The Facts About Late Prematurity

by Melissa Garvey, ACNM Writer and Editor



Did you know that November is Prematurity Awareness Month? More than half a million babies are born prematurely in the United States each year. More than 70% of those half a million premature babies—which translates to more than 350,000—are born late preterm, between 34 and 36 weeks gestation.

Often, late-preterm births occur as a result of pregnancy complications or health problems in the mother or fetus. However, the March of Dimes and other organizations, are concerned that many late-preterm births happen via induced labor or cesarean section at the request of the mother and/or health care provider without medical justification.

Why the concern? Although 99% of late preterm babies survive, a few weeks gestation makes a huge difference in infant health. Here are the facts.

Late preterm babies are:

• six times more likely than full-term infants to die in the first week of life (2.8 per 1,000 vs. 0.5 per 1,000).


• three times more likely to die in the first year of life (7.9 per 1,000 vs. 2.4 per 1,000).


• usually between 4½ and 6 pounds and may appear thinner than full-term babies.


• at higher risk than full-term babies for newborn health problems, including breathing and feeding problems, difficulties regulating body temperature, and jaundice.


• at increased risk for learning and behavioral problems. At 35 weeks, a baby’s brain weighs only two thirds of what it will weigh at 40 weeks.
  

Learn more and take action by joining the March of Dimes Fight for Preemies. You can also learn more about the prematurity in your state by viewing the March of Dimes premature birth report cards.

Can We Reduce Premature Birth with Better Communication?

by Eileen Ehudin Beard, CNM, FNP, ACNM Senior Practice Advisor

We are so time conscious in our society. Life in the fast lane frequently requires scheduling out major events. Childbirth is one of the important life events that cannot and should not be scheduled. I wonder if midwives and other health care providers are taking the time to explain why. More specifically, how many women understand how the estimated due date (EDD) is calculated and what constitutes a full-term pregnancy?

Last month, we looked at a study in Obstetrics and Gynecology that analyzed women’s perceptions of full-term birth. And in December, we made note of the rising incidence of premature birth in the United States. I’d like to expand on one aspect of the study authors’ conclusion:

“…with the trend of an increased patient role in medical decision-making, ensuring that women understand the implications of the timing of delivery may be an important component of interventions to reduce the number of elective or semi-elective late preterm and early term deliveries.”

Do women and their families really understand the possible consequences of a preterm delivery? Perhaps we need to spend more time explaining how the EDD is calculated and why it is important to avoid delivery before 39 weeks.

Midwives need to take time to explain that the 40 weeks used to calculate EDD is 9 months because there are 4½ weeks in most months. We need to explain that for the EDD to be most accurate, a woman must be certain of her last normal menstrual period and have a regular 28-day cycle. Even then, EDD is an estimate. Women are not machines and don’t always have the same cycle. The EDD can often be unreliable, which may unwittingly lead to early induction of what looks like a full-term pregnancy on paper—more reason to avoid unnecessary induction.

Since many women and obstetricians are “scheduling delivery’” before 40 weeks, the picture can get pretty fuzzy for women. Early delivery may appear safe since it happens so often. There are many important issues to discuss on the initial prenatal visit, but I wonder if we breeze over the issue of what constitutes preterm delivery and how the EDD is calculated. We need to give this topic the careful explanation that it deserves. It could turn out to be a key intervention that helps decrease the incidence of late preterm and early term delivery.

How Many Preemies Does it Take?

by Melissa Avery, CNM, PhD, ACNM President

As National Prematurity Awareness Month closes, we’re digesting a lot of statistics. Today, in the US, more than 1,400 babies will be born prematurely. Between the early 1980s and 2006, the rate of premature birth rose by 36%. These are fascinating and disturbing statistics, but as a midwife who is actively engaged in research, there is one companion statistic that startles me even more: From 1992 to 2002, the average gestational age at birth in the US dropped from 40 weeks to 39 weeks.

It does not take a statistician to appreciate that a drop in the average time a baby is born by a full week over the course of just 10 years means something big has been happening. Over 4 million babies are born each year in the US. A substantial increase in the rate of prematurity would be needed to reduce the average time of birth by a full week.

Why the rise in prematurity despite advances in medical knowledge and technology? According to the most recent March of Dimes prematurity summit, the primary reason is not obesity or smoking, as you might expect—it’s labor induction. In 1990, the rate of inductions was 9.5%. By 2006, the rate more than doubled to 22.3%.

Research documents that preterm infants have an increased risk of being admitted to level 2 or 3 nurseries and that important brain development continues all the way to full-term. More recently, late preterm infants (born at 34-37 weeks gestation) have been shown to have a 30-fold increase in complications like respiratory problems, hypoglycemia, and hypothermia.

Certified nurse-midwives and certified midwives have a long history of reserving labor induction for the situations when it is absolutely necessary. The American College of Obstetricians and Gynecologists (ACOG) recently issued a statement calling for an end to inductions prior to 39 weeks unless there is a clear medical indication. Now that the US has enough preemies to impact a national statistic and a national medical organization, let’s support a re-examination of medical indications for labor induction prior to full-term and promote a renewed emphasis on waiting for spontaneous labor and birth.

It’s Time to Fight For Preemies

by Melissa Garvey, ACNM Writer and Editor

In honor of National Prematurity Awareness Month, Midwife Connection is participating in the March of Dime’s Fight for Preemies, a blog event to raise awareness of the premature birth crisis. Every year, 20 million babies are born too soon, and half a million of them are born in the U.S. Today is the day to put a face on prematurity by blogging for a baby you love. We asked ACNM Facebook fans to tell us their stories. Here’s what they shared [please note that some comments were edited to preserve patient privacy]:

Cristal M Churchill
I took care of a lady who had twin-to-twin transfusion. She was being seen by MFM [Maternal Fetal Medicine] and OB due to her high risk status! Then she came in laboring and was c-sectioned at 30 weeks. We were so worried about them that first night. I remember being there and crying with them. As I finish my CNM degree, this family will always hold a spot in my heart.

Sharon Harkey
My beautiful IVF nieces born at 31 weeks because one was IUGR [intrauterine growth restriction]. Luckily, I started teaching OB clinical 2 days later at that hospital with a group of 8 RN students. It gave me precious access to the NICU to visit them while they grew over the next 6 weeks. They will be 4 in January and are doing wonderful, thanks to those awesome nurses! And all my students are out there practicing with a better view of OB thanks to taking clinical with a CNM!

Lisa Weston
My beautiful daughter, Zoe, now 17...preterm labor with dilation at 28wk, home uterine monitoring, terbutaline, SROM [spontaneous rupture of membranes] and delivery of my 4#8oz girl at 34 wk. So strong-willed, so mad at the world from day 1...always precocious, graduating from high school, a semester early (natch!) in 4 short weeks.

Leigh Wood
35 weeks gestation, his mom had prom [premature rupture of membranes] at 32 weeks and held him in and safe until she could deliver with us instead of at a tertiary care center.

Jackie Robins
My precious Eli and Vinny, preterm labor held off til 36 weeks. Eli had nasal CPAP for several days. Thank God for the advances in NICU care!!!!!

Let’s continue the fight for preemies. If you have a story about a premature baby you know or cared for, add a comment to this post. (Midwives and other health care providers, please remember to observe HIPAA privacy regulations. If you're not a health care provider, feel free to share as much as you want!)

U.S. Infant Mortality Rate Compares Poorly with Europe

by Melissa Garvey, ACNM Writer and Editor

Just in time for Prematurity Awareness Month, the CDC released a new NCHS Data Brief that ranks the U.S. 30th in the world in infant mortality rate. At 6.8 infant deaths per 1,000 live births (5.8 when excluding births less than 22 weeks of gestation), the U.S. falls behind most European countries, Canada, Australia, New Zealand, Hong Kong, Singapore, Japan, and Israel.















What’s the reason for our poor performance in this critical indicator of national health? It’s our “very high percentage of preterm births.”

Since 1984, the percentage of preterm births (infants born before 37 weeks of gestation) in the U.S. has risen 36%. Lowering that percentage appears to be the key to bringing the U.S. infant mortality rate in line with the rest of the developed world.

The Data Brief goes on to show just how dramatic lowering the preterm birth rate in the U.S. could be:

“If the United States had Sweden’s distribution of births by gestational age, the U.S. infant mortality rate (excluding births less than 22 weeks of gestation) would go from 5.8 to 3.9 infant deaths per 1,000 live births—a decline of 33%.”

Sweden and Norway have the lowest infant mortality rates in Europe. Here’s an interesting fact that was not included in the Data Brief: In stark contrast to the U.S., Sweden and Norway (along with most of the developed world) use midwives as their primary birth care providers.

The Real Risk of Late Prematurity

A study in the August 2009 issue of Obstetrics and Gynecology shows that late prematurity is an independent risk factor for neonatal morbidity. For those of us who aren’t women’s health experts, that means babies born between 34 and 37 weeks of pregnancy are at greater risk for health problems than babies born on or after week 37.

Midwives already know that late prematurity puts babies at risk for complications, but this retrospective study involving nearly 10,000 low-risk pregnancies singles out late prematurity as an independent risk factor. After adjusting for potential confounders, including maternal age, birth weight, and mode of delivery, researchers found a 30-fold increase in complications like respiratory problems, hypoglycemia, and hypothermia in babies who were born at 34 weeks. Researchers also observed a “gradual and consistent decrease” in risk of neonatal morbidity as gestational age increased with risks leveling off at about 39 weeks.

Study authors note that late prematurity has increased dramatically over the past two decades to about 8% of all deliveries and 75% of preterm deliveries. Interestingly, ACOG recently revised their labor induction guidelines, encouraging avoidance of induction before 39 weeks of pregnancy (the previous recommendation was 37 weeks). Do you think this study had anything to do with this?