Tuesday, April 13, 2010

A Due Date is Not a Deadline

I'm officially on call for my first birth.

How exciting is that? This is sort of an "unofficial" client, since despite my obsessive independent study, my actual labor support training won't take place until June. It's a long story as to how it came about, which I won't go into for confidentiality reasons, but though I was apprehensive about whether or not it was okay to attend a birth pre-certification, one of the 'senior' doulas in the area encouraged me, saying "You don't need to be certified to hold a woman's hand and bring her a glass of water." True that!

So, as we're heading into the home stretch, the stress and exhaustion of the final weeks of pregnancy are taking their inevitable toll, and mom is anxious to get the show on the road, understandably. Mom's body is gearing up in a number of unmistakable ways, there is no question, and she's a total champ - but there's a lot of stopping and starting and revving up and decelerating, all of which can be so confusing and frustrating. I'm doing my best to reassure her that this is perfectly, absolutely and quintessentially normal, especially for a first time mom. Her due date hasn't even arrived yet, in fact - we have two more days until she's even 40 weeks along, and the hard numbers show that the average length of pregnancy for primips is 41 weeks plus one day.

Yet, I worry that for her, the due date seems like a looming deadline that she has to try to make or even beat, when this couldn't be further from the truth.

When it comes to child development, we know that there is endless variation that all falls within the range of normal. Some babies start teething at 4-5 months, others don't start until 7. Some are crawling by 5 months, some take quite a while longer. Some walk first, some talk first. Sitting up, rolling over, the milestones are endless - and mothers do sometimes get concerned that their babies aren't doing things "on schedule" . . . and they immediately get reassurance from other moms, especially moms with more than one kid, that every child is different and their kid will indeed reach them all in their own good time.

Yet when it comes to pregnancy, we culturally expect every baby to be 'done' at EXACTLY the same time, TO THE DAY?! Makes. No. Sense. Our fixation on one specific, magical date has really done a number on us, so to speak, collectively, to the point where we have come to think of that 40 week delineation not as an estimate but as a deadline. Combine this with a recent study showing that an alarming number of mothers believed the normal length of a pregnancy was 34-36 weeks, fold in an intervention-happy care provider, and add a liberal dash of normal end-of-pregnancy weary impatience, and you have an underbaked recipe for inductions at pandemic levels.

Sorry, my inner food-blogger took over there. Going on: A due "range" is much more realistic, and considering that it can be perfectly healthy two weeks (or sometimes more) in either direction - we really ought to start considering it a 'due month'. Anywhere from 37 or 38 weeks up to 42 weeks can be considered term. Even a "due week" is an improvement. I also like the growing-in-popularity term "guess date" a lot, and am trying to change my own habitual language to use that term more regularly. Now, don't get me wrong, in some cases being truly post-term can be problematic, but this is rare and deserves to be scrutinized on an individual basis, depending on circumstances.

Really think about it. That date is the mid-point on the bell curve of an entire range of days that could be acceptable, not to mention that it is an ESTIMATE in the first place. Hence, its official nomenclature, the Estimated Due Date, a.k.a. EDD. Furthermore, the estimate is itself based on what is often an approximate recollection of LMP. It is a riddle wrapped in a mystery inside an enigma, if you admire Churchill. A mystery wrapped in a riddle inside an enigma, if you liked "JFK". Or a riddle wrapped in an enigma wrapped in a vest, if you're Lisa Simpson. If there was only one thing, only ONE, that I could change about maternity care in this country, the fixation on the singular so-called due date would be a very, very strong contender.

There are a plethora of wonderful resources out there talking about the many advantages to avoiding early inductions, discuss various non-reasons sometimes given to pressure a mom into induction, and in general talking about the vital importance of the final weeks of pregnancy, and I'll share a bunch of them in a minute here, but let me first illustrate one point with a great visual from the March of Dimes:

Quite the difference there, eh? Among the last things to fully develop in pregnancy are the brains and the lungs - two things that I would never want to take any chances with. From a wonderful read titled "Why Every Week of Pregnancy Counts".
New research shows that those last weeks of pregnancy are more important than once thought for brain, lung and liver development. And there may be lasting consequences for babies born at 34 to 36 weeks, now called "late preterm."

A study in the American Journal of Obstetrics and Gynecology in October calculated that for each week a baby stayed in the womb between 32 and 39 weeks, there is a 23% decrease in problems such as respiratory distress, jaundice, seizures, temperature instability and brain hemorrhages.

A study of nearly 15,000 children in the Journal of Pediatrics in July found that those born between 32 and 36 weeks had lower reading and math scores in first grade than babies who went to full term. New research also suggests that late preterm infants are at higher risk for mild cognitive and behavioral problems and may have lower I.Q.s than those who go full term.

What's more, experts warn that a fetus's estimated age may be off by as much as two weeks either way, meaning that a baby thought to be 36 weeks along might be only 34.
Forgive the overzealous marking-up, there, but these are crucial details. Groups like the March of Dimes are getting increasingly concerned about early inductions and scheduled c-sections for this very reason, due to the risk of what is now being called a "late preterm" baby. 36 weeks is an extremely precarious age already- and then what if the "due date" is off, and you've actually got a 34 or 35 weeker? The entirely preventable increase in complications is unconscionable.

As promised, more linkage: Here's a good overall collection of some of the abstracts against induction, and here's more on the inaccuracy of many due dates. Lamaze discusses the pitfalls of babies being born even "a little" too early. And finally, here's a great overall piece from Lamaze on why adhering slavishly to a "due date" is NOT a healthy birth practice. It's worthwhile to bring up early in pregnancy. If any care provider insists on going only by the calendar and applies this cookie-cutter to all his or her patients, I personally would keep looking. To reiterate: there are some valid medical reasons for induction (as with any intervention), but just hitting 40 weeks? Not one of them.

Again with the food bloggering - innie-to-outie belly buttons aside, mama's bellies do not come with pop-out turkey timers.


  1. Thank you for this post, the image and the stats. As a mama to a 36+5'er, I want to scream every time I hear someone say "Well, I'm 36 weeks, that's term, I'm just going to ask for an induction." NO!!!

    My son (deceptively large at 9lbs7oz,) was a true 36+5, and we were VERY lucky to make it that far, as I had been steadily dilating and effacing from week 30. The morning we had to induce due to my kidneys failing and my BP rising, I was at 6 cm/80% and that was with terbutaline and mag.

    My "close enough to full term" (according to some of the misinformed) son had severe jaundice, RDS, and needed a radiant warmer for a week. When we came home, we battled with gastric immaturity and failure to thrive, as well as a bout of pertussis and non-RSV bronchiolitis.

    The impacts of his prematurity have been lasting: poor muscle tone in his upper body that we're seeking PT for, delayed milestones and apnea to name a few.

    This is all anecdotal, though. Every time I share these things with someone I know who thinks that scheduling their child's birth around a football game or a work meeting swears up and down that my case is an isolated incident, and besides... "He weighed so much, he must have had something else going on. Just look at how big he was!"

    Perhaps slapping them with some hard, published statistics will make them at least stop and think a little bit harder. Thanks again.

  2. I have been really frustrated lately, as I've heard SEVERAL women talk about 36 weeks being the 'magic' full term age. When did this become acceptable?! To just think that last 4-6 weeks in the womb is optional!? I was just talking about this with a friend last week! I'll have to forward on this post!

  3. Wow. The "lower reading and math scores in first grade" and lower IQ fact made my jaw drop. Thats SUCH an impact just for being late pre-term! Incredible, thank you for sharing.

  4. As a first time mom at nearly 38 weeks, I appreciate this post. I am fully committed to letting baby decide when to arrive, and have been so since I found out I was pregnant...but I am now also finding myself so anxious to meet this little person, be comfortable again, etc... I've found myself wanting to do everything possible to make baby come earlier (EPO, walking, spicy food, having sex, etc)... but after reading this post, I'm reminded of the importance of letting my little one be the decider here.

  5. Accidentally Mommy and Hilary, this might be further edifying for your info arsenal: I found that study that assessed women's grasp on what full-term actually means. I updated the above with a link, but rather than re-editing the whole post and breaking it all up to shoehorn this excerpt in, I'll share it here:

    "Recently a study was done to estimate women’s understanding of the definition of full term and the gestational age at which it is safe to deliver a baby.

    Twenty-four percent of women surveyed considered a baby of 34–36 weeks of gestation to be full term, and 50.8% believed full term to occur at 37–38 weeks of gestation. Only 25.2% considered full term to occur at 39–40 weeks of gestation.

    In response to, 'What is the earliest point in pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery?' 51.7% choose 34–36 weeks of gestation, and 40.7% choose 37–38 weeks of gestation, while only 7.6% choose 39–40 weeks of gestation."


    Emily, I know, it's staggering, isn't it?

    And last but so-for-surely not least, Mamma M, HANG IN THERE! I know those final weeks are brutal! But you're doing such a wonderful thing, allowing our baby to enter in his or her own good time. Cheers!

  6. Actually, one more thing for Mamma M, when the going gets tough, read this: Dear I-feel-like-I've-been-pregnant-forever.

  7. This is a fabulous topic. Thanks so much for the post and for sharing the March of Dimes info. The closer women make it to 40 weeks, the better.

  8. by the way....your senior doula was correct....it doesn't take a certificate to help out a mom in labor... ;)
    As a L&D RN I can assure you, that you will be the best thing for that mom! :)

  9. Thanks for the link to that letter. I seriously have ABSOLUTELY NO intention of induction...AT ALL. I'd rather cut my arm off. But it's always good to read something like that. :)

    I watched a birth show on tv the other day (I know, I should avoid them!), and the story showed a mother who was like 3 days "overdue" and decided to go for an induction because she was uncomfortable. She ended up with a c-section less than 24 hours later because of "failure to progress". I felt so sad for her. She was crying, but at that point, I felt like, "you did this to yourself!" I know it's not her fault...she's just doing what the system wants her to, etc... but, ugh...it's just sad.