Why Every Week of Pregnancy Counts

New Research Shows Why Every Week of Pregnancy Counts
By MELINDA BECK

This time of year, some hospitals see a small uptick in baby deliveries thanks to families eager to fit the blessed event in around holiday plans or in time to claim a tax deduction. Conventional wisdom has long held that inducing labor or having a Caesarean section a bit early posed little risk, since after 34 weeks gestation, all the baby has to do was grow.
But new research shows that those last weeks of pregnancy are more important than once thought for brain, lung and liver development. And there may be lasting consequences for babies born at 34 to 36 weeks, now called "late preterm."
New research shows that the last weeks of pregnancy are more important than once thought for brain, lung and liver development.
A study in the American Journal of Obstetrics and Gynecology in October calculated that for each week a baby stayed in the womb between 32 and 39 weeks, there is a 23% decrease in problems such as respiratory distress, jaundice, seizures, temperature instability and brain hemorrhages.
A study of nearly 15,000 children in the Journal of Pediatrics in July found that those born between 32 and 36 weeks had lower reading and math scores in first grade than babies who went to full term. New research also suggests that late preterm infants are at higher risk for mild cognitive and behavioral problems and may have lower I.Q.s than those who go full term.
What's more, experts warn that a fetus's estimated age may be off by as much as two weeks either way, meaning that a baby thought to be 36 weeks along might be only 34.
The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics and the March of Dimes are now urging obstetricians not to deliver babies before 39 weeks unless there is a medical reason to do so.
"It's very important for people to realize that every week counts," says Lucky E. Jain, a professor of pediatrics at Emory University School of Medicine.
It's unclear how many deliveries are performed early for nonmedical reasons. Preterm births (before 37 weeks) have risen 31% in the U.S. since 1981 -- to one in every eight births. The most serious problems are seen in the tiniest babies. But nearly 75% of preterm babies are born between 34 and 36 weeks, and much of the increase has come in C-sections, which now account for a third of all U.S. births. An additional one-fifth of all births are via induced labor, up 125% since 1989.
Are parents too eager to induce labor or schedule an early C-section for sheer convenience? Are doctors too willing to go along?
Many of those elective deliveries are done for medical reasons such as fetal distress or pre-eclampsia, a sudden spike in the mother's blood pressure. Those that aren't can be hard to distinguish. "Obstetricians know the rules and they are very creative about some of their indications -- like 'impending pre-eclampsia,'" says Alan Fleischman, medical director for the March of Dimes.
Why do doctors agree to deliver a baby early when there's no medical reason? Some cite pressure from parents. "'I'm tired of being pregnant. My fingers are swollen. My mother-in-law is coming' -- we hear that all the time," says Laura E. Riley, medical director of labor and delivery at Massachusetts General Hospital. "But there are 25 other patients waiting, and saying 'no' can take 45 minutes, so sometimes we cave."
There's also a perception that delivering early by c-section is safer for the baby, even though it means major surgery for the mom. "The idea is that somehow, if you're in complete control of the delivery, then only good things will happen. But that's categorically wrong. The baby and the uterus know best," says F. Sessions Cole, director of newborn medicine at St. Louis Children's Hospital.
He explains that a complex series of events occurs in late pregnancy to prepare the baby to survive outside the womb: The fetus acquires fat needed to maintain body temperature; the liver matures enough to eliminate a toxin called bilirubin from the body; and the lungs get ready to exchange oxygen as soon as the umbilical cord is clamped. Disrupting any of those steps can result in brain damage and other problems. In addition, the squeezing of the uterus during labor stimulates the baby and the placenta to make steroid hormones that help this last phase of lung maturation -- and that's missed if the mother never goes into labor.
"We don't have a magic ball to predict which babies might have problems," says Dr. Cole. "But we can say that the more before 39 weeks a baby is delivered, the more likely that one or more complications will occur."
In cases where there are medical reasons to deliver a baby early, lung maturation can be determined with amniocentesis -- using a long needle to withdraw fluid from inside the uterus. But that can cause infection, bleeding or a leak or fetal distress, which could require an emergency c-section.
Trying to determine maturity by the size of the fetus can also be problematic. Babies of mothers with gestational diabetes are often very large for their age, but even less developed for their age than normal-size babies.
Growing beyond 42 weeks can also pose problems, since the placenta deteriorates and can't sustain the growing baby.
Making families aware of the risks of delivering early makes a big difference. In Utah, where 27% of elective deliveries in 1999 took place before the 39th week, a major awareness campaign has reduced that to less than 5%. At two St. Louis hospitals that send premature babies to Dr. Cole's neonatal intensive-care unit, obstetricians now ask couples who want to schedule a delivery before 39 weeks to sign a consent form acknowledging the risks. At that point, many wait for nature to take its course, says Dr. Cole.

http://online.wsj.com/article/SB122999215427128537.html?mod=article-outset-box

More Moms Choose To Give Birth At Home

More moms choose to give birth at home
Too pricey » Many cite economic factors when deciding not to deliver in a hospital.

By Heather May
The Salt Lake Tribune
By Heather May
The Salt Lake Tribune

If Samara Hines had health insurance, she'd deliver her baby in a hospital, away from the demands of her five other children and with help from nurses for the new little one.
But Hines' husband is self-employed and the family can't afford insurance or the estimated $6,000 hospital fees, plus the cost of a nurse-midwife and prenatal care. So in August, the Provo woman will deliver her baby at home, where it will cost $1,900 for everything.
Spending thousands of dollars is "excessive, considering birth is a natural thing," said her husband, Dane. With no history of pregnancy complications and no insurance, home birth is "the most reasonable way to go," he said.
Midwives say the same economic forces that have led consumers to stay home instead of shopping is hitting the birthing business, albeit on a small scale. Licensed home-based midwives say they are seeing a slight increase in interest in their practice, in part because of cost.
A hospital-based birth can run about $8,300. That includes the $6,000 average hospital charge in 2006, calculated by the state health department. Women who want a certified nurse-midwife to care for them and the baby add an average fee of about $2,350.
"The fact people are having a lot of financial troubles is causing people to look for alternatives," said Suzanne Smith, Hines' midwife, who is taking more calls from people who are uninsured or have high deductibles. "Once they look at it they say, 'This is actually a pretty good option and it costs me a lot less.'?"
Smith placed an advertisement in the magazine Healthy Utah , noting the cost of pregnancy and delivery could be as low as $1,000 with supervised midwife students, though the average home birth is a little less than $2,000. Smith also runs a one-room birthing suite -- with a fridge stocked with snacks, a jetted tub and queen-sized bed -- in Orem, called BellaNatal. A birth there costs $2,800, including the midwife's fee.
She said eight women a week are making initial consulting appointments, when the norm in December is three.
It costs $4,350 to deliver at the Birth and Family Place, a birth center in Holladay, including the provider fee. The percentage of women touring the center who say they are attracted by its price has spiked to about a third, according to medical director Rebecca McInnis. "I don't think it's been that high before," she said.
Ann Stuart, who's due in March, would give birth at home, even if she had insurance. The Springville mother has delivered three times in the hospital and once already at home.
"It was so nice just to be in my own surroundings, not have to worry about packing a hospital bag, just be where I could go get food when I wanted it," she said, noting this birth will cost $1,400 because a supervised student will be her attendant. "If I feel more comfortable going one way and it's cheaper, I'd much prefer spending less."
Delivering at home or in a birthing center only makes sense for certain women, midwives say, noting that cost is rarely the only factor. The women must be willing to forgo an epidural or Caesarean section and must able to cope with pain using alternative methods. They must be healthy and have low-risk pregnancies. And they have to weigh the risks and benefits to delivering outside of a hospital.
"You really should be where you feel safe, where you feel good," Smith said. "Nobody's going to go to the cheapest place when it comes to the life of their baby."
That's why even though Shara Sumnall wanted to deliver her son, Jackson, in Smith's less-expensive birthing suite, she ended up in the hospital on Dec. 19 when her labor wouldn't progress.
Sumnall, whose husband works on commission in the sputtering auto industry, has insurance but could have saved money paying out of pocket to deliver at BellaNatal. After 12 or 13 hours of labor, she was admitted to a hospital and tried an epidural and pitocin to move things along. When that didn't work, she had a Caesarean section.
Sumnall hasn't received the bill and is "trying not to stress about it right now. I'm just enjoying my baby. There's a certain level of hope things will pick up with the economy."
Besides the cost, midwives tout the amount of control women can have at home, including the ability to deliver in water or in various positions instead of prone in a bed.
Cost and control were important to Paula Williams, of Provo. She wanted a home birth with her second child after a natural birth in the hospital with her first. Like many women who choose home birth, the massage therapist was dissatisfied with her hospital birth, particularly the rushed delivery of the placenta. She said she was so tired she didn't want to hold her baby.
The price tipped the scale in favor of birthing at home, because Williams doesn't have insurance. In late November, she delivered her son in a tub in her parents' house in Highland. She showered soon after the delivery and was in bed with her husband that night.
"It was a lot better experience. I got to do it my way," she said. "I will be doing it again, not just because of the money."

Midwives Deliver

Midwives deliver
America needs better birth care, and midwives can deliver it.
By Jennifer Block December 24, 2008

Some healthcare trivia:
In the United States, what is the No. 1 reason people are admitted to the hospital? Not diabetes, not heart attack, not stroke. The answer is something that isn't even a disease: childbirth.Not only is childbirth the most common reason for a hospital stay -- more than 4 million American women give birth each year -- it costs the country far more than any other health condition. Six of the 15 most frequent hospital procedures billed to private insurers and Medicaid are maternity-related. The nation's maternity bill totaled $86 billion in 2006, nearly half of which was picked up by taxpayers.

But cost hasn't translated into quality. We spend more than double per capita on childbirth than other industrialized countries, yet our rates of pre-term birth, newborn death and maternal death rank us dismally in comparison. Last month, the March of Dimes gave the country a "D" on its prematurity report card; California got a "C," but 18 other states and the District of Columbia, where 15.9% of babies are born too early, failed entirely.The U.S. ranks 41st among industrialized nations in maternal mortality. And there are unconscionable racial disparities: African American mothers are three times more likely to die in childbirth than white mothers.In short, we are overspending and under-serving women and families. If the United States is serious about health reform, we need to begin, well, at the beginning.

The problem is not access to care; it is the care itself. As a new joint report by the Milbank Memorial Fund, the Reforming States Group and Childbirth Connection makes clear, American maternity wards are not following evidence-based best practices. They are inducing and speeding up far too many labors and reaching too quickly for the scalpel: Nearly one-third of births are now by caesarean section, more than twice what the World Health Organization has documented is a safe rate. In fact, the report found that the most common billable maternity procedures -- continuous electronic fetal monitoring, for instance -- have no clear benefit when used routinely.The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. This model of care is not just cheaper; decades of medical research show that it's better. Mother and baby are more likely to have a normal, vaginal birth; less likely to experience trauma, such as a bad vaginal tear or a surgical delivery; and more likely to breast feed. In other words, less is actually more.

The Obama administration could save the country billions by overhauling the American way of birth.

Consider Washington, where a state review of licensed midwives (just 100 in practice) found that they saved the state an estimated $2.7 million over two years. One reason for the savings is that midwives prevent costly caesarean surgeries: 11.9% of midwifery patients in Washington ended up with C-sections, compared with 24% of low-risk women in traditional obstetric care.

Currently, just 1% of women nationwide get midwife-led care outside a hospital setting. Imagine the savings if that number jumped to 10% or even 30%. Imagine if hospitals started promoting best practices: giving women one-on-one, continuous support, promoting movement and water immersion for pain relief, and reducing the use of labor stimulants and labor induction. The C-section rate would plummet, as would related infections, hemorrhages, neonatal intensive care admissions and deaths. And the country could save some serious cash. The joint Milbank report conservatively estimates savings of $2.5 billion a year if the caesarean rate were brought down to 15%.

To be frank, the U.S. maternity care system needs to be turned upside down. Midwives should be caring for the majority of pregnant women, and physicians should continue to handle high-risk cases, complications and emergencies. This is the division of labor, so to speak, that you find in the countries that spend less but get more.In those countries, a persistent public health concern is a midwife shortage. In the U.S., we don't have similar regard for midwives or their model of care. Hospitals frequently shut down nurse-midwifery practices because they don't bring in enough revenue. And although certified nurse midwives are eligible providers under federal Medicaid law and mandated for reimbursement, certified professional midwives -- who are trained in out-of-hospital birth care -- are not. In several state legislatures, they are fighting simply to be licensed, legal healthcare providers. (Californians are lucky -- certified professional midwives are licensed, and Medi-Cal covers out-of-hospital birth.)

Barack Obama could be, among so many other firsts, the first birth-friendly president. How about a Midwife Corps to recruit and train the thousands of new midwives we'll need? How about federal funding to create hundreds of new birth centers? How about an ad campaign to educate women about optimal birth?

America needs better birth care, and midwives can deliver it.

Jennifer Block is the author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care."