Either spontaneous or induced delivery before a gestational age of 39 weeks is associated with an increased risk of adverse neonatal outcomes. A significant proportion of induced early-term (37–38 weeks) deliveries are elective and not medically indicated. There has been a national effort to reduce early-term deliveries through implementation of a policy limiting elective delivery before 39 weeks of gestation. After implementation of this policy, several studies reported initial success at shifting the timing of elective delivery at individual hospitals and large regions. However, the effect of this policy on neonatal outcomes has not been fully evaluated. This retrospective cohort study investigated the effectiveness of a new institutional policy limiting elective delivery before 39 weeks of gestation on obstetric practice and neonatal outcomes at a large regional medical center. Outcomes for term singleton deliveries were compared for a period 2 years before and 2 years after implementation of the new policy. Data on medical risk factors for outcomes of interest were obtained from electronic obstetrical records. The study cohort included 12,015 term singleton live births that occurred before implementation and 12,013 after implementation of the policy. The overall percentage of deliveries before 39 weeks of gestation was decreased from 33.1% before to 26.4% after implementation (P < 0.001); the greatest difference was found among women with induced labor and repeat cesarean delivery. After intervention, there was also a significant reduction in the proportion of term live-birth infants admitted to the neonatal intensive care unit: 1116 admissions (9.29%) before and 1027 (8.55%) after (P = 0.044). However, after implementation, there was an 11% increase in the adjusted odds of birth weight >4000 g (odds ratio, 1.11; 95% confidence interval, 1.01–1.22), as well as an increase in stillbirths at 37 and 38 weeks' gestation, from 2.5 to 9.1 per 10,000 term pregnancies (relative risk, 3.67; 95% confidence interval, 1.02–13.15, P = 0.032). These findings demonstrate that implementation of an institutional policy limiting elective delivery before 39 weeks of gestation is effective in changing the timing of term deliveries. However, examination of the data reveals an increase in the rate of macrosomia and stillbirth in contrast to the reduction in neonatal intensive care unit admissions after the intervention.
Evidence-based guidelines discouraging elective delivery prior to 39 weeks have been implemented at institutions across the US. The purpose of this study is to assess the impact of such a guideline on rates of labor induction and cesarean delivery at a large regional hospital. We performed a retrospective cohort study using a pre-post design comparing rates of labor induction and cesarean delivery (CD) for all singleton live births 37 or more weeks gestational age before (2005, 2006) and after (2008, 2009) the 2007 implementation of the guideline. Data from electronic obstetrical records were used; babies delivered between 37 and 38 weeks completed gestation were considered to be "early term". Outcomes before and after were compared using Chi-squared test of significance. Between 2005 to 2009 there were 30,089 term singleton births. Overall, 30% were "early term", 31% had an induced labor, and 31% delivered by CD. Annual rates for each from 2005 to 2009 are shown in the Figure: the percentage of term babies delivered "early term" decreased from 33.4% to 23.7% (p<0.0001), the use of labor induction fell from 36.5% to 26.9% (p<0.0001), however, the rate of CD rose from 28.5% to 34.2% (p<0.0001). Before and after comparisons showed a decrease in the use of pre-induction cervical ripening (p<0.02) and an increase in women with a prior CD from 14.8% to 16.5% (p<0.001). Among women with a CD, there was a decrease in delivery for reason of a breech presentation (p<0.02) and no change in CD for indications of fetal distress or labor dystocia. There was, however, a significant increase in reporting of "other" indications (p<0.01). Implementation of evidence-based guidelines limiting elective delivery prior to 39 weeks was successful at changing delivery patterns for a large institution, but was associated with a significant rise in cesarean delivery. Further study is needed to assess the relationship between guideline implementation and the rate cesarean delivery.
In Brief OBJECTIVE: To evaluate the association of a new institutional policy limiting elective delivery before 39 weeks of gestation with neonatal outcomes at a large community-based academic center. METHODS: A retrospective cohort study was conducted to estimate the effect of the policy on neonatal outcomes using a before and after design. All term singleton deliveries 2 years before and 2 years after policy enforcement were included. Clinical data from the electronic hospital obstetric records were used to identify outcomes and relevant covariates. Multivariable logistic regression was used to account for independent effects of changes in characteristics and comorbidities of the women in the cohorts before and after implementation. RESULTS: We identified 12,015 singleton live births before and 12,013 after policy implementation. The overall percentage of deliveries occurring before 39 weeks of gestation fell from 33.1% to 26.4% (P<.001); the greatest difference was for women undergoing repeat cesarean delivery or induction of labor. Admission to the neonatal intensive care unit (NICU) also decreased significantly; before the intervention, there were 1,116 admissions (9.29% of term live births), whereas after, there were 1,027 (8.55% of term live births) and this difference was significant (P=.044). However, an 11% increased odds of birth weight greater than 4,000 g (adjusted odds ratio 1.11; 95% confidence interval [CI] 1.01–1.22) and an increase in stillbirths at 37 and 38 weeks, from 2.5 to 9.1 per 10,000 term pregnancies (relative risk 3.67, 95% CI 1.02–13.15, P=.032), were detected. CONCLUSION: A policy limiting elective delivery before 39 weeks of gestation was followed by changes in the timing of term deliveries. This was associated with a small reduction in NICU admissions; however, macrosomia and stillbirth increased. LEVEL OF EVIDENCE: III Limiting elective delivery before 39 weeks of gestation is associated with a reduction in neonatal intensive care unit admission but only a small increase in macrosomia and stillbirth.
