Salt Lake City, UT
In 2010, after nearly two decades of steady increase, the U.S. rate of labor induction for singleton births reached a high of 23.8 percent. This more than doubled the 1990 rate of 9.6 percent.1 While that rate has been slowly declining in recent years, non-medically indicated, elective inductions remain common. The American College of Obstetrics and Gynecology says that inductions that do not meet recommended criteria can increase the risk of infection and can result in premature birth, longer labor, increased need for Cesarean deliveries and do not improve pregnancy outcomes.
Located in the state with the nation’s highest birth rate, Intermountain Healthcare began to focus in 2001 on reducing the incidence of elective inductions prior to 39 weeks. Working with nine labor and delivery units in Utah hospitals, researchers determined that 28 percent of all elective deliveries were being performed before 39 weeks. A clinical improvement team developed guidelines to discourage early-term inductions and met with hospital staff to promote them. The guidelines included a new protocol: Clinicians wishing to schedule an early-term elective delivery were asked to get advanced permission from their department chair or a perinatologist.2
Within six months of the program’s implementation, the percentage of elective deliveries prior to 39 weeks had dropped to less than 10 percent. By 2007, that number had decreased to less than 3 percent.3
Intermountain’s guidelines for elective induction decision-making, including a decision algorithm and accompanying notes to support best practice, have been updated several times since they were first created, including most recently in 2017.
Despite good progress at reducing the percentage of early elective inductions among Intermountain patients, in 2014 the state’s preterm birth rate was 9.1 percent, according to the National Center for Health Statistics; the March of Dimes 2020 goal is 8.1 percent.
The Utah Department of Health recognized the challenge and approached the health plan for help. Could SelectHealth and Intermountain lead the way toward further statewide reductions in unnecessary elective inductions? Working with the Utah March of Dimes chapter, and a statewide quality collaborative focused on women and newborn health, SelectHealth and Intermountain leaders set a new, more ambitious goal: eliminate all elective inductions prior to 39 weeks’ gestation.
To help reach that goal, SelectHealth leaders established an important new policy: Beginning in July 2015, the health plan would no longer pay for non-medically indicated elective deliveries prior to 39 weeks’ gestation in its network. If such deliveries occurred, financial sanctions would be applied against both the provider and the facility where the delivery occurred.
Communicate the Plan
Clinical leaders of the women and newborns clinical program held meetings with members of the maternal fetal medicine department to discuss the goal of eliminating all elective inductions prior to 39 weeks for SelectHealth members who get their care in the Intermountain network. They reviewed and discussed the evidence for eliminating early elective deliveries, and gathered feedback from clinicians about what support they needed to achieve that goal. The health plan was particularly well-positioned to provide support through patient education. Clinicians indicated that pressure from patients to deliver prior to 39 weeks was often hard to resist.
Patient Education and Repeated Reminders
Chris Chytraus, Health Services Manager, Medicaid, SelectHealth
Pregnant women are encouraged to join SelectHealth’s Healthy Beginnings program, which offers free prenatal help, education and support. Among other topics, Healthy Beginnings care managers educate expectant mothers about the importance of carrying their babies to full term. Educational materials are available through the program and in clinics. All pregnant women receive information in the mail about the important growth that takes place for their baby in the final weeks of gestation, and the risks that accompany an early birth. Women are also reminded that due dates can be off by as much as two weeks.
Intermountain’s Care Process Model on Elective Labor Induction, updated in 2017, was distributed to all obstetrical providers. Created by the Obstetrical Development Team of the Women and Newborns Clinical Program at Intermountain Healthcare, the guidelines are derived from Intermountain practice outcomes, expert consensus and recommendations of the American College of Obstetricians and Gynecologists.
The Care Process Model on Elective Labor Induction includes the evidence-based rationale for the guidelines, including data showing an increase in NICU admissions and ventilator usage in relation to gestational weeks. The guidelines spell out the steps in assessing whether a potential elective induction is medically indicated or not, and offer detailed notes along with each step on topics such as assessing gestational age, patient counseling, and contraindications and precautions.
For SelectHealth members who get their care in the Intermountain network, the rate of early elective inductions that are not medically necessary has dropped from 28 percent of all elective inductions in 2001, to zero today. This has resulted in shorter labors, fewer C-sections and cost savings of $2.5 million per year.
As a result of this successful initiative, SelectHealth has recently spread this model by creating Care Process Models for five surgical procedures: hip and knee replacements, spinal surgery, tonsillectomies and adenoidectomies, and hysterectomies. Similar to the financial sanctions imposed on unnecessary elective inductions, payment is also denied to providers who perform these procedures without authorization in cases that do not meet criteria.
1. Osterman, M.J.K, Martin, J.A. Recent Declines in Induction of Labor by Gestational Age. Centers for Disease Control and Prevention. NCHS Data Brief No. 155. June 2014. https://www.cdc.gov/nchs/products/databriefs/db155.htm
2. Oshiro, B.T., Henry, E., Wilson, J., Branch, D.W., Varner, M.W. Decreasing Elective Deliveries Before 39 Weeks of Gestation in an Integrated Health Care System. April 2009. Obstetrics & Gynecology, Vol. 113, No. 4. American College of Obstetrics and Gynecology.
CASE STUDY: Eliminate Inappropriate Early Inductions
Download a PDF of the "Eliminate Inappropriate Early Inductions" case study
INFOGRAPHIC: Eliminating Unnecessary Inductions
Physician engagement paired with financial incentives helped SelectHealth improve pregnancy outcomes