Nursing News:
Mystery surrounds increase in rate of premature births

by Warren King
When Morgan Thomas arrived in this world ‹ red, fragile and on the edge of survival ‹ it was almost too much for her young parents to comprehend. Born nearly four months early and weighing 1 pound, 9 ounces, she was so premature that her mother, Rhonda Thomas, did not recognize her labor was beginning with a dull ache in her back. The first-time mother had not started childbirth classes. Morgan, at 12 inches, was the tiniest, most fragile of beings: Her eyes were closed tight, her ears just tiny flaps, and her skin so translucent that her blood gave her a purplish hue. ³It was very scary and so unreal. ... We couldn¹t believe this was actually happening,² says Thomas, 34, in the living room of her Arlington home.
Morgan, still small as she approaches her third birthday, is mostly healthy but is monitored for a chronic lung problem. No one knows whether she will develop learning problems, common among children born prematurely. Statewide, the proportion of premature births ‹ less than 37 weeks gestation (average term is 40 weeks) ‹ rose from 8.5 percent to about 10 percent over the past decade. That¹s less than the U.S. average of 12 percent but is still more than 8,100 infants a year born too early, many in grave danger. With their underdeveloped bodies and brains, such infants, especially the earliest, may face a variety of lifelong consequences, including cerebral palsy, mental retardation, chronic lung disease, blindness or deafness. More than half of the babies born before six months gestation die within weeks of birth; prematurity accounts for nearly a quarter of all deaths in the first month of life.
When they do survive, ³It is a horrible struggle ... and it is horrendous stress for the family,² says Dr. David Woodrum, a University of Washington professor of pediatrics who has treated the tiniest of babies for more than 30 years.
Human suffering is not the only cost. Based on federal research, the March of Dimes, which focuses on preventing birth defects, estimates the national bill for preemies¹ hospitalizations is $13.6 billion a year. The average hospital stay costs $75,000, compared with $1,300 for an uncomplicated birth. State officials estimate inpatient and outpatient hospital care is $216 million a year. Major risks for premature delivery
€ Multifetal pregnancy (twins, triplets, etc.)
€ A past premature delivery
€ Certain uterine and cervical abnormalities Other risks for premature delivery
€ High blood pressure, diabetes, obesity, clotting disorders or other chronic illnesses
€ Certain infections during pregnancy
€ Cigarette smoking, alcohol use or illicit-drug use during pregnancy Signs that labor is beginning With any of these warning signs, pregnant women should call their doctor or midwife or go to a hospital. Sometimes, drugs can be given to stop or delay delivery.
€ Contractions every 10 minutes or more
€ Vaginal discharge of pink or brownish fluid
€ Feeling that the baby is pushing down
€ A low, dull backache
€ Cramps
Source: March of Dimes
No one fully knows why the number of preemies continues to rise. The March of Dimes has launched a $75 million campaign to fund research and educate pregnant women about premature labor. Its goal is to cut the premature birth rate 15 percent by 2007.
Preventing early births has long been a goal of researchers and clinicians. They are encouraged by the limited success of new treatments with progesterone for the highest-risk pregnancies. But the causes of prematurity remain a mystery. About half of the women who deliver early have no known risks; most of those identified as high risk deliver on time. ³We have poor predictive abilities. We haven¹t understood prematurity well in the past, and we still don¹t,² says Dr. Tom Benedetti, a UW professor of obstetrics and gynecology and an expert on high-risk pregnancies.
The stuff of nightmares
Rhonda Thomas was a smoker, and studies suggest smoking may increase risk of a preterm delivery by about 25 percent. But she was healthy, and her doctors, though they urged her to quit, were not overly concerned because she had none of the other risk factors. When the first twinges of labor came on a Thursday evening in April 2001, Thomas thought they were aches from a back problem. But the next day, there was no question she was in labor. Physicians put her on an intravenous infusion of magnesium to slow labor and quietly outlined the dangers to her baby. Morgan had a 30 percent chance of dying. She could end up with any or all of the complications, the doctors said. ³It was basically everything you have nightmares about when you think about having a child,² says Rhonda¹s husband, John Thomas, 32, a mechanic for the Monroe Fire Department.
A team of 12 doctors and nurses attended the birth Sunday. Three short cries, and Morgan had a breathing tube in her throat and was headed to her home for the next three months: the neonatal intensive-care unit at UW Medical Center. The Thomases were numb. Driving home from the hospital the next day, they talked about possible complications. They refused to consider her dying. ³I won¹t say that I wasn¹t scared, but I never doubted she would survive,² says John Thomas. ³I was too gosh-darned stubborn to accept that our daughter would not survive,² says Rhonda Thomas.
The current research
Scientists can¹t point to any major cause for the increase in premature births. But one frequently cited is the increase in multiple births from the use of fertility drugs and in-vitro fertilization. Multiple-birth babies are more likely to be early and of low weight.
Nationwide, the percentage of such births has risen by a third in 10 years and preterm births by 42 percent, according to the National Center for Health Statistics. More babies also are born to older women, who are more likely to have problems such as high blood pressure or diabetes that can lead to premature births. During the past 20 years, the birth rate has more than doubled for women 40 to 44, federal statistics show.
³You think of a 45-year-old woman with years of infertility who now is pregnant ... and has only once chance for a baby,² says Dr. Larry Shields, UW associate professor of obstetrics and gynecology. ³If monitoring shows the pregnancy is having complications at 35 weeks, you deliver that baby.²
Advances over the past 20 years have increased the number of preemies who survive. Underdeveloped lungs, one of the biggest dangers, for example, can function in many babies with improved assisted-breathing devices and use of artificial surfactant, normally a naturally produced substance that helps the lungs inflate. Still, scientists are frustrated with the number of unexplained premature births and their inability to stop many of them ‹ even when they know a woman is at risk. At a recent March of Dimes symposium in Seattle, researchers discussed a range of known or probable causes for prematurity:
€ Infection: Sometimes bacteria normally present in the vagina travel through the cervix into the uterus. Immune-cell reactions lead to the production in the uterus of hormonelike substances that cause muscle contractions. But uterine infections are difficult to diagnose before labor begins, and treatment of vaginal infections doesn¹t always prevent premature birth. So experts generally recommend screening and treatment only in women with other risks.
€ Anatomical abnormalities: These include a short cervix, the neck of the uterus needed to help retain the fetus; a uterus stretched from multiple fetuses; or a uterus divided into two compartments. One technique tried with limited success is cerclage, encircling the cervix with one or more sutures.
€ Stress: Research increasingly implicates emotional stress in preterm deliveries. ³There is really no doubt now that such a link exists,² says Dr. Vivette Glover, an internationally known scientist at Imperial College London who lectured at the symposium. Researchers think some forms of stress cause the release of hormones that trigger labor.
A recent University of North Carolina study of nearly 2,000 women, for example, showed the risk of early delivery increased up to 200 percent if the woman was anxious about the pregnancy, was dealing with disturbing life events or believed she was the subject of racial discrimination. Glover says events or factors typically cited as very stressful included death or serious illness of a close relative, having to keep a job but wanting to quit, losing a job, divorce and having to move.
o Racial disparity: African American women are about 50 percent more likely to deliver preterm babies and twice as likely to deliver babies of low birth weight. No one knows why. Researchers speculate that many of the women may get less care because of socioeconomic factors. The stress of poverty also could contribute. And scientists wonder why about 20 percent of early deliveries in African Americans are linked to infection, compared with 5 percent in white women. Perhaps factors such as genetics and stress cause different immune responses leading to labor, says Dr. Jane Hitti, UW assistant professor of obstetrics and gynecology.
Progesterone offers hope

Promising research published in June showed a 34 percent drop in risk of preterm birth when women who had previously delivered premature infants got progesterone injections. About 36 percent who had the shots delivered before 37 weeks, compared with 55 percent on a placebo. The risk reduction for delivery before 32 weeks was 42 percent. The study involved 463 women at 19 U.S. medical centers. ³These are very exciting results,² Dr. Alan Peaceman, one of the study authors and a Northwestern University obstetrician, told the symposium.
FAMILY PHOTO
Morgan Thomas, born nearly four months premature, spent three months in the neonatal intensive-care unit at the University of Washington Medical Center.No one knows why progesterone works, but some researchers think it relaxes uterine muscles. Many doctors provide the treatment to high-risk patients, though it is not yet approved for that use by Food and Drug Administration.
Difficult first days
There are almost always consequences in the earliest preterm deliveries. Morgan Thomas, whose three months at UW Medical Center cost $300,000, has experienced her share. Her tiny, underdeveloped lungs needed artificial surfactant to stay inflated and more than six weeks of mechanical breathing assistance. The worst, says Rhonda Thomas, was watching her daughter struggle as nurses regularly inserted a tube down her throat to remove fluid. Near her first birthday, a virus so challenged her lungs for two weeks that she needed repeated hospital checks. ³At night, we set the alarm to go off every hour to check on her,² Rhonda Thomas says. ³We worried she could be suffocated.²
Morgan still has a bad time with colds, her damaged lungs congested and crackling with the illness. Her parents worry about pneumonia. But over the years, new healthy tissue will far exceed scarred tissue, and she is likely to have near-normal lung function.
There were other challenges.
At less than 24 hours old, Morgan had a brain hemorrhage that physicians feared would kill her or cause her to be mentally retarded, blind or deaf. She was lucky, and today she tests at her age level in mental development. At three weeks, she needed surgery to close a fetal blood vessel that misrouted blood in her heart, something that should have no long-term effects.
Today, Morgan is a happy, busy girl. She observes and chats nonstop, proudly identifying colors or showing her cat, Scarlet, a newly filled food dish. She gives and receives an abundance of hugs and fills her parents with joy after an ordeal no one except other such parents can really fathom. ³We are stronger, I would definitely say,² says John Thomas, an Army veteran who was wounded in Somalia and faced other challenges. ³There is no such helpless feeling as thinking you might lose your daughter and you can¹t do anything about it.²
Reprinted with permission of the Seattle Times.