Sarah Biro took her sweet time coming out, but her mother was willing to wait.
“She’s in there for a reason and she’s not ready to come out,” said Ashley Biro, who delivered Sarah in the 42nd week of her pregnancy. “I don’t want to force my body to do something it is not ready to do.”
Soon, expectant mothers in Georgia on Medicaid might have to make the same choice about waiting. Gov. Nathan Deal’s proposed budget for fiscal year 2014 includes a line item under Medicaid that would end coverage for elective births before 39 weeks of pregnancy, or what is considered full-term.
The move would save the state $5.12 million, according to the budget, though others are skeptical about that.
South Carolina Medicaid already has the policy, and discouraging such elective births has long been the position of the American College of Obstetrics and Gynecology and advocacy groups including the March of Dimes.
The Centers for Medicare and Medicaid Services has a campaign to work with states and providers on curbing elective births before 39 weeks in order to prevent medical complications.
However, some obstetricians argue that making it a mandate hampers their ability to work with pregnant women, particularly in areas such as Augusta, where almost all of the surrounding counties lack birthing services and expectant mothers live hours from their provider.
A 39-week rule at one medical center increased the number of stillbirths and heavier babies, according to a 2011 study, while decreasing the number of babies that went to the Neonatal Intensive Care Unit with complications. That kind of trade-off might be inevitable, physicians said.
The rate of women who decided to be induced or have a cesarean section without medical cause between 37 and 39 weeks of pregnancy had been around 10 percent to 15 percent nationally about five years ago, according to the Medicare center.
It was around 12 percent to 14 percent for Georgia, but then the March of Dimes and others began pushing hospitals to agree to a “hard stop” to elective deliveries before 39 weeks without a valid medical reason.
Delivering earlier puts the baby at greater risk for complications, such as short-term breathing problems from immature lungs, said Dr. Alan Joffe, an obstetrician and community medical director for Peach State Health Plan, a Georgia Medicaid Care Management Organization.
That can put the baby in intensive care for two to three days, he said. Keeping a baby out of intensive care saves about $15,000 and means better outcomes for the family, said Dr. Dean Greeson, the senior vice president and chief medical officer at Peach State.
“The 39-week issue caught our attention because it really is a quality of care issue for us and for moms and babies in general,” Greeson said.
Dr. William Barfield, the chairman of University Hospital’s Department of Obstetrics and Gynecology, argues that having a mandate ties physicians’ hands when trying to respond to the individual needs of the mother.
“They would like the opportunity to make decisions between themselves and their patients,” he said.
Many expectant mothers coming to Augusta are travelling a long distance to see their physicians, which puts them in a tricky position if they are close to their due date and in early labor but not quite at 39 weeks, Barfield said. Inducing would allow the birth in a controlled environment as opposed to sending the mother home and having her rush back to the hospital in labor, he said.
“You come flying in, in the middle of the night, deliver rapidly, it’s not healthy for the baby or the mother,” Barfield said. “There’s some healthy things about us being able to make a better decision.”
There are also dangers in waiting too long. A 2011 study published in Obstetrics & Gynecology found that instituting the 39-week rule did decrease the number of children admitted to intensive care from 9.3 percent to 8.5 percent. But the number of stillbirths increased from seven to 17 for the same number of births. That’s what Barfield fears will be the case with a mandate.
“Every doctor has some of those, and those are your nightmare (cases),” he said. “A healthy baby that should be born in a couple of days and you go to do it and it is too late.”
Those issues are legitimate, and while he supports decreasing the 39-week elective rate, Joffe said Georgia physicians might also bristle at a hard and fast rule.
“What the Georgia (Obstetrical and Gynecological) Society is concerned about is penalties to the physician and loss of autonomy to be able to deal with that situation,” he said.
Dr. Paul Browne, the director of maternal-fetal medicine at Georgia Regents Medical Center, said the 39-week rule has already been a success in Georgia as hospitals have implemented it on their own, often in partnership with the March of Dimes initiative.
From that 12 percent to 14 percent rate of elective births before 39 weeks, Georgia is now down to 3 percent, he said, citing data the Georgia Hospital Association released last fall. The rate of stillbirths has been largely unchanged in that time.
For that reason, Medicaid’s projected savings is probably a “gross overestimate,” Browne said. “The savings we’re going to have we’ve realized already.”
But reducing that elective rate clearly results in fewer NICU admissions and fewer C-sections, which is a better use of resources, said Browne, who serves on an advisory committee for South Carolina Medicaid.
“I think that is reasonable,” he said.
It also seemed reasonable to Biro to wait, and to have the birth the way she – and Sarah – decided it should go.
“I think it is important,” she said. “In my opinion, I’d rather be pregnant longer and be uncomfortable and give my baby the best chance. She’s doing good.”