When I was in medical school, residency and fellowship (the entirety of the 1980s and early 1990s), I recall 80% of babies being born following an uneventful pregnancy precisely when it was their time (39-41 weeks gestation), with little or no pharmacological or surgical help from the obstetrician. Given the uncertainty of when (exactly) that baby would be ready within that two week window, the OB practice had an obstetrician in the hospital 24 / 7 / 365, in order to accommodate any timeline the baby wanted, or emergencies encountered.
Then I entered fee-for-service practice (FFS) here in Atlanta in 1992 and saw something VERY different. Often the obstetrician was not in the hospital. And worse, sometimes the baby’s delivery was “scheduled” prior to full term (39 weeks) – the mom-to-be checked into the hospital at 7am on a given day, delivering the baby that afternoon, following the administration of labor-inducing drugs, which led to Cesarean Section more frequently than during my training.
I was given varying explanations by the labor nurses for the excessive medical/surgical intervention: (1) mom wanted to ensure the presence of grandparents to help the first week or two (~5% of the time according to later studies), or (2) the solo-practice or small-group doctor wanted to “control the delivery” in order to have a civil work-life (minimize night-time deliveries), or be the one to deliver the child rather than a competing obstetrician (self-serving financial interests). Such “convenience deliveries” put babies (and sometimes moms) at risk. This observation, among many others, drove me from FFS into Permanente Practice in 1994.
Thankfully, many hospitals in the US are putting an end to such poor practices. A study recently published in Obstetrics & Gynecology, led by a physician well known for his work in this area (Dr. Bryan Oshiro of Loma Linda University), reported that participating hospitals reduced the rate of these medically unnecessary early deliveries from 28% (!) to 5% of all deliveries. Other hospital systems have reduced these unnecessary early deliveries to <1%. As a result, the number of weak babies admitted to the NICU fell. The Caesarean rate fell too. Baby brain function appears to be better (lower cerebral palsy rates) the closer the delivery to 40 weeks gestation.
The story of how Dr. Oshiro and colleagues achieved this result is worth noting. They used strategies for patient and doctor education/communication, empowerment of L&D nurses to stop an elective delivery that does not meet medical-necessity criteria, and process improvement techniques, all led by physicians and nurses, collaboratively. And by the way, it all started with Evidence-Based Medicine (see my recent posts on EBM).
Our PMG Obstetricians have always believed “Healthy Babies are Worth the Wait” (the March of Dimes campaign for eliminating convenience deliveries). Throughout the history of our PMG practice in Atlanta, our obstetricians have been in the hospital 24 / 7 / 365, patiently attending to women in labor, delivering their baby on the baby’s schedule, not ours. Our primary Caesarean rates are naturally lower too. Women who want caring, thoughtful, effective obstetrical care should choose a Permanente obstetrician, like Dr. Sharon Smith of our Alpharetta office.