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The Excess Morbidity and Cost of Elective Planned Delivery

Elective planned delivery before 39 weeks’ gestation is associated with significantly increased neonatal morbidity and excess cost.

Elective planned deliveries — including induction of labor for anticipated vaginal delivery and repeat cesarean delivery — have increased in frequency for medical reasons and for the convenience of physicians and patients. The American College of Obstetrics and Gynecology (ACOG) advocates restricting elective term delivery to women with confirmed gestational age of 39 weeks and states that "cesarean delivery on maternal request should not be performed before gestational age of 39 weeks has been accurately determined unless there is documentation of lung maturity" (Obstet Gynecol 2007; 110:1501). However, concerns exist that this precept is not strictly followed, resulting in increased neonatal morbidity.

In a recent U.S. study of about 13,250 term elective repeat cesarean deliveries, 36% were performed before 39 weeks’ gestation (N Engl J Med 2009; 360:111). Delivery before 39 weeks was associated with significantly increased risk for neonatal morbidity, including admission to a neonatal intensive care unit (NICU) and hospitalization for >5 days (adjusted odds ratios at 37 and 38 weeks, 2.1 and 1.5, respectively). Women who delivered before 39 weeks were more likely than those who delivered later to be married, to be white, to undergo early prenatal ultrasound, and to be privately insured. The authors estimated that postponing elective cesarean delivery from 37 to 39 weeks might prevent 48% of adverse-outcome cases and that postponing from 38 to 39 weeks might prevent 27% of cases. An editorialist opined that mothers who delivered before 39 weeks likely were private patients who requested that their own obstetricians perform deliveries. In turn, obstetricians honored such requests to promote patient satisfaction. The editorialist speculates that even if the optimal strategy for elective delivery could be defined, overcoming patients’ wishes would be difficult (N Engl J Med 2009; 360:183).

In another study, investigators examined neonatal morbidity associated with elective term delivery among nearly 17,800 deliveries at 27 U.S. hospitals in 14 states in 2007 (JW Pediatr Adolesc Med Mar 25 2009). About 84% of deliveries (15,000) were at term (37 weeks’ gestation), 44% of term deliveries were planned, and 71% of planned deliveries were elective (without medical reason for early delivery). Nearly 10% (161 of 1712) of planned elective deliveries at <39 weeks resulted in NICU admissions compared with 5% (136 of 2933) at 39 weeks (mean duration of stay, 4.6 days). The authors are developing guidelines to curtail elective delivery before 39 weeks’ gestation. They attribute noncompliance with ACOG guidelines to "normalization of deviance" — the continuation of unsound practice as a result of anecdotal favorable experience. For example, if obstetricians deliver about 200 infants annually, each obstetrician would deliver an infant who requires NICU care because of early delivery every 3 to 4 years, and this might not be attributed to the early delivery.

Based on these data, if planned elective deliveries at <39 weeks were delayed to 39 weeks, about half could have been prevented. Based on a mean NICU stay of 4.6 days, delaying delivery might prevent 377 days in the NICU. If we assume that these data are nationally representative, an excess NICU admissions rate of 5.5 per 1000 live births for a mean of 4.6 days would result in an estimated 25 excess days per 1000 term deliveries. Nationally, with an estimated 4 million term deliveries per year, this translates to 22,000 excess admissions annually and 100,800 excess NICU days at an estimated excess cost of US$252 million (based on an NICU cost of $2500/day).

This calculation does not take into account additional costs of follow-up care, professional fees, family expenses, or long-term morbidity. In view of soaring medical costs, such unnecessary excessive cost is hard to reconcile. Health planners are evaluating the cost of providing universal coverage for the American population and hope to pay for this by reducing administrative costs and improving patient care. Elective planned delivery performed without medical indication is a practice that warrants scrutiny.

The obstetrical community is developing programs to reduce elective inductions (http://www.ajog.org/article/S0002-9378(09)00210-5/abstract). Pediatricians need to support this effort and work with our obstetrical colleagues to develop medical staff guidelines to identify iatrogenic NICU admissions and enforce ACOG guidelines. Legitimate medical reasons for planned term deliveries are not part of the problem, but excess morbidity and cost associated with elective deliveries without medical indication are worrisome. In an era when payers are refusing to cover iatrogenic complications, such as nosocomial infections, could third-party payers refuse to pay for NICU admissions that could have been avoided?

— William P. Kanto, Jr., MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 27, 2009

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