Questions and answers about early elective childbirth
We’ve reported extensively on how hospitals across the state and country are reducing early elective deliveries of babies. To follow up my report on scheduling childbirth, I talked with research sociologist Christine Morton, PhD. Morton is project manager for the California Pregnancy Associated Mortality Review and other projects at California Maternal Quality Care Collaborative.
Q. I’ve heard that one of the driving factors in eliminating elective deliveries before 39 weeks is an assumption that cesarean section rates will decrease. Is this true?
A. Most experts expect to see only a minor decrease in overall cesarean rates if hospitals and physicians adopt and enforce a policy of eliminating elective deliveries before 39 weeks. This is because most of these elective deliveries are scheduled, repeat cesarean deliveries and they are simply put off 3-7 days or so. In the matter of elective inductions, the likelihood of cesarean is dependent on many factors, including the woman’s physical readiness to give birth, which can be assessed by a Bishop’s score of cervical shortening and opening. See definition here. (The primary ways to reduce overall cesarean rates are to focus on policies and practices for first labor to prevent the first cesarean, and to support and advocate availability (and desire) for vaginal birth after cesarean (VBAC).
Q. Research shows that babies born between 37 and 39 weeks don’t do as well as babies born between 39 and 41 weeks. Is there any talk about non-medical inductions or Cesarean sections between 39 and 41 weeks? If a mother’s labor is induced after 39 weeks, is that OK?
A. The CMQCC/March of Dimes toolkit does not address safety of inductions past 39 weeks. This is an area in obstetrics were there is not consensus, and there are debates over what the existing evidence says. Many factors affect the risks/benefits of induction after 39 weeks gestation, including the woman’s prior birth history, the status of her cervix (as discussed in Q1), and her care provider’s assessment.
Q. There doesn’t seem to be a consensus among mothers about the definition of “term pregnancy.” What is term? When is the best time for a baby to be born?
A. In terms of optimal outcomes and in most cases, the best time for a baby to be born is when the baby decides! Defining “term” as 37 weeks can best be understood historically. 37 weeks was defined as ‘term’ in an era when most women went into labor spontaneously. There is a significant improvement in maternal and neonatal morbidity when labor starts on its own. We are still discovering how the complex interaction between the baby, the placenta and the woman signals the start of spontaneous labor. In contrast, when labor is induced or a scheduled Cesarean is performed, both the woman’s body and the baby may be caught unaware, and so different rules apply. Thus a woman who goes into labor at 37 weeks will be considered “term” and nothing will be done to stop her from giving birth, but if she is being ELECTIVELY induced, the standards are higher (39 weeks or more) to reduce the likelihood of harm to the baby.
Q. What role do neonatal intensive care units play in elective births? Does the presence of NICUs make early births safer and therefore more prolific?
A. This is a good question. There is no doubt that advances in NICU care for very preterm babies have lulled obstetricians into a sense of security. They worry less about baby outcomes because the NICUs are there and most of the time, either the outcomes are good or obstetricians do not see the data on the infrequent babies with problems. Some of this false sense of security may also account for the rise in “late preterm” births (those born at 34-36 weeks gestation). These have been shown to be correlated to the rise in cesarean section and induction. The national rise in overall prematurity has been attributed to the rise in these late preterm births.
Q. How is data collected at hospitals on births? What is the best source for perinatal data?
A. Data on births is collected at hospitals internally by logbooks or in some hospitals by computer databases and of course data is sent to the state via the birth certificate. Birth Certificate data is limited, especially for medical complications. Summary information at the hospital level for researchers generally becomes available 2-3 years after the birth. The best source for population level perinatal data is from the March of Dimes.
Q. What tools exist in California for expectant mothers (i.e. hospital compare websites, etc.) to learn more about their birth options?
A. There are a few websites for expectant mothers in California to learn about their birth options. Very data-savvy people can go the resources listed on a new website, Birth by the Numbers, but most of those sites don’t list data by hospital. Some comparative hospital data is available at CalHospitalCompare.org but it is a few years old and the cesarean measure is not clearly defined as the AHRQ primary cesarean rate (vs. the TOTAL cesarean rate), which is what is reported on a new website: http://www.CesareanRates.com. In all these sites, the data are outdated, in some cases by four years; and in the meantime, local rates are likely to have increased, giving consumers a false picture of the hospital’s current rate. As a corollary, older data are deniable—that is, hospitals can claim that they are “much better now” without having to show valid and recent comparative data. Finally, data on public sites can be confusing to consumers if they try to compare the reported local data with the more recent national data that are typically used in media reports, or if the reported data do not apply to the total cesarean delivery rate. This has the unintended effect of making the older local data look favorable if care is not taken to verify the years reported, or if the reported cesarean delivery rate is not the total rate but rather the AHRQ primary cesarean rate. In short, unless the particular measure is carefully constructed, defined, and examined, public reporting can be misleading and result in unfounded conclusions on the part of the local user.
The best way to learn about local birth practices and options is to contact a local childbirth education group or organization, as some keep local statistics and update them annually. Another good strategy is to ask labor & delivery nurses at a particular hospital! The best time to call and ask to speak to the charge nurse is on the evening, weekends or night. They have more time to answer questions and may have different answers!
Q. What questions do you think pregnant women should be asking?
A. Pregnant women should feel very comfortable and entitled to ask a prospective or current care provider what their rates are for Primary (first birth) cesareans and Labor inductions, and when their provider typically recommends or does these procedures. If the provider doesn’t know their rate, or answers with a general “only when medically necessary,” women should ask for the hospital rate and request that the hospital provide them with their provider’s individual rate. For midwives, one can also ask their transfer rate to a physician care and the cesarean rate among those transferred).
Christine Morton, PhD is a research sociologist; she is project manager for the California Pregnancy Associated Mortality Review and other projects at California Maternal Quality Care Collaborative; she conducts research on maternal quality advocates and writes about maternal quality improvement projects. She consulted with Dr. Elliott Main, MD to answer these questions. He is the medical director of CMQCC.