Measure Description
Percentage of patients, regardless of age, who gave birth during a 12-month period, delivered a live singleton at < 39 weeks of gestation, and had elective deliveries (without medical indication) by cesarean birth or induction of labor.
Instructions
This measure is to be submitted each time a procedure is performed for patients undergoing delivery by cesarean birth or induction of labor at less than 39 weeks of gestation during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
Denominator
All patients, regardless of age, who gave birth during a 12-month period delivering a live singleton at < 39 weeks of gestation
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Single live birth during the performance period (ICD-10-CM): Z37.0
AND
Patient procedure during performance period (CPT): 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, 59622
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10
AND
Delivery at < 39 weeks of gestation
Numerator
Patients who had elective deliveries (without medical indication) by cesarean birth or induction of labor
Numerator Instructions:
INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care.
Numerator Options:
Performance Met: Elective delivery (without medical indication) by cesarean birth or induction of labor performed (< 39 weeks of gestation) (G9356)
OR
Denominator Exception: Medical indication for delivery by cesarean birth or induction of labor (< 39 weeks of gestation) [Documentation of reason(s) for elective delivery (e.g., hemorrhage and placental complications, hypertension, preeclampsia and eclampsia, rupture of membranes (premature or prolonged), maternal conditions complicating pregnancy/delivery, fetal conditions complicating pregnancy/delivery, late pregnancy, prior uterine surgery, or participation in clinical trial)] (G9361)
OR
Performance Not Met: Elective delivery (without medical indication) by cesarean birth or induction of labor not performed (< 39 weeks of gestation) (G9355)
Rationale
Elective delivery or early induction often leads to prematurity, increased costs, and an increased incidence of cesarean birth. Studies have determined that elective delivery prior to the gestational age of 39 weeks may result in significant short-term neonatal morbidity (neonatal intensive care unit admission rates of 13%–21%). Recent research shows that infants born prior to 39 weeks face a higher risk of breathing disorders and other problems than those who remain in the uterus longer [1].
Substantial disparities exist in the prevalence of preterm birth, fetal demise, maternal mortality, neonatal mortality, and obstetric care utilization [2]. As noted by Kozhimannil et al., “differences in cesarean use or labor induction, including differences not driven my medical need, may contribute to racial disparities in neonatal and maternal outcomes” [3]. A retrospective study of vital statistics found that disorders related to short gestation and low birth weight were the secondleading cause of fetal demise and that Black, American Indian, and Puerto Rican women experience the highest risk of unfavorable birth outcomes [4]. Black-White differences in early elective delivery have been recognized, with Black women having 30 percent higher odds of early elective cesarean compared to non-Hispanic White women [3]. At least one study found that policy change effectively eliminating early delivery eliminated Black-White differences in early elective cesarean [3], suggesting that successful implementation of this measure’s intent may have positive downstream impacts on disparities in maternal and fetal outcomes overall.
References
1. Clark, S. L., Miller, D. D., Belfort, M. A., Dildy, G. A., Frye, D. K., & Meyers, J. A. (2009). Neonatal and maternal outcomes associated with elective term delivery. American Journal of Obstetrics and Gynecology, 200(2), 156.e1– 156.e1564. https://doi.org/10.1016/j.ajog.2008.08.068
2. Bryant, A.S., Worjoloh, A., Caughey, A.B., Washington, E. (2010). Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. American Journal of Obstetrics and Gynecology, 202(4), 335-343. https://doi.org/10.1016/j.ajog.2009.10.864
3. Kozhimannil, K.B., Muoto, I., Darney, B.G., Caughey, A.B., Snowden, J.M. (2018). Early elective delivery disparities between non-hispanic black and white women after statewide policy implementation. Women's Health Issues, 28(3), 224–231. https://doi.org/10.1016/j.whi.2017.11.008
4. MacDorman, M.F. (2011). Race and ethnic disparities in fetal mortality, preterm birth, and infant mortality in the United States: an overview, Seminars in Perinatology, 35(4), 200-208. https://doi.org/10.1053/j.semperi.2011.02.017
Clinical Recommendation Statements
Decisions regarding maternal delivery are complex and must take into account maternal and newborn risks, practice environment, and patient preferences [1]. The goal of induction of labor is to achieve vaginal delivery by stimulating uterine contractions before the spontaneous onset of labor. Generally, induction of labor has merit as a therapeutic option when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy [2]. Labor may also be induced for logistic reasons, e.g., rapid labor, distance, or psychosocial reasons. However, indications for induction of labor are not absolute, but should take into account maternal and fetal conditions, gestational age, cervical status, and other factors [3].
ACOG and the Society for Maternal-Fetal Medicine have long discouraged nonindicated delivery before 39 weeks of gestation because the neonatal risks of late pre-term (34 0/7–36 6/7 weeks of gestation) and early term (37 0/7–38 6/7 weeks of gestation) births are well-established, and the potential neonatal complications associated with elective delivery at less than 39 0/7 weeks are well described. Based on these and other data, timing of elective delivery at 39 weeks of gestation or later is recommended even when a cesarean is to be performed at maternal request [4].
Deferring delivery to 39 weeks of gestation is not recommended if there is a medical or obstetric indication for early delivery [1]. In these cases, health providers will need to weigh competing risks and benefits for the woman and her fetus. The following are examples of maternal or fetal conditions that may be indications for elective delivery by cesarean birth, or early induction of labor [1,3]:
- Placenta previa*
- Suspected accreta, increta, or percreta*
- Vasa previa*
- Prior classical cesarean*
- Prior myomectomy requiring cesarean delivery*
- Previous uterine rupture*
- Oligohydramnios
- Growth restriction
- Multiple gestations—uncomplicated
- Multiple gestations—complicated
- Alloimmunization
- Hypertensive disorders of pregnancy
- Diabetes
- HIV
- Intrahepatic cholestasis of pregnancy
- PROM (prelabor rupture of membranes)
* These conditions may be indications for early delivery by cesarean birth; they are not indications for early induction of labor.
References
1. ACOG Committee Opinion 838: Medically Indicated Late-Preterm and Early-Term Deliveries Committee Opinion (2021)
2. ACOG Practice Bulletin “Induction of Labor” (No. 107, issued August 2009, reaffirmed 2020)
3. ACOG Committee Opinion 765 Avoidance of Nonmedically Indicated Early-Term Deliveries and Associated Neonatal Morbidities (issued 2019, reaffirmed 2021)
4. ACOG Committee Opinion 761: Cesarean Delivery on Maternal Request (2019)