Women & pregnancy.

Andrea Johnson was 32 when her first child was born, 33 when the second came along. Eight years later and remarried, she started a second family, having her third child at 41 and discovering just six months later that she was pregnant again.

Ms. Johnson, of Dickerson, MD, is part of a growing trend in the United States for older women to have babies. Between 1990 and 2003, the birth rate for women aged 40 to 44 jumped 58 percent, while the number of births to women aged 45 to 49 grew fourfold (1) The reason? Greater use of assisted reproductive techniques like in vitro fertilization, donor eggs and surrogate mothers--technologies that were still developing 10 years ago but which today have entered the reproductive mainstream.

That's just one change in the pregnancy/birth picture over the past decade. Today, newer, less invasive tests and greater use of prenatal counseling can help women better assess their risk of giving birth to a child with serious problems; more women are delivering via cesarean section than ever before; and a new specialty--fetal surgery--has evolved to correct certain abnormalities like some types of spina bifida even before babies are born.

"We have become more medicalized, more technologically based," says Sidney Wu, MD, an attending physician at New York Presbyterian Hospital in Manhattan. "There's more reliance on electronic fetal monitoring, greater acceptance of epidurals and more genetic testing before the twentieth week of pregnancy."

Specifically:

* Eighty-five percent of babies born in 2003 were electronically monitored during delivery compared to 68 percent in 1989, even though the risks and benefits of the procedure remain controversial. (1)

* Sixty-seven percent of women with live births had at least one ultrasound during their pregnancy in 2003 compared to 48 percent in 1989. (1)

* About 21 percent of women had their labor induced (artifically started) in 2003, more than twice the number in 1990. At least one study found no medical reason for 25 percent of inductions. (2)

* Nearly 30 percent of all deliveries were cesarean deliveries in 2004--the highest ever reported in the U.S. and a 40 percent increase since 1996. One reason for the increase: fewer vaginal births after an earlier cesarean (VBAC), rates of which dropped 16 percent since 1996. (3)

As with anything, our increasing reliance on technology has pros and cons, says Heather Reynolds, CNM, MSN, FACNM, a certified nurse midwife and associate professor at Yale Medical Center in New Haven, CT. "You always have to weigh the risks and benefits of any technology we use," she notes.

Planning for Pregnancy Earlier

Technology can help in many ways, but don't overlook basic health practices. For example, one of the most important things you can do for yourself and your baby is also one of the simplest: remember to take a daily vitamin before you try to get pregnant and throughout your pregnancy. Folic acid, found in prenatal vitamins, can slash the risk of major birth defects of the fetus' brain and spine between 50 and 70 percent. (4), (5) There's even some evidence it can reduce the risk of other birth defects, including cleft palate, stomach problems and defects in arms and hands. (6)

That's why the U.S. Food and Drug Administration mandated fortifying all cereal products with folic acid in 1998. Since then, the incidence of neural tube defects dropped 26 percent. (7)

All of which makes pre-pregnancy planning important, says Michelle Collins, CNM, a certified nurse midwife and clinical faculty member at Vanderbilt University in Nashville, TN. Pre-pregnancy or "preconception" planning involves a visit to your health care provider for a full medical evaluation, including a detailed medical history before you begin trying to get pregnant.

It's a time to consider how you'll treat any preexisting condition that requires medication, such as depression, diabetes or epilepsy. A woman with diabetes, for instance, runs the risk of having a child with cardiovascular disease or other problems if her blood sugar levels aren't well-controlled before and during her pregnancy, says Ms. Reynolds. Plus, certain anti-seizure medications may cause defects in the infant by interfering with a woman's ability to use folic acid. And in late 2005, the FDA warned pregnant women not to use paroxetine (Paxil), a popular antidepressant, during pregnancy because of a potentially higher risk of birth defects.

That doesn't mean you have to stop taking all medications during pregnancy, says Ms. Reynolds. Usually, there are alternatives available that have been shown to be safer during pregnancy.

The time before pregnancy is also the time to address any weight problems. Studies find that being overweight can increase your risk of gestational diabetes and may even make it harder to get pregnant. Conversely, being underweight can interfere with fertility.

And, of course, it's a time to quit smoking. Smoking not only increases the risk of having a low birth-weight baby, but also a baby with Down syndrome and a multitude of other birth defects. (9), (1)

In addition to preconception counseling, women might consider genetic counseling before they get pregnant, says Ms. Reynolds. During genetic counseling, a specially trained counselor takes a detailed medical history of you and your partner, as well as your families, to identify any potential or known genetic disorders. "Often, it is only when a woman becomes pregnant that genetic disorders come up, and for some, it's too late to make a difference in promoting a healthy outcome," she says. But even here, technology can step in.

A relatively new form of in vitro fertilization called preimplantation genetic diagnosis (PGD) can enable couples who carry genes for genetic disorders like Tay-Sachs or sickle cell anemia to have a healthy child. The procedure involves removing one cell from an eight-cell embryo and studying it for any genetic abnormalities. Only those embryos with no obvious problems are implanted into the woman's uterus.

The procedure isn't 100 percent effective, however. University of Florida researchers find that about 1.5 percent of embryos may be implanted with undetected genetic disorders because of a rare condition called chromosomal mosaicism. (8)

But for women who know they have a genetic risk for one of these devastating diseases, PGD can be a tremendous advantage.

Another advantage is a test given to women in the first trimester of pregnancy who have a risk of having a child born with Down syndrome. The disorder is the most common chromosomal abnormality, affecting about one in 800 babies born each year. (9)

Previously, the only way to know if a woman was having a baby with Down's was with second-trimester blood tests and/or invasive amniocentesis or chorionic villus sampling (CVS) tests, all of which carry a slight risk of miscarriage. If a woman then decided to terminate the pregnancy, she faced a more complex and emotionally wrenching second-trimester abortion.

But a major study published in the New England Journal of Medicine in November 2005 found that screening in the first trimester with an ultrasound and blood test can identify most fetuses with Down syndrome between the 11th and 13th weeks of pregnancy, allowing women to decide what they want to do earlier in their pregnancy. (10)

The blood tests measure levels of certain proteins and hormones that could indicate Down's, while the ultrasound assesses the thickness of the fetus' neck, called the nuchal translucency. By learning of her risk in the first trimester, often before she even starts showing or telling people about her pregnancy, a woman has more privacy to make her decision and, if she decides to continue the pregnancy, more time to grow accustomed to the idea of having a child with Down syndrome, says Dr. Wu.

Debunking Common Practices

The past decade has also seen more scientific scrutiny of once-routine procedures and recommendations during pregnancy and childbirth.

For instance, some health care professionals routinely perform episiotomies, or cuts in a woman's perineum, during birth to prevent tearing of the vagina and perineum and damage to the pelvic floor. But studies in the past few years find that allowing the perineum to tear on its own results in less pain after childbirth than an episiotomy, and that women who don't tear, or who tear naturally, resume sexual relations sooner than women with episiotomies. (11) In 2005, a major government review of episiotomy concluded that the benefits of the procedure don't outweigh the harm. (12) Nonetheless, episiotomy is still routinely performed, with 716,000 performed in 2003. (13)

While some episiotomies may still be medically necessary, says Dr. Wu, the concept of an episiotomy for every woman is not valid. "Probably the number of episiotomies (still) being performed is a reflection of the idea that old habits die hard," she said. "It used to be that all patients received episiotomies. For doctors who were trained in that era, it may be a hard habit to break."

Health care professionals also often recommend bed rest for women with certain pregnancy-related complications, like high blood pressure, spotting or cramping. But two major reviews of existing studies find there simply isn't enough evidence to support such a recommendation, either for high blood pressure or to prevent miscarriage during the first half of pregnancy. (14), (15)

And despite the fact that there is no evidence that electronic fetal monitoring improves birth outcomes in normal deliveries, 85 percent of deliveries in 2003 involved monitoring, a figure that has been steadily climbing since 1989. (15), (16)

Finally, there is the rising rate of cesarean sections. The rate has been increasing for numerous reasons, including the growing reluctance of physicians to recommend vaginal births once a woman has had a c-section and an increasingly law-suit oriented society, notes Dr. Wu.

But another reason is the rising rate of elective c-sections. A study published in 2005 found that elective primary cesarean deliveries increased from 20 percent of all cesarean deliveries in 1994 to nearly 28 percent in 2001, about a 43 percent jump. (17) A surgical procedure, elective cesarean carries significantly more risks to mother and baby than a routine vaginal birth.

While the American College of Obstetricians and Gynecologists (ACOG) supports a woman's right to an elective cesarean section, there's still no clear evidence regarding its potential benefits compared to its risks. (18) In the United Kingdom, however, the British version of ACOG suggested that simply asking for a cesarean was not a good enough reason to perform one. (11)

Why the desire for a surgical procedure rather than a "natural" birth?

"I think there is a need in the current generation for instant gratification," says Ms. Collins, who left her job of 17 years as a labor and delivery nurse to become a nurse midwife, because she wanted to bring more human touch and less technology into the delivery room.

"Women may think, 'Why wait for labor to ensue and then go through it when I can just pick the date and schedule the c-section?' What is not being considered is the total cost of that type of thinking--emotionally, financially and physically."

Plus, she says, the old thought of "less is more" has lost favor. "I think women have bought into the idea that the more we do as providers--the more testing, the more intervening--the better the outcome."

The bottom line: "Women need to empower themselves with current data, so they're able to address these important subjects with their obstetrical provider," Ms. Collins stresses. "By asking such questions as: 'What is the cesarean section rate of your practice?' and, 'How often are episiotomies performed?' a woman can feel that she has made the most informed decision."

And, while studies aren't always clear about the risks and benefits of interventions, the best options will vary from woman to woman. A woman and her health care provider can decide together what is reasonable and practical for her overall health and wellbeing, Ms. Collins notes.

Benefiting from Increased Monitoring

Of course, sometimes monitoring and interventions are all that stand between a pregnancy with a good outcome and one without. That's the case for Amber McCracken, 32, of Arlington, VA, who has a pre-existing medical condition that could affect her second pregnancy.

Ms. McCracken had no problems during her first pregnancy or delivery. But just before getting pregnant the second time, she learned she has a rare blood disorder that makes her blood clot too quickly. It's not life threatening, but it could interfere with the amount of blood the placenta receives, thereby impairing the growth and development of the fetus.

So during this pregnancy, Ms. McCracken sees a team of doctors that specializes in high-risk pregnancies and deliveries. She visits the doctor every couple of weeks--instead of just once a month as during a normal pregnancy--receiving regular ultrasounds to watch for any problems.

One emerged in her first trimester, when preliminary tests suggested she might be carrying a child with Down syndrome. Another came in her 26th week, when an ultrasound showed that one of the two arteries supplying the placenta seemed to be operating at reduced capacity--precisely the problem her doctors feared.

Further testing, however, showed the baby didn't have Down's, and an ultrasound in her 30th week found that the baby, although small, was growing fine.

"I am glad this technology exists. I'm truly benefiting from it," says Ms. McCracken.

Resources

American Academy of Pediatrics 

www.aap.org

Web site offers a wide range of information on child health, safety and development.

The American College of Obstetricians and Gynecologists (ACOG)

202-638-5577

www.acog.org

Web site provides information on conception, pregnancy and delivery.

American College of Nurse-Midwives

240-485-1800

www.midwife.org

Professional association for nurse midwives; offers a variety of educational materials.

March of Dimes Birth Defects Foundation

1-888-663-4637

www.marchofdimes.com

The March of Dimes offers information on preventing birth defects and improving infant mortality.

U.S. Centers for Disease Control and Prevention 

www.cdc.gov

Provides information on wide range of pregnancy-related topics.

References

(1) Births: Final Data for 2003. National Vital Statistics Reports; 54;2. Sep 8, 2005.

(2) Glantz JC. Labor induction rate variation in upstate New York: What is the difference? Birth 30 (3)168-74. 2003.

(3) 2004 Preliminary Birth Data: Maternal and Infant Health. Centers for Disease Control. November 15, 2005. http://www.cdc.gov.

(4) Ahluwalia IB, Daniel KL. Are women with recent live births aware of the benefits of folic acid? MMWR Recomm Rep. 2001 May 11;50(RR-6):3-14.

(5) Folic acid. Centers for Disease Control and Prevention. Nov. 16, 2005. http://www.cdc.gov

(6) Canfield MA, Collins JS, Botto LD, et al. Changes in the birth prevalence of selected birth defects after grain fortification with folic acid in the United States: findings from a multi-state population-based study. Birth Defects Res A Clin Mol Teratol. 2005 Oct;73(10):679-89.

(7) Centers for Disease Control and Prevention (CDC). Spina bifida and anencephaly before and after folic acid mandate-United States, 1995-1996 and 1999-2000. MMWR Morb Moral Wkly Rep. 2004 May 7;53(17):362-5.

(8) Genetic testing still smart choice, despite uncertainties. [press release]. Gainesville: University of Florida; Dec 20, 2005.

(9) Yang Q, Sherman SL, Hassold TJ, et al. Risk factors for trisomy 21: maternal cigarette smoking and oral contraceptive use in a population-based case control study. Genetics in Medicine 1999;1:80-88.

(10) Malone FD, Canick JA, Ball RH, et al. First-trimester or second-trimester screening, or both, for Down's syndrome. N Engl J Med. 2005 Nov 10;353(19):2001-11.

(11) Simpson KR, Thorman KE. Obstetric "conveniences": elective induction of labor, cesarean birth on demand, and other potentially unnecessary interventions. J Perinat Neonatal Nurs. 2005 Apr-Jun;19(2):134-44. Review.

(12) Viswanathan M, Hartmann K, Palmieri R, et al. The use of episiotomy in obstetrical care: a systematic review. Evid Rep Technol Assess (Summ). 2005 May;112:1-8.

(13) National Hospital Discharge Survey (NHDS) Data 2003. Advance Data No. 359. Centers for Disease Control and Prevention.

(14) Aleman A, Althabe F, Belizan J, Bergel E. Bed rest during pregnancy for preventing miscarriage. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003576. Review.

(15) Meher S, Abalos E, Carroli G, Meher S. Bed rest with or without hospitalisation for hypertension during pregnancy. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD003514.

(16) Cole C. Admission electronic fetal monitoring does not improve neonatal outcomes. J Fam Pract. 2003 Jun;52(6):443-4.

(17) Meikle SF, Steiner CA, Zhang J, Lawrence WL. A national estimate of the elective primary cesarean delivery rate. Obstet Gynecol. 2005 Apr;105(4):751-6.

(18) American College of Obstetricians and Gynecologist. Surgery and Patient choice: The Ethics of Decision Making. Washington, DC: ACOG; 2003. Committee Opinion No. 289.

RELATED ARTICLE: Questions to Ask Your Health Care Professional

1. What do you recommend as a healthy weight gain for my pregnancy?

2. What kind of exercise, and how much, is safe for me during pregnancy?

3. Am I at risk for any specific complications during pregnancy or labor and delivery?

4. What are your recommendations about alcohol, tobacco and caffeine?

5. What over-the-counter medications can I take if I'm sick, and which ones should I avoid?

6. What can I take if I have indigestion or heartburn?

7. Which diagnostic and monitoring tests do you recommend? What are the risks and benefits of these tests? Will my insurance cover them? Are they really necessary?

8. If I'm diagnosed with gestational diabetes or pre-eclampsia, what changes should I make to keep my baby and me healthy?

9. Are there any foods that I should avoid during my pregnancy?

10. Can I have sex while I'm pregnant? Is there any danger to the baby?