Did you know there are organizations out there that work to set checks and balances for our system of medical professionals? The ABIM Foundation, founded by the American Board of Internal Medicine, has made it their mission to enhance quality of care by encouraging regular assessment and improvement of our physicians, bringing diverse groups and leaders together, and promoting research. In line with their mission, ABIM Foundation developed the Choosing Wisely® initiative. Choosing Wisely aims to promote conversations between physicians and patients by helping patients choose care that is:
- Supported by evidence
- Not duplicative of other tests or procedures already received
- Free from harm
- Truly necessary
As a result, ABIM developed a list, with input from national medical organizations, of “Five Things Physicians and Patients Should Question.” The idea is that these lists (separated by medical specialty) will spark discussion about the need—or lack thereof—for many frequently ordered tests or treatments. This is great news for us as consumers — what more do we want than transparency with our care? We want to know if the test or treatment that’s been prescribed is truly necessary and helpful. We also want to know the risks, weighed properly against the benefits. With regard to maternity care, Choosing Wisely developed the following recommendations:
Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks 0 days gestational age.Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.
Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.Ideally, labor should start on its own initiative whenever possible. Higher Cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.
Considering the high rates of elective inductions, often prior to 39 weeks, these recommendations are a breath of fresh air. Of course, this is not the first stand that has been taken against unnecessary inductions (the American College of Obstetricians, ACOG, has included this directive for some time). But with these particular recommendations, there is added stress on the importance of not inducing unless there is a favorable cervix, and the added emphasis that “labor should start on its own initiative.”
While these recommendations represent a healthy step forward in improving our maternity care, there are some concerns about how they could be misunderstood. In a review of these guidelines on the Lamaze blog, Science & Sensibility, Amy Romano of Childbirth Connection questions, “will the new message lead women and care providers to think that delivery is indicated once a woman’s cervix is ripe?” In other words, Romano cautions:
The best indicator of readiness is still the spontaneous onset of labor at term, the culmination of an intricate interplay of hormonal signals between the fetus and the woman. Anytime we intervene with the timing of birth we have to weigh the potential benefits and harms of overriding that process in the context of the fully informed preferences and values of women.
Have you experienced pressure to induce? What did you do? How did you discuss it with your care provider?