Do We Really Need OBs?

February 1, 2015 Leave a comment Go to comments

by Lindsey J. Wimmer, MSN, CPNP, CPLC

Looking at many of the trends in obstetric care of recent years, it appears that obstetricians aren’t really needed.  The increasingly-popular desire toward home deliveries further supports this point.  There are many rules that tell our OBs exactly what to do, when to do it, and how to do it, so it seems that anyone who can follow directions should be able to perform their duties.  We have turned obstetric care into a recipe.  As long as the ‘chef’ doesn’t stray from the recipe, all will be great.  Right?

Clearly, I’m being sarcastic and exaggerating in the process.  But the thought has crossed my mind recently.  I sympathize with the obstetricians who are often caught in a difficult spot between their patients’ desires, their medical opinion, their Hippocratic obligation (“primum non nocere” – first do no harm), and the rules from hospital, professional organizations or insurance companies.  Their ability to do what they are trained to do and that they believe is in the best interest of all involved must often be compromised.  The best example of this phenomenon at the moment is the restriction of delivery before 39 weeks gestation.

complianceIf you’re not familiar with this movement, the short version is that physicians are now prohibited from scheduling a delivery before 39 weeks and 0 days unless one of the specific criteria is present. Even at 39 weeks if there are no cervical changes that target moves out as far as 42 weeks.

I  was trained, as were most obstetricians currently in practice that ‘full term’ was 37-40 weeks gestation.  Suddenly, that definition has been changed to 39 weeks by ACOG.  Yet, I have not seen any research to show a solid reason for this.  Yes – many babies have fewer complications at later gestations, but this is not an absolute fact and I don’t understand the benefit of changing the definition.  (The fact that it was changed without solid research is particularly irritating to me because they often tell stillbirth advocates that changes to practice cannot be based on provider experience/knowledge or anecdotal evidence – yet that is exactly what they have used in this case).

When I first heard of this initiative, it was presented as an education effort to reduce convenience deliveries before 39 weeks.  It’s safe to say that the vast majority of people understand that it is not good practice to induce labor because the mother is tired of being pregnant, she wants a specific doctor to deliver her child, or it works better in the physician or family’s schedule.  But I also know that many deliveries that were scheduled before 39 weeks were for reasons other than convenience – including my own 4 children.  In my opinion, best practice lies somewhere between convenience and the specific criteria listed (as I can think of many conditions that place the baby at risk that are not represented in that list).  The list of exceptions to the 39 week rule that will “buy your ticket” to early delivery consists mainly of maternal conditions such as hypertensive disorders, oligohydraminos, prior classical cesarean delivery, gestational diabetes, placental abruption, premature rupture of membranes, and cholestasis.  However, indicators of fetal distress such as decreased fetal movement or even previous history of stillbirth are absent from the list and there are others we believe should be considered in these decisions.

It is a great example of how a simple and good idea can be taken to an extreme.

Many organizations jumped on board with this idea since 2008 – including ACOG (professional organization of obstetricians), AWOHNN (professional organization of women’s health nurses), ACNM (professional organization of nurse midwives), March of Dimes, JCAHO (hospital accrediting organization), many insurance organizations and others.

There are financial consequences for providers and/or hospitals that do not follow this guideline.  The Leapfrog Group, a coalition of big corporate health-care purchasers, in 2009 began asking hospitals around the nation to report their rate of early term induced births that weren’t medically necessary according to the extremely short list of approved “medical necessity”. Beginning Jan. 1, 2013 United Healthcare, the nation’s largest private health insurer, began paying hospitals more money if they take steps to limit early deliveries and show a drop in their rates. Insurer Aetna is funding a March of Dimes program that helps hospitals adopt implementation policies, and it is using claims data to advise newly pregnant women of the importance of 39 weeks in the womb. (Of course this data does not even discuss the potential or rate of stillbirth.) Aetna asks hospitals to report their rate of earlier elective deliveries, and it highlights hospitals that meet Leapfrog targets on its website.  The hospital accrediting organization, JCAHO implemented ‘quality standards’ that requires measurement and tracking of early so called elective delivery rates.  This in and of itself isn’t a big deal – but noticeably absent is a quality standard that tracks and measures the numbers of stillbirths in any given hospital. Hospitals take JCAHO standards very seriously because federal funding (medicare/medicaid) funding is tied to their accreditation.

This all appears understandable because after all – who doesn’t want healthier babies?  NICUs are scary places and everyone would rather their baby not ever need their care.  In addition, the care provided in NICUs is extremely expensive.  If we can keep babies out of NICUs, it will mean babies are healthier and we save millions in health care dollars.

Sounds like a no-brainer.

One of the major problems with is that we are assuming every pregnancy can and should continue until the mom goes into labor naturally after 39 weeks.  However, we know that that we have significantly lowered the fetal death rate, the neonatal death rate, the birth injury rate, and maternal morbidity and mortality rates by utilizing the technologies that have been developed over the last 50-60 years.  Much of that happened because we were able to deliver babies before they or their mothers suffered serious or fatal consequences.  It is not routine care to look for fetal distress without other symptoms.  That means there could be a lot of babies in distress and we are making them wait for delivery.  In these cases, the NICU might be their best option for survival!  NICU care can be a wonderful thing.

We’re also assuming that every baby born between 37 and 39 weeks will need to be cared for in the NICU.  This is not the case. Millions of babies are born at that gestation around the world without needing any extra care or interventions.  Even if they do need help, it may only be for a few hours or days.

I was taught that if something sounds too good to be true, it probably is.  Where’s the catch?  In this case, the catch is that sometimes our obstetricians are saving our babies’ lives by removing them from an intrauterine environment that is no longer the optimal place for them to be.  It is true that some of these babies may need NICU care after delivery.  But is that the worst possible outcome?  I know thousands of stillbirth families that would have gladly spent time in a NICU giving their child a chance at life if the other option was to be planning their child’s funeral.  We must keep in perspective ALL potential outcomes of our decisions.

This is the balancing act that obstetricians must deal with on a daily basis – particularly in earlier gestations.  A mother’s health or the baby’s status must be very compromised for the physician to feel delivery is the best option at 24 weeks gestation (as an example).  But until recently, that decision at 37-38 weeks was much easier for the doctors to make.  Now – it has another layer of difficulty because of the scrutiny they will endure for their clinical decisions.

I am routinely hearing stories about families who make a decision with their obstetrician that delivery is the best option, yet they are turned away from the hospital because they don’t meet the far too short list of criteria for an ‘early’ delivery.  The decision-making process has been taken out of the hands of the patients and the providers.  This is wrong on so many levels – both clinical and ethical.  We need the people who have been involved in the pregnancy all along, who are evaluating the circumstances, and who will be most affected to be making the decisions.  Not ‘experts’ who are thinking about general populations or insurance companies thinking about their expenses and their shareholders.

aj_stop_sign_angled_clip_art_18120We also hear about women who go into labor at 36-39 weeks.  When they present to the hospital, their labor is immediately stopped.  This would not have been an issue just a few years ago.  Most troubling is when the labor is stopped, the family is sent home, and they return in the following days or weeks to deliver a stillborn child.   It appears that these pregnancies had reached the end of their ability to sustain the baby, yet we intervened for a rule that was created without adequate research or reasoning.

Medicine is not a cookbook.  Every person and every situation is different.  Sweeping rules that remove autonomy from the patient and disregard the professional opinions of the providers are asking for trouble.  And that is what has happened.  Data is beginning to emerge that these hard-stop rules are working in regard to the number of babies who are delivered before 39 weeks, the number of babies who are admitted to NICUs, and the amount of money spent on NICU care.  However, the data also indicates that the number of stillborn babies born at 37-39 weeks is increasing.  Other victims of this new rule are babies that are stillborn after 39 weeks, but induction wasn’t allowed because mom didn’t have sufficient cervical changes to qualify for delivery.  These are extremely viable babies that we have the ability to save!

Patients have the right to refuse any medical treatment they don’t want for ANY reason.  This is well-established principle of medical ethics and honored time and time again.  We ensure they are counselled about the pros and cons of all decisions.  If a patient is making an informed decision – we must honor that (even if we disagree or would not choose the same for ourselves).  However, patients don’t have the same level of control over their health if they choose a medical treatment that the hospital, professional organization, or insurance company doesn’t want to happen.  We should treat it the same as we do refusal of treatment.  Educate the family of the pros and cons of ALL options, and honor their decision.

The “39 week rule” is a good idea taken to an extreme with significant, unintended consequences. 

I have learned of conversations our obstetricians have with their colleagues around the world will hear about what is happening with this issue in the US.  The international OB community’s first reaction is disbelief that it is really being implemented in such a way.  When they are reassured that it is true, they are flabbergasted.   It seems absurd to limit the expertise of the medical professionals.  I agree.

In adopting this practice, our medical establishments have chosen mortality over morbidity.  They find it acceptable for more babies to die in utero in order to reduce the number of babies who need NICU care.

  • It bothers me that our society is letting this happen.
  • It bothers me that families have been unethically removed from the decision-making process.
  • It bothers me that our providers have their hands tied when it is their practices and licenses at risk.
  • It bothers me that we don’t value the impact of stillbirth on families enough to end this ‘rule’ immediately.

We absolutely need obstetricians and their expertise.  I, for one, want my doctor and I to make medical decisions for my family together.  We should all have that right.

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Does this sound like your story?  Were you told your delivery must wait until 39 weeks (or later)? Did you spontaneously go into labor between 32-39 weeks and have your labor stopped? If so, we’d like to hear your story whether your story ended joyfully or otherwise.  Click here to share your story.  Stories submitted will NOT be posted on any website and will only be used anonymously.  

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  1. Mike Jones
    February 7, 2015 at 1:36 am

    After reading your post I came across this study on PUBMED:
    Risk of Stillbirth and Infant Death Stratified by Gestational Age – Rosenstein.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719843/

    It seemed to indicate that expectant management had lower mortality at 37 weeks compared to delivery. At 38 weeks delivery and expectant management had approximately equal mortality. It is well known that the morbidity decreases with the length of gestation at least up to 39 weeks.

    If mortality rates from delivery vs waiting an additional week are equal at 38 weeks, but morbidity goes down, it seems pretty reasonable to wait until 39 weeks.

    Also, in some ways this rule protects the providers and gives them a reason to not do an elective induction at 37 weeks, rather than it being simply their preference not to do it they can point to the hospital policy, reducing the tension between them and the patient. And in my limited medical experience when rules like this are in place it is fairly easy for the physician to maneuver around them when they want to, it usually just takes a little extra effort doing some extra paperwork.

    -Just throwing out another perspective, curious to hear your thoughts on this.

  2. Mike Jones
    February 22, 2015 at 12:18 pm

    After reading your post I came across this study on PUBMED:
    Risk of Stillbirth and Infant Death Stratified by Gestational Age – Rosenstein.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719843/

    It seemed to indicate that expectant management had lower mortality at 37 weeks compared to delivery. At 38 weeks delivery and expectant management had approximately equal mortality. It is well known that the morbidity decreases with the length of gestation at least up to 39 weeks.

    If mortality rates from delivery vs waiting an additional week are equal at 38 weeks, but morbidity goes down, it seems pretty reasonable to wait until 39 weeks.

    Also, in some ways this rule protects the providers and gives them a reason to not do an elective induction at 37 weeks, rather than it being simply their preference not to do it they can point to the hospital policy, reducing the tension between them and the patient. And in my limited medical experience when rules like this are in place it is fairly easy for the physician to maneuver around them when they want to, it usually just takes a little extra effort doing some extra paperwork.

    -Just throwing out another perspective, curious to hear your thoughts on this?

  3. Lindsey Wimmer
    February 23, 2015 at 11:01 am

    Thank you for your comments, Mike. Your comments highlight exactly how this concept began with really good intentions. However, we are hearing more and more that they are not being implemented with the common sense you indicate. I agree that there probably are physicians who employ this policy to reduce tensions with their patients – but I think the physician should use the patient’s concerns into consideration and listen to them. If they are related to a maternal intuition or a previous poor outcome or a symptom that isn’t on the list – that deserves a real conversation and not a blanket rule. I also used to believe that physicians could maneuver the system fairly easily – but I am hearing more and more from patients and physicians that they are turned away at the hospital doors. In addition, some physicians have reported being required to defend their decision before a hospital committee even in the absence of a poor outcome. It seems unethical to me that the financial incentives in place should require our physicians to “work” the system to do what they believe is in the best interest of both mother and baby.

    At the end of the day – I understand how this began from a good idea. What bothers me most is that we are hearing more and more about extreme implementation, lack of consideration of symptoms/concerns/issues outside the limited list, lack of proactive investigation to see which babies are really healthy in the womb or not and if they are better candidates for delivery or not, and the unethical influence of monetary incentives to and from people who are not personally involved in the pregnancy or outcomes.

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