Report: Late pre-term babies not out of woods

When Tom Cavaliero arrived at the neonatal intensive care unit with his newborn a few weeks ago, he felt like he'd brought in Andre the Giant.

The other babies in the NICU at Children's Hospital of The King's Daughters were a fraction of the size of Gunner, who weighed 7 pounds, 8 ounces.

Still, Gunner's entry into the world was not easy. For a week, a maze of feeding tubes and oxygen lines weaved around him as he struggled to breathe.

The poster child for premature babies has pencil-thin limbs and fits in the palm of your hand. But Gunner is an example of a bigger wave of babies born too soon.

In the United States, the rate of premature births rose by more than 20 percent from 1990 to 2006, with the largest increase in babies born when the mother was 34 to 36 weeks pregnant. That's according to a federal report - "Born a Bit Too Early" - released this month.

These babies, some 70 percent of the premature population, fare better than the 1- and 2-pound infants born earlier. But they often have more problems breathing, feeding and maintaining their body temperature than full-term babies.

They also have a greater risk of dying.

That's why these so-called "late preterm babies" have drawn the concern of health care providers.

In Gunner's case, there was not much choice. His mother's water broke a month before her due date.

But statistics show that, over the past decade, doctors have increasingly induced labor early or conducted a cesarean before full term.

The percentage of induced late preterm births more than doubled between 1990 and 2006, from 7.5 to 17.3 percent, according to the report by the U.S. National Center for Health Statistics. The percentage of late preterm births delivered by cesarean rose by 46 percent, from 23.5 to 34.3 percent.

There are many medical reasons for a baby to be delivered early: the mother's blood pressure is too high, or the baby has stopped growing, or the sac of protective fluid around the baby has ruptured.

But health officials say there are plenty of non-legitimate reasons, too: a family wants a baby born before a father deploys, or when a relative is available to help out, or before the doctor goes on vacation.

Health care providers have even heard of families who want a baby born before the end of the year for a tax deduction. Sometimes the expectant mother is just tired of being pregnant.

Locally, health care professionals are trying to home in on that population.

A committee called OB Right - made up of Sentara Healthcare, Eastern Virginia Medical School and other obstetricians in the community - has been working for several years to bring down the rate of unnecessary early inductions.

In 2005, Sentara Norfolk General Hospital and Sentara Leigh Hospital began to require medical documentation from doctors who schedule an induction or cesarean before 39 weeks of pregnancy. Tests must show that the baby's lungs are mature enough or that there is a medical reason for early induction. The other Sentara hospitals followed suit in 2008.

"We have better outcomes, less respiratory and transitioning issues," said Diana Behling, who manages OB Right. "The longer we can keep the baby inside the mother, the less risk for the baby."

Dr. Holly Puritz, medical director at Sentara Leigh, is the person providing what she calls "push-back" at that hospital when an elective induction crosses the scheduling desk. Over time, she said, families and health care providers have become more aware that the policy is about protecting a baby's health.

"There is so much press about the really tiny babies that people get cavalier and think 38 weeks is good enough," Puritz said. "But there are more and more studies that show term is better."

Virginia Health Information, an agency that compiles statistics from private and public sources, released a database in September that for the first time shows the cesarean rates of hospitals and doctors. Those statistics show that cesarean births statewide went from 22 percent of all births in 1996 to 35 percent in 2007, a rate higher than the national average.

If that trend continues, by 2016 half the births in Virginia will be by cesarean. Federal health goals call for a rate of 15 percent.

In Hampton Roads, Bon Secours DePaul Medical Center had the lowest rate in 2006, at 14 percent, and Sentara Norfolk General the highest at 32 percent.

But there are reasons for both: Sentara Norfolk handles the most high-risk pregnancies in the region, and DePaul houses the Midwifery Center, the only hospital-based midwife center in the region. Midwives historically have performed births with as little medical intervention as possible.

"This is not new for us. We've always had the philosophy of 'birth is normal until proven otherwise,' " said Blair Conger, a certified nurse midwife at DePaul.

Joan Corder-Mabe, who directs women and infants' health at the Virginia Department of Health, said a state task force recently examined the statistics. She said she thinks new guidelines from an obstetrical organization will keep cesarean and early-induction rates in check.

The American College of Obstetricians and Gynecologists made guidelines more stringent earlier this year to clarify when babies should be delivered before 39 weeks.

But Corder-Mabe said other trends also contribute to more early inductions, including rising numbers of older mothers, who tend to have more complications; of women pregnant with multiple babies; and of overweight pregnant women, who are prone to conditions such as diabetes and high blood pressure.

Dr. Edward Karotkin, a neonatologist at Children's Hospital of The King's Daughters, said addressing the late preterm population has been tough because the babies don't stay in the hospital for as long as earlier-born preemies and they usually end up doing pretty well, so there's not the same urgency.

Many don't even wind up in neonatal intensive care units. But studies show they're more likely to be jaundiced or return to the hospital after discharge than term babies. Even though their hospital stays are shorter than the very early preemies, there are more of them, so collectively the costs add up.

The March of Dimes has been focusing on late preterm births in the past few years, and its most recent report card on prematurity showed Virginia made improvements in 2007.

The parents of these children recognize they are better off than a lot of babies, but early birth still takes an emotional toll.

Heather Shuster, who lives in Toano in James City County, said that when her water broke on Nov. 4, she worried it was too early. But the 36-year-old first-time mom had also read that once a woman reaches seven months, babies have fairly good outcomes.

Fortunately, her fiance, Cavaliero, was home and drove her to Sentara Williamsburg Regional Medical Center. Labor and delivery proceeded quickly, and when Gunner was born, he looked perfect.

"I thought absolutely nothing would be wrong with him once I heard him cry," Cavaliero said.

By the next morning, though, a doctor said Gunner needed to be transferred to CHKD because his lungs were underdeveloped and he was having trouble breathing.

"You hear about children who need to go to CHKD, but you never expect your child will need to go, especially a baby close to 8 pounds," Cavaliero said.

Dad followed the ambulance, ferrying Shuster's breast milk to Gunner, while Mom recuperated. Once there, Cavaliero was amazed at the tiny size of the other babies, and he worried about his own son's breathing.

"Every 20 minutes someone asked if I had any questions," he said. "I'd start to ask one and start bawling. I said, 'I don't have any question I can ask without crying.' "

Gunner improved every day, though, and gradually one tube after another was removed. He was released a week later, in the middle of a nor'easter.

Before Gunner came home, Cavaliero saw another baby about the same size in the NICU. His grandmother was with him, looking just as stressed as Cavaliero had looked the week before.

He went over to her.

"See that little boy?" he said pointing to his healthy-looking son. "He was laying in this same exact situation a week ago. And now he's going home."

Elizabeth Simpson, (757) 446-2635, elizabeth.simpson@pilotonline.com