Almost 20 years ago, we both finished Ob/Gyn residency training programs and joined obstetrics and gynecology practices in the northeastern part of the United States. We each remember our in-hospital days–Thursday and Friday, because they always began by starting several inductions on the labor floor and then performing 1 or 2 scheduled cesarean deliveries.
Scheduling deliveries was the norm in those days. Patients would eagerly take out their brand new Palm Pilots to pick a date for their induction or cesarean. Once a patient had reached “term,” defined as 37 weeks gestation, everyone agreed that it was fair game to start planning for delivery.
The high rate of planned delivery represented a perfect storm in which patients’ and providers’ interests aligned precisely. What patient didn’t want to schedule her induction or cesarean by the light of a day and avoid a mad dash to the hospital? Wouldn’t it be nice to be able to tell your boss exactly when your maternity leave would start and be sure that Grandma was in town to watch your other kids? And planning was a win–win for providers as well, because it allowed you to personally deliver your patients. Once a woman had reached 37 weeks, delivery was often scheduled on your hospital day and patients were particularly pleased to know you would be the attending.
The perfect storm was predicated on the underlying reassurance that if delivered at term, the infant’s health would be fine. But what was missing from that conversation was outcome data: short- and long-term outcome data regarding the health of the infant.
In this issue of Pediatrics, Bentley et al1 provide important long-term outcome data from a population-based study in Australia suggesting that planned birth before 39 weeks is associated with poor child development. This study evaluated the physical health, social and emotional maturity, language and cognition, and general knowledge and communication among over 150 000 children in New South Wales at entry to school and revealed that the risk of being developmentally high risk increased with decreasing gestational age at birth. The study also revealed that the risk of being developmentally high risk for planned birth, via labor induction or prelabor cesarean, was 1.26 (95% confidence interval: 1.18–1.34) at 37 weeks and 1.13 (1.08–1.19) at 38 weeks.
These findings are consistent with and expand upon the spectrum of short- and long-term adverse pediatric outcomes associated with what has variously been called early elective delivery, nonmedically indicated delivery, and planned birth (all descriptors of labor induction or prelabor cesarean, without a medical indication, before 39 weeks). Over the past decade, a growing amount of valuable data has been published detailing multiple aspects of short- and long-term outcomes for childhood health and development. The data remind us that gestational age is a continuous variable and that gestational age at delivery follows an inverse dose–response relationship with risk of adverse short- and long-term pediatric outcomes, including, but not limited to, neonatal ICU admission, death in the first year of life, respiratory distress syndrome, jaundice, sepsis, and neurodevelopmental delays including poor development at school age.2
To be clear, there is another element to this discussion: maternal or fetal complications that warrant early delivery. Pregnancy complications, such as placenta previa, preeclampsia, or poorly controlled diabetes, often require intervention, and clinical judgment on the part of obstetrician is more important than ever in determining the optimal timing of delivery.3 In such circumstances, a preterm birth may certainly provide the best outcomes for mothers and infants. But, the case for avoiding elective or planned delivery before 39 weeks is strong, and getting stronger with data such as that presented by Bentley et al1 in this issue. So what can be done to eliminate this practice?
Hospital-based quality improvement efforts that assure a gestational age of at least 39 weeks before scheduling an elective induction or cesarean delivery have been effective in the United States4–7 and are credited with some of the success in decreasing the US preterm birth rate from 12.8% in 2006 to 9.57% in 2014.8 Public awareness has been promoted by March of Dimes through programs such as Healthy Babies Are Worth the Wait.7,9 The Association of Women’s Health, Obstetric and Neonatal Nurses has developed a grassroots public health campaign called Don’t Rush Me . . . Go the Full 4010 that educates women about the benefits of full-term pregnancy for themselves and their infants. Programs such as these, designed for pregnant women, can be adapted and scaled globally to reach the broadest possible audience.
From an obstetric perspective, guidelines relabeling term as “early term” to describe 37 0/7 to 38 6/7 weeks’ gestation versus “full term,” which includes 39 0/7 to 40 6/7 weeks’ gestation, emphasize the importance of the fetal maturation that occurs until 39 weeks.11 Outcome data and clinical guidelines are being emphasized for obstetricians and other prenatal care providers, and various countries are seeing changes in clinician-initiated deliveries with subsequent improvements in preterm birth rates.12 Continued efforts to educate both patients and providers should be supported.
From a pediatric perspective, continuing to study outcomes for planned births at various gestational ages will be important. This is only 1 piece of the puzzle, however, and we must broaden the research agenda to look at even longer term health outcomes extending into adulthood such as obesity, heart disease, diabetes, and mental health.
Equally important is that obstetricians and pediatricians provide a unified message to women and families that the optimal timing of planned delivery is at least 39 weeks. Let’s continue to work together to insure that patients’ and providers’ interests align in a new perfect storm, one based on outcome data, where births are not planned before 39 weeks in order to give every child the healthiest start in life and in school.
- Accepted September 20, 2016.
- Address correspondence to Siobhan M. Dolan, MD, MPH, Montefiore Medical Center, 1695 Eastchester Rd, Suite 301, Bronx, NY 10461. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on online at www.pediatrics.org/cgi/doi/10.1542/peds.2016-2002.
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- Roberts C,
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- Martin A,
- Morris J,
- Nassar N.
- Dolan SM,
- McCabe ERB
- Donovan EF,
- Lannon C,
- Bailit J,
- Rose B,
- Iams JD,
- Byczkowski T; Ohio Perinatal Quality Collaborative Writing Committee
- ↵March of Dimes. 39+ weeks quality improvement. Available at: www.marchofdimes.org/mission/39-weeks-quality-improvement.aspx. Accessed September 11, 2016
- ↵March of Dimes. Why at least 39 weeks is best for your baby. Available at: www.marchofdimes.org/pregnancy/why-at-least-39-weeks-is-best-for-your-baby.aspx. Accessed September 11, 2016
- Copyright © 2016 by the American Academy of Pediatrics