Today the Fourth Atlas of Healthcare Variation was launched, and I was just asked to comment on it on ABC Perth.
It is a report by the Australian Commission on Safety and Quality in Health Care, and its number one concern was the rising number of early planned births with no medical reason.
“Early planned births are when babies are born before 39 weeks of pregnancy by planned caesarean section (that is, without established labour) or induction of labour”.
It found that 42.8–56.1% of caesarean sections performed for no clear medical reason were on babies less than 39 weeks gestation, which is quite a shocking statistic.
(BTW, the variation is state-based, with WA apparently being the highest ).
C/section before 39 weeks is often suggested for breech baby’s. But is being breech a medical reason for a c/section, let alone a preterm one?
Why is this shocking?
Because it means too many obstetricians and maternity services are still saying that babies are “ready” at 37 weeks, which is just not true.
The definition of term being from 37 weeks is outdated and not supported by evidence.
We know that:
“short-term risks, such as respiratory problems and the need for intensive care, are higher for babies born at early term (by caesarean section or induction of labour) than at full term. Longer-term risks in children born before 39 weeks gestation (either vaginally or by caesarean section) compared with those born at full term include cognitive deficits and a higher risk of attention deficit hyperactivity disorder.”
However some care providers continue to use 37 weeks because that’s what they were taught.
Well, I was taught a lot of things at university and through my midwifery studies that I now know aren’t true, so I have stopped saying them.
I think any Maternity Care Provider that is still suggesting caesarean sections (or inductions) before 39 weeks for no clear medical reason needs to be held to account.
And so do the authors of the report.
Here are their strategies to reduce rates of planned birth without a medical or obstetric indication before 39 weeks gestation:
• Changing policies of state and territory governments, hospitals and insurers to block booking of early planned births without a medical or obstetric indication
• Giving parents information about the risks and benefits of early planned birth, and support for shared decision making
• Giving clinicians information about the risks and benefits of early planned birth
• Collecting data on the reasons for early planned birth.
They have also recommended that planned birth before 39 weeks without a medical or obstetric indication doesn’t get a Medicare Benefits Schedule payment or Private Health Fund payments.
These are great initiatives but sadly, this will take time and if you are pregnant now, it will be too late for you.
So make sure you educate yourself about this issue.
The Every Week Counts website is a great place to start.
It shows the differences in outcomes in babies born between 35 and 40 weeks.
It also states that :
“Every week that a baby is born before 40 weeks can impact their health – whether that’s increasing their need for medical treatment at birth or related to brain development and future learning difficulties.”
and that
“Aiming for 40 weeks to give birth offers you and your baby health benefits. “
It really is time to redefine Term for planned births.
However, I do have to point out that not all babies mature at the same rate.
The numbers on the website and in the research are population-based.
If a baby comes on their own before 40 weeks, then they are ready, and they will have completed all their lung and brain development.
But similarly, some babies will not be ready by 40 weeks.
If there are no medical reasons for planned birth, then waiting for spontaneous labour will protect any baby against the complications associated with prematurity, because we don’t know when any individual baby is ready.
Medicine has to draw a line in the sand but you have to realise that the cut-offs aren’t as exact as medicine would like to think.
For some babies, before 40 weeks, it is still too soon to be born.
The media has picked up on the increased risk of learning difficulties and attention deficit disorders as a risk that is not told to parents.
Whilst you and I may think all OBs and midwives should have to keep up with all the latest research, especially those midwives teaching hospital antenatal classes, sadly, they don’t all do this. So perhaps they can be forgiven for not knowing about this risk.
However, we have known other long-term risks of a caesarean section to mothers and babies for a long time and I know these aren’t always discussed fully either.
It is so important that the benefits of any intervention outweigh the risks.
If there are no medical reasons for a caesarean section, it is hard to believe that there are any benefits that outweigh the risks at any gestation.
This amazing image was taken by Perth’s award-winning photographer, Cat Fancote, https://birthphotographyperth.com.au/
Risks to Mothers :
Some of the more common risks and complications include:
- above-average blood loss
- blood clots in the legs
- infection in the lining of the uterus
- a longer stay in hospital
- pain around the wound
- problems with future attempts at vaginal birth
- a need for a caesarean section for future births
- complications from the anaesthetic.
- breastfeeding difficulties
Longer-term Risks:
- intermenstrual bleeding
- chronic pelvic pain
- secondary infertility
- placenta previa and accreta
- miscarriage with subsequent pregnancy
- stillbirth with subsequent pregnancy
- increase risk of the need for hysterectomy
Risks to Babies:
- Respiratory problems post-birth
- Surgical injury
- Asthma
- Obesity
- Type 1 Diabetes
Of course, some mothers and babies will need a caesarean birth for a medical reason and then the risk-benefit analysis changes.
But they still need to know about the risks and if there are any ways to reduce them.
As soon as, and for as long as, skin to skin after the birth; and support to initiate and maintain breastfeeding are the first lines of defence. But perhaps we should also look at early learning interventions for these babies.
If you are making choices about early planned birth or any other intervention in your pregnancy, labour or birth, this is a great book to read.
What’s Right for Me? By Dr Sara Wickham
(Edited to include references 28th April 28, 2021)
References:
https://www.safetyandquality.gov.au/our-work/healthcare-variation/fourth-atlas-2021 (accessed April 27, 2021)
https://everyweekcounts.com.au/ (Accessed April 27, 2021)
https://www.betterhealth.vic.gov.au/health/HealthyLiving/caesarean-section (accessed April 27, 2021)
https://vbacfacts.com/2012/03/30/placenta-problems-in-vbamc-after-multiple-repeat-cesareans/ (accessed April 27, 2021)
https://vbacfacts.com/2019/08/05/placenta-accreta-ptsd/ (accessed April 27, 2021)
Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med. 2018 Jan 23;15(1):e1002494. doi: 10.1371/journal.pmed.1002494. PMID: 29360829; PMCID: PMC5779640.