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Study Links Caesareans With Births Before Term

May 28, 2008

NY Times

Premature single births have been increasing in the United States, mostly among
infants delivered by Caesarean section, researchers are reporting. And they say
some of the increase may be due to Caesareans that are not medically necessary.


Get Health News From The New York Times » The trend is worrisome because
premature babies are at risk for breathing and feeding disorders, delayed brain
development, other health problems and death.

A study of single births from 1996 to 2004 found an increase of one percentage
point in premature deliveries, to 10.7 percent from 9.7. Ninety-two percent of
those premature deliveries were by Caesarean. Most were "late preterm," born
after 34 to 37 weeks of pregnancy, instead of the normal 38 to 42 weeks.

Late preterm babies make up more than 70 percent of all premature births in the
United States, and are the fastest growing subgroup of preterm births, the
researchers found. Even though they may seem close to full-term, they still
face increased risks of serious problems from being born too early.

The study focused on single births rather than multiple ones, because multiple
births are much more likely to involve complications that require Caesareans.

The report was based on a review of birth records and previous studies,
conducted by the March of Dimes Foundation, Albert Einstein College of Medicine
and the federal Centers for Disease Control and Prevention. It is to be
published in the June issue of Clinics in Perinatology, a medical journal.

The researchers say they cannot be sure how much prematurity can be blamed on
unneeded Caesareans, because it is often hard to tell from medical records
exactly why a Caesarean was done. The Caesarean rate has been climbing steadily
in recent years, from 20.7 percent in 1996 to 30.3 percent in 2005.

"The practice of obstetrics has changed so dramatically in the past 20 years, so
that induction of labor and Caesarean section have become the norm," said Dr.
Alan R. Fleischman, the medical director and senior vice president of the March
of Dimes.

In observations at community hospitals across the country, researchers have seen
obstetricians stretching diagnoses a bit to justify Caesareans that are not
truly necessary, Dr. Fleischman said.

"Perhaps for convenience, perhaps out of fear of litigation, perhaps in response
to a maternal request, they are scheduling their deliveries rather than allowing
labor to begin," he said. "And this comes when there is an epidemic in America
of prematurity."

Dr. Sarah J. Kilpatrick, chairwoman of the department of obstetrics and
gynecology at the University of Illinois, and chairwoman of the committee on
obstetric practice for the American College of Obstetrics and Gynecology, took
issue with some of Dr. Fleischman's comments and said there was no proof that
unnecessary Caesareans were occurring or leading to premature births.

Noting that the college of obstetricians has guidelines stating strongly that
labor should not be induced and Caesareans should not be performed before 39
weeks unless there is a genuine medical need for it, Dr. Kilpatrick said, "We
stand by that."

She continued, "On the other hand, what I would agree with, I think there is
pressure by patients on physicians to deliver early-ish when someone's
uncomfortable, and there is medico-legal pressure. Obstetricians are afraid of
being sued."

The fear of lawsuits is so great that at the first hint of a problem, Dr.
Kilpatrick said, obstetricians "may proceed with a Caesarean to deliver the
fetus when the fetus is probably fine."

She also said that obstetricians might have grown a bit complacent about
delivering babies a few weeks early because pediatricians and neonatologists
had become so good at taking care of premature infants.

"They may let their guard down around 36 weeks because they're so sure the baby
will be fine," Dr. Kilpatrick said. "This paper is a good reminder to everybody
that 36 weeks is still preterm."




http://www.nytimes.com/2008/05/28/health/research/28birth.html?ref=health