On an uneventful Monday night, Kim Cowan, 31 weeks into her first pregnancy, was sprawled on the couch reading about ways to pay down her debt. Then, without warning, she felt a thrust in her abdomen. "There was a kick, a pop, and then a gush of water," says Cowan, 31. She yelled to her husband, Kelly, and ran to the bathroom. "Is your water breaking?" he asked. No way, thought Cowan, who still had a good two months to go.
"I was terrified," says Cowan, who didn't have any risk factors for pregnancy complications. Too panicked to drive, the couple had a neighbor rush them to the hospital, where their fears were confirmed: Cowan's water had broken and she was in labor. Suddenly, her life was in chaos. "Nurses and doctors were poking and prodding me, and asking a million questions." Her doctor was able to delay delivery with medication, so she could be given steroids to help her baby's lungs develop. Three days later, Cowan gave birth to a son, Cayce, who weighed only 3 pounds, 11 ounces. He was immediately rushed to the neonatal intensive care unit, where he stayed for a month.
Cowan's experience is becoming a more common one for moms-to-be. Rates of preterm birth -- one that occurs before 37 weeks of pregnancy -- have increased a frightening 28 percent since 1981. It affects about 480,000 babies annually, or one in eight live births, according to the National Center for Health Statistics. Experts say the increase is due to the widened use of fertility treatments (and the related rise in multiple births) and the older age at which women today begin having children.
Premature birth is not to be taken lightly. It's the number one cause of neonatal death in the first month of life, and it can trigger health problems such as developmental delays, chronic lung disease, and cerebral palsy. These conditions take an emotional and financial toll on families and doctors. The average hospital cost of a newborn is $4,300; for a preterm baby, it's $58,000, according to the March of Dimes. In addition, 65 percent of women and 59 percent of men mistakenly attribute preterm labor to risky prenatal behavior, according to a March of Dimes survey, though that link often can't be made.
While modern medicine has made great strides in treating premature babies, there have been few advances when it comes to preventing or stopping preterm labor. In fact, the American College of Obstetricians and Gynecologists (ACOG) recently stated that the effectiveness of common treatments for preterm labor -- such as bed rest, pelvic rest (abstaining from sex), and increased fluids -- is not known.
"We don't understand the mechanism of preterm birth enough to come up with safe, effective ways to prevent it," says Ronald Gibbs, M.D., chair of the department of obstetrics and gynecology at the University of Colorado Health Sciences Center, in Denver. "Strategies so far have focused on trying to stop preterm labor, but that's like closing the barn door after the horse is out." But new research is beginning to hint at both the causes of preterm labor and ways to prevent it. And more may be on the horizon: The March of Dimes recently launched a $75 million campaign dedicated to lowering national rates by 15 percent, and has designated November 18 Prematurity Awareness Day. Here's what you need to know now.
Senior editor Lisa Singer covers health for BabyTalk.
Early Prenatal Care
1. Get early prenatal care. One of the best and easiest ways to reduce your risk of preterm labor is to see your health care practitioner as soon as you know you're pregnant or are going to try to get pregnant. Your doctor can advise you on how to eat right and gain the proper amount of weight and screen you for infections that can harm your pregnancy.
Your doctor can also give you a prescription for a prenatal vitamin. Among other essential nutrients, it contains folic acid, a key B vitamin that can prevent neural-tube birth defects like spina bifida (an opening in the spine). The most important time to take folic acid is during the first month of pregnancy -- before a woman misses her period and knows she's pregnant. So it's a good idea to start taking a prenatal vitamin when you decide you're going to try to get pregnant, or to take a daily multivitamin which contains folic acid all the time, since nearly 50 percent of pregnancies are unplanned.
What's more, new research suggests that folic acid may also lower the risk of placental abruption (when the placenta separates from the uterine wall) and preeclampsia (high blood pressure during pregnancy), two conditions that are responsible for about 20 percent of early deliveries, according to Charles Lockwood, M.D., chair of the department of obstetrics, gynecology, and reproductive sciences at the Yale University School of Medicine in New Haven.
Know The Risks
2. Know your risks. Certain pregnant women are more likely to deliver early. Risk factors include a prior early delivery; smoking or illegal drug use; high blood pressure or diabetes; carrying multiple fetuses, such as twins; a uterine infection during pregnancy; an age of 35 or older; pregnancy complications such as preeclampsia; being over- or underweight; and being African-American.
Talk to your doctor if you have any of these risk factors -- she can suggest ways to minimize them, such as improving your lifestyle through diet and exercise or treating a uterine infection. In addition, she may recommend that you take a tour of the neonatal intensive care unit (NICU) and read up on preterm infant care. Keep in mind, however, that half of all women who deliver early have no known risk factors. So it's a good idea for all moms-to-be to have a general understanding of how to care for a preemie.
3. Get tested. Recent research suggests that uterine infections that can begin in the lower genital tract may be responsible for up to half of all preterm births, particularly those that occur before 30 weeks' gestation, according to Dr. Gibbs. During a vaginal bacterial infection, for example, the body releases infection-fighting chemicals known as cytokines, which cause inflammation. This inflammation, in turn, launches the release of prostaglandins, which begin the chemical process that initiates contractions and the dilation of the cervix.
That infections can trigger preterm birth isn't new information -- it's been known for years that such sexually transmitted diseases as gonorrhea and chlamydia increase preterm birth risk. But doctors are now looking at other suspect infections like bacterial vaginosis (BV), a condition that can cause an unpleasant odor and gray discharge. It's more common in African-American women who, incidentally, also have higher rates of preterm birth.
Recent studies have found that treating high-risk women who have symptoms of BV with an oral antibiotic appears to reduce their rates of early delivery. But BV doesn't always cause symptoms, and studies to determine whether precautionary antibiotics would lower a woman's risk have not shown a beneficial effect.
Recognizing and treating infections early or before pregnancy may hold the key to lowering preterm birth rates as much as 30 percent, says Dr. Gibbs. Other risky conditions that are being studied include periodontal (gum) disease, untreated urinary-tract infections, and trichomoniasis. Get screened for all of these during pregnancy -- it can improve your odds of having a healthy baby.
Dentist Visits Are Key
4. Visit the dentist. Many pregnant women think they should skip the dentist during pregnancy, but regular cleanings may help prevent preterm delivery. It's believed that the same chain of events initiated by a uterine infection can occur if you have a dental condition such as periodontal (gum) disease (when tissues begin to separate from the teeth, become infected, and even break down). Adding to the problem are hormone changes that occur during pregnancy which make women more susceptible to gingivitis -- a condition marked by swollen, red gums that are more sensitive to the negative effects of plaque -- which can lead to gum disease.
In one recent study of 366 women with gum disease, premature births were reduced by 84 percent in women who received a deep cleaning by a dentist above and below the gum line. "Most periodontal disease in young women is very simple to treat, and the results are dramatic," says Marjorie Jeffcoat, dean of the School of Dental Medicine at the University of Pennsylvania, in Philadelphia, and the study's lead researcher.
Dr. Jeffcoat recommends that all women visit the dentist before or early in pregnancy to be checked for gum disease. If the condition is present, a deep cleaning by a dentist or hygienist, followed by regular dental care, can keep the problem under control. For women who don't have gum disease, dental checkups are still a smart idea, as is brushing and flossing after meals.
Watch Your Weight
5. Watch your weight. The average woman should put on 25 to 35 pounds during pregnancy. Gain too much and you up your odds of complications like gestational diabetes and preeclampsia, which increase preterm labor risk. Talk to your doctor if you were heavy before pregnancy -- it's recommended that overweight and obese women gain less weight (usually 15 to 25 pounds) -- and follow a nutritious diet and exercise to lower your risk.
Underweight women should be concerned too. Research has shown that women who have a body mass index (BMI) under 20 (a healthy BMI is 20 to 25) are less likely to carry their baby to term. These women may be prone to nutritional deficiencies that adversely affect the fetal environment, says Robert Goldenberg, M.D., professor of obstetrics and gynecology at the University of Alabama School of Medicine, in Birmingham.
To calculate your BMI, divide your weight before pregnancy in pounds by your height in inches. Divide that number by your height in inches again, then multiply by 703. Women are considered overweight if their BMI is over 25, and obese if it's over 30. If you're under- or overweight, talk to your doctor about seeing a nutritionist for help with proper diet and weight gain.
6. Eat right and exercise. Eating a nutritious diet during pregnancy can be vital to healthy fetal development. That means whole-wheat carbs, healthy sources of protein and dairy, and an abundance of fruits and vegetables. While it's too early to make definitive dietary recommendations, recent studies suggest that women who have higher levels of omega-3 fatty acids (found in such fish as salmon) have lower rates of preterm birth. Since these fatty acids are essential to healthy fetal brain development, it's worth including them in your diet.
Other preliminary studies suggest that calcium and vitamin C may help prevent preterm labor -- and both are a smart idea during pregnancy. Healthy sources of calcium, such as skim milk and low-fat yogurt, help build healthy baby bones. Vitamin C, found in citrus fruits and juices, helps your body absorb iron and produce connective tissue in your baby. It's recommended that pregnant women consume 1,200 milligrams (mg) of calcium per day (the equivalent of four 8-ounce glasses of skim milk) and 85 mg of vitamin C, roughly the amount in one orange.
Another no-brainer is regular exercise. It can reduce your risk of developing gestational diabetes, and recent research suggests that it may help prevent preeclampsia as well. One study found that women who walked for exercise during the first 20 weeks of pregnancy lowered their risk of preeclampsia by a third. Exercise can also help you relax, which is important given that severe chronic stress may kick-start labor.
Talk to your doctor about pregnancy-safe workouts; in general, swimming, walking, and yoga are good options. Contact sports and activities that involve heavy lifting or could cause you to lose your balance are out. You'll also want to stop smoking, drinking alcohol, or using recreational drugs, all of which drastically increase your odds of early delivery.
Check Your Meds
7. Check medications. Pregnant women who are depressed or anxious have a twofold increase of preterm birth, according to Dr. Lockwood, so treatment is crucial. One recent study, however, suggests that a class of antidepressants used to treat these conditions, known as selective serotonin reuptake inhibitors (SSRIs), may be associated with a slightly higher risk of preterm delivery.
Another class of drugs, tricyclic antidepressants, did not show this association. (Neither type of medication has been shown to cause birth defects.) It's important to remember, however, that many women have used SSRIs such as Prozac and Paxil safely during pregnancy, and the benefits of treating depression often outweigh any risks. Consult your doctor if you feel you should consider switching medication.
A Repeat Occurrance?
8. Talk to your doctor if you've had a prior preterm birth. A recent groundbreaking study found that a progesterone-like hormone reduced the risk of preterm birth by 34 percent in women who had a prior early delivery. "This is the first hint of some effective treatment to prevent preterm labor," according to Paul Meis, M.D., professor of obstetrics and gynecology at Wake Forest University Baptist Medical Center, in Winston-Salem, North Carolina, and lead researcher of the study.
It's not clear why the hormone helps, but it may be because it's a muscle relaxant that inhibits contractions and reduces inflammation. Since the drug is widely available, inexpensive, and considered safe for pregnant women, doctors could begin prescribing it now, says Dr. Meis, who uses it in his clinic. If you had a prior preterm birth (there's no evidence that it's effective for other groups), you can discuss these findings with your doctor.
Your doctor may also recommend that you use a condom during sex, since semen contains prostaglandins, the chemicals that initiate contractions. High-risk women may be told to avoid breast or nipple stimulation and having an orgasm, all of which can initiate contractions.
Recognize The Signs
9. Recognize the signs of early labor. Although little can be done to reverse the course of preterm labor once it's started, delivery can usually be delayed for a few days to a week using tocolytics, drugs that suppress contractions. During this critical window, a doctor can administer corticosteroids, which can improve fetal health by speeding up lung maturation. (Without treatment, a preemie may suffer from respiratory distress syndrome, a breathing complication which can lead to health problems and even death.) Delaying labor also allows time to transfer a woman to a hospital with a more sophisticated NICU.
So it's important to recognize the signs of preterm labor, even if you don't think you're at risk. According to the March of Dimes, these include contractions that occur every ten minutes or more, fluid leaking from your vagina, pelvic pressure, lower back pain, menstrual-like cramps, and abdominal cramps that begin in the back and move to the front. False labor (also known as Braxton Hicks contractions) may stop when you change position, is often weak, and is usually felt only in the front. Not sure if it's the real thing? Call your doctor right away.
It's essential to remember that a full 80 percent of women who have symptoms of preterm labor will not deliver early, according to ACOG. And the vast majority of pregnancies result in babies who are born healthy and full-term. While medical strides in preventing and reversing the course of preterm labor have been slow, our ability to care for premature babies has skyrocketed. Between 90 and 95 percent of babies born after 30 weeks' gestation survive, with most growing up to be healthy adults.
Cayce Cowan is now a robust 2 1/2-year-old with a younger brother, Cody, who weighed a whopping 9 pounds, 13 ounces at birth. But Kim Cowan will never forget the stress of a surprise early delivery. "The days before Cayce was born were the worst. We had no idea what was happening, and not knowing was the hardest part. We were very fortunate to have a healthy little boy." Hopefully, new research will help doctors find ways to identify and treat women who are at risk of preterm labor, delivering healthier babies and happier moms.