Elective Deliveries: A Sign of a Healthcare System Out of Control

My husband is always getting on me about the number of tabs I have open in my browser at any one time. I think one time I had more than 100 open.

Within the past few days, at least 10 of those tabs dealt with the same topic: medical tests and procedures that we either don’t need or that don’t work. There are simply too many for a single blog, so I’m focusing on one here and will write more about others in the coming days.

The lucky winner? Births.

Seems like an obvious medical procedure, doesn’t it? Baby is delivered when mom goes into labor or, if problems develop or mom goes over her due date, labor is induced. So why, as  Kaiser Health News recently reported, are 10 to 15 percent of U.S. babies  delivered early without medical cause, up to 40 percent in some hospitals?

Early delivery increases the risk that the baby will have feeding and breathing problems, infections, and developmental problems, requiring a stay in costly neonatal intensive care units. It also increases the risk that mothers will need caesarian sections (indeed, many of these births are scheduled c-sections).

Why the early deliveries? Convenience for mom and her doctor.

How to stop these elective early deliveries? Do what the South Carolina Medicaid program and BlueCross BlueShield of South Carolina did last year: Stop paying for them. Voila! As the Kaiser story reported and data from the quality organization Leapfrog showed, the rate of early elective deliveries in the state’s hospitals fell by half, from 19 percent in 2011 to 10 percent in 2012.

Massachusetts hospitals are also stepping up to the proverbial plate, with some  banning–yes, banning–elective deliveries before 39 weeks.

You’d think women would be grateful for efforts to reduce the risk of costly and potentially deadly complications. But as one mom quoted in an article about the Massachusetts’ hospital ban said: “You’re already out of control of your body, so at least to know if you go to your doctor’s office and say, ‘Look, we’re at 37 weeks, and I feel like I’m ready . . .To know that I would have that choice would just make me feel better. But to take it away from me just adds to the pressure of being pregnant.”

How about the pressure of out-of-control health costs?

We need more insurers and hospitals to step up to the plate and stop paying doctors for unnecessary or ineffective procedures and tests. More doctors telling patients “no,” or, at the very least, refusing to provide the requested service. No, you cannot have an MRI for a headache. No, you cannot demand a procedure (like an induced birth) that is not only costly but dangerous. And if you still demand either,  be prepared to pay out of pocket.

Watch this space in the coming weeks for more on just how much we waste in our healthcare system and how it’s not just the fault of the doctors–but ours, as well.

7 Responses to “Elective Deliveries: A Sign of a Healthcare System Out of Control”

  1. Alison @ L is for Latte

    Deb, you know I love you, but trust me: elective deliveries are not all about what the mom wants. In 2006, when I was pregnant with Lucy and 2 weeks away from my due date, Kaiser Permanente told me it was time to schedule my induction. (!) I resisted, but they insisted. They wouldn’t let it go, so I scheduled it out for as far as I could–I pushed it to my actual due date and then just simply didn’t show up at the hospital for the big “elective delivery.” (As my independent childbirth class instructor said, ‘What are they going to do, come to your house and arrest you?'”) This was not some tiny ob-gyn practice–this was Kaiser Permanente, which is all about fitting people into their system. I seriously doubt my experience with them was anything but standard operating procedure. I seriously doubt “the public” is the group that needs to be educated here–let’s talk about doctors who need to follow their colleagues’ own research and malpractice insurers that understandably influence ob-gyns’ decision-making.

  2. Patti Peeples

    Deb,
    This issue is not quite as black and white as you are making it seem. The predominant metric is not gestation ( 37 weeks, for example). Other variables to consider include mother’s health status (something as simple as hypertension, even MILD, can raise risks associated with failure to induce) and whether the patient lives in a developing country vs. US, access to emergency birth procedures, etc. Of course, these US policy bodies such as the SC Medicaid program are looking at their own patient population and determining the costs and benefits, but this issue definitely has additional considerations. As you point out, while induced labor babies have a higher admission to specialized care units (e.g., NICU), there is also a lower mortality rate in this population when compared with expectant management births. That’s sobering. This statistic alone causes one to want to delve further and figure out the what/why/who/when issue of induction. Lastly, as awful as this sounds, there are other costs to consider when evaluating this from a purely economic standpoint (which, sadly, is often what is considered by these insurers): what are the costs borne by the hospital for ensuring that there is enough staff, birthing rooms, emergency back-up personnel, etc. to handle pregnancy case loads that are largely “expectant managed” vs. scheduled….these costs must be considered in a full economic analysis, as well as the costs associated with induction.

    Now all these things make me seem as if I’m a proponent of induction. Indeed, quite the contrary. My own two children spent 3 months in the NICU, and that is not a situation I’d wish on my own worst enemy. However, I simply had to put my medical economist hat on to suggest that simple analyses of a politically-correct medical bandwagon (which tends toward poo-pooing induction) also be written with some consideration for the full picture. It’s just not that simple. Birthing babies, using Ms. Prissy’s colloquialism in Gone With the Wind, is an entirely natural process…we hope. Efforts should be made to preserve that process, and let nature take its course. And a reasonable society ought to be prepared to pay for that process. But, costs and consequences for that process (vs. an altered one) are borne by many and the full picture must be viewed.

  3. David Bynon

    Hi Deborah,

    Here’s a thought. Could this also be another sign of just how defensive our healthcare system is? Doctors run test after test to avoid liability risk. Could inducing labor be another way that doctors reduce their risk while driving up our cost?

  4. Steve

    Hi Deborah,

    I think there are 2 arguments that are a bit conflated in this post.

    I agree with the overall argument against elective delivery. This seems to be an educational problem, mostly with the public. Were the risks more widely known, the request for these procedures would likely fall.

    However, I am a bit uncomfortable with the argument that either physicians or health care organizations should act as economic (or other) gatekeepers. I can see this sliding down some very slippery slopes very fast.

  5. Qi Cheng

    For patients, it’s the feeling of “control everything by myself”. For doctors, it’s not bad to please the patients and get the higher payment. Same situation occurs in many other medical issues.

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