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Mandatory Induction at 39 Weeks: ACOG Has Gone Too Far

admin May 16, 2016

Mandatory Induction at 39 Weeks ACOG Has Gone Too Far

In a special session on Monday, May 16th, a group of obstetricians gathered to discuss an issue.  Their topic was, “Should it be mandatory for women to be induced at 39 weeks?”

This discussion centered on all women, not just high risk women, and they were not discussing ‘encouraged’ or ‘elective’ procedures, but the possibility of making it formal policy that women must be induced at 39 weeks if they have not spontaneously gone into labor prior to that point.

It’s important to be clear that this was a theoretical discussion and no policy has been made and no official statements have been issues.

Even so…wow.  ACOG has gone too far.

Mandatory Induction at 39 Weeks: ACOG Has Gone Too Far

This is ridiculous.

Basically, two doctors are making a case, after reviewing some studies, that all women should be induced at 39 weeks.  I’m going to quickly summarize some of the key arguments they used, because some seriously blew my mind…and not in a good way.

The first doctor said that accurate dating would be important, and suggests that an early ultrasound (8 – 10 weeks) would be necessary since last menstrual period does not always give accurate dating.  He goes on to say that there is no long-term benefit, and potential risks, to continuing a pregnancy beyond 39 weeks.

A major focus is on the risk of still birth, and that it increases after 39 weeks.  But when it came time to explain why, he simply said, “We don’t know.”

This doctor actually says, “Think like a fetus” and goes on to say that the fetus knows that there is no benefit to remaining inside past 39 weeks, and that there is potential risk, and that if the fetus isn’t smart enough to then trigger labor, OBs should intervene.

And then he says that there is little data on the risks of inducing at 39 weeks, and that we don’t know if it increases the risk of a c-section.  But he compares induction at 39 weeks to induction at 41 weeks (closest data available) and basically says, “They’re pretty much the same thing.”  And the reason they are the same…is because the babies are the same size or maybe even smaller at 39 weeks (as if size has anything to do with this).

“This is me, scratching my head, why are we even having this debate?  39 weeks and out is the answer.  …rescued by birth.”

Then the second doctor gets a turn.  He starts by saying he agrees with everything the first guy said.  Then, he goes on to say that that there are clear risks to continuing a pregnancy beyond 39 weeks, one of which was shoulder dystocia — it apparently just makes sense.

Too bad the evidence says otherwise.  This study shows that while shoulder dystocia does increase if the baby is larger (and for several other reasons), length of gestation is not one of the risk factors!

He also claims that macrosomia is a risk of longer gestation pregnancies, but this study shows that pregnancy length between babies with and without macrosomia wasn’t really different (not statistically significant), although the average pregnancy was actually a couple days shorter with macrosomia.  (This could obviously be due to induction for suspected macrosomia — but at any rate, the differences weren’t statistically significant.)

This doctor goes on to criticize studies that exist that look at elective induction at 39 weeks vs women who go into labor naturally, because it excludes women who are induced for medical reasons, and therefore, appears that going into labor naturally is safer.  But, wait — we’re looking specifically at a population of low-risk women!  Including those who required induction for a medical reason would have skewed the data.  He is suggesting the opposite!

He also glosses over the fact that there is no significant evidence comparing induction at 39 weeks vs. 41 weeks — so they are just trying to “guess” right now which is better, and making an argument with evidence that skirts the issue but doesn’t specifically address it.

And then he shows a study where women who underwent current “protocol” (waiting for labor until/unless there is a medical indication or she reaches 42 weeks gestation) vs. women who were electively induced at 39 weeks, which found a c-section rate of 30% in the latter group, and 17% in the former, and called the difference “not statistically significant.”  Since when is an almost doubled rate not significant?!

He goes on to quote another, similar study, that shows no differences between the two groups — but, it is limited to only high-risk women, over 35 years of age.  It’s not really applicable to healthy younger women.

Finally, he concludes, through statistical modeling (not actual data) that elective induction at 39 weeks is “always better.”

Towards the end, the first doctor says, “I happen to think nature’s a lousy obstetrician.”

And additionally, the second doctor says, “We would need very accurate dating — if we were off by even a week either way, it would increase risk.”  Which brings up the question; how accurate were the dating methods used in the women in the studies and modeling that we do have?  If they were off by several days or weeks, then we’re not really modeling by week of pregnancy at all, and the whole thing falls apart.  With an early dating ultrasound not the standard of care, and many women being uncertain about their actual ovulation dates, it would be easy to be off by a matter of several days.

You can watch the discussion for yourself here.

Highly Managed Obstetrics

Basically, what they are suggesting is that pregnancies be highly managed from day 1.

Women would require an early dating ultrasound, and potentially more than one if the first was inconclusive.  Currently, ultrasounds can date a pregnancy between 8 and 12 weeks with an error range of 7.3 days.  (Source)

But wait!  That’s not good enough!

If dates could be off by a week in either direction, it would be easy to deliver the baby at 38 weeks (when we know that complications of late-preterm are increased) or 40 weeks (which supposedly increases risks as well).  We currently do not have an accurate enough dating method to deliver women at exactly 39 weeks.

Supposing that we were able to date pregnancies exactly…gestational lengths seem to have some genetic link (source).  So while one baby may truly be ready at 39 weeks, another may not be until 40 or 41.  How do we know which is which?

In general, there is too much variability to be certain that inducing all women within such a narrow window is acceptable or at all in line with best practices.  In an otherwise healthy pregnancy, the only true indication that baby is ready to be born, is the triggering of spontaneous labor.

Obviously, should concerns develop, interventions should occur as needed to prevent a poor outcome.  Women and their care providers would need to know what to look for and be willing to communicate as needed to get tests or care if anything cropped up.

Rather than trying to control every iota of the experience, wouldn’t we be better off finding the biological norms, and then trying to facilitate those?  Shouldn’t we be identifying clear risk factors (none of these studies looked at maternal diet/nutrition, vitamin deficiencies, or other potential underlying causes of issues) and then educating patients on how to minimize these risk factors?

It seems logical that we cannot improve all outcomes, and that we shouldn’t trade one set of risks for another without clear benefit to doing so.  Yet, this is what they’re suggesting.

We Don’t Trust ACOG

In general, we don’t trust ACOG, and this discussion is a prime reason why.  ACOG is looking at the data in a vacuum, and interpreting it the way they want to see it.  They are ignoring evidence that doesn’t fit what they believe, and are avoiding asking questions about how and why some of these negative outcomes are occurring in the first place.  All they see is, a negative outcome did occur, and if we “do more stuff” maybe we can stop that.

We need a much more big-picture or holistic view of pregnancy and birth (and health in general).  We need to see what is truly “normal” and what deviates from the norm, and how we can maximize health and minimize outside risk.  Interventions can and should be used in cases of high risk or when symptoms present that require it.  But heavy “management” of a low-risk, normally progressing pregnancy is not the solution.

It is clear that ACOG’s entire worldview and mindset is in opposition to what we believe and what the data we have actually shows, which is why we do not trust their assessment.

It’s sad, that in today’s world, we can’t have a more cautious and judicious use of technology, and that we feel that more is always better.  That simply cannot be true.

We recognize that the debate was a mere exercise, but it represents a thought pattern that is pervasive, faulty, and potentially dangerous to women and babies.  That’s why it is time for women to take back birth, and trust themselves.

How do you feel about mandatory induction at 39 weeks?  Do you think it is a good idea, or not?

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40 Comments

  1. As a former natural childbirth educator I cringe at this article. The grab at control of every aspect of a woman’s health is the scariest thing imaginable to me. And, as you know, it’s not only women… it’s women, men, our children…anyone that they can get their claws into. From pregnancy to birth, to vaccination, to the way cancer patients are forced into chemotherapy- there is no room for questioning, as far as they are concerned. It’s frightening.

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  2. This is worrisome. Not just for pregnancy. Not just for women. Not just for babies. For everyone. If the establishment is able to start dictating our lives to this extent, what is next?

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  3. This is absurd. All my my children were born naturally after 41 weeks. No complications. No interventions. I’d rather give birth in the woods than be subjected to this bull.

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  4. No NO NO ! JUst NO!

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  5. This article is bias and subjective. I am much more interested in reading what the doctors have to say and ACTUAL FACTS FROM SCHOLARLY SOURCES then your opinion

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    • Of course it’s an opinion; it’s a blog. There are scholarly sources cited within the text, if you care to click on them. But if you don’t, well…why are you even reading?

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      • You as the author of this blog asked for honest opinions so when you get them why is your response “why are you even reading?”— if differing opinions is that difficult to swallow then that’s something that you should consider when asking for opinions. In regards to the article it WAS very one sided and that’s ok- I love reading things from people who are passionate. Your article has driven me to research this topic more so I thank you for that. As for me, I have 3 children- I’ve been induced for all 3.. (2 at 37 weeks and 1 at 39 weeks)— my son Eldon was stillborn at 39 weeks, I will always wonder what could’ve been if he had been induced the same gestational time frame as his brother and sister. I will never know. It’s dangerous to assume that a mandatory 39 week induction is the correct method for everyone so I definitely disagree that it’s the best solution, but I’m also not fearful of induction as some people clearly are. In the end, the most important thing is to have a healthy mom, baby, and delivery for whoever is involved.

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  6. 1. Who is the ACOG?
    a. Are they some sort of governing body?
    b. Are their recommendations mandatory to all OBs?

    2. Is the ACOG just two doctors?

    3. So…some doctors had a discussion and nothing was implemented?

    4. I’m confused about what we’re supposed to be outraged over.

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    • ACOG = American College of Obstetrics and Gynecology. It is the professional body that creates all of the policy and recommendations for obstetricians and gynecologists in America and sets the standards of practice. I wouldn’t say the recommendations are mandatory, but many OBs take them very seriously and tend to follow most of their guidelines.

      ACOG is all OBs and GYNs, not just these two doctors.

      This discussion was observed by many other doctors both in-person and via web, and sets the tone for moving towards 39-week inductions. Nothing has been implemented YET, but having this discussion is dangerous because it could lead to implementation.

      In general, this promotes highly-managed pregnancies — in healthy, low-risk women. This will actually increase the risk to mothers and babies, as well as further removing informed consent. Women during birth are already treated like mere vessels to carry babies, with no brains and no ability to make decisions for themselves/their babies. They are bullied by ‘protocol’ and ‘procedure.’ So many of ACOG’s current recommendations are NOT evidence-based; obstetrics is the least evidence-based field out there. This is yet another step in the wrong direction.

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      • A discussion about what the scientific evidence shows and whether or not current policies are supported by data is dangerous? Okay.

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    • Your article petercfly shows what I needed to know, thanks!

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  7. It took a lot for me NOT to scream and yell while reading this. The over managing of pregnancy is why in America we have such abysmal mother/infant mortality/morbidity rates. We are going further and further in the WRONG direction and things will only get worse if we continue to let the government tell us what is best for our bodies and our children.

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    • You are absolutely right, as a midwife I am opposed to this, I work in a teaching hospital I am educating my pregnant women to say NO if they happened to need an ultrasound towards the end.

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  8. Where is the original article that you are referring to? The work of OBGYN’s has saved the lives of women and their infants for decades. Before you make a determination that “ACOG is bad – don’t trust ACOG” at least share with your readers the original source and let them see for themselves. Also invite ACOG to weigh in here. This is irresponsible at best.

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    • It clearly says, at the bottom of my summary section, “You can watch the discussion for yourself here.” It is linked to this: http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Meeting/Educational-Program/Colloquia/Colloquia-Monday That is the original source…and readers are absolutely welcome to go watch the discussion for themselves. That was abundantly clear already.

      No, we will not be inviting ACOG to weigh in here, although I doubt they would if we invited them. They said their piece; we are now reacting to it.

      OBGYNs, in many cases, mean well and have saved women and babies. In some cases, they have also killed women and babies. Either way, women are autonomous and deserve the right to make their own health care decisions. That’s what really matters here. Discussing what doctors will or won’t make women do is wrong. THAT is what is irresponsible.

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  9. Speaking as a person who was born at 43 weeks 3 days (this was nearly 30 years ago, before birth was so micromanaged), I can say that this is insane. Does that mean that if the ACOG starts saying this, the midwives in my state will have to refer me to a hospital if I can’t spontaneously start labor before 39 weeks? That would be awful.

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  10. I birthed my 12 pound baby at home, with 2 midwives. My son and I received the best care throughout the entire course of my pregnancy. I couldn’t really talk much about my home birth because it was against “the law” at that time in my state. I would add that my grandmother had all of her 10 children at home, and nursed them all. When I brought my son to the doctor 3 days later, he said he had never seen such a healthy child. I would also like to say that all 4 of my children self weaned, and I hear all the time what remarkable children I have. The medial Establishment is not about health it is about profit. There is no substitute for Nature,and a Mother’s Love and Intuition .

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  11. Good points. Also, take note that shoulder dystocia is INCREASED when the parent is induced

    this is so gross

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  12. Good points.
    Shoulder dystocia has also proven an increased risk with inducement.

    sogross

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  13. Thank the powers that be that I have my 2 kids and aren’t planning on anymore. If someone tried to tell me I had to be induced at 39 weeks (both mine born at 41 naturally) I would stop visiting the doctors at 38 weeks and hope for the best. A “study” based on such shoddy statics and a complete disregard for facts scares me. I live in Dubai and they strongly encouraged me to be induced at 38 weeks as my baby was going to be big (or rather wanted more money for intervention). I politely declined and baby was born (water birth) with no intervention in 2 hours weighing 4.3 kgs at 41+2. Perfect health for both of us. Stupid men getting involved in a process they can never truly understand

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  14. Thanks for this write up, and I appreciate that you took the time to respond sensibly and succinctly to even the inane of comments/questions here. 😀

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  15. After stewing about the original debate for some time, I had a brilliant idea. If we removed all men’s prostates by 39, we could virtually eliminate prostate cancer. Sure some men may disagree, but we’ll just do it anyway. #outby39 #you’llgetusedtoit #keepmensafe #Natureisalousyurologist

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  16. Just want to remind everyone that nothing is “mandatory” in medical care. As consenting adults nobody can force an induction on you at any point of your pregnancy. Recommendations can be made, but again, you’re the captain of your own ship. So before we get all hot and bothered by this discussion (that has in no way resulted in an ACOG policy change), take the word “mandatory” with a very loose interpretation.

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  17. Omg! I birthed six children naturally. Five of the six were at or beyond 39 weeks. Two were just before or just after 41 weeks! Three I was age 35 or older! All were perfectly healthy with no issues for any of us. And I even spent 5 of 6 pregnancies on lovenox following a post partum DVT after my first. This makes me want to scream.

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  18. This article is ridiculous – I clicked because another alarmist friend of mine has been linking to it screaming that no one is safe to be pregnant in the states anymore because the evil doctors of america are now inducing everyone at 39 weeks.

    We are NO WHERE near this being a reality, but what IS a reality is that so sadly the majority of americans are now obese and it IS unsafe for them to often carry out a pregnancy. I think a lot of the research is coming from this area for one.

    I don’t think anyone of normal weight, healthy, seeking quality care will ever need to worry about this – this is rather alarmist and a little silly.

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  19. A research presentation at a scholarly meeting does not constitute an overwhelming committee opinion regarding the topic of early induction. Most OBs would see this as dangerous and necessary in a normal pregnancy. Either way, this is a topic that should be discussed between a woman and her physician with the risks and benefits discussed if there is an indication for an early delivery. I find your approach offensive and disrespectful to those members of ACOG who support in natural childbirth in our patients who wish to pursue this option in a safe environment.

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  20. Annnnndddddd this is (one of the many reasons) why I switched go freebirthing and will never go back. ACOG does not have birthing individuals and babies best interedt in mind. All i see with this is $$$$. A highly managed birth/ induction (and then subsequently higher chance of Csection) brings in more money then a natural one….and is more convenient time wise. Let’s just hurry them up and get them on the conveyer belt and get them done so we can move on to the next.

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  21. Hello,

    A friend of mine reposted this on her Facebook who had two beautiful home births. I know the implications go far beyond this but how many home births would be made impossible by this being implemented and shouldn’t every woman have the right birth at home, in their own comfort and surrounded by their family rather than sickness and machines? However, I need to add some balance to your blog, because four years ago I was 21 weeks pregnant and I moved to Australia, found a wonderful state run home birth organisation and planned to have a home birth. I had a completely normal healthy pregnancy until the last couple of days, just a few days shy of 40 weeks. Out of the blue, I developed pre-eclampsia and my baby died. (I feel compelled to add for the sake of clarity that I attribute no responsibility for my baby’s death to that home birth organisation, who provided excellent care). So it just so happens that if there was a mandatory induction at 39 weeks, my son would have been born alive. Oh and he had shoulder dystocia when I gave birth to him in hospital. I understand and respect the rights that you want to protect but nothing is ever black and white, though you would be forgiven for thinking so from your article. It was a discussion that had saving lives as its priority. It doesn’t mean we have to conclude anything based on that but it would be nice if we could be more respectful of the goal, even if we disagree with the method ultimately.

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  22. You can thank the very litigious society we live in for these ideas. If the outcome isn’t perfect, SUE THE DOCTOR, THE HOSPITAL THE NURSES, EVERYONE WHO WAS INVOLVED!! I have heard multiple stories of poor fetal outcomes due in part to the laboring/postpartum mother’s decisions. In all instances they sued, because the doctor should have made them do whatever would have saved the baby. And in those very instances the families won huge $$$ because of the sympathy factor. BTW I am a cardiac nurse, NOT L&D.

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  23. I watched the whole thing. You have distorted the presentation greatly. You have pointed out the difference in c-section rate of 17% vs 30% found in one study as enormously important and significant but fail to mention it was a study of only 160 women. You entirely left out the other studies including 31,000 women and 1.27 million women that show that there is a decrease in c-section and perinatal mortality with induction because those results don’t suit your purpose.

    You have also framed this as ACOG suggesting “mandatory” induction. Nowhere in this presentation does anyone use the word mandatory. OBs do not strap people down and force oxytocin through IVs against their will. Offering to induce is not the same as “mandatory” anything. This is compelling data and is worth sharing with women in a way they can understand so they can make a decision for themselves about whether or not they want to be induced. Currently many hospitals have policies prohibiting even offering such a thing based on outdated, incomplete, or inaccurate information. Being able to offer it doesn’t mean that all women have to accept it.

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  24. Jenny do you have a working link to the ACOG debate? I had it but lost it and cannot find it again. Could you please email it to me?

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  25. And the medical community wonders why the rate of home births is increasing. Enough already!

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  26. Just had a friend tell me the other day that her doctor mentioned inducing at 39 wks, that it was a new recommendation! Ridiculous! I go to the same doctor and if she tries to tell me the same thing, I hope she’s ready to get an earful!

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  27. Thank you for this blog post. As a 42yo woman, physician, and mother of three–the youngest currently 3 wks and healthy, born at 39+5 in planned uncomplicated homebirth with midwives in attendance–it was OB recommended (without informed consent discussion) at a (totally normal) 30wk ultrasound that I be induced at 39 weeks. Reason? “Your age and increased risk of stillbirth”. No info offered on relative vs. absolute risk (re: stillbirth risk by age–mother’s/ gestational). Thank God Canadian midwives made hard number data available online so I, a healthy mother, could understand the risk of stillbirth and make an informed decision: http://www.ontariomidwives.ca/images/uploads/client-resources/PB40-KT-Eng.pdf. Based on the data and consideration of my values, induction was not the best option. I recoil at the trends of obstetric care in this country and will continue to fight for the right to shared decision making for me, my family, and yours.

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  28. The elephant in the room is that ACOG OBGYNs are a male-dominated fraternity of surgeons; the more procedures they do, the better for them; and they need ‘practice material’ to support the fraternity.

    A better analogy is: the old white men in charge of ACOG OBGYNS are to women’s health as the Ku Klux Klan was to civil rights.

    And the only women allowed in the frat are the ones who play along – which is why the saying on the street is: ‘The women in OBGYN are worse than the men.’ (Amy Tuteur for instance).

    Given the vast majority of women now in the field, we hope that may change. However, the training of OBGYNs still means that few if any women in the field will ever actually attend (or experience) a natural healthy normal pregnancy or birth.

    In fact, one requirement for OBGYNs is that they have to have borne at least 3 children before qualifying to attend anyone else’s pregnancy. Competency should be assessed rigorously by patients. Men should be banned from women’s health for about 100 years.

    It’s funny to hear men crying about ‘sexism’ when this is proposed; but it’s actually a much-needed correction.

    The rallying call for the revolution should be: MEN OUT OF WOMEN’S HEALTH

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  29. Here are actual current ACOG recommendations. I’m sure 2 scientists/doctors could present a paper like this to a body like this.

    That doesn’t mean that their opinions represent the body as a whole.

    http://www.mothering.com/articles/4-acog-new-recommendations-might-surprise/

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  30. The link you give for watching the discussion is not working. Has it moved?

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  31. Hi there – I am a student midwife interested in this topic and would like the read the original transcript. The link you have provided is broken, do you know where else I could find it?

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  32. I’ve known three women that have lost their children at 40 weeks. Had they been induced at 39 weeks they would be raising their sweet babies today. Just saying. If it gets them here safely im all for medical intervention. All you holistic naturalists need to sit back and think for a minute. Before modern medicine the mortality rate for women and babies during child birth was 50%!! Obviously our doctors know something that you dont. Also there is a midwife in my town who has killed several babies in her attempt to provide natural deliveries. Well congrats guys, you got your natural delivery and a dead baby. Hope that satisfied their desire for natural birth. Ugh…ok rant over.

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  33. My opinion: I don’t think a world in which all women are induced at 39 weeks is possible. The amount of resources this would involve make it out of reach. There is nothing to really worry about here.

    In general I shy away from extremist thought on any topic. The type of extremist thinking that lands doctors at this conclusion is easily and commonly observed in the natural child birth community–they just cling to different studies than the ones the doctors use here. Usually there is more openness to data based change in a science community rather than one that is more ideological though both speak from a place of authority.

    The best thing to do is treat your pregnancy as the individual pregnancy that it is. Find a place to birth that makes sense for you, and don’t allow anyone to scare you away from life saving interventions that you may very well need. Birthing is just one phase of parenting, and you have to choose the style that fits you.

    Myself, I have had two wonderful hospital births with epidural. Horror stories about that kind of birth do not resonate with me because they were not true for me or anyone I know. Many natural birth advocates ignore or discredit the horror stories related to such a birth as well, though facts out of Oregon and MANA’s own findings make that even riskier a bet. I am thankful to have been able to birth in a place I felt safe and to have two healthy babies that both received point of birth care for unexpected birth complications. They happen, and my babies got prompt care.

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I’m Kate, mama to 5 and wife to Ben.  I love meeting new people and hearing their stories.  I’m also a big fan of “fancy” drinks (anything but plain water counts as ‘fancy’ in my world!) and I can’t stop myself from DIY-ing everything.  I sure hope you’ll stick around so I can get to know you better!

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