This post is one in a series on Booby Traps, made possible by the generous support of Motherlove Herbal Company.
Six months ago, California Watch (a project of the Center for Investigative Reporting) published an article that alternately made my blood boil and gave me chills. I’m going to quote liberally from it, and I hope you’ll follow the link and read it for yourself.
This article shows that pregnancy and birth have undergone a dramatic shift – “an evolutionarily dramatic event” – in recent years. Our babies are born significantly younger than they were 20 years ago, and there are serious consequences to this shift, in everything from life-threatening infant complications to intractable breastfeeding problems.
The article relies heavily on a report by the California Maternal Quality Care Collaborative (CMQCC), a coalition of organizations such as the California Department of Public Health, the March of Dimes, the American College of Obstetricians and Gynecologists (ACOG), and the Association of Women’s Health, Obstetric and Neonatal Nurses. This organization has developed a Toolkit for health care providers to try to change the norm around elective birth before 39 weeks gestation.
Read on to learn about a Booby Trap™ that poses perils for breastfeeding – and far beyond.
What is the trend in early, elective birth before 39 weeks gestation?
According to the California Watch article and the CMQCC:
The average time a fetus spends in the womb has fallen seven days in the United States since 1992.
Of all births between 1990 and 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 vital statistics. There was a corresponding drop in the number of babies born in later weeks.
One study of nearly 18,000 deliveries in 2007 showed that 9.6 percent were early births – through scheduled inductions or C-sections – for nonmedical reasons.
Deliveries at 37 and 38 weeks account for about 17.5 percent of total births in the United States
There are now more babies born at 39 weeks than at full term.
The trend is so dramatic that the California district chairwoman of ACOG states, “The entire bell curve has shifted.”
What are the health risks of delivering a baby before 39 weeks for no medical reason?
According to the California Maternal Quality Care Collaborative, babies born to by elective delivery between 37 and 39 weeks are at risk of:
- Increased NICU admissions
- Increased transient tachypnea of the newborn
- Increased respiratory distress syndrome
- Increased ventilator support
- Increased suspected or proven sepsis
- Increased newborn feeding problems and other transition issues [emphasis mine]
- Increased risk of stillbirth
- Increased risk of “any adverse outcome or death”
The CMQCC also notes: “Recent studies highlight concerns that late preterm and possibly early term deliveries may increase babies’ risk of brain injury and long-term neurodevelopmental abnormalities. Approximately 50% of cortical volume growth occurs between 34 and 40 weeks. At 37 weeks, the brain weighs only 80% of the weight at 40 weeks and gray matter volume increases at a rate of 1.4% per week between 36 and 40 weeks.”
The CMQCC reports that the risk is highest for pre-labor scheduled cesarean sections 37 weeks gestation, but “is significant for all subgroups examined. Even babies delivered at 38 4/7 to 38 6/7 weeks have higher risk of complications than those delivered after 39 weeks.” [emphasis mine]
What’s behind this trend toward early, elective delivery?
Both the California Watch article and the CMQCC cite two factors responsible for this trend: Doctors pushing for earlier deliveries and mothers requesting them. They also note that both groups may be unaware of the risks of early elective delivery.
The CMQCC notes: “Non-medically indicated (elective) deliveries described above…indicate that physician decisions may, in part, be driving higher rates of early elective deliveries. In addition, it has been suggested that women may not have an accurate perception of the benefits of carrying a baby to term.”
It’s easy to blame mothers here. Most of us can remember the challenges of the home stretch in pregnancy, and the fervent desire of many to just get it over with. But the truth is that mothers just don’t know the risks. The CMQCC reports: “Women request earlier deliveries without knowing the negative clinical implications. A survey of insured women who recently gave birth (Goldenberg 2009) found that…92.4% of women reported that giving birth before 39 weeks was safe.”
What happens when mothers do know the risks? The California Watch article quotes the vice president of the Association of Women’s Health, Obstetric & Neonatal Nurses: “I haven’t met a woman who wasn’t willing to continue her pregnancy if given information.”
How do early, elective births make breastfeeding harder?
Babies born at 36-38 weeks have a nickname among breastfeeding support people: “impostor babies.” Their size and weight make them appear like full term babies, but when it comes to breastfeeding they are a class unto themselves.
For many of you who have had near term babies this description will sound sadly familiar: Impostor babies are notoriously difficult to feed because they tire out at the breast quickly. Because they fall asleep early at the breast, they don’t take in enough milk. And because they don’t take in enough milk, they conserve calories by sleeping even more. Many will develop jaundice because of poor intake, making them sleepier still and sometimes requiring re-admission to the hospital. In the meantime, your breasts aren’t getting the stimulation they need at a critical time, and you end up struggling to develop a full milk supply. Supplementation is often recommended and sometimes necessary, further increasing the risk of not developing enough milk. I’ve seen firsthand the result: a downward spiral that can take weeks, lots of support and resources, and an iron-clad will to reverse.
And this is all if your baby doesn’t have any of the complications listed above (NICU admission, respiratory distress, etc.). Of course, those problems make breastfeeding even more challenging, and for many moms it ends before it’s even begun.
[For more information on breastfeeding the late-preterm or "near term" infant, see this protocol from the Academy of Breastfeeding Medicine, this podcast interview I did with Marsha Walker, or this article on "impostor babies."]
What’s being done about this?
Since 1979, ACOG has urged that elective deliveries not take place before 39 weeks’ gestation. That policy hasn’t done much to stem the recent tide of early elective delivery.
But when doctors are made aware of the risks of early elective delivery, an interesting thing happens: less babies are born early.
The California Watch article cites the case of Intermountain Healthcare, a system of hospitals in Utah: “28 percent of elective deliveries occurred before 39 weeks until the health system began talking to doctors who were routinely performing early cesarean surgeries and inductions for nonmedical reasons. Now, 3 percent of elective deliveries occur before 39 weeks’ gestation.”
At the risk of over-quoting the California Watch article, here’s one section I want everyone to read:
Earlier in his career, Loma Linda University’s [Bryan] Oshiro worked for Intermountain as a neonatologist in Ogden, Utah, where he had the defining experience that made him an evangelist for this issue. The head of the neonatal intensive care asked him to look in on a group of babies with problems.
“He said, ‘You doctors are doing this. These babies are here because you allowed them to be delivered early,’ ” Oshiro remembered. “That just kind of stopped me dead. It was really clear – we’re hurting babies, and we can stop it.”
How can you avoid having a non-medically necessary early birth?
So, knowing the risks of an early elective delivery before 39 weeks, what can you do to avoid having one?
First, choose a provider who understands the risks of a non-medically necessary delivery before 39 weeks to your infant and to breastfeeding. How can you tell if he or she knows? Ask. And if he or she can’t name at least a few of the risks listed above, think long and hard about whether this is a provider you want to stick with.
Second, if your provider is pushing you into an early birth without medical reason, stand up for yourself and your baby by talking about the risks of an early delivery. Share The Toolkit. And if that doesn’t work, get a second opinion or even change providers. Yes, sometimes you can do that, even at a very late stage in pregnancy.
Third, hang in there. To be clear, we are not talking here about medically necessary early births. We’re talking about everything being normal and you just not wanting to be pregnant anymore. We know you’re tired, your back hurts, you feel bloated and huge. We’ve been there. But we hope you’ll remember that every day you hang in there reduces the chances that your baby will have any one of a number of health problems, and that you’ll have a much easier start to breastfeeding.
And finally, if you do end up with an early delivery and find yourself in the downward spiral I described above, be sure to get fast and skilled help from a breastfeeding support person, such as a lactation consultant.
If you’ve had a baby early or are expecting to deliver early, we also offer the following advice on our Fast Facts page, written by Marsha Walker, IBCLC:
What should my game plan be if I deliver between 34 and 37 weeks?
- Late preterm infants (born between 34 and 37 weeks) and even those born between 37 and 39 weeks need at least 10-12 feedings per 24 hours (Meier et al, 2007).
- Late preterm infants are easily overwhelmed by bright lights, noise, and visitors. You should ask friends and family to limit or avoid visiting for the first 2 weeks until you and your baby are in a good breastfeeding groove. Please don’t interrupt or postpone breastfeeding because of visitors!
Were you pushed into an early birth for no medical reason? What did you do about it? How did the outcome affect your start to breastfeeding?