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As early elective births increase so do health risks for mother, child

Michelle Van Norman's son, Christian, was born 11 days early by C-section, though there were no medical reasons for early birth.Michelle Van NormanMichelle Van Norman's son, Christian, was born 11 days early by C-section, though there were no medical reasons for an early birth.

The number of women giving birth early – often for no medical reason – has increased dramatically over the past two decades, altering the way we bear children and posing new health risks to both mothers and newborns, experts say.

The average time a fetus spends in the womb has fallen seven days in the United States since 1992, according to researchers and data from the Centers for Disease Control and Prevention. Experts call this trend an “evolutionarily dramatic event.”

Researchers say shorter pregnancies coincide with a large number of women and doctors now scheduling childbirth for convenience. One study of nearly 18,000 deliveries in 2007 showed that 9.6 percent were early births – through scheduled inductions or C-sections – for nonmedical reasons.

Shortening a pregnancy could affect a baby’s lung development, vision, weight, and some fine-tuning of the brain, experts say. Babies born too early often sleep longer than normal and have trouble learning how to breast-feed, causing dehydration and jaundice.

“For every day and every week before 39 weeks, it's an increasing risk to the baby,” said Dr. Bryan Oshiro, vice chairman of obstetrics and gynecology at Loma Linda University. “The vast majority of early term babies do fine, but it's like playing Russian roulette.”

California Watch reported in September that women are significantly more likely to experience C-sections at for-profit hospitals across the state. In February, California Watch reported that the number of women who die each year from causes directly related to childbirth had more than doubled in California since 1996. 

The rise in deaths during childbirth is an indicator that obstetric health has deteriorated in many important ways, according to the California Maternal Quality Care Collaborative, a task force of medical researchers. 

The group has recently focused its efforts on the number of babies delivered for nonmedical reasons before they would naturally arrive. For the most part, the public has been left in the dark; the problem has been confined to articles in medical journals and among maternal health experts.

The normal length of pregnancy is 40 weeks, although researchers believe induced delivery at a full 39 weeks is probably safe. Women often naturally give birth earlier than this, and in some cases, medical problems require an early delivery. The problems come when babies are born before they are ready.

Of all births between 1990 and 2006, the number of babies born at 36 weeks increased by about 30 percent, and babies born at 37 and 38 weeks rose more than 40 percent, according to national vital statistics. There was a corresponding drop in the number of babies born in later weeks. There are now more babies born at 39 weeks than at full term.

The data examined is considered fresh by academic standards and covers such a long period of time – 16 years – that experts say the trend is unmistakable.

“The entire bell curve has shifted,” said Dr. Jeanne Conry, California district chairwoman of the American Congress of Obstetricians and Gynecologists

Some early births are scheduled for the convenience of the mother or doctor; some are judgment calls that require weighing relative risks. 

A California Watch inquiry through the Public Insight Network, which solicits observations from people around the country, asked mothers around the country about their experiences with early deliveries. The questionnaire elicited responses from more than 300 women and produced several cases in which mothers said their doctors had pushed for early births.

One mother, Michelle Van Norman, gave birth to her second child, Christian, 11 days early in 2006, despite no urgency noted on her medical records. The doctor wrote on her chart: “This is a pleasant white female in no apparent distress.” 

Van Norman, a 31-year old mom, living in Las Vegas, said her doctor didn’t seem worried about the delivery date.

“There were no medical reasons for the delivery being early,” Van Norman said. “He told me the week he could do it and asked me to choose which day was best for us.” 

After his birth by C-section, one of Christian’s lungs collapsed. He spent three weeks in intensive care and 10 days on a ventilator with six tubes going into his chest. It’s unclear what caused Christian’s lung to collapse, but this condition is strongly associated with early childbirth.

“The whole experience was horrific,” Van Norman said. “It didn't end with the birth it continued for the first year of his life, and we still don't know if the oxygen deprivation has had any affect on him.”

When Van Norman’s surgeon cut the cord, Christian seemed robust. The doctor declined to comment about the case.

“The doctor came in the day after and asked where the baby was,” Van Norman said. “When I told him, he asked me if I was joking. … I swore from that day on I would never put another baby through that kind of torture for any reason.”

Raising awareness

Babies born early through induction or C-section without a medical reason are nearly twice as likely to spend time in the neonatal intensive care unit, researchers say. They also are more likely to contract infections and need the assistance of breathing machines, according to a 2009 study in the New England Journal of Medicine and a number of other reports. 

“We are finding out that the last weeks of pregnancy really do count,” said Leslie Kowalewski, an associate state director for the March of Dimes. “At 35 weeks, the brain is only two-thirds of what it will weigh at 40 weeks.”

Many organizations are responding with programs designed to eliminate early elective deliveries. Most significantly, chapters of the American Congress of Obstetricians and Gynecologists have begun to notify doctors about the serious consequences of performing early elective births.

In California, the state Department of Public Health, March of Dimes and California Maternal Quality Care Collaborative have released what its authors call “the Toolkit,” which makes the case that, unless medically necessary, cesarean sections and artificial induction of labor before full gestation should be eliminated.

The state chapter of the American Congress of Obstetricians and Gynecologists has thrown its weight behind this recommendation and is taking measures to see that it is carried out, holding teaching sessions and reaching out to obstetrics leaders at every hospital in the state. 

“Nothing on this scale has ever been done before in California,” Conry said. At the same time, physicians groups are rolling out the toolkit’s guidelines in New York, Florida, Illinois and Texas.

The authors of the Toolkit note that rates of medically induced labor more than doubled between 1989 and 2004. The increase in deliveries between 37 and 39 weeks “has been associated with an increase in obstetrical interventions such as induction of labor and cesarean sections,” the Toolkit authors said.

Lack of knowledge both among clinicians and patients seems to have driven this trend.

Part of the problem has to do with education, said Kowalewski, one of the authors of the Toolkit. Because we learn that human gestation lasts nine months, many people think that 36 weeks is full term. It’s a misconception even within the March of Dimes, which has worked for years to teach people about infants born too early.

“When I started talking about this, members of our own state board said, ‘Wait, what are you talking about, nine times four is 36 right?’ ” Kowalewski said. “But nine months isn’t always a complete pregnancy.”

To complicate matters, doctors start the pregnancy clock at a woman’s last menstrual period before becoming pregnant, which is usually about two weeks before conception. All this is confusing enough that when doctors tell women they are at 36 weeks gestation and must wait at least a month before starting labor, they can grow impatient, Conry said. 

“We call it tired of being pregnant,” she said. “Some women have 36 weeks in their heads as the end point, especially when their mother and girlfriends have delivered at 36 weeks and had an easy birth.”

Societal changes also push women to seek an early delivery. Some women schedule births before their due date so they can better plan for taking time off work and flying in family members, Kowalewski said. 

“It’s at least a weekly discussion, where one of my patients wants to get an induction before 39 weeks,” said Dr. John Wachtel an obstetrician and adjunct professor at the Stanford University School of Medicine. 

A little information can change this. 

“I haven’t met a woman who wasn’t willing to continue her pregnancy if given information,” said Debra Bingham, an author of the Toolkit and vice president of the Association of Women's Health, Obstetric & Neonatal Nurses in Washington, D.C. “I’ve had experience with women who clearly didn’t understand the risks of an elective induction, but it’s also fair to say that there are a lot of doctors, nurses, and childbirth educators who aren’t aware of the risks.”

Doctors’ role

There are signs that doctors are driving part of the rise in earlier births. Since 1979, the American Congress of Obstetricians and Gynecologists has advised doctors not to do elective inductions before 39 weeks gestation, but early elective deliveries have continued to rise, except in the places where there is a system to hold doctors accountable.

Deliveries at 37 and 38 weeks account for about 17.5 percent of total births in the United States, according to authors of the Toolkit.  

At Intermountain Healthcare, a system of hospitals based in Utah, 28 percent of elective deliveries occurred before 39 weeks until the health system began talking to doctors who were routinely performing early cesarean surgeries and inductions for nonmedical reasons. Now, 3 percent of elective deliveries occur before 39 weeks’ gestation.

“Physicians are data driven,” said Daron Cowley, spokesman for Intermountain, which performs about 30,000 deliveries a year. “When the data were presented to physicians, practice patterns changed.”

Earlier in his career, Loma Linda University’s Oshiro worked for Intermountain as a neonatologist in Ogden, Utah, where he had the defining experience that made him an evangelist for this issue. The head of the neonatal intensive care asked him to look in on a group of babies with problems. 

“He said, 'You doctors are doing this. These babies are here because you allowed them to be delivered early,' " Oshiro remembered. "That just kind of stopped me dead. It was really clear – we're hurting babies, and we can stop it."

MemorialCare Health System in Orange County has achieved similar results by requiring doctors to call their medical director and explain the reasons for an early birth. At Intermountain, these types of changes have led to fewer cesarean sections and $5 million in savings for patients over the past five years, Cowley said.

Still, Conry, of the American Congress of Obstetricians and Gynecologists, cautions that part of this improvement may be because such systems motivate better record keeping, eliminating births incorrectly coded as “elective.”

Weighing the risks

Often, the decision to deliver early requires weighing risks. Elizabeth Regan of Frankfort, Kentucky, was at 37 weeks gestation when she had her first child in 2001.

Doctors wrote that Regan went into labor during an exam. But Regan said she merely had a Braxton Hicks contraction, something that commonly occurs weeks before birth. Nonetheless, she was rushed off to the operating room, she said.

Doctors also delivered Regan’s second child at 37 weeks gestation, concerned that this baby was too small, according to medical records. A small baby can be a sign that the mother isn’t delivering enough nutrients through the placenta, said Dr. Stephen Hall, who advised Regan to deliver early.

“You are trying to make the decision, is the baby safer inside mom while you are waiting for the lungs to mature, or is it better off in the mother’s arms, fed by breast milk rather than worrying about the placenta?” he said in an interview.

The problem is that estimates of the baby’s size can be off by a pound, Hall said. Regan’s baby turned out to be of normal weight, similar to his sister’s size at 37 weeks. Both children had trouble breathing – a common problem in early births – and were treated with inhalers and steroids. They are now healthy.  

When Regan learned it was possible to deliver vaginally after two cesarean surgeries she decided to try it, but had grown wary of doctors. 

“Needless to say, I stayed far away from the hospital and doctors offices at 37 weeks,” she said. She carried her third child to 40 weeks when labor began spontaneously and she gave birth to a healthy boy at home.

Researchers now are finding that some of the medical justifications for early delivery actually don’t help. 

Jennifer Penick of Omaha, Neb., had her labor induced at 38 weeks. She said her doctor told her baby was too large. The authors of the Toolkit point out that numerous studies show that babies induced early to limit their growth are actually more likely to get stuck in the birth canal and need a C-section.

Penick’s baby was average size, but her induction turned into a cesarean surgery, she said. Her doctor did not return calls seeking comment. 

Alegent Health, which runs the hospital where Penick delivered seven years ago, has adopted a 39-weeks policy. Penick has since given birth there three more times. As more evidence accrues in support of waiting until at least 39 weeks gestation, medical practice is beginning to change. 

It’s easy for doctors to get the impression that delivery a few days early doesn’t matter, because complications occur so infrequently, said Bingham, one of the Toolkit’s authors. 

“It reminds me of all the years of research on seat belt safety,” she said. “How many times have you actually needed a seat belt? You need to look at the entire population to see the cumulative risk.”

Dr. Elliott Main, lead author of the Toolkit and head of obstetrics at California Pacific Medical Center in San Francisco, said problems occur in just one in 33 babies delivered early through elective induction. That’s why it’s crucial to begin quality-improvement measures, rather than simply relying on the experience of doctors, he said. 

“The tendency is to shave a day here and a day there,” Main said, “and if you get away with it you are going to shave another.”

In the past, the American Congress of Obstetricians and Gynecologists has hesitated to do anything that could restrict the freedom of doctors to choose techniques, said Wachtel, the Stanford professor.

“There’s something of a philosophical change where we are not just educating people, but trying to improve outcomes,” he said.

 

 

This story was edited by Robert Salladay and Mark Katches.

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Jill--Unnecesarean's picture
This is a very sobering report. Great work, Nathanael.

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