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A Complicated Choice - Early Elected Delivery

Posted on Jan 29, 2013 by Ailee Slater ()

The idea of a doctor deciding when to deliver a baby is strange - if comedy films have taught us anything, it's that natal labor is not an event you plan for. By the time the fetus has developed all important functions and is ready to come into that world, usually at around 39 weeks, he will let his mother know. Contractions will begin, water will break, and you'd better hope there's a licensed caregiver somewhere nearby.

Some physicians, however, are not content to sit and wait. Over the past 20 years, more and more people are choosing to have an early elected delivery, and this trend does not sit well with plenty of physicians, insurers and public health organizations.  Early elected delivery means that on the wishes of the doctor or the patient, a baby is delivered vaginally or more commonly, by Caesarian section before real labor has begun and before the entire term of the pregnancy has been carried out. Early elected delivery does not refer to pre-term births performed out of medical necessity. Why would anyone want to deliver a baby early? For some doctors, it's a scheduling issue - the ability to definitively mark a baby's due date on a calendar is certainly easier than spending weeks waiting for a sudden call to the operating room. Women likewise may be tempted by the security of choosing their child's date of birth, especially if travel is on the horizon or if auspicious dates play a large role in the mothers culture.

Doctors and patients alike may also look into early elected delivery for financial reasons; the idea being that less time pregnant equals less money spent on the check-ups and general care in the weeks prior to giving birth. However, early delivery comes with a huge number of health risks. Medical institutions such as the American College of Obstetrics & Gynecology strongly recommend against the practice of elected early delivery due to the likelihood of complication and even death for children delivered before natural labor has occurred. The Centers for Disease Control estimates that a baby delivered even just three weeks before the average 39 weeks gestation period is more than three times as likely to die. An infant born early may have to contend with feeding, breathing and developmental problems; most need to be hooked up to a ventilator, and many will be admitted to the Neonatal Infant Care Unit. Important brain and lung development occurs even during the final week of pregnancy, and so losing this developmental opportunity is highly detrimental to a fetus. What's more, fetal dating methods are not always exact, so even if a doctor believes that the elected delivery is occurring at 37 weeks, the actual date of the fetus may be only 35 weeks - that's an entire month earlier than the average baby is born.

Along with these high costs to patient health, the financial cost of elected early delivery is plenty high as well. The average stay in a Neonatal Infant Care Unit comes with a price tag of $76,000, so it's no wonder that insurers and public health services such as the Centers for Medicaid & Medicare (CMS) are eager to discourage early elective delivery. CMS has estimated that early elective delivery is costing the United States around $2.6 billion per year, and the costs in terms of general health and infant mortality are even more grave. To combat the financial and medical strain of early elected delivery upon the U.S. Health System, CMS along with the Health Resources and Services Administration and the Administration on Children and Families, have come together to form a joint program called Strong Start. This initiative advises hospitals and other healthcare providers on strategies to educate patients about the dangers of early elected delivery, and provides incentives for hospitals to record data and work to reduce the yearly number of early elected births.

Through the Strong Start Initiative, hospitals can apply to become a Medicaid testing ground; evaluating the effectiveness of Strong Start techniques in reducing preterm births. Seeing as Medicaid is responsible for funding 45 percent of births in the United States, it makes sense that this insurance group would have a vested interest in improving education and health for pregnant women. The Strong Start Initiative will collect data and evaluate techniques during the next four years, at which point CMS and its program partners should have a good amount of information as to what techniques are best when it comes to explaining that the choice to deliver early is not always a good one. In fact, similar programs have already proven effective at reducing early elected births.

One of the first of its kind, a 2010 study published in the American Journal of Obstetrics & Gynecology (AJOG) examined 27 hospitals and three different methods of elected birth reduction. The first method was known as the Hard Stop approach, wherein a hospital would make a policy decision to prohibit early elected births; if a patient or doctor asked for such a procedure, they would be refused. The second method, a Soft Stop approach, was similar to Hard Stop, however if a patient or doctor pressed the issue and was not content to be refused elected delivery, a peer review committee would be set-up to evaluate what should be done.

Finally, the third method was an Education Only approach. Early elected delivery was not prohibited, but the hospital provided literature to health care personnel recommending that the practice not be performed. Overall, this AJOG study was able to reduce early elected births by 55 percent; hospitals involved in the study also saw a 16 percent decrease in admissions to the Neonatal Infant Care Unit. The best results were seen in hospitals which took the Hard Approach and refused to allow early elected birth. Of course, this bring up issues of choice and patient rights; a debate which may become more important if some hospitals begin to outright ban mothers from scheduling an early delivery. As the CMS Strong Start Initiative gets underway and more data is collected around the nation, we will surely have a better idea of which strategies are best when it comes to improving the health of mothers and babies, and at the very least providing education about the risks of electing to deliver a baby before it has elected to be born.

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