1. Click to edit Master title style Click to edit Master subtitle style 1 A Note to the Speaker DELETE THIS SLIDE BEFORE PRESENTATION The following slides have been developed to support presentations on the elimination of non-medically indicated deliveries <39 weeks gestational age and should be tailored to meet the needs of the audience. When adapting the slide deck, the following guidelines must be considered: The slide deck is copyrighted by the State of California. Slides contained in this deck should not be changed or amended. Additional slides can be added, but new slides must not contain the CMQCC logo, March of Dimes logo or the State of California copyright.

2. Click to edit Master title style Click to edit Master subtitle style 2 Eliminating Non-medically Indicated (Elective) Delivery Before 39 Weeks in Our Hospital: Difficult Q&A

3. Click to edit Master title style Click to edit Master subtitle style 3 Difficult Q&A 1.Physician autonomy 2.Medical leadership 3.Consensus 4.Absolute refusers 5.Data collection 6.Stillbirths

4. Click to edit Master title style Click to edit Master subtitle style 4 Physician Autonomy Outdated thinking Reflective of underlying anxiety about loss of control and autonomy Lack of understanding that standardization of care improves patient outcomes

5. Click to edit Master title style Click to edit Master subtitle style 5 Medical Leadership Most “Hard Stop” reports in the literature have involved a hospital-based physician who can “take the heat” Many other specialties have standardized protocols Protocol examples include: Door-to-cardiac catheterization time Stroke ICU - for prevention of ventilator associated pneumonia and central line infections

6. Click to edit Master title style Click to edit Master subtitle style 6 Consensus Use logic and literature to build a consensus among hospital providers An outlier may conform to guidelines if data demonstrating their practice patterns vs. their colleagues is presented, instead of forcing a doctor to follow new rules

7. Click to edit Master title style Click to edit Master subtitle style 7 Absolute Refusers (1) Important to not allow a few physicians to affect the majority Physician level data can be very persuasive Accurate data are critical - if data are wrong everyone loses credibility A few months of using “Scouts’ Honor” (“Soft Stop”) can show the entire department how a few refusers can spoil the outcomes

8. Click to edit Master title style Click to edit Master subtitle style 8 Absolute Refusers (2) Require every physician upon admission to write a full note in the chart describing why they plan to perform a non- medically indicated cesarean or induction before 39 weeks Require that all patients sign a full consent that describes the neonatal risks before undergoing induction/cesarean before 39 weeks without medical indication Require all cases be reviewed in Perinatal Committee and require that formal letters be returned and placed in their Medical Staff file The department Chair can use physician-level data on this measure for Ongoing Professional Practice Evaluation (JC requirement)

9. Click to edit Master title style Click to edit Master subtitle style 9 Absolute Refusers (3) A key influence in many hospitals has been the Director of the Nurseries and/or Director of the NICU (Neonatologist or Pediatrician) They are part of the team of champions for babies They can illustrate examples of poor outcomes and hopefully some statistics It is much harder to challenge the “baby’s doctor’s” reasons for eliminating non-medically indicated deliveries than those of another obstetrician

10. Click to edit Master title style Click to edit Master subtitle style 10 Data Collection Data collection on non-medically indicated deliveries <39 weeks can be onerous Variety of methods used to calculated rates of elective deliveries <39 weeks A number of organizations have made collecting data and calculating the rates of elective deliveries <39 weeks easier: The Joint Commission California Maternal Quality Care Collaborative (CMQCC) March of Dimes

11. Click to edit Master title style Click to edit Master subtitle style 11 What About the Risk of Stillbirths? Even one day longer “in-utero” does increase the risk for stillbirth, but it is extremely low. What is the reported risk of stillbirth during the 38th week? U.S. data (NCHS)1 = 0.36/1,000 births Population rate - includes all risk categories 1 MacDorman MF, Kirmeyer SE, Wilson EC. Fetal and perinatal mortality, United States, 2006. National vital statistics reports; vol 60 no 8. Hyattsville, MD: National Center for Health Statistics. 2012.

12. Click to edit Master title style Click to edit Master subtitle style 12 What Have Intervention Studies Observed for the Risk of Stillbirth? Intervention StudyTotal Population Studied Stillbirth Rate Findings Oshiro (2009) 1 (large health system) 160,394Decline during intervention period Clark (2010) 2 (large health system) 433,551No change during the intervention period Ehrenthal (2011) 3 (single hospital) 24,028 (>37 wk only)Increase noted at 37 and 38 wks Benedetti (2012) 4 (state of Washington) 505,445 (>37wk only)No change during the intervention period 1 Obstet Gynecol 2009;113:804–11 2 Am J ObstetGynecol 2010;203:449.e1-6 3 Obstet Gynecol 2011;118:1047–55 4 Obstet Gynecol 2012;119:656-7

13. Click to edit Master title style Click to edit Master subtitle style 13 Increased Infant Mortality (birth to 1 year) for Babies Born at 37/38wks Gestation Compared to 39wks or Greater StudyRelative Risk compared to 39 wks Absolute Increase per 1,000 births Zhang (2009) 1 (US cohort, 1995-2001) 37wk: 1.75 38wk: 1.25 37wk: 1.0 38wk: 0.3 Donovan (2010) 2 (Ohio 2003-2005) 37wk: 1.9 38wk: 1.4 37wk: 1.8 38wk: 0.8 Reddy (NICHD)(2011) 3 (NCHS US 1995-2001) 37wk: 1.9 38wk: 1.4 37wk: 2.0 38wk: 0.5 Altman (2012) 4 (Sweden 1983-2006) 37wk: 2.1 38wk: 1.4 37wk: 1.6 38wk: 0.5 1 J Pediatric 2009;154:358-62 2 Am J ObstetGynecol 2010;203:58 3 Obstet Gynecol 2011;117:1279-87 4 BMJ Open 2012;2:e001152 Results are quite consistent and show higher rates of observed infant mortality at 37/38 weeks than predicted for fetal mortality.

14. Click to edit Master title style Click to edit Master subtitle style 14 For More Information, Contact: Barbara Murphy barbar@stanford.edu Leslie Kowalewski LKowalewski@marchofdimes.com