Determining the rate of elective deliveries before 39 weeks of gestation: methodology matters.

Abundant evidence suggests that neonates delivered during the early-term period (before 39 weeks of gestation) have a small but significantly increased risk of morbidity. In an effort to reduce preventable adverse outcomes, there has been growing momentum aimed at eliminating elective deliveries before 39 weeks of gestation. One of the strategies to accomplish the goal is public reporting of institutional rates. Several organizations and institutions have developed measures to report early elective delivery rates. Methodology used to derive currently reported rates varies considerably. There are differences in how an elective compared with an indicated delivery is defined. There are also differences in the denominator used to calculate the rate, ranging from all of an institution's deliveries to a subset of deliveries occurring between 37 0/7 and 38 6/7 weeks of gestation. The former denominator will give a much smaller rate than the latter despite both having the same number of elective early-term deliveries. These variations make comparison of reported rates all but impossible. In this commentary, we describe several of the currently used methodologies and their effect on reported rates to make a case for standardization. It is our opinion that the Joint Commission methodology using a large list of International Classification of Diseases, 9th Revision codes to define indications for acceptable early-term deliveries and a defined subset of 37- and 38-week deliveries for the denominator combined with a requirement for validation of the reported data is the best method available at this time.

Standardizing criteria for scheduling elective labor inductions.

Induction of labor has become routine practice in perinatal units across the United States, with rates reaching a high of 21.2% of births in 2003-2004. This article describes the process our institution used to standardize the criteria for scheduling inductions. Specifically, we aimed to increase the consistency in practice for scheduling and performing elective inductions, including mandating gestational age of 39 completed weeks, ensuring cervical ripeness, and disallowing the use of cervical ripening agents. The nurses' participation, from planning to implementation, was critical in the success of this evidence-based practice change.

Abuse and psychosocial stress as factors in high utilization of medical services during pregnancy.

High utilization of medical services during pregnancy has not been described as most studies have focused on women who receive inadequate or no prenatal care. This paper describes the characteristics and medical utilization data of 500 pregnant women enrolled in a prospective study. High utilizers (HU), who had a mean of 7.8 utilizations (SD = 3.2), were significantly more likely to be nonwhite, low income, and younger than low utilizers (LU) who had a mean of 0.99 utilizations (SD = 1.1). HU reported a 32% rate of recent abuse compared to 9% for LU. HU also reported significantly more stress, lower self-esteem, and more ambivalence about the pregnancy. Consistent with their higher utilization, they were more likely to be diagnosed with preterm labor, hyperemesis, and gestational diabetes. HU had a higher proportion of complaints of nausea, vomiting, diarrhea, and pain and more mental health diagnoses than LU. Overall, HU were a vulnerable group characterized by recent abuse, economic disadvantage, psychosocial stress, and mental health issues. Their high utilization of medical services may have been due in large part to unmet psychosocial needs.

Nurse case management for pregnant women experiencing or at risk for abuse.

OBJECTIVE: To determine whether individualized nursing case management can decrease stress among pregnant women at risk for or in abusive relationships. DESIGN: A multisite randomized controlled trial. SETTING: Two prenatal clinics in the Pacific Northwest and rural Midwest. PARTICIPANTS: 1,000 women who spoke English and were 13 to 23 weeks pregnant at time of recruitment. INTERVENTION: All intervention group women (N = 499) were offered an abuse video and had access to a nurse case manager 24/7. Additionally, participants at risk for or in abusive relationships received individualized nursing care management throughout the pregnancy. RESULTS: The most frequent nursing care management activities were providing support (38%) and assessing needs (32%). The nursing care management group received an average of 22 contacts, most (80%) by telephone and had a significant reduction in stress scores as measured by the Prenatal Psychosocial Profile. Compared to the control group, the differences were in the predicted direction, but not statistically different. A major finding was the choice by abused women to focus on basic needs and their pregnancies rather than the abuse, although all received safety planning. CONCLUSIONS: Pregnant women at risk for or in abusive relationships experience very stressful and complex lives. Nurses need to focus on the needs they identify, which may not be the abusive relationship.