Recent research shows that the final stretch of the long haul of pregnancy is a time when important organ development occurs in the lungs, eyes, ears and brain, and that late preterm infants -- those born just one to three weeks too soon -- are also at greater risk for later learning and behavioral problems .
The costs to society of preterm births in 2006, when the number peaked at 12.5 percent of all births, was $26.2 billion, according to a report by the Institute of Medicine. The number is dropping, down to 11.7 percent in 2011, the lowest rate in a decade, according to the March of Dimes , which, in partnership with the U.S. Department of Health and Human Services, is working with hospitals and health educators to raise awareness about the importance of carrying pregnancies to no less than 39 weeks
"So far, it appears that the attempt to reduce prematurity is also reducing C-sections," says McCabe. While surgical deliveries still account for almost a third of births in the United States, the numbers have remained steady since 2009, following 12 years of consecutive increases. Costs differ dramatically across the country, but the average hospital cost of vaginal delivery without complications in the United States is $2,900, while the average cost of a C-section without complications is $4,700, according to the Agency for Healthcare Research and Quality. Complications for mother or baby, NICU stays and additional hospital days add to the price, as do physician fees.
The rate of premature birth is still too high. The goal set by the March of Dimes in 2012 of no more than a 9.6 percent premature birth by the year 2020, so far has been met by only four states: Vermont, New Hampshire, Maine and Oregon.
Good medical reasons exist for both C-sections and early induction of labor. Women with gestational diabetes, high blood pressure and other medical complications, or a fetus showing signs of distress, can mean an early delivery is medically necessary.
But impatience with the discomforts of pregnancy, out-of-town grandparents eager to buy plane tickets, or physicians' vacations are among the motives for scheduling early deliveries. "Scheduling a birth because in-laws are in town, or some other reason for convenience, isn't wise," says Dr. Jane Dimer, chief of Women's Health and Maternity Child Clinical Services for Group Health Cooperative in Seattle, Wash.
Some insurers are beginning to try to lower rates of both premature birth and elective C-sections by penalizing doctors and hospitals for delivering babies earlier than 39 weeks without a medical reason. Medicare, which covers disabled women, now requires hospitals to report their rate of elective deliveries before 39 weeks. In 2015, the federal insurer will fine hospitals whose rates continue to be high, according to Kaiser Health News.
Other insurers are following suit. South Carolina, for example, had a premature birth rate of 14.1 percent in 2010. So last year, both its Medicaid program and the state's largest insurer, Blue Cross Blue Shield of South Carolina, stopped paying for elective deliveries prior to 39 weeks gestation.
Hospitals around the country are gearing up for the change. A recent survey reported by ACOG in May found that two-thirds of hospitals handling non-emergency deliveries have instituted policies to eliminate elective deliveries prior to 39 weeks gestation. Within HCA Holdings, the nation's largest for-profit hospital chain, 90 percent of the hospitals don't allow elective deliveries before 39 weeks. In Washington state hospitals, after a statewide education effort on the risks of late pre-term birth, the percentage of babies born at 37 to 39 weeks due to early induction or scheduled C-section plummeted between 2010 and 2011 from 15.3 percent to 5.4 percent . Using the carrot of incentives, rather than the stick of penalties, the Washington state Medicaid program offers a 1 percent bonus to hospitals that reduce their rates of non-medical early delivery and C-section.