Early elective inductions, C-sections get a no from hospitals

Safety is more important than convenience

Risk managers and patient safety experts across the country are catching on to a dangerous trend: Too many physicians and patients are agreeing to early induction or Cesarean sections, they say, and it has to stop.

On the first day of September 2011, 17 Oregon hospitals — including all nine birthing hospitals in the Portland area — agreed to a "hard stop" on elective inductions and Cesarean sections before 39 weeks. The hospitals agreed to the new policy, which prohibits physicians from scheduling the procedures without proof of medical necessity, in conjunction with a campaign sponsored by the March of Dimes.

The agreement covers about half of the deliveries in the state, says Scott Berns, MD, senior vice president of chapter programs for the March of Dimes in White Plains, NY. The number of Cesareans and inductions at 37 and 38 weeks has been growing as women schedule their deliveries for their convenience or to be delivered by their own doctor, she says. Deliveries at those weeks have risen in the United States in the last decade and now account for 17.5% of live births, she says, and about one in three C-sections are done before 39 weeks.

A baby is considered full term at 37 to 41 weeks, Berns says, but the March of Dimes believes the longer the term, the better for babies. New research has shown that a baby's brain nearly doubles in weight in the last few weeks of pregnancy, he says. Also, important lung and other organ development occur at this time. And, although the overall risk of death is small, Berns notes that it is double for infants born at 37 weeks of pregnancy, when compared to babies born at 40 weeks, for all races and ethnicities.

The March of Dimes has been addressing the issue across the country, and hospitals in California, Texas, New York, and Illinois also have adopted the ban on early elective deliveries, Berns says. Intermountain Healthcare, with 23 hospitals in Utah and Idaho, has prohibited elective early inductions and C-sections for the past decade.

Risk managers should address early inductions and C-sections as a patient safety issue, Berns says. Clinicians and patients will need to be educated, he says. Expect some pushback at first.

When you first broach the topic, clinicians are likely to respond that this is not a problem for them, Berns says. That's when you need to provide the data showing how many babies are delivered early and the corresponding rates of complications, admission to the neonatal intensive care unit, and other factors.

"There has been this assumption that it's fine to deliver before 39 weeks, and people unfortunately can get very casual about their reasons, trying to work around vacation plans or holidays," Berns says. "But once they see some of this data about the outcomes and how the early delivery affects the child, you can turn them around. The next step after that is the policy change."

Simply declaring that you won't allow early inductions or C-sections is not enough, Berns cautions. There must be a process in place that actually prohibits them. The best method is for administration to make clear to the individuals responsible for scheduling deliveries that they may not schedule an early induction or C-section without proof of medical necessity, he says.

"They just won't schedule it. They have to say no," Berns says. "When the physician gets upset about that, he or she has to take it up with the department head."

Hold physicians accountable

Any policy must carefully distinguish between the necessary but early C-section or induction and the one performed for convenience, says Georganne Chapin, president and CEO of Hudson Health Plan, a nonprofit Medicaid insurer in Tarrytown, NY. In response to rising local C-section rates, Chapin has directed Hudson to work with several of Hudson's network hospitals, a large community health center, the Lower Hudson Valley Perinatal Forum, and the perinatology department at the regional tertiary care hospital to examine the high C-section rate among enrollees. 

Chapin's goal is to reduce unnecessary C-sections and to ensure the safety and appropriate level of care for mothers and babies. "This initiative will rely heavily on data collection in multiple care settings to piece together all episodes of care into one comprehensive overview," she says. "Everybody will win from this initiative: Mothers and babies will be safer, and the community will benefit from lower healthcare costs."

Chapin calls on risk managers to hold physicians more accountable for their delivery practices by requiring them to justify their statistics on early deliveries. She also says risk managers should enact "hard stop" policies on some procedures.

"There is no reason for elective C-sections. They should be forbidden," Chapin says. "There are too many things that happen during labor that are good for the baby and good for the mother, and that is the way the body has been working for thousand years. I believe there is no good reason to have an elective C-section."


• Scott Berns, MD, Senior Vice President of Chapter Programs, March of Dimes, White Plains, NY. Telephone: (914) 997-4488. E-mail: sberns@marchofdimes.com.

• Georganne Chapin, JD, President and CEO, Hudson Health Plan, Tarrytown, NY. Telephone: (901) 907-0448. E-mail: gchapin@hudsonhealthplan.org.