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| choosing wisely, USA |
Choosing Wisely campaign[1]
was launched in April 2012 by the American Board of Internal Medicine
Foundation, Consumer Reports, and nine medical specialty societies in
guiding physician towards wise management of healthcare resources and to
encourage patients to have conversation with physician about unnecessary tests,
procedures and care.
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| Saving Healthcare Resources |
The campaign released a list of “Top
Five” lists from nine founding specialty societies. Today More than 70
societies comprising over one million clinicians are now partners of the Choosing
Wisely campaign.[2]
American
College of Obstetricians and Gynecologists (ACOG)released a list of 10 ‘ Do’
and ‘Don’t’ for the physicians in February 21, 2013 and updated it again on August
24, 2016.
The first in
the list is “Don’t schedule
elective, non-medically indicated inductions of labor or Cesarean deliveries
before 39 weeks 0 days’ gestational age.”
ACOG and Choosing Wisely strongly
advises against elective delivery before 39 weeks as it is associated with
increase in cognitive disorders and morbidity in the newborn. It further adds
that delivery before 39 weeks should be only carried out based on clear
indication that favors positive outcome for mother and fetus. A fetal lung
maturity in the absence of clear indication is not the reason for delivering
the baby.
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| The '39 weeks rule' |
The 39-week rule is now a strict
clinical guideline that is enforced by professional organizations, governmental
agencies and the medical insurance industry in US.
In November 2013, ACOG and
Society for Maternal and Fetal medicine(SMFM) made a recommendation of replacing
the use of “term” pregnancy which accommodated gestations between 37 wks
to 42 wks with the following designations:[3]
• Early term: 37 weeks through
38 weeks and 6 days
• Full term: 39 weeks
through 40 weeks and 6 days
• Late term: 41 weeks
through 41 weeks and 6 days
• Postterm: 42 weeks and
beyond
These changes were made by growing
research evidence, a part of which has been led by Eunice Kennedy ShriverNational Institute of Child Health and Human Development, indicating that
key developmental process for the fetus continue well beyond 37 weeks till 39 weeks.
They also advocated that “Babies born at or after 39 weeks have the best chance
at healthy outcomes compared to those born before 39 weeks.”
It was seen that the percentage of infants born preterm declined for
the seventh straight year in 2013. The NIH also published a report that
shows a decline in induction of labor for singleton birth in year 2011 (23.7%) and
2012 (23.3%), after 20 years of consecutive increases. There was also a decline
in Early Elective Deliveries across the UnitedStates, from 17% of babies in the United States were delivered before 39
weeks in 2010 to a sharp decline to 4.6% in 2013.
But many researchers and clinicians
across US are not in favor of strict implementation of the ‘39 weeks rule.’
Dr. Baxi from New York University
Langone Medical Center in New York City opined that timing of delivery is
refined decision depending on many variable and it should be individualized per
the circumstances and not governed by a rule.
Dr J.Nicholson is a strict opponent
of ’39 weeks rule’ and says “the 39-week rule is not supported by
high-quality evidence, its strict application unjustifiably obstructs patient
autonomy, and it may actually cause harm in the form of early-term stillbirth.
Because of these problems, the 39-week rule should be modified, made optional,
or withdrawn. Patients should be able to request and receive early-term labor
induction if they believe that such an intervention is in the best interest of
themselves and/or their fetus.”[4]
