The World Health Organization (WHO) recently released Born Too Soon, the first country-by-country comparison of national rates of pre-term birth. This 125-page report, funded by dozens of public agencies and private foundations, claims to be “the global action report on preterm birth.” Hidden in its pages is a story of what must be better understood to help women carry a healthy baby to term.
Pre-term birth (sometimes called premature birth or PTB) is birth before thirty-seven weeks gestation. (“Very pre-term birth” means birth at less than thirty-two weeks.) Pre-term birth carries serious risks for both child and mother. It’s the leading cause of infant morbidity and mortality, and very pre-term birth is associated with cerebral palsy and autism.
Contrary to the conventional wisdom that the United States has the best maternal health in the world, the study reported what data has shown for the last two decades: the U.S. has had a rising rate of preterm birth. In fact, the rate of preterm birth in the U.S. has increased thirty percent since 1981. While some of this is due to better record-keeping, more aggressive use of newborn intensive care, and wide access to assisted reproduction in the U.S., much of the increase remains unexplained.
Some findings of the WHO report are very troubling. As the New York Times reported in its front-page story on the WHO report, “the U.S. is similar to developing countries in the percentage of mothers who give birth before their children are due . . . [The U.S.] does worse than any Western European country and considerably worse than Japan or the Scandinavian countries.”
What is the cause of this thirty percent increase in the U.S. since 1981?
The Times mentions a number of possible risk factors—age, cesarean sections, obesity, diabetes, high blood pressure, and smoking. And the authors of the WHO report suggest as a potential cause “the unique American combination of many pregnant teenagers and many women older than 35 who are giving birth, sometimes to twins or triplets implanted after [IVF].”
In the end, the researchers throw up their hands and express confusion: “Experts do not know all the elements that can set off early labor.” The Times quoted an author of the WHO report: “Even after controlling for risk factors like age, poverty, smoking, obesity and diabetes, ‘we really don’t have an explanation for what’s behind it.’”
Unfortunately, one significant, and modifiable, risk factor for preterm birth was completely ignored by the WHO report: prior termination of pregnancy. There is a large and growing body of scientific data documenting this risk factor for pre-term birth. More than 120 peer-reviewed studies, from more than a dozen countries, have found a statistically significant increased risk of preterm birth or low-birth weight after a termination of pregnancy.
Some studies have found an almost twofold increased risk of very early deliveries (twenty to thirty weeks gestation) after a pregnancy is terminated. And the risk increases when a woman has had multiple terminations of pregnancy—what researchers call a “dose effect.” The more prior terminations, the greater the increased risk. This is significant because approximately fifty-five percent of terminations in the U.S. each year are “repeat abortions.”
A December 2011 study from the Italian Preterm Network Study Group found that prior terminations of pregnancy almost double the risk of preterm birth. It reinforces previous studies which implicated abortion as a risk factor in preterm birth, including:
• A 2006 Institute of Medicine (IOM) report that acknowledged termination of pregnancy is a risk factor for preterm birth.
• Three 2009 published studies (systematic evidence reviews) which all found an increased risk of pre-term birth after abortion.
• A 2010 study published in Human Reproduction that concluded that “prior pregnancy termination is a major risk factor for cervical insufficiency,” noting that black women have an increased risk of cervical insufficiency. The WHO report buries some of these studies in the bibliography, but the findings in these studies never make it into the WHO report.
• A 2003 study in the Obstetrical & Gynecological Survey (OGS) concluded that “women contemplating their first induced abortion early in their reproductive life should be informed [that] their risk of subsequent preterm birth, particularly of a very low-birth weight infant, will be elevated above their baseline risk in the current pregnancy.” They emphasized that preterm delivery is an important factor “in women’s health and avoidance of induced abortion has potential as a strategy to reduce [its] prevalence.”
The impact isn’t trivial. There are real world costs, both physically and financially, to consider. A study in the October 2007 issue of the Journal of Reproductive Medicine concluded that complications of preterm birth for mother and child after termination of pregnancy cost an estimated $1.2 billion annually.
The data on the increased risk of pre-term birth after abortion has to be part of informed consent for women and girls considering the termination of pregnancy in order for doctors to consider all the facts, and to enable women to make critical medical decisions.
In a report calling for women to be fully informed, claiming to want all the answers, claiming to be the “global action report,” it’s tragic that the WHO fails to mention this significant risk factor. Women should not be kept in the dark about such a known, well-documented and serious risk factor, and no organization calling for answers and solutions should be complicit in furthering that ignorance.
John M. Thorpe, Jr. is Professor and Director of Women’s Primary Healthcare in the Department of Obstetrics and Gynecology at the University of North Carolina School of Medicine. Clarke Forsythe is Senior Counsel with Americans United for Life.
World Health Organization, Born Too Soon: The Global Action Report on Preterm Birth
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