Ahead Of Their Time - rise in preterm births

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Ahead Of Their Time

How doctors are rethinking the growing problem of preterm births--by

focusing on the moms, not the babies

By COCO MASTERS / LEXINGTON

http://www.time.com/time/magazine/article/0,9171,1558331,00.html

In the U.S., one of the richest countries in the world, the number of

babies born too early keeps going up--and with all their medical savvy,

doctors can't figure out why. Today nearly 13 out of every 100 births are

premature, an increase of 30% over the past 20 years. Part of that rise is

due to the advent of modern fertility treatments, which caused a sharp

jump in the number of twins, triplets and higher multiples--most of whom

are born early. But it turns out that 83% of preemies in the U.S. are

singletons whose prematurity can be caused by any number of factors,

including bacterial infections, ruptured membranes, cervical

abnormalities, high blood pressure, stress, inflammation and the effects

of smoking and alcohol consumption.

So now doctors are starting to rethink their approach to the problem of

prematurity, which is defined as being born at least three weeks shy of a

full 40-week term. Rather than focusing primarily on the care of the

newborn, they are going back to the beginning of pregnancy and paying a

lot more attention to the health of the mother.

You can see the new approach in action at the University of Kentucky's

Chandler Medical Center in Lexington, one of six hospitals to be named

this week as lead participants in a 3 1/2-year, $1.5 million joint project

aimed at reducing preterm birth, sponsored by the March of Dimes and the

& Pediatric Institute.

What immediately draws your eye at the hospital is the neonatal intensive

care unit (NICU)--where up to 30 babies at a time spend their first days

and weeks tangled in tubes and wires, struggling to keep warm and learning

what full-term babies already know: how to breathe, suckle and swallow.

Zachary Noble is one of the smallest. Born three months early at 1

lb. 7 oz.--as light and fragile as a carton of eggs--he can breathe only

with the help of a ventilator. As he sleeps, his tiny chest heaves and the

translucent fingertips of his right hand open and close over his crumpled

face.

Zach represents what used to be the cutting edge in pediatrics: the heroic

effort to keep younger and younger babies alive. Today neonatal

specialists can ensure the survival of up to 95% of infants born preterm.

But as Dr. Callaghan of the Centers for Disease Control and

Prevention's Division of Reproductive Health puts it, " We're reaching down

to the limits of our viability. " That is why he, like many other experts

in the field, is advocating a shift in focus from survival to prevention.

The change in philosophy comes not a moment too soon. Preterm births

account for more than a third of all infant deaths in the U.S. and cost

Americans $26.2 billion a year. And although many of the half a million

preemies born in the U.S. each year go on to live long, healthy lives, for

too many the problems of their entry into the world are compounded by

long-term complications ranging from mental retardation and cerebral palsy

to hyperactivity and respiratory disorders. " We all bear the costs, " says

Dr. RuthAnn Shepherd, director of the Kentucky department of health's

division of adult and child health improvement.

One of the reasons Kentucky was singled out for special attention is that

its rate of preterm births--1 in 7--is one of the highest in the nation.

The Chandler Medical Center's is even higher, a stunning 27%. But that's

in large part because so many high-risk patients are transported to its

state-of-the-art NICU facility, designed to accommodate the most

vulnerable newborns. Like many other teaching hospitals, the medical

center could be viewed as a victim of its success. But Dr. Ferguson,

chair of the University of Kentucky's department of obstetrics and

gynecology and a seasoned professor who flashes a smile when he says

things you should pay attention to, sees an opportunity in his hospital's

large number of preemies. As part of the March of Dimes project, Chandler

has set a goal of reducing late preterm singleton births 15%.

Taking a cue from earlier interventions that singled out one factor or

another and failed to make a dent in the problem, the March of Dimes is

trying what medical director Dr. Green calls a " kitchen-sink

approach. " Much of its focus is on the nuts and bolts of a healthy

pregnancy: screening for bacterial infections, watching for signs of

domestic violence, discouraging alcohol consumption, encouraging smoking

cessation (1 in 4 pregnant women in Kentucky smokes), monitoring weight

gain and nutritional intake and, when necessary, giving drugs to prevent

preterm labor. Weekly injections of a progesterone-based drug after week

16, for example, can reduce the recurrence of premature births by

one-third.

A major emphasis of the new project is on educating the public about the

dangers of preterm labor--and reminding physicians that a vacation, for

instance, isn't a good-enough reason to schedule an early delivery. The

assumption: if mothers knew the real risks of prematurity, they would be

less likely to request induced labor or a C-section and would stick out

the pregnancy to term.

The project is also focused on the final three weeks of pregnancy, a time

when most mothers-to-be assume they are out of the woods. But as Dr.

Henrietta Bada, chief of neonatology at the University of Kentucky,

explains, those last few weeks in the womb are critical for a newborn's

development. The health risks for a baby born at week 35, she says, are

more like those of a baby born at week 30 than one born at week 37. " The

perception is that a big baby--even if he's premature--is going to act

like a term baby. He's not. "

Nobody understands those risks better than Zach's parents, and Terri

Noble. Terri, 34, suffered from pregnancy-induced high blood pressure, a

condition that can often be treated if caught early enough but that in

Terri's case led to severe preeclampsia and the emergency C-section that

saved her life--and that of her tiny son. His life, she says, " is a

miracle. " The true miracle, however, might be to keep babies like Zach

from being born too soon.

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