Human Development

Healthy Babies are 'Worth the Weight': 39-Week Initiative (2011) updated 10/2011

Healthy Babies are 'Worth the Weight': 39-Week Initiative Component of the Birth Outcomes Project

[Ed. Note: This project is gaining momentum and is well underway in several states including Wisconsin, North Carolina, South Carolina, Ohio, and Louisiana. At least one hospital in Alabama, Southeastern Alabama Medical Center in Dothan, has had significant success with this initiative in its first quarter of use in 2011.]

 
Louisiana becomes first state to target elective births before 39 weeks; 20 hospitals sign on to 39-Week Initiative 

DHH Secretary joined by health care leaders to applaud hospitals' commitment to healthier moms and babies

Louisiana Department of Health and Hospitals Secretary Bruce D. Greenstein today gathered with the Louisiana Hospital Association (LHA), the Louisiana State Medical Society (LSMS), the American College of Obstetricians and Gynecologists (ACOG) and other Louisiana health care leaders at Woman's Hospital to celebrate the 20 Louisiana hospitals that have demonstrated a commitment to healthier moms and babies through their participation in DHH's 39-Week Initiative.

DHH introduced the 39-Week Initiative as a key component of the Birth Outcomes Project, which was established to combat Louisiana's historically poor birth outcomes.

The 39-Week Initiative is a voluntary program in which hospitals agree to establish policies to end the practice of elective, non-medically necessary deliveries prior to 39 weeks gestation.  DHH officials have been meeting with the state's largest birthing hospitals to teach them about the 39-week Initiative, encouraging them to adopt the initiative and providing support for its adoption.

"I was genuinely shocked to learn how many births were being done early that weren't medically necessary. Too many doctors and too many women just don't fully understand the risks, even in a healthy pregnancy. That's what makes the 39-Week Initiative so effective, as it brings the government and private sectors together toward a common goal that benefits everyone," Secretary Greenstein said.  "I want to thank ACOG, LHA, LSMS, LAMMICO, Woman's Hospital and East Jefferson General Hospital for partnering with DHH on this initiative from the very beginning. And I want to commend the hospitals that have signed on. As the first state to implement this type of project, we are truly pioneers, and I am proud to have such innovative leaders with me on this endeavor. While there are no simple solutions to infant mortality and prematurity, this is one relatively easy step that just makes sense."

Babies' organs, including the brain and lungs, continue to develop during the last few weeks of gestation. Babies who are born premature have a greater chance of newborn health complications, such as breathing problems, and often must spend time in the NICU receiving costly specialized care.

Louisiana consistently ranks poorly when compared to the rest of the nation in most reports, rankings, studies and analyses of health status.

For birth outcomes, the state's rankings are particularly troubling. The National Center for Health Statistics ranks Louisiana 49th in infant mortality, preterm birth and in the percentage of low birth weight and very low birth weight babies. Additionally, Louisiana earned a failing grade on the 2010 March of Dimes Prematurity Report Card, and at 38 percent, has the second highest C-section rate in the country.

Also joining Secretary Greenstein today was State Rep. Regina Barrow, who has served as a staunch advocate for reducing infant mortality and prematurity. She also joined Secretary Greenstein in November when he announced specifics of the department's Birth Outcomes Initiative.

"Last November, after the March of Dimes announced Louisiana had earned an 'F' on the annual Report Card, Secretary Greenstein and I stood on the steps of the Louisiana State Capitol, and we vowed to do everything in our power to help Louisiana produce healthier moms and babies," Rep. Barrow said.

"This initiative is a positive step toward that goal, and it is with great pleasure that I join Secretary Greenstein today to acknowledge our partners and these hospitals for their tremendous efforts toward improving the health of Louisiana's babies – our state's future leaders – and their mothers." 

[Twenty LA] hospitals have signed on to implement the 39-Week Initiative, vowing to eliminate all elective, non-medically necessary deliveries prior to 39 weeks gestation… 

"The Louisiana Hospital Association is proud to be a strategic partner in the Louisiana Birth Outcomes Initiative," said John Matessino, president and CEO of the LHA. "We are excited that so many Louisiana hospitals have embraced the initiative and taken the necessary actions to improve birth outcomes, including adopting a statewide policy to eliminate elective, non-medically indicated deliveries prior to 39 weeks. The LHA applauds Governor Jindal, Secretary Greenstein, and Dr. Gee in their commitment to the health of Louisiana's infants and mothers."

Two hospitals that implemented the initiative prior to the department launching the statewide initiative have already seen the benefits firsthand. From 2007 to 2010, East Jefferson General Hospital reduced the number of elective inductions prior to 39 weeks from 503 to 16. Since implementing the initiative at Woman's Hospital in September 2007, neo-natal intensive care unit (NICU) admissions dropped 20 percent.

"Because healthy babies are worth the wait, the obstetricians and nurses at Woman's have supported the 39-Week Initiative since 2007. As a result, the admission of premature babies into our NICU has declined by 20 percent," said Teri Fontenot, Woman's Hospital president and CEO. "I am pleased that our staff's commitment to improving newborn health is serving as positive proof of the impact on newborns to other Louisiana hospitals adopting this initiative."

At 8,500 births a year, Woman's is the largest obstetrics hospital in Louisiana and among the top 20 in the country.

As an added incentive, LAMMICO, a mutual insurance company that provides malpractice insurance for most Louisiana doctors, has partnered with the Department to offer physicians who participate in a "39 Week" training course an hour of continuing medical education (CME) credit. LAMMICO-insured physicians also will receive an hour of credit toward the two-hour credit needed for a 10 percent premium reduction at the next renewal.

"LAMMICO is proud to partner with the Louisiana Birth Outcomes Project to help educate physicians who dedicate themselves to improving the health of mothers and their babies," said Kenneth E. Brown, MD, MBA, FACOG, member of LAMMICO's Board of Directors. We believe that the people of Louisiana deserve exposure to the nationally held best health care practices, and we are pleased to play a role in making that goal a reality."

F. Dean Griffen, MD, President of the Louisiana State Medical Society said, "As medical professionals, we have a duty to treat our patients using approaches that are evidence-based to yield the best outcomes.  The Louisiana State Medical Society applauds these hospitals, as well

as their employees and members of their medical staffs, for choosing to take a stand against elective deliveries before 39 weeks gestation. It is our hope that this initiative will have a domino effect that leads to improved health outcomes not only in our state, but for the entire nation."

…Compounding poor health outcomes is the financial burden associated with high labor and delivery costs… the average cost for premature infants in Louisiana is $33,000 compared to the national average of $4,000 for full-term newborns.

Secretary Greenstein added, "Last year, 65,429 babies were born in Louisiana, and Medicaid – the taxpayers – paid for nearly 70 percent of them. With approximately 7,000 premature births covered by the Medicaid program, the excess costs to the state exceed $200 million each year. This is unacceptable. Not only do our state's families deserve healthier moms and babies, our taxpayers deserve a better return on their investment. I encourage the rest of our state's hospitals to join their peers – the leaders standing with me today – to take these simple steps to building a healthier Louisiana."

The Louisiana Department of Health and Hospitals strives to protect and promote health statewide and to ensure access to medical, preventive and rehabilitative services for all state citizens. To learn more about DHH, visit http://www.dhh.louisiana.gov.

Related:
Birth Outcomes Initiative
http://new.dhh.louisiana.gov/index.cfm/subhome/27/n/215
Program Designed to Improve NC Birth Outcomes is Underway
http://www.communitycarenc.org/about-us/update-archive/sample-update-2/
Quality and Patient Safety Update, August 31, 2011, South Carolina
http://www.scha.org/newsletters/quality-and-patient-safety-update-august-31-2011
Toward Improving Birth Outcomes: A BCAP Toolkit
http://www.chcs.org/publications3960/publications_show.htm?doc_id=212947

 [Wednesday, July 13, 2011,  BATON ROUGE; ADPH, OWH, 22 Sept 11]

"Late Preterm" is Premature — It's Worth the Weight to Wait!!
Give Your Baby the Best Chance for a Healthy Start
39 Week Initiative of Birth Outcomes Project

Fetal Brain Development and Growth
— Lower functions mature first; the cerebral cortex is last to develop
— The brain at 35 weeks weighs only 2/3 what it will weigh at term
— The immature control of the late preterm brain can be evidenced by problems with periodic breathing, apnea, decreased HR variability, REM sleep difficulties, and feeding difficulties
— Volume of the cerebellum at 34 weeks is only 55% of that at term
— Cerebellar function is related to: fine motor control, coordination, motor sequencing, cognition and language, social function, and learning
— Volume of the white matter increases 5-fold from 35-41 weeks
— Cerebral cortex volume at 34 weeks is only 53% of the term volume
— Cerebral cortex is the seat of higher order functions: cognition, perception, reason, motor control
— The brain organizes during the late preterm period; there is tremendous development of synapses, axon growth, dendrites, and neurotransmitters in these final weeks
        "Late Preterm" is Premature — It's Worth the Weight to Wait!!

There is an association between Gestational Age at Delivery and Special Education Need — the earlier the delivery, the higher the need for Special Education … the later the delivery, the lower the need for Special Education [retrospective cohort study of 407,503 schoolchildren, 2010, United Kingdom]

Morbidity (incidence of disease or rate of complications/adverse effects following a procedure):
In Massachusetts, a 2008 study found that 22% of Late Preterm Infants suffered morbidity, versus only 3% of Term Infants…
Morbidity rates doubled for each gestational week earlier than 38 weeks:
40 wks: 2.5%
39 wks: 2.6%
38 wks: 3.3%
37 wks: 5.9%
36 wks: 12.1%
35 wks: 25.6%
34 wks: 51.9%
[Shapiro-Mendoza et al, Effect of later-preterm birth and maternal medical conditions on newborn morbidity risk, Pediatrics, 2008. 121, 223-232]

What We Know:
— Widespread, convincing evidence that elective delivery under 39 weeks has increased morbidity
— There are still elements of fetal maturity occurring during the 38th to 39th week
—  Inducing women with an unfavorable cervix is associated with a higher cesarean rate
— There are significant challenges associated with implementing a "39 week" elective delivery policy
— The challenges can be overcome with appropriate leadership, oversight, and available tools
— In 2008, the rate of Late-Preterm Births (34-36 weeks) for All States was 12.3%

Why are Late Preterm Delivery Rates Rising?
— Changing culture of childbearing
— More high risk pregnancies
   * advanced maternal age, advanced paternal age
   * more complications such as infections, high blood pressure, gestational diabetes, obesity
   * more multiple births
   * high risk behaviors including substance abuse (smoking, drinking, illicit drug use)
— Public preferences / autonomy
   * date of delivery scheduled for convenience
   * cesarean delivery on maternal request (CDMR)

"Late Preterm" is Still Premature

— Late preterm infants (34-36 weeks) typically receive routine care in well-baby nurseries and are presumed low risk
— Problems may not be noticed until illness is more advanced and symptoms are evident
— Late preterm infants are much more likely than term infants to have:
   * NICU Admissions
   * depression at birth (low Apgar scores)
   * respiratory distress, including respiratory failure
   * hypoglycemia
   * feeding problems
   * temperature instability
   * apnea
[NICHD Invitational Conference, July 2005]

ACOG Evidence-Based Guidelines
NO elective induction or elective cesarean delivery before 39 weeks unless evidence of fetal lung maturity
To assess fetal lung maturity an amniocentesis is usually done to collect amniotic fluid for testing — as for any invasive procedure, there are potential risks

In Alabama, Southeastern Medical Center (SAMC) began the 39 Week Initiative in May 2011.
New Scheduling Policy for Cesarean Section and Induction of Labor
Documentation Criteria
Hard Stop on Under 39 Week deliveries without medical indications
New guidelines implemented on the standardization and management of oxytocin during labor.

A review of the First Quarter, May-July 2011:
Total Deliveries – 379
— 1 under 39 weeks delivery without medical indications
— neonatal morbidity due to under 39 week elective delivery (respiratory distress, temperature drops, feeding issues, jaundice) — 0.3% while prior data revealed a 63% morbidity
— overall SCN admission rates have declined by 33%
— neonatal transfer rates have declined by 66.7%

State-Wide Initiatives
Tennessee, Louisiana, North Carolina, California, Washington State, West Virginia, Florida