Pre-term Birth

According to the CDC stats, in 2003-2004, there were over 1 million live births that happened prior to 37 weeks of gestation. This excludes all stillbirths, because babies born dead are not issued birth certificates, which I think is a shame. They were born, even if they didn’t live to see it. I used to think that just as there is a “certificate of live birth”, so there would be a “certificate of still birth” which would include the baby’s birth weight and so forth. Some states issue fetal death certificates and/or have some sort of birth certification, but only babies issued birth certificates are included in these statistics.

For a breakdown, over 3,000 births in this listing occurred prior to 20 weeks; some 50,000 were between 21 and 27 weeks; over 100,000 were from 28-31 weeks; 470,000+ were at 32-35 weeks, and 370,000+ were at 36 weeks.

I believe that some of these births are classified differently from how they were many years ago. For instance, at the time of the famous Roe v. Wade decision, “viability” was (I think) generally considered to be around the start of the 3rd trimester, or perhaps later; and fetal deaths prior to this were still called “miscarriages” whereas now they are called stillbirths, if they happen at or after 20 weeks of gestation. So this is something to keep in mind when looking at past records of miscarriage, stillbirth, perinatal deaths, neonatal mortality, and infant mortality. This also is a factor in comparing the U.S. to some other countries — because they cannot save some babies who could live if they were born here, they may not even count them the same way — may count them as miscarriages, if at all. (This is especially problematic in poorer countries where women may not seek care during pregnancy until near term, if at all; if the baby dies in utero and passes without a problem, she would have no reason to take the time and spend the money on going to a clinic to register the stillbirth and/or miscarriage — she probably couldn’t even afford it.)

But why does every 1 in 8 live births in the U.S. happen prior to term? There may be many reasons for that.

First, there are unavoidable reasons (perhaps some of these could have been avoided in retrospect, but at the time they were not able to have been avoided) — such as incompetent cervix, in which mothers and doctors tried to avert a preterm birth using every way they could, to no avail. Then there are early births which could have been avoided, but it was better for mother or child (or both) for birth to take place. My cousin’s birth is such.

My aunt was 8 months along when she had an full-blown attack of toxemia (as it was called then), becoming unconscious from the seizures. They called the ambulance (both she and my mom were visiting their mother at the time), and she was taken to the hospital. My mother believes her labor was induced, although nowadays they probably would have performed a C-section on her. This was in 1973, and C-sections were much more uncommon (probably about 5% of births), and reserved for truly necessary cases, because at the time, C-sections were considered much riskier than they are now. Since the end of the pregnancy is the only medically known “cure” for eclampsia, birth probably saved my aunt’s life, and therefore that of my cousin’s.

There are undoubtedly many others in which it is obvious to anyone that a preterm birth is the best and perhaps only viable option.

There are other births which are less cut-and-dried — for instance, a C-section at 36 & 1/2 weeks for known placenta previa. This is done because of the fear that the cervix will begin to dilate prior to the onset of labor and may compromise the fetus. But since it might not dilate until 38 or 39 weeks or later, this technically pre-term birth could have been avoided by waiting a few more days. Obviously, that’s a call for the mother to make in concert with her doctor and the best available evidence, and I’m certainly not decrying it.

Then there are preterm births that are not medically indicated — even partially. The mom who is “just tired of being pregnant” or wants to schedule her birth a little early because it’s the easiest time for her husband to get off of work, or it’s a good time for herself to get off of work, etc. One case of an induced preterm birth that was not medically indicated was of a woman whose first baby died during the term period, and she was so fearful of that happening again that she chose to have her second baby slightly before that time. Understandable. Unfortunately for the baby, he was not ready to be born and spent six weeks in the hospital, much of that time in the NICU due to problems breathing. While he ultimately did live, he had a rough start at life because of his slightly preterm birth (36 & 1/2 weeks). Perhaps he would have been one of those babies who naturally would have been born at 41-42 weeks, and then instead of his birth being “just a few days early” it was actually five weeks early — based on Mother Nature’s time, anyway. The mother said of his “slightly” early birth, “we thought it would be all right.”

Finally, there is another class of preterm birth entirely, that is also not medically indicated, and that is the induced birth of a baby with fetal anomalies or a genetic defect. Pro-life proponents call it “live birth abortion”; most medical professionals call it “induced preterm birth.” It’s a kind of middle ground, a gray area, between abortion and birth, and is actually quite complex when you think of it.

First of all, some people who choose a pre-term birth for fetal anomaly do so because the particular defect their baby has, has a high rate of stillbirth if the pregnancy is attempted to be carried to term, and the parents wish to have time with the baby out of the womb and alive before it dies. That’s their choice, and one which I’ve not had to encounter, so I might change my mind if I were actually faced with it. But while I do not “condemn” them for their choice, I don’t think I would make the same one. What if the diagnosis was wrong — either entirely inaccurate, or not as bad as they feared? A baby that might survive with problems at 35 weeks might succumb to problems related to immaturity if born at 31 weeks. Instead, parents could just savor their baby’s life with him or her still in the womb, being constantly hugged and carried by the mother’s womb. But to each her own.

Others may choose an induction or an early C-section to end the pregnancy because the baby has a lethal defect, and they are choosing to terminate the pregnancy early, and presumably hasten the baby’s unavoidable death. Some do this as a way of “getting on with their lives”; others may not give it much thought and just do it because the doctor suggests it. In this case, it may sometimes be rightly considered an abortion, although it would be called a pre-term induction; and if the baby survives the birth process, it will be given a birth certificate and be included in the CDC stats.

One such case involved a woman whose baby was diagnosed prior to 24 weeks with an abnormality, and the doctors pressured her to have an abortion. Being pro-life, she declined, and breathed a sigh of relief when she got past 24 weeks, because that was the latest legal time for her to have an abortion, so she assumed she wouldn’t be pressured any more. Her first appointment after that, though, she was offered a preterm induction, which she of course declined, because it was too close to abortion, even if called by a different name.

This is where it gets a little “iffy.” If the intent of the parents was not the death of the baby, they may spend time holding their baby until it succumbs to either immaturity or its defects. (However, some parents do choose a preterm induction for defects that are not lethal, and do hold it until it dies.) If the defects are not as bad as were thought based on the prenatal diagnosis, then care will be given to the baby and attempts at prolonging its life will be made. But if the baby has a defect which in the opinion of the medical community is lethal, then even if it lives, it may not be offered any care, beyond being held until it dies — and this happens at full-term, too, depending on the opinion of the doctor, the protocol of the hospital, or the wishes of the parents.

But if the parents’ intent was the death of the baby (for example, in one of the cases mentioned by this L&D nurse who for 45 minutes held a baby with Down Syndrome after he born alive from a preterm induction when the parents refused) and the baby’s inherent problems (such as Downs or some other typically non-lethal defect), then often no care is given to the baby, even if it could have lived with intense treatment. This is where BAIPA comes in and says that if a baby is living after being born, then steps should be taken to try to preserve its life.

So, while preterm births are increasing, there are many reasons behind it. Some of these preterm births are life-saving, others are death-inducing. The above-mentioned nurse said that if babies are born alive following an induction abortion, then they are given birth and death certificates — so it seems that if these inductions took place in an abortion clinic, they’d not be counted as live births; but if done in a hospital, they would be — assuming the tiny and fragile babies survive the birth process. Some of these premies are induced early because they have a defect which the parents don’t want. While some of these preterm births do reduce the number of stillbirths, they may not be saving any babies’ lives, if they are saved from stillbirth only to die of immaturity or anencephaly.

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