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Childbirth by Appointment

It started as a little joke. Sherry Martin of Tennessee was almost at the end of her fourth pregnancy  -- and the end of the year  -- when she made a lighthearted comment to her obstetrician. "I told him my husband said he might not get paid if he didn't get the baby here before New Year's so we could get a tax deduction," says Martin (whose name has been changed). That's not a problem, her doctor told her. He suggested that he could induce labor on her due date  -- December 31  -- and be perfectly justified in doing so, since her third child had been nine and a half pounds and he wanted to avoid another big baby. "At the hospital, doctors have to give a medical reason to induce," says Martin, "so my reason was that I tend to have big babies."

When the day came, Martin, who'd never been induced before, hesitated. "I thought, 'This is crazy. Why am I doing this?' But I was tired of being pregnant, and it was such a good time, with the kids out of school on Christmas break. You can definitely control things much better when you do an induction."

Martin went to the hospital and was hooked up to an IV of Pitocin, a drug that's often used to bring on labor. Six hours later, she delivered a healthy seven-pound girl. She says she never worried that anything would go wrong with the delivery because she was never told of any potential dangers, such as an increased chance of fetal distress, c-section, and, though rare, uterine rupture, which can be fatal to the baby or mother. "I might not have done it if I'd known the risks," she says now.

Martin is part of a growing number of women who are having inductions, some for medical reasons, some not. The rate of induced births has increased from 18 percent of all deliveries in 1997 to 22% in 2006, according to the National Center for Health Statistics  -- but there's also a trend toward outright promotion of elective inductions, those done mainly for the doctors', or parents', convenience.

Elective inductions increased 15-fold, according to a study by Barbara Yawn, M.D., director of research at the Olmsted Medical Center, in Rochester, MN. "Scientifically speaking, no more than ten percent of birthing women should be induced," says Marsden Wagner, M.D., former director of women's and children's health for the World Health Organization. "What this means is that our rate is more than double what it should be. That's something to be very concerned about." According to Dr. Wagner, the rates of induction in other highly industrialized countries, such as England and Sweden, are between five and ten percent of births.

In a study published in the American Journal of Obstetrics and Gynecology, induction rates were more than twice as high for patients at private hospitals as for those at government-owned hospitals. They were also higher for mothers with some college education and those with private insurance, as opposed to Medicaid.

At the Chicago obstetrics practice of Lauren Streicher, M.D., for example, almost 50 percent of her patients are induced. "Patients come to us because they know we're okay with a more controlled situation." She says her clients are affluent women who tend to want to be in charge of things a little more  -- their return to work, childcare for their other kids. "They have more of a relationship with their physician," she adds, "and there's more of an emphasis that they want 'Dr. X' to deliver."

Dr. Streicher is a firm believer in elective inductions; she says that when the baby's head is in the pelvis and the cervix is ready  -- soft and sufficiently effaced and dilated  -- inducing is no more dangerous than spontaneous labor. "It's natural for some women to want to control this process as much as possible," she says, noting that she won't do an induction before a woman is 39 weeks along, for fear of delivering a baby who's not mature enough.

Other doctors claim that such attitudes are behind the boom in inductions and present a threat to women and their babies. "The procedure should never, ever, be done if the risk of induction is higher than the risk of staying pregnant," says Charles Lockwood, M.D., a former chair of the committee on obstetrical practice for the American College of Obstetricians and Gynecologists (ACOG), which officially discourages elective inductions.

"The body is not a machine; you can't just punch in numbers and it will deliver a baby," says Robbie Davis-Floyd, Ph.D., an anthropologist at the University of Texas who specializes in the study of birth and medicine. "I believe childbirth should not be overmedicalized and that, in most cases, the body knows best."

Dr. Streicher dismisses this notion. "If the body knew best, there wouldn't be stillbirths or preterm births," she says, pointing out that nature can make mistakes in any circumstance. "It's okay to give the body a push, as long as you're careful."

Dangers Ahead

The major concern about the induction explosion is that even when well-meaning doctors induce labor according to their definition of "careful," problems may develop. "Once you start an induction, there is a cascade of interventions that follow," says Karen Swenson, M.D., an obstetrician in Austin, TX. An induction increases the chance that a laboring woman will need an epidural, a forceps and vacuum extraction, and an episiotomy. There is a greater risk of fetal distress, and induced births also lead to longer hospital stays and a higher cost of care for mother and baby, according to Dr. Yawn's study.

Plus, an induction might fail because a woman's cervix isn't ready and drugs can't kick-start the body. In this case, the patient would be sent home  -- even if her water had broken, barring signs of infection or fever  -- to wait for labor to begin.

Four out of six major studies on the subject found that inductions increase c-section rates as well  -- by as much as three times. (The two others found no significant increase.) However, another study published in Obstetrics & Gynecology found that the risk of c-section isn't increased by labor induction alone but rather when a woman is induced on her first delivery or when her cervix isn't ready.

Dr. Lockwood says a woman induced before 41 weeks also has a greater chance of a c-section, as does a patient whose baby goes into distress during labor. "If Pitocin is given at too high a dose, contractions will come one right on top of another, which doesn't give the fetus  -- or the mother  -- time to rest," he says. "This can cause acid levels to build up in the fetus and oxygen levels to drop."

But, says Dr. Streicher, in a recent two-year period, she didn’t perform a c-section on any patient who's undergone an elective induction. She believes ACOG and other organizations discourage such procedures because many doctors might not be as cautious as she is in only inducing women whose cervixes are ready, and because inductions generally are more expensive.

Who's Pushing Whom?

It's not clear who is fueling the jump in inductions: doctors or patients. Critics charge that some ob-gyns are selling women on inductions so that the baby can come on a more convenient timetable  -- or may, at the very least, be failing to discourage the procedure by glossing over the risks involved.

Dr. Wagner calls the practice of managing deliveries so that babies are born during business hours "daylight obstetrics." "The average obstetrician has a plate that's overflowing, with all the different types of work  -- from gynecological surgery to family planning to preventive gynecology," he says. The greatest thorn in an ob-gyn's side is normal birth, which can take on average 12 or more hours, and it happens 24 hours a day, seven days a week. So, he contends, some obstetricians solve this by inducing births. Statistics show that far more babies are born on any weekday than any weekend day, and the numbers born on weekend days have dropped over the past ten years.

What may have emboldened doctors to induce more births is a change in ACOG's recommended practices. Although the guidelines used to forbid inductions not done for medical reasons, the wording was later altered to allow doctors to do the procedure when a woman lives far from a hospital or for "psycho-social" reasons. Dr. Lockwood says an example of this is a woman who had a stillbirth earlier and is afraid to go to term  -- but he admits the wording could be misinterpreted.

And it may be the patient pushing for the induction. "I begged and pleaded with my doctor to get it out," says Debi Strydom of Cottage Grove, MN, referring to her third child, who was ten days overdue when her reluctant doctor finally agreed to induce. "It was uncomfortable for me to walk or even cough. I had morning sickness all day long through my pregnancy. I got to the point when enough was enough."

Doctors say they hear such pleas regularly. "Sometimes, patients do a lot of arm twisting trying to get you to induce," says Ashley Hill, M.D., an obstetrician in Orlando, FL. "When a patient begs for an induction, it wears on the doctor. There are mothers who want to conceive on the fourth of August and deliver on the ninth of April. Childbirth just doesn't work that way."

Some of the most common reasons women ask for the procedure, according to the doctors who were interviewed, are that they're tired of being pregnant, their husband is traveling, or a relative is visiting and wants to see the baby. Dr. Streicher says almost 90 percent of inductions she performs are on women having their second or third baby; they may need to arrange childcare, or they live far away from the hospital and want to get there in time for an epidural.

"When a patient wants an induction for a nonmedical reason," says Dr. Hill, "I always say, 'If you have to get a hysterectomy because your uterus ruptures, will having a relative see the baby still seem important?'"

"It's odd because so many mothers won't drink alcohol or eat anything bad while they're pregnant, and then they'll do something that may hurt them during labor," says Dr. Yawn. "We don't need to stress babies for the comfort and convenience of the doctor or the mom."

 

For women who ask to be induced, says Richard Roberts, M.D., former president of the American Academy of Family Physicians, "it seems like an easy, safe end to nine months of feeling like a beached whale. They need to understand that inductions are not so easy  -- the average one is twenty-four to thirty-six hours  -- and come with risks. They may not be so enthusiastic then."

Nor might they be if they knew about the pain. Many women who have experienced both induced and spontaneous labor say that the pain is more severe during an induction. Most obstetricians agree, noting that the contractions are more intense and come closer together. Dr. Lockwood says that the strength of contractions when an induced woman is one centimeter dilated can be the same as that experienced at eight centimeters by a woman not induced. "The contractions when I went into labor on my own were so much more manageable," says Karen Akins, whose first baby was induced, but her second was not. "It was like a wave of pain, with peaks and valleys, and I had time to recover between each one. With Pitocin, they were almost violent and came one after another without a break."

A Management Question

There's been a change in the way doctors handle deliveries, and researchers point to this as a factor in the increase in inductions. This includes inducing women earlier when they are past their due date and not waiting if their water breaks and they don't go into labor on their own. Plus, says Dr. Lockwood, "More older women are having babies, and they have an increased risk of complications  -- such as toxemia and gestational diabetes  -- that can lead to inductions.

The most common medical reason for the procedure is that a woman is overdue. For years ACOG has recommended inducing when a woman's pregnancy has lasted 42 weeks  -- or two weeks past the due date  -- because it was determined that the incidence of stillbirth increased after this point. But recent research shows that the average induction is at 41 weeks. Dr. Lockwood says this is because statistics show that a significant number of stillbirths occur in babies born between 41 and 42 weeks. Doctors are making an "educated guess based on the latest information," he says.

Women are being induced for going past their due date even before they reach 41 weeks, according to Dr. Yawn's study. "Doctors may reason that induction at forty or even thirty-nine weeks' gestation may prevent even more fetal deaths," she says, adding that research doesn't support this theory.

Even though due dates are just estimates  -- and first pregnancies commonly go long  -- some women report feeling pressure for an induction soon after their due date passes. "My doctor started to talk about an induction when I was two days past my due date," says Martha Outlaw, who has a daughter, Isabelle. "But I didn't want to be induced. I have a feeling that nature and your body know what they're doing and if they don't start labor on their own, you might be missing something. I hadn't heard much about induction problems, but I felt like 'Hey, maybe my due date is off, but maybe she wants to cook some more.'" Outlaw told the doctor she wanted to wait, but then had to be induced ten days later, after her amniotic fluid began to leak.

Another contributing factor in the increase in inductions: Doctors are now more apt to do the procedure when a patient's water has broken prematurely rather than wait for her to go into labor on her own (a majority will do so within 48 hours). The risk of waiting is that she's more susceptible to infection without the barrier the membranes provide. Although ACOG suggests that a baby should be born within 24 hours of the membranes' breaking, Dr. Lockwood says that new concerns about infection and strep sepsis have pushed some doctors to induce after 4 to 6 hours (he prefers to wait 12 hours in his practice).

Another growing justification for inducing is a suspected large baby. According to Dr. Yawn, these cases have increased 22-fold in recent years. Some doctors think if they estimate that a woman will have a large baby, or if her previous ones were big, inducing before term will get the baby out before it grows too large, thus helping to avoid a c-section.

But, says Dr. Lockwood, "There's not a shred of evidence that this reduces the c-section rate or benefits women. ACOG strongly discourages it." One reason: It's difficult to correctly guess a baby's weight in utero. Half the time Dr. Lockwood thinks a baby will be big, he says, it's not.

Says Dr. Yawn, "I think saying that a baby is big is an induction in search of a reason." Making such a determination helps doctors bypass the rules at many hospitals that forbid inductions for anything but a medical reason.

Most of the doctors interviewed  -- no matter their viewpoint on the issue  -- advise women to discuss the risks with their maternity caregiver before agreeing to an induction. "If a doctor's doing right by women and babies, there needs to be a thoughtful conversation with the family about induction," says Dr. Roberts, "so everyone knows what they're getting into." That seems to be the very least a mother should expect.

Jeannie Ralston is a contributing editor to Parenting.

 

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