1. EARLY TERM BIRTHS 37 – 38 6/7 WEEKS GESTATION Scott D. Duncan, MD, MHA, FAAP Associate Professor – Pediatrics University of Louisville

2. Changing Gestation of Spontaneous Birth Davidoff, et al. Semin Perinatol, 2006

3. Definitions Fleischman, et al. Obstet Gynecol, 2010 Preterm – Less than 37 weeks Late Preterm – 34 – 36 6/7 Term – 37 – 41 6/7 Early Term – 37 – 38 6/7 Full Term – 39 0 41 6/7 Post-term – 42 weeks and beyond

4. Births: Final Data for 2009 Martin, et al. NSVR, 2011 Distribution of births by gestational age, all births: United States, 1990, 2000, 2005–2009 Modified

5. NQF #0469 PC-01 Elective Delivery A reduction in the number of non-medically indicated elective deliveries at >=37 to <39 weeks gestation will result in a substantial decrease in neonatal morbidity and mortality, as well as a significant savings in health care costs. The rate of cesarean sections should decrease with fewer elective inductions, resulting in decreased length of stay and health care costs. The measure will assist health care organizations (HCOs) to track non-medically indicated early term elective deliveries and reduce the occurrence.

6. © 2009 The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins, Inc. Fig. 1. Rate of neonatal intensive care unit admissions for normal pregnancies by gestational age. Two standard deviations shown by vertical lines. Data from Intermountain Healthcare.Oshiro. Decreasing Elective Deliveries Before 39 Weeks. Obstet Gynecol 2009. Decreasing Elective Deliveries Before 39 Weeks of Gestation in an Integrated Health Care System Decreasing Elective Deliveries Before 39 Weeks of Gestation in an Integrated Health Care System. Oshiro, Bryan; Henry, Erick; Wilson, Janie; Branch, D; Varner, Michael Obstetrics & Gynecology. 113(4):804- 811, April 2009. DOI: 10.1097/AOG.0b013e31819b5c8c

7. © Mosby-Year Book Inc. 2009. All Rights Reserved. Neonatal and maternal outcomes associated with elective term delivery. Clark SL; Miller DD; Belfort MA; Dildy GA; Frye DK; Meyers JA American Journal of Obstetrics & Gynecology. 200(2):156.e1-4, 2009 Feb. TABLE Elective delivery and neonatal outcome Neonatal and maternal outcomes associated with elective term delivery

8. Late Preterm Infants, Early Term Infants and Timing of Elective Deliveries Table 6 -- Respiratory distress syndrome in late preterm and term infants Data from Madar J, Richmond S, Hey E. Surfactant-deficient respiratory distress after elective delivery at ‘term.’ Acta Paediatr 1999;88:1245 Engle, et al. Clin Perinatol, 2008

9. Copyright © 2009 Massachusetts Medical Society. All rights reserved. Timing of elective repeat cesarean delivery at term and neonatal outcomes. Tita AT; Landon MB; Spong CY; Lai Y; Leveno KJ; Varner MW; Moawad AH; Caritis SN; Meis PJ; Wapner RJ; Sorokin Y; Miodovnik M; Carpenter M; Peaceman AM; OSullivan MJ; Sibai BM; Langer O; Thorp JM; Ramin SM; Mercer BM; Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network New England Journal of Medicine. 360(2):111-20, 2009 Jan 8. Figure 2. Timing of Elective Repeat Cesarean Delivery and the Incidence of the Primary Outcome According to the Number of Completed Weeks of Gestation. Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes

10. Copyright © 2009 Massachusetts Medical Society. All rights reserved. Timing of elective repeat cesarean delivery at term and neonatal outcomes. Tita AT; Landon MB; Spong CY; Lai Y; Leveno KJ; Varner MW; Moawad AH; Caritis SN; Meis PJ; Wapner RJ; Sorokin Y; Miodovnik M; Carpenter M; Peaceman AM; OSullivan MJ; Sibai BM; Langer O; Thorp JM; Ramin SM; Mercer BM; Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network New England Journal of Medicine. 360(2):111-20, 2009 Jan 8. Table 2. Incidence of Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery. Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes

11. Adverse Outcomes

12. Variations in Mortality and Morbidity by Gestational Age among Infants Born at Term Zhang et al. J Pediatr, 2009

13. © Mosby-Year Book Inc. 2010. All Rights Reserved. Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis. Robinson CJ; Villers MS; Johnson DD; Simpson KN American Journal of Obstetrics & Gynecology. 202(6):632.e1-6, 2010 Jun. TABLE 2 Mean costs/charges by adverse outcomes Timing of elective repeat cesarean delivery: a cost analysis

14. © Mosby-Year Book Inc. 2010. All Rights Reserved. Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis. Robinson CJ; Villers MS; Johnson DD; Simpson KN American Journal of Obstetrics & Gynecology. 202(6):632.e1-6, 2010 Jun. TABLE 3 Costs/charges by adverse outcome incidence Timing of elective repeat cesarean delivery: a cost analysis

15. © Mosby-Year Book Inc. 2010. All Rights Reserved. Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis. Robinson CJ; Villers MS; Johnson DD; Simpson KN American Journal of Obstetrics & Gynecology. 202(6):632.e1-6, 2010 Jun. TABLE 4 Costs/charges by timing of cesarean Timing of elective repeat cesarean delivery: a cost analysis

16. Early Term Births KY Cabinet for Health & Family Services, 2012

17. Inductions KY Cabinet for Health & Family Services, 2012

18. Cesarean Sections KY Cabinet for Health & Family Services, 2012

19. Cost - Neonatal Respiratory Distress Syndrome Incidence ranges from 1.9 – 3.7% Mean charge $147,017 Costs approximates $1,363,142 to $2,654,539 Total charges ~ $4,014,681 Prematurity w/o cc Incidence ranges from 8 – 17.8% Mean charge $12,515 Charges ranges $977,171 to $2,174,206 Total charges ~ $3,151,377 KY Cabinet for Health & Family Services, 2012 Cost Data - http://hcupnet.ahrq.gov/

20. Advisory Committee on Infant Mortality

21. HRSA Infant Mortality Collaborative

22. © 2009 The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins, Inc. Decreasing Elective Deliveries Before 39 Weeks of Gestation in an Integrated Health Care System. Oshiro, Bryan; Henry, Erick; Wilson, Janie; Branch, D; Varner, Michael Obstetrics & Gynecology. 113(4):804-811, April 2009. DOI: 10.1097/AOG.0b013e31819b5c8c Fig. 3. Percent of elective deliveries before 39 weeks of gestation. Data from Intermountain Healthcare.Oshiro. Decreasing Elective Deliveries Before 39 Weeks. Obstet Gynecol 2009. Intermountain Healthcare

23. © Mosby-Year Book Inc. 2010. All Rights Reserved. A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks' gestation. Donovan EF; Lannon C; Bailit J; Rose B; Iams JD; Byczkowski T; Ohio Perinatal Quality Collaborative Writing Committee American Journal of Obstetrics & Gynecology. 202(3):243.e1-8, 2010 Mar. FIGURE 2 Percent of births at 36-38 weeks induced without medical or obstetric indication Ohio PQC

24. Approach – Clinical Effectiveness “Hard stop” Adoption of a policy Policy enforcement “Soft stop” Adoption of a policy Peer review committee “Education only” Clark, et al., Am J Obstet Gynecol, 2010

25. Approach – Clinical Effectiveness Clark, et al., Am J Obstet Gynecol, 2010 500,000 NICU Days $1,000,000,000 per year

26. Policy Development The campaign to reduce early term deliveries applies only to purely elective procedures. Elective refers only to those scheduled deliveries that are performed without a valid medical indication. Clark, et al., Am J Obstet Gynecol, 2012

27. “THE LEVEL OF CIVILIZATION ATTAINED BY ANY SOCIETY WILL BE DETERMINED BY THE ATTENTION IT HAS PAID TO THE WELFARE OF ITS CHILDREN.” - B.F. ANDREWS