Medscape interviews Dr. Fleishman, expert from the March of Dimes, on the prevention of prematurity. The March of Dimes has gotten my respect these last 7 years for their prematurity prevention campaign. In the beginning, I used to muse, what we midwives could teach these folks. Well, someone else must have been thinking that same thing. And better than that, Dr. Fleishman is watching the numbers.
Here are some of Dr. Fleishman’s bold statements:

“About 72% of all premature babies are now born “late preterm,” defined as 34 and 0/7th to 36 and 6/7th weeks’ gestation. That so many of these babies are being born early is directly correlated with actively managed pregnancy… We believe that a substantial proportion of these births are not medically indicated.

“…actively manage pregnancy has gone overboard. It has caused any small change — any increase in blood pressure, any concern about diabetes, or fetal well-being — to result in a very aggressive management strategy with inductions before they’re needed. Inductions tend to result in cesarean deliveries.

“The other thing that has increased iatrogenic prematurity is the fact that both women and health professionals are scheduling deliveries. This clearly has convenience benefits for both parties, but I don’t think we were sufficiently aware of the serious consequences of doing this….

“The reason we’re fairly certain that much of the late prematurity is iatrogenic [Doctor caused (and could be midwife-caused, too, if the midwife induces early] is because of what happened at this symposium. We invited the Hospital Corporation of America, Ascension Health, Premier Health, Geisinger Health System, Intermountain Health, and United Health to give us their data. All of these programs have done interventions of one sort or another to decrease early — pre 39 weeks — inductions and consequent cesarean deliveries. And, in fact, when they do that, they dramatically decrease, first, their late preterm birth rate, second, their C-section rate, third, their neonatal intensive care admission rate, and they have better outcomes and lower costs with no increased adverse outcomes of pregnancy, and no increase in stillbirths.

“What we see from those programs — and we now have published data, which were presented at this meeting — is that you can decrease these inappropriate iatrogenic deliveries and have better outcomes without any adverse effects. So, that proves the hypothesis that some of these [early births] are certainly unnecessary.”

So what he’s saying is that when the March of Dimes acts as a Watch Dog group and fewer inductions are done before the mother is 39 weeks pregnant, injuries and illnesses are reduced without causing more problems in other areas.

Women are often told to be induced because amniotic fluid is low, their baby is large, or their blood pressure is a little high (if it is a lot high induction can be a good idea, especially if no one knows to counsel the mother to eat high protein, greens, water and a bit of salt immediately and daily).

Anyway, such generalized reasons for induction are not proving induction is good but that induction is bad. When mother’s are not induced before 39 weeks, there are not more problems. If induction was a good idea then we’d have seen healthier babies after induction. We do not generally see that. Some doctors and midwives understand this and do not generally induce.

When to induce? There are times, perhaps lack of fetal movement even after feeding the mother (and so the baby), lack of fetal heart rate variability (and not just for the baby’s nap) or when the mother is truly sick with high blood pressure or worse – the kind of thing that only giving birth can solve (though you know from my other posts that I have seen amazing things from 100 grams of protein daily plus other dietary rescues). There are times to induce labor, but rarely.

More from Dr. Fleischman: “…I think that the increase in cesarean rate directly correlates to the increase in induction rates. If you induce women early, when the cervix and uterus aren’t ready for labor, you will have an increased cesarean rate. Once the woman is admitted and induced, and her membranes are ruptured, that’s a train that isn’t going to stop until the baby is born. The increase in the rate of cesarean deliveries is a big part of the increase in late preterm births.

“The obstetric community, to its credit, is absolutely in favor of no inductions or C-sections before 39 weeks unless there is a clear medical indication. … We’re helping them [our obstetric colleagues] to learn… to insist that women not deliver before 39 weeks.

“… we can’t leave it up to doctors alone. We can’t leave it up to the nurse who’s booking the induction or the C-section; we’ve got to create rules in hospitals with clear standards. That’s why quality improvement — analysis of data, the creation of rules, and holding people accountable — is so important.

“…there is an increase in prematurity around the world; we reported in the March of Dimes White Paper on Preterm Birth: The Global and Regional Toll that in fact there are 13 million premature babies born every year around the world. About a million of those babies die. The United States leads the increasing rate of prematurity in developed countries. North America and Africa are the 2 regions with the highest rates of prematurity. “

Read that again, folks. North America and Africa lead with prematurity. We know Africa is afflicted with a drought and AIDS and I guess American pregnant women have a drought in their aid. They aren’t getting the simple care they need to prevent prematurity.

Now it gets fun.

Dr. Fleishman, expert at March of Dimes, goes on to say,

“In comparing outcomes between women using midwifery, home birth, or expectant management vs a more active management strategy … there is no question that the midwifery programs end up with deliveries not being induced unless there are clear indications. Midwifery services don’t just wait until 39 weeks; they wait until the initiation of labor, which God in Her wisdom used to think was a good idea, and I think that it’s probably a good idea for most women, yet only about half of the women in America are being allowed to go into natural labor. So yes, there is a lot of benefit to thinking about the expectant management, “high-touch,” caring approach, which we think is quite appropriate.”

Read more straight talk from Dr. Fleishman at Medscape.

Pregnant women today need to know that some midwives, as well as some physicians, will push for induction for practice standards rather than indicated reasons. This means that when they advise for induction they will give scary reasons why a woman should comply. It may be that all women in their care are induced by 42 weeks, or if fluid is low, the baby is big, etc. And to get free-thinking women who chose midwives to agree to questionable intervention fear is sometimes played upon, let’s be honest. I’ve seen it played out many times.

Even if a woman who is 42 weeks has a baby who is active, passes her biophysical exam with and 8 out of 8, etc, the midwife is still so unlikely to say Your particular baby is healthy, we can wait a few days on this induction. No, she will push for induction to maintain a working relationship in her clinic and hospital (to get along with her colleagues).

Thats the dark side of Standards of Care. There is a bright side, too, but I’m ranting here.

Women will comply rather than disrupt their support system, rather than alienate their midwife. They will go home in tears and rant to their doula and come back and get induced. They will sit by their babies bed side in NICU and hold their head in their hands and not go back for their second birth, but they will not walk away from the bad idea of induction for a less than obvious health reason.
Dr. Fleishman says March of Dimes is teaching Dr.s a script to hold women off from inducing so that grandma can give postpartum care during her scheduled visit.
Midwives and Birth Activists must give women a script for talking to their doctor or midwife when induction is discussed.

Its not uncommon for a woman to be told she must be induced to save her baby’s life on, let’s see, theirs an opening on Thursday morning. Your baby’s life is in danger, so come Thursday morning. And then on Thursday morning it may be that there are no available beds. So the mother is told to come back tomorrow. Now, finally, she has the evidence to see that there is no emergency. Yet she is so scared by now that she can’t relax. She fears that some crisis is impending and she wants her baby to survive it. She now begs to be induced when instead, she can go home, eat well, relax in her own bed, and come back when labor starts on its own.

How can a woman tell when an induction is necessary and when it is not?
How does a woman navigate the fear of her providers?

How can women disagree and still hope to get compassionate, quality care during spontaneous labor? Leave a comment and tell us!
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