Day Two of Things That Work: Preventing Early Elective Deliveries

Today’s Managing Health Care Costs Indicator is 39

Something is broken with deliveries in the United States.  Our Caesarian Section delivery rate has increased to over 34% - and the VBAC rate (vaginal birth after C-section) has plummeted.  Caesarian sections are a major abdominal procedure, requiring significant recovery time, and raising health care costs.  Further, women who have had C-sections are more likely to have placenta previa complicating later pregnancies, which can threaten the life of the mom and the baby.

Early elective inductions – done for convenience of patient or physician without medical indications – are an important cause of preventable C-sections.  Attempting an induction when the cervix isn’t ready is more likely to result in failure of labor to progress –which can trigger the cascade toward C-section.  Early elective inductions also lead to premature births that require extra days to weeks in a neonatal ICU.   Again, this leads to higher costs and worse outcomes.

Here’s what’s working.  The Leapfrog Group began publicizing voluntarily-reported early induction rates earlier this year – and hospitals are taking notice. WBUR’s Martha Bebinger reported late last week that top Massachusetts maternity hospitals are prohibiting early elective deliveries.  In her report some expectant moms argued that they wanted ‘control’ over when to deliver their babies.  But excellent medical evidence suggests that early inductions increase adverse outcomes – and physicians shouldn’t offer patients options that increase the risk to them and their unborn babies. 

It’s important that the approach of hospitals is to administratively interdict unindicted early inductions.  Clark et al showed that a “hard stop” is substantially more effective than peer review or physician education.  These researchers also showed a 16% decline in NICU use associated with implementing this hard 

There are many other issues with organizational structure and payment methodology that drive increased C-section rate. These include lack of obstetrical practice integration and labor coverage, underuse of nurse midwives, and higher hospital payments for C-sections.  So – there is plenty more work to do.  Catalyst for Payment Reform recently published a tools for employers to promote maternity payment reform.   

For now, we can celebrate that many hospitals are doing serious work to prevent early inductions that are not medically indicated.