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A Multistate Quality Improvement Program to Decrease Elective Deliveries Before 39 Weeks of Gestation

Oshiro, Bryan T. MD; Kowalewski, Leslie BS; Sappenfield, William MD, MPH; Alter, Caroline C. MS; Bettegowda, Vani R. MHS; Russell, Rebecca MSPH; Curran, John MD; Reeves, Lori MPH; Kacica, Marilyn MD, MPH; Andino, Nelson MPA; Mason-Marti, Peyton MPH; Crouse, Dennis MD, PhD; Knight, Susan MA; Littlejohn, Karen MMHS; Malatok, Sharyn MPA; Dudley, Donald J. MD; Berns, Scott D. MD, MPH

doi: 10.1097/AOG.0b013e31828ca096
Original Research
Annual Awards

OBJECTIVE: Nonmedically indicated (elective) deliveries before 39 weeks of gestation result in unnecessary neonatal morbidity. We sought to determine whether implementation of a process improvement program will decrease the rate of elective scheduled singleton early-term deliveries (37 0/7–38 6/7 weeks of gestation) in a group of diverse community and academic hospitals.

METHODS: Policies and procedures for scheduling inductions and cesarean deliveries were implemented and patient and health care provider education was provided. Outcomes for scheduled singleton deliveries at 34 weeks of gestation or higher were submitted through a web-based data entry system. The rate of scheduled singleton elective early-term deliveries as well as the rates of early-term medically indicated and unscheduled deliveries, neonatal intensive care unit admissions, and singleton term fetal mortality rate were evaluated.

RESULTS: A total of 29,030 scheduled singletons at 34 weeks of gestation or higher were delivered in 26 participating hospitals between January 2011 and December 2011. Elective scheduled early-term deliveries decreased from 27.8% in the first month to 4.8% in the 12th month (P<.001); rates of elective scheduled singleton early-term inductions (72%, P=.029) and cesarean deliveries (84%; P<.001) decreased significantly. There was no change in medically indicated or unscheduled early-term deliveries. Neonatal intensive care unit admissions among scheduled early-term singletons decreased nonsignificantly from 1.5% to 1.2% (P=.24). There was no increase in the term fetal mortality rate.

CONCLUSION: A rapid-cycle process improvement program substantially decreased elective scheduled early-term deliveries to less than 5% in a group of diverse hospitals across multiple states.


Supplemental Digital Content is Available in the Text.A comprehensive rapid-cycle process improvement program can be effective in eliminating elective deliveries before 39 weeks of gestation in a group of diverse hospitals.

Loma Linda University School of Medicine, Loma Linda, California; the University of South Florida College of Public Health and College of Medicine, Tampa, Florida; the New York State Department of Health, Albany, New York; the University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, Texas; Carle Foundation Hospital, Urbana, Illinois; and the March of Dimes, National Office, White Plains, New York, California Chapter, San Francisco, California, Florida Chapter, Maitland, Florida, Illinois Chapter, Chicago, Illinois, New York Chapter, New York, New York, and Texas Chapter, Houston, Texas.

Corresponding author: Bryan T. Oshiro, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, 11234 Anderson Street, Suite 3400, Loma Linda, CA 92350; e-mail:

Financial Disclosure Ms. Kowalewski, Ms. Alter, Ms. Bettegowda, Ms. Russell, Ms. Reeves, Mr. Andino, Ms. Mason-Marti, Ms. Knight, Ms. Littlejohn, and Dr. Berns are employed by the March of Dimes. The other authors did not report any potential conflicts of interest.

Funded by the March of Dimes Foundation.

The authors thank Gerald Carrino, PhD, MPH, and Jennifer Howse, PhD (March of Dimes Foundation), for editorial assistance, Karalee Poschman, MPH, and Julie Solomon, PhD (J. Solomon Consulting, LLC), for technical assistance with the surveys, Todd Dias, MS, for assistance with the statistical analysis, and the California Department of Public Health and the California Maternal Quality Care Collaborative for collaborating on the development of the Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age Toolkit.

© 2013 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.