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 Johnson & Johnson 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 Sean 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. William 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. James 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. Nancy 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, Sean 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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