Pregnancy, Prematurity and Pumping

First up — I was invited to do a guest post on the “Breastfeeding with Comfort and Joy” blog on my experience with pumping breastmilk for someone else’s baby. The post was inspired by this video, entitled “Prescription Milk,” which focuses primarily on the importance of babies — particularly premature babies — getting human milk for their nutrition.

It was so touching that the mother featured in the trailer chose to celebrate and memorialize her daughter’s brief life, by continuing to pump milk even after her own baby died, so that other babies might live.

My personal experience was that I had over-supply issues, so being able to pump extra was a blessing, instead of having to try to minimize my production. Some mothers may not be able to pump enough milk to feed their babies, but there isn’t enough donated milk to supply all the babies who need it. If you are currently pregnant or breastfeeding, or know someone who is, please look into becoming a milk donor through the Human Milk Banking Association of North America, your local hospital, some other organization, or (like I did) just giving a friend bottles or bags of milk. You have to be screened to make sure you aren’t carrying any diseases that may be transmissible through breastmilk, so get started on the process as soon as you can.

Pregnancy is the perfect time to start preparing yourself for breastfeeding. The best way to do that is to talk to women who have successfully breastfed, and watch women breastfeed. I emphasize, “successfully breastfed,” because so many women tell horror stories of how awful breastfeeding was, and how they ended up with sore, cracked, even bleeding nipples, or how they “tried to breastfeed, but I never could make enough milk,” or some other unsuccessful breastfeeding experience. You wouldn’t ask a poor man how to become a millionaire; you wouldn’t ask a teenager for tips on a successful marriage; and you definitely wouldn’t ask me for tips on how to run fast or throw a baseball. 😉 You would instead seek out someone who had been successful in whatever it is you were wanting to succeed. Likewise, don’t ask someone who had a horrible time breastfeeding for breastfeeding tips (even if the lactation person she saw at the hospital said she was doing everything right, or she is otherwise sure she did what she was supposed to do). Or if you do, don’t be surprised if you, too, have a horrible time breastfeeding! Instead, seek out those who had an easy time, who were successful, who had no pain, who nursed as long as they wanted to (and/or longer than they expected). If you don’t know anyone that fits that description, or feel awkward asking to watch them as they nurse their babies, don’t despair! There is a book filled with beautiful and intimate breastfeeding images, along with clear and simple text, to help you see what a good latch really looks like and how to achieve that.

Get the book now, while you’re still pregnant, read the text, study the pictures, take it with you to the hospital (or just keep it at your bed-side table if you’re having a home birth), and start breastfeeding off not just correctly but confidently. As World Breastfeeding Week draws to a close, let’s not just celebrate breastfeeding, but help support women as they breastfeed, and remove hindrances that would keep them from success.


Update — I just noticed that WP has added a “like” feature to posts — that’s cool! 🙂

Fantastic Kangaroo Care and Skin-to-Skin Contact Resources

One of my friends emailed this to a childbirth educators list I’m on, and I thought it was fantastic, so wanted to share with others.

First, is a Power-Point presentation (in pdf format) from  Dr. Bergman on the importance of skin-to-skin contact for full-term newborns, and even greater importance of kangaroo care for preemies. Drawing on developmental curves of other mammals, Dr. Bergman points out that humans are basically born immature — dogs, cats, monkeys, etc., are all born more highly developed (as measured by percentage of brain growth, etc.); and preemies are born more on the “marsupial” level of immaturity and prematurity. Animals are born with brains that are 80% of the size of adult brains; humans are not. Based on brain development (as a percentage of the adult size, compared to newborn/adult brains of animals), humans don’t reach the 80% marker until about a year after full-term birth. When born premature, they are even less that. The presentation presents powerful and compelling arguments for attachment parenting concepts (such as, sleeping with the baby, carrying the baby in an infant carrier on the mother or father, breastfeeding on demand, skin-to-skin contact, not crying it out which can be harmful, etc.), and even stronger arguments for “kangaroo care” for preemies.

The second resource is the Kangaroo Mother Care website which has even more links, stories, research, etc., on kangaroo care and premature birth. Dr. Bergman draws a distinction between “Kangaroo Care” as practiced in U.S. hospitals (“This has been defined as “intra-hospital maternal-infant skin-to-skin contact”. KC is generally started later, and on stabilised prematures, and is used an adjunct to technological care”) and “Kangaroo Mother Care” which in part includes NEVER separating the mother and the baby — if the baby needs additional care, then technology is brought to him, rather than him taken away from the mother to go to the technology.

Dr Nils Bergman was the Doctor who introduced Kangaroo Mother Care (KMC) to South Africa. He has recently published the results of a strict scientific trial (in Acta Paediatrica) comparing skin to skin immediately after birth to incubator care . What he found was that skin to skin care was much better for the newborn than the incubator. Babies were warmer and calmer, breathed better and had a more stable heart rate with skin to skin care.

Surprisingly, the smaller the baby was-down to 1200grams- the more stable they were, and the more unstable in the incubator! This is opposite to what people think!

In fact there is other research suggesting that the incubator is harmful! Babies’ brain development requires skin to skin contact and being held and carried, and eye to eye contact to form the right brain pathways. Depriving babies of this skin to skin care makes alternative stress pathways which can lead to ADD, colic, sleep disorders etc.

Surprisingly incubators are still used for the very reason of stabilizing the baby when they in fact do the opposite!

There is a lot of information on the website, and I can’t do it justice, so just explore it for yourself, share with friends, and remember for future reference. Although the following story is anecdotal (although if a doctor wrote it, it would not be a mere “anecdote” but would be a “case study”), this woman saved her baby’s life by instinctively picking her up and putting her on her chest. The baby was born at 24 weeks gestation, weighing 20 oz (566 grams), and doctors didn’t believe she would live — her heart was beating only every 10 seconds and she wasn’t breathing.

She said: “I didn’t want her to die being cold. So I lifted her out of her blanket and put her against my skin to warm her up. Her feet were so cold.

“It was the only cuddle I was going to have with her, so I wanted to remember the moment.” Then something remarkable happened. The warmth of her mother’s skin kickstarted Rachael’s heart into beating properly, which allowed her to take little breaths of her own.

Miss Isbister said: “We couldn’t believe it – and neither could the doctors. She let out a tiny cry.

The baby was eventually taken and put on a respirator, but “Her heart rate and breathing would suddenly sometimes drop without warning” — which reminds me of one of the graphs in either the PDF or the website — that the baby’s heart rate and breathing and temperature were all more stable and regular when on the mother than in an incubator.

I don’t think that this doctor is suggesting that the only thing a premature baby needs, no matter how early it is born, is to be put on his mother’s chest — after all, he pointedly says that technology needs to be brought to the mother-baby when needed. But what if the interventions that are currently being done on premature infants are actually harmful, or at least, would be more helpful if the baby is on his mother’s chest (unless that is totally impossible). Yes, I’m sure there is a ton of research showing that babies receiving the current standard of care do better than babies in a “control group” — but what if standard interventions done on the mother’s chest were vastly superior than standard interventions done in a plastic box?

As an example of what I’m angling at, consider a hypothetical research project: babies are born, and divided into two groups — the first group is put in an orphanage where their physical needs are met (they are fed, clothed, and given diaper changes) but are basically kept in cribs all the time. The second group is put in a different orphanage where their physical needs are met and they also receive some social interaction, playing with other orphans and also sometimes the caregivers who are not as overwhelmed and busy as in the first orphanage. Obviously, the second group is likely going to do much better. However, neither of these settings is natural or normal — consider that there is also the possibility of babies not taken from the mother at all, but are given the level of maternal care and attention that you and I take for granted — breastfed, lovingly held and cared for, played with on a one-to-one basis, read to, etc. (in addition to the basic physical needs being met). Don’t you think that this third group would greatly excel either of the first two groups? Of course! So, is it not possible that our current standard of care, while better than that of the 70s or 80s, still pales in comparison to what might be possible if the technology (breathing assistance, drugs, fluids, nourishment, etc.) were done in the context of kangaroo care, rather than KC being more or less an afterthought?

“First, do no harm.” If, as that newspaper article demonstrated, it could shown that a mother’s natural inclination is to hold her premature infant on her chest, and that it holds some benefit to the baby (in this case, warming her, starting her breathing, and regulating her heartbeat), then that should be promoted — not necessarily at the expense of technology that has also been proven beneficial, but in conjunction with that technology to attain even better outcomes.

Several months ago, Reality Rounds posted a couple of heart-wrenching posts. She got a lot of flak, too, for it — all of it undeserved. I’m linking to them so that you can get a better idea of what’s involved in extremely preterm birth care; but, as my mother always says, “If you don’t have something nice to say, don’t say it at all.” First, “For they know not what they do” — which describes the extreme fragility of tiny babies, and the great caution the NICU team must employ not to hurt the baby as they try to help and save the baby:

We do everything.  Dry the infant with towels.  Careful.   Not too rough.  Do not want the gelatinous, friable skin to break and bleed unto the blankets. Listen for heart sounds.  Heart rate is barely 60 beats per minute.  No need for chest compressions.  We breathe air and oxygen into the tiny lungs.  Careful.  Too much air can blow a hole in the tiny lungs.  Too much oxygen can cause lung damage and blindness. We walk the wire.

It must be so extremely difficult to do everything that can be done to save the babies, knowing that it is hurting them physically (needles hurt! and worse for preemies — not to mention everything else). I liken it to what nurses in burn units must go through, as they try to save people who are badly burned — knowing that what they are doing, while necessary, is torture. And that even in the best of circumstances, the patient will endure untold pain, and be scarred for life — perhaps even unrecognizably scarred, perhaps losing fingers or toes or arms or legs. And perhaps when all is said and done and the patient is released to go home, he may even wish himself dead. Yet some people beat the odds and their injuries are not as life-altering or as scarring as they might have been; and many people are glad to be alive. But some people die in burn units, in spite of all the care given; and nurses and doctors must occasionally feel guilty that they did not “let nature take its course,” because then the person’s pain would have been shorter — when people die despite the best care given them, and die in pain, we can say in retrospect that it “would have been better” for them to have had no care at all and died quickly, than to have had their pain dragged out over days and weeks. But until we have a crystal ball to know which ones will have good results and which will not, we have to take care of them all.

The second post is NICU is a war zone — stressful for the parents, stressful for the baby, stressful for the workers. Finally, “Is letting a 21-week baby die health care rationing?” which includes the following paragraph on “Benevolent Injustice”:

I have cared for many infants at the edge of viability.  It is always emotionally draining.  There is no justice to it.  The extreme measures involved to keep a 22-23 week infant alive is staggering, and it is ugly.   I once had a patient who had an IV placed on the side of her knee due to such poor IV access.  When that IV infiltrated, I gently pulled the catheter out, and her entire skin and musculature surrounding the knee came with it, leaving the patella bone exposed.  I have seen micro-preemies lose their entire ear due to scalp vein IV’s.  I have watched 500 gram infants suffer from pulmonary hemorrhages, literally drowning in their own blood.  I have seen their tiny bellies become severely distended and turn black before my very eyes, as their intestines necrose and die off.  I have seen their fontanelles bulge and their vital signs plummet as the ventricles surrounding their brains fill with blood.  I have seen their skin fall off.  I have seen them become overwhelmingly septic as we pump them with high powered antibiotics that threatened to shut down their kidneys, while fighting the infection.  I have seen many more extremely premature infants die painful deaths  in the NICU, then live.

I do not claim any knowledge much less prowess in the field of premature birth. I do not blame anyone for allowing their extremely preterm baby die a natural death, rather than be subjected to these procedures. Nor do I blame parents who request that “everything” be done to save their babies. But care for premature babies is heart-wrenching either way, and painful. But what if there is a better way? I don’t know if this Kangaroo Mother Care extends to the micro-preemies, or there is some sort of cut-off point where it no longer helps — previously, I quoted that “babies down to 1200 grams” did better with KMC — which is about 2.5 pounds, and probably all late-second or early-third-trimester, much bigger than 20-23 week babies, for the most part (which is primarily the focus of the above blog posts). But what if current care is like the hypothetical orphanage study above — better than nothing, but not as good as kangaroo care in conjunction with life-saving interventions.

Sr Agneta Jurisoo studied what little literature was available on KMC during 1987. The following year she and Dr Bergman arrived at a small mission hospital in Zimbabwe, where premature births were common. There were no incubators, poor transport over great distances, and overloaded referral centres: only one of ten premature babies survived.

In the absence of incubators, they started a care plan in which the mother became the incubator. Instead of waiting for the baby to “stabilise”, the mother was used to stabilise premature infants immediately after birth. It was immediately clear this was highly effective, no matter how small or how premature, stabilisation took a mere six hours. With this care, now five of ten very low birth weight babies survived.

One problem is that current care is so entrenched, that it is very scary (and may even seem to be malpractice) to make the huge paradigm shift from taking the baby away from the mother for care, to putting the baby on the mother for care. Obviously, doctors and nurses are trained to take care of the baby alone, in an incubator — much like doctors are trained to have the mother on her back with her legs in stirrups when she gives birth. It can be very disorienting to have the baby come out “the wrong way” when the mother is on hands-and-knees or is squatting or kneeling. In the same way (only much, much bigger), it will take someone with a lot of guts to bring the NICU to the mother-baby pair, instead of taking the baby to the NICU. Who am I kidding? — it is a big shift to have full-term healthy babies put directly on the mother’s chest and kept there, instead of being put almost immediately into the warmer. Technology is very deeply entrenched in normal births and normal postpartum, and much more so in premature births! But “first do no harm” — first make sure that what you’re doing that is not physiologically normal (taking the baby from the mother) is going to first be not harmful, and second be beneficial. Certainly, there are times when babies need immediate surgery or other care that is not feasible or practical to be done on the mother. But I think steps need to be taken to keep mothers and babies together, if possible.

Iatrogenic Prematurity

This month is Prematurity Awareness Month, and although I missed the “calling all bloggers” Prematurity Awareness Campaign for Nov. 17 [I just didn’t feel like writing about it — sorry — nothing “sparked” in me at the time], since that time, I’ve gotten “sparked” about iatrogenic prematurity. If you’re unfamiliar with the term, it just means “doctor-caused” prematurity.

The March of Dimes is the main organization leading the Prematurity Awareness campaign, but I have to admit to being a little perturbed that they didn’t speak more strongly about the one cause of prematurity that could be most easily changed — iatrogenic prematurity, caused by elective inductions and C-sections.

It’s possible that “iatrogenic prematurity” might include necessary or beneficial cases of babies born by induction or C-section too soon — for instance, a baby who suddenly stops moving at 34 weeks and is obviously compromised. But for my purposes, I’m restricting it to medically unnecessary inductions and C-sections.

Here is one link: Why do women deliver early? Did you catch the discussion on elective inductions and C-sections? No? Not surprising — it receives only the briefest of mentions. However, this March of Dimes article, “Why the last weeks of pregnancy count” does dwell on the topic a bit more. Elective C-sections and inductions are (thankfully!) not one of the four main causes of prematurity, but iatrogenic prematurity could be stopped tomorrow. And I think that’s important to note.

Some doctors have a laissez-faire attitude about inductions and C-sections, and have no problem with either as soon as the mom hits 37 weeks. Perhaps that attitude is changing a bit, since research has demonstrated that infant outcomes are much worse in several different areas if the baby is born unnaturally at 37 weeks, compared to 38 and especially compared to 39 weeks. [And when I say “unnaturally,” I’m meaning, by induction or C-section — babies born to women who go into labor naturally at 37 weeks do as well as those born at 38 and 39 weeks, naturally — it’s the unnaturally early births that are the problem. When the woman goes into labor, that is an evidence that her baby is actually ready, as opposed to having reached some arbitrary date on the calendar.] Some doctors may even do an elective induction or C-section at 36 weeks. I read a story some time ago about a woman who had a late-term fetal demise in her first pregnancy, so opted for an elective induction at 36 and a half weeks. She thought he was ready “enough” — that it was “close enough” to term for him to be born. Her baby was in the NICU for 6 weeks, and had long-term health problems (mostly related to his lungs and breathing), because he was not ready.

A woman’s dates can be off, which could really cause problems with her baby, if she electively induces or has a C-section at 37 weeks (or even later). What if her little one would have been born naturally at 41-42 weeks? That’s 5 weeks early. And if her dates are off, it may be even earlier. There’s a lot of brain, lung, and body development that happens in those last few weeks, that ought not be circumvented without an awfully good reason. Although rare, “superfetation” — conceiving a second baby many days or even a month after the first baby was conceived — is also a possibility, as Abby Epstein found out. What if she had gone by “I thought I was pregnant a month ago,” even though that baby died, and her later-conceived baby lived? Perhaps they were conceived at the same time, and this was just “vanishing twin,” but perhaps some of these super-long gestation times one occasionally reads about were actually due to undiagnosed superfetation with a hidden/missed miscarriage. Could happen. I remember in reading through some of the causes of death listed on the CDC linked birth-death certificates, that one hospital-born baby born at 42 weeks died due to “extreme prematurity.” It could be a typo — perhaps it should have been “24 weeks”; or maybe the code was entered wrong. Or maybe the mother’s dates were miscalculated. Or maybe she happened to skip a period prior to conception, so she thought she was at 42 weeks, when she was 6-8 weeks earlier. I wonder, though, if she was induced because she was “42 weeks” and her baby was nowhere near ready. Unlikely, but possible.

Then there’s this little gem of an article: Many Women Miscalculate Time to Full-Term Birth. One paragraph reads,

“About one-quarter of new mothers surveyed in the study considered a baby born at 34 to 36 weeks of gestation to be full term, while slightly more than half of women considered 37 to 38 weeks full term.”

Only problem is, that’s not what the question was. Here’s the actual question (also from the article):

“What is the earliest point in pregnancy that it is safe to deliver the baby, should there not be other medical complications requiring early delivery?”

It didn’t say “when is full term?” It asked “when is it safe?” Ok, so define “safe”. Most babies will do fine born electively at 34 weeks. Obviously, not all will — some will die that would have lived; of those who live, some will have long-term negative effects related to their prematurity. If safe is some sort of “beating the odds” — well, 90% of babies born at 30 weeks survive, and the odds go up every week. Many (perhaps even most) of these babies will not suffer long-term negative effects (like cerebral palsy, blindness, etc.) which used to be so common at this age, but now are more common with preemies born at earlier gestational ages; and the risk goes down with age. Even fewer babies born at 37 weeks will have problems, than those born at 36, 35, or 34 weeks. Does it mean it’s “safe” for them to be electively induced or sectioned then? Well, sure, compared to preterm babies; but not compared to 38-weekers, or 39-weekers. But again, babies are naturally born at 37 weeks all the time and have no long-term problems compared to babies naturally born at 38, 39, 40, 41, etc. weeks And if a woman goes into labor at 36 weeks, doctors will not try to stop the labor. I daresay that many people would say, “If the doctor won’t stop labor at 36 weeks, then it must be safe for the baby to be born then.” Is that a wrong supposition? Yes, if you’re talking about elective inductions; perhaps no if you’re talking about natural labor.

I will also note that the question was not, “When is the earliest point in pregnancy that an elective induction or C-section should be used?” Had this been the question, I would have answered “never” if that was a possibility 🙂 or else “39-40 weeks,” if that were the latest time frame given. However, in the question that actually was used, I probably would have answered 37-38 weeks, because that’s “term”; or possibly at 36 weeks — if the woman goes into labor at that point, the doctor won’t stop it, after all. Not because it is best for the baby to be born at that point, but because I don’t know if it totally meets the threshold of “unsafe” for the baby to be born early. Not optimum, but perhaps “safe.” Is it “safe” to drive a car? Almost everybody would unhesitatingly say “yes!” but people are injured and killed in car wrecks every day. And some people are injured or killed as pedestrians, who would have lived had they been in a car. “Safe” does not necessarily mean “absolutely no risk,” because as probably everybody over 12 understands, there is almost nothing in life that is completely risk-free.

Although there were several good parts of it, this article was irritating on a few points, including the following:

Misconceptions about what constitutes full gestation and how soon it’s safe to schedule an elective induction or cesarean delivery are contributing to increasing numbers of premature births in the United States, said lead study author Dr. Robert L. Goldenberg, professor of obstetrics and director of research at Drexel University College of Medicine in Philadelphia.

Ah, yes — blame the mother! I feel so sorry for these poor spineless doctors who just can’t stand up to the strong woman who demands an early end to her pregnancy, regardless of how much damage it does to her baby. You know how thoughtless and uncaring women are! They don’t give a rip about the baby they’ve just spent the last 8-9 months of their lives growing! Odds are, they’ll leave the baby at the hospital and just walk away!

Ok, so maybe the sarcasm was a little heavy in that last paragraph, but seriously, folks!! It makes me want to scream! Sure, some women are selfish and truly don’t care about their babies — after all, some women abuse alcohol and use illicit drugs while pregnant. But I daresay that if doctors tell most women that their baby will be twice as likely to die (or whatever the actual rate is), if born electively prior to 37 weeks, or even in the early term period, and will be 3-4x more likely to have serious morbidity, that would put a curb on elective inductions. Some women may have legitimate or quasi-legitimate non-medical reasons for induction — husband home from Iraq for two weeks, previous stillbirth in the term period, severe pregnancy discomfort, and maybe others. [The  McCaughey septuplets just celebrated their 12th birthday (I remember because they were “due” the same day my sister was due with her first child), and they were born two full months early. In an interview soon after the birth, their mother, Bobbi, said that she just couldn’t stand the nausea and other side effects of the pregnancy itself and the drugs she was on to maintain the pregnancy. She held on as long as she could, knowing that every day they were inside her, it would be better for her babies; but finally she just couldn’t take it any more. That doesn’t apply to most women.]

So, yeah, educating women about prematurity and the problems babies have when born too early (by the babies’ clocks, even if not by the doctor’s calendar!) will help, because it will likely reduce the number of women wanting an early end to their pregnancy, and those who look at their due date as an expiration date. But women could not induce if doctors did not allow it! Inductions and C-sections don’t schedule themselves. Last time I checked, women can’t call the hospital and set up an induction or C-section without their doctor’s approval. They also don’t perform themselves — doctors (and nurses) have to perform an induction or a C-section. So, why does this article have such a strong tone of “it’s all the women’s fault!”?

I’ll say it again — iatrogenic prematurity could be stopped tomorrow, if doctors wanted to.

What’s the Rush?

Reality Rounds has been posting on different issues with her role as a NICU nurse, and a recent comment inspired this post. The post itself was on the realities of prematurity, and the struggles that the babies (and their parents, nurses, and doctors) face when they’re born too soon.

The comment was from a mother whose two children were both born early — at 30 and 31.5 weeks. She relates:

As a side note, one day when my second was still in the NICU, I was taking the elevator up to the NICU floor and another NICU mom was in there with me. There were a couple of pregnant women going to see their OBs on a higher floor and they were lamenting that they wished their babies would just come *now*. As the elevator doors opened at the NICU floor, the other NICU mom and I gave each other knowing looks and as we walked out the door, we simultaneously said “No, you don’t.”

Yes, indeed! I remember what it’s like to be “great with child,” getting anxious for the pregnancy to be done, to meet the baby, to no longer have him kicking you 24/7, to get your body back, to not have your back hurt any more, etc., etc. But you don’t really want your baby born too soon!

I think it may would probably cut down on the numbers of elective inductions (and requests for early inductions or C-sections that are not medically indicated), if women were to be given a tour of the NICU sometime in their second trimester (much like they might take a tour of the L&D unit prior to giving birth), so that they could see the realities of premature birth. And it doesn’t even have to be really preterm birth — even slightly preterm may have problems, as At Your Cervix attests:

A [fetal lung maturity] test was done and showed “mature” levels for a recent “near term” gestation infant. Baby was delivered. Guess what? Baby had respiratory distress shortly after birth and was sent to the NICU. Baby was NOT ready to be born. The lungs were NOT fully ready for life outside the confines of his former uterine home. One can only wonder how much brain growth and development was also lost, from not having the last few precious weeks in the womb.

[Make sure you read all the comments at AYC, especially “Lonely Midwife.”]

Plus, there is research to show that babies born by elective C-section at 37 weeks have double the risk of problems as those born at 38 weeks; and the 38-weekers have double the problems of those born at 39 weeks. So, what’s the rush?!?

I don’t know. Have we gotten so arrogant, that we are doing what Jeff Goldblum’s character said in Jurassic Park? — “Your scientists were so preoccupied with whether or not they could, they didn’t stop to think if they should.”

Obviously, doctors will not induce before 36 weeks for no maternal or fetal indication. At least, I hope that would not be the case! So, it’s not like most preemies are intentional. Yet, if a baby is born before his due time, but is born just because “well, it’s term, and you’re tired of being pregnant, so why not?” he will likely have complications that he would not have had, had birth started naturally. While the worst and most difficult NICU stays are likely to be unavoidable, there are some that could be avoided — like the one AYC mentioned — by waiting on nature. What’s the rush?

Pollution and Prematurity

Since September is National Infant Mortality Awareness Month, and since 67% of infant deaths in the first year occur in babies born prematurely, if we can lower the premature birth rate, we can lower infant mortality.

In June of this year, a new study was released, which showed a higher rate of preeclampsia and preterm birth among women who lived within 2 miles of the busy Southern California interstate system. Here’s the full study.

Background: Preeclampsia is a major pregnancy complication leading to substantial maternal and perinatal morbidity, mortality, and preterm birth. Increasing evidence suggests air pollution adversely affects pregnancy outcomes. Yet, few studies have examined how local traffic generated emissions affect preeclampsia in addition to preterm birth.
Objectives: Examine effects of residential exposure to local traffic-generated air pollution on
preeclampsia and preterm delivery.
Methods: We identified 81,186 singleton birth records from four hospitals (1997-2006) in Los
Angeles and Orange Counties, California. We used a line-source dispersion model (CALINE4)
to estimate individual exposure to local traffic-generated NOx and PM2.5 across the entire
pregnancy. We used logistic regression to estimate effects of air pollution exposures on
preeclampsia, preterm delivery (PTD, gestational age <37 weeks), moderate preterm delivery
(MPTD, gestational age <35 weeks), and very preterm delivery (VPTD, gestational age <30
Results: We observed elevated risks for preeclampsia and preterm birth from maternal exposure to local traffic-generated NOx and PM2.5. The risk of preeclampsia increased 33% (odds ratio (OR) =1.33, 95% confidence interval (CI): 1.18–1.49) and 42% (OR=1.42, 95% CI: 1.26–1.59) for the highest NOx and PM2.5 exposure quartiles, respectively. The risk of VPTD increased 128% (OR=2.28, 95% CI: 2.15–2.42) and 81% (OR=1.81, 95% CI: 1.71–1.92) for women in the highest NOx and PM2.5 exposure quartiles, respectively.
Conclusion: Exposure to local traffic-generated air pollution during pregnancy increases the
risk of preeclampsia and preterm birth in Southern Californian women. These results provide
further evidence that air pollution is associated with adverse reproductive outcomes.

What can be done about this? Not really sure. Move? Try to avoid the freeways, and use the car’s air conditioning system so the air goes through the filter (the researchers’ suggestion). Have a lot of plants in your house, if you live close to a high-traffic or high-emissions area? Perhaps get a personal air purifier?

It’s interesting that only about 60 years ago, doctors “knew” that the placenta acted as a barrier to protect the fetus (which it does… partially), so they gave drugs to mothers under the assumption that the baby could not be hurt. The nausea drug Thalidomide vividly proved them wrong (images of babies born after their mothers took Thalidomide here). Now, doctors are rightly concerned about the air we breathe.

Reducing Infant Mortality

Unfortunately, I can’t embed the video in WordPress, so you’ll just have to click here to watch this free 15-minute video on reducing infant mortality. The thing that struck me the most was the woman with the “MD, JD” after her name that taught at UCLA, saying something about there being the midwifery model of care and the medical model of care — that women need to know that there are two models, and then saying, “But why are there two models? We should see which one works better, and then move toward that one.” Yes, indeed.

Obviously, some women will actually need the medical safety net, but why does midwifery care often get the short shrift?

Op-Ed Piece on Elective Cesareans

This opinion piece was written by the CEO of UnitedHealthcare of New Jersey, a health insurance carrier, on elective C-sections and NICU admissions, etc., which I’ve blogged about previously, and I’ve seen it blogged about extensively on other blogs.

I’ll pull a few quotes from here, but I urge you to read the whole thing [any bold or italics will be mine]:

It turns out that in an audit of all UnitedHealthcare-insured ba bies admitted to the NICU in one market, 48 percent of all newborns admitted to NICU were delivered by elective admission for delivery including scheduled C-sections (cesareans), many taking place before 39 weeks of pregnancy, or full term.

Note that “elective admission” includes scheduled C-sections as well as inductions of labor — inductions which may ultimately have failed and then required a C-section to complete the birth of the baby. While I find it extremely interesting, not to mention unsettling, that almost half of the NICU admits were due to “elective admission” for birth (I would assume from the language that these are all not medically necessary; although I could be wrong in that), I will point out that “full term” is not usually defined as 39 weeks of pregnancy, but rather 37 weeks — although not too many years ago it was 38 weeks. Still, in another way of looking at it, I only consider “full term” to be when labor begins spontaneously — there is so much we don’t know about labor and birth and a baby’s maturity, that to cause the baby’s birth prior to natural onset of labor is to risk prematurity — regardless of the week of gestation.

When we shared this startling data about C-sections and health problems in newborns with a pilot group of physicians and hospitals, they significantly reduced the number of elective admissions for delivery prior to 39 weeks, including C- sections. The result: There was a 46 percent decline in NICU admis sions in three months, a decline that has held stable for more than a year. That’s almost half the number of newborns with potential health problems, almost half the number of distraught parents, almost half the number of potential tragedies. The cost savings to these hospitals, the parents and the health-care system is enormous.

Reducing elective admissions prior to 39 weeks significantly reduced the number of babies that needed to have intensive care in a hospital setting. Not only does this translate into significant cost savings (which is of high importance to an insurance provider, naturally), but think of how many lives have been altered, perhaps tragically, by these unnecessary inductions and C-sections which led to many days or even weeks in the NICU, for no medical reason!

There is evidence that reducing the overall number of Cesarean deliveries would significantly reduce health risks for mothers and their newborns. More than 1.2 million C- sections are performed annually in the United States at a cost of more than $14.6 billion per year, according to the federal Agency for Healthcare Research and Quality (AHRQ). While some women do need C-sections because of fetal distress and other medical issues, AHRQ says that more than half of all Cesareans are medically unnecessary.

My thanks to Empowering Birth for originally blogging about this article, thus bringing it to my attention.