Editorial: Discouraging Scheduled Deliveries
The evidence has been in for some time. Scheduling births may be convenient for physicians, hospitals and expectant parents, but it generally isn’t good for the health of mothers and children. It’s expensive to boot.
To get a baby to arrive on schedule, doctors often perform a cesarean section, the most common surgery in the United States. Since 1996, C-section rates have risen every year to 33 percent of all births in 2009. According to the World Health Organization, the right figure for any country is about 15 percent. The desire to deliver by appointment also prompts doctors to induce labor, for instance by injecting mothers with a hormone or breaking the amniotic sac. Induction rates have doubled over two decades to 23 percent in 2009.
These procedures are sometimes medically necessary — a cesarean, for instance, when the baby is in the breech position, or induction when the baby is more than two weeks overdue. Their elective use, however, has contributed to babies being born too early. From 1990 to 2009, the percentage of U.S. babies delivered at 37 to 38 weeks increased from 19 percent to 27 percent. These newborns aren’t technically premature, but a growing body of research shows they are vulnerable. According to a study published last year, children born at 37 weeks are twice as likely to die in their first year as those born at 40 weeks. They have significantly more health problems as well.
These complications tax the health system. Weak newborns often wind up in neonatal intensive care units, which can cost $2,500 a day. Even when all goes well, a cesarean section, because it is surgery, costs 60 percent more than a vaginal delivery, averaging $24,300 versus $15,200.
As hospitals and insurers struggle to contain expenses, a confluence of interests emerges. By reducing elective birth interventions, providers and insurers can cut costs while mothers and newborns achieve better health.
A two-year effort in Washington state shows the possibilities of such an approach. After studying records from across the state, Washington health authorities concluded that 15 percent of the 80,000 annual births were elective deliveries at 37 to 39 weeks; no medical reason for a C-section or induction was given.
To discourage unnecessary surgeries, the state shaved off $1,000 from the $7,000 to $10,000 in Medicaid payments hospitals received for uncomplicated C-sections, saving $3 million a year. (Medicaid covers about half of all births in Washington, as in the rest of the country.)
On top of this disincentive, an incentive was added. The Legislature created a $10 million reward to be shared by hospitals that showed marked improvement on five measures, including reducing optional early births. Consequently, hospitals began requiring physicians to document a medical reason for every delivery before 39 weeks; others required all such births to be approved by a senior medical officer. For some, educating staff about the risks of delivering at 37 to 39 weeks was sufficient to bring rates down.
The initiative’s results have been impressive. Elective early deliveries have been reduced 77 percent, from 15 percent of births to 3.4 percent; in the last year, 600 babies who would have been delivered before 39 weeks were born after. The perinatal group is using data it collected on C-section rates to help hospitals and physicians zero in on best practices.
A handful of other states are experimenting with measures to reduce optional early births. Others should look to Washington’s proven success and model the virtues of its program.