County Wide Hospital Ban on Early Inductions in Portland

By Peter Korn © 2011
Posted with permission. More from Korn at the Portland Tribune. 

Beginning September 1, 2011 birthing may be a little less "convenient" for some in Multnomah County, but a greater percentage of the babies born there will be healthy as a result of a historic agreement reached this week among local hospitals.

All 17 Portland-area hospitals have agreed to put what they call a “hard stop” on elective induction and caesarian section births before 39 weeks, unless those inductions are medically necessary.

Induced births and unnecessary c-sections have been a controversial issue for years in health care circles. Rates of elective inductions and c-sections have continued to rise even as a growing collection of data has made clear that early births sacrifice the health of newborns and add to overall health care spending.

Pregnant women often want to schedule births to make them more convenient for out-of-town family members. Obstetricians have been known to suggest inducing births that might be just a day or two before 39 weeks so that they can deliver on a Friday afternoon, for instance, rather than be called into the hospital on a weekend or during the middle of the night.

In addition, hospitals find they can operate more cost effectively by scheduling births, and women sometimes induce because they want their regular obstetrician to deliver the baby, rather than any physician who might be on call.

That won’t happen anymore at Oregon Health and Science University, the hospitals of Providence Health and Services, Legacy Health System, Kaiser Permanente, Tuality Health Care or Adventist Medical Center.

Wednesday’s announcement, through the Oregon chapter of the March of Dimes, means that induced births even one day before 39 weeks will now require patients to present their case to a designated arbiter at the hospital and prove that there is a medical reason why the early birth should take place.

“We’ve become accustomed to being able to schedule our lives, especially moms,” says Joanne Rogovoy, spokeswoman for the March of Dimes greater Oregon chapter. “When they learn why the last weeks of pregnancy are so important, especially with brain development, I believe they will embrace the concept that healthy babies are worth the price.”

Until recently, most physicians did not believe that a birth at 38 weeks and six days had a significant difference from a birth at 39 weeks, says Dr. Duncan Neilson, clinical vice president of Legacy Medical Groups and chief of women’s services.

But new research has shown that there is significant brain development going on right through 38 weeks. Babies born before 39 weeks of pregnancy are two to three times more likely to be admitted to intensive care as well as have trouble breathing, according to recent studies.

Salmon Creek Medical Center, a Legacy hospital in Vancouver, Wash., studied the problem on its own earlier this year and found that 42% of its babies born electively did not meet the criteria for medical exceptions. In April, Salmon Creek instituted its own hard stop on induced births before 39 weeks.

Neilson says the new policy will require some adjustment from pregnant women. “There are huge pressures to deliver just a little bit early,” he says. A common request, Neilson says, is from women whose husbands have been given a short leave from the war in Afghanistan, and don’t want to go back without spending time with their newborn baby. Neilson says that under the new agreement, even those parents won’t be able to induce an early birth because the births won’t be medically necessary.

Neilson says that getting all area hospitals to sign on to the agreement was crucial. If even one or two had refused to commit, Neilson says, that would have undermined the others by providing a local option for women wanting to induce for convenience’s sake.

“This is unprecedented in the Portland area,” Neilson says of the agreement. “Hospitals often compete, but this is a case where collaboration is the only way to improve the performance.”

Dr. Aaron Caughey, chairman of the ob/gyn department at OHSU, says some physicians still haven’t gotten the message that there is a significant health risk in delivering babies even a few days before the 39th week. And some families have personal reasons for wanting to schedule births on specific dates.

For instance, Caughey says, certain numbers are considered lucky in some cultures. Caughey says that on Aug. 8, 2008, he had a number of Asian women who wanted to induce labor because of the significance of the date.

From a hospital’s point of view, Caughey says, the new ban on inducements will create inefficiencies to which they will have to adjust. “In running labor and delivery units scheduling is everything,” Caughey says. “Unfortunately, we know the more we schedule the birth experience and interventions, we don’t improve outcomes, and sometimes we lead to worse outcomes.”

Scheduling births when rooms and physicians are available may increase hospital efficiency, but it doesn’t lower costs, according to a study earlier this year out of Utah.

Intermountain Healthcare, a consortium of 23 hospitals there, put a hard stop on elective inductions at all its facilities after discovering that babies born at 38 weeks needed newborn intensive care for breathing problems twice as frequently as those born at 39 weeks or longer.

By instituting a ban on inductions before the 39th week, Intermountain kept an estimated 500 newborns from having to use ventilators after birth and saved at least $1 million in health care costs in one year, according to hospital officials. Fewer inductions also resulted in fewer overall c-sections, according to Intermountain. And that resulted in an additional savings of over $45 million.

Caughey says he hopes the new agreement also leads to a reduction in unnecessary c-sections. A study this year to which OHSU researchers contributed concluded that c-section rates are rising so quickly in the United States, that by the year 2020 they could account for 56% of all U.S. births. The World Health Organization recommends that no country exceed a c-section rate of more than 15% max, but the current U.S. rate, which has been steadily climbing for decades, now stands at about 33%. [Most home birth midwives attending birth in the U.S. have a c-section transfer rate of 3-8%.]


Related Reading:

Fetal Lungs Protein Release Triggers Labor to Begin

Fish Can't See Water: The Need to Humanize Birth

The Lie of the Estimated Due Date

Why Pregnancy Due Dates Are Inaccurate

No Induction is Normal 

VBAC / HBAC Resource Page

C-section Not Best For Breech Babies

C-sections Cause Infertility or Emotional Trauma for 1 in 3 Women

The Premature Baby Book

Recommended Birth Books

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