Early Elective Deliveries Accounted For Nearly 9 Percent Of Births Paid For By Medicaid

Preterm Birth and Other Measures of Infant Biological Vulnerability: Associations with Maternal Sensitivity and Infant Cognitive Development

INTRODUCTION

Low birth weight (LBW), biological vulnerability that includes preterm birth (PTB) and small for gestational age (SGA), is associated with reduced maternal sensitivity ("making accurate inferences about an infant's physical and emotional needs and responding appropriately") and impaired infant cognitive development. However, research does not examine if preterm birth, SGA, or both drive these associations. This study separated these measures of biological vulnerability to examine associations of LBW, PTB, and SGA with maternal sensitivity and infant cognitive development (controlling for maternal depression, breastfeeding, and demographic covariates).

METHODS

The sample included 6900 9-month-old infants from the Early Childhood Longitudinal Study-Birth Cohort and used birth certificate data, maternal interviews, assessments of maternal sensitivity and infant cognitive development. Multiple linear regressions examined LBW, PTB, and SGA associations with concurrent measures of maternal sensitivity and infant cognition.

RESULTS

Of the biological vulnerabilities, preterm birth had the strongest negative association with maternal sensitivity (F_1,6450 = 29.48 versus 15.33 and 5.51, ps < .001) and infant cognitive development (F_1,6450) = 390.65 versus 248.02 and 14.43, ps < .001). In the final regression model, preterm birth and maternal sensitivity were uniquely associated with infant cognitive development (R² = .05, p < .001), after controlling for maternal depression, breastfeeding, and demographics.

CONCLUSION

In this nationally representative infant sample infants, PTB had a stronger negative association with both maternal sensitivity and infant cognitive development in comparison to SGA or LBW. The LBW designation combines infants born preterm with SGA infants, potentially minimizing differences in developmental outcomes of PTB and SGA infants.

Screening for and Experiences of Intimate Partner Violence in the United States Before, During, and After Pregnancy, 2016-2019

Objectives. To measure rates of intimate partner violence (IPV) screening during the perinatal period among people experiencing physical violence in the United States. Methods. We used 2016-2019 Pregnancy Risk Assessment Monitoring System data (n = 158 338) to describe the incidence of physical IPV before or during pregnancy. We then assessed the prevalence of IPV screening before, during, or after pregnancy and predictors of receiving screening among those reporting violence. Results. Among the 3.5% (n = 6259) of respondents experiencing violence, 58.7%, 26.9%, and 48.3% were not screened before, during, or after pregnancy, respectively. Those reporting Medicaid or no insurance at birth, American Indian/Alaska Native people, and Spanish-speaking Hispanic people faced increased risk of not having a health care visit during which screening might occur. Among those attending a health care visit, privately insured people, rural residents, and non-Hispanic White respondents faced increased risk of not being screened. Conclusions. Among birthing people reporting physical IPV, nearly half were not screened for IPV before or after pregnancy. Public health efforts to improve maternal health must address both access to care and universal screening for IPV. (Am J Public Health. 2023;113(3):297-305. https://doi.org/10.2105/10.2105/AJPH.2022.307195).

Elective Deliveries and the Risk of Autism

INTRODUCTION

Cesarean section and induced deliveries have increased substantially in the U.S., coinciding with increases in autism spectrum disorder. Studies have documented associations between cesarean section deliveries and autism spectrum disorder but have not comprehensively accounted for medical risks. This study evaluates the extent to which cesarean section and induced deliveries are associated with autism spectrum disorder in low-risk births.

METHODS

In this retrospective cohort study, California's birth records (1992-2012) were linked to hospital discharge records to identify low-risk births using a stringent algorithm based on Joint Commission guidelines. Autism spectrum disorder status was based on California Department of Developmental Service data. Logistic regression models were used to estimate associations between autism spectrum disorder and induced vaginal deliveries, cesarean section deliveries not following induction, and cesarean section deliveries following induction, with noninduced vaginal deliveries as the reference category.

RESULTS

A total of 1,488,425 low-risk births took place in California from 1992 to 2012. The adjusted odds of autism spectrum disorder were 7% higher for induced vaginal deliveries (AOR=1.07, 95% CI=1.01, 1.14), 26% higher for cesarean section deliveries not following induction (AOR=1.26, 95% CI=1.19, 1.33), and 31% higher for cesarean section deliveries following induction (AOR=1.31, 95% CI=1.18, 1.45) than for noninduced vaginal deliveries. Lower gestational age and neonatal morbidities did not appear to be important underlying pathways. The associations were insensitive to alternative model specifications and across subpopulations. These results suggest that, in low-risk pregnancies, up to 10% of autism spectrum disorder cases are potentially preventable by avoiding cesarean section deliveries.

CONCLUSIONS

After accounting for medical risks, elective deliveries-particularly cesarean section deliveries-were associated with a substantially increased risk of autism spectrum disorder.

Severe Maternal Morbidity and Mortality Risk at the Intersection of Rurality, Race and Ethnicity, and Medicaid

OBJECTIVE

We examined differences in rates of severe maternal morbidity and mortality (SMMM) among Medicaid-funded compared with privately insured hospital births through specific additive and intersectional risk by rural or urban geography, race and ethnicity, and clinical factors.

METHODS

We used maternal discharge records from childbirth hospitalizations in the Health care Cost and Utilization Project's National Inpatient Sample from 2007 to 2015. We calculated predicted probabilities using weighted multivariable logistic regressions to estimate adjusted rates of SMMM, examining differences in rates by payer, rurality, race and ethnicity, and clinical factors. To assess the presence and extent of additive risk by payer, with other risk factors, on rates of SMMM, we estimated the proportion of the combined effect that was due to the interaction.

RESULTS

In this analysis of 6,357,796 hospitalizations for childbirth, 2,932,234 were Medicaid funded and 3,425,562 were privately insured. Controlling for sociodemographic and clinical factors, the highest rate of SMMM (224.9 per 10,000 births) occurred among rural Indigenous Medicaid-funded births. Medicaid-funded births among Black rural and urban residents, and among Hispanic urban residents, also experienced elevated rates and significant additive interaction. Thirty-two percent (Bonferroni-adjusted 95% confidence interval, 19%-45%) of SMMM cases among patients with chronic heart disease were due to payer interaction, and 19% (Bonferroni-adjusted 95% confidence interval, 17%-22%) among those with cesarean birth were due to the interaction.

CONCLUSIONS

Heightened rates of SMMM among Medicaid-funded births indicate an opportunity for tailored state and federal policy responses to address the particular maternal health challenges faced by Medicaid beneficiaries, including Black, Indigenous, and rural residents.

The impact of voluntary and nonpayment policies in reducing early-term elective deliveries among privately insured and Medicaid enrollees

OBJECTIVE

To assess the impact of a voluntary pledge policy and a mandatory nonpayment policy on reducing early-term elective deliveries among privately insured and Medicaid-enrolled individuals.

DATA SOURCES/STUDY SETTING

Birth certificate data from 2009 to 2015, from South Carolina and 16 control states.

STUDY DESIGN

We use a difference-in-differences approach to test the impact of two different policy types. Outcomes include the probability of an early elective delivery, gestation time, and birthweight.

PRINCIPAL FINDINGS

The voluntary pledge and mandatory nonpayment policy reduced overall EED rates from 13.1 to 11.4 (-12.7 percent, [P < .05]), and 10.9 ([-16.6 percent, P < .05]), respectively. Compared to the privately insured, we found greater relative decreases in Medicaid EED rate, the proportion of Medicaid births occurring before 39 weeks, and the proportion of Medicaid babies born with low birthweight.

CONCLUSIONS

Both voluntary and mandatory nonpayment policies are effective in reducing the rate of EEDs, especially among Medicaid enrollees. Given the high costs and poor outcomes associated with EEDs, policy makers may consider using either tool as a way to improve care value.

Evaluation of a Tennessee statewide initiative to reduce early elective deliveries using quasi-experimental methods

BACKGROUND

Concerted quality improvement (QI) efforts have been taken to discourage the practice of early elective deliveries (EEDs), but few studies have robustly examined the impact of directed QI interventions in reducing EED practices. Using quasi-experimental methods, we sought to evaluate the impact of a statewide QI intervention to reduce the practice of EEDs.

METHODS

Retrospective cohort study of vital records data (2007 to 2013) for all singleton births occurring ≥36 weeks in 66 Tennessee hospitals grouped into three QI cohorts. We used interrupted-time series to estimate the effect of the QI intervention on the likelihood of an EED birth statewide, and by hospital cohort. We compared the distribution of hospital EED percentages pre- and post-intervention. Lastly, we used multivariable logistic regression to estimate the effect of QI interventions on maternal and infant outcomes.

RESULTS

Implementation of the QI intervention was associated with significant declines in likelihood of EEDs immediately following the intervention (odds ratio, OR = 0.72; p < 0.001), but these results varied by hospital cohort. Hospital risk-adjusted EED percentages ranged from 1.6-13.6% in the pre-intervention period, which significantly declined to 2.2-9.6% in the post-intervention period (p < 0.001). The QI intervention was also associated with significant reductions in operative vaginal delivery and perineal laceration, and immediate infant ventilation, but increased NICU admissions.

CONCLUSIONS

A statewide QI intervention to reduce EEDs was associated with modest but significant declines in EEDs beyond concurrent and national trends, and showed mixed results in related infant and maternal outcomes.

Elective Deliveries and Neonatal Outcomes in Full-Term Pregnancies

Cesarean and induced delivery rates have risen substantially in recent decades and currently account for over one-third and one-fourth of US births, respectively. Initiatives to encourage delaying deliveries until a gestational age of 39 weeks appear to have slowed the increases but have not led to declines. The rates are at historic highs and the consequences of these interventions when not medically necessary have not been systematically explored at the population level. In this study, we used population-level data on births in New Jersey (1997-2011) to document trends in elective deliveries (induced vaginal delivery, cesarean delivery with no labor trial, and cesarean delivery after induction) and estimate logistic and linear regression models of associations between delivery method and neonatal morbidities and cost-related outcomes in low-risk pregnancies. We found that elective deliveries more than doubled during the observation period and were associated with neonatal morbidities and cost-related outcomes even at gestational ages of 39 and 40 weeks. Findings suggest that delaying beyond 39 weeks and avoiding delivery interventions when not medically necessary would improve infant health and reduce health-care costs.

Early Elective Delivery Disparities between Non-Hispanic Black and White Women after Statewide Policy Implementation

BACKGROUND

In 2011, Oregon implemented a policy that reduced the state's rate of early (before 39 weeks' gestation) elective (without medical need) births.

OBJECTIVE

This analysis measured differential policy effects by race, examining whether Oregon's policy was associated with changes in non-Hispanic Black-White disparities in early elective cesarean and labor induction.

METHODS

We used Oregon birth certificate data, defining prepolicy (2008-2010) and postpolicy (2012-2014) periods, including non-Hispanic Black and White women who gave birth during these periods (n = 121,272). We used longitudinal spline models to assess policy impacts by race and probability models to measure policy-associated changes in Black-White disparities.

RESULTS

We found that the prepolicy Black-White differences in early elective cesarean (6.1% vs. 4.3%) were eliminated after policy implementation (2.8% vs. 2.5%); adjusted models show decreases in the odds of elective early cesarean among Black women after the policy change (adjusted odds ratio, 0.47; 95% confidence interval, 0.22-1.00; p = .050) and among White women (adjusted odds ratio, 0.79; 95% confidence interval, 0.67-0.93; p = .006). Adjusted probability models indicated that policy implementation resulted in a 1.75-percentage point narrowing (p = .011) in the Black-White disparity in early elective cesarean. Early elective induction also decreased, from 4.9% and 4.7% for non-Hispanic Black and non-Hispanic White women to 3.8% and 2.5%, respectively; the policy was not associated with a statistically significant change in disparities.

CONCLUSIONS

A statewide policy reduced racial disparities in early elective cesarean, but not early elective induction. Attention to differential policy effects by race may reveal changes in disparities, even when that is not the intended focus of the policy.

Texas Medicaid Payment Reform: Fewer Early Elective Deliveries And Increased Gestational Age And Birthweight

Infants born at full term have better health outcomes. However, one in ten babies in the United States are born via a medically unnecessary early elective delivery: induction of labor, a cesarean section, or both before thirty-nine weeks gestation. In 2011 the Texas Medicaid program sought to reduce the rate of early elective deliveries by denying payment to providers for the procedure. We examined the impact of this policy on clinical care practice and perinatal outcomes by comparing the changes in Texas relative to comparison states. We found that early elective delivery rates fell by as much as 14 percent in Texas after this payment policy change, which led to gains of almost five days in gestational age and six ounces in birthweight among births affected by the policy. The impact on early elective delivery was larger in magnitude for minority patients. Other states may look to this Medicaid payment reform as a model for reducing early elective deliveries and disparities in infant health.

Achieving higher-value obstetrical care

Obstetrical care in the United States is unnecessarily costly. Birth is 1 of the most common reasons for healthcare use in the United States and 1 of the top expenditures for payers every year. However, compared with other Organization for Economic Cooperation and Development countries, the United States spends substantially more money per birth without better outcomes. Our team at the Clinical Excellence Research Center, a center that is focused on improving value in healthcare, spent a year studying ways in which obstetrical care in the United States can deliver better outcomes at a lower cost. After a thoughtful discovery process, we identified ways that obstetrical care could be delivered with higher value. In this article, we recommend 3 redesign steps that foster the delivery of higher-value maternity care: (1) to provide long-acting reversible contraception immediately after birth, (2) to tailor prenatal care according to women's unique medical and psychosocial needs by offering more efficient models such as fewer in-person visits or group care, and (3) to create hospital-affiliated integrated outpatient birth centers as the planned place of birth for low-risk women. For each step, we discuss the redesign concept, current barriers and implementation solutions, and our estimation of potential cost-savings to the United States at scale. We estimate that, if this model were adopted nationally, annual US healthcare spending on obstetrical care would decline by as much as 28%.

Worth the Wait? The Effect of Early Term Birth on Maternal and Infant Health

Early term birth is defined as birth at 37 or 38 weeks gestation. While infants born early term are not considered premature, the medical literature suggests that they have an increased risk of serious adverse health outcomes compared to infants born at term (39 or 40 weeks). Despite these known harms, we document a rise in early term births in the United States from 1989 to the mid-2000s, followed by a decline in recent years. We posit that the recent decline in early term births has been driven by changes in medical practice advocated by the American College of Obstetricians and Gynecologists, programs such as the March of Dimes’ "Worth the Wait" campaign, and by Medicaid policy. We first show that this pattern cannot be attributed to changes in the demographic composition of mothers, and provide some evidence that efforts to reduce early term elective deliveries (EEDs) through Medicaid policy were effective. We next exploit county-level variation in the timing of these changes in medical practice to examine the effect of early term inductions (our proxy for EEDs) on infant and maternal health. We find that early term inductions lower birth weights and increase the risks of precipitous labor, birth injury, and required ventilation. Our results suggest that reductions in early term inductions can explain about one-third of the overall increase in birth weights between 2010 and 2013 for births at 37 weeks gestation and above.

Rural Implications of Expanded Birth Volume Threshold for Reporting Perinatal Care Measures

BACKGROUND

In 2016 the minimum annual birth volume threshold for required reporting of the Joint Commission Perinatal Care measures by accredited hospitals decreased from 1,100 to 300 births.

METHODS

Publicly available Joint Commission Quality Check data from April 2014 to March 2015 for three Perinatal Care measures were linked to Medicare Provider of Services and American Hospital Association Annual Survey data. For each measure, hospital-level reporting and performance among accredited hospitals providing obstetric care were compared using Fisher's exact tests.

RESULTS

Sixty-seven percent of the 2,396 accredited hospitals with obstetric services reported at least one eligible patient for two of the four reported Perinatal Care measures: Elective delivery and exclusive breast milk feeding. Fewer hospitals (35.0%) had data on the antenatal steroids measure; many hospitals may not have any eligible patients for this measure. Hospitals with higher birth volume, those in urban counties, and those with private, nonprofit ownership or system affiliation were more likely to report the perinatal measures (p < 0.001). Across states, reporting rates varied considerably. By hospital volume, performance varied more on the antenatal steroids measure (78.0% to 91.5%) than on the breast milk feeding measure (48.4% to 49.5%) and the elective delivery measure (2.5% to 3.0%).

CONCLUSIONS

Expansion of the minimum birth volume threshold nearly doubles the number of accredited hospitals required to report the Perinatal Care measures to The Joint Commission. However, 485 accredited hospitals with obstetric services that are either critical access hospitals or have fewer than 300 births annually are still exempt from reporting. Although many rural hospitals remain exempt from reporting requirements, the measures offer an opportunity for both rural and urban hospitals to assess and improve care.