A dramatic increase in the number of U.S. women and physicians choosing an early childbirth comes with new health risks for 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.Researchers see an "evolutionarily dramatic event" in the trend, and perinatal health experts see dangers. Shortening gestation could affect lung development and some fine-tuning of brain functions, they say.
One concern: 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 in Southern California. "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 in the state who die each year from causes directly related to childbirth had more than doubled since 1996.
The rise in deaths during childbirth indicates 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 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.
A normal pregnancy lasts 40 weeks, although researchers believe it probably is safe to induce delivery at a full 39 weeks. Women often naturally give birth earlier than this, and in some cases medical problems call for an early delivery. The problem comes when babies are forced out of the womb.
Of all births from 1990 to 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 statistics. There was a corresponding drop in the number of babies born in later weeks. Now, more babies are 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 A California Watch inquiry through the Public Insight Network, which solicits opinions from a group of nearly 100,000 Americans, 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 argued for early births.
One mother, Michelle Van Norman, gave birth to her second child, Christian, 11 days early in 2006, with no need for urgency noted in her medical records. "This is a pleasant white female in no apparent distress," the doctor wrote on her chart:" Van Norman, a 31-year old mom living in Las Vegas, said her doctor didn't seem worried about the 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."
None of those days was best for the baby. 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.
"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."
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." The authors note that deliveries at 37 and 38 weeks account for about 17.5 percent of total births in the United States
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 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.
Authors of the Toolkit make the case that cesarean sections and artificial induction of labor before full gestation should be eliminated unless medically necessary.
The state chapter of the American Congress of Obstetricians and Gynecologists is taking measures to see that the recommendation 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, physician groups are rolling out the Toolkit's guidelines in New York, Florida, Illinois and Texas.
Confusion and ignorance complicate the issues.
Doctors start the pregnancy clock at a woman's last menstrual period before becoming pregnant, which is usually about two weeks before conception. This is confusing enough that women can grow impatient when doctors tell them they are at 36 weeks gestation and must wait at least a month before starting labor, Conry said.
"We call it tired of being pregnant," she said. "Some women have 36 weeks in their heads as the end point." Societal changes also push women to seek an early delivery. Some women schedule births before their due date so they can better plan time off work and flying in relatives, Kowalewski said.
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."
Mercurynews.com
