Quotes of the Day
The birth of a newborn IS usually a joyful event in the life of a family. The memory of nine often uncomfortable months — not to mention the intense effort of labor and delivery — begins to fade and the focus shifts to a wrinkled little miracle with 10 impossibly cute fingers and toes. Everyone is trying to decide whether the baby looks more like Mom or Dad. There are smiles all around, and in a day or two the happy family will leave the hospital to begin a grand new adventure at home.
Thankfully, this enchanting scenario remains the case most of the time. But the odds of a healthy start in life quickly begin to fall whenever a baby is born more than a few weeks shy of the typical 40-week-long pregnancy. Premature birth — by which doctors mean at least three weeks early — is the leading cause of developmental disability in children, including cerebral palsy and mental retardation, according to Dr. Eve Lackritz of the National Center for Chronic Disease Prevention and Health Promotion. It is also a significant cause of blindness, chronic lung problems and birth defects.
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Yet, for a combination of reasons — not all of them clear--1 out of 8 babies in the U.S. is born at least three weeks before it is due. Even more alarming, that ratio represents a 27% increase since 1980. Advances in neonatal care have saved many children who might otherwise have died. And lots of babies who leave the intensive-care unit grow up to be healthy, vibrant adults. But no incubator — no matter how high tech — will ever replace the womb. The goal, as doctors and nurses who treat ultrafragile preemies will tell you, should be to keep infants from ever needing extraordinary measures in the first place.
Much of the jump in premature births in the U.S. can be tied to the growing number of multiple births — twins, triplets or more — that result from infertility treatments. If you have one baby, your chance of delivering prematurely is just over 10%, according to Dr. Charles Lockwood at Yale University, and your chance of delivering what is called a very preterm baby (one born before 32 weeks) is less than 2%. But if you have twins, the most recent federal data show, your chance of preterm delivery jumps to 58%, with a 12% chance of very early delivery. With triplets, you have almost no chance of reaching full term and a 60% chance of delivering before 32 weeks.
Specialists in the U.S. often transfer several embryos into the womb during in vitro fertilization (IVF) in hopes of boosting the chance that one of them will "take" and therefore boost their clinic's success rate. Studies suggest, however, that the odds of a successful pregnancy may be the same whether you implant one, two or three embryos. Many European countries have decided to restrict their IVF clinics to one or two embryos per pregnancy. Dr. Lockwood and other physicians think such a limit might make sense in the U.S. as well.
Assisted reproduction isn't the only problem. Doctors have long known that smoking, uterine infection, high blood pressure and a prior history of preterm delivery also place an expectant mother at greater risk of delivering early. They're looking into the possibility that other factors, such as stress, diet (both before and after conception) and inflammation may also play a role. But they have something of a medical mystery on their hands. "Nearly half of preterm births are from unclear causes," says Dr. Nancy Green, medical director of the March of Dimes, which is in the early stages of a five-year, $75 million campaign to address the issue. You can do everything right and still give birth to a premature baby.
Doctors admit that some of their best ideas for preventing early delivery haven't worked very well. A drug called Ritodrine, which was approved by the Food and Drug Administration in 1980, successfully stops preterm labor in many women, but subsequent studies have shown that it has no overall effect on a baby's health or survival. Treating all uterine infections, no matter how mild, also appears to make no difference on the timing of delivery — suggesting that infection is only one stage in a larger, much more complex process. "We've been taking the one-cause-at-a-time approach for 20 years," says Dr. Jay Iams at Ohio State University in Columbus. "But it doesn't work that way." Indeed, many researchers believe they won't really have a good grasp of how to prevent prematurity until they answer an even more fundamental question: How does a woman's body decide it's time to give birth in the first place?
One intervention has shown some promise in early trials of women with a history of premature delivery and no other known risk factors. Injecting these women once a week with the hormone progesterone reduces their chance of delivering early by a third. Researchers still don't quite understand why it works. The placenta produces a lot of the hormone, so it wouldn't seem that adding a little more would make a big difference. The treatment has not been studied in women who are carrying more than one child.
Caution may be in order. No one wants a repeat of the problems that happened with diethylstilbestrol (DES), a synthetic estrogen-like drug that was used in the 1950s and '60s to prevent premature delivery and turned out to cause, among other things, reproductive-tract abnormalities and a rare cancer. Unlike DES, however, progesterone has a long safety record. And it is not being used in the earliest days of pregnancy, when birth defects are more likely to occur. What progesterone doesn't have is a major manufacturer, because the drug is not protected by a patent. Instead it is usually produced in small batches at compounding pharmacies.
Anyone who has ever cared for an extremely premature infant knows the stakes are high. Doctors can sustain a tiny baby with severe bleeding in the brain, with lungs so fragile that even the gentlest respirator can permanently damage them. But should they? "That's when neonatology becomes a difficult and ethically fraught field," says Dr. Myra Wyckoff of the University of Texas Southwestern Health Science Center in Dallas. No matter how you answer the question, surely the best solution is to find a way to reduce the number of extremely premature births from happening in the first place.
- CHRISTINE GORMAN