A new study published in the journal Pediatrics investigates a possible association between planned birth before 39 weeks gestational age and early childhood development. It concludes that an early, scheduled delivery is linked to poor childhood development at school age.
A population-based record linkage cohort study of those born in South Wales, Australia between 2002-2007 was performed on 153,730 live-born infants of greater than or equal to 32 weeks gestation with assessments of development in their first year of full-time school 2009 or 2012. The five avenues interpreted: physical health and well-being, language and cognition, social competence, emotional maturity, and general knowledge and communication. Those scoring in the bottom 10% were deemed vulnerable and if in 2 or more domains were classified as developmentally at high risk (DHR). Then, Poisson models were implemented to determine individual and combined adjusted relative risks of gestational age and mode of birth for those labelled DHR. The birth, hospital and developmental data was probabilistically linked.
My two cents: When you look for a link, often you will find one. Especially in population style designs analyzing records —from another continent no less— that might not fully reflect all confounding factors. In addition, ethical issues come to the forefront when effectively studying optimal modes of delivery, timing and routes. Picking who delivers early or not poses quite the dilemma. All to say, with a discerning eye, this publication is not entirely without merit.
When and how a baby is born, requires assessing a myriad number of influencing factors. Is there enough or too much amniotic fluid? Is the baby in distress? Are the fetus’ lungs mature enough to deliver and survive? Is mom’s blood pressure too high risking stroke? What underlying fetal and maternal diagnoses are in the mix? Was the last c-section too close putting mom at risk of a uterine rupture? The medical and personal realities abound. Hence, why sometimes the decision to induce a woman pre labor or plan a C-Section is often not cut and dry.
Fortunately, women have been giving birth since the beginning of time and most babies do quite well these days. It is also true that the advancement of medicine and science permits us to reverse, treat and cure previously deleterious scenarios. In certain settings, the ability to perform a c-section can be the difference between life or death of mom and/or baby as well as long-term well-being. An unavoidable gift.
That said, for a multitude of reasons, the study report (and I agree) doesn’t encourage inducing labor for non-medical purposes. We know, for example, that c-section rates are higher in those induced. Though an acceptable alternative that can be the safest choice for mother and/or baby, the preferred route is as nature intended via vaginal birth whenever possible. Despite Hollywood images of surgical ease for mother and baby, the reality of the procedure carries risks (e.g. anesthesia exposure, delayed transitioning and so on). Risks that might not even enter the picture if the baby were allowed to reach full-term in a spontaneous labor.
Planning to deliver in an otherwise healthy pregnancy when not primed for labor can expedite the aforementioned. Creating a cascade of events.
We all hear truths and tales of being in labor for 36 hours. The reality is labor has stages. Women are not in active labor for that duration. The baby in mom’s uterus needs to drop and properly position, the cervix needs to thin and dilate, the contractions need to grow in strength and coordination and closer interval till pushing comes into play. It is a series of complex events.
There is a reason it takes nine months to create a child in the singlehandedly most well-designed suspension system known to man. And, what it takes to allow that infant’s entry into the world is a miraculous and multi-level, dynamic process.
Bypassing the vaginal canal in a cesarean can cause transient tachypnea of the newborn (TTN), for instance. The baby uses the umbilical cord instead of the lungs while in utero. Upon first breath, the pressure differential changes between the heart and lungs as they expand. Squeezing through the vaginal passageway is a protective mechanism that clears out a lot of the fluid so the tiny airways can open once outside the mother. TTN occurs because the baby misses out on this process. Though often easily managed with supplemental oxygen, suctioning and close monitoring, it can be a more significant clinical course.
Each week of gestation is like a year of development to an adult. The difference in challenges between an infant born at 28 versus 33 weeks can be quite significant. The lung maturation is critical to survival as is brain development, for instance. This study recognizes “clinical research suggests that the threshold for planned birth and the gestational age for intervening has decreased…The study findings support clinical guidelines and policies recommending that labor induction or pre labor cesarean delivery for non medical reasons should not be routinely carried out before 39 to 40 weeks’ gestation.”
There is variation in clinical practice and, as stated, prematurity carries co-morbidities. The article further touches upon the public perception— with limited knowledge of the risks and benefits—that planning a c-section without medical indication should be performed upon request. It is especially important that the message is a better informed one when it comes to proceeding for the sake of convenience, for example.
Streamlining recommendations and policies on what should be the right decision at a particular birth can often reflect a Monday morning quarterback type opinion. It is usually not something adequately portrayed or clear by records alone. However, educating the masses about the risks and benefits of planning an early birth for non-medical reasons is a whole other topic that can only help improve decision-making, raise awareness and facilitate a truly informed choice.