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Oregon aims to curb early elective C-sections: will other states follow?

Dominika Osmolska Psy.D.'s picture

On September 1st , Oregon will become another state – one of seven so far – to scale back on elective, non-medically necessary inductions and cesarean sections before 39 weeks of pregnancy. The goal is to give babies a chance to mature in utero and stem the tide in the still-rising rates of C-sections across the nation, despite active campaigns to the contrary.

Seventeen Oregon hospitals, including all nine birthing hospitals in the Portland area, have agreed to a “hard stop” on the elective procedures, according to the March of Dimes’ Oregon chapter, which announced the agreement earlier this month. The agreement covers about half of the deliveries in the state.

A baby is defined as being full term at 37 weeks gestation, with 39 to 40 weeks being the optimal term at delivery. Unfortunately, however, increasing numbers of women are choosing to induce labor or have a C-section earlier than 39 or even 38 weeks because they would like the birth to occur at a convenient and scheduled time, or because they would like their doctor to do the delivery, instead of a doctor or mid-wife available at the time a natural birth would have occurred.

“Thirty-nine to 40 weeks is the gold standard,” says Michele Larsen, the Oregon chapter’s communications director. “So much more research is coming out showing how vital those last weeks are to the development to the children’s brain, liver and lungs. It makes a huge difference.”

Dr. Carey Winkler, a maternal and fetal medicine doctor with one of the 17 hospitals, Legacy Health system, agrees. “Babies born in the early-term time frame are at increased risk of complications, which increases the costs to the health care system,” Winkler said of those born from 37 to 39 weeks. “In the short run and the long run, these kids have more problems.”

The problems include increased risk for respiratory problems, jaundice, feeding problems, temperature instability and greater risk of being re-admitted to the hospital for poor weight gain or failure to thrive, he said.

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Despite the advantages inherent in a longer gestational period, deliveries at 37 and 38 weeks have risen in the U.S. in the last decade and now account for 17.5 percent of live births, she said. About one in three C-sections are done before 39 weeks, according to a 2009 study published in the New England Journal of Medicine.

The national C-section rate reached the astonishing rate of 34 percent in 2009. While C-sections are generally considered safe, they are still major abdominal surgery with its concomitant risks such as blood clots, infections and bleeding. The recovery time is usually longer than after a vaginal delivery. Recovery time and risk of complications go up with maternal age, and of course this is the age group which is more likely to have a C-section.

Lest the reader believe the skyrocketing rates of C-sections are the scourge of Western decadence, news releases today also report on a virtual epidemic in the procedures in – of all places – Iraq. That blighted nation reports an 80 percent rate in C-section rates in its private hospitals. Although private hospitals account for just 10 percent of that nation’s hospitals, and public hospitals report the more familiar 26 percent C-section rate, the 8 out of 10 Iraqi women who can afford it speak volumes about the attraction to the convenience of C-sections.

The women, whose mothers typically gave natural birth to multiple children, are often urged by those very mothers to undergo the procedure. They report not wanting to see their daughters in such excruciating pain if they can help it. While it is an understandable sentiment, it highlights a lack of understanding about the risks and burdens that a C-section involves. The increased rates are already having repercussions for women and Iraq's overburdened health care system. Doctors report longer medical stays for women who undergo cesareans, more women needing blood transfusions and suffering from infections, and babies with serious breathing problems.

Adel Muhsen, Iraq’s Health Ministry's inspector general, says that doctors' greed is often behind the decision for the surgery. At private hospitals, C-sections cost two to three times as much as vaginal births.

In Oregon, the new policy may lower that rate in the state once women have more time to go into labor on their own before an elective induction, which carries a risk of needing a C-section if the induction fails, experts say.

Dr. Stella Dantas, a Portland obstetrician and spokeswoman for the American College of Obstetricians and Gynecologists, is hopeful that the Oregon policy will lead to fewer cesareans in her state.

“We’re hoping that this will decrease the cesarean rate,” she said. “The C-section rate nationally is concerning for all ob/gyns.”