2.4: Childbirth and Perinatal Health

Learning Objectives

By the end of this section, you will be able to:

• Describe the stages of labor and birth
• Compare the birthing options available to parents
• Explain the methods for assessing the health of the birth mother and the newborn

Emily and Omar are expecting a baby in a few short months. As their due date approaches, they discuss options for the birth. Emily has always been drawn to the idea of a quiet birth at home, accompanied by a midwife. Omar, on the other hand, expresses anxiety about this option and would feel safer with a hospital birth. After all, what if something goes wrong? Wouldn’t Emily want a doctor in such a situation? The couple weighs the pros and cons of each option and arrives at a compromise. Emily will plan to give birth at home with the support of a midwife but will switch to the hospital if any complications arise. Luckily, when the time comes, Emily’s labor is uncomplicated, and the couple marvel at the beauty of their newborn in the comfort of their home. They are grateful for the compromise they reached. The birth was a journey that blended the intimacy of home with the safety net of the hospital, creating a unique and special experience for them.

Pregnancy can be an exciting experience, although the actual birth may not be the first thing on parents’ minds when they discover that they’re expecting. Like Emily and Omar, parents need to consider where the birth might take place and who may be present (Figure 2.18). Medications to ease labor pain are available, but natural childbirth (without the use of medication) is also an option. Doctors, midwives, and doulas can all be present at a birth, along with partners and supportive friends or family members. A baby’s arrival can also be a more private experience. Regardless, childbirth can cause anxiety or fear. Understanding the birthing process, the signs that labor has started, and where and how birth can occur can help expectant parents prepare.

Figure 2.18 Birth experiences vary, and labor often looks very different from the way it is depicted on TV. Some options for managing the pain and process of childbirth include (a) using a birthing pool particularly in early stages, and (b) using certain positions and pressure techniques throughout various stages of labor. (credit a: modification of work “birth2” by Lindsey Turner/Flickr, CC BY 2.0; credit b: modification of work “Doula” by Agência Senado/Flickr, CC BY 2.0)

The Birth Process

The process of giving birth starts approximately two weeks before the big event with changes in birth hormone levels, including oxytocin. The most common observable first sign of labor is contractions. Contractions may be true contractions or may include Braxton-Hicks contractions, also called “false labor” (Raines & Cooper, 2023). Braxton-Hicks contractions are typically not painful and may help prepare the body for the process of labor.

Though it occurs before labor in only a minority of cases, another sign that birth is approaching is the rupture of the amniotic sac membranes (often called “water breaking”) (American College of Obstetricians and Gynecologists, 2020). The mucus plug, which serves as a barrier between the developing fetus and the vagina and prevents bacteria and other contaminants from entering the uterus, may also be dislodged. Once the cervix starts to dilate, the mucus plug may be released, and amniotic fluid begins to leak out.

Though the exact mechanisms underlying the timing of birth are still not completely understood, the process includes hormone-mediated physiological changes that ready both the pregnant person and the fetus for the event (Hutchinson et al., 2023). One such hormone is oxytocin (Walter et al., 2021), which plays a role in many behaviors including initiating labor and forming bonds with others. In fact, when labor is medically induced (started early), birth mothers are often given a synthetic form of oxytocin, called Pitocin, which helps start the contractions that allow the fetus to be born. Birth mothers may also have an amniotomy, in which their water is broken manually to speed labor and reduce the likelihood of surgical intervention (De Vivo et al., 2019).

Labor may be induced for several reasons, including to avoid an overdue pregnancy. After forty weeks, the fetus and birth mother both face potential complications, including more difficult and longer labor, injury during the birth process, and low blood sugar in the newborn (Šimják et al., 2022). Labor may also be induced if medical issues like problems with the placenta, such as placental separation, arise that don’t require an emergency cesarean delivery.

Regardless of whether labor begins on its own or is induced, the process of giving birth has three stages: dilation, active labor, and afterbirth delivery.

Stage 1: Dilation

The first stage of labor is marked by two different types of contractions, both of which allow dilation (opening) and effacement (thinning) of the cervix to occur (Figure 2.19). Early contractions are irregular and infrequent and occur before the cervix dilates to 6 cm. Active contractions are more frequent and powerful and last longer. The cervix dilates to approximately 10 cm during labor to allow the fetus to pass through the birth canal. Hormones including estrogen, progesterone, relaxin, and prostaglandins are released to soften the cervix so that it can dilate and efface (Walter et al., 2021).

Figure 2.19 The stages of childbirth begin with stage 1, cervical dilation. (CC BY 4.0; Rice University & OpenStax)

The amniotic sac usually ruptures during the first stage, often due to the fetus’s head placing extra pressure on it. If active labor (the second stage) doesn’t start naturally within the next twenty-four hours, the birth mother may require a cesarean delivery (through a surgical incision in the abdomen) because the fetus no longer has enough amniotic fluid surrounding it to survive (Obrowski et al., 2016).

Though the duration of each stage of labor varies, the first is typically the longest. On average, it takes several hours, and it can be as long as twenty hours before the second stage starts (Hutchinson et al., 2023). The first stage may be shorter for subsequent births.

Stage 2: Active Labor

The second stage of labor, called active labor, doesn’t start until the cervix is fully effaced (100 percent) and dilated to 10 cm (Figure 2.20). In this stage, the birth mother will be asked to push downward through the peak of the contractions to help the baby move through the birth canal quickly and assist with delivery. Contractions may last up to a minute each and occur less than five minutes apart (Raines & Cooper, 2023).

Figure 2.20 The cervix dilates from completely closed to 10 cm over the course of labor. (credit "Grape": modification of work "Solaris grapes in Chateaux Luna vineyard 24" by "W.carter"/Wikimedia Commons, CC0 1.0; credit "Kumquat": modification of work "Meiwa ripe fruit at Pali o Waipio Huelo, Maui, Hawaii" by Forest and Kim Starr/Flickr, CC BY 2.0; credit "Plum": modification of work "Bluebyrd plum" by Keith Weller, U.S. Department of Agriculture/Wikimedia Commons, Public Domain; credit "Apple": modification of work "Nittany fruit at Hawea Pl Olinda, Maui, Hawaii" by Forest and Kim Starr/Flickr, CC BY 2.0; credit "Pomegranate": modification of work "Punica granatum (Pomegranate)" by "Bj.schoenmakers"/Wikimedia Commons, CC0 1.0)

Crowning occurs when the top of the baby’s head appears and is about to come out. Occasionally an incision called an episiotomy will be made to increase the size of the vaginal opening and help the baby’s head and shoulders emerge, though many medical professionals avoid this practice (Jiang et al., 2017). Both episiotomy and tearing often require stiches to repair the vaginal opening after birth. If necessary, doctors may use forceps or vacuum suction to help hasten the delivery of the baby.

Typically, the head of the fetus passes through the vaginal opening first, followed by the shoulders and then the rest of the newborn (Figure 2.21). A fetus that has not moved to a headfirst position in the uterus by thirty-six weeks is at risk for a breech birth (Cluver et al., 2015), in which the feet or buttocks appear first. Because this position increases the chance of complications during the birth process, a cesarean delivery may be needed if doctors cannot get the baby into proper birth position using drugs or other maneuvers (Cluver et al., 2015).

Figure 2.21 Stage 2 of the labor process includes full dilation and expulsion of the newborn. (CC BY 4.0; Rice University & OpenStax)

Stage 3: Afterbirth Delivery

Once the fetus has been born, the placenta, the fetus's source of nutrients and oxygen, is no longer needed. During the last stage of labor, therefore, the placenta is expelled (Figure 2.22). This process may last between five and thirty minutes and requires a few final contractions that separate the placenta from the uterus and help eject it (Hutchinson et al., 2023). If the placenta is not fully expelled, medical intervention may be necessary to remove the placenta, because its retention can cause serious complications, including infection and excessive blood loss.

Figure 2.22 Stage 3 of labor involves the expulsion of the placenta. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license; credit right: modification of work “Human placenta uterine side” by “Ravedave”/Wikimedia Commons, Public Domain)

In many Western countries, hospital staff dispose of the placenta after it has been expelled. However, in some cultures, it has significant cultural value, and it may be buried, consumed, or turned into memorabilia (Moeti et al., 2023).¹

Link to Learning

Watch this video about the stages of labor from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Childbirth Options

The end goal of labor is to successfully deliver a healthy infant. But there are innumerable combinations of circumstances and ways in which that can happen. Decisions about how to give birth, where to give birth, whether it can be scheduled, how much medical intervention will be available or is desired, and how best to deal with the discomfort associated with childbirth have led to a wide variety of options.

Intersections and Contexts: Birthing Positions around the World

Various birthing positions are popular around the world, including standing upright, sitting, kneeling on all fours, lying on the side, and the most widely known, lying on the back (called the supine position). Giving birth while squatting, kneeling, or standing is believed to reduce pain and increase the ease of delivery, because these positions rely on gravity to help the fetus complete the journey through the birth canal (Berta et al., 2019; Peters et al. 2021; Satone, 2023). Before the seventeenth century, giving birth in an upright position was the most common method in Western countries (Satone, 2023).²

Today, the supine position is most frequently used in the United States, and it is also growing more prevalent in countries where medicine is becoming Westernized and births are taking place primarily in hospitals. However, this position may extend the pain associated with giving birth and increase complications (Satone, 2023).³ Most recently, midwives and other professionals in the United States and other countries have started educating pregnant people and medical staff about the advantages of alternate childbirth positions.

Alternatives to the supine position tend to be more common in countries like Uganda, Ethiopia, Kenya, Tanzania, Nepal, and Peru, where more births occur in the home (Beinempaka et al., 2015; Peters et al., 2021; Regassa et al., 2022). In Nepal, mothers often give birth on their hands and knees (Peters et al., 2021). Though it’s difficult to stand or squat during a prolonged labor, a labor chair can offer support when in the squatting position.

In parts of Tanzania, the traditional birthing position was upright, though most birth mothers (80 percent) now give birth in the supine position due to the influence of Western medicine (Mselle & Eustace, 2020).⁴ This is also true in parts of Peru. However, the Peruvian government has begun funding birthing centers where traditional upright positions are used, to decrease the nation’s high maternal mortality rates (Palomino, 2008).

Lack of information about the variability of birthing positions may also be a factor. A study from Nigeria, where more than 90 percent of birth mothers at birthing centers give birth in the supine position, found that 69 percent believed this was the only birthing position (Okonta, 2012). Unawareness of the options may inhibit birth mothers from making informed choices about their labor experience (Okonta, 2012). The WHO updated its birthing practice recommendations in 2018 to ensure that birthing mothers know their options and understand research data showing that upright birthing positions may ease delivery and reduce the risk of postdelivery hemorrhage (WHO, 2018).

Vaginal versus Cesarean Delivery

Vaginal deliveries are generally considered to be the safest for the birth mother and for infants born near or at full term (Desai & Tsukerman, 2023; Gregory et al., 2011). In this process, the fetus passes through the birth canal and pelvis during delivery. This type of delivery can occur in multiple settings, including in a hospital, a birthing center, or at home, and depending on the location, in water. Vaginal delivery, when possible, typically allows faster recovery for the mother and improved immune functioning for the newborn (Desai & Tsukermann, 2023).

In some circumstances, however, a vaginal delivery isn’t the best or safest option. For example, if a sexually transmitted infection may be passed to the newborn through the birth canal, the fetus is too large or is in a breech position, the umbilical cord is tangled around the fetus, or the mother has placenta previa (which causes excessive bleeding during birth) or certain other medical conditions, a vaginal birth may not be advisable. In a cesarean birth, or C-section, an incision is made in both the abdomen and the uterus, and the newborn and placenta are delivered through the resulting opening. Complications for the birth mother such as bleeding, blood clots, and infections can arise due to the invasive nature of the procedure. Cesareans also require longer hospital stays and longer recovery times. Having a cesarean also increases the chances of needing one again for subsequent pregnancies, but many birth mothers are able to give birth vaginally after a cesarean delivery, commonly referred to as “vaginal birth after cesarian section” (VBAC).

Pain Management Techniques

Regardless of how birth happens, many options are available for dealing with the pain of labor. In the 1960s, the epidural, an injection of anesthetics into a space in the mother’s spinal cord to block the sensation of pain, became common. However, nitrous oxide, widely used in the early 1900s, has been making a comeback (Nanji & Carvalho, 2020). Depending on the drugs used and their concentrations, however, pain medication may weaken uterine contractions and prolong labor (Halliday et al., 2022).

In contrast, natural childbirth uses nonpharmaceutical techniques to help minimize both pain for the birth mother and the need for medical intervention (Table 2.6). While only some of these techniques are evidence-based practices for pain management, they all can support pain management in combination with stretching and specific childbirth positions.

Table 2.6 Natural Childbirth Options (sources: Gallo et al., 2018; Hao & Mittelman, 2014; Madden et al., 2016; Santana et al., 2022; Sharifipour et al., 2022; Smith et al., 2020; Vanderlaan et al., 2018; Varner, 2015, Wax et al., 2010)

Childbirth Technique	Description
Lamaze	Classes teach individuals what to expect and introduce specific breathing techniques and behaviors to support the birth mother during the birthing process.
Bradley	Classes promote nutrition and exercise to help reduce pain and complications during delivery. The method also teaches breathing and relaxation techniques and includes partners as labor coaches.
Water birth	Birth or part of labor occurs in clean warm water, which may soothe both birth mother and newborn and relieve pain. Being delivered into a warm, wet environment may also be less of a shock for the newborn, who is leaving the warm, wet environment of the uterus.
Acupuncture	Needles are inserted into specific areas of the body to reduce pain and relieve stress. This method can be used during early labor to help decrease discomfort and may reduce pain during labor as well as the need for medications.
Massage	Massage techniques, warm showers, and the use of delivery balls have all been shown to reduce pain.
Hypnosis	A practitioner lulls the birth mother into a state where they are more open to suggestions and then suggests relaxation and pain management strategies for pain management. Hypnosis has yet to be shown to definitively improve the childbirth experience.

Link to Learning

Use this helpful online birth plan tool created by the American College of Obstetricians and Gynecologists to learn more about all the decisions a person might make in a birth plan.

Professional Assistance

Many people choose to give birth under the care of an obstetrician/gynecologist (OB/GYN). In addition, several types of midwives can support the birthing process. Their duties vary from culture to culture, but generally, midwives provide help and care over the prenatal period as well as assist parents during the birth of their child. Some spend substantial time with birth mothers both before and after delivery and may even help with housework and visitors, depending on cultural norms. Most midwives in the United States have some level of medical or nursing training and credentials (Table 2.7).

Table 2.7 Types of Midwives in the United States (source: Backes & Scrimshaw, 2020)

Midwife Type	Description
Certified Nurse-Midwife (CNM)	A registered nurse who has received extra training (a graduate degree) and credentialing to become a midwife
Certified Midwife/Direct-entry midwife (CM)	A midwife who has earned graduate degrees that include some medical training, allowing them to provide pre- and postnatal care, along with birthing a child
Certified Professional Midwife (CPM)	A midwife who has mastered an apprenticeship or educational program granting credentials ranging from a certificate to a graduate degree

Other credentialed individuals who may assist a pregnancy are known as doulas. In the United States, doulas may take certification courses to become licensed, but they do not receive the same type of training as a midwife (Backes & Scrimshaw, 2020). Most of their training focuses on ways to support and assist birth mothers during pregnancy and after giving birth. Doulas may also support breastfeeding success and provide emotional support, by being a source of support through home visits and advocacy for pregnant women (Sobczak et al., 2023). They can also be helpful in bridging cultural and language barriers for those giving birth outside their country of birth (Kathawa et al., 2021).

Birth Locations

Many factors come in to play in the decision of where to give birth, including health insurance coverage, economic resources, the availability of nearby options, and existing health conditions or other considerations that may require special care. The question for the birth mother or future parents is, what is most important to them about the birth process.

About 98 percent of births in the United States occur in a hospital (Backes & Scrimshaw, 2020). In some parts of Europe and elsewhere around the world, birth more frequently occurs in a birthing center (Peters et al., 2021). One of the advantages of delivering in a hospital or birthing center is the ability to have vital signs like the heart rate and blood pressure continuously monitored. Changes in these can indicate distress or potential complications during the labor process, and medical interventions can be started quickly to ensure a safe delivery. More powerful medications are also available to assist with any discomfort during labor. Another benefit of institutional delivery is the series of automatic health screenings performed on newborns in hospitals and other medical settings.

Last, if something goes wrong during the birth, hospitals and birthing centers are typically well-equipped to provide immediate medical interventions, and many have specialized neonatal units that undertake the care of infants born prematurely or with complications. However, the quality of care available during labor is not uniform across the globe. In some countries, such as Finland, medical centers are equipped to handle many common complications while also providing extensive support for new mothers (Wrede et al., 2021). In contrast, though health care is free in birthing centers in Malawi, these centers are often short-staffed or not available in rural areas (Wrede et al., 2021). Though most deliveries are free of complications, issues that necessitate medical intervention include fetal distress, a tangled umbilical cord or problem in the uterus, and excessive maternal bleeding (Table 2.8).

Table 2.8 Birthing Locations (sources: Galková et al., 2022; Pomeroy et al., 2014)

Location	Overview
Hospital	Hospitals provide a medical and clinical focus, monitoring of baby and mother’s vital signs, and medical intervention ready for high-risk births or complications. Hospital birth is common in the United States.
Birthing center	Centers provide overall “wellness of mother” focus; monitoring of baby and mother’s vital signs; and sometimes birthing rooms with tubs for water-based births, beds, and other means to make families comfortable during the process. Birthing centers are becoming more frequent in India and Indonesia.
Home	Home offers a familiar environment that might include a room set up for birthing where a midwife or doula may assist. Giving birth at home is common in the Netherlands.

Link to Learning

Watch this TED talk about a Simple Birth Kit for Mothers in the Developing World that could decrease maternal mortality.

For some with low-risk pregnancies, giving birth at home is an option. This method allows the birth to occur in a familiar place, and choices regarding the circumstances surrounding the event, such as whether music is playing, to be made in ways that can’t always be achieved at a hospital or birthing center. Home births are also associated with a reduction in unnecessary medical interventions (Committee on Obstetric Practice, 2017), but only about 1 percent of U.S. births occur at home (Backes & Scrimshaw, 2020). Ensuring the safety of both mother and newborn requires substantial advance planning. Birthing at home typically relies on the help of midwives or doulas (or both), but a doctor or medical practitioner should be available if there are complications. Transportation to a medical facility should also be standing by.

Globally, nearly half of all births occur at home. Income seems to be an influential factor, however (Figure 2.23). In most countries, even those whose populations have the lowest socioeconomic status, women with higher incomes gave birth in a hospital or birthing center (Montagu et al., 2011). In many parts of Africa, and parts of Asia such as Nepal, birth often occurs at home and the mother may be assisted by a midwife, though midwives’ training may be more culturally based rather than medically based as it is in the United States and Europe (Peters et al., 2021).

Figure 2.23 Birth locations around the world vary between public facilities like hospitals and birthing centers, homes, and private hospitals or birthing centers. (credit: modification of work “Figure 1. Place of birth by region” by Montagu et al./PLOS One, CC BY)

Perinatal Health and Screening

Perinatal health refers to the health of both the pregnant person and fetus from the twenty-fourth week of gestation to about two to four weeks after birth of the infant. Pregnant individuals at risk of complications or of advanced maternal age may be offered more frequent ultrasounds after the twenty-eighth week of gestation. This noninvasive test helps the OB/GYN or others to assess the size of the fetus, whether it is in breech position or has turned, and whether it is growing at a typical pace. The fetal heart rate will also be measured to ensure the vital signs are healthy.

Other important aspects of perinatal health and screening involve newborn tests and care for low-birth-weight babies. After giving birth, people remain important and valuable outside of any role related to the pregnancy and the infant. It is essential to care for their emotional and physical wellbeing in the weeks and months following the arrival of the child.

Caring for People After Giving Birth

Much of the focus after birth is on the newborn and its care. However, birth mothers are still recovering and need postpartum care as well. In the United States, they will often have a follow-up appointment to assess their physical recovery, but they also need help coping with the stress of caring for a newborn while healing. In Ghana, birth mothers often did not realize that they, too, needed care during the postpartum period (Yenupini et al., 2023). The lack of such care is thought to contribute to high mortality rates for birth mothers (Yenupini et al., 2023).

According to the American College of Obstetricians and Gynecologists (2018), postpartum care should be viewed not as a single-visit issue but as a long-term process with consequences for the future health of both birth mother and infant. The focus should also be on social and emotional health, not just physical health, and should assess the mother’s emotional well-being, sleep, and any issues related to feeding and caring for the newborn (American College of Obstetricians and Gynecologists, 2018). Postpartum care is beneficial in reducing a variety of emotional and physical health risks in both birth mothers and adoptive parents (Lopez-Gonzalez & Kopparapu, 2022; Mott et al., 2011).

Newborn Tests

In many Western countries, newborns delivered in a medical facility will be screened for various diseases and conditions, including genetic and metabolic disorders, usually within the first two days of life. For example, blood tests and hearing tests are often common screenings, as well as screening for congenital heart issues. The first test administered to a newborn is the Apgar test.

The Apgar test is typically given one minute after birth and then again at five minutes after birth. This test assesses how stable an infant is after going through the birth process by measuring five aspects of newborn functioning: reflex irritability (activity), heart rate (pulse), muscle tone (grimace), body color (appearance), and respiratory effort (Figure 2.24). A total score over seven is considered good, and most newborns score between seven and nine, with very few achieving ten.

Figure 2.24 The Apgar is a very quick test used to assess whether a newborn is healthy immediately following birth. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license; credit top: modification of work “Baby, Newborn, Child image” by Engin Akyurt/Pixabay, Pixabay Content License)

A score between four and six may require intervention for the newborn. Scores below four require care because they mean the newborn is not in good condition (American College of Obstetricians and Gynecologists, 2015). The Apgar test has limits, however. It detects only major neurological problems, not subtle ones, and scores are based on one moment in time. They can also be influenced by other factors, such as how sedated or medicated the birth mother is (which affects the newborn) and whether there was birth trauma such as anoxia (oxygen deprivation) (American College of Obstetricians and Gynecologists, 2015). Apgar scoring of appearance, which helps determine if a healthy amount oxygen is flowing in the blood, may also be more difficult to assess on newborns with a darker skin tone. Some guidelines therefore suggest measuring oxygen saturation directly with a pulse oximeter (Furness et al., 2024).

The neonatal behavioral assessment scale, or NBAS, is most often given by a pediatrician three to four days after birth but can be used to assess neurological behavior for up to two months after birth (Brazelton, 1995). It looks at twenty-eight factors related to behavior, including reflexes, in addition to assessing twenty neurological items on a four-point scale. It assesses how well infants are doing, shows their individuality, and can assess potential neurological issues that may require intervention. It looks specifically at three broad areas: the functioning of the autonomic nervous system and motor systems, how well the infant follows and responds to social stimuli like a face or voice, and infant states, such as being quiet and calm or actively moving while awake. The NBAS can be a useful tool in assessing neurobehavioral health in newborns (Malak et al., 2021).

Care of Infants with Low Birth Weight

Babies considered to have low birth weight generally weigh less than 5 lb 8 oz when born (Cutland et al., 2017). In contrast, a high weight for babies is typically defined as being more than 9 to 10 lb (Akanmode & Mahdy, 2023). There is a difference between having low birth weight and being “small for gestational age” (Cutland et al., 2017). Newborns who are small for their gestational age weigh less than the tenth percentile, meaning 90 percent of infants that age are larger (Cutland et al., 2017). Two reasons for low birth weight are premature birth and a condition called fetal growth restriction, which hampers the fetus’s ability to grow.

Low birth weight does not automatically result in developmental problems. Some babies with low birth weight are healthy, and many catch up physically to others of the same age if they have good care and no other health issues or complications. However, low birth weight can indicate health risks, and babies born weighing less than 1 lb typically have the most complications and a higher mortality rate (Jeschke et al., 2016).

Maternal risk factors for having a newborn with low birth weight include the following (Adugna & Worku, 2022; K. C. et al., 2020):

• not gaining enough weight during pregnancy
• already having a child with low birth weight
• using drugs or alcohol, or smoking
• being under the age of twenty years when pregnant (DeMarco et al., 2021)
• being of advanced maternal age (typically over age thirty-five years) (Glick et al., 2021)
• having poor nutrition when pregnant (Cutland et al., 2017)
• lacking access to prenatal care

Poor access to prenatal care and poor nutrition are among the driving factors behind low birth weight, causing it to disproportionately affect babies born to those with lower socioeconomic status. In many countries, public health or government programs exist to bridge the nutritional gap for birth mothers with low income and those in poverty (UNICEF, 2024).

Babies with low birth weight who have complications are treated medically in much the same way as premature babies. Depending on their needs, they may require being seen by a neonatal specialist, being kept warm in an incubator, getting fed intravenously to help them gain weight, and receiving medical treatments to help them breathe if their lungs are not fully developed or strong (Soleimani et al., 2020).

Premature Birth

A preterm infant (premature or preemie) is any newborn born before thirty-seven weeks’ gestation and weighing less than 5.5 lb. There are many risk factors associated with a premature birth, including the following maternal characteristics (CDC, 2024a):

• having already had a preterm child
• getting pregnant quickly after a previous birth (typically within a year)
• having health issues such as diabetes or high blood pressure
• using drugs or being a regular smoker
• being pregnant with multiples
• being under age eighteen years or over age thirty-five years
• having issues with the placenta, such as placenta previa, placental abruption, or bleeding
• having low socioeconomic status and/or food insecurity (lacking access to food of sufficient quantity or quality)

A pregnant person with risk factors associated with an increased chance of having a premature baby may receive steroid treatments before giving birth that help the fetus’s lungs develop more quickly and improve the infant’s chances of doing well once born (Htun et al., 2021). Sometimes, however, a baby is born early with no known risk factors.

Researchers have investigated the relationship between premature labor and socioeconomic status, food insecurity, and stress. They found that lacking prenatal care and experiencing stress and food insecurity were strongly related to having a child before the thirty-seventh week of pregnancy (Dolatian et al., 2018). Other research has found food insecurity to be strongly related to complications during pregnancy as well, including high blood pressure and gestational diabetes (Dewing et al., 2013; Sandoval et al., 2020). Infants born prematurely often need extended and costly care, which may further exacerbate the challenges faced by families who experience high levels of stress, food insecurity, and inconsistent access to medical care.

Currently Black women are much more likely to give birth prematurely than White or Hispanic women (Hollenbach et al., 2021; Scommegna, 2023). While socioeconomic factors such as lower income or disadvantaged neighborhood increase premature birth risks for new mothers, research is also revealing that structural racism is an influential factor particularly for U.S. Black mothers (Hollenbach et al., 2021; Scommegna, 2023). Maternal mortality rates are also significantly higher for Black and Native American women than for White women (Leonard et al., 2019). The CDC recommends a variety of community and health-care provider–based interventions and prevention efforts, such as improving and standardizing prenatal and postpartum care, to reduce maternal mortality health risks and disparities (CDC, 2024b).

Link to Learning

Watch this video to learn more about how racism harms pregnant mothers and racial disparities in pregnancy care,.

Though some preterm births are unavoidable, there are several steps to help decrease the risk of giving birth before 37 weeks. These include eating healthily; getting enough sleep; avoiding excessive stress; trying to be active (even if by just taking a short walk daily); addressing medical conditions like diabetes or high blood pressure; going to prenatal check-up appointments; and not smoking, drinking, or taking drugs that might affect the pregnancy.

Premature infants are at higher risk of developmental issues and other ailments because their skin, lungs, nervous system, and digestive system still needed time to grow and develop before they were born. Some may face problems with respiration, digestion, and cardiac health (such as a slower heart rate). They may be more susceptible to infections or failure to thrive, meaning their height and weight are below the third percentile (only 3 of 100 full-term infants will be as small) (Mattison et al., 2003).

Infants born before 28 weeks are at greatest risk and require substantial medical care, usually from medical specialists called neonatologists, to have a chance of survival. Their lungs are not yet fully developed, and they did not have the time to develop the normal layer of body fat, so they may require help such as the use of a ventilator, oxygen hood, or CPAP machine to assist in breathing, a feeding tube, and a special incubator for warmth (Figure 2.25). They must also be monitored to ensure they have enough oxygen in their blood. These infants are at higher risk of having health problems that last a lifetime. Issues associated with being born prematurely and underweight are some of the leading causes of infant death.

Figure 2.25 Medical interventions such as (a) ventilators and (b) incubators are tools used in neonatal intensive care units to help premature or high-risk newborns to recover and thrive. (credit a: modification of work “Lyra” by Chris Sternal-Johnson/Flickr, CC BY 2.0; credit b: modification of work “Incubator-tahrir” by United States Agency for International Development/Wikimedia Commons, Public Domain)

References

Adugna, D. G., & Worku, M. G. (2022). Maternal and neonatal factors associated with low birth weight among neonates delivered at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia. Frontiers in Pediatrics, 10, Article 899922. https://doi.org/10.3389/fped.2022.899922

Akanmode, A. M., & Mahdy, H. (2023). Macrosomia. StatPearls. StatPearls Publishing. www.ncbi.nlm.nih.gov/books/NBK557577/

American College of Obstetricians and Gynecologists. (2015). The apgar score [White paper]. https://www.acog.org/clinical/clinic...he-apgar-score

American College of Obstetricians and Gynecologists. (2018). Optimizing postpartum care [White Paper]. https://www.acog.org/clinical/clinic...ostpartum-care

American College of Obstetricians and Gynecologists (2020). Prelabor rupture of membranes: ACOG practice bulletin, number 217. Obstetrics and Gynecology, 135(3), e80–e97. doi.org/10.1097/AOG.0000000000003700

Backes, E. P., & Scrimshaw, S. C. (Eds.). (2020). Birth settings in America: Outcomes, quality, access, and choice. National Academies Press. https://nap.nationalacademies.org/re...5636/chapter/1

Beinempaka, F., Tibanyendera, B., Atwine, F., Kyomuhangi, T., Kabakyenga, J., & MacDonald, N. E. (2015). Traditional rituals and customs for pregnant women in selected villages in Southwest Uganda. Journal of Obstetrics and Gynaecology Canada, 37(10), 899–900. https://doi.org/10.1016/s1701-2163(16)30026-3

Berta, M., Lindgren, H., Christensson, K., Mekonnen, S., & Adefris, M. (2019). Effect of maternal birth positions on duration of second stage of labor: Systematic review and meta-analysis. BMC Pregnancy and Childbirth, 19, Article 466. https://doi.org/10.1186/s12884-019-2620-0

Brazelton, T. B., & Nugent, K. J. (1995). Neonatal behavioral assessment scale (3rd ed.). Mac Keith Press.

Cluver, C., Gyte, G. M., Sinclair, M., Dowswell, T., & Hofmeyr, G. J. (2015). Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. The Cochrane Database of Systematic Reviews, 2015(2), Article CD000184. doi.org/10.1002/14651858.CD000184.pub4

Committee on Obstetric Practice. (2017). Committee Opinion No. 697: Planned home birth [White Paper]. Obstetrics and Gynecology, 129(4), e117–e122. doi.org/10.1097/AOG.0000000000002024

Cutland, C. L., Lackritz, E. M., Mallett-Moore, T., Bardají, A., Chandrasekaran, R., Lahariya, C., Nisar, M. I., Tapia, M. D., Pathirana, J., Kochhar, S., Muñoz, F. M., & The Brighton Collaboration Low Birth Weight Working Group. (2017). Low birth weight: Case definition & guidelines for data collection, analysis, and presentation of maternal immunization safety data. Vaccine, 35(48 pt A), 6492–6500. https://doi.org/10.1016/j.vaccine.2017.01.049

De Vivo, V., Carbone, L., Saccone, G., Magoga, G., De Vivo, G., Locci, M., Zullo, F., & Berghella, V. (2019). Early amniotomy after cervical ripening for induction of labor: A systematic review and meta-analysis of randomized controlled trials. American Journal of Obstetrics & Gynecology, 222(4), 320–329. https://doi.org/10.1016/j.ajog.2019.07.049

DeMarco, N., Twynstra, J., Ospina, M. B., Darrington, M., Whippey, C., & Seabrook, J. A. (2021). Prevalence of low birth weight, premature birth, and stillbirth among pregnant adolescents in Canada: A systematic review and meta-analysis. Journal of Pediatric and Adolescent Gynecology, 34(4), 530-537. https://doi.org/10.1016/j.jpag.2021.03.003

Desai, N. M., & Tsukerman, A. (2023). Vaginal delivery. StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/32644623/

Dewing, S., Tomlinson, M., le Roux, I. M., Chopra, M., & Tsai, A. C. (2013). Food insecurity and its association with co-occurring postnatal depression, hazardous drinking, and suicidality among women in peri-urban South Africa. Journal of Affective Disorders, 150(2), 460–465. https://doi.org/10.1016/j.jad.2013.04.040

Dolatian, M., Sharifi, N., & Mahmoodi, Z. (2018). Relationship of socioeconomic status, psychosocial factors, and food insecurity with preterm labor: A longitudinal study. International Journal of Reproductive Biomedicine, 16(9), 563–570. www.ncbi.nlm.nih.gov/pmc/articles/PMC6312711/

Furness, A., Fair, F., Higginbottom, G., Oddie, S., & Soltani, H. (2024). A review of the current policies and guidance regarding Apgar scoring and the detection of jaundice and cyanosis concerning Black, Asian and ethnic minority neonates. BMC pediatrics, 24, Article 198. https://dx.doi.org/10.1186/s12887-024-04692-4

Galková, G., Böhm, P., Hon, Z., Heřman, T., Doubrava, R., & Navrátil, L. (2022). Comparison of frequency of home births in the Member States of the EU Between 2015 and 2019. Global Pediatric Health, 9, Article 2333794X2110709. doi.org/10.1177/2333794x211070916

Gallo, R. B. S., Santana, L. S., Marcolin, A. C., Duarte, G., & Quintana, S. M. (2018). Sequential application of non-pharmacological interventions reduces the severity of labour pain, delays use of pharmacological analgesia, and improves some obstetric outcomes: A randomised trial. Journal of Physiotherapy, 64(1), 33–40. https://doi.org/10.1016/j.jphys.2017.11.014

Glick, I., Kadish, E., & Rottenstreich, M. (2021). Management of pregnancy in women of advanced maternal age: Improving outcomes for mother and baby. International Journal of Women’s Health, Volume 13, 751–759. https://doi.org/10.2147/ijwh.s283216

Gregory, K., Jackson, S., Korst, L., & Fridman, M. (2011). Cesarean versus vaginal delivery: Whose risks? Whose benefits? American Journal of Perinatology, 29(01), 07–18. https://doi.org/10.1055/s-0031-1285829

Halliday, L., Nelson, S. M., & Kearns, R. J. (2022). Epidural analgesia in labor: A narrative review. International Journal of Gynecology & Obstetrics, 159(2), 356–364. doi.org/10.1002/ijgo.14175

Hao, J. J., & Mittelman, M. (2014). Acupuncture: Past, present, and future. Global Advances in Health and Medicine, 3(4), 6–8. doi.org/10.7453/gahmj.2014.042

Hollenbach, S. J., Thornburg, L. L., Glantz, J. C., & Hill, E. (2021). Associations between historically redlined districts and racial disparities in current obstetric outcomes. JAMA Network Open, 4(9), Article e2126707. doi.org/10.1001/jamanetworkopen.2021.26707

Htun, Z. T., Schulz, E. V., Desai, R. K., Marasch, J. L., McPherson, C. C., Mastrandrea, L. D., Jobe, A. H., & Ryan, R. M. (2021). Postnatal steroid management in preterm infants with evolving bronchopulmonary dysplasia. Journal of Perinatology, 41, 1783–1796. https://doi.org/10.1038/s41372-021-01083-w

Hutchinson, J., Mahdy, H., & Hutchison, J. (2023). Stages of Labor. StatPearls [Internet]. StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/31335010/

Jeschke, E., Biermann, A., Günster, C., Böhler, T., Heller, G., Hummler, H. D., & Bührer, C. (2016). Mortality and major morbidity of very-low-birth-weight infants in Germany 2008–2012: A report based on administrative data. Frontiers in Pediatrics, 4, Article 23. https://doi.org/10.3389/fped.2016.00023

Jiang, H., Qian, X., Carroli, G., & Garner, P. (2017). Selective versus routine use of episiotomy for vaginal birth. The Cochrane Database of Systematic Reviews, 2017(2), Article CD000081. doi.org/10.1002/14651858.CD000081.pub3

K. C., A., Basel, P. L., & Singh, S. (2020). Low birth weight and its associated risk factors: Health facility-based case-control study. PloS ONE, 15(6), Article e0234907. https://doi.org/10.1371/journal.pone.0234907

Kathawa, C. A., Arora, K. S., Zielinski, R., & Low, L. K. (2021). Perspectives of doulas of color on their role in alleviating racial disparities in birth outcomes: A qualitative study. Journal of Midwifery & Women’s Health 67(1), 31–38. doi.org/10.1111/jmwh.13305

Leonard, S. A., Main, E. K., Scott, K. A., Profit, J., & Carmichael, S. L. (2019). Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Annals of Epidemiology, 33, 30–36. https://doi.org/10.1016/j.annepidem.2019.02.007

Lopez-Gonzalez D.M., & Kopparapu A.K. (2022). Postpartum care of the new mother. StatPearls Publishing. www.ncbi.nlm.nih.gov/books/NBK565875/

Madden, K., Middleton, P., Cyna, A. M., Matthewson, M., & Jones, L. (2016). Hypnosis for pain management during labour and childbirth. The Cochrane Database of Systematic Reviews, 2016(5), Article CD009356. doi.org/10.1002/14651858.CD009356.pub3

Malak, R., Fechner, B., Sikorska, D., Rosołek, M., Mojs, E., Samborski, W., & Baum, E. (2021). Application of the neonatal behavioral assessment scale to evaluate the neurobehavior of preterm neonates. Brain sciences, 11(10), Article 1285. https://doi.org/10.3390/brainsci11101285

Mattison, D. R., Wilson, S., Coussens, C., & Gilbert, D. (Eds.). (2003). The role of environmental hazards in premature birth: Workshop summary. National Academies Press. https://nap.nationalacademies.org/re...0842/chapter/1

Moeti, C., Mulaudzi, F. M., & Rasweswe, M. M. (2023). The disposal of placenta among indigenous groups globally: An integrative literature review. International Journal of Reproductive Medicine, 2023, Article e6676809. doi.org/10.1155/2023/6676809

Montagu, D., Yamey, G., Visconti, A., Harding, A., & Yoong, J. (2011). Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS ONE, 6(2), Article e17155. https://doi.org/10.1371/journal.pone.0017155

Mott, S. L., Schiller, C. E., Richards, J. G., O’Hara, M. W., & Stuart, S. (2011). Depression and anxiety among postpartum and adoptive mothers. Archive of Women’s Mental Health, 14, 335–343 https://doi.org/10.1007/s00737-011-0227-1

Mselle, L. T., & Eustace, L. (2020). Why do women assume a supine position when giving birth? The perceptions and experiences of postnatal mothers and nurse-midwives in Tanzania. BMC Pregnancy and Childbirth, 20, Article 36. https://doi.org/10.1186/s12884-020-2726-4

Nanji, J. A., & Carvalho, B. (2020). Pain management during labor and vaginal birth. Best Practice & Research Clinical Obstetrics & Gynaecology, 67, 100–112. https://doi.org/10.1016/j.bpobgyn.2020.03.002

Obrowski S., Obrowski M., & Starski K. (2016). Normal pregnancy: A clinical review. Academic Journal of Pediatrics & Neonatology, 1(1), Article 555554. https://doi.org/10.19080/ajpn.2016.01.555554

Okonta, P. I. (2012). Birthing positions: Awareness and preferences of pregnant women in a developing country. The Internet Journal of Gynecology and Obstetrics, 16(1). https://ispub.com/IJGO/16/1/13974

Palomino, M. L. (2008, July 11). Peru embraces vertical births to save lives. Reuters. www.reuters.com/article/us-p...8571520080711/

Peters, J., Logan, S. & Sneed K. B. (2021) A cross-cultural examination of prenatal care and birthing practices. Chemical & Pharmaceutical Research. 3(1), 1–7. http://dx.doi.org/10.33425/2689-1050.1019

Pomeroy, A. M., Koblinsky, M., & Alva, S. (2014). Who gives birth in private facilities in Asia? A look at six countries [Supplemental material]. Health Policy and Planning, 29(1), i38–i47. doi.org/10.1093/heapol/czt103

Raines, D. A., Cooper D. B. (2023) Braxton Hicks contractions. StatPearls Publishing. www.ncbi.nlm.nih.gov/books/NBK470546/

Regassa, L. D., Tola, A., Weldesenbet, A. B., & Tusa, B. S. (2022). Prevalence and associated factors of home delivery in Eastern Africa: Further analysis of data from the recent demographic and health survey data. SAGE Open Medicine, 10, Article 205031212210880. doi.org/10.1177/20503121221088083

Sandoval, V. S., Jackson, A., Saleeby, E., Smith, L., & Schickedanz, A. (2020). Associations between prenatal food insecurity and prematurity, pediatric health care utilization, and postnatal social needs. Academic Pediatrics, 21(3), 455–461. https://doi.org/10.1016/j.acap.2020.11.020

Santana, L. S., Gallo, R. B. S., Quintana, S. M., Duarte, G., Jorge, C. H., & Marcolin, A. C. (2022). Applying a physiotherapy protocol to women during the active phase of labor improves obstetrical outcomes: A randomized clinical trial. AJOG Global Reports, 2(4), Article 100125. https://doi.org/10.1016/j.xagr.2022.100125

Satone, P. D., & Tayade, S. A. (2023). Alternative birthing positions compared to the conventional position in the second stage of labor: A review. Cureus, 15(4), Article e37943. https://doi.org/10.7759/cureus.37943

Scommegna, P. (2023, March 28). Action to address pregnancy-related deaths among U.S. Black women urged by Dr. Shalon’s maternal action project, PRB, and tank worldwide. Population Reference Bureau. https://www.prb.org/news/action-to-a...ank-worldwide/

Sharifipour, P., Kheirkhah, M., Rajati, M., & Haghani, H. (2022). The effect of delivery ball and warm shower on the childbirth experience of nulliparous women: A randomized controlled clinical trial. Trials, 23, Article 391. https://doi.org/10.1186/s13063-022-06358-x

Šimják, P., Krejčí, H., Hornová, M., Mráz, M., Pařízek, A., Kršek, M., Haluzík, M., & Anderlová, K. (2022). Establishing the optimal time for induction of labor in women with diet-controlled gestational diabetes mellitus: A single-center observational study. Journal of Clinical Medicine, 11(21), Article 6410. https://doi.org/10.3390/jcm11216410

Smith, C. A., Collins, C. T., Levett, K. M., Armour, M., Dahlen, H. G., Tan, A. L., & Mesgarpour, B. (2020). Acupuncture or acupressure for pain management during labour. Cochrane Database of Systematic Reviews, 2, Article CD009232. doi.org/10.1002/14651858.cd009232.pub2

Sobczak, A., Taylor, L., Solomon, S., Ho, J., Kemper, S., Phillips, B., Jacobson, K., Castellano, C., Ring, A., Castellano, B., & Jacobs, R. J. (2023). The effect of doulas on maternal and birth outcomes: A scoping review. Cureus, 15(5), Article e39451. https://doi.org/10.7759/cureus.39451

Soleimani, F., Azari, N., Ghiasvand, H., Shahrokhi, A., Rahmani, N., & Fatollahierad, S. (2020). Do NICU developmental care improve cognitive and motor outcomes for preterm infants? A systematic review and meta-analysis. BMC Pediatrics, 20, Article 67. https://doi.org/10.1186/s12887-020-1953-1

UNICEF. (2024). Maternal nutrition: Preventing malnutrition in pregnant and breastfeeding women. https://www.unicef.org/nutrition/maternal

U.S. Centers of Disease Control and Prevention. (2024a, May 15). Preterm Birth. U.S. Department of Health and Human Services. https://www.cdc.gov/maternal-infant-...preterm-birth/

U.S. Centers of Disease Control and Prevention. (2024b, May 15) Maternal Mortality Prevention. U.S. Department of Health and Human Services. https://www.cdc.gov/maternal-mortali...ths/index.html

Vanderlaan, J., Hall, P. J., & Lewitt, M. (2018). Neonatal outcomes with water birth: A systematic review and meta-analysis. Midwifery, 59, 27–38. https://doi.org/10.1016/j.midw.2017.12.023

Varner, C. A. (2015). Comparison of the Bradley Method and HypnoBirthing childbirth education classes. The Journal of Perinatal Education, 24(2), 128–136. doi.org/10.1891/1946-6560.24.2.128

Walter, M. H., Abele, H., & Plappert, C. F. (2021). The role of oxytocin and the effect of stress during childbirth: Neurobiological basics and implications for mother and child. Frontiers in Endocrinology, 12, Article 742236. https://doi.org/10.3389/fendo.2021.742236

Wax, J. R., Lucas, F. L., Lamont, M., Pinette, M. G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: A metaanalysis. American Journal of Obstetrics and Gynecology, 203(3), 243.e1–243.e8. https://doi.org/10.1016/j.ajog.2010.05.028

World Health Organization (2018, February 15). Individualized, supportive care key to positive childbirth experience, says WHO. https://www.who.int/news/item/15-02-...ience-says-who

Wrede, S., Novkunskaya, A., Sarlio-Nieminen, J., & van Teijlingen, E. (2021). Birth systems across the world: Variations in maternity policy and services across countries. In Sandall, J. (Ed.). The continuous textbook of women’s medicine series: Obstetrics module volume 1. Global Library of Women’s Medicine. https://doi.org/10.3843/GLOWM.415183

Yenupini, J. A., Miller, M. L., Agbenyo, J. S., Ehla, E. E., & Clinton, G. A. (2023). Postpartum care needs assessment: women’s understanding of postpartum care, practices, barriers, and educational needs. BMC Pregnancy and Childbirth, 23, Article 502. https://doi.org/10.1186/s12884-023-05813-0

Footnotes

• 1This study (Moeti et al., 2023) uses the terms “Western” and “indigenous.”
• 2This study (Satone, 2023) uses the term “Western.”
• 3This study (Satone, 2023) uses the term “Western.”
• 4This study (Mselle & Eustace, 2020) uses the term “Western.”