Temporal and demographic trends in cerebral palsy - Fact and fiction

The rate of cerebral palsy has not decreased in developed countries over the past 30 years, despite the widespread use of electronic fetal heart rate monitoring and a 5-fold increase in the cesarean delivery rate over the same period of time. However, neonatal survival has improved during these decades. These observations have lead to the hypothesis that increased survival of premature, neurologically impaired infants may have masked an actual reduction in cerebral palsy among term infants as a result of the use of electronic monitoring and the avoidance of intrapartum asphyxia. A review of the medical literature, as well as a demographic analysis of term and preterm birth rates in the United States, refutes this hypothesis on four grounds. First, cerebral palsy prevalence has been separately analyzed in term infants and shows no change over 30 years. Second, the prevalence of cerebral palsy is the same or lower in underdeveloped countries than in developed nations; in the former, the availability of emergency cesarean delivery based on electronic monitor data is limited or absent. Third, the increase in prevalence of cerebral palsy among low-birth-weight infants and the increase in cesarean sections based on presumed fetal distress were not simultaneous events - the former preceded the latter by a decade. Improved neonatal survival since the 1980s has been associated with a stable or decreasing rate of neurologic impairment and thus could not have obscured improvement from reduced term asphyxia. Finally, compared with the number of infants born by cesarean section for fetal distress, there are simply not enough infants born in the most vulnerable weight groups to make any impact on even a minimal improvement of outcome in the group delivered by cesarean section for presumed fetal distress. Except in rare instances, cerebral palsy is a developmental event that is unpreventable given our current state of technology.