Worth the Wait


Rise in Premature Births Reaches Dangerous Levels

Later rather than sooner is the motto doctors want expecting mothers to keep in mind when awaiting the delivery of their bundle of joy. That’s because having a baby born too soon can quickly turn a parent’s joy into sadness far more often than they may realize.

In fact, the Centers for Disease Control and Prevention says that premature birth is now the number-one cause of infant death in the United States. Unfortunately though, early childbirth is becoming much more common. According to the March of Dimes, a leading advocacy organization, one in eight babies is now born too soon in this country — a rate that has increased more than 20 percent since 1990. As a result, many experts are sounding the alarm that premature birth is becoming an epidemic that demands urgent action.

“Preemies,” as such babies are called, not only have a higher risk of infant death but also of long-term health problems, including mental retardation, cerebral palsy, gastrointestinal problems, vision and hearing loss, learning disabilities and attention deficit disorders. The financial costs — both immediate and long term — are also staggering. According to a 2006 Institute of Medicine report, the economic burden of preterm birth in the United States was at least .2 billion in 2005, or ,600 per infant born preterm.

Having a baby born early “is a deeply emotional experience and few parents expect it,” according to Dr. Billie Short, chief of neonatology at Children’s National Medical Center in Washington, D.C. “Their whole life changes.”

During her time at Children’s, Short has seen a significant increase in the admission of premature infants over the last eight years. Children’s, which offers specialized care in its Neonatal Intensive Care Unit, is not a traditional birthing hospital. It treats the smallest and sickest babies born locally or flown in from elsewhere. “We get babies from 40 hospitals, currently about 700 a year, up from 400 eight years ago. Our average has gone from 28 to 43 infants a day,” Short noted.

A national gathering of medical experts and community health workers in Bethesda, Md., in mid-June called for immediate action to halt this alarming rise in premature births — generally defined as a birth that takes place more than three weeks before the due date. Acting U.S. Surgeon General Steven K. Galson convened the group to craft a national action plan for long-term clinical health strategies and new research goals to combat the growing crisis of premature birth.

Conference attendee Dr. Susan Allan of the Oregon Department of Human Services said more research and action to address the problem must start immediately, “but we’re not doing enough with what we do know.”

And unfortunately what doctors do know is not a lot. Although there are known risk factors for premature birth such as smoking, any mother can deliver early, sometimes for no obvious cause.

Nevertheless, there are clues and likely causes behind the rise in early births. One main reason is simply better technology and an increased number of physician “interventions” in risky pregnancies.

According to the March of Dimes, “About 25 percent of preterm births result from early induction of labor or cesarean delivery due to pregnancy complications or health problems in the mother or the fetus. In most of these cases, early delivery is probably the safest approach for mother and baby.”

Three-dimensional ultrasound, which involves running a small hand-held device over a mother’s abdomen and projecting the resulting images onto a large screen, can offer amazingly detailed images of even the smallest fetus in a woman’s womb. It provides cross-section “live video” and instant snapshots of bones and internal organs, including the brain and the chambers of the heart. It can even capture images of tiny waving arms, legs and distinct facial features.

With this type of advanced ultrasound, if problems do develop, the family and medical team can work to decide on the best course of action, which could include early delivery.Dramatic advances in technology can also keep the tiniest preemies alive when they are delivered. For instance, back in the early 1960s, when President John F. Kennedy’s wife Jacqueline gave birth to Patrick, who was born five and a half weeks prematurely, only 50 percent of such preemies survived. Today, the rate is nearly 100 percent, said Short of Children’s Hospital, adding that there are more and more “miracle babies” thanks to today’s evolving technology.

But technological advances can also have a downside. Another leading cause of premature births is the increasing use of fertility treatments that can result in twins, triplets or more multiple sets of babies, which are likely to be born smaller and earlier. In part related to the increase in fertility treatments, older maternal age and delayed childbearing — a worldwide social change — also increases the risk of preemies, a trend that is likely to continue.

In addition, certain medical conditions in the mother, including cervix abnormalities, diabetes and high blood pressure, have been linked to early birth and potentially sickly babies, as has the use of cigarettes and drugs (including alcohol). General stress and toxins in the environment, along with some sort of genetic-environment interaction, may also play a role.

Another problem mentioned at the surgeon general’s conference is one not many people like to admit to: early deliveries done for maternal or physician convenience — i.e., timing a caesarean section or inducing labor to fit a certain schedule. “We’re dead set against it,” one registered nurse at the conference said, emphasizing the need to discourage such trends through aggressive patient and physician education efforts.

New data about the hazards of even a “late” premature birth relatively close to the due date explain why such efforts are urgently needed. The June conference highlighted some of these lesser-known risks, pointing out that although babies at the 34th to 38th week of pregnancy can look much like full-term infants, looks can be deceiving.

Compared to babies born within the normal 40-week stage, “late preterm babies are six times more likely to die in the first week of life and three times more likely to die in their first year. They’re also twice as likely to die of sudden infant death syndrome,” warned Dr. Ruth Ann Shepherd, a child health director with the Kentucky Department for Public Health, who spoke at the surgeon general’s conference.

“The brain is the last major organ system to develop and the unborn baby’s brain at 35 weeks weighs only two-thirds of what it will weigh at term. We’ve been so concerned about preemie lung function, we’ve missed this,” Shepherd said, explaining that brain white matter increases five-fold from 35 to 41 weeks, and that the cerebral cortex, site of higher brain functions, is only about half-developed at 34 weeks. As a result, motor control, higher-thinking functions, and things such as being able to breathe and suck at the same time are put in jeopardy by these later yet still premature births.

Moreover, even if an infant makes it past the initial stages of development, problems can surface much later on in life. One study found behavior and learning problems in 20 percent of late-term preemies at age 8 as well as an increased risk for attention deficit disorder and developmental delays. “Kindergarten teachers can pick out preemies in their classes by looking at fine motor control and social functioning,” Shepherd noted.

“We closely monitor late-term premature infants,” Short said of Children’s Neonatal Intensive Care Unit, which doesn’t treat these infants like full-term babies, so problems can be immediately picked up and addressed. To prevent the type of long-term problems Shepherd described, Short advised that late preemies not be moved too quickly from intensive care to an “intermediate care” nursery, nor should they be pushed out of the hospital too early.

Other effective prevention and treatment options that are easily available should be put to greater use, urged Allan of the Oregon Department of Human Services. At the conference, she presented an expert-consensus report outlining eight evidence-based “action items” that can immediately reduce the number of premature births and improve preemie survival and infant health.

One obvious recommendation is for expecting mothers to stop smoking. Other “action items” include providing every pregnant woman with an ultrasound scan before the 20th week of pregnancy to clearly determine gestational age and obtain a reliable due date, as well as using only the best practices in all fertility treatments to reduce the frequency of multiples, from twins on up.

Unless demanded by medical emergency, Allan also advised avoiding elective Caesarians before 39 weeks and following the guidelines set by the American College of Obstetricians and Gynecologists for C-sections births. Doctors should also make sure that all high-risk mothers and preterm infants have access to appropriate levels of neonatal intensive care.Finally, Allan’s report said there is evidence that screening pregnant women for drug use and domestic abuse — though controversial — works.

The good news is that most major hospitals, clinics and medical practices are likely to have these guidelines in place, often providing a dedicated setting for high-risk mothers such as those with diabetes.

Shepherd’s Public Health Department in Kentucky demonstrated firsthand how dramatic the effect of practical preventive measures can be. The state combined smoking cessation programs with home visits to high-risk or first-time parents and other education efforts to cut the rates of preterm births in parts of Kentucky to 4.6 percent. And the more visits that were made, the lower the rate went, Shepherd said.

But statistics tell only part of the story. Asked to describe one of her own “miracle babies,” Dr. Short went back to the year 1984, when the ECMO (extracorporeal membrane oxygenation) program at Children’s began putting dying premature and term infants on a heart-lung machine. Today, Short proudly said, “One of our first ECMO babies went off to medical school last year.”

About the Author

Anna Gawel contributed to this report. Carolyn Cosmos is a contributing writer for The Washington Diplomat.