[Editor's Note: In this final segment of Christine Morton and Kathleen Pine's series on the Maternal Quality Care landscape in the United States, the post authors look at where the <39 weeks elective deliveries bans have been effective, and where such attempts may have some unintended outcomes. Finally, Morton and Pine offer a feasible list of actions childbirth educators and doulas can take in their own communities. To read this entire series from the beginning, go here.]

Unintended consequences

We would like to now draw your attention to some of the unintended consequences of quality measurement.

There has been strong support for this initiative among many stakeholders, including ACOG, the March of Dimes, and several National Quality organizations, such as NQF, TJC and Leapfrog. Many states or major hospital systems have convened collaboratives, such as Ohio and Intermountain HealthCare in Utah, and several more are in the works, such as North Carolina,Oregon, Oklahoma and Illinois. State Medicaid programs are expressing interest, especially in payment reforms and commercial insurance companies have launched initiatives, such as Anthem Blue Cross Patient Safety First initiative in California. This type of support from a wide range of stakeholders is impressive, and positive. Yet, some stakeholders promoting the <39 weeks measure assumed its adoption would lead to a significant reduction in the overall cesarean section rate. Unfortunately, this assumption is largely unwarranted since only about 4-10% of all births are elective deliveries between 37 and 39 weeks, and most of these are scheduled repeat cesareans.

Another unintended consequence is that this measure may affect the way elective inductions are scheduled. At the micro-level, it is possible that schedulers may simply schedule inductions so as to not negatively impact the hospital's statistics (for example, by scheduling inductions automatically for 39 weeks and 1 day gestation). However, this brings up a big-picture question: If we focus on 39 weeks, what are we doing to prevent elective inductions at any gestational age, which may arguably be the bigger issue? It is possible that this measure may sensitize stakeholders to the wrong issue: timing of birth rather than the fact that it is generally best when labor begins on its own. Additionally, is it possible that 39 weeks could become the new 'ideal' gestational age, because it will be assumed that 39 completed weeks is the best time to be born? While the measure does not state that 39 weeks is ideal for all inductions, providers and the general public may not understand that selecting 39 weeks as an upper limit is not an endorsement of this age as the ideal age to be born.

The last unintended consequence we discuss has to do with how the public message is conveyed via the media, such as the recent NPR story with the title, 'Doctors to Pregnant Women: Wait at Least 39 Weeks.' Some reports, like the one in the Portland Tribune, cover the issue in a balanced way, and note that there are pressures/drivers from both women and physicians in early term deliveries. Yet, others, with headlines like 'More hospitals banning elective C-sections' convey the message that women have been the driving force behind this trend in early deliveries and hospitals/providers are finally drawing the line in the sand. Data from Listening to Mothers II doesn't support such claims, but while it's true some women seek early elective deliveries there are also physicians who recommend or 'lead women' to that decision. After all, women can't schedule a cesarean or an induction - only hospital staff can, upon orders from a provider. The result of this framing is that public comments on such stories often take women to task for being selfish and unthinking, unfit mothers. There are a few who provide the other side, however, citing providers as drivers, and hospitals as willing partners, of the increase in early deliveries.

What can childbirth educators and doulas do?

• Take advantage of education resources, including the March of Dimes' 'brain card' which illustrates the differences in brain development at 35 and 40 weeks of pregnancy, and can be used to help women understand the importance of waiting.
• Share this excellent article by Kathleen Rice Simpson and colleagues on the success of an educational intervention to decrease the rate of elective labor indication among nulliparous women at a community hospital with hospital staff in your community, and implement in your own classes.
• Make sure your local hospital maternity nursing staff is aware of AWHONN's new education campaign: '40 Reasons to Go the Full 40 Weeks.'
• Reach out to a local March of Dimes organization to partner with them on a public education seminar- this is an issue for the general public as much as for pregnant women. March of Dimes chapters tend to have good relationships with hospitals and may be a new ally in your community for promoting optimal birth practices.
• Set up Google Alerts for key words ('Elective Deliveries' 'cesarean') so that you are notified by email when new content appears online (news or blogs). Then monitor the public comments pages and offer your perspective as a childbirth educator/doula and be sure to include information on your services or cite Lamaze as a place for people to get evidence based information.
• Ask the perinatal nurse manager at your local hospital(s) whether the facility is going to report on TJC perinatal measure set. If not, ask when they plan to, and who in the hospital is the decision maker. But understand it may be a struggle for hospitals to report on this measure set, and the process might be slower than advocates would like.
• Reach out to non-mainstream audiences, especially among those who are not likely to attend typical childbirth classes but who may be at greater risk for elective deliveries 'Latinas, African American women, younger and non-native English speaking women and those without partners.

Posted by: Christine Morton, PhD and Kathleen Pine (University of California, Irvine)

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