Written by Alison Johnson
Recent data shows progress in lowering Virginia’s prematurity rates, thanks to statewide initiatives and greater public awareness
Jessica Hosang was just 23 weeks pregnant—barely past the midpoint of a normal 40-week pregnancy— when her water broke in the middle of the night. That sickening moment began a frantic fight to keep her second child, Evelyn, alive. Rushed to the hospital, the James City County resident delivered Evelyn by emergency caesarean after four days of literally hanging with her legs above her head to hold the baby inside as long as possible. Weighing 1 lb., 3 oz., Evelyn couldn’t breathe on her own and came so close to death that Jessica and her husband, Michael, almost put her on a “Do Not Resuscitate” list.
During Evelyn’s five months in intensive care at Children’s Hospital of The King’s Daughters in Norfolk, Hosang cycled from pure shock to depression, imagining that even if her baby survived, she would have severe physical or mental problems. “She looked so awful,” Hosang remembers. “You could see through her skin and her color was terrible, and then she was sick and suffering and bloated and full of tubes. It was unbelievably painful to see.”
Against the odds, Evelyn survived and, at age 6, is thriving. The little girl has just one obvious residual effect from her struggle to survive: permanently damaged eyes that require her to wear glasses with thick lenses to see at all clearly. But even with such a happy outcome, the ordeal—the birth, months in the hospital and two years of physical and occupational therapy—put an enormous strain on the family. “Something like that has a long, hard impact on your life,” Hosang says.
Thankfully, rising awareness about the dangers of early birth is slowly cutting into what had been a skyrocketing rate of premature births nationwide, according to the March of Dimes. The country’s rate spiked at 12.8 percent of all live births in 2006—an increase of 36 percent since the early 1980s—due in large part to a greater number of multiple births and deliveries scheduled before 39 weeks of pregnancy. Preterm birth is the leading cause of infant death and can cause long-term health issues such as breathing disorders, brain damage and cerebral palsy. Preemies also may be at greater risk of chronic conditions in adulthood, including diabetes, high blood pressure and heart disease.
In March of Dimes’ latest report on prematurity, released late last year, almost all states showed improvement in the rate of births before 37 weeks of pregnancy. Virginia’s rate for 2009, 11.4 percent, bested the national rate of 12.2 percent, and the state made progress in three critical areas: reducing the percentage of women ages 18 to 44 who smoke (from 16.7 percent a year earlier to 15.4 percent), the rate of uninsured women of childbearing age (18 percent to 17.2 percent) and the percentage of all births between the 34th and 36th weeks of pregnancy (a slight 8.1 to 8 percent drop).
Recent positive steps in Virginia include a statewide smoking ban in restaurants, streamlined registration for health insurance programs for low-income families and educational campaigns on the importance of good prenatal care, says Sara Long, director of program services for March of Dimes’ Virginia chapter. “Slowly, we are making an impact—but slowly,” Long says. “It’s encouraging, but we’ve still got a lot of work to do.” The organization’s goal is to reduce the nationwide rate of preterm births to 9.6 percent.
The March of Dimes aims to reduce the nationwide rate of preterm births to 9.6 percent.
Locally, hospitals are working to prevent scheduled inductions and C-sections before 39 weeks unless there’s a critical medical issue such as extreme high blood pressure or injury to mother or child. That means educating doctors and women who want to deliver sooner because of more minor complaints such as back pain or for a social reason – before a military deployment, say, or on a Friday so a spouse is off work for the weekend. About 75 percent of women believe fetuses are full term by between 34 and 38 weeks, according to a 2009 survey published in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists.
“In fact, a lot of research is showing that important brain and lung development goes on in those last few weeks,” says Diana Behling, a registered nurse and manager of Sentara Healthcare’s Ob Right Program, a patient safety initiative. “A lot of nuanced development happens then too, like the ability to regulate temperature and maintain blood sugar levels.” Late pre-term babies most often land in intensive care for breathing problems, although they also may not be strong enough to nurse well.
Many hospitals now have official policies to question doctors who try to schedule a delivery before 39 weeks, and to review all such cases that go forward. Those “39-Week Initiative” programs, which dovetail with MOD’s “Healthy Babies are Worth the Wait” campaign, have impacted admission rates to neonatal intensive care units. At Riverside Regional Medical Center in Newport News, for example, the rate has fallen from 11 percent of all live births to 8.6 percent over the past four years, says Nikki Downs, a registered nurse and administrator of Women’s Services. “We’re always going to get some extremely premature babies here, but we can reduce the number of elective late pre-term births with good education,” Downs says. Sentara hospitals, Behling says, “have virtually eliminated all elective deliveries between 37 and 39 weeks. Once people understand the risks, there is little resistance.”
While doctors often don’t know what triggers early labor—that was the case for Jessica Hosang—risk factors include late or no prenatal care, smoking, use of alcohol or illegal drugs, lack of social support, high stress levels, long periods of standing, obesity and even poor dental health. All women should
be aware of symptoms of preterm labor, says Dr. James Marquardt, an obstetrician/gynecologist with Bon Secours Richmond Health System who practices at The Woman’s Center in Midlothian.
“It can just be a tightening, or low back pain that comes and goes, or a little bleeding,” says Marquardt, whose practice begins counseling women on signs of labor as early as 20 weeks. “It’s not necessarily painful or dramatic.” Women who are at all worried should call their doctor and likely be examined, he says; in some cases, rest can help and in others, doctors can use medications to delay delivery while treating the unborn child with drugs to speed lung maturation.
For women with a history of preterm birth, new treatments using the hormone progesterone during pregnancy can reduce the chances of a repeat case by one third, Marquardt adds. Progesterone injections also can help some women who have a short cervix—the lower portion of the uterus—that appears on regularly scheduled ultrasounds.
Finally, simply understanding the dangers of preterm birth is critical, March of Dimes leaders say. “We’ve had such advances in neonatal intensive care that some of the fear of early birth has been taken away, for both patients and doctors,” Long says. “What we’re learning now is that yes, miracles can be done and we can save these babies, which is wonderful. But then problems can show up later in childhood or even years down the road.”
Baby Evelyn, happily, has no apparent physical or mental issues other than her eyesight, which could affect her ability to play sports or drive when she gets older. She is on the small side but not abnormally so, and she is in a regular kindergarten classroom. Talkative and strong-willed, she loves playing with her big sister Isabella, 9—who, incidentally, was born right on her due date—taking Irish step dancing lessons and playing with her two pet cats. One of those cats, Clementine, has only one eye. “The girls picked her out because she has ‘boo-boo eyes’ too, like Evelyn,” Jessica Hosang says. “She gets around fine, though—also like Evelyn.” Hosang now shares her story to help other parents with babies fighting to survive. “When Evelyn was so sick, I devoured any stories with a positive outcome,” she says. “It was completely traumatic. So I know what they are going through.”