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All in good time

As induced labors have increased, so have the questions. Now some hospitals say nature should take its course.

August 13, 2007|Shari Roan | Times Staff Writer

Her first baby wasn't due for four days, but Misa Hayashi was advised by her obstetrician during a routine exam to check into the hospital that day.

"The doctor said the baby was too big for me to push out and we should go ahead and induce labor," says the Alhambra woman, 24. "I didn't really question it. Induction sounds so common. We went home and packed a bag and checked in at the hospital."

Once there, however, Hayashi's plans for an uncomplicated birth faltered. After receiving the drug Pitocin to trigger contractions, she labored for 20 hours. The pain was so intense she needed medication to ease it -- something she had hoped to avoid -- and eventually the baby became distressed, requiring constant monitoring of his heart rate.

Finally, almost a day after Hayashi entered the hospital, her son was born. Although he was healthy at 7 pounds, 10 ounces, Hayashi was left questioning the wisdom of labor induction.

Some hospitals and healthcare organizations across the nation share her concerns. Several have barred elective labor induction under certain circumstances, such as before 39 weeks of gestation (one week before the due date) or when there isn't clear evidence that the mother's cervix is primed for childbirth.

"There is renewed interest in these seemingly benign medical interventions," says Dr. William Grobman, an assistant professor of maternal-fetal medicine at Northwestern University. "But the topic is somewhat hazy. We don't have all the information we'd like to have about risks and benefits."

The move appears to be a push back against the trend in recent decades to medically manage childbirth. Fewer than 10% of women underwent induction in 1990, but more than 21% did so in 2004, according to federal government statistics. No one knows how many of those inductions were prompted by legitimate medical concerns. But various studies have put the number of inductions for convenience at 15% to 55% of the total number.

At the same time, rates of caesarean sections increased to more than 29% in 2004, up from 23% in 1990, with many women requesting elective C-sections -- surgical births without any medical justification. That trend too has generated debate about whether patients are undertaking unnecessary risks.

Labor induction is frequently, and legitimately, recommended when health problems complicate a pregnancy or when pregnancies are more than two weeks past the due date, obstetricians and gynecologists say. But sometimes the procedure is done solely for convenience. In a busy society, doctors and patients have grown increasingly comfortable with this practice.

"People want to schedule their birth like they schedule their nail appointments," says Janie Wilson, director of nursing operations for women and newborns at Intermountain Healthcare, a Salt Lake City-based chain of hospitals that has tried to reduce the rate of labor inductions.

Until recently, few have questioned whether elective labor induction is appropriate. "There is not a unique description of elective labor induction that every single provider can agree on," Grobman says. Indeed, the practice appears to vary widely among patients, doctors and hospitals. According to the national figures, for example, labor induction for both medical and nonmedical reasons occurs in 25% of white women but in only 18% of black women and 14% of Hispanic women. And a study published in 2003 in the journal Birth found that the percentage of inductions that were elective varied from 12% to 55% among hospitals and from 3% to 76% among individual doctors.

But some experts say the practice creates unnecessary risks and costs. It can lead to more interventions, such as caesarean sections, and increased use of forceps and vacuum devices to assist in delivery, research has shown. A 2005 study in the journal Obstetrics & Gynecology found that C-sections occurred 12% of the time among women having spontaneous labor compared with 23.4% for women having medically necessary labor induction and 23.8% for women having elective labor induction.

Other studies have found that, compared with spontaneous labor, elective induction leads to longer hospital stays and higher costs. Induced labor also may be more painful because some of the drugs administered to trigger labor can cause more intense contractions.

The risks of C-section or other complications appear highest when induction is performed before 39 weeks and in women who have not had a previous vaginal birth.

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Charting a new course

Now, some hospital administrators are saying, "Enough." Intermountain Healthcare, which operates 21 hospitals in Utah and Idaho, implemented strict guidelines on elective labor induction eight years ago. Today, the company's results are held up as a model for reining in birth practices that cannot be medically or financially justified.

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