This article was on the news service today.  If the authors read Lactnet
they would *know* why there were more twins born prematurely to the mothers
who had the most intensive health (?) care.

Pat Gima, IBCLC
Milwaukee, Wisconsin

NEW YORK (Reuters Health) - The number of twins delivered preterm--before
37 weeks gestation--has risen dramatically in the US as have the number of
women pregnant with twins who receive intensive prenatal care, researchers
report.

This would seem to be a puzzle since prenatal care is viewed as how we
improve birth outcomes and reduce the number of premature deliveries, lead
author Dr. Michael D. Kogan, of the Health Resources and Services
Administration's Maternal and Child Health Bureau in Rockville, Maryland,
told Reuters Health. The double paradox is that ``although more twins are
being delivered earlier, those are the twins associated with more prenatal
care visits, but those are also the twins who have the best chance of
surviving,'' Kogan explained.

Kogan and his colleagues conducted a review of all twin births from 1981 to
1997--about 1.5 million--and found an almost 34% increase in the number of
premature twin births during this time period, from almost 41% in 1981 to
55% in 1997.

``Twins, almost by definition, are a high-risk group,'' Kogan commented,
yet ``the steepest increase (in premature births) was for twins whose
mothers received the most prenatal visits.'' The percentage of low birth
weight (LBW) twin infants showed a smaller, albeit significant, increase as
well, from 51% in 1981 to 54% in 1997.

During this time period there was also an increase in the number of women
pregnant with twins who had intensive prenatal care--from 8.3% in 1981 to
almost 23% in 1997, the authors write in the July 19th issue of The Journal
of the American Medical Association. Yet among these ``intensive prenatal
care users'' there was an almost 60% increase in premature births, from
35.1% in 1981 to 55.8% in 1997.

Likewise among this group, the rate of premature infants who were small for
their gestational age rose from almost 9% in 1981 to 14% in 1997. However,
the authors note that the rate of premature births remained higher among
those women who made ''adequate'' use of prenatal care.

``These observed trends...indicate that twin births are increasingly less
likely to be delivered at term,'' the authors write. However, the study
findings are ``generally positive,'' Kogan stressed.

``More intensive utilization of prenatal care services may allow for the
earlier detection of problems which require earlier intervention,'' he stated.

``More aggressive and more successful management of twin pregnancies may be
accounting for part of the elevation in the preterm rate,'' the team
concludes. Early intervention may also be saving the lives of many of these
twin babies.

The increase in the use of reproductive technologies and in the number of
births to older women may also be playing a role in the rise of twin
deliveries, the researchers suggest.

Yet the reason for the association between increased use of prenatal care
and premature births of twins remains unclear, the report indicates. Kogan
hypothesized that it may be due to ''changes in obstetric practices and
interventions.'' On the other hand, he emphasized that these changes may be
only ''partly responsible'' for the observed trend.

``The relationship between prenatal care use and birth outcomes can be
rather complex--there may not be a simple association and (it) needs to be
looked at further,'' Kogan concluded.

SOURCE: The Journal of the American Medical Association 2000;283:335-341.



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