Tip Sheet: Preterm Birth and Elective Inductions Prior to 37 Weeks

The American College of Obstetricians and Gynecologists (ACOG) recommends that elective deliveries not occur before 39 weeks of gestation. The ACOG Practice Bulletin on Induction of Labor further states that doctors should warn women having their first babies that their risk of having a Caesarean section doubles if labor is induced and the cervix is not ready.

Preterm births and induction of labor preterm are on the rise, and it is increasingly evident that even late preterm babies are less healthy and incur higher costs than infants born at full term. Employers can play a key role in reducing preterm birth and its associated costs.

In November 2009, the Agency for Health Care Research (AHRQ) published Thinking About Inducing Your Labor: A Guide for Pregnant Women and a companion guide for clinicians. The two publications summarized the current clinical evidence on elective induction of labor (defined as induction without medical indication), which is on the rise and is linked with the increase in late preterm birth. While the evidence base on this issue is still being established, current research indicates cause for concern:

• Between 1990 and 2006, the U.S. preterm birth rate (birth at less than 37 full weeks of gestation) rose by more than 20%.¹ Most of this increase was among infants born during the "late preterm" period, 34 to 36 full weeks of pregnancy.²
• The percentage of late preterm births for which labor was induced more than doubled from 1990 to 2006, climbing from 7.5% to 17.3%.²
• It is becoming increasingly recognized that infants born late preterm are less healthy than infants born full term.²
• Late preterm babies are more likely than full-term babies to suffer complications at birth such as respiratory distress, to require intensive and prolonged hospitalization, to die within the first year of life, and to suffer brain injury that can result in long-term neurodevelopmental problems. They also incur higher medical costs.²

Late Preterm Births Often Result in Higher Medical Costs

• Late preterm infants have higher rates of hospital readmission during the neonatal period than do term infants.³
• The average hospital stay at birth for term infants was 2.2 days, and the average cost was $2,061. Infants born late preterm had a substantially longer average stay of 8.8 days and a significantly higher average cost of $26,054.⁴
• Total first-year costs after the initial hospitalization were, on average, three times as high for late preterm infants ($12,247) as for term infants ($4,069). Late preterm infants were rehospitalized more often (15.2% versus 7.9%). The higher costs during rehospitalization of late preterm infants, especially those whose hospital stays at birth were longer to begin with, indicate their propensity to have more severe illness.⁴ (Findings based on preterm defined as 33-36 weeks' gestation).

What can employers do to reduce preterm birth and associated costs?

• Incorporate preterm birth prevention information into existing prenatal education programs, wellness initiatives, and the content of the company Intranet site.
• Ensure that people understand that elective delivery should not occur before 39 weeks of gestation.
• Provide information about the possible health risks associated with having a baby in the late preterm period. Use the recommendations of authoritative professional medical organizations such as ACOG and the March of Dimes.
• Stress the importance of a preconception health visit before becoming pregnant, to identify any medical issues that need to be addressed before pregnancy.
• Educate all women of childbearing age about the importance of taking a multi-vitamin with folic acid even before becoming pregnant.

• Do plans have specific programs in place to monitor and address issues related to preterm birth?
• Determine how plans are working with the physicians in their network on the issue.
• Require in-network hospitals to conduct a review to ensure that all C-sections and inductions meet established professional guidelines.
• Are health plans willing to cover sonograms during the first trimester for more accurate gestational dating?
• Do health plans with PPO hospitals set high standards for doctors seeking to obtain preferred provider status?
• After educating in-network providers on elective inductions, do plans monitor data to determine whether all physicians are following the recommendations?
• New patients should receive a brochure, issued by the March of Dimes, ACOG, or the American Academy of Pediatrics.

• For onsite clinics, consider asking physicians to draft fact sheets or talking points on the risks associated with elective inductions for the use of nurses who work with pregnant women.
• Make sure clinical staff members are aware of current research and clinical recommendations on late preterm birth and induction.

Other Resources

Reference:
¹ Martin JA, Hamilton BE, Sutton PD, et al. Births: Final data for 2006. National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics. 2008.

² Martin JA, Kirmeyer S, Osterman M, Shepherd RA. Born a bit too early: Recent trends in late preterm births. NCHS data brief number 24. Hyattsville, MD: National Center for Health Statistics. 2009.

³ Engle W, Tomashek K, Wallman C, The Committee on Fetus and Newborn. "Late-Preterm" Infants: A Population at Risk. Pediatrics 2007 120: 1390-1401.

⁴ McLaurin K, Hall C, Jackson E, Owens O, Mahadevia P. Persistence of Morbidity and Cost Differences Between Late-Preterm and Term Infants During the First Year of Life. Pediatrics 2009 123: 653-659.