The Choosing Wisely and Strong Start campaigns
In 2011 the American Board of Internal Medicine and Consumer Reports started an initiative entitled “Choosing Wisely.” It grew out of of an article published by Dr. Howard Brody on “Medicine’s Ethical Responsibility for Healthcare Reform – The Top Five List.” He suggested that each medical specialty carefully evaluate the top 5 areas of reform in their particular specialty. Over 25 medical specialties have now joined in the campaign. I want to focus on the ACOG (American College of Obstetrics and Gynecology) top 5 areas that needed reform.
The first and most widely published reform is shared by ACOG, The American Academy of Family Physicians, and The American Academy of Pediatricians. It is entitled the “Strong Start” program. It states that “Non-medically indicated deliveries should not be performed prior to 39 weeks of gestation.” This statement is also strongly supported by The American College of Nurse Midwifery, The American Hospital Association, and the March of Dimes.
In essence, babies should not be induced or delivered unnecessarily prior to 39 weeks unless absolutely medically necessary for the welfare of the infant or mother. This statement arose out of another very comprehensive study also published in the New England Journal of Medicine by Dr. Alan Tita that very clearly demonstrated a significant detriment to infants born before 39 weeks compared to those born after 39 weeks of gestation. By far the greatest risk to the unborn child is prematurity. With the advances in neonatal care over the past decades, some physicians became somewhat cavalier in inducing babies at earlier and earlier gestation.
Hard Stop to Elective Inductions
In 2012, a letter was sent to all 3,100 obstetric hospitals in the USA stating that there needed to be a “hard stop to all non-medically indicated elective deliveries before 39 weeks gestation.” This does not include those instances where there is a true need to deliver the baby early for infant or maternal indications. Some possible indications for early delivery would include things like pre-eclampsia, poorly controlled diabetes, severe growth restriction, poorly controlled hypertension, or placental abruption. However, these indications need to be clearly delineated in the medical record.
2-Why Risk a C-Section?
The second area of reform that ACOG chose to target was that “doctors should not induce a woman between 39 weeks and 41 weeks of gestation unless the cervix was favorable.” Way back in 1964, Dr. Bishop introduced what is now called the “Bishop Score.” It was meant to determine the likelihood of a vaginal delivery if a woman with previous children were to be induced. If a woman had a Bishops score of 9 or greater, then the chance of a successful vaginal delivery was the same as if she went into labor on her own. This only applied to multiparous women with at least one prior normal delivery. Therefore, if a multiparous woman has a Bishop Score of 9 or greater, then and only then is it safe to deliver her at 39 weeks or beyond with an elective induction. This does not apply to women who have not had a baby previously. In fact, in a study recently published by the Oregon University and Health Science Center, the risk of a cesarean section increased 13 fold if a first time mother was induced with an “unripe cervix.” By adhering to the policy of only inducing multiparous women with a ripe cervix at or beyond 39 weeks, we can help reduce the horrible cesarean rate in the USA. I personally won’t induce a first time mother till 41 weeks, unless medically indicated to try to substantially reduce their risk of a c-section.
3-Pap Smears↓, Annual Wellness Exam ↑
The last 3 initiatives actually focus on reduced rather than increased screening. The 3rd on the Choosing Wisely list is to decrease the frequency of pap smears. In the past, yearly pap smears were recommended for all women over age 18. This is now changed to not start to do pap smears till age 21, and then only every 3 years till age 30. After age 30, co-testing with pap and HPV tests only every 5 years. This does not obviate the need for your annual exam however. You still ought to see your OB/GYN every year for things like breast cancer screening, appropriate blood tests, vaccinations, and for a complete physical exam.
The fourth also focuses on pap testing. It states that “women with mild cervical dysplasia need not be treated.” In other words, some OBGYNs were too aggressive in treating women with pre-cancerous lesions of the cervix. In treating women with LEEP procedures they were inadvertently causing premature deliveries by removing too much of the cervix in treating disease that was very unlikely to progress to cancer.
The last issue to be addressed was to “NOT SCREEN ASYMPTOMATIC WOMEN AT ANY AGE FOR OVARIAN CANCER.” This seems wrong, but in reality it is very good. Unfortunately we currently do not have a good screening modality for ovarian cancer. It would take about 10,000 asymptomatic women to be screened to find one ovarian cancer. What would happen would be very many unnecessary surgeries and many needless deaths if we were to try to screen every woman for ovarian cancer. Even now, when 21 women are suspected to have ovarian cancer with an ovarian mass, only one will actually have ovarian cancer.
In summary, by not being induced prior to 39 weeks, if you’ve had a prior baby, or 41 weeks if your having your first one, we can decrease fetal and maternal risks. Also by decreasing the frequency of pap smears and not screening for ovarian cancer, we can actually improve the quality of care for women of all ages.
For other advise on women’s healthcare, contact Dr. Mark T. Saunders at 801-692-1429.