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.
Filed under: C-section, induction Tagged: | baby, birth, C-section, cesarean section, childbirth, elective C-section, elective induction, iatrogenic prematurity, induction, march of dimes, pregnancy, pregnant, prematurity, prematurity awareness month