Preterm Births and Changing Minds

TIME’s Laura Blue notes that the U.S. has an appalling rate of preterm births (we were ranked 30th in the world in 2005, behind Cuba and Poland) and that prematurity costs us around $26 billion a year – but, she tells us, researchers don’t know why we have this problem. In many cases, there’s an apparent cause – like the mother’s age or health status, the babies being multiples, or a caesarean-section delivery – but doctors still can’t pinpoint a culprit in approximately 40% of preterm births.

Blue highlights the work of Emory University researcher Dr. Alfred Brann, who uses a different strategy than most other researchers studying this issue:

Brann settled on a strategy: focus on the health of mothers instead of that of the babies — and most important, get them before they’re pregnant. It was a turnaround in a field that had previously “jumped over the problem of why are women having very low-birth-weight babies and started on saving the babies,” says Brann. Infant mortality dropped sharply in the U.S. throughout the 20th century, with improvements first in infectious-disease control and later in survival of vulnerable infants. But even as neonatal care improved, scientists were still uncertain why some babies were born so fragile to begin with. Brann felt the single-minded focus on infant health was keeping the problems in women’s health hidden in plain view.

In six months during 2003 and ’04, Brann and his colleagues ran a small pilot project. They enrolled 29 women in greater Atlanta who had recently given birth to a very low-birth-weight baby and gave each mother two years of free primary health care. Women received regular checkups, nutritional screenings and chronic-disease management when appropriate. Women who said they did not want to get pregnant again got free contraception. Participants also had access to what Brann calls a “resource mother,” who helped each woman with day-to-day life improvements, like securing an apartment or enrolling in school.

The trial results were impressive. Compared with a similar group of women who had preterm, very low-birth-weight babies two years earlier, the intervention group had roughly one-quarter as many repeat adverse outcomes — like ectopic pregnancies, underweight babies or stillbirths. The decrease was achieved mostly by reducing unwanted pregnancies overall. “Now a woman who is healthy and has some control over her own life and elects to become pregnant will have a healthier outcome. That’s not rocket science,” Brann says.

The surprise was just how unhealthy some of these women giving birth to preterm infants really were. Nearly one-fourth of the mothers were sick when the program began. They had severe hypertension, sickle-cell disease or uncontrolled heart problems. Even though they would have automatically become eligible for Medicaid once they were pregnant, for these most at-risk women, “pregnancy is too late,” Brann says.

Although research on the causes of preterm birth is still ongoing, I think it’s safe to say that our country’s high rates of uninsurance and underinsurance play a role.  We’ve made important progress by offering Medicaid to low-income pregnant women; according to the Center on Budget and Policy Priorities, expansions of Medicaid coverage to this population led to an 8.5% reduction in infant mortality and a 7.8% reduction in low birth weight. But we’re at a point now where we’ve picked most of the low-hanging fruit, and expanding insurance coverage further – say, to all women of child-bearing age, or even to all adults – will require a significant investment.

Given some of the outraged reactions to the estimate that healthcare reform proposals may cost $1 trillion over the next decade, it doesn’t seem like people have come to terms with the idea that expanding healthcare coverage is going to be an expensive undertaking. Reform proponents face an uphill struggle in convincing colleagues and constituents that it’s worth it, because the Congressional Budget Office, which provides estimates of the costs and savings of various proposals, won’t recognize much in the way of savings from prevention. That’s understandable, since it’s hard to put an exact price tag on the benefits we’ll see from expanded healthcare coverage. Besides, many of the benefits won’t be apparent until people have good coverage for several years, and the CBO is only looking at a 10-year window.

Another hurdle is resistance to helping women make their own choices about when to be pregnant – which Brann identified as the most important factor in the reduction in preterm births in his study. This isn’t just an issue in the healthcare debate; it also comes into play when school districts are making decisions about sex education and employers and insurers are choosing which services their plans will cover.

When there’s a simple solution to a problem, we’re pretty good at adopting it. To further reduce this country’s rate of preterm birth, though, we may have to change attitudes about government’s role in ensuring universal healthcare coverage and women’s ability to control the timing of their pregnancies. How many more premature babies will die before we succeed?