I continue to slog forward in the writing of this book about prematurity and our experience, and the chapter I’ve been working on the most lately is the one on prevention methods. This is of particular interest to us because if we get pregnant again, we would really like to prevent a repeat of our five-month NICU stay. One of the titles I came up with for our book was “Darth Baby and the Hope for an Easier Sequel,” but Miri told me that was too silly. But, we really are interested in prevention — we’ll resolve to do everything right and be super careful and get really good prenatal care and take control of this problem and not cost the health insurance system $1 million…
Turns out it doesn’t work like that. I’ve been searching through an assortment of articles in medical journals on available prevention methods and there are a couple that are somewhat helpful, and the rest are a mixed bag. The paper that’s got the best summary is the Institutes of Medicine Report titled “Preterm Birth: Causes, Consequences, and Prevention.” It’s both a summary of the current state of research and treatment, and it sets out a national agenda for research on the topic. I’m not sure, but I think when the medical community gets together to do big, long-term plans, this is how they do them. I’ve also looked at a number of individual studies that are cited by the big Institutes of Medicine report. Chapter 9 focuses on prevention.
Here’s a list of some of the things I’ve learned from this:
1. There are two categories of preterm births, “indicated” and “spontaneous.” The indicated preterm births are ones in which there’s an obvious condition causing it, such as preeclampsia, placental previa, gestational diabetes, intrauterine growth restriction, and others. The spontaneous ones are where there’s no particular cause. The indicated preterm births only account for 25 to 30 percent of preterm births, leaving the rest to the spontaneous category.
2. There are a number of risk factors that probably contribute to the spontaneous preterm births. But, if you read the risk factors in the Institutes of Medicine report, you’d go “duh.” Cocaine use is bad. Underweight mothers are at higher risk. Stress is bad, poverty is bad, unemployed women are at higher risk, women having unintended pregnancies are at higher risk, as are women using in-vitro fertilization. Being married is good, having leisure exercise is good, and fish oil seems to be associated with longer gestations. Looking at this list, you could see them as Yet Another Reason that America needs to do something about its poverty problem and its racism problem, and it might get its preterm birth rate down from the 11-13 percent range to the 8-10 percent range, where the rest of the industrialized world is. But, these risk factors don’t really get at the larger (mostly unknown) medical problems that are causing preterm births.
3. There’s a mystery about weight. Several studies have made ultrasound estimates of the weight of fetuses at various stages of development, and then compared them to the weights of preemies at their respective gestational age. The preemies come in consistently lighter than the fetuses that go on to make it to term, and researchers don’t really know why. In the spontaneous births, has there been some unknown illness lurking in there that’s causing the babies to be smaller? Maybe some day we’ll know.
4. More prenatal care isn’t going to help, at least not until they change prenatal care. That’s because prenatal care was designed around preventing and detecting preeclampsia. Going after preeclampsia is certainly a good thing, but it focuses in on blood pressure. Preterm labor, on the other hand, is believed to be related to the uterus and cervix being unable to deal with the stretching involved with pregnancy, or has to do with chemical processes that set off an inflammatory response, or has to do with hormonal issues that make it difficult to maintain the pregnancy. So, we wondered, what would prenatal care look like if it were designed around preterm labor, too? This is where the Institute of Medicines report does its maddening thing and say “more research is needed.” Argh.
5. There’s all this stuff you’d think would help, but it doesn’t. There have been studies of nutritional supplements, antibiotics, cervical cerclage (a stitch in the cervix), nursing visits, progesterone supplements, educating mothers to self-detect contractions, and bed rest. The only one that seems to have any effect is the progesterone supplements, which have been shown to reduce preterm birth by one third. (More on that later.)
6. Studies on preterm labor are generally boggled by the difficulty of diagnosing it. Real preterm labor and false preterm labor often look like each other, so if you do a study on preterm labor, you’re going to get a lot of women in it who are not really having preterm labor. One study estimated that there was a 40 percent false positive rate for diagnosing preterm labor. This fits with our experience in antepartum — at first they called it preterm labor, then they called it cervical incompetence, then they went back to calling it preterm labor, and then we got the impression that they really didn’t know what it was.
7. Progesterone is called “the pregnancy hormone,” and it’s one that increases in the woman shortly after ovulation, and remains up until menstruation begins, or if she gets pregnant, for the remainder of the pregnancy. Progesterone is a hormone that convinces the uterus and cervix to not contract during pregnancy, and it’s believed to suppress the woman’s immune responses. There is this drug called 17 alpha hydroxyprogesterone coproate that a study published in the New England Journal of Medicine in 2003 found could reduce preterm birth in at risk-women from 55 percent to 36 percent.
8. There’s also the possibility of a cerclage, or a stitch in the cervix, that has a mixed bag of results. Some studies have found that there was a reduction in the number of preterm births, while others have found that there isn’t. The American College of Obstetricians and Gynecologists recommends that if a woman has a prior preterm birth, she should receive progesterone supplements. If she is then detected to have a shortened cervix, then a cerclage can also be given. Studies have shown a reduction in preterm births when that two-step process is followed, but giving a cerclage to all high-risk women doesn’t seem to be effective.
9. While this research is helpful, progesterone and the cerclage can only get preterm birth risk down to one in four for high-risk women, which is kind of depressing for us, having had a 22 week – 6 day preemie.
10. One bit of hope is that some of the studies that said that the cerclage doesn’t reduce preterm birth did point out that they do still seem to have the effect of adding a couple of weeks to a pregnancy, which would have made a huge deal for us. As we made friends with other parents in the waiting room of the NICU, we were awfully jealous of the parents of 28 weekers and 29 weekers. Certainly, their babies had lots of issues like Gabriel did, but once they overcame those issues, they moved downstairs to the step-down unit so quickly. We were stuck in the NICU for three and a half months, and then in the special care unit for a month and a half, but the more mature babies got through in a month or so. Gabriel was the senior baby of his room, with two or three classes of babies recycling completely before he graduated to the second floor.
So that’s what I’ve learned on prevention. Now back to work on the manuscript, that big ugly project. And then I need to make a book proposal, find an agent, write some articles to magazines, etc., etc. A writer’s life is not easy.