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Elective pre-term births raising concern by Heather Woolwine Public Relations MUSC physicians are voicing concern over the increased rate of late pre-term births and are urging expectant mothers to consider the consequences of elective cesarean sections and inductions prior to full term.   While some late pre-term births are necessary due to health concerns for the mother and fetus, the debate about whether to electively induce birth or wait it out looms over the birthing profession.    Scientific data compiled in the last several years indicates that pre-term births in the United States have risen more than 30 percent in the last two decades.   In many instances, the decision to deliver early is supported by medical maternal and fetal factors, according to the March of Dimes, a not-for-profit organization dedicated to reducing pre-term births.  However, both the organization and an increasing number of obstetricians and neonatologists are concerned that some late pre-term births may occur when the delivery is not exclusively medically indicated. Evidence suggests that some late pre-term deliveries reflect non-medical concerns such as distance from the hospital, scheduling and patient preferences.   “We, as the regional perinatal center in our state, support the March of Dimes and its mission to decrease the number of pre-term births,” said Dilip Purohit, M.D., MUSC Neonatology, who is firmly against inducing birth or elective cesarean sections prior to a mother’s full term if there is no medical reason to do so.   “The complications that arise from not waiting an additional couple of weeks can increase the risk for an otherwise healthy baby of developing severe breathing problems requiring mechanical ventilation,” he said. “For many women and their babies, there are valid medical reasons to allow or induce a pre-term delivery, and we know that we cannot eliminate all pre-term births, but each case must be considered carefully and individually. C-sections on demand and elective inductions before the baby is due are an unnecessary risk. Why put a baby through that if there is no medical reason to keep you from waiting? ... It’s not an issue of medical risk in that instance; it instead has become a question of convenience.”   Infants born between 34 and 36 weeks gestation are called late pre-term infants and have a higher incidence of morbidity and mortality when compared to term infants (37-42 weeks). Late pre-term births compromise about 71 percent of all pre-term births and account for the majority of the increase in pre-term birth rates.   Late pre-term infants are the fastest growing subgroup of pre-term babies. However, more emphasis has been placed on very pre-term births (less than 32 completed weeks). Since 1990, the rate of very pre-term births in the nation has stayed at 2 percent of pre-term births.   “I don’t think any obstetrician, no one who’s competent, anyway, would deliver a baby at less than 37 weeks electively, and it would just be stupid. It would be against any and all recommendations,” said Roger Newman, M.D., vice chairman for Academic Affairs and Research in the Department of Obstetrics and Gynecology and a high-risk obstetrician. “But we are seeing increased rates of pre-term births and I understand why the March of Dimes is so concerned.”   Newman is the director of a March of Dimes-sponsored pre-term birth prevention program at MUSC. Patients at risk for pre-term birth are seen weekly on Wednesdays in the March of Dimes clinic at 135 Cannon Place where they meet with Newman's certified nurse midwife Amelia Rowland.   He believes that the increased frequency in late pre-term births comes from a variety of reasons, including the tendency for obstetricians not to use tocolytic (labor-suppressing) drugs for as long as they used to; many physicians will stop giving them to patients at around 36 weeks, especially if the patient has been taking them for a long time during the pregnancy or has been on bed-rest for much of that time.   “There’s been an increase in the comfort level provided by NNICU’s (neonatal intensive care units) and people’s confidence in them to care for pre-term babies. Modern dating technology allows obstetricians to better evaluate babies prior to delivery to determine maturity and, then, whether to proceed or leave the baby in utero until closer to term. That said, purely elective deliveries prior to 39 weeks are inappropriate,” Newman said.   Meanwhile, late pre-term infants are typically healthier than very pre-term infants, but they have elevated risks for potentially serious health problems when compared to term infants. Complications, including instability, feeding difficulties, breathing problems, and jaundice, can complicate a late pre-term infant’s development or survival.   Statistics have indicated that infant mortality among late pre-term infants is three times higher than term infants. Late pre-term infant births have resulted  in greater costs and lengths of stay in the hospital than term infants, and also experience higher rates of re-hospitalization after discharge. Maternal choice—When she doesn’t want to go full term Between 1992 and 2002, there was a 26-percent decrease in births occurring after 39 weeks and a nearly 20 percent increase in births delivered between 34-39 weeks, according to information complied by the March of Dimes. Increasing rates of c-section deliveries and induced births seem to have contributed to, but don’t completely explain, the shift.   Medical reasons to induce birth and those conditions or diseases reflect the growing number of high-risk pregnancies and early deliveries. But as trust in modern technology, health care and science continue to grow, women and health care providers face an array of options and choices when it comes to labor and delivery.   The possibility of delivering a late pre-term baby seems to increase when considering the combination of maternal choice, risk factors and the margin of error in dating gestational age.   “Obstetrics is quickly becoming consumer-driven, and we need to be careful because no dating method is 100 percent accurate,” Newman said.   But Newman is familiar with the other side of the coin, too, when discussing earlier deliveries for healthy mothers and babies.  “It’s important to find the balance of what’s good for the particular patient and what’s good for public health—delivering a baby for a patient at 38 weeks who can’t walk because she is so swollen and absolutely miserable may be the best thing for her, but not necessarily for the promotion of public health,” Newman said.   Purohit believes that it’s important for mothers to understand the implications of delivering a late pre-term birth if they become tired of being pregnant within a week or two of a full term pregnancy.   While it may seem a question of risk and convenience for healthy mothers who choose to have their babies early via induction or c-section, at-risk pregnancies are more complicated.   “Early induction is always a difficult choice for a provider to make, regardless if the pregnancy is high-risk or not. With an at-risk patient who  has undergone fetal testing, do you let the pregnancy progress until something goes wrong, which it might, or should she be delivered at 34-35 weeks? For a mother who’s faced with the decision of taking a chance at having her baby in the NNICU or it being stillborn, it is easy to see why she often takes the risk of dealing with prematurity outcomes versus losing a child,” Newman said. “Most physicians bail out at 34 or 35 weeks for at-risk pregnancies rather than allow the patient to get worse or the baby’s condition to get worse.”   Non-medically indicated inter-ventions to deliver early should be carefully reviewed and should follow national guidelines that call for confirmation of 39 weeks gestation, Newman and Purohit said. Friday, Sept. 1, 2006 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. 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