The March of Dimes and dishonesty about prematurity

Schweig still / be silent

What does an organization do when it achieves it’s goal? You might think it would disband in triumph, but that’s not the case with The March of Dimes.

The organization was created by President Franklin Roosevelt to combat the scourge of polio and was spectacularly successful in its goal. Polio has been nearly wiped off the face of the earth because of the polio vaccine. Instead of disbanding, however, the organization has sought to perpetuate itself by finding another cause.

For a while, The March of Dimes concentrated on “birth defects”: congenital medical anomalies and illnesses. They have not been nearly as successful in addressing that problem because it is complex and multi-factorial. Now they’ve moved on to prematurity. It is also a complex multi-factorial problem that does not lend itself to easy answers. The March of Dimes has scored no successes in preventing prematurity, but they’re undaunted. Unfortunately, instead of greater efforts to address the major problem of extreme prematurity that is responsible for a large proportion of neonatal deaths, The March of Dimes has chosen to misrepresent the problem in order to be seen as doing something. The misrepresentations are disingenuous and, in some cases, border on outright dishonesty.

The March of Dimes has chosen to misrepresent prematurity as being caused by early elective delivery. While early elective delivery poses risks, it also has significant benefits (reducing the stillbirth rate) and, in any case, is only a tiny contributor to the problem of prematurity. I suppose one could argue that hyping the issue of early elective delivery is like looking for your keys under the streetlamp even though you dropped them elsewhere. The answer is not likely to be there, but at least that’s where the light is.

I can think of no good reason the be dishonest about prematurity and race, however, and The March of Dimes is thoroughly dishonest on that point. Black African ancestry is a major risk factor for prematurity, but the MOD has not simply ignored this reality, they started denying it, too.

The MOD has been publishing a yearly “report card” on prematurity. The report card is rather farcical since while claiming to grade states on prematurity rates, it is basically grading them by the proportion of African-Americans in each state.

According to NBC.com:

Vermont led the nation with just 8.7 percent of births coming before 37 weeks gestation. Alaska, California, Maine, New Hampshire and Oregon had rates of 9.6 percent or lower, the target recommended by the March of Dimes…

The states with the highest rates of preterm birth are Mississippi (17.1 percent), Louisiana (15.3 percent) and Alabama (14.6 percent). If they were countries, they would be among the 14 worst of the 184 for which data are available, according to the U.N. report. The global average is 11.1 percent…

The high U.S. rate for preterm births is often blamed on the nation’s racial, ethnic and economic diversity, said McCabe [medical director of the March of Dimes], “but the California example refutes that.”

California, with half a million births each year, “has an incredibly diverse population, but it set up policies and procedures to make reducing preterm births a priority,” he said.

Not exactly.

The scatter plot below compares prematurity rates to the proportion of African-American’s within each state.

Prematurity vs Race

As you can see, there is a strong correlation between prematurity rates and the proportion of African American in each state. I calculated a correlation coefficient (Pearson’s r) of 0.75. The whitest states have the lowest prematurity rates and the blackest states have the highest prematurity rates. In other words, the whitest states merit an A grade, while the blackest states are awarded F’s.

The arrow identifies the data point for California. Contrary to Dr. McCabe’s claim that California refutes the relationship between race and prematurity, California actually has a very low proportion of African Americans, corresponding to its low prematurity rate.

Why is any of this important?

We aren’t going to be able to solve the problem of prematurity if we aren’t honest about the reality of prematurity. Yes, there is an iatrogenic component to American prematurity rates, but this is a trivial aspect of the problem. Not to mention that reducing iatrogenic prematurity has risks of its own.

More importantly, the strong correlation between race and prematurity suggest a major genetic component. We should be aggressively searching for a genetic basis for prematurity instead of pretending that it doesn’t exist. But that, of course, it hard, and The March of Dimes would prefer the easy way out, grandstanding by “grading” states on prematurity rather than do the difficult work of solving the actual problem.

 

Addendum:

March of Dimes state by state prematurity statistics can be found here: http://www.multivu.com/players/English/59684-march-of-dimes-75th-anniversary/

African-American state by state population statistics can be found on Wikipedia: http://en.wikipedia.org/wiki/List_of_U.S._states_by_African-American_population

  • lucy logan

    well, while i think the the general argument about MOD is quite right, the fact that prematurity is correlated with race is not necessarily indicative of a genetic component. race itself is a major correlation with racism adn its social effects. medical anthropologist Leith Mullings has written on this particular subject.

    • Becky05

      That then calls into question why it is only African Americans and not other minority races that have such high rates of prematurity.

      • lucy logan

        well not if if you study the structure of racism in america

  • GreyOneSoon

    I’m not sure that this graph and the calculated correlation coefficient really make the point that genetics is driving the relationship. An ecologic study such as what was presented here is probably the weakest of the epidemiological study designs (google ecological fallacy). This study design does not address causality and/or even potential biological mediators of these effects. You’ve talked about genetics might be the driver of this association, but it could still be an environmental factor such as SES or a number of different factors. It’s an interesting hypothesis.

    I couldn’t agree more, however, with this stance on the MOD. My wife is currently 20 weeks pregnant after having a full term stillbirth at 38w2d. The OB is suggesting a c-section (gasp…) at 37 weeks (double gasp!). This baby was conceived using IUI so we are certain of gestational age, yet the hospital will make us jump through number of hoops since we want the baby out at 37 weeks. Hospital won’t allow “elective” c-section until the 39th week of gestation unless there is an amniocentesis to determine lung function. Clearly a one-size fits all rule such as the one we’ll be forced to deal with makes no sense.

    • Ob in OZ

      I would not call the timing of delivery in this case elective. Cannot comment on the indication for c-section, but a maternal request c-s is of course reason enough. Maybe too personal, but would be interested if they recommend steroids for fetal lung maturity prior to delivery, and who is the one making that recommendation (peds, ob, hospital policy/admin). The hard part is a lack of good evidence rgarding timing of delivery in your circumstance, and yet to me it is a no brainer that 37 weeks is the right time and no amnio needed. Hopefully common sense prevails and you don’t have to worry about that aspect of the pregnancy the entire way. I’m sure you both are worried enough.

      • GreyOneSoon

        Our OB considers it a no brainer too, but still has to operate within hospital policy. According to the OB, she can’t do anything induction/c-s wise prior to 39 weeks unless it is medically indicated. Apparently hx of FDIU isn’t considered medical indication by the hospital; I think you’re right about no good evidence to suggest timing of c-s will improve outcome the second time around so I understand why it might be disallowed as well. We have time to get it figured out, but now I’m curious about steroids for lung maturity too – question for the next visit I suppose.

  • TG

    can you please stop using apostrophes in plurals (and it’s instead of its)? thanks.

    • Captain Obvious

      Someone who cannot contribute to the discussion but only corrects grammar has an instigating drive of ego that I find frivolous. In today’s txt messaging, autocorrecting smart phones, and diversity of persons who got access to the web, you really must just have the decency To get what someone is trying to say wothout slamming them for grammar. Really? Is that what you wasted your post on? Correcting a grammar spot? How pathetic. I suppose u judge people by what clothes they wear or how many piercing a or tats that they have two. 😛

      • Antigonos CNM

        I’m an apostrophe Nazi, too. But while I will never quibble about the right to say things that I differ with, I declare that I really do prefer them to be couched in proper English. I can’t bear what texting has done to literacy.

        Sue me; I’m a language snob.

    • Just me

      Well that drives me batty also (apostrophes in plurals).

    • Squillo

      If she agrees to use the apostrophe correctly, will you agree to use sentence case?

      Thanks.

    • LibrarianSarah

      I find not capitalizing much more onerous than a misplaced apostrophe. I can at least read and make out it’s as opposed to its. I know you only wrote one sentence but people who write a wall of text without a single capitalized letter should be shot. The shift key is on both sides of the keyboard and are not very hard to locate.

      Not everyone has 20-20 vision. Capitalize at the beginning of a sentence so I don’t have to squint and search for a period. Failing to do so will result in either me not reading your comment or me wanting to gut you while I struggle to try and read it.

      This has been a public service announcement by Near-Sighted Librarians of America.

      • Ob in OZ

        Never bothered with capitals much in the past, but you make a great point. Will try to do better.

      • Carlson

        “I find not capitalizing much more onerous than a misplaced apostrophe. I can at least read and make out it’s as opposed to its.”

        You… can’t read a sentence that doesn’t include capitalization?

  • stacey

    (I posted this below as a reply, but thought it deserved its own thread.)

    MOD could spend all the MILLIONS they put towards ads promoting waiting for “spontaneous” delivery post 39 weeks (and thats only cost for ONE ad campaign!), and go after the low hanging fruit of maternal/infant health- access to basic medical care for moms in developing nations. Add in cash spent on other such campaigns, and their skill with organization and fundraising? So much could be accomplished, for so many more women.

    By providing poor/developing areas with skilled attendants to work and train the locals, along with much needed supplies, medicines, transportation, they can save thousands of lives, or more. The number of lives that could be saved in those areas, with the same level of spending and efforts, would dwarf any possible reduction in deaths here. This would be true even if they managed to do something useful regarding prematurity, which is unlikely given their current trajectory.

    There are places where just having power at the hospital on a semi regular basis is huge. Places where the nearest medical center is many hours away, and/or there is no transportation; one now defunct blog I used to follow (Aira Hospital) talked quite a bit about how just having a few jeeps for transport would save SO many lives. They are always lacking in funds- see one of the links below to see how far 15k goes there, and then think of the number of lives (families) even that small amount saves.

    But MOD is spending MILLIONS telling American women to wait for labor to start on its own? Its a SICK WORLD when a group that claims to be dedicated to babies and mothers has their priorities this out of whack. See links below to see who they could be saving if they used JUST the funds from that awful commercial they have been airing all over. MILLIONS for this one ad campaign, one commercial, which is not helpful at best, and harmful at worst (“just wait for labor” is not the best advice).

    And no, I do not want to hear: “Well, someone always has it worse, does that mean I can’t fight for things to get better here?” While thats true, and of course one can fight for improvements in their area, in this case, its not about that. Its about the ability to use the existing funds to save MANY real lives, instead of focusing on elective deliveries in the USA, which are not even a cause of death. (I know MOD does other stuff, but I am focusing on the MILLIONS they spent on the “wait” campaign, OK?)

    Does MOD care more about telling moms in our affluent nation to “wait for labor”, than they care about the millions of non American, black, brown, native, moms and babies that die totally preventable deaths? I don’t know. I would think that saving lives is of utmost importance, regardless of where those lives are saved.

    No excuses either- MOD has changed their focus before. I don’t think they would alienate donors by funding health care that saves many actual lives, instead of one ad campaign that will save zero lives.

    LINKS:
    For 15k, they can refurbish this hospital, and for another 45k they can get the basic equipment they need shipped in (a doppler! a new OR table!)

    PLEASE view this, and scroll down to see their current OR table. You WILL CRY. And this is where all the complicated deliveries and Obstetric disasters go (although there is no OBGYN there….).
    http://www.ghm.org/index.php/ethiopia/56-projects/92-ethiopia

    Here is a quick video about the hospital. Their blog was amazing, but it is down now.
    http://vimeo.com/47922538

    Here is a place where at least they have Doctors without Borders.
    but are still lacking in funds for the basics:
    http://blogs.msf.org/stephent/

    • VeritasLiberat

      Reading Jeevan’s blog, I was struck by how happy they were at his hospital to receive a donated CPAP machine — how thrilled they were at the patients they would be able to help in their acute care unit.
      These machines are an everyday sight here in the US — they cost about $900, and there is one sitting on the night stand of at least three of my close male relatives.
      Yes, there’s lots of good the MOD could do with that advertising money.

    • rh1985

      I have to say I am also puzzled by the tons of money and effort put towards things like preventing elective deliveries at term, raising breastfeeding rates in developed nations, etc instead of infant and maternal deaths in poor regions and countries.

  • SK

    Did they control for poverty?

    • Young CC Prof

      I take issue with the cancer prevention, and also with the part about preventing osteoporosis in mothers. The first is unproven and unlikely. The second, however, is biologically implausible to the point of insanity, as breast feeding suppresses estrogen and draws out huge amounts of calcium. In fact, some studies show that breast-feeding slightly increases the risk of osteoporosis, although it seems to depend on the mother’s age and other factors, and plenty of calcium in the diet can protect Mom’s bones and teeth.

      But on Planet Lactivist, up is down.

      • Antigonos CNM

        The old saying was that a woman “lost a tooth for each child” from the calcium which went from her bones to the baby via her milk. This was, of course, in the days before good nutrition and supplements.

        • Becky05

          I lost a tooth during both of my last two pregnancies, but I’m pretty sure it was due to the constant vomiting eroding my tooth enamel. Still one of the reasons we’re probably done with five.

          • Antigonos CNM

            Hyperemesis can definitely ruin your teeth, but I think the proverb came about because the fetus will get the calcium for its bones by leaching it from the mother’s, if her nutrition is inadequate — and prior to the current time, that was too often true.

    • rh1985

      I really resent the idea I wouldn’t be as close to my baby since I am bottle feeding. You can certainly hold a bottle feeding baby close to you for more bonding! Yuck.

      • Clarissa Darling

        So I’ve been at this formula thing for about a week now which pretty much makes me an expert 😉 I think the reason behind the whole “bonding” argument finally clicked for me with the pediatrician (who didn’t bat an eye at my bottle feeding) came to check on my son in the hospital and told us “new babies can only see about 8-12 inches so, when you are feeding him try and hold him up close if you can so he can see you.” Coincidentally this is about the distance at breast level so maybe this is what the lactivists are all worked up about when they talk about “bonding”. I really think they believe all us formula moms are hooking up baby to some milk distributing robot and never providing any kisses and cuddles. It’s the only explanation I can think for them getting so worked up on “bonding”. I mean, how much logical sense does it make that it would be the milk or the boob that results in a stronger bond rather than interaction with mom? Of course you can bond while bottle feeding! I couldn’t be more bonded to mine if I used super glue.

        • Wren

          I have heard that as the argument, but there never seems to be any response when it is pointed out that most people hold a tiny baby in their arms to bottle feed too. I got pretty good at not paying a whole lot of attention to a breastfeeding baby in the middle of the night.

          • Allie

            Ha! Yes, when my LO was newborn and cluster feeding and wanting to be held into the wee hours, Netflix got me through it. I didn’t sit there gazing lovingly into her eyes for 8 hours. In fact, as someone else has pointed out, she can’t really look at my face when she’s nursing. Preferably, her eyes are closed, but if not, she’s only got the side of my boob to look at. Both breast feeding and formula feeding have benefits and drawbacks. Which you choose will depend on your own unique circumstances.

        • EmbraceYourInnerCrone

          I bottle-fed my daughter from the start and feeding times were always one of my favorite times(my husband agrees, he loved those 2am talks with her about football and how to cook the best BBQ). I think I delayed switching her drinking from a cup because I didn’t want to give up that cuddle time.

          I always thought the people who claim you can’t bond as well if you don’t breastfeed were idiots.

          She’s 19 now, commuting to college and we have a great relationship. I will miss her when she transfers to SUNY next year.

        • Antigonos CNM

          If you really think about it, a baby at the breast does NOT see his mother; he sees her breast. Assuming his eyes are even open while nursing. The correct angle for nursing is NOT with the baby looking up at the mother’s face but rather facing the nipple directly as he is on his side. I can’t tell you how many mothers I’ve worked with where I had to correct the position in which they held the baby so it would latch on properly.

          Since the bottle nipple does come from above rather than from in front, a bottle-fed baby DOES look up at its mother.

          • KarenJJ

            That was one of the main benefits from going to bottlefeeding from the constant breastfeeding (outside of the fact that she put on weight and was healthier for it). I finally got to stare at her face. It was really lovely bonding for us.

        • araikwao

          Congratulations to you, too! It’s quite the SOB baby boom 🙂

        • MichelleJo

          I’ve heard this argument lots of time, but it’s easy to turn it on it’s head. If you do believe in intelligent design, then the source of the babies milk supply is in exactly the right place so to be the most comfortable for the mother and the baby. Because if you give a mother a baby and a bottle, she’ll likely sit in that exact position, as it is the most comfortable. I did combo feeding with my first, and how we sat, angled and whatever, was exactly the same regardless of the feeding source. So this business about bonding and level is irrelevant because they are identical no matter how you feed.

      • Clarissa Darling

        This article is basically a run down of all the information I received from my hospital regarding why I should breast feed. Mind you, none of the doctors or nurses provided this information, it just happened to be printed in the standard new baby care book they handed out. There was about 15 pages of breastfeeding information and support followed by “Very few women can not breastfeed. If you formula feed, the nutritional needs of your baby will be adequately met. Ask you doctor for information on formula feeding.”
        I went into the hospital convinced that formula feeding was the best option for us for various reasons but, even I was shaken by that alarming information. The public heath campaign is missing the boat. They need to provide fair and balanced information on ALL healthy infant feeding options.

        • Clarissa Darling

          Whops, that was my reply to Mrs. W’s original post. My reply to you re: bonding is below 🙂

      • theadequatemother

        I’m having those postpartum uterine cramps right now. You know the ones caused by the release of oxytocin with nursing? The love hormone that’s supposed to make you magically bond?

        Guess when else I get them:
        Bottle feeding my newborn (were combo feeding for jaundice while waiting for milk to appear)
        Cuddling with my husband
        Playing trains with my toddler
        Patting my toddlers back last night when he couldn’t sleep through the new baby’s crying…

        You get the idea.

        • Karen in SC

          Congratulations!

        • araikwao

          Congrats on the new baby! (and geez, those cramps hurt so much more the second time, or at least I thought they did – commiserations) Did I miss a comment somewhere with the news?

        • AmyP

          Congratulations!

        • MichelleJo

          Congrats on the new baby, and I’ve always wondered how nursing mothers cope with the after pains.

          I bottle feed, and the first three days are so difficult, with contractions every few minutes. I cannot stand up straight, and if I have to walk I am bent over double. I feel like I’m still in labor, minus the nerves. I can’t imagine that it could be much worse. And there is no correlation with anything at all in my case, just counting down to the 72 hour mark for blessed relief. If nursing mothers have it worse, how on earth they bond with their babies in all that pain beats me.

    • Amy M

      Can you call or email them and inform them they are certainly NOT providing enough information to make an informed decision about infant feeding? Until they list the benefits of formula feeding and the risks of breastfeeding, that page is incomplete. I would do it, but I live in the US and they probably won’t take me seriously.

  • Sue

    Very few ”causes” drop the cause when they have been successful – they just keep moving the goalposts. Witness accident prevention, motor vehicle safety, hypertension treatment, children’s cancer treatment. Nobody ever thinks the statistics have improved ”enough”. Also driven my rising community expectations.

    • Young CC Prof

      Well, with those, the job legitimately isn’t done. At least 80% of children with cancer attain long-term remission and go on to live nice adult lives, but that’s by no means all, and the treatment takes years. It’s a vast improvement, but there’s plenty of room for further improvement.

      Car accident deaths have dropped a lot over the last few decades, but they’re still the leading cause of death in adolescents. Further, sustaining a low rate of car accident deaths depends in large part on the general public continuing to make good choices, like buckling up.

      But yeah, sometimes the horse is actually dead.

      • AlisonCummins

        There aren’t any preventable disabilities any more?

        Vaccine uptake for serious childhood diseases is 100%?

        • Sue

          Nothing in life will ever be 100% safe or effective but, as we become more successful, there are diminishing returns for the effort and expenditure.

          As we eliminate the more serious diseases of childhood with immunisation, we don;t spend less on the health care of children, we try harder to minimise disability.

          I’m not saying that is a bad thing to do, I’m just pointing out the natural human tendency to continue to feel dissatisfied with results in the area we are passionate about, even when things are demonstrably better.

          • AlisonCummins

            Yes Sue, I completely agree.

            The horse is not actually dead and never will be. When to retire it is a judgement call.

            However misguided the MoD’s single-minded focus on elective pre-term delivery, the cause is still out there. Vaccination is still not 100%. There are still preventable disabilities. It’s completely legitimate for the MoD to apply its infrastructure and decades of experience to these and they have chosen to focus on prematurity, which would be completely fine if they had chosen to do it differently.

            If they had chosen to focus on immunization rates, would people here be saying the MoD should give up, admit their job is done and cease to exist?

            If they had chosen to focus on other contributors to prematurity?

    • Antigonos CNM

      I seem to remember that when I was a child the MOD was trying to decrease the incidence of cerebral palsy, but I could be mistaken. Anyway, once the incidence of extremely prolonged labors went down, and with it the incidence of CP, they changed their goal.

  • WhatPaleBlueDot

    I still think it’s allostatic load from living in a systemic culture of racism. This isn’t iatrogenic in the classic sense.

    • thepragmatist

      What is allostatic load? Is that a sociological or evolutionary term?

  • Amy Tuteur, MD

    I forgot to include the data sources, so I’ve added them in an addendum.

  • attitude devant

    Don’t even get me started on this one. We have to go over all these charts at peer review, and computer systems that spit this stuff out for our critique are BEYOND literal. For instance, we just got dinged because a lady with no prenatal care came in and delivered. We didn’t know her due date so we left that blank, so the computer spit it out as a preterm elective induction…..even though she showed up in active labor. Well, our chief of service argued with the regional reviewers all the way to the top, and the case is STILL being flagged as a pre-term elective induction. Then there was the lady with the gall bladder problem that we delivered so she could have surgery at 37 weeks. Not elective, but that got spit out because the code for gall bladder disease was not on the list of indications for delivery. Because you know, pregnant women are just pregnant. They never have any other problems.

    • Young CC Prof

      And that is the real problem with cracking down on elective preterm deliveries. Truly elective preterm births get a lot of press, but really almost no one ever does that, so then folks turn their attentions to ones that aren’t actually elective, which is not necessarily in the best interests of mother and child. Kind of like the “Fewer c-sections!” campaign, it’s too much focus on an indirect measure of obstetrical care quality.

      • You know what I want to see – a “Fewer birth traumas!” campaign – really….

    • This! This is why guideline centred care is an awful thing and should be seen as the enemy of quality. Flag the woman who has an awful outcome and better understand why that happened…focus the attention where it might actually make a difference to what really matters.

      • Young CC Prof

        There’s nothing inherently wrong with guidelines, but you’ve got to be really careful when you write them, and you’ve got to be super-careful when you start using guideline adherence as a measure of the quality of care, just as with any indirect measure. Whatever you measure is what winds up improving, so you’d better pick your metrics carefully.

        A few years ago, I had surgery. Prophylactic antibiotics are usually indicated for this surgery, and the relevant medical association has identified one particular antibiotic as “best.” Trouble is, I was allergic to the best. And the second choice, and the third. So, with me already on a stretcher, the surgeon, a pharmacist and a couple other people came out and talked, and, after some debate, a feasible antibiotic was chosen. I didn’t have an allergic reaction and I didn’t get an infection, so as far as I’m concerned, it was a fine choice.

        Believe it or not, there’s actually a metric for what percent of patients get the “best” antibiotic during certain common surgical procedures. Since realizing this, I’ve wondered if I could have counted against that hospital’s statistics. Being as they clearly went to extra trouble to do what was best for me, I sincerely hope not.

        • KarenJJ

          Even in my job (not related to health care) one of my managers was very wary of KPIs, in that they would drive behaviour that was target-based and not customer focussed. EG he discovered that customer sales orders were being kept in a drawer on a good month when targets were met so as to ensure that there would be enough orders to meet the target next month. It meant that some customer orders were needlessly delayed for a week or two.

    • Sue

      The system is confusing audit filters with performance indicators.

  • Just me

    I stopped paying attention to MOD years ago once I found out that they fund needless animal experiments (yeah, I don’t think you need to torture innocent animals to “prove” smoking or alcohol consumption during pregnancy is bad, we already know that). What’s sad is that moms of preemies, needing some kind if purpose to strive for, will hold MOD walks in honor of their living or dead children. What a waste. I still remember MOD coming to speak to my jr high in the early 80s trying to get us kids to walk to raise money for them.

    • Amy M

      Yeah, a few years I did some fund raising for them, not realizing they were a bit shady in how they use the funds they raise, and what they are actually attempting to accomplish. I did it for a friend who lost a baby due to extreme prematurity. My children were premature as well (twins), but not very and they have no obvious signs of ill effects from it so far, apart from small stature. (But my husband and I are small, so they were likely to be anyway.) Anyway, apart from losing them altogether, my other greatest fear when I was pregnant with them was that they would be born early and end up with severe problems, so I feel like we dodged a bullet there and feel for the families who weren’t so lucky. As a result, I feel drawn to this issue and it stinks that MOD has warped what could be a good cause.

  • Captain Obvious
    • rh1985

      Have to say I’m not thrilled. Especially knowing exact date of conception, I’d feel way more comfortable delivering at 38 weeks + any amount of days vs 40 weeks 6 days.

      • renee

        I prefer 38 weeks as well, because the benefit of missing the stillbirth rate outweighs any risk of possible “prematurity”.

        • rh1985

          Even though I hate the idea of surgery while awake, in some ways I hope for a clear cut need for a scheduled c-section because I think my doctor would be willing to schedule it by my due date and possibly a bit earlier. I will be so anxious about stillbirth if I go over. This is an IVF pregnancy so there’s no chance of dates being off at all.

          • Ceridwen

            I was very nervous about going past 40 weeks as well. My mother had large babies, late, and ran into complications related to those things in 3 out of 4 cases, so I was concerned I might face the same issues. My docs were OK with induction at any time after 39 weeks if it was what I wanted and our intent was to schedule one at my 40 week visit. I never wound up needing to as I went into labor on my due date and had the baby 40 hours later (with pitocin augmentation, the horror!). There are a lot of people who think it’s terrible that my doctors would have been willing to induce me though, despite it being a totally reasonable, well-informed decision.

          • Ob in OZ

            most doctors are reasonable and listen to their patients and the choices they want to make. Sme patients have unreasonable choices ( induce 37 weeks just because) and think that if they are private patients they should get what they want. Others have very reasonable choices (favorable exam at 39 weeks and would like my partner at the birth because we can’t afford extra time off work) and it is the hospital/ admin/midwife led care at the public hospital, etc that try to prevent this from going forward. A shame that so much trust is lost that the basic doctor-patient relationship is going, going, gone.

          • Courtney84

            I am curious if I fall into the “reasonable” category. Pending favorable Bishop score I have requested an induction at 39+6 (Dec 26) to try and make sure me and the baby are home from the hospital in 2013. If we are still there on Jan 1 our big deductible will need to be met again. Having twice the medical bills will effect how many hours and how soon I need to return to work.

          • Ob in OZ

            To be honest, anyone with a favourable exam at 39-40 weeks should demand to be induced. You are at no greater risk for a c-section than the person who arrives in labor or with ruptured membranes, and you are eliminating the complications to your fetes of going beyond 40 weeks (meconium and stillbirth are the biggies). Plus there is there is what we call social inductions that are different from elective inductions in my mind. Elective is for no reason at all. Social is a non-medical reason but a reason nevertheless. Examples are family members ability to attend birth, or living far from the hospital and prior precipitous delivery. The trade-off is hospitals think (arguably) that you would be a more expensive patient and that is what can make it difficult for the physician. My feeling is a financial burden is a real burden for most patients, and your Doctor should be able to work with you to make it happen.

      • Becky05

        This redefinition is based on pretty consistent evidence on differences in outcomes, though. The neonatal mortality rate as well as morbidity rate is higher at 37 and 38 weeks, so you’re not gaining a reduction in deaths by electively delivering then.

  • The Computer Ate My Nym

    One other point about African-American women and premature birth: About 9% of AA people have sickle trait and a substantial number have sickle cell disease of one sort or another. SCD is a major risk for premature birth, fetal loss, death of the newborn, and death of the pregnant women. Sickle trait is less of an issue, but it’s not the non-issue once believed either. Then there’s G6PD deficiency. As far as I know, G6PD doesn’t affect pregnancy per se, but it further limits therapeutic options if something does happen.

    So, I think it’s pretty clear that the problem is multifactorial and involves both genetic and environmental issues. What it doesn’t involve is hopeless issues: We can find and treat the problems involved. If we have the political will to do so and don’t hide behind denial of the problem. (/steps down off soapbox.)

    • AlisonCummins

      However, Amy Tuteur, MD says the MoD is being dishonest about the role of race because they say that the existence of states with lots of people with african-american ancestry but without high rates of prematurity makes it reasonable to assume that any racial contributions can be overcome.

      The MoD cites the example of California to support this argument, though it’s not clear why; Amy Tuteur, MD cites DC and PR as better examples… but then ignores them completely, saying that because California is a bad example the entire argument must be discarded.

      Maybe the argument should be discarded, but “DC and PR offer better support for the argument than CA” is hardly a compelling reason to discard it. If there are compelling reasons, then state them already. If there is no compelling reason to discard the argument, it’s ok to reframe it as “Yes, you’re right, but use DC and PR instead of California.”

      • Captain Obvious

        Can it be race along with socioeconomic status? The southern states are predominantly black and poor. DC has poor but may also have more affluent persons and get earlier prenatal care? There definitely is a relationship with race and prematurity, for MOD to say there isn’t based on this one paper with all the other studies demonstrating it is, is naive’.

        • attitude devant

          EXACTLY! And since when is MOD the CDC?

        • Young CC Prof

          Most of DC’s wealth is in the suburbs, the District proper is quite poor on average. Still, there’s good hospitals, population density, public transportation, etc. So, your average desperately poor pregnant lady in DC can probably get to a good clinic once a month for proper prenatal care. A desperately poor woman with no car in Alabama, no way.

          • amazonmom

            You would think they could, CC prof. I started my NICU career in DC. The hospital I worked for served the poorest of the poor. Ward 8 was like another country compared to the surrounding wards. No grocery stores, bus trips to the nearest community clinic took 3 hours on average one way, taxis refused to go there, and EMS response times were 45 minutes or more for ambulance calls. It was heartbreaking and confusing at the same time, because despite the large amount of services available it never seemed to lessen the numbers of no prenatal care, desperately ill pregnant mothers coming through the doors either in labor or very close to dying. I do agree that in a rural environment the problem is even worse, there is often zero transportation available slow or not.

          • Me Me

            I’ll admit to being from AL. I’m not sure why the numbers are higher. My experience with Ob’s in the state is that they do not deliver before 39 weeks just because it’s what the mom wants.

            I have a labor & delivery nurse friend who says women will show up at the hospital anywhere from 35 weeks up and demand to have their baby because they are ready. (Or they may claim some type of labor, but clearly aren’t laboring.) She said they usually stay awhile for observation, drink free cokes and then get sent home.

    • Antigonos CNM

      Here in Israel, the question of race and/or ethnicity can be very important, however NOT politically correct it might be. 56% of Kurdish Jews [from regions of Iraq, Iran, Afghanistan, and Turkey] have G6PD; 25% of Iraqi Jews do too. Tay-Sachs is a major concern for Ashkenazi parents AND the descendants of Ashkenazi Jews who emigrated from France to North Africa in the 19th century. And there are other diseases related to national and ethnic origin. So when a woman registers for antenatal care, it is usual to ask about the antecedents of her and the father of the baby.

  • Courtney84

    Is there data available for what portion of inductions were “elective”. I mean if they want to pat themselves on the back for reducing elective inductions they should at least use the correct data.

    • Young CC Prof

      Keep in mind, the medical definition of elective is not the common-English definition of elective. In medicine, an elective procedure is one that is scheduled in advance, rather than done on an emergency basis, even if it was obviously necessary.

      Early deliveries with no medical indication whatsoever are actually pretty darned rare. And when they do happen, it’s generally a week or two early, not dreadfully early.

      • FormerPhysicist

        Yeah, there was the woman who made national news because she wanted to be induced at 39 weeks so her deployed husband could be there. And I’m sure a few people ask for a day or two earlier if induction or c/s is in the cards anyhow.

        • Young CC Prof

          And the fact that it made the news should show just how rare it is.

        • Dr Kitty

          My Daughter was born on July 9th.
          My EDD based on LMP was 14th of July.
          My EDD based on scans and when I actually could have conceived was July 20th.

          My OB and I discussed things and decided that while he couldn’t book the CS before 39w, we had a choice of which due date to use…

          I think it was a good call.

        • Antigonos CNM

          I was 40+2 when I got word that my terminally ill mother, in the US, was sinking fast, and wanted badly to see me, and if possible, her first grandchild, before she died. So I requested an elective induction, which I got, but when there was no progress, I had quite a fight to get a C/S as the resident was afraid he’d be reprimanded for an unnecessary C/S [in the event, with pregnancy #2, I was 41 weeks with a completely unripe cervix, and a baby over 4kg, so I was right all along], and I probably would have had the first C/S sooner if not for the “elective induction for social reasons”.

          Computers do not recognize that “guidelines” are meant to be just that, GUIDE lines, not laws engraved on stone tablets. It’s a problem.

          I once assisted a woman who had an elective induction because her Mafia hitman husband was due to begin a 20 year prison sentence in a few days and he wanted to be with her for the birth. Wonder how you’d code that for a computer!

  • Ainsley Nicholson

    Another confounding factor….black women are more likely to have twins (http://www.ncbi.nlm.nih.gov/pubmed/11441679) and twins are more likely to be premature than singletons.

    • Amy M

      When I was 27wk pregnant with my twins, there was a black woman, pregnant with identical twin girls, due at the same time I was, on one of the online discussion forums I was on at the time. That week, I was put on bedrest for threatened pre-term labor, and she went into pre-term labor. She lost her twins, it was very sad, and it scared me, of course because all I could think was “that could be me.” It was clear something was wrong with them, they were half the size they should have been for 27wk. I don’t know what happened to her, if she went on to have more children or what. Whenever this sort of discussion comes up I think of her, and her girls who would be almost 5 now, if they lived.

  • Amy M

    This is what I don’t understand: why doesn’t the March of Dimes put the funds they raise, and their efforts into researching the real causes of prematurity, and finding ways to prevent it (if possible) based on those causes? Other research that would be helpful and relevant would be exactly what signaling cascade leads to labor beginning…then drugs could be developed to interfere with the process should it start too early, even if the original reason the labor started too early couldn’t be prevented (some genetic component). It takes money to get all of that research done, and if the March of Dimes, and/or other organizations like it really want to end prematurity as the leading cause of neonatal mortality in America, that’s where they’d direct their energy and funds.

    • moto_librarian

      They could funnel the money towards determining the cause of pre-eclampsia, for one. That is a major cause of early deliveries since it is lethal.

      • Certified Hamster Midwife

        The Sybil Crawley Branson Memorial Fund for Pre-Eclampsia Research

    • S

      Exactly what i was thinking. It sounds to me as though they are stuck in the mindset that they must advocate for _something_ and are unable to redirect their efforts.

    • attitude devant

      Excellent question! I have pondered this one myself. Perhaps because the real causes of extreme prematurity are not straightforward or pretty, and because things that are politically unpopular (like universal access to quality healthcare and contraception, and eradication of poverty and homelessness) would be a huge part of the solution? Can’t piss off conservative donors, right?

      • Young CC Prof

        I think you hit the nail on the head.

        If you want to, say, increase vaccination rates, all you really have to do is make a bunch of vaccine, convince people to come and get it, and pay some nurses to give the shots. Step 2 is a bit tricky, but ultimately it’s not a terribly complicated problem, and the financial cost of such a campaign isn’t terribly high.

        Putting a real dent in prematurity would require addressing larger social issues.

        • AmyP

          For vaccinations, you could even PAY parents in to bring their kids in. (It could be like a negative copay.)

  • The Computer Ate My Nym

    More importantly, the strong correlation between race and prematurity suggest a major genetic component.

    Suggest, but don’t prove. African-Americans and Hispanics are at higher risk for quite a number of conditions, including many that appear to have a stress-related component (diabetes, heart disease, etc). There may well be genetic issues that lead to higher rates premature births in these populations, but the stress of dealing with prejudice every day is likely a component as well. Decrease poverty, decrease prejudice and you’d likely see a decease in the disparity.

    • The Computer Ate My Nym

      There’s also this: http://www.biomedcentral.com/1471-2458/10/285

      Experiencing discrimination can increase the risk of heart disease, so it’s a demonstrated, not just a speculative correlation.

      • Certified Hamster Midwife

        Yet everyone gets all snippy when people in the fat acceptance movement mention this.

    • EricaS

      Studies have taken into account socioeconomic status and there still exist a disparity in premature birth among blacks and whites. Matter of fact, foreign-born black women, including those of lower socioeconomic status, giving birth in America have better birth outcomes than American born blacks. Educational level, income level, marital status and employment have all been controlled in previous studies and still show a disparity in birth outcomes.

      • AlisonCummins

        Right — which specifically throws into doubt the assumption that it *must* be genetics and that’s just the way it is and there’s nothing that can be done.

        It might be genetics (american-born african-americans are more likely to be of mixed ancestry than are african-born african-americans, and mixed ancestry might be a factor in preeclampsia, which is itself a factor in premature birth) or it might be social factors (american-born african-americans might feel more under siege than foreign-born african-americans).

        • The Computer Ate My Nym

          Even if it is genetics–and it probably is partly genetics, ie sickle trait–why does that mean that nothing can be done? Lots of diseases have genetic bases, including diabetes, heart disease, some cancers, and hypertension. We still treat them and still look for ways to treat them more effectively. We only sigh and look resigned when we don’t want to bother trying to find a solution.

          • AlisonCummins

            Exactly! That DC outlier is so important.

          • auntbea

            I grew up in the DC area. If I now lived in DC proper, and was threatened with a serious pregnancy complication, I would head out to the better hospitals in the suburbs, especially since one of the country’s best obgyn hospitals is 20 minutes away. I am not sure that this represents better health care in DC, but health care that is so bad that anyone who can selects out.

          • AmyP

            DC has a large African immigrant population with a lot of East Africans, if I’m not mistaken, as opposed to indigenous African Americans.

        • Young CC Prof

          People have also tossed around the idea of epigenetics. Everyone’s ancestors were deprived, but there aren’t too many recent-history examples of generational deprivation the way we saw in the slave and jim-crow south, multiple generations of people who were born, produced children, and died without ever really having enough to eat or feeling safe and in control of their lives.

          I have no IDEA how to test a theory like that, or how to fix it if it’s true.

          • The Computer Ate My Nym

            High throughput RNA and protein analysis? The best comparison groups might be African-Americans versus African immigrants versus immigrants from other areas of the world with similar levels of deprivation. Or maybe comparing Africans in Britain (where slavery was less prominent and prejudice a bit less) versus in the US. None of these comparisons would be problem free, but they might start to build a case…

          • auntbea

            Though I take your point, I would suggest that being born and raised in the inner city could CERTAINLY lead to never feeling safe or in control of your life. It’s like another country.

        • fiftyfifty1

          We need to be really careful when we talk about American born African-americans vs African immigrants. Because many, if not most, of African immigrants are East African (Somali and Ethiopian etc.). These people are genetically and culturally distinct from American-born African-Americans and West African immigrants.But they all get listed as “black”.

          • AlisonCummins

            Good point. Where I live, african-born african-canadians are most likely to be from Senegal or Côte d’Ivoire.

          • EricaS

            Good point but studies still show that Caribbean born black women had better birth outcomes than black American women. Almost all blacks in the Caribbean have ancestry that trace to West Africa similar to Black Americans..

          • EricaS

            You do make a really good point. I was curious to know what countries
            represented Black immigration in the United States. Two-thirds of blacks migrated from the Caribbean (Jamaica, Trinidad and Haiti). Most African
            immigration came from Nigeria, followed by Ethiopia, Ghana, Liberia and Somalia. The majority of black immigrants, like Black Americans, are of West African ancestry (African born and Caribbean born), but including East Africans still might have skewed the numbers. There should be a study comparing birth outcomes of black Americans with foreign-born blacks of Caribbean and West African ancestry to get more accurate results.

  • The Computer Ate My Nym

    Maybe the MOD should go back to its original mission. Polio is making a comeback. If the MOD put its weight behind getting everyone in this generation vaccinated, worldwide, then polio would disappear. Then, if they really didn’t want to disband, they could go for the MMR diseases, HPV, etc. That should keep everyone employed for a while. (Also just to point out, there is no cure for polio, only a preventative medication. Actual treatment for viral illness is another potentially fruitful ground…with difficult but achievable goals.)

    • Young CC Prof

      Actually, at this point the biggest reasons we haven’t eliminated polio are political. We get almost-there, a war breaks out, sets the cause back ten years. (Nigeria, now Syria.)

      But yeah, I’d love to see some more muscle thrown into the polio eradication campaign, then measles. All we need are money and will.

    • T.

      They intended target demography would abbandon them would they start promiting vaccine I think.

  • Maternal health is such a complex and diverse area – there are tonnes of fish to fry that really need attention and resources directed to them. Childbirth education has become the foray of NCB zealots – what if the March of Dimes took it on and helped to empower patients to have effective relationships with their care providers, including helping women choose qualified care providers? Or what about birth trauma? How about post-partum depression, and post-natal PTSD? What about safe feeding practices? It is very disappointing that they’ve taken early elective deliveries on as the cause, when there are so many other problems in desperate need of attention.

    • AlisonCummins

      Or just, what about vaccines generally?
      They likely took on prematurity because CP is the closest common analogue to polio we have today. What is the relationship between CP and prematurity?

      • Amy M

        There is a strong correlation. Of course not all people with CP were preemies, and not all preemies end up with CP. CP, like all neurological disorders, is very complicated. But being born prematurely, especially before 34wk gestation is more likely to lead to complications that can include brain damage. There are people here who know WAY more about CP than I do, but I think it is clear that a normal gestational length is best for neurotypical brain development. Of course brain damage can occur during birth, and after birth, but the best start for one’s brain is being born full term.

    • stacey

      Better yet- They could spend all the MILLIONS they (MOD) put towards ads promoting waiting for “spontaneous” delivery post 39 weeks (and thats only cost for ONE ad campaign!), and go after the low hanging fruit of maternal/infant health- access to basic medical care for moms in developing nations. Add in cash spent on other such campaigns, and their skill with organization and fundraising? So much could be accomplished, for so many more women.

      By providing poor/developing areas with skilled attendants to work and train the locals, along with much needed supplies, medicines, transportation, they can save thousands of lives, or more. The number of lives that could be saved in those areas, with the same level of spending and efforts, would dwarf any possible reduction in deaths here. This would be true even if they managed to do something useful regarding prematurity, which is unlikely given their current trajectory.

      There are places where just having power at the hospital on a semi regular basis is huge. Places where the nearest medical center is many hours away, and/or there is no transportation; one now defunct blog I used to follow (Aira Hospital) talked quite a bit about how just having a few jeeps for transport would save SO many lives. They are always lacking in funds- see one of the links below to see how far 15k goes there, and then think of the number of lives (families) even that small amount saves.

      But MOD is spending MILLIONS telling American women to wait for labor to start on its own? Its a SICK WORLD when a group that claims to be dedicated to babies and mothers has their priorities this out of whack. See links below to see who they could be saving if they used JUST the funds from that awful commercial they have been airing all over. MILLIONS for this one ad campaign, one commercial, which is not helpful at best, and harmful at worst (“just wait for labor” is not the best advice).

      And no, I do not want to hear: “Well, someone always has it worse, does that mean I can’t fight for things to get better here?” While thats true, and of course one can fight for improvements in their area, in this case, its not about that. Its about the ability to use the existing funds to save MANY real lives, instead of focusing on elective deliveries in the USA, which are not even a cause of death. (I know MOD does other stuff, but I am focusing on the MILLIONS they spent on the “wait” campaign, OK?)

      Does MOD care more about telling moms in our affluent nation to “wait for labor”, than they care about the millions of non American, black, brown, native, moms and babies that die totally preventable deaths? I don’t know. I would think that saving lives is of utmost importance, regardless of where those lives are saved.

      No excuses either- MOD has changed their focus before. I don’t think they would alienate donors by funding health care that saves many actual lives, instead of one ad campaign that will save zero lives.

      LINKS:
      For 15k, they can refurbish this hospital, and for another 45k they can get the basic equipment they need shipped in (a doppler! a new OR table!)

      PLEASE view this, and scroll down to see their current OR table. You WILL CRY. And this is where all the complicated deliveries and Obstetric disasters go (although there is no OBGYN there….).
      http://www.ghm.org/index.php/ethiopia/56-projects/92-ethiopia

      Here is a quick video about the hospital. Their blog was amazing, but it is down now.
      http://vimeo.com/47922538

      Here is a place where at least they have Doctors without Borders.
      but are still lacking in funds for the basics:
      http://blogs.msf.org/stephent/

  • Young CC Prof

    Actually, the relationship between race and prematurity is really complicated and interesting. Black women are three times as likely as white women to deliver prematurely, and thousands of babies die every year as a result, so this IS a real problem. I looked into it a year or so ago, and here’s the weird stuff I found:

    1) It’s apparently NOT entirely genetic. Recent African immigrants have a prematurity rate similar to white Americans or other recent immigrants. This is something that only happens to the daughters of those who made the middle passage.

    2) The obvious socioeconomic factors don’t seem to explain the phenomenon, either. One study looked only at college-educated black women married to black men, between age 20 and 40, with prenatal care the whole pregnancy. They found a prematurity rate almost as high as the black population overall.

    3) At the same gestational age, in the same hospital with the same care, premature black babies are more likely to survive than white babies. Not sure how that plays into the whole thing.

    By the way, which state is the outlier in the scatterplot? The dot above the letters, near C and D? Outliers are interesting.

    • Young CC Prof

      Oh, right. The outlier is DC, isn’t it? And the states to the right of it are all in the Deep South. DC may be poor, but at least people there have some access to medical care. The Deep South is entrenched rural poverty and next to no welfare provisions, which means particularly bad health stats.

      • Julia

        I agree that the 50+% state is DC, but what is the state with ~46%? According to Wikipedia (obviously the ultimate source of all correct information), the state with the highest African American population of is Mississippi at 37%

        • Amy Tuteur, MD

          The other outlier is Puerto Rico.

          • Julia

            Thanks!

          • auntbea

            Wait, which outlier is PR? Every thing I can find says PR is about 7% black. Is that not right?

      • Me Me

        No welfare provisions? That has not been my experience. I had single moms bringing more from welfare than my annual salary when i was teaching!

        It may be more a lack of healthcare providers in rural areas and inability to travel to the larger metro areas.

    • Zornorph

      Given that the percentage of black people is over 50%, I assume it’s D.C.

    • AlisonCummins

      Ok, so in DC the population is over 50% african-american but 1) doesn’t show the expected prematurity rate and 2) doesn’t follow the same social divisions as the Deep South. So that suggests that MoD is *correct,* that the outlier (though DC, not California) challenges the explanation that prematurity is tightly tied to genetic components of race.

      Does the weirdly mistaken choice of DC instead of California as the outlier that requires an account not tied to genetic components of race change the argument? If not, can the argument be addressed in any other terms than “wrong state!”?

      Is there an alternative explanation for the MoD’s choice of outlier beyond “wierdly mistaken”?

      • Young CC Prof

        The prematurity rate in DC is still pretty high. My conclusion is: Rich white state: Low prematurity rate. Economically together with a high black population: Moderate prematurity rate. High poverty AND high black population, as per Mississippi: Awful prematurity rate.

        By the way, I think the graph is backwards. Shouldn’t racial breakdown be X and prematurity rate be Y?

        If you really want to analyze data, go to the CDC’s website, download the whole report, and look at the breakdown by state AND race. Might take you a few hours, but I guarantee it’ll be fun. (OK, maybe I’m just weird that way.)

        • AlisonCummins

          Ok, so the MoD is right: there are significant non-genetic contributors to prematurity and they are presumably more amenable to intervention than genetic factors are.
          I’m not seeing the dishonesty.

          • Young CC Prof

            Yes, there are factors that are amenable to intervention. The problem is:

            1) They don’t acknowledge that a significant part of the problem is beyond the reach of current medical science or near research, nor are their statistics and reports trying to sort out the fixable from the nonfixable.

            2) Most of the fixable factors are complicated, like the mother’s prior state of health, or else require lots of money, like hospitalization. About the only true low-lying fruit is dental hygiene, believe it or not.

            3) They’re heavily focused on elective preterm deliveries, which are a tiny part of a big and messy problem.

          • fiftyfifty1

            Pelvic infections/STDs are another low-lying fruit. Or would be low-lying if reproductive health clinics weren’t under constant attack.

        • AlisonCummins

          Do you have a link to the CDC report?

          (I’m just weird that way too.)

          • Young CC Prof

            Actually I couldn’t find that table. I think I was thinking of an infant mortality table, rather than premature birth.

            This report, however, is the tabulated data from US birth certificates of 2011, all of them. It’s hours of fun and fascination: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf

        • AlisonCummins

          I haven’t found the data sets Amy Tuteur, MD is using because I don’t have Puerto Rico and my r-value for AA ancestry vs rate of prematurity by state is only 0.49, much less than her 0.75.

          Per-capita income plotted against the portion of prematurity rates that are unexplained by AA ancestry also has an r-value of 0.49.

          Interestingly, the state’s Gini coefficients don’t explain anything at all. Even after AA ancestry and per-capita income are taken into account, the r-value for the remaining unexplained variation by state is only r=.03.
          But we aren’t using the same data set, so…

          • Young CC Prof

            Interesting! So this suggests it’s half race, half poverty. I’d have to ask a high-risk obstetrician what percent of premature births he thinks are preventable. Maybe I’ll ask the MFM guy at my next ultrasound.

            Perhaps the irrelevance of the Gini coefficient is because in the US, inequality has less effect on prenatal care than it does on so many other health issues. Even in “low-service” states, there tend to be programs to look after indigent pregnant women. (Now, after the kid is born, you’re on your own.) Or maybe it’s because the states with the highest Gini coefficients are wealthier overall? I don’t know.

        • auntbea

          YES! Dr. Amy, can you fix the axes easily?

    • S

      Not sure how relevant this is, but just last night i came across a study suggesting that women of African (and Asian) descent have a slightly shorter median gestation rate than European women and that African (and Asian) babies may mature a bit faster. I am not qualified to evaluate this study at all.

      http://ije.oxfordjournals.org/content/33/1/107.full

      (I was trying to decide whether to just give my provider LMP when she requests it, or probable actual date of ovulation by OPK. I think i will just stick with LMP, which gives me the earlier due date. Is that bad? I want to avoid any 39-week bullshit if i can.)

    • fiftyfifty1

      1. This may be because recent African immigrants are largely EAST African (Somali) who are genetically and culturally distinct. I don’t know if we have study data yet, but Somali women have the reputation in the medical community for being at risk of post-dates (and its associated risks) not prematurity. They also have a near-zero rate of STDs. West-African immigrants seem to have a prematurity rate more like American-born African Americans.

      • Young CC Prof

        Interesting! I have heard that there’s more genetic diversity within African populations than in the rest of the world put together. Can’t believe it never occurred to me to ask WHICH Africans!

      • EricaS

        Not all black immigrants came from Africa. Half came from the Caribbean. The majority of African immigrants to the United States was from West Africa not East Africa. East Africans do make up a large part of African Migration though.

        http://www.immigrationpolicy.org/just-facts/african-immigrants-america-demographic-overview

    • baileylamb

      You cant just look at someone and tell how much African Ancestry they have. That would take a DNA test, and there are issues with that… Also, I like how we pretend that Africian Americans do not have mixed ancestry…

  • Kumquatwriter

    What a disappointment! I had great respect for the march of dimes once.

  • Zornorph

    I can just imagine the people who worked at The March of Dimes when Dr. Salk came out with his vaccine. They would have been like, wtf do we do now? We’ll have to get other jobs! And then someone came up with the idea of going after birth defects because you’ll NEVER get rid of all birth defects. No chance that they’ll have to get other jobs with that as their goal.
    I did not know that black people had a higher change of delivering premature. That’s very interesting, but why can’t they just say that? Is it considered politically incorrect? I would think black people would want attention on that since their babies are most at risk. Or is it that the MOD thinks that donors would be less interested in helping black people?

    • Young CC Prof

      Possibly because then they’d have to admit that an awful lot of premature births are unpreventable? Or maybe they are afraid that if it becomes known as a black problem, it’ll get more swept under the rug.

      At the same time, it’s a problem, and in order to solve the problem, you have to understand the facts. I teach inner-city community college, and I can tell you, when the topic came up in my statistics class, the black woman who’d lost a 29-week preemie was RIVETED.

      This is something that, IMHO, pregnant black women would be better off knowing. There ARE a few things that can be done to prevent prematurity, like treating or preventing infections. Sometimes hospital bed rest for premature labor or rupture of membranes can delay the birth, and even if you can’t delay until term, a couple weeks can still make a big difference to the baby’s future. (It’s probably cost-effective, too, I have to imagine that hospitalizing someone who can breathe and eat on her own costs less than a tenth what caring for a micropreemie in the NICU does)

      And if you know that your risk of a complication is elevated, you and your doctor can plan for it and watch out for it better.

      • Mel

        Amen to that! I teach in a predominantly Hispanic and African-American district with many girls having their first baby by age 17. I spend a lot of time making sure all of my students know that, for reasons that we are not exactly sure about, they are at a higher risk of having a premature baby. Knowledge DOES help. I’ve had students who knew to call the doctor when they realized that they were having symptoms of early labor during their second trimester. Some of the girls still had babies early, but being able to push labor back even a few days – long enough to get steroid shots – can make such a difference in infant survival.

        If nothing else, the effect of lack of knowledge is far too sad. I’ve been too far to many funerals for students’ premature infants……

        • Young CC Prof

          Isn’t being a teen ALSO a risk factor for prematurity and complications?

          • Amy M

            Yes.

          • fiftyfifty1

            yes, also closely-spaced pregnancies.

          • Mel

            Yup. We cover that, too. For many of them, though, that ship has sailed.

    • Antigonos CNM

      Black and Hispanic* women also have higher rates of pre-eclampsia, and the reasons are obscure.

      I tend not to think that race is the determining factor, though, in the absence of studies which can definitively show that comparable white and black populations have equal antenatal care, incomes, educational level, etc. There might also be a relevant factor in previous generations — we are now seeing a variety of conditions in adults whose mothers were nutritionally deprived long before they were even capable of childbearing [such as Dutch girls who suffered from Nazi-induced famine before they reached puberty, and whose sons, conceived years later, have had a high level of cardiac problems] Grandparents who were one step removed from slavery and suffered severe poverty might have passed something on.

      However, the connection between certain obstetric complications and race needs to be studied much more.

      *Many Hispanics have mixed blood.

      • Courtney84

        I understand that cholestasis of pregnancy is most frequently seen in Hispanic women. Yet another pregnancy complication that leads to prematurity.

        What is it the March if Dimes is doing to help better understand these complications (pre-e, cholestasis, I’m sure there are others) that cause prematurity?

    • cliff

      It’s not unusual for an organization to pursue a new mission when the old one is resolved. For example, City of Hope in California started out as a tuberculosis sanatorium but today specialized in cancer and diabetes.