Editor’s note: This is the first of two stories examining the costs of early scheduled births in Kansas and efforts to reduce them.
The practice of delivering babies a few days early for the convenience of mothers and doctors has been a common one for years at hospitals across the country and in Kansas.
But when research established that deliveries done even a little ahead of schedule can threaten the health of newborns, Kansas health care providers decided it was time to end the practice.
Costs of early births
The Institute of Medicine estimated premature births cost the U.S. economy at least $26.2 billion in 2005, or about $51,600 per pre-term baby.
It cautioned the actual cost may be higher over time, because it only analyzed medical costs early in life, special education services and lost earnings for people who grow up with severe disabilities, leaving out some medical costs from conditions that affect a person over a lifetime.
A quality improvement initiative launched in mid-2012 hasn’t accomplished that goal but it has reduced the rate of “early elective births” at participating Kansas hospitals by 70 percent, according to officials at the Kansas Healthcare Collaborative, which spearheaded the effort with the Kansas Hospital Association and March of Dimes.
“We want to change the culture in this state toward one of constant improvement, and one of safety, more importantly,” said Kendra Tinsley, executive director of the Kansas Healthcare Collaborative, a nonprofit formed in 2008 by the hospital association and the Kansas Medical Society.
The goal of the initiative is to reduce early elective births at 52 Kansas hospitals participating in a quality improvement to less than 2 percent of all deliveries. The partnership focused on convincing hospital administrators to adopt “hard stop” policies, which essentially prohibit doctors from delivering babies before the 39th week of pregnancy unless deemed medically necessary.
The American College of Obstetricians and Gynecologists revised its recommendations in 2013 to define full term as a birth occurring at the 39th week or later. Until then, OB-GYNs viewed outcomes as roughly the same for babies born at the 37th week of pregnancy or later, and some performed cesarean sections or induced labor in the last weeks of pregnancy when mothers requested, even if there was no medical risk in continuing the pregnancy.
However, research showed that babies had the best outcomes when they were born during at least the 39th week of pregnancy, mostly because their lungs and brains weren’t fully developed before then.
But Tinsley said front-line practitioners may not always be aware of developments in research and changes in recommendations. Even if they are, a patient’s desire for the convenience of a scheduled birth can push the physician to perform one, or the patient may change doctors to find someone who will accommodate her preference, she said.
Some early births can’t be avoided because labor begins spontaneously or because the mother or baby has a medical problem that makes continuing the pregnancy a greater risk than delivering the baby early. The goal is to target early births that don’t fall into either of those categories, Tinsley said.
‘Goal of perfection’
Early indications show the changes are having an effect. As of December 2014, the number of early elective deliveries had fallen 70.5 percent at participating hospitals since June 2012, Tinsley said.
However, when deliveries at all of the 67 Kansas hospitals that provide obstetric services are included, the overall rate of early elective births still totaled 4.4 percent in 2014.
That, Tinsley said, means the collaborative still has work to do educating doctors and hospital administrators.
“We always strive for zero,” Tinsley said. “We always have the goal of perfection.”
Keeping the message at the forefront of providers’ minds is particularly important because quality improvement sometimes stalls or even slides back when a hospital’s leaders who pushed for change go to work somewhere else or move on to other priorities, she said.
The Kansas Healthcare Collaborative doesn’t have data on home-based births or those at birthing centers.
Insurer offers incentive
BlueCross and BlueShield of Kansas joined the effort in 2013. The insurer offers incentives for hospitals where the early elective delivery rate doesn’t exceed 3 percent, spokeswoman Mary Beth Chambers said. That includes elective cesarean sections and induced vaginal births before the 39th week, if they aren’t medically necessary, she said.
Hospitals participating in the Blue Cross and Blue Shield quality program continued to reduce their early elective birth rates in 2015, Chambers said. The rate for participating Kansas hospitals fell from 2.7 percent of births in 2014 to 1.1 percent in 2015, she said.
The idea is that doctors will respond to financial incentives, benefiting the families under their care and the system as a whole, Chambers said. She declined to say how much Blue Cross and Blue Shield offered Kansas hospitals that met the 3 percent threshold.
“From a medical perspective, we know that babies born full-term have the greatest opportunity to reach their full potential in life; from an insurance perspective, we know that babies born early for the convenience of the physician or mother can end up in the neonatal intensive care unit for a period of time, which unnecessarily adds to the cost of health care claims,” she said in an email.