More than four years ago, the Seton family of hospitals stopped inducing labor in women who wanted to have their babies before full term, a move its doctors say prevents expensive complications that can accompany early births. Trouble is, that decision also cost Seton millions of dollars — those women now have babies elsewhere — and so it wants the Legislature to stanch the balance-sheet bleeding by approving extra public financing for any hospital with such a policy.
The issue raises sensitive questions about government management of both patient choice and the medical marketplace. While Seton asserts its competitors put mothers and babies at risk by allowing electively induced births before 39 weeks of pregnancy, its competitors counter that public officials have no business meddling in the private decisions of patients and their physicians. While they concede that some risks exist, doctors at the Hospital Corporation of America, or HCA, and the University of Texas Medical Branch say mothers can and should be educated about potential complications. The state, they argue, has no place in the delivery room.
Dr. Frank Mazza, chief patient safety officer for Seton Hospitals, which operates five major medical centers in Central Texas, believes lawmakers should craft a system that financially rewards hospitals that reduce neonatal costs and harm to patients — two results of banning early elective inductions. The Legislature could, for instance, increase Medicaid reimbursements for births by 2 or 3 percent, or by whatever amount would be enough to get hospitals to buy in. Seton has seen fewer premature babies and cesarean sections, along with a decrease in birth trauma, since it stopped inducing labor before 39 weeks, Mazza says. Inducing labor can cause an increased use of vacuums and forceps in deliveries, he says, which can unnecessarily harm infants.
When Seton hospitals adopted the new rules, yearly charges for expenses related to birth trauma dropped from about $4.5 million to $180,000, Seton officials say, adding that government incentives would motivate other hospitals to “do the right thing” and allow the state to spend less on Medicaid reimbursements.
State Rep. John Zerwas, R-Richmond, says the House Subcommittee on Health and Human Services, which he chairs, has not discussed elective inductions since Mazza brought up the matter at a hearing last month.
Seton's bottom line is at least partly behind the push for lawmaker intervention; the practice of not inducing early has cost the hospital millions, Mazza says. When a mother heads across town for an early delivery elsewhere, Seton loses money as a result of fewer expensive procedures being performed and shorter stays for its pregnant patients. Some doctors have defected from the Seton system because of the policy, Mazza says.
Most in the medical community agree that inducing labor prior to 39 weeks can be dangerous, says Dr. Steven L. Clark, medical director of women and children's clinical services at HCA. Premature babies may need respirators, incubators and IVs to survive, and with those procedures come inflated medical costs. A study that Clark worked on found that 18 percent of babies delivered between 37 and 38 weeks need intensive care. If mothers wait until 38 to 39 weeks to give birth, only about 8 percent need intensive care, and after that just 4 percent.
“Because doctors are not seeing babies dying or [getting] crippled from [early induction], it’s kind of been swept under the rug,” Clark says. Yet though babies born pre-term are at higher risk for complications, no evidence suggests the practice of inducing labor causes increased trauma for the baby, Clark says. Labor requires the same care whether it is induced or not; the potential complications stem from the timing of the birth alone, he says.
In addition, not all early deliveries are elective, Clark says. Many medical conditions can require early induction, including gestational diabetes, hypertension and bleeding. The motivations for elective inductions, on the other hand, have nothing to do with medicine and can range from a woman wanting to deliver when her family or her obstetrician is in town to a doctor wanting to avoid delivery at 4 a.m. Up to 15 percent of American women choose to give birth before 39 weeks. Despite the risks, Clark says, doctors and patients can make those choices without interference from politicians.
[Update: HCA recommends its hospitals avoid induced deliveries before 39 weeks; and one of Seton's competitors, Austin-based St. David's, partly owned by HCA, follows a two-year-old policy against early inductions except when medically necessary. "We are concerned about safer patients and we will worry about reimbursements later," says Dr. Steve Berkowitz, chief medical officer for St. David's HealthCare.]
It’s a choice that mothers have been making since at least the 1930s, says Dr. Gary Hankins, chairman of obstetrics at UTMB. And, he says, most mothers are unaware of all the risks involved. Cesarean sections, for instance, cause infections for mothers and babies. And the cesarean births occur more often with induced labor, he says.
Still, Hankins has serious concerns about how lawmakers would regulate the birthing room. A doctor’s work “is as much an art as it is a science,” he says. If the public were aware of all the risks, the medical market would naturally trend toward a policy such as Seton's because consumers would avoid other hospitals. “I think what Seton did is admirable,” Hankins says. “What I don't understand is why they need the Legislature to do this. Heaven help us when the lawyers are the ones setting the practice for medicine.”