National Birth Defects Prevention Month

The focus this year during January, National Birth Defects Prevention Month, is on the judicious use of medicines before, during and after pregnancy.

That goes for prescription and over-the counter drugs, as well as herbal remedies and dietary supplements.

Perhaps two-thirds of women use some kind of medication during pregnancy, according to the Centers of Disease Control and Prevention in Atlanta, Ga. Yet many of the effects of these drugs are poorly understood.

Pregnant women are often excluded from drug trials because of concerns for their unborn babies. As a result, we often know little about how drugs will affect fetuses.

Birth defects affect about 3 percent of babies born in the United States and cause more than 20 percent of infant deaths, according to the CDC.

The March of Dimes

President Franklin Roosevelt founded the forerunner of the March of Dimes, the National Foundation for Infantile Paralysis, in 1938, to raise money for research to find a cure for poliomyelitis, and to care for victims of the disease.

Roosevelt himself was paralyzed after being stricken by "polio," also called infantile paralysis, in 1921. The NFIP itself was an expansion of Roosevelt's Warm Springs Foundation, which sponsored a rehabilitation center for polio victims in Warm Springs, Ga.March of Dimes poster

In 1938, during a radio fund-raising campaign for the NFIP, the entertainer Eddie Cantor coined the term "The March of Dimes" as he urged listeners to contribute their spare change to defeat polio. The term, as Cantor used it, was a play on the popular newsreel series "The March of Time."

The campaign against polio is one of the great medical success stories. The March of Dimes provided the money for the development of two effective vaccines, by Jonas Salk and Albert Sabin. Within little more than a decade, polio was reduced from one of the scourges of the 20th century to a footnote in the 21st.

A global effort to eradicate polio altogether by the year 2000 fell short; the latest target date for eradication, in parts of Africa and Asia, is 2013.

In 1958, with polio under control in the United States, the March of Dimes re-directed its efforts toward a new campaign, to eliminate birth defects. The following year, Dr. Virginia Apgar, who in 1953 had devised a scoring system for the well being of newborns, joined the organization that was then still headed by President Roosevelt's former law partner, Basil O'Connor.

For the past half-century, the March of Dimes has been involved in virtually every effort undertaken to improve the health of babies in this country and, more recently, around the world.

The March of Dimes supported research that showed that a pregnant woman's consumption of alcohol could cause birth defects, as well as the development of surfactant therapy for premature babies with respiratory distress, to name a couple.

Image from Wikimedia Commons

A perfect baby every time

Every pregnancy begins with a 3 percent chance that the resulting baby will have birth defects, and that is before individual genetic and environmental histories come into play. Some birth defects cannot be prevented or fixed. Medicine cannot work miracles.

That's the message in "The perils of the imperfect expectation of the perfect baby," an article in this month's American Journal of Obstetrics and Gynecology. Prospective parents need to understand that "perfection in pregnancy is not attainable now or even in the foreseeable future," according to the article's authors.

Doctors too can get drawn into "expecting more from medicine than its limited diagnostic and therapeutic capacities justify," say the article's authors, led by Frank A. Chervenak MD. Not only that, but "many pregnant patients are optimistic about the advances in medicine and are confident that their physicians will solve all problems that could occur with their pregnancy."

In fact, everyone needs to get in touch with "the inherent errors of human reproduction, the highly variable clinical outcomes of these errors, the limited capacity of medicine to detect these errors, and the even more limited capacity to correct them," the article states.

The expectation that a perfect baby can eventually be taken away from every pregnancy "assumes powers of medicine to control human reproduction that medicine does not possess," the article states.

The mother of the Apgar score

Virginia Apgar MD devised the simple observational test that bears her name after watching doctors swiftly give up on struggling newborn babies, leaving them to die, Atul Gawande writes in his book, Better. At the time, a few years after World War II, one in 30 births in the United States ended in the infant’s death.

Virginia Apgar

Dr. Virginia Apgar

The Apgar score, introduced in 1953, is a 10-point scale for assessing how a newborn baby is doing — first with the birth process, and then with adjusting to the world. It is given in hospitals one minute after birth, and again at five minutes. A robust baby might garner 10 points, but a baby with an Apgar score of four or less draws serious concern and, likely, vigorous intervention.

Dr. Apgar’s scoring system transformed delivery, Gawande writes. “Even if only because doctors are competitive, it drove them to want to produce better scores—and therefore better outcomes—for the newborns they delivered,” he writes.

The daughter of a Westfield, N.J., insurance executive, Dr. Apgar graduated from Mount Holyoke College in 1929, and began medical school at Columbia University’s College of Physicians and Surgeons, where eight of her classmates were women and 81 were men. She began a surgical residency but, in the depths of the Great Depression, decided it might be difficult, especially as a woman, to make a living as a surgeon.

Dr. Apgar enrolled first in a course for nurse-anesthetists and then in Dr. Ralph Waters’ seminal residency program in anesthesiology at the University of Wisconsin in Madison, followed by a stint with Emery Rovenstine at Bellevue Hospital in New York — strong training for the day.

She founded the anesthesiology program at Columbia’s College of Physicians and Surgeons. However, when the program became a department, Dr. Apgar was passed over for the job as chairman, in favor of a man. She did become a full professor, though — in itself an accomplishment at the time — and was a pioneer in obstetrical anesthesiology.

Dr. Apgar saw a number of birth defects during the thousands of births she attended, and in 1958 she went back to school in public health at Johns Hopkins’ medical school in Baltimore. In 1959, Dr. Apgar joined the March of Dimes in its campaign to eliminate birth defects.

Dr. Apgar never married. Her entire life, she was famous for intelligence, energy, empathy and a great sense of humor. She was still working on behalf of the most vulnerable babies when she died in 1974, at the age of 65, of liver failure.

Gawande’s chapter about Dr. Apgar, “The Score,” also ran in the New Yorker.

A “monstrous” birth

Having a baby with a birth defect could get you killed in colonial America, and attending such a birth as a midwife was also perilous.

Anne Hutchinson, the subject of the previous post, was already in serious trouble in Puritan Boston for her unorthodox ideas when she was summoned along with another midwife, Jane Hawkins, to the childbed of her friend, Mary Dyer, who had remained loyal to Anne. On that day in October of 1637, Mary bore a deformed, stillborn baby girl.

Mary Dyer

Statue of Mary Dyer in Philadelphia

The birth of a "monster," as such a child was called in colonial America, was seen as a sign of God's disfavor, at the very least. The charge that the mother and her attendants had been consorting with the devil was always possible, and the penalty for witchcraft could be death.

Anne asked her old minister for help -- John Cotton, who had sided with the religious authorities against her. Summoning some of his old friendship for her, he advised the secret burial of the dead infant.

However, in March of 1638, when Anne was excommunicated and sent from the congregation, Mary got up and followed her. Someone at the emotional scene, perhaps a fourth woman who had been present at the birth, cried out that Mary had borne a monster. Governor John Winthrop's interest was piqued.

Winthrop interrogated Cotton, who confessed his role in covering up the birth. Winthrop had the child exhumed.

In his journal, the governor reported that the dead infant had, among other features, "four horns, hard and sharp," two mouths, and three claws per foot where her toes should have been.

The birth was, Winthrop declared, evidence of  "the Lord declaring his detestation of their monstrous errors." By this time, however, Anne and her followers, including the Dyers, were safe in Rhode Island.

In 1660, long after Anne's death, Mary Dyer was hanged on Boston Common for the crime of having become a Quaker. She had come back from Rhode Island knowing she would likely be executed, to strike a blow for religious freedom.