Scheduled births rise, and draw scrutiny
ST. LOUIS -- With her due date just over three weeks away, Cole Kelley's labor was induced because she was told her baby was getting too big. The induction failed, however, after a painful two days of drug-induced contractions. Warned the baby co...
ST. LOUIS -- With her due date just over three weeks away, Cole Kelley's labor was induced because she was told her baby was getting too big. The induction failed, however, after a painful two days of drug-induced contractions. Warned the baby couldn't fit through her pelvis, Kelley had a caesarean section eight days later.
She suffered an irregular heartbeat and drop in blood pressure after the surgery, she said. Her baby girl Maddi -- weighing a normal 7.4 pounds -- had trouble breathing. They both had trouble nursing, and Kelley reluctantly switched to formula. Her daughter got sick often and still suffers from asthma. Kelley attributes the problems to medically intervening before her and her baby's bodies were ready.
New research shows this could be true.
"I was a first-time mom. I trusted my physician and relied on my physician to know what's best," said Kelley, 29, of Ladue, Mo., who did not want to name her doctor. The experience left her uncertain she wanted to have any more children.
Birth in this country is increasingly scheduled. Medically induced labor has more than doubled since 1990 to 22.5 percent of births in 2006 (some studies suggest the number is closer to 34 percent). The caesarean rate has hit an all-time high -- 31.8 percent.
The medical procedures carry with them a longer list of risks and cost than spontaneous birth for mom and baby, and mounting evidence is pointing to one more -- preterm birth.
Nearly 20 years ago, U.S. health officials set a goal of a 7.6-percent preterm birth rate. But nearly 13 percent of babies are born preterm, a 20 percent rise since 1990. Most of the increase is due to babies born a bit early, between 34 and 37 weeks, known as "late preterm."
Many late preterm births are spontaneous or scheduled because of serious medical conditions such as low amniotic fluid, a compromised placenta, infection or gestational diabetes. But researchers and health providers fear other reasons behind the trend -- women's lack of knowledge and doctors' more liberal use of medical indications.
A report released in November shows the percentage of late preterm births for which labor was induced more than doubled between 1990 and 2006 -- to 17.3 percent from 7.5 percent; and the percentage delivered by caesarean also rose substantially, to 34.3 percent from 23.5 percent. A study released last year also found C-sections account for nearly all the increase in U.S. singleton preterm births between 1996 and 2004.
The dramatic increase has health advocates like the March of Dimes and Lamaze International concerned that some early deliveries occur at the request of the mother or based on an inappropriate recommendation from the doctor.
"We need to look into why these inductions are happening. We don't have enough data to tell us right now. Have women really become so much sicker in the last two decades, or is it because the practice-style of physicians has changed, and medico-legal concerns are driving them to intervene earlier and earlier?" said Lamaze president Sharon Dalrymple.
The National Institutes of Health and The Pediatric Academic Societies gathered experts in 2005 to address the rising number of late preterm babies. Their summary stated that other than multiple pregnancies, medical indications causing preterm births do not appear to be on the rise.
While much effort has focused on the riskiest early preterm babies, research over the past five years show late preterm babies also have problems. They are more likely than term babies to die within the first year of life and suffer complications at birth such as respiratory distress, brain injury and prolonged hospitalization, according to studies the U.S. Centers for Disease Control compiled for its recent report. Late preterm babies also have more difficulty eating and maintaining their body temperature, pediatricians warn. Imprecise methods for estimating due dates -- which can be off by up to two weeks -- compound the problem.
Recent studies show that even babies born between 37 and 39 weeks have greater chances ending up in the NICU, suffering respiratory complications and having long-term learning and behavioral problems. A baby's brain at 35 weeks weighs only two-thirds of what it will weigh at 39 to 40 weeks. However, elective (without medical reason) inductions and C-sections during these weeks are common in the U.S., according to two large studies published over the past two years.
This American College of Obstetricians and Gynecologists has since 1999 recommended against elective delivery before 39 weeks. "Many didn't follow the guidelines because anecdotally, babies were doing well," said Dr. F. Sessions Cole, director of newborn medicine at St. Louis Children's Hospital. "But lately, we have larger studies that show these babies don't do as well."
Dr. Jacob Klein, the head of obstetrics at Missouri Baptist Hospital, said more remains to be learned about the long-term affects of babies delivered early.
"My definition of a normal birth is when you have a normal-acting and normal-achieving child in the third grade, not that your baby goes home (from the hospital) in three days," Klein said. "We've made the deviance normal, and we shouldn't have made the deviance normal."
Scheduled births also carry maternal risks. Women who are induced are more likely to have a longer labor and medical interventions such as continuous fetal heart rate monitoring, epidural anesthesia and artificial rupture of the amniotic sac. Each has its own risks which can lead to further complications and interventions. Several studies show labor inductions are more likely to end up as caesarean, especially among first-time mothers or when the cervix has not dilated, according to the Coalition for Improving Maternity Services.
Caesarean carry a higher risk of infection, hemorrhage, injury to organs, anesthesia complications, difficulty breastfeeding and breathing problems for baby.
Over the past five years, hospitals in the St. Louis area have instituted guidelines discouraging elective deliveries before 39 weeks. "It was a huge push back from both physicians and patients because patients don't understand it and doctors thought it was an intrusion into their decision-making," said Klein at Missouri Baptist. The hospital instituted its guidelines four years ago and saw a more than 30 percent drop in NICU admissions, he said.
Cole at St. Louis Children's said doctors and small hospitals in rural areas, however, are more lenient, "then the baby ends up staring at me up here in St. Louis with a tube sticking out of his mouth."
Guidelines also don't prevent doctors from being liberal with medical indications, says Dr. David Stamilio, who teaches at Washington University School of Medicine and is an attending physician for high-risk pregnancies at Barnes-Jewish and Missouri Baptist hospitals. "I feel like over the last several years, we've lowered the threshold to get people delivered with certain diagnoses," Stamilio said. "You can develop these apparently black and white indications for delivery, but they are never black and white."
The most common indications used by doctors are preeclampsia and similar conditions characterized by high blood pressure and protein in the urine, Klein said. He's seen women admitted for inductions because of preeclampsia, yet they show no signs. "They come in and their blood pressure is fine," he said, "and we've sent them home."
Insurer gets involved
UnitedHealthcare, which contracts with 5,000 hospitals, launched a campaign this year to educate its providers and patients regarding the risks of scheduled births before 39 weeks. The insurance company studied some of its southwestern hospitals and found 48 percent of newborns admitted to the NICU were from scheduled deliveries, many between 37 and 39 weeks. A 2006 pilot education program targeting physicians achieved a 46 percent decrease in NICU admissions in just the first three months.
Education is lacking as well. A survey of 650 women who had just given birth found that over half of them chose 34 to 36 weeks as the earliest point in pregnancy that was safe to deliver, according to results released in this month's Obstetrics and Gynecology. Only 7.6 percent chose 39 to 40 weeks.
Kathleen Simpson, a perinatal clinical nurse specialist at St. John's Mercy Medical Center, said she believes educating women is key.
More than two years ago, Simpson and St. John's head of obstetrics Dr. Octavio Chirino, began including information in the hospital's childbirth classes about the risks of scheduled births before 39 weeks. A slideshow discusses non-medical reasons for induction, such as suspecting a large baby. After adding the information, the hospital found a 20 percent drop in inductions among women who took the class compared to those who didn't.
When Kelley became pregnant a second time, she interviewed 10 doctors to find one willing to allow her to attempt a vaginal birth after having a caesarean. On July 7 last year, her labor began spontaneously, a day after her son Jack's due date. He weighed over a pound more than her daughter, "and he fit fine," Kelley said. She nursed him. Her recovery was quicker. He is rarely sick. "It was a night and day difference," she said.
Next summer, she's considering getting pregnant again.
Experts are learning that scheduling an early birth for non-medical reasons can cause problems for mom and baby. For women facing a scheduled birth, the March of Dimes offers the following list of questions:
If your provider recommends delivery before 39 weeks:
• Is there a problem with my health or the health of my baby that may make me need to have my baby early?
• Can I wait to have my baby until I'm closer to 39 weeks?
About inducing labor
• Why do you need to induce labor?
• How will you induce labor?
• Will inducing labor increase the chance that I'll need to have a C-section?
• Why do I need to have a C-section?
• What problems can a C-section cause for me and my baby?
• Will I need to have a C-section in future pregnancies?