A Warning About Premature Babies

Gov. Pete Wilson’s recent executive order that could deny prenatal care to the state’s illegal immigrants is “penny-wise and pound-foolish” given the number of pre-term births that could be prevented with access to care, according to an expert in premature births.

“It’s going to end up costing the state a lot more money. You’ll have a lot more expensive preemies in the nursery and a lot of suffering to go along with that,” said Dr. Helayne Silver, an authority on maternal-fetal medicine at Women and Infants Hospital of Rhode Island, Providence. Silver’s comments were made here Monday at the annual American Medical Assn. meeting for science writers.

Premature delivery and low-birth weight babies remain two of the most difficult and costly unsolved problems in obstetrics, experts say. Access to regular prenatal care is critical to this problem because assessing a patient for risk and educating her on early warning signs are the most effective strategies for averting the problem, Silver said.

“If you can do something and save money, that’s the kind of thing you like to see,” Silver said. “Pre-term birth is a substantial economic drain. The more attention this problem gets from politicians, hopefully, we’ll come up with better solutions.”

The governor’s executive order, which was signed in August, cuts certain state benefits to illegal immigrants, including a $70 million state program that pays for prenatal visits. “The question is not whether prenatal care is beneficial,” the governor told the San Francisco Chronicle. “The question is whether or not the United States will discard its immigration laws, throw open its borders and simply say we will take all comers, whether they are citizens or not.”

The care of a baby born prematurely can cost from $20,000 to $100,000, studies show. If the baby suffers permanent disabilities from prematurity, lifetime care costs can reach $500,000, Silver said.

The incidence of pre-term birth--infants born in less than 37 weeks gestation--is rising in the United States and now stands at about 10% of all deliveries. And no one really knows why.

One of the lingering questions in reproductive science is: What triggers labor to begin? And even less known is what triggers labor to begin early.

Research is underway to test certain biochemical markers in a woman’s body for clues of impending pre-term labor. In addition, ultrasound technology is being used to look for changes in the cervix that might expose a woman to early labor.

The information divulged during a prenatal office visit, however, is perhaps the best screening technique. For instance, some lifestyle factors, such as smoking and drug use, are known to put a woman at higher risk of pre-term labor. Health conditions like vaginal infections, anemia and poor nutrition are also risk factors. And, any woman who has had a premature birth is at higher risk for subsequent premature births.

“The best approach is to assess the woman for these historical risk factors and conditions that we know lead to pre-term birth,” Silver said. “The problem with all of our other screening tools is they’re not that great. I really think that patient education and staff education is the way to go.”

For example, one study of Latinas in west Los Angeles looked at the risk factors associated with early labor. The women were randomly assigned to either a group that received standard prenatal care or a group that received additional prenatal visits, nutrition counseling and psychosocial support. At the conclusion of the study, 9.1% of the women in the standard-care group gave birth prematurely compared with 7.4% of the women in the additional-services group.

“The study showed a net savings of $1,800 per patient by preventing the pre-term labor,” Silver said. “The challenge in front of us for the next several decades is to really address our risk-assessment tools. But the low-tech programs, for now, seem to work best.”

Even when women are identified as being at high risk for an early delivery, the tactics to prevent or stop pre-term labor are not always successful.

“Bed rest is something we use commonly for someone who has well established premature labor. There is absolutely no scientific proof that it works, but we do it every day,” she said.

Medications can be used to stop or slow delivery, although they have limitations as well.

“Most centers do use drugs, in addition to bed rest and hydration. But, until recently, there were very few placebo-controlled trials to show if these drugs worked. We just assumed they worked,” Silver said.

A recent Canadian study, however, did yield evidence that drugs can slow labor for a short time. Postponing an infant’s birth even 48 hours can be important because it allows doctors to administer steroid medications that will help the baby’s lungs to mature.

Another approach to arresting premature labor is the use of home monitors to identify uterine contractions. But this equipment is expensive--about $100 per day--and there are no clear-cut guidelines for who should have the monitors or solid studies on just how effective the technology is, Silver said.

The most promising treatment strategy appears to be as “low-tech” as the best prevention strategies, Silver said. It involves teaching women how to recognize the first clues of premature labor, thus increasing the chances that the labor can be stopped.

“The major problem we have in stopping pre-term labor is that women come to the hospital too late because they don’t recognize the symptoms of early contractions. The contractions can be so subtle that by the time someone comes into the hospital, they’re already in fairly advanced labor,” she said.

The early clues may feel like cramps or tightening of the abdomen. Or women may feel pelvic pressure, low back pain or note a change in vaginal discharge, she said.

“If a woman is at high risk and develops one or several of these symptoms, I recommend she lie down, drink a lot of fluid, and monitor how often she is feeling whatever it is she is feeling,” Silver said. “If she’s feeling it more than four times an hour, then she should go to the hospital. And if she’s feeling it four times, she’s really probably having about 10 contractions, because women often don’t feel every single one.”

* BIRTHS OF A NATION

Americans have seen many changes in delivery. E3