Iatrogenic Prematurity

This month is Prematurity Awareness Month, and although I missed the “calling all bloggers” Prematurity Awareness Campaign for Nov. 17 [I just didn’t feel like writing about it — sorry — nothing “sparked” in me at the time], since that time, I’ve gotten “sparked” about iatrogenic prematurity. If you’re unfamiliar with the term, it just means “doctor-caused” prematurity.

The March of Dimes is the main organization leading the Prematurity Awareness campaign, but I have to admit to being a little perturbed that they didn’t speak more strongly about the one cause of prematurity that could be most easily changed — iatrogenic prematurity, caused by elective inductions and C-sections.

It’s possible that “iatrogenic prematurity” might include necessary or beneficial cases of babies born by induction or C-section too soon — for instance, a baby who suddenly stops moving at 34 weeks and is obviously compromised. But for my purposes, I’m restricting it to medically unnecessary inductions and C-sections.

Here is one link: Why do women deliver early? Did you catch the discussion on elective inductions and C-sections? No? Not surprising — it receives only the briefest of mentions. However, this March of Dimes article, “Why the last weeks of pregnancy count” does dwell on the topic a bit more. Elective C-sections and inductions are (thankfully!) not one of the four main causes of prematurity, but iatrogenic prematurity could be stopped tomorrow. And I think that’s important to note.

Some doctors have a laissez-faire attitude about inductions and C-sections, and have no problem with either as soon as the mom hits 37 weeks. Perhaps that attitude is changing a bit, since research has demonstrated that infant outcomes are much worse in several different areas if the baby is born unnaturally at 37 weeks, compared to 38 and especially compared to 39 weeks. [And when I say “unnaturally,” I’m meaning, by induction or C-section — babies born to women who go into labor naturally at 37 weeks do as well as those born at 38 and 39 weeks, naturally — it’s the unnaturally early births that are the problem. When the woman goes into labor, that is an evidence that her baby is actually ready, as opposed to having reached some arbitrary date on the calendar.] Some doctors may even do an elective induction or C-section at 36 weeks. I read a story some time ago about a woman who had a late-term fetal demise in her first pregnancy, so opted for an elective induction at 36 and a half weeks. She thought he was ready “enough” — that it was “close enough” to term for him to be born. Her baby was in the NICU for 6 weeks, and had long-term health problems (mostly related to his lungs and breathing), because he was not ready.

A woman’s dates can be off, which could really cause problems with her baby, if she electively induces or has a C-section at 37 weeks (or even later). What if her little one would have been born naturally at 41-42 weeks? That’s 5 weeks early. And if her dates are off, it may be even earlier. There’s a lot of brain, lung, and body development that happens in those last few weeks, that ought not be circumvented without an awfully good reason. Although rare, “superfetation” — conceiving a second baby many days or even a month after the first baby was conceived — is also a possibility, as Abby Epstein found out. What if she had gone by “I thought I was pregnant a month ago,” even though that baby died, and her later-conceived baby lived? Perhaps they were conceived at the same time, and this was just “vanishing twin,” but perhaps some of these super-long gestation times one occasionally reads about were actually due to undiagnosed superfetation with a hidden/missed miscarriage. Could happen. I remember in reading through some of the causes of death listed on the CDC linked birth-death certificates, that one hospital-born baby born at 42 weeks died due to “extreme prematurity.” It could be a typo — perhaps it should have been “24 weeks”; or maybe the code was entered wrong. Or maybe the mother’s dates were miscalculated. Or maybe she happened to skip a period prior to conception, so she thought she was at 42 weeks, when she was 6-8 weeks earlier. I wonder, though, if she was induced because she was “42 weeks” and her baby was nowhere near ready. Unlikely, but possible.

Then there’s this little gem of an article: Many Women Miscalculate Time to Full-Term Birth. One paragraph reads,

“About one-quarter of new mothers surveyed in the study considered a baby born at 34 to 36 weeks of gestation to be full term, while slightly more than half of women considered 37 to 38 weeks full term.”

Only problem is, that’s not what the question was. Here’s the actual question (also from the article):

“What is the earliest point in pregnancy that it is safe to deliver the baby, should there not be other medical complications requiring early delivery?”

It didn’t say “when is full term?” It asked “when is it safe?” Ok, so define “safe”. Most babies will do fine born electively at 34 weeks. Obviously, not all will — some will die that would have lived; of those who live, some will have long-term negative effects related to their prematurity. If safe is some sort of “beating the odds” — well, 90% of babies born at 30 weeks survive, and the odds go up every week. Many (perhaps even most) of these babies will not suffer long-term negative effects (like cerebral palsy, blindness, etc.) which used to be so common at this age, but now are more common with preemies born at earlier gestational ages; and the risk goes down with age. Even fewer babies born at 37 weeks will have problems, than those born at 36, 35, or 34 weeks. Does it mean it’s “safe” for them to be electively induced or sectioned then? Well, sure, compared to preterm babies; but not compared to 38-weekers, or 39-weekers. But again, babies are naturally born at 37 weeks all the time and have no long-term problems compared to babies naturally born at 38, 39, 40, 41, etc. weeks And if a woman goes into labor at 36 weeks, doctors will not try to stop the labor. I daresay that many people would say, “If the doctor won’t stop labor at 36 weeks, then it must be safe for the baby to be born then.” Is that a wrong supposition? Yes, if you’re talking about elective inductions; perhaps no if you’re talking about natural labor.

I will also note that the question was not, “When is the earliest point in pregnancy that an elective induction or C-section should be used?” Had this been the question, I would have answered “never” if that was a possibility 🙂 or else “39-40 weeks,” if that were the latest time frame given. However, in the question that actually was used, I probably would have answered 37-38 weeks, because that’s “term”; or possibly at 36 weeks — if the woman goes into labor at that point, the doctor won’t stop it, after all. Not because it is best for the baby to be born at that point, but because I don’t know if it totally meets the threshold of “unsafe” for the baby to be born early. Not optimum, but perhaps “safe.” Is it “safe” to drive a car? Almost everybody would unhesitatingly say “yes!” but people are injured and killed in car wrecks every day. And some people are injured or killed as pedestrians, who would have lived had they been in a car. “Safe” does not necessarily mean “absolutely no risk,” because as probably everybody over 12 understands, there is almost nothing in life that is completely risk-free.

Although there were several good parts of it, this article was irritating on a few points, including the following:

Misconceptions about what constitutes full gestation and how soon it’s safe to schedule an elective induction or cesarean delivery are contributing to increasing numbers of premature births in the United States, said lead study author Dr. Robert L. Goldenberg, professor of obstetrics and director of research at Drexel University College of Medicine in Philadelphia.

Ah, yes — blame the mother! I feel so sorry for these poor spineless doctors who just can’t stand up to the strong woman who demands an early end to her pregnancy, regardless of how much damage it does to her baby. You know how thoughtless and uncaring women are! They don’t give a rip about the baby they’ve just spent the last 8-9 months of their lives growing! Odds are, they’ll leave the baby at the hospital and just walk away!

Ok, so maybe the sarcasm was a little heavy in that last paragraph, but seriously, folks!! It makes me want to scream! Sure, some women are selfish and truly don’t care about their babies — after all, some women abuse alcohol and use illicit drugs while pregnant. But I daresay that if doctors tell most women that their baby will be twice as likely to die (or whatever the actual rate is), if born electively prior to 37 weeks, or even in the early term period, and will be 3-4x more likely to have serious morbidity, that would put a curb on elective inductions. Some women may have legitimate or quasi-legitimate non-medical reasons for induction — husband home from Iraq for two weeks, previous stillbirth in the term period, severe pregnancy discomfort, and maybe others. [The  McCaughey septuplets just celebrated their 12th birthday (I remember because they were “due” the same day my sister was due with her first child), and they were born two full months early. In an interview soon after the birth, their mother, Bobbi, said that she just couldn’t stand the nausea and other side effects of the pregnancy itself and the drugs she was on to maintain the pregnancy. She held on as long as she could, knowing that every day they were inside her, it would be better for her babies; but finally she just couldn’t take it any more. That doesn’t apply to most women.]

So, yeah, educating women about prematurity and the problems babies have when born too early (by the babies’ clocks, even if not by the doctor’s calendar!) will help, because it will likely reduce the number of women wanting an early end to their pregnancy, and those who look at their due date as an expiration date. But women could not induce if doctors did not allow it! Inductions and C-sections don’t schedule themselves. Last time I checked, women can’t call the hospital and set up an induction or C-section without their doctor’s approval. They also don’t perform themselves — doctors (and nurses) have to perform an induction or a C-section. So, why does this article have such a strong tone of “it’s all the women’s fault!”?

I’ll say it again — iatrogenic prematurity could be stopped tomorrow, if doctors wanted to.


11 Responses

  1. I study extensively about many subjects, one of which is pregnancy/birth. I agree that doctor induced prematurity could end tomorrow if doctor’s just stopped getting ‘in the way’ and stopped being so eager to cut woman open just to justify their fears of malpractice (think of it this way, a doc sees a possible prob on an ultrasound at 36 weeks and thinks, if I don’t do something and this baby gets injuried, I can be sued. So he does a c-section, the baby ends up with serious issues so he thinks, gee, good thing I did something, I would have gotten sued for sure! But how likely is the serious issue HIS fault for doing the early c-section?)
    However, as much as I am aware of the issue of prematurity, I refuse to support the March of Dimes. The March of Dimes is in bed with the abortion industry, and is guilty of actively concealing from women a HUGE cause of prematurity to protect their political bed fellows. Studies have shown that a single abortion causes a 70% increase in a woman’s likelihood of premature birth in a future pregnancy (they type or timing of the abortion doesn’t seem to matter a chemical abortion in the first trimester or a third trimester surgical abortion caries the same rates of increase). Just two previous abortions increase a women’s likelihood of premature birth in furture pregnancies by 90%! Yet you will not hear this from the March of Dimes. Abortionists aren’t going to give you this information, it will hurt their bottom line to tell a woman that abortion isn’t ‘safe’, but an oganization like the March of Dimes should have it front and center in all their literature. Until they do, I urge women to reconsider their support of the March of Dimes (while continuing to try to get the word out to as many woman as possible to reduce premature births) and to tell the March of Dimes why they have withdrawn their support. Thank you Kathy, for a wonderful blog about doctor induced prematurity.

    • I agree about the MoD and abortion, which is why I don’t support them. In September (Infant Mortality Awareness Month), I did several posts on infant mortality — mostly related to prematurity, since that is the biggest single cause of mortality. And I blogged about the abortion-premature birth connection. That’s part of the reason why I didn’t want to blog on the 17th — felt like I had said as much as I could on the subject only 2 months ago (that, and a lingering feeling that I would be supporting MoD if I did).

  2. Glad I’m not the only one! It just seemed that I’ve seen so much on prematurity in the blogophere this month (and similiar replies about how abortion increases prematurity in future pregnancy were deleted or never posted by the author/moderator on a few blogs), since you were talking about completely avoidable prematurity, I felt compelled to reply about another type of completely avoidable prematurity. And I was pretty sure you wouldn’t delete me! I think of all the blogs I follow online, you are the person I would be most interested to actually converse with and know. Praying for your current pregnancy!

  3. Ugh, I didn’t know that about the March of Dimes. I always considered them a mainstream organization so I have not paid much attention to them, lol.

    So now, what confuses me with prematurity is this: if the numbers show that most newborns born premature will be fine, besides the birth not being optimal nor the immediate postpartum time, I can see why this is not such a big deal in your regular OB model of care. Or am I not getting it?

    • Yeah, in my opinion, doctors are a bit too laissez-faire about this whole thing. Of course, much of the time, there isn’t anything doctors can do to stop preterm births. What midwives do isn’t “sophisticated” enough for them (taking care of the “whole woman”, giving nutritional advice, etc.), and often isn’t studied to see if it might make a difference. It might not (although I remember one study in which women who saw midwives had fewer miscarriages and fetal losses prior to 24 weeks than doctors did; although the perinatal rate after that time was the same for midwives and doctors), but if it’s not studied, it won’t ever become “official,” even if it’s true.

      Just like the old joke/riddle: What was the smallest continent before Australia was discovered? Australia, of course! Just because it wasn’t discovered didn’t mean it didn’t exist!

      And I think most doctors have blinders on, when it comes to early birth — they cut out or catch the baby, hand it off to the nurses, pediatricians, and/or perinatologists, and their job is done, in large measure. There is a medical disconnect that takes place then. Sure, there has to be some level of pure human connection and interest, but how many midwives, doctors, and nurses will remember the mother or baby in a week, a month, or a year? If the OB does not see the baby who went to the NICU for days or even weeks because of his prematurity, will it even register as an adverse outcome? If the baby dies due to his prematurity (which may be given another name — some breathing difficulty due to immature lungs, or acquiring some infection, or something), will the doctor connect the early birth with the unnecessary death? will he even notice? or might he merely say, “The baby would have died anyway and been stillborn, and then the parents would have sued me for *not* acting. At least now, I can say, I did everything I could”?

      Our advances in technology (it is now normal for babies as early as 34 weeks to survive without many noticeable problems) have, I believe, made doctors lax about trying to keep immature babies inside the womb. Our postnatal care is excellent, but is a far cry from the near-perfection inside the womb (except for certain specific conditions that make early birth better for mother and/or baby). It’s also very expensive.

      So, a doctor might not even realize all the negative repercussions of the premature birth, being somewhat insulated by his distance from the situation; but the affected baby and mother do not have the luxury of “distance.” Probably 90% of babies have no long-lasting side effects (as far as we can tell), and possibly higher; probably fewer than 1% of preterm babies die or are seriously injured due to iatrogenic prematurity. A doctor might easily forget the 1 in 100 babies who had a bad outcome (or might not know that the baby born so early ended up dying at 3 or 6 months); but the mother and baby will not.

  4. Right, and to think that if there were 1 in 100 dead babies in home birth, we would have the police on our doorstep… The numbers of home birthing women are lower than premature birth!

  5. Here is a very interesting article about infant mortality. Doctors are scratching their heads trying to figure out what has been the factor(s) in dropping infant mortality in certain areas of Wisconsin. One paragraph states,

    “And a federally supported clinic, Access Community Health Center, which serves the uninsured and others, has cared for a growing number of women using nurse-midwives, who tend to bond with pregnant women, spending more time on appointments and staying with them through childbirth. “

  6. Ya think??
    I hope this becomes a trend!

  7. This is Maria by the way… just noticed it just says ‘name’!

  8. I’m giving a presentation tonight on this. I’m having trouble finding what % are iatrogenic. Do you have those stats? I know my prematurity rate is 1/10th the nat’l average, so I must be doing something right!

  9. So, I gave the presentation last yr. Only 3 people showed up to hear me. 😦 Another cause of prematurity that I haven’t seen mentioned here is malnutrition. Medical schools are in bed w big Pharma & Monsanto! If women would just eat real food, not junk, a lot of prematurity would be avoided! But yes, I totally agree the #1 preventable cause is iatrogenic!
    The MoD called me to solicit a donation. I told them that preventing prematurity was near & dear to my heart & I do everything I can to prevent it. I’d be glad to help in any way I can. Since my prematurity rate is 1/10th the nat’l average, how much are you (meaning the MoD) willing to donate? Where do you want me to give my presentation?They’ve never called back!

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