This past September, news hit the popular media that several Oregon state hospitals introduced a 'hard stop' on elective deliveries - including elective cesarean sections - prior to 39 completed weeks of gestation, with the potential to decrease the incidence of late term premature birth - birth occurring between 37 and 40 weeks (Flam, 2011). This topic was discussed heavily in last week's series by Christine Morton and Kathleen Pine. This step, championed by the local March of Dimes chapter, adds Oregon to a small list of other states, including California, Texas, New York and Illinois, that have seen similar bans implemented. As governmental organizations and public advocacy groups further strive to improve maternal outcomes in our country, replication of this policy across all fifty states is a lofty goal.

In order to implement a nation-wide ban on elective deliveries, we can argue a state-by state approach, beginning at the institutional level, and expecting a very gradual process. Pairing the strength of interest group mechanics (and lobbying power) with the state law-making process, organizations such as Lamaze International, The March of Dimes, Childbirth Connection and the American College of Nurse Midwives could join forces to encourage policy change at individual institutions prior to pairing with state legislators in the bill writing process. Let's call this policy, 'No Elective Birth Before Forty (weeks)' (NEBBF).

By initiating an NEBBF policy locally, geographically influential maternity care facilities would be targeted and guided by interest group leaders to establish a trial period in each facility. The trial period would give facility administrators time to develop and implement training for their maternity care providers and support staff into the benefits of and goals for banning elective labor induction and surgical birth prior to 39 completed weeks. Touch points might include avoiding: uterine hyperstimulation and its deleterious outcomes; progression of a cascade of interventions, including their associated risks; and increased risk of cesarean delivery in the nulliparous (first time) woman (Shialang, et al. 2007; Simpson & Atterbury, 2003). An important component of this first phase would be acute data collection in the form of tracking changed rates of complications associated with elective induction and cesarean surgery, prior to 39 completed weeks. Anticipated changes might include: decreased exposure to analgesia during labor, fewer cases of postpartum hemorrhage, fewer cases of amniotic fluid embolism - a largely fatal occurrence that has been associated with labor induction - and decreased incidence in cesarean surgeries (particularly for nulliparous women) (Hofmeyer et al. 2005; Kramer, 2006).

A second and equally important component of this first phase of policy implementation would be consumer education. Popular media coverage and educational pamphlets distributed by maternity care practices and facilities could be harnessed to increase public awareness and understanding of the timing and reasons behind the NEBBF ban (Simpson & Thorman, 2005).

Following successful implementation of this ban at the institutional level, the aforementioned public interest groups and maternity care administrators could approach state legislators, seeking support in drafting a bill which would expand this ban to a state-wide policy.

Potential opponents to this policy might range from individual citizens - pregnant women and their partners who prefer the option of delivering at convenience - to maternity care providers who maintain a higher degree of comfort with the risks associated with elective delivery. Interest groups like the American Civil Liberties Union could pose a threat to implementation of this policy, citing an invasion of privacy upon a woman's right to electively complete her pregnancy during this controversial late preterm, or term, point in time.

As Kersh & Moron (2002) point out in their article, The Politics of Obesity: Seven Steps to Government Action, implementing a policy which restricts an individual's right to make a personal choice (like the timing of their baby's birth, within reason) also opens up the door to more than just a dissenting attitude about such a policy. In our highly litigious society, law suits aimed at preserving a woman's right to make this choice become a very real possibility.

Another foreseeable challenge to an NEBBF policy includes the political environment in which it might be implemented. Proposing a policy that enables the government to disallow such a personal choice as labor induction or elective cesarean surgery would likely incite vigorous public debate over individual rights versus governmental police power.

Lastly, considering the current economic climate, politicians and private sector stake holders are more likely to disagree with the importance of reducing labor induction and cesarean surgery rates and may argue that this 'discretionary' topic be tabled in exchange for other more pressing issues.

[To read this series from the beginning, go here.]

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Posted by: Kimmelin Hull, PA, LCCE, FACCE

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