Saving Babies’ Lives with Shades of Gray

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Big news for women who are 38 weeks pregnant: you are no longer considered “full term.” The American College of Obstetricians and Gynecologists announced today that they would introduce a new classification system for the end of pregnancy. Previously women who were 37 to 41 weeks pregnant were all considered “full term” and women 42 weeks pregnant or over “postterm.” The new classification system calls for four groups: early term (37 to 38 weeks); full term (39 to 40 weeks); late term (41 weeks) and postterm (42 weeks and more).

(MORE: New (and Hopefully Improved) Definition of Term Pregnancy)

I know, that’s a lot of terms. But the big change here is to separate out the 37- to 38-week period and acknowledge that, for most babies, this isn’t the ideal time to be born. Evidence has been piling up that babies born in this period do worse than babies born at 39 or 40 weeks. One very recent paper shows babies at 37 to 38 weeks are more likely than those born later to need time in the NICU, mechanical ventilation and IV fluids. But as induction and scheduled C-sections have become more common, the share of babies born at 37 or 38 weeks has risen from 17% in 1983 to 27% in 2009. Many of these deliveries are elective and driven, at least in part, by the perception by women (or their doctors) that things are ready to go at 37 weeks. The push to reduce these early-term deliveries has been going on for years.

This change in wording could make a big difference in practice. Early-term births are expensive because of their added complications, and by explicitly distinguishing them it makes it easier for insurers to refuse to cover elective births in this period. The problem, however, with having a strict guideline like this is that sometimes people start to treat it the cutoff itself as meaningful.

It is worth reflecting back on why this change is even necessary. The idea that 37 weeks is “full term” is intended to be descriptive. As pregnancy moves forward, the baby becomes more developed. Among the last organs to develop are the lungs, and usually this happens by 37 weeks, so calling 37 weeks “full term” is simply an acknowledgement of this. But women, and their doctors, can start to think that when you move from 36 weeks 7 days pregnant to 37 weeks 0 days pregnant, there is a magic switch that means your baby is ready. This is obviously not the case.

(MORE: I Still Trust Online Breast-Milk Sites for My Baby)

This is illustrative of a broader issue, in medicine and elsewhere, with any kind of sharp rulelike cutoff. In one example, researchers have shown that as a result of drawing the cutoff for very low birth weight at 1,500 g, babies born right below 1,500 g of weight actually have better outcomes than those right above, because they are given extra treatment. Again, there is nothing biologically special about 1,500 vs. 1,499. The cutoff is descriptive, and when it’s treated as a rule, odd things happen. The same issues come up in finance, closer to my own field, when looking at lenders who used sharp cutoffs in credit scores in deciding whom to lend to. There is nothing special about a credit score of 620 compared with 619, and when you treat it like there is, you can get into trouble.

The worry, of course, to return to the babies, is that what is happening here is we are replacing one rule with another. The new guidelines fix one issue, but could lead doctors (in theory) to be too cautious about delivery in 37 or 38 weeks when medically warranted. It could also lead them to be too gung ho about delivery as soon as you hit 39 weeks. The best case would be if women and their doctors took these terms as they are intended — as descriptive guidelines, not rules — and got better about letting nature take its course unless there is a medical reason not to. If that happens, this truly will be a major change, and not just for the women at 38 weeks.

MORE: Women Need to ‘Lean In’ to Pregnancy Too

18 comments
Katie62058541
Katie62058541

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AndrewKristinaSeymour
AndrewKristinaSeymour

This happened to me. I was 38 weeks in ACTIVE labor, not progressing and was sent home by the hospital because of the new 39week rule. I returned, 2 days later, in serious pain, and my daughter was stillborn. My placenta had removed itself from my Uterous. After 5 early losses, and having 2 "odd" deliveries, including my eldest son being born BLUE because of long-labor, my doctor WANTED to induce me, but couldn't because of the rule. Ontop of all of this, I'm not alone. 2 other moms had the exact same situation happen... all because the HOSPITAL would not allow the OB to induce, even though it was warranted. 

THE issue is that IF this is going to be a "thing"... If someone comes in in labor before 39weeks... a COMPLETE U/S specifying Cord position, and Placenta issues, needs to be done. When your body goes into labor, it's getting ready.. but it's also telling you that something is happening. I also feel that after 37 weeks if you have early labor, you should be held in the hospital until delivery, but thats another story. Thankfully, my OB will be inducing me at 37 weeks, or sooner if any situations arise, and I will be extrememly high-risk here on out.

^^THIS doesn't bring back my daughter. It never will. I hope that there can be new policies implimented to reduce this happening to anyone else.

AND. No. I didn't have trauma, blood clotting, or any other reason for this to happen. It was a fluke that we can only assume extended labor caused. 

 http://www.youtube.com/watch?v=8QQP94Ljn5s

JessicaAnne
JessicaAnne

So there is no magic switch for 36w0d but there is a magic switch for 38w0d to 39 weeks? I don't believe any of this. Sorry but my daughter was born at 37w4d and she is so smart! She is perfectly healthy, and very active. She communicates well, and functions like any other baby does! Saying babies who are born before 39 weeks are inferior to those who are born post 39 weeks is completely bias to me. Straight ignorance. Maybe they are more developed but to say they are "better" babies is just ignorant. 

karl2632
karl2632

Wouldn't it be easier to skip the terminology and just state the number of weeks?  I'm in engineering, not medicine, so maybe numbers are natural to me.

StaceyEason
StaceyEason

This definition is meant to specifically address the elective procedures going on. I am an OB nurse. I've been working in labor and delivery for 18 years. This has truly been an issue, inducing for convenience. But practically speaking, I don't see the problems postulated actually happening. My current place of employment has changed policy for induction not before 39 weeks. Unless medically warranted. It has been great. While this part is true...."It could also lead them to be too gung ho about delivery as soon as you hit 39 weeks." it's not a change in mind set. It just bumped things back. OBs are already too gung ho about elective induction, no matter the gestational age guidelines of the time. This is nothing new. I'm just go happy that studies like these  have pushed those guidelines to 39 weeks. I have yet to see a doc hold off on a medically needed induction. If anything, they will often look for a reason to do it. Slightly elevated blood pressures? Let's have a baby, when really a week of taking it easy at home would benefit baby immensely. 

The 39 week rule HAS been implemented in many locations, voluntarily, so the data IS already out there, if people chose to locate and compile it. I'm sure it would be discovered that out comes are far better. My own anecdotal thoughts are that if a baby come on his/her own at 37-38 weeks, then they do far better than a baby who is forced out at the same gestation. The "shades of gray" here are about us NOT knowing, and therefore, allowing nature to decide, and baby to choose his own birth date.

cristenpascucci
cristenpascucci

So happy to see this new "definition," although, as Ms. Oster says, it does bring a new set of problems when people replace old "rules" with new "rules" and ignore individual circumstances.  In childbirth, individualized care is so important for better health outcomes - not broad, population-based policies. All the same, it's great to see ACOG put forth this new classification that will, hopefully, lead to some real improvements in moms' and babies' health.

JLH
JLH

Oster brings up some very real concerns, however, it won't be until these new terms have been implemented for awhile before we know the effects this will have--there's no data for it yet.

EmilySutherlin
EmilySutherlin

I don't think it will stop doctors from medically inducing when NECESSARY. The problem here is that we're trying to stop unnecessary inductions from happening. 

I realize that some women get "tired of being pregnant", but those are the first moments of realizing that life isn't about you anymore. As long as the baby has a healthy heartbeat and mom is also healthy, there's no reason not to let a pregnancy go to 42 weeks, as that is normal, especially in first time mothers. The longer a baby develops in utero, the healthier they will be when they are born. It's worth the wait! 

bojimbo26
bojimbo26

A bunch of idiots trying to tell nature what to do .

DeweySayenoff
DeweySayenoff

I know this isn't going to be even remotely popular, but it's just an observation intended to get people to think about things in a bit more depth than they usually do.

Not too long ago, mankind didn't have IV's or ventilators.  Babies born prematurely who are saved today usually died back then.  If they did live, they USUALLY didn't live long enough to reproduce. 

Now, from a purely objective point of view, taking into the notion of how nature improves a species and keeps it healthy, in the wild, the newborn weak DIE.  This ensures that those who live are strong and improves the overall chances of survival for the whole species.  Weak animals that survive become lunch or dinner, or maybe a snack.  In this way, the strong survive and improves the odds of the whole species surviving as well.

Mankind IS an animal in a biological, "need the strong to survive and the weak to die" sense.  And until just the last several decades, that's exactly what happened.  The strong survived (strong as in those who could best cope with the challenges of existence) and the weak died.

But that's not the case anymore.  The weak are living, and it has an impact on the rest of us.  As an example, recent studies suggest that Western man's average IQ has DROPPED since the 1880's.  That means what is considered "average IQ" today is what a denizen of the Victorian Era would be calling a "moron" (A politically incorrect and obsolete clinical term meaning someone 61-90 in IQ) since today's "average" would be 14 points below the 100 average of 1880.

This is due to the fact that for decades and continuing today, more than ever, the weak survive to reproduce.  The things that used to kill off the weak among us before they could do that no longer kill them off anymore.

I'm not proposing anything.  I'm not calling for mass executions of the "weak", or even mandatory sterilization for those who don't measure up.  I wouldn't know where to begin to decide what "measuring up" means.  But the fact is, we do need to do something about how to address the declining "fitness" of the human race in a controlled fashion before nature catastrophically does it for us.  Because one thing mankind has not conquered is nature (not even our own) and it has a not so gentle way of restoring a kind of balance when it gets thrown out of whack.

Just food for thought here, folks.  Make of it what you will.

AndrewKristinaSeymour
AndrewKristinaSeymour

@jones.grace.e As fantastic as that is... an EDD is ESTIMATED. It's not exact, and can be as much as several weeks off. The placenta stops working as well at 37 weeks, too. Stillbirth rates increast once you hit 40 weeks. This rule is rediculous, because no one can give you an EXACT 40 week date. They are going off of estimations, and the assumption that every baby will make it to the 39 week mark. 

EDJ07
EDJ07

@jones.grace.e  The problem with that theory...my "full term" kid born at 42 weeks has Autism/SPD/ADHD my "pre term" kid born at 36 weeks doesn't have any developmental or IQ issues...

debrlyn
debrlyn

@DeweySayenoff  The intelligence quotient wasn't defined until the twentieth century. There was no standardized way of testing for or knowing the average IQ of an individual from the Victorian Era. Please cite your sources. 

If we disregard your lack of evidence and, for a moment, accept that the 'weak' minded are more prevalent in the world today then I say your point is still moot. Regardless of the stereotypes, some of the greatest contributions to our society did not originate from people with a 100+ IQ. If our prosperity was solely dependent on the people sitting around a Mensa conference table, we would be so screwed. 

Seriously, did you not get hugged enough as a child or something? 

Scientist
Scientist

@DeweySayenoff You are 100% and totally wrong, about everything including the IQ drop.  Average IQ scores have risen substantially in the last few generations, look up the Flynn Effect.


Next time you go hypothesizing about evolution, make sure you're trying to explain a real phenomenon rather than the product of your imagination.

DaniJaydenHammer
DaniJaydenHammer

You're a complete idiot. Thank God my 36 week baby was healthy and not in the NICU or I would hunt you down just to smack you upside your idiotic head.

cjensen
cjensen

@DeweySayenoff Interesting and thoughtful take on the issue.  Natural selection is a strong driver in nature, but mankinds intellect and technology allows us to intervene to frustrate the natural selection process.  Whether that is a good thing is debatable, but given respect for life, seems unlikely to change, though prenatal DNA and ambiotic fluid analysis, looking for known defects, is still accepted in society unless the religious Right gains control of everything...though they would do us all a favor if they started with themselves.

If parents want to call a severely austic, mongoloid or spina bifida child a "gift", so be it, but it is indisputable that they are a societal negative as they consume massive resources while producing nothing.  We can tolerate some of that, but not an endless amount if we are to remain productive and thrive.

SlappyE
SlappyE

@DeweySayenoff  Until this post, I thought the first Twilight book was the dumbest thing I'd ever read.  At least now we know who is bringing down the average IQ....