Elective induced labor risky, costly

By Diane Carman

The March of Dimes has a news flash for women everywhere: pregnancy is more than a nine-month commitment.

Actually, its closer to 10. And if you want a healthy baby, there are no loopholes.

As a society weve really focused on nine months of pregnancy, said Scott Matthews, director of program services for the Colorado Chapter of the March of Dimes. Surveys have found that women view pregnancy as 36 weeks long. But full term is 40 weeks, and research has shown that significant fetal respiratory and brain development occurs in those last four weeks.

In the comprehensive report, Toward Improving the Outcome of Pregnancy III, released nationwide on Dec. 15, the March of Dimes expanded its campaign to educate physicians and pregnant women to make sure that no baby is born before 39 weeks gestation unless labor occurs naturally or there is a clear medical reason for earlier physician intervention.

That means an end to nearly all elective sometimes called social inductions of labor before 39 weeks.

Steven Holt

Steven Holt

If theres good medical indication, such as hypertension or preeclampsia in the mother, or fetal abnormalities, clearly the physician should do so, said Dr. Steven Holt, chair of the Department of Obstetrics and Gynecology at Rose Medical Center and president of the Colorado chapter of the American College of Obstetrics and Gynecology. But if its strictly for the convenience of the patient or the physician, you should not do so.

Babies born at 37 or 38 weeks gestation are more prone to problems and more likely to wind up in the intensive care unit, said Dr. Ron Gibbs, chair of the Department of Obstetrics and Gynecology at the University of Colorado School of Medicine.

In those last few weeks in the womb, Matthews said, respiratory systems mature and brain development occurs that enables infants to regulate their body temperature. Some babies born early develop sleep apnea, and they are statistically more likely to die of Sudden Infant Death Syndrome.

Late pre-term babies also often have low birth weights, a key determinant of newborn health, and a serious problem in Colorado where the rate of low birth weight babies is consistently higher than the national average.

Matthews said that babies born before 39 weeks often have been found to have problems with learning and behavior later in childhood.

Social induction common

While the research on the importance of late-term fetal development has been around for at least a decade, the number of elective inductions has remained stubbornly high across the country.

Preterm birth by the numbers

  • Rate of induced labor in U.S. in 1990 9.5 percent
  • Rate of induced labor in U.S. in 2006 22.5 to 31.1 percent
  • Rate of low birth weight babies in U.S. in 2007 8.2 percent (1 in 12)
  • Rate of low birth weight babies in Colorado in 2007 9 percent (1 in 11)
  • Cost of preterm birth from all causes in U.S. $26 billion per year

A study published in the journal Minnesota Medicine last November reported that in 1990, U.S. women were induced into labor about 9.5 percent of the time.By 2006, the percentage of deliveries that were induced had increased to between 22.5 and 31.1 percent.

A report found that at one large hospital in 2010, induction was used in 43.6 percent of births and that a troubling 39.9 percent of those inductions were elective.

Dr. Holt of Colorado cited a 2007 study of 17,794 deliveries in 27 obstetric facilities operated by the Hospital Corporation of America. The deliveries occurred between May 1 and July 31, 2007 in 14 states (including Colorado).

The study found that 11 percent of the deliveries were elective and occurred prior to 39 weeks in violation of longstanding American Congress of Obstetricians and Gynecologists/American Academy of Pediatrics recommendations.

He said that figure probably was low, however, because many of the medical indications cited by physicians were considered spurious. For example, doctors frequently cited hypertension as the medical indication for early induction, but the womens charts in many cases revealed normal blood pressure readings at admission.

Since that report was published, educational campaigns across the HCA system have resulted in reductions in the incidence of elective inductions, Holt said, but expanded patient-education is still needed.

Tide turning in Colorado

While no comprehensive studies are available for induction rates statewide, there are indications that Colorado providers are doing fewer elective procedures.

Abby Burton, a midwife at University Nurse Midwives in Colorado, said that requests for elective inductions usually are declined, despite the sometimes adamant demands from pregnant moms.

Some of the patients are very persuasive, she said, and when we tell them we wont induce before 39 weeks, some say, Im going to go somewhere else.

The reasons for requesting the early inductions generally fall into two categories: comfort and convenience.

They say, Im so tired. I can hardly walk. I cant move, said Burton. Or they mention their husbands travel plans, the limited availability of family members who can help with the new baby, or the need to have the baby in December to get an income tax advantage.

The one reason Burton and her colleagues occasionally will consider as justification for a social induction is if the father is a soldier briefly home on leave from active duty. Even then theyll call for amniocentesis to make sure the respiratory system is mature before scheduling a delivery.

Legitimate reasons still valid

Dr. Gibbs emphasized that its important not to confuse medically indicated inductions with elective deliveries. Some

Ronald Gibbs

Ronald Gibbs

physicians are getting so turned around on this theyll have a patient with preeclampsia and wont want to deliver before 39 weeks, he said.

Thats why the educational campaign surrounding the issue is so important. Both doctors and patients need to understand when induction is appropriate and when it is too risky.

The Minnesota Medicine report doesnt mince words in its opposition to social inductions. It notes that there is no medical benefit to elective induction and it is associated with risks to both the mother and the infant. It cites statistics showing a two-fold increase in the risk of cesarean delivery and that 3.1 percent of infants born via elective induction at 37 weeks need care in the neonatal intensive care unit.

As a result of the report, the Minnesota Department of Human Services has proposed instituting a policy to require hospitals statewide to create plans to reduce elective inductions before 39 weeks. The penalty for failure to comply: a torrent of paperwork.

Utah system paves the way

One hospital system, Intermountain Healthcare of Salt Lake City, confronted the problem of elective inductions a decade ago and the results have been dramatic.

Proposed policies

  • Changes in reimbursement policies of public and private health insurers to discourage elective induction
  • Statewide measures to require expert approval of inductions when not medically indicated
  • Intensive educational efforts aimed at physicians and patients

Daron Cowley, spokesman for the system of nonprofit hospitals and clinics in Utah and Idaho, said that an analysis of data gathered by the systems electronic medical records show that in 1999, 28 percent of all inductions at the 18 Intermountain hospitals that offer obstetric services were done before 39 weeks gestation. Today that percentage is around 3 percent, he said.

That change has resulted in a reduction in the average labor time by 90 minutes, a c-section rate of 21 percent compared to the national average of 32 percent, and reduced numbers of newborns in intensive care units.

It also has resulted in significant savings to patients and their insurance companies, Cowley said. He estimated the loss in revenue to the hospital system at about $1 million a year.

Education critical

Scott Matthews said the March of Dimes is working hard to create and distribute educational tools for physicians and their patients. Brochures and a brain card, which illustrates how the fetal brain grows by 50 percent between 35 and 40 weeks gestation, are available. Were hoping to swing the pendulum back the other way, he said.

Most physicians are on board with the initiative and are happy to have the tools they need to work with their patients.

Theres no organized opposition to this, said Dr. Gibbs of CU. Thats because theres no real rational opposition.

Addressing the issue of elective inductions is just the beginning though.

If were looking at ways for preventing premature birth this [elective induction] is the low-hanging fruit, said Dr. Gibbs. There arent easy ways to tackle the problems of premature births that result from spontaneous pre-term labor, premature rupture of the membrane or maternal or fetal complications.

The real breakthrough is going to come when we understand the cause of preeclampsia better, when we can reduce poverty and when we can reduce stress in a large segment of our population.