A two-year effort in Washington state shows the possibilities of such an approach. After studying records from across the state, Washington health authorities concluded that 15 percent of the 80,000 annual births were elective deliveries at 37 to 39 weeks; no medical reason for a C-section or induction was given.
To discourage unnecessary surgeries, the state shaved off $1,000 from the $7,000 to $10,000 in Medicaid payments hospitals received for uncomplicated C-sections, saving $3 million a year. (Medicaid covers about half of all births in Washington, as in the rest of the country.)
On top of this disincentive, an incentive was added. The state Legislature created a $10 million reward to be shared by hospitals that showed marked improvement on five patient-health measures, including reducing optional early births. Consequently, hospitals began requiring physicians to document a medical reason for every delivery before 39 weeks; others required all such births to be approved by a senior medical officer. For some, educating staff about the risks of delivering at 37 to 39 weeks was sufficient to bring rates down. Significantly, the effort is led by a committee, the Washington State Perinatal Collaborative, that includes doctors.
The initiative's results have been impressive. Elective early deliveries have been reduced 77 percent, from 15 percent of births to 3.4 percent; in the last year, 600 babies who would have been delivered before 39 weeks were born after. The perinatal group is using data it collected on C-section rates to help hospitals and physicians zero in on best practices.
A handful of other states are experimenting with measures to reduce optional early births. Others should look to Washington's proven success and model the virtues of its program.