Perinatal Health, Prematurity, and the March of Dimes
Sources: Medical Program Records et al, March of Dimes Archives; March of Dimes annual reports; Prematurity Campaign Report, 2008; Virginia Apgar Papers, Mount Holyoke College.
April 21, 2008 / David Rose / March of Dimes Archives
Baby in an isolette, 1976
Introduction: This timeline portrays the increasing involvement of
the March of Dimes in the areas of perinatology, perinatal health, and neonatal
intensive care after the foundation changed its mission from polio to birth
defects prevention in 1958. The emphasis here is not on birth defects per se,
nor on genetics, even though these areas have been integral to the March of
Dimes mission in the past fifty years. The timeline accounts for some important
milestones only and is not intended to be comprehensive or complete.
Birth Defects Mission: The National Foundation for Infantile Paralysis
launched its Expanded Program on July 22, 1958, “to determine the causes of
birth defects, develop means of prevention, and promote improvement in methods
of diagnosis and treatment.” It became quickly apparent to the foundation that
ameliorating birth defects was completely unlike fighting polio epidemics. The treatment
of birth defects was so complex, and the issues involved such a number of
factors (pregnancy, perinatal health, and the environment) and medical fields
of study (genetics, obstetrics, and pediatrics) that the magnitude of the
problem exceeded the clinical delineation and treatment of the 3000 known birth
defects of the time. Within a few years, the March of Dimes broadened its approach
to birth defects to incorporate perspectives in perinatal health that appropriately
considered the health of all pregnant women and babies and truly emphasized prevention.
Virginia Apgar: Virginia Apgar, MD (1909-1974) was an obstetric anesthesiologist
best known for the “Apgar Score,” a clinical system for evaluating the physical
condition of newborns at birth. She joined the March of Dimes in 1959 and became
Senior Vice President for Medical Affairs. The Apgar Score, developed in 1952,
measures an infant’s pulse, skin color, reflex, muscle tone, and respiration,
quickly indicating whether a newborn needs special medical attention to stay
alive. In her March of Dimes career, Dr. Apgar campaigned vigorously for birth
defects registries, immunization against rubella (German measles), and the
prevention of Rh disease; and she led the way to the foundation’s increasing
involvement in the field of perinatal health in the 1960s.
Earliest Involvement in Prematurity: Virginia Apgar participated in two conferences: 1)
“Prematurity, Its Prevention and Management,” First Annual Scientific Symposium
of The Perinatal Study Committee for Allegheny County; Pittsburgh, PA; November
20, 1960; and 2) Third Annual Seminar on Premature Care, The Good Samaritan
Hospital; Cincinnati, Ohio; April 15, 1965; “Anesthesia and Prematurity” was
the title of Dr. Apgar’s talk. Her active participation in these conferences is
the earliest instance of March of Dimes involvement in the problem and
prevention of premature birth.
Newborn Screening: Robert Guthrie, MD (1916-1995) was a March of Dimes
grantee best known for the development of a simple blood test to detect
phenylketonuria (PKU), a cause of brain damage and mental retardation. The
March of Dimes initiated discussions about newborn screening and a practical
program to detect PKU on a large scale in 1959 when mandated newborn screening
was non-existent. Dr. Guthrie’s breakthrough with early PKU detection ushered
in an era of state-mandated newborn screening. In 1963, Massachusetts became
the first state to pass a law making the Guthrie PKU test mandatory, and New
York followed suit with a similar law in 1965. At present, all 50 states
require PKU testing, and the March of Dimes today vigorously continues its
advocacy of newborn screening to include 29 inherited disorders.
Rubella Epidemic: Rubella (German measles) causes a spectrum of
serious birth defects such as blindness, deafness, heart defects, and mental
retardation when the mother is infected by the virus during pregnancy. An epidemic
of rubella occurred in the U.S. in 1964 and 1965, affecting 12.5 million
individuals and causing over 20,000 babies to be born with congenital rubella
syndrome (CRS). With the arrival of a rubella vaccine in 1969, Virginia Apgar
led March of Dimes advocacy and education efforts to promote rubella
immunizations. March of Dimes chapters helped obtain community funds for
vaccine purchase, promoted public health education, and facilitated rubella
vaccination clinics. These efforts reduced the incidence of CRS dramatically
and reinforced the importance of emphasizing prenatal care and the external
factors that affect the fetus as the March of Dimes continued to embrace the
field of perinatology in a campaign for overall perinatal health as a
fundamental approach to birth defects prevention.
Perinatal Health: From 1961 to 1968, the March of Dimes established 100
birth defects clinical study centers and treatment and evaluation centers in
hospitals throughout the U.S. However, by 1966 the foundation began to shift
attention to the importance of prenatal care for all women. In 1966, the March of Dimes sponsored the Symposium on
the Placenta, which emphasized the importance of healthy pregnancy in the
development of the fetus. The March of Dimes slogan, Be Good to Your Baby before It Is Born, embodied a philosophy about
proactive prenatal care as the foundation in 1965 launched Operation Stork to
educate women about healthy pregnancy. By 1969, the March of Dimes focus on
prevention of birth defects and infant mortality began to encompass the
problems of premature birth and low birthweight to integrate these fully into
our mission.
Neonatal Intensive Care: March of Dimes grants for medical services shifted
from birth defects clinics to “neonatal intensive care nurseries” beginning in
1968. By 1970, the clinic concept had been reframed to “medical service center”
that also included genetic counseling services. Through the 1970s the March of
Dimes funded statewide networks of intensive care for high-risk infants,
equipment for intensive care nurseries, and direct care for premature and sick
newborns. These initiatives led to grants for perinatal training of nurses and
physicians and the prenatal evaluation and care of high-risk pregnancies.
Committee on Perinatal Health: In 1972, the March of Dimes convened the Committee
on Perinatal Health (COPH), headed by Sprague H. Gardiner, MD, to develop
guidelines and recommendations for the care of pregnant women and newborns. The
committee was a joint effort of the American Academy of Family Physicians, the
American Academy of Pediatrics, the American College of Obstetricians and
Gynecologists, and the American Medical Association. The sole objective of the
committee was the reduction of rates of maternal, perinatal, and infant
mortality and morbidity in the United States. The culmination of the
committee’s work was the publication Toward
Improving the Outcome of Pregnancy.
Toward Improving the Outcome of
Pregnancy: In 1976, the COPH issued Toward Improving the Outcome of Pregnancy
(TIOP), a landmark document that called for the regionalization of perinatal health
care in the United States. TIOP established recommendations for systematized,
cohesive regional networks of hospitals and defined three levels of inpatient care
based on patient risks and needs. Level I hospitals provide care for routine,
uncomplicated labor and delivery; Level II hospitals of larger urban centers
provide a full range of services and can treat the majority of complicated
obstetrical and neonatal problems; Level III hospitals provide care for all
serious types of maternal-fetal and neonatal illnesses and abnormalities. TIOP
quickly led to the establishment of regionalized perinatal care, communication and
neonatal transport systems, and professional education about perinatal health
in the U.S.
Nursing Education: In 1975, the March of Dimes published the
first in a series of training modules utilized in nursing education curricula
in hospitals, nursing schools, prenatal clinics, and midwifery and public
health agencies. March of Dimes nursing modules are a series of training
booklets for the continuing education of nurses in the field of perinatal
health on the care of pregnant women and newborn infants; the curriculum is accredited
by the New York State Nursing Association. The modules cover key topics in neonatal clinical care, the pregnant
woman and her fetus, labor and delivery, and contemporary issues in nursing
such as adolescent pregnancy, diabetes, multiple births, and obstetrical
emergencies, as well as issues in genetics and ethics. The modules provide the
most up-to-date information on nursing practice, assessment of risk,
care of the client, and provision of care in normal and emergency situations.
Mommy
Don’t Campaign:
In 1986, the March of Dimes initiated a public health education campaign
against substance abuse with English (Mommy
Don’t) and Spanish (Mami No)
components. Since 1973, when Fetal Alcohol Syndrome was clinically identified
by March of Dimes grantees David Smith, MD and Kenneth Lyons Jones, MD, the
foundation had consistently included warnings against the consumption of
alcohol during pregnancy to avoid this birth defect syndrome. In keeping with a
philosophy of prevention to counter the increasing incidence of substance abuse
during pregnancy, the Mommy Don’t
campaign’s educational messages against drinking, smoking, and drug use during
pregnancy were positioned as fundamentals in a plan of sensible prenatal care.
Surfactant: One of the most important breakthroughs in neonatal
medicine in the 1980s was pulmonary surfactant therapy. Surfactant is a substance
which lowers the surface tension in the air sacs of a baby’s lungs and keeps
them from collapsing, and it is used to treat and prevent respiratory distress
syndrome (RDS), a leading cause of death among premature infants, whose
immature lungs often don’t produce enough of their own surfactant. From 1983 to
1987, the March of Dimes supported the research of T. Allen Merritt, MD, of the
University of California, San Diego Medical Center with grants to test
surfactant therapy using surfactant purified from human amniotic fluid. Dr.
Merritt’s research showed the safety and effectiveness in surfactant therapy in
babies with RDS, which has subsequently led to a dramatic reduction in infant
mortality from this disorder.
NICU Technology: By the late 1980s and early 1990s, neonatal
intensive care units (NICUs) had incorporated much of the advanced medical
technology that we associate with NICUs today. This technology includes
ventilatory assistance for immature lungs, nitric oxide therapy, surfactant
therapy, sonography, incubators, radiant heaters for thermoregulation of
newborns, and special formulas for nutrition. NICUs have the capability of
providing medical, surgical, and nutritional care for gestationally premature
infants, newborns of low birth weight, and compromised full-term infants. NICU
technology has contributed to the tremendous progress in keeping even extremely
premature infants alive and reducing the risks of their subsequent health
problems. The March of Dimes has helped to fund the start-up, equipment
purchase, and life-saving therapies of NICUs through hundreds of research and
community grants since the 1970s.
Campaign for Healthier Babies: First launched by the Greater New York Chapter in the
late 1980s, the Campaign for Healthier Babies became a nationwide program in
1990 whose focus was low birthweight and infant mortality with emphasis on the
cost effectiveness of prenatal care for American society. The campaign had
three objectives: to mobilize community resources, to increase public
awareness, and to target priority populations; and in a multitude of local,
chapter programs it addressed such diverse problems as maternal substance
abuse, teen pregnancy, and lack of access to prenatal care. In 1991, the
Campaign for Healthier Babies also assisted Healthy Start, a federal government
pilot project to reduce infant mortality.
Toward Improving the Outcome of
Pregnancy II: Finding that progress in
reducing birth defects, infant mortality, and prematurity was hampered by
poverty, lack of health insurance, unintended pregnancy, and substance abuse,
the March of Dimes convened a second Committee on Perinatal Health in 1990. The
committee was chaired by George A. Little, MD, and led by the American Academy
of Pediatrics and the American College of Obstetricians and Gynecologists. It
focused on four key areas: 1) care before and during pregnancy; 2) care during
birth and afterwards; 3) data, documentation, and evaluation; 4) financing. Specific
recommendations on the creation of perinatal networks, prenatal care and
related issues were set forth in Toward
Improving the Outcome of Pregnancy II.
Think
Ahead Campaign: This
March of Dimes public health education campaign evolved in the wake of the U.S.
Public Health Service recommendation in 1992 that women of child-bearing age
take 400 micrograms of the B vitamin folic acid daily to reduce the incidence
of neural tube defects in newborns. Think
Ahead, a nationwide pre-pregnancy campaign launched in 1995, supported this
recommendation by teaching women what behaviors lead to healthy pregnancy:
regular medical check-ups, taking folic acid daily and practicing a healthy
lifestyle; all of which are simple steps that women can take prior to pregnancy
to give babies a healthy start.
Folic Acid Campaign: The National Folic Acid Campaign was preceded by the
March of Dimes folic acid education campaign (1994) and the Think Ahead
campaign. After the U.S. Food and Drug Administration authorized adding folic
acid to enriched grain products in 1996 after three years of March of Dimes
advocacy efforts, the foundation initiated a three-year, $10 million campaign
to increase the number of women who know about folic acid and who take a daily
multivitamin containing it. The national campaign spanned five years, 1998 to
2002. The Journal of the American Medical
Association reported that neural tube defects in the U.S. decreased by 19%
after these efforts.
Perinatal Epidemiology Research
Initiative: This $3.75 million
research initiative began in 1998 to investigate the biology and epidemiology
of premature birth. PERI research covers a multitude of medical, psychological,
and social factors responsible for the rising incidence of preterm birth. These
include genetic predispositions, infections, medical disorders, stress, low
socioeconomic status, racism, and violence.
Pittsburgh Prematurity Prevention
Project: This pilot project marshaled
community resources in 1999 to bring public attention to the problem of
prematurity among African-American women in Pittsburgh, Pennsylvania. The
objectives of the program were to educate medical professionals about the
severity of the problem of prematurity in this group; to launch a demonstration
project for the treatment of specific infections in pregnant women; and to
create grassroots partnerships. The project also tested the feasibility of
developing the nationwide Prematurity Campaign in 2003.
Prematurity Campaign: In 2003, the March of Dimes launched its Prematurity
Campaign to confront the challenge of preterm birth, the nation’s most serious
perinatal health problem. Prematurity Campaign goals were to increase public
awareness of the problem and to decrease the preterm birth rate by at least 15%
by 2010. While awareness has measurably increased, the preterm birth rate
itself has also continued to climb: over 520,000 babies were born preterm in
the U.S. in 2005. In 2008, the March of Dimes extended the campaign to the year
2020 in an effort to bring additional scientific, clinical, and public policy
advances to bear in order to solve the problem of prematurity.
NICU Family
Support: March of Dimes first began
its NICU Family Support program in three pilot projects in 2001. This
family-centered program provides information, comfort, and support to families
during NICU hospitalizations, of which there are over 400,000 each year. Implemented
by March of Dimes chapters, over 20 hospitals offered this service by 2005, and
it expanded to hospitals in all 50 states, Washington, DC, and Puerto Rico in 2007.
However, the March of Dimes had committed resources to creating parent support
groups for families with babies in NICUs as early as 1982.
Prematurity Research Initiative: This special research initiative augments the
general research grant program of the March of Dimes and has resulted in 34
grants from 2004 through 2007 focused especially on genetics and
gene-environment interactions relating to the causes of prematurity.
Prematurity Prevention Initiative in
Kentucky: Also known as “Healthy
Babies Are Worth the Wait,” the March of Dimes launched this initiative in 2006
in collaboration with the Johnson & Johnson Pediatric Institute and the
Department of Public Health of Kentucky. The purpose of the three-year
partnership is to concentrate an array of clinical, education, and public
health interventions through six major Kentucky hospitals and local communities
to prevent preterm birth and reduce the preterm birth rate in the state.
