A pink bow in her dark hair, a blush on her chubby cheeks, Deborah de Assis looked the picture of newborn health as she slept in her bassinet at St. Luke’s Hospital in New Bedford.
But, despite her robust appearance, Deborah was tethered to monitoring equipment in the intensive care unit. And there she spent the first 17 days of her life. Although she weighed 9 pounds, she was premature, born after 35 weeks and 3 days’ gestation.
Deborah doesn’t fit the typical image of a premature baby. She’s not a scrawny “micro-preemie” fighting for her life. Those babies born at the edge of viability have the biggest challenges, the most dramatic stories and, individually, the highest costs.
Alessandra Silva, with her newborn Deborah de Assis, and her other children: Ricardo de Oliveira, 14, Sulamita de Oliveira, 17, and David de Assis, 5. Born May 14 at 35 weeks at St. Luke's Hospital in New Bedford, Mass., Deborah weighed 9 pounds and had some trouble eating.
But it’s babies like Deborah who are actually driving the epidemic of premature births. Seven out of 10 premature babies are born at 34 to 36 weeks’ gestation. The number of these “late-term” or “near-term” preemies has been increasing over the past decade, while the proportion born before 32 weeks’ gestation has held steady at about 2 percent.
A normal pregnancy is about 40 weeks, and babies born before 37 weeks are considered premature.
At one time late-preterm babies were considered ready to go home right after birth. But doctors found that despite appearing healthy, they’d often end up back in the hospital a few days later.
Compared with full-term babies, late-term preemies are three times more likely to die and significantly more likely — seven times more likely, according to one recent analysis — to have a serious health problem. These include difficulty breathing, eating, staying warm or gaining weight, as well as jaundice, infections and low blood sugar. Because there are so many late-preterm babies — some 374,000 were born in 2005 — the costs of caring for them quickly add up.
The March of Dimes, a charity that in recent years has focused on fighting premature births, says that a baby’s brain at 35 weeks is only two-thirds its size at 40 weeks. What does that mean over a lifetime? A British study of 7-year-olds born at 32 to 35 weeks found that up to a third had problems with muscle coordination, speaking, writing or math. But little is known about the long-term effects of leaving the womb a few weeks too early.
Deborah’s mother, Alessandra Silva, was 33 years old when Deborah was born last May. Silva suffered from gestational diabetes, which can produce larger babies, and carrying a large baby may have prompted her body to go into labor early.
Audio: 'Size doesn't always dictate how an infant is going to fare.' -- Dr. Mara Coyle
“That last four to six weeks of pregnancy is an important time for continued maturation of very important skills,” says Dr. Mara G. Coyle, medical director of the neonatal intensive care unit, better known as the NICU, at St. Luke’s.
Deborah, for example, hadn’t developed the ability to coordinate sucking, swallowing and breathing all at once. She sometimes stopped breathing when she ate.
If that happened at home, Coyle says, a baby might turn blue before the mother realized that something was wrong, or the baby might expend so much energy trying to eat that she didn’t have enough calories left to grow.
THE NICU at St. Luke’s is classified as a “level 2” facility; it offers a less intensive level of care than the NICU at Women & Infants Hospital, in Providence. Babies born before 32 weeks and women showing signs of a very early delivery are all transferred to Women & Infants.
Coyle says the eight bassinets in St Luke’s NICU are always full, and the vast majority of patients are late-term preemies like Deborah, who typically stay for a week to 10 days. But even the high-tech NICU at Women & Infants sees its share of late-preterm babies.
One such baby was Nicholas Chin, born at Women & Infants in January after 36 weeks and 2 days’ gestation. Nicholas was technically just a few days premature, and he was a good size, weighing seven pounds.
Xiulian Li comforts her son Nicholas in the neonatal intensive care unit at Women & Infants Hospital in Providence in January. Though only a few days premature, Nicholas had trouble breathing. Here, his head is inside a hood filled with 100 percent oxygen. Later, he went on a ventilator for 12 days while his lungs got used to breathing on their own.
But Nicholas wasn’t ready to breathe. The lungs are the last organs to mature, and not until late in pregnancy do a baby’s lungs produce their full complement of surfactant — a coating on air sacs that keeps them inflated.
Nicholas was taken to the NICU, where he lay on his back on a warming bed, receiving fluid and nutrition through a needle into a vein in his abdomen. As he struggled to breathe, a hollow formed in his chest, as if his ribcage were about to collapse. The nurses gave him artificial surfactant to help inflate his lungs, and surrounded his head with a plastic hood into which they pumped 100 percent oxygen; normal air is 21 percent oxygen.
But still, Nicholas could not get enough. The oxygen levels in his blood stayed too low, and a doctor ordered the staff to place Nicholas on a ventilator. Instantly, a team surrounded the infant’s bed, tilting his head back and holding his mouth open as they worked a tube down his throat. A nurse gently held his kicking legs. The ventilator brought oxygen directly into his lungs and also forced them open. The baby needed the ventilator for 12 days and stayed in the hospital for 14.
His mother, Xiulian Li, of Cranston, says Nicholas has been healthy and happy since he went home.
At their home in Cranston in October, Xiulian Li cradles her son Nicholas Chin, then nine months old. Born only days premature, Nicholas is happy and healthy.
Nicholas was born early because Li, then 28, had a rare condition known as placenta previa, in which the placenta — the organ that supplies the fetus with nutrients — implants in the lower part of the uterus, blocking the opening through which the baby emerges. Women who have placenta previa must deliver their babies by cesarean section, and Li was scheduled to have the operation at 37 weeks. But she started bleeding a few days earlier, necessitating immediate delivery.
Roughly a quarter of preterm births happen that way: a medical condition threatening mother or baby leads doctors to induce labor or perform a cesarean section. These are called “indicated” preterm births. Three out of four preterm births are “spontaneous”: the mother goes into labor early or the membranes that enclose the baby rupture prematurely.
Little is known about how to prevent spontaneous preterm birth. But lately doctors and researchers have been focusing on indicated preterm births and the question of whether they are always necessary –– whether they are truly indicated.
A study published this year looked at single births from 1996 to 2004 and found an increase in preterm births from 9.7 percent to 10.7 percent. Of the additional premature deliveries, 92 percent were done by cesarean section. That is, the increase in preterm single births occurred primarily among babies delivered by cesarean section, and most were late-term preemies.
Why is this happening?
OBSTETRICIANS say that they’re encountering more pregnant women who are older than 35 or have health problems that can complicate a pregnancy, such as obesity. For example, the rate of gestational diabetes has doubled in the past 10 years because women are larger. Often these complications require an early c-section delivery for the good of the mother or the child.
But Karla Damus, a senior research associate with the March of Dimes and one of the authors of the c-section study, says that increases in health problems don’t explain such a large increase in c-sections. “There’s no evidence that the rates of complications for mothers have gone up that fast,” she says.
Instead, Damus and others suspect that some late-preterm babies are delivered early for comfort or convenience. Attitudes have changed: women and their doctors are at ease with c-sections and may underestimate the risks. Today about 1 in 3 babies is delivered by cesarean, up from 1 in 5 just 10 years ago, and 1 in 20 in 1970. Some early c-sections may occur because the mother, feeling uncomfortable or perhaps wanting to accommodate a relative’s visit, requests the operation, or because the doctor wants the baby out before the weekend or fears something is amiss.
Allesandra Silva checks on her baby, Deborah, at St. Luke's, where she was being monitored for feeding problems.
At one time, doctors tried to sustain every pregnancy as long as possible, Damus says. But today, NICU care has gotten so good that virtually any late-preterm baby will survive. In contrast, the womb can be a scary black box. Sometimes the mother has vague symptoms, and there’s no way to know for sure if something is wrong with the baby. Anyone would prefer a slightly premature baby to a dead one.
“They’re too ready to get the baby out,” Damus says. “We’re just very anxious to avoid problems. We got very comfortable delivering these babies a little bit early.” Often that exposes the baby to health risks.
PRACTICES APPEAR to vary by region. Kentucky, for example, has a high preterm birth rate, and early c-sections are suspected as a major factor. Damus is leading a multifaceted campaign to reduce premature births in Kentucky. Called “Healthy Babies are Worth the Wait,” it focuses in large part on convincing doctors and patients not to deliver babies too early. According to one Kentucky obstetrician who spoke at a meeting there this year, some doctors list laughable reasons for early c-sections, such as “impending labor” and “pre-preeclampsia,” a nonexistent condition.
Recently, UnitedHealthcare, the big insurer, was able to dramatically reduce NICU admissions in six hospitals in the Southwest simply by focusing attention on cesareans. At these hospitals, 20 percent of newborns were being admitted to the NICU — double the national average. Medical records showed that nearly half the babies admitted to NICUs in that region were born from mothers who did not wait for labor to start on its own. Instead, their doctors administered drugs to induce labor, or performed c-sections.
United launched an educational effort, says Dr. Tina Groat, United’s national medical director for women’s health. The insurer reminded doctors of medical guidelines discouraging elective delivery before 39 weeks and gave them comparative information about their own c-section rate and NICU admission rates. Just by sharing this information — Groat says there were no financial incentives or penalties — within two years United was able to cut NICU admissions nearly in half in the targeted region. The insurer is considering taking the campaign nationwide.
United’s experience in Rhode Island, however, is very different. Among United patients here, only 9 percent of newborns end up in the NICU, a hair below the national average, and among United’s NICU babies roughly 38 percent are delivered by cesarean (compared with 48 percent in the six targeted hospitals in the Southwest).
Indeed, obstetricians in Rhode Island are adamant that here, preterm deliveries don’t happen without a clear medical reason. Dr. Joanna M. Cain, chief of obstetrics and gynecology at Women & Infants, says that her hospital — where the majority of Rhode Island babies are born — rides herd on this issue: if a doctor wants to induce labor or perform a c-section before 39 weeks’ gestation, he or she must first justify it medically.
Audio: 'Women are more obese, they're older, they're more likely to have diabetes.' -- Dr. Donald Coustan
Cain’s predecessor, Dr. Donald R. Coustan, looked into the issue in 2006. He reviewed the records of 100 babies born between 35 and 39 weeks’ gestation, and found no evidence doctors were inducing labor or performing cesareans without a verifiable medical reason.
Even so, in Rhode Island c-sections are more common among preterm deliveries than full-term ones; last year, 32 percent of all babies were delivered by c-section, but among preemies alone, the rate was 42 percent.
“Doing a cesarean section doesn’t cause a preterm birth,” Coustan says. “Either you make the decision or nature makes the decision that the baby’s going to be born now, and then you decide what the safest way to deliver is.”
Coustan agrees that obstetricians today are more willing to end a pregnancy early when there are problems. But in his view, that leads to less risk and better outcomes. “I think that’s a good thing,” he said.
MAIN STORY In a blink,
a baby's fate changes
Chrystal Swenson had given birth to two healthy, full-term sons, and she had every reason to think her third pregnancy would go well, too. But when she ended up in the hospital after just 23 weeks, she and her husband faced a choice that no parent ever expects. Read the story
High costs follow rise
in preterm births
Throughout the country, more than 530,000 preemies are born each year, including about 1,500 in Rhode Island. A lot of preterm infants die, but if they survive, they need days to months of intensive care, at costs that can run into hundreds of thousands of dollars or more — expenses that contribute to the price of health insurance for everyone. Read the story
GRAPHIC Every day matters
Track the week-to-week development of the heart, lungs, brain and digestive system in the womb, the impact of premature birth on these organs, and on a preemie's survival Explore the graphic
