Birthing Research

The March of Dimes funds both basic science and intervention research. Our primary interests are in the prevention of prematurity and birth defects and infant mortality, so much of our work in the areas of preconception and prenatal testing has to do with the ability to predict and prevent both genetic abnormalities and metabolic abnormalities as well as prematurity in general.

Imaging

With the advances in the technology of ultrasound, both the ultrasound through the abdomen as well as the transvaginal ultrasound are very exciting because it gives us some objective measures of fetal size and fetal growth and development when used serially. It also allows us to look at fetal congenital abnormalities and, of course, there are now some really exciting fetal interventions for some of the congenital abnormalities. Also, some new work suggests that looking at cervical length can be a predictor of risk for premature delivery.

Combining that with the potential to think about a history of premature birth or a family history of premature birth and we do have an intervention now, the use of progesterone in pregnancy. So, combining history with predisposition and cervical length may give us some real focused interventions to prevent prematurity. So the imaging is exciting. The 3D imaging is certainly exciting for families. It’s beginning to have some clinical utility, but it’s certainly a marvelous thing to share with families. The interesting thing is that imaging makes the fetus more real to the family and it allows the family to bond in ways that certainly 20 and 30 years ago was much less likely.

Screening

There are standard recognized important universal screening tests and those tests are to find out whether people have a problem or are at risk of a problem. They range in the types of tests from simple things like a hematocrit to look for anemia, to infectious disease screening for things like HIV and chronic infections like syphilis and assuring the rubella titers are available for someone who’s had a rubella immunization. Then there are screening tests for genetic abnormalities, depending again on family history. The question of whether something should be universal or focused really has to do with great specificity as to what that test is. When we do screening tests we have to be concerned about cost and we have to be concerned about value – are we able to justify a test on five million women a year in order to find a very small number of problems.

There is universal prenatal testing and the ACOG (American College of Obstetricians and Gynecologists) does a pretty good job of assessing those tests. We have met with a group from the American Thyroid Association who are amassing the evidence that perhaps all women should be screened for thyroid levels as well as antibody levels because there’s increasing evidence that antibodies to thyroid or low levels of thyroid may be a very high risk factor for prematurity and even for poor fetal brain development. I would predict that it will be recommended, and within a short period of time that all women will be screened because it’s a simple and not very expensive test and it can be done with the same blood draw that one would do early in pregnancy at the routine first visit. But those are the kinds of decisions based on good evidence.

Research

The March of Dimes is committed to preventing pre-term birth, but also committed to doing the research or reviewing the research that supplies the evidence of effective screening measures. We’re very supportive of research studies to show the efficacy of testing new assays surrounding amniotic fluid and fetal fibronectin. We are interested in these kinds of tests and studying who would benefit from them – are they the sorts of tests that should be universally done, and at least at the present time there’s not a lot of evidence that says they should be universally done. However, there are some groups of women who might benefit from more careful evaluation because of history or other signs that would suggest the clinician do those tests.

In the recent issue of Pediatrics – the journal published by the American Academy of Pediatrics – there are a set of recommendations about late pre-term birth. And according to the CDC National Center for Health Statistics, prematurity continues to increase in America and about 72 percent of all the prematures are late pre-term births. They’re the babies between 34 and 37 weeks and that is really a national crisis. This late pre-term group is increasing and as the American Academy of Pediatrics notes that there is real morbidity risk for these kids.

An article that the March of Dimes published in November 2007, argues that it is six times more likely for a late pre-term baby to die in the first week of life than a full term baby, and three times more likely for late pre-term babies to die in the first year of life than a full term baby. So both mortality and morbidity are very serious in this group.

I like to think that the neonatal world has done such wonderful work that it perhaps inappropriately suggested that as long as a baby gets to 34 weeks we’ll give you a nice baby to take home. And, in fact, that’s true, I mean the mortality rates are very low past 34 weeks, but they’re still six times greater in the first week than full termers because these babies are subject to serious respiratory problems, feeding disorders, temperature instability, problems with holding their sugar, their glucose metabolism, and jaundice, which is another real problem.

It is a challenge for us now to make sure that the obstetric community and the public realize that late prematurity is a real problem and that whenever we do an elective induction or an elective caesarian section, we really have to be very careful to assess the risk of early delivery versus the benefits of that early induction or caesarian. The ACOG for instance argues that there shouldn’t be any elective caesarians before the 39th week and we agree. However, we find when you go out into the real world that some of those so called 39th week babies are really 37 or maybe they’ve even missed the dates and they’re really 35. So, we would argue that the obstetricians need to be very careful in thinking that through. We also know that there are women who are requesting caesarian sections if they’re doctors, requesting without any medical indication. And we want the public to understand the risks of those requests.

About Dr. Alan Fleischman

Born in New York City, Dr. Alan Fleischman graduated from the City College of New York and earned his medical degree from the Albert Einstein College of Medicine. He continued his education in pediatrics at the Johns Hopkins Hospital in Baltimore, Maryland, and completed a fellowship in perinatal physiology at the National Institutes of Health and through a Royal Society of Medicine Scholarship at Oxford University in England.

Fleischman has written extensively in the field of neonatal and fetal physiology with a research emphasis on nutrition. He has also written, taught, and lectured about many aspects of the developing field of bioethics. In addition, he currently serves as the co-chair of the March of Dimes National Bioethics Committee and a fellow of the Hastings Center in Garrison, New York.

Fleischman is a member of the Society for Pediatric Research, the American Pediatric Society, the Ambulatory Pediatrics Association, and the American Public Health Association.