Non-Medically Indicated Early Deliveries(NMIED) in Illinois

Using Birth Certificate Data, 2010-2012 Julia Howland, MPH

Amanda Bennett, MPH Deborah Rosenberg, PhD

IL Department of Public Health

Division of Patient Safety and Quality Office of Women's Health, Title V Maternal and Child Health Program

UIC School of Public Health

Division of Epidemiology and Biostatistics

The Context for Perinatal Quality Improvement in Illinois

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• Illinois ranks in the bottom half of all 50 states and DC in rates of low birthweight, preterm delivery, and infant mortality

• The black/white disparity in infant mortality is highest in the Region V states—Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin

• In Illinois, the black / white disparity in infant mortality is 2.48

The Context for Perinatal Quality Improvement in Illinois

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• Approximately two-thirds of births in Illinois occur at 39 weeks gestation or later

• One quarter of births occur at 37 or 38 weeks;

• The rate of preterm birth is approximately 8%.

Gestational Age Distribution Illinois Singleton Live Births, 2012

Preterm Term TOTAL

< 34 Wks 34-36 Wks 37-38 Wks >= 39 Wks

2,965 2.0%

8,565 5.8%

36,568 24.6%

100,727 67.7%

148,825 100%

Gestational Age Distribution, Illinois Singleton Live Births, 2012 by Maternal Race

Race Preterm Term TOTAL

<34 Wks 34-36 Wks 37-38 Wks >=39 Wks

White 1,156 1.5%

4,134 5.3%

18,274 23.2%

55,184 70.1%

78,748

Black 978 3.8%

1,877 7.3%

6,797 26.4%

16,058 62.5%

25,710

Hispanic/ Latina

653 1.9%

1,975 5.9%

8,572 25.5%

22,446 66.7%

33,646

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The Context for Perinatal Quality Improvement in Illinois

Racial disparity is evident across the gestational age distribution.

Gestational Age Components of Excess Infant Mortality in Region V Compared to All Other Regions,

2007-2009

The excess infant mortality in IL was almost entirely due to higher rates of very preterm birth—the gestational age distribution.

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OH MI IN IL WI MN Total

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due to gestational agedistribution

due to higher mortalityamong preterm infants

due to higher mortalityamong term infants

Focus on Non-Medically Indicated Early Deliveries (NMIED)

• Joint Commission National Quality Measure

• Quality Improvement initiatives by many partners

• As part of the federal CoIIN to Reduce Infant Mortality, states are using vital records data to enrich our understanding of the extent of the problem and to monitor improvement over time

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Identifying NMIED: Methods

• Algorithm for identifying EED using birth certificates is being promulgated nationally, authored by Dr. William Sappenfield

• Analysis includes only women who are considered "at risk" for a non-medically indicated delivery at 37-38 weeks gestation

• Gestational age determined by clinical estimate of gestation on birth certificate

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Identifying NMIED: Methods • General Exclusions:

– Preterm Births (<37 weeks) – Multiple births – Non-resident and Out-of-State births

• Exclusions Based on Medical Indication:

– women with: hypertension (including chronic, gestational, and eclampsia), diabetes (including chronic and gestational), or previous poor pregnancy outcomes

– births with: non-vertex presentation at birth, anencephaly, meningomyelocele/spina bifida, down syndrome, suspected chromosomal disorder, cyanotic congenital heart disease, diaphragmatic hernia, omphalocele, or gastroschisis

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• Indications for early delivery (inclusions):

– Premature rupture of membranes

– Prolonged labor

– Fetal distress

– Abnormal fetal heart rate

– Chorioamnionitis

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Identifying NMIED: Methods

Identifying NMIED: Methods Numerator:

Births delivered at 37-38 weeks gestation after non-indicated induced labor or a cesarean section with no trial of labor

Denominator Choices After Exclusions:

1. All term deliveries (≥37 weeks)

2. All early term deliveries (37-38 weeks)

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Non-Medically Indicated Early Delivery (37-38 Weeks Gestation)

Select Results for IL Overall

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29.5% 27.4%

25.0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

2010 2011 2012

% E

arly

Te

rm B

irth

s w

ith

no

MI

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation) In Illinois

Among Early Term Births

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0%

5%

10%

15%

20%

25%

30%

35%

40%

2010 2011 2012

% E

arly

Te

rm B

irth

s w

ith

no

MI

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation) by Payer In Illinois

Among Early Term Births

Medicaid

Private

Self-Pay

13

0%

5%

10%

15%

20%

25%

30%

35%

40%

2010 2011 2012

% E

arly

Te

rm B

irth

s w

ith

no

MI

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation) by Region In Illinois

Among Early Term Births

Cook County

Collar Counties

Other UrbanCounties

Rural Counties

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0%

5%

10%

15%

20%

25%

30%

35%

40%

2010 2011 2012

% E

arly

Te

rm B

irth

s w

ith

no

MI

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation) by Race/Ethnicity In Illinois

Among Early Term Births

White

Black

Latina

15

0%

5%

10%

15%

20%

25%

30%

35%

40%

Cook County CollarCounties

Other UrbanCounties

Rural Counties

% E

arly

Te

rm B

irth

s w

ith

no

MI

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation) by Region and Race/Ethnicity

In Illinois, 2012 Among Early Term Births

White

Black

Latina

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22.0%

13.7%

21.7% 24.3% 25.2%

27.2%

32.4%

24.6%

30.1% 27.1%

0%

5%

10%

15%

20%

25%

30%

35%

40%

% E

arly

Te

rm B

irth

s w

ith

no

MI

Perinatal Network

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation) by Perinatal Network In

Illinois, 2012 Among Early Term Births

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0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

2010 2011 2012

% E

arly

Te

rm B

irth

s w

ith

no

MI

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation) by Perinatal Network In Illinois,

2012 Among Early Term Births

#1 - U of C

#2 - Stroger

#3 - Northwestern

#4 - U of I

#5 - Loyola

#6 - Rush

#7 - Rockford

#8 - St. Francis

#9 - St. John

#10 - Card Glennon

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26.5% 25.3%

22.2%

26.6%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Level I Level II Level II+ Level III

% E

arly

Te

rm B

irth

s w

ith

no

MI

Hospital Perinatal Level

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation) by Perinatal Level In

Illinois, 2012 Among Early Term Births

19

0%

5%

10%

15%

20%

25%

30%

35%

40%

2010 2011 2012

% E

arly

Te

rm B

irth

s w

ith

no

MI

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation) by Perinatal Level In

Illinois Among Early Term Births

Level III

Level II+

Level II

Level I

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21.4% 19.3% 17.3%

77.1% 73.7%

71.1%

90.7% 90.0% 89.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2011 2012

% E

arly

Te

rm B

irth

s w

ith

no

MI

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation) by Previous C-Section Status In

Illinois Among Early Term Births

No prior c-sections

1 prior c-section

2+ prior c-sections

Non-Medically Indicated Early Delivery (37-38 Weeks Gestation)

Data Sheet for Each Hospital

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0%

10%

20%

30%

40%

50%

60%

% N

MIE

D a

t 3

7-3

8 w

ks g

est

atio

n

Example: Percent Non-Medically Indicated Elective Deliveries (NMIED) at 37-38 weeks gestation By Illinois Hospital and Perinatal Level, 2012

Level III Level II+ Level II Level I

Your Hospital

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0%

10%

20%

30%

40%

50%

60%

2010 2011 2012

% N

MIE

D a

t 3

7-3

8 w

ks g

est

atio

n

Year

Example: Percent Non-Medically Indicated Elective Deliveries (NMIED) at 37-38 weeks gestation, 2010-2012

Illinois Overall

PerinatalNetwork

Your Hospital

Looking forward...

• Commitment to continued use of data to contribute to perinatal quality improvement initiatives:

– Facilitate the use and reporting of timely data

– Produce more refined look at NMIED

– Update the IL Breastfeeding Blueprint

– Provide epidemiologic analysis of other perinatal quality issues as requested by ILPQC, PAC, or others

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