"When doctors who treat pregnant women recently met to debate the best time to induce labor they came up with a surprising answer  weeks  three weeks earlier than currently recommended. Their organization the American College of Obstetricians and Gynecologists ACOG has not changed its guidelines  http lateterm pregnancies. The guidelines say that doctors may consider elective induction at  weeks and should proceed with it at  weeks. But the question has some doctors reconsidering their assumptions about induction and has sparked criticism by women who contend there is already too much interference with uncomplicated pregnancies. The question was presented in May at the yearly ACOG meeting in Washington Why not induce everyone at  weeks Two doctors had been asked to debate Errol Norwitz chairman of obstetrics and gynecology at Tufts University School of Medicine and Charles Lockwood dean of the Morsani College of Medicine at the University of South Florida. Heres whats being done to lower the maternal death rate https_story.html  My original assumption when asked to participate in this debate Lockwood said was that Dr. Norwitz would take the pro side since he has written about the risk of stillbirth after  weeks and I would take the con side since older literature suggested that Csection rates would likely be higher in the elective induction of labor at  weeks. Norwitz was a vigorous proponent. There is no benefit to the fetus waiting beyond  weeks in welldated pregnancies he told the doctors. And as Lockwood reviewed research he found that he was more and more in agreement with that point of view. But Errol and I decided we would not tell each other which side we were taking in order to conduct independent assessments of the literature and report on our conclusions Lockwood said. Beyond adding an element of suspense this strategy allowed us to come to unbiased conclusions. After Lockwood found that recent studies suggest that elective inductions at  weeks decrease Caesarean delivery rates and might reduce the rate of infant and maternal complications what was supposed to be a debate proceeded as a discussion in support of induction. Before either doctor spoke the audience in a crowded ballroom was polled  percent opposed having most women deliver at  weeks  percent supported it and  percent were unsure. Norwitz argued against simply letting nature take its course. Nature is a terrible obstetrician he said referring to the continuum of pregnancy and birth the large number of zygotes that never implant the  percent lost before  weeks and stillbirth. And he said the risk of stillbirth and neurological injuries rises after  weeks. Stillbirth is a hugely underappreciated problem he said. There are anywhere between  to  stillbirths a year in the United States. Lockwood and Norwitzs support for induction at  weeks not only surprised many of the doctors at the session it also upset those who believe less intervention is the safest route for mother and baby. Labor may be induced by breaking the amniotic sac or by using hormones called prostaglandins or medication such as oxytocin which can set off contractions. Labor can begin immediately or take a day or two if it becomes too lengthy Caesareans are performed. Cristen Pascucci an advocate for giving women more control over childbirth decisions thinks the doctors remarks suggest that all babies need to be rescued by birth creating an antiwoman mentality. Its as if women and their babies are fundamentally in opposition to each other and the female body is dangerous by design said Pascucci a vice president of the advocacy group Improving Birth. Pascucci who is based in Lexington Ky. travels the country speaking and consultingon issues related to birth rights. She said the induction recommendation reinforces a centuryold prefeminist American obstetric view that birth is pathological and the doctors job is to extract the fetus from the incubator  like in the s when every baby was pulled out of its shackled unconscious mother by episiotomy. Consumer groups such as hers she said have been calling on ACOG to evolve toward care that is more centered on women. Its disheartening to see how hard thats going to be for some physicians to do. Lockwood and Norwitz are aware that there is strong opposition to induction at  weeks. I think a lot of this gets very emotional Norwitz said. Although both doctors support induction at  weeks for all healthy pregnancies Lockwood said that obstetricians shouldnt routinely adopt the practice just yet. As with any change in standard medical care extensive research is needed before it can be safely and widely adopted. Even so Norwitz thinks that its a very healthy discussion to have. Due dates are calculated  weeks from the first day of a womans normal menstrual period and according to ACOG full term is defined as a pregnancy that lasts between  weeks and  weeks and six days. As he prepared for the debate Lockwood created a microsimulation model to predict the outcome of various care decisions and results suggested lower rates of stillbirth Caesarean delivery and maternal and neonatal complications for elective induction at  weeks. That prompted him to take the debate stage as a proponent of early induction. Still he was surprised by an audience poll at the end of the discussion  percent now supported the idea that women deliver at  weeks  percent remained unsure and only  percent were against the idea. I didnt understand the pressure to have a Csection until I was about to deliver https_story.html  Traditional medical thinking assumes that early induction could lead to higher infection rates and the need for a Caesarean. But Norwitz said the evidence doesnt support that. Rather he said the latest literature suggests that the drugs available to soften the cervix in preparation for contractions help to decrease the Caesarean risk adding a small caveat For a small number of firsttime mothers with unfavorable long and hard cervixes  as opposed to cervixes that are soft and receptive to induction  the risk of Caesarean is increased. Rebecca Dekker who has a doctorate in nursing and founded the website Evidence Based Birth which aims to make research on childbirth more accessible to families and professionals watched a live stream of the session and described the presentations as misleading and the research as flawed. She called it concerning and rash for doctors at the meeting to make broad conclusions that could potentially affect at least  million women a year in the United States alone. Norwitz said that the presentations were evidencebased. This is my interpretation of the published literature he said. This is not a personal opinion based on belief or ideology. Lockwood said he finds pushback inevitable and part of the broader scientific process. Dekker said there were flaws in the research showing that women who received elective induction had lower rates of Caesarean delivery. For the women who waited for labor to start on its own about half ended up being induced for medical complications. They still analyzed the data as if the women had spontaneous labor so it sways the results of the studies she said. Dekker isnt disputing that there are about  stillbirths per year or that this is a concern. However she said a Centers for Disease Control and Prevention report  http_.pdfshows about half of stillbirths occur between  and  weeks of pregnancy and the other half at later points. Its obvious that a blanket policy of week inductions would not affect all of the stillbirths that happen before  weeks Dekker said adding that the CDC report concludes Despite intensive investigations for a substantial number of fetal deaths a specific cause of death cannot be determined. And Dekker said the public has the misconception that inductions are simple noninvasive procedures. Pitocin the most commonly used drug for induction is classified as a highalert medication that can increase the risk of patient harm if an error occurs. The drug can cause contractions that are too frequent increasing the risk of decreased blood flow and oxygen to the baby she said. Also the drug can cause the placenta to detach from the uterine wall too early and it can cause the uterine wall to tear. For Dekker the major benefit of spontaneous labor is avoiding the risks of a medical induction. There are clear philosophical differences. One early morning in his hospitals labor and delivery unit Norwitz said he spoke with a midwife colleague who compared labor to walking through a forest. We midwives stand behind the patient and if she gets off the path we coax her back onto it she told him. Obstetricians are in front of her hacking through the forest. Esther Hausman a certified nurse midwife in Concord Mass. argues for restraint. Since we dont know exactly what triggers labor why mess with it Hausman suggested learning from countries such as Denmark or Sweden where midwifery is the first line of care and where fetal and maternal mortality rates are lower than in the United States. In a  CDC report  http_.pdfthe U.S. infant mortality rate . per  births put it in th place among a selection of developed countries. Finland and Japan had the lowest rates . per  births. Dekker said that the ACOG debate should have instead compared the medical model of care to midwifeled care. Midwives are less likely than doctors to induce a woman electively she said and studies http have found they intervene less than doctors and have moresatisfied patients. Beverly Siegal a retired obstetriciangynecologist in Newton Mass. attended the debate and was among those who changed their thinking on induction. What changed my opinion at the end of the presentation was the really convincing argument that there is nothing gained for the baby to stay in beyond  weeks Siegal said. I would personally recommend that any woman with a favorable cervix at  weeks be encouraged to get induced. Of course Lockwood said women should be heard. Finally needless to say it is expectant mothers that should have the final say as to whether to let nature take its course or undertake this potentially salutary but clearly artificial intervention he said. But obviously our messages  how you talk  does make a difference Norwitz said."