A Womb Without a View
Major birth defects come as a surprise for most parents, but they don’t have to.
Photo by Photodisc/Thinkstock.
Here’s something to freak out expectant parents: Over 2 percent of all American pregnancies are complicated by serious birth defects, and more than 0.5 percent of all fetuses have either a missing or an extra chromosome—a condition that leads to problems like Down or Edwards syndrome. Birth defects are a leading cause of infant mortality in the country, and most problems occur in pregnancies without any obvious risk factors. (For example, most babies with Down syndrome are born to women under 35 years of age.) There are ways to screen fetuses for birth defects like these, but due to a lack of clear guidance from caregivers or policymakers, parents may not find out about them until it’s too late.
Knowing about problems before birth is important for at least two reasons. First, it allows doctors to treat the condition. Take heart problems, where a major artery may be connected incorrectly or a pumping chamber may be missing. Prenatal detection and immediate treatment at birth can prevent the sudden oxygen deprivation and shock that might occur if doctors were surprised by the defect. Some types of spina bifida can be surgically fixed before birth, preventing future paralysis.
A second benefit of prenatal screening is that it gives families a chance to decide whether they wish to continue a pregnancy at all. A huge number of women now choose abortion when faced with major birth defects. In Hawaii, which collects comprehensive information on pregnancy outcomes, more than 90 percent of women who learn they have a fetus with Down syndrome choose to terminate their pregnancies. (Other states are likely to have similar proportions.) Roughly one-half of all women whose babies have brain defects or major abdominal defects also elect abortion. To be sure, many families continue their pregnancies, and love and nurture their babies. Such families deserve support from doctors and insurers. But many families choose differently and they also deserve support.
Most of the time, however, expectant parents never realize there might be a problem. Major heart defects go unnoticed until birth an astounding 70 percent of the time. Three-quarters of all babies with missing limbs come as a surprise to both doctors and patients. More than one-half of cases of Down syndrome are overlooked. The list goes on and on.
Why are we missing so many important birth defects during pregnancy? Insurers and advisory groups don’t support the necessary procedures. To diagnose the vast majority of problems—such as those related to the heart, lung, gut, and brain—one must visualize the fetus’s body by ultrasound during the second trimester. But back in 1993, the New England Journal of Medicine reported results from the so-called RADIUS study (that’s “Routine Antenatal Diagnostic Imaging with Ultrasound”). According to its findings, the blanket use of such ultrasounds “clearly indicate” no impact on a baby’s outcome; parents would do just as well by letting their doctors decide whether to do the scans on a case-by-case basis. As a result, several insurance companies, such as Aetna, don’t cover comprehensive fetal scans for routine pregnancies—a policy that affects roughly one-third of American women. The American Congress of Obstetricians and Gynecologists does not recommend the scan for all women, either. (When my wife was pregnant with our first child, our obstetrician actually advised us to make up a family history of birth defects, since our insurer wouldn’t cover the scan in a normal pregnancy.)
Yet the RADIUS study, now almost 20 years old, shouldn’t guide our approach today. First, treatments have gotten better. RADIUS actually showed that screening increased the number of major birth defects identified by a factor of more than 3—but given the therapies for heart defects and other problems that were available back then, this extra information didn't help. Second, the technology for scanning fetuses has vastly improved. At least one-half of the detections of major birth defects in the RADIUS study came too late for women to consider pregnancy termination; if we did the study over using today's technology, it’s very likely that would change. Third, many parents want to know whether their unborn child has a major birth defect, even if there's nothing they can do about it. (As with many screening tests, false positives worry doctors and policymakers. However, even the RADIUS study showed no measurable harms to babies from ultrasound screening.)
Darshak Sanghavi is Slate's health care columnist. He is chief of pediatric cardiology and associate professor of pediatrics at the University of Massachusetts Medical School as well as the author of A Map of the Child: A Pediatrician's Tour of the Body. Follow him on Twitter.