KPCC: Childbirth by appointment

Nurses attach fetal monitors to hear the baby's heartbeat during labor. (Lauren M. Whaley/CHCF Center for Health Reporting)

This story originally aired on The Madeleine Brand Show on Southern California Public Radio.

Corrie Carroll’s husband travels for work a lot. So, when it came time to give birth to their daughter, the couple made an appointment. Carroll said the experience was perfect.

“He arrived home from Europe on a Wednesday night and we drove to the hospital at 6 a.m. on Thursday morning,” said the mother of three, who lives in Pasadena. “I checked in. I put my hospital gown on. They gave me Pitocin. About an hour later, they gave me an epidural and eight hours later I had a baby.”

Carroll is not alone in wanting more control over when the baby comes. More and more doctors are inducing their patients’ labors without a medical reason, said Dr. David Lagrew, a maternal-fetal medicine specialist at MemorialCare Health System in Orange County.

“If you really look at inductions and say, what percentage of inductions we do today fall into the elective category, it’s the vast majority of them,” he said.

Elective means that the labors are induced without a medical reason, usually for the convenience of doctor or patient. Lagrew at said these planned childbirths have been going up for many reasons: Grandma is coming to town to babysit or pregnant moms are sick of being pregnant. He also said there is pressure from physicians.

“If I can deliver everybody from 8 to 5 Monday through Friday, that’s a better lifestyle than being up all night,” he said.

In some practices, there is a financial incentive for a doctor to deliver his or her own patients. In these cases, if the doctor delivers her own patient, she doesn’t have to split the delivery fee with another doctor.

Chart designed by Erin Leiker, CHCF Center for Health Reporting

A recent Stanford study showed that elective induction rates vary widely across California. Women who live in Pasadena, Burbank and Glendale, for example, are twice as likely as other moms in California to have their labors induced for non-medical reasons. That’s six times the rates for women who live in Napa and Red Bluff.

The study’s author, Laurence Baker, adjusted the rates to try to eliminate differences in the health of populations and their access to health care. He adjusted each region’s results for age, sex, race, education, income and health insurance status.

Given these adjustments and the disparity in elective induction rates in California, Baker suspects that these rates show that habits catch on. Doctors in a certain area get used to the convenience of inducing their patients. Or, neighbors tell each other about picking their babies’ birthdays.

But, such practices have some people concerned.

I think induction is a huge issue,” said Tracy Hartley, a birth doula in LA. Hartley has coached 455 women through their childbirths over the last 15 years. She helps women with prenatal questions and birth preparation and goes with with them to the hospital for their labors and births. She says inductions are often unnecessary and that women should know all their birth options.

“If the doctor says, come in Thursday morning for an induction, you say, ‘I’m just not ready,’” she said. “And the doctors have to go along with that as long as the baby is safe.”

In fact, Hartley recommends some moms hold off on inducing labor until week 42, which is considered overdue. Women give birth between 37 and 42 weeks, a timeline that has been up for debate recently, with some experts wanting to re-define what “term pregnancy.” Most women have a due date set for 40 weeks gestation.

Doctors and parents want the same thing

Conflicts arise when doctors and mothers disagree on the best way to deliver a healthy infant.

“It’s safe to say that mothers and fathers want a very happy and healthy delivery and as healthy as a baby as they can get,” said Dr. David Finke, an OB/GYN who delivers babies at Cedars-Sinai Medical Center in Los Angeles. “When you have a baby and you’re in labor, you’ve been thinking about how it’s going to be for nine months. And if isn’t exactly how you think it’s going to go, you may not be happy.”

Some mothers sign up for an induction and don’t realize what it entails, Finke said. Induction of labor means chemically starting contractions with intravenous medicine: usually Synthetic Oxytocin or Pitocin. These synthetic hormones get women into labor faster than mother nature does.

If your labor is induced as a first time mom, you double your chances of having a cesarean section.

Finke and other doctors, including Lagrew from Orange County, said natural labor should be the preferred method of delivery in most cases.

“The greatest gift in the world is a spontaneous labor,” said Lagrew. “It’s the shortest. It’s the easiest. There’s the least amount of pain.”

It is also the cheapest. The longer women have to stay in the hospital, the more money it costs, said Aaron Caughey, a Maternal-fetal medicine specialist and health economist at Oregon Health and Science University.  

“A lot of labor is one-on-one nursing ... And that’s around the clock,” Caughey said. “So, you’re paying somewhat continuously around the clock.”
Hospitals in California and around the country are starting to clamp down on what they’re calling early elective deliveries. That is, scheduled births before 39 weeks done without a medical reason. Last week, the Obama administration jumped on the bandwagon of limiting early elective births. In California, that charge is being lead by the March of Dimes, California Maternal Quality Care Coalition and others. These groups have been trying to curtail early elective births for years.

Babies born by induction of Cesarean section before 39 weeks are at greater health risks than babies born between 39 and 41 weeks.

“Thirty-six weekers don’t do as well as 37,” Caughey said. “Thirty-seven doesn’t do as well as 38. And even 38 on average doesn’t do quite as well as 39.”

Babies born between 37 and 39 weeks have a harder time breathing and eating. They’re also more likely to end up in neonatal intensive care. Dr. David Lagrew knows something about this. He helped reduce elective inductions at Saddleback Memorial Medical Center.

“I do think we will see the vast majority of hospitals put a stop to elective deliveries less than 39 weeks,” he said.

As for elective inductions after 39 weeks, those are different.

If women are OK with the risks of a potentially more painful and longer labor as well as the risk of Cesearean section for first time moms, Lagrew said elective deliveries after 39 weeks are OK, health-wise. Dr. David Finke from Cedars-Sinai agreed.

“If they’re over 39 weeks and the woman agrees to it, I really don’t think there’s a whole lot wrong with it,” Finke said.

Corrie Carroll, the mother of three in Pasadena, has had two inductions at 39 weeks.

“I support induced births,” she said. “I think 39 weeks is a good time to have baby. It’s really hard at the very end to wait for your baby and to wait for labor. I trusted my doctor. But she never once said that there was a chance that the baby wasn’t ready."

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Lauren M. Whaley

Freelance journalist Lauren M. Whaley is a photographer, radio producer and print reporter specializing in topics related to mental illness, reproductive health care and health disparities. She is also a childbirth photographer.This year, She is working on a series about how low-income parents access care for perinatal mental illnesses. The project is funded in part by the Rosalynn Carter Fellowships for Mental Health Journalism.She was a 2016-17 Knight Science Journalism Fellow at the Massachusetts Institute for Technology.Her work has been recognized by the Association of Health Care Journalists, the Scripps Howard Foundation and the Public Radio Exchange (PRX) STEM story project. She has contributed radio, video, photography and written stories to KQED Public Radio, Southern California Public Radio, the San Jose Mercury News, the New York Times and other media outlets. For six years, she worked as the Center for Health Reporting's multimedia journalist. She is a past president of the national organizationJournalism and Women Symposium (JAWS) and spent her early 20s leading canoe expeditions for young women, including a solo-led 45-trip in the Canadian Arctic. She is based in Los Angeles.

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