be the ones to deliver the baby, and so did patients.
Add the typical discomfort of the last few weeks of pregnancy, maybe a planned visit by family members, a vacation schedule or two, and pressure often mounted to deliver at 37 or 38 weeks, or even earlier.
“There are a lot of social pressures on patients, and patients pressure the doctors,” said Dr. Brigit Brock, a maternal and fetal-medicine specialist at Swedish.
Then, in the last five years, studies began appearing.
Benedetti, who focuses on quality outcomes in obstetrics, stared at the numbers. On graphs, they were so clear it hurt.
In every case, charting the bad things that can happen to babies, the graphs dipped dramatically in the 39-to-40-week range.
Early-term babies were more likely to have respiratory problems, difficulties regulating their temperature, blood-sugar levels and clearing bilirubin, necessary to prevent jaundice.
Babies born before 39 weeks were 6-½ times more likely to need a ventilator, more likely to end up in the neonatal ICU, more likely to have hypoglycemia, more likely to have cerebral palsy, and more likely to be delivered by C-section.
A Danish study of thousands of 10-year-olds who had been born between 33 and 38 weeks found they were more likely to have reading and spelling problems than full-termers.
The studies didn’t separate out babies delivered early because of medical problems.
But even with that caveat, Benedetti said, the numbers were overwhelming.
“I was shocked,” he said. “I didn’t think you’d be able to show significant differences between a 37-week-baby versus a 39-week.”
Benedetti organized the data into a slideshow, and in 2010, took his graphs on the road.
Meeting with hospital administrators, and at gatherings organized by the Washington State Hospital Association, Benedetti laid it all out, including hospital-specific statistics.
Looking at the graphs, Debbie Raniero, director of Franciscan Health System’s Family Birth Center at St. Joseph Medical Center in Tacoma, was doubly distressed.
“To be candid, we weren’t really paying too much attention, we were just reporting data,” she said. “I go to the meeting, and I see this — 22 percent of our elective deliveries were before 39 weeks. So you go, ahhhhhh, are we, the medical profession, causing harm to babies?” Raniero recalled.
Their performance was not the worst, but “it wasn’t anything to be proud of,” Raniero said. “We had a lot of work to do.”
Somebody said — actually, lots of people said — that you can’t improve if you don’t know where you are now. And that means data.
Thanks in part to Benedetti, the hospitals had better data. And they had Benedetti himself, slapping those slides onto screens all over the state, his role an amalgam of wise senior colleague and, as he puts it, “the sheriff.”
For Franciscan, the numbers — and where they stood relative to their peers — were a reality check. The hospital’s commitment to evidence-based practice, Raniero said, meant it had to change. But she knew it wouldn’t be easy.
“This was going to be changing a culture,” she said.
Just educating and talking wouldn’t be enough, they quickly realized. There had to be what in the business is called a “hard stop.” That means, no go, no va, not happening, not scheduling, unless some very specific medical criteria were met or an exception was approved.
“We got lots of pushback from physicians and from patients,” Raniero recalled. “For the past 30 years, pretty much doctors have practiced based on their opinion… . ‘This is how I do it.’ “
Telling patients they couldn’t schedule a convenient delivery time before 39 weeks was equally unpopular. “I blame a lot of it on the entitlement mentality. People want something right now, and they don’t want to wait,” she says.”
Pregnant patients argued. ” ‘My friend had a baby earlier, and there weren’t problems,’ ” she recalls.
Women came into the hospital at 37 weeks, mistakenly thinking they were in labor. “They say, ‘Why can’t I stay? Why can’t I be induced?’ “
“We took it one day at a time, one conversation at a time,” Raniero says. Her not-so-secret weapon: The March of Dimes’ “brain card” showing that a baby’s brain at 35 weeks weighs a third less than it would at full term.
So far this year, only one patient out of about 5,000 deliveries has “snuck through” Franciscan’s system for an early-term elective delivery, says Raniero.
“We’re very proud of the work we’ve done here,” she says. “I don’t think we’ve ever done anything like this in Washington.”
Room for improvement
When this campaign began, Franciscan wasn’t the only hospital that needed improvement — six hospitals had higher rates.
The state of Washington was alarmed; half of the births in Washington are paid by Medicaid, and every baby who goes to the neonatal ICU costs thousands of dollars.
As it turned out, it took a village of collaboratives and organizations, as well as some changes in financial incentives by Medicaid, to make headway.
The Washington State Perinatal Collaborative helped support Benedetti’s work, the hospital association and individual hospitals pitched in to get accurate data, and the March of Dimes lent expertise.
Most recently, the work was taken on by a state-convened group called the Bree Collaborative, a first-in-the-nation group of employers, insurers, hospitals and clinical experts. Its members were appointed by Gov. Chris Gregoire to identify and help solve health-care problems, using evidence-based protocols. The hospitals agreed to go public with their own rates, a controversial, powerful step, Benedetti says.
There’s still room for improvement, says Cassie Sauer, spokeswoman for the state hospital association: four hospitals still have rates of 15 to 31 percent.
But overall, rates of early elective births in Washington hospitals have dropped steeply from 2010 — from 15.3 percent of deliveries to 3.3 percent. “I don’t think anybody thought we’d have such a dramatic effect so quickly,” Benedetti says.
“It’s a new way of thinking,” Sauer says. “The fundamental thing is if you want an early delivery, without a medical reason, the answer is going to be ‘no.’ “
Carol M. Ostrom: 206-464-2249 or firstname.lastname@example.org. On Twitter @costrom.