Jennifer Kuelz's baby came too soon when her water broke 29 days before her due date. Ryan, now three months old, is healthy, thriving and meeting milestones of growth and development. But beginning life earlier than expected made for a rough couple of weeks.
Fetal development is rapid throughout pregnancy, and the uterus is the ideal place for that development for, we now know, at least 39 weeks. Babies born at 34, 35 and 36 weeks are considered late preterm births, and babies born at 37 to 39 weeks are considered early term births. But a baby born even a few days earlier than 39 weeks gestation, recent research shows, can have more health problems than a full-term infant born at 40 weeks.
Premature births add billions of dollars to the nation's health care costs, as well as added health problems for infants and mothers. Science has yet to figure out why labor sometimes spontaneously begins too soon, and researchers have yet to develop successful ways to stop it. But changes in hospital and public health policy may be able to significantly reduce the number of late preterm and early term births.
Premature birth is the leading cause of infant mortality in the United States, and accounts for 35 percent of health care spending for infants In the U.S., nearly one in three births is by Cesarean section. The two are related: Inducing labor with drugs can put a woman on a track toward a C-section. In a 2003 study of 14,000 women, induced labor was associated with an increase in C-section rate from about 14 percent among women whose labor started spontaneously to nearly 25 percent among women whose labor was induced.
Kuelz's labor was not induced. It began spontaneously, but early on baby Ryan faced the same problems any infant might confront when coming four weeks too soon. Because of his prematurity, he took what is called a car seat challenge on his first day of life. The American Academy of Pediatrics (AAP) recommends the test for all babies born before 37 weeks gestation, to make sure the baby can breathe properly while seated. Ryan was unable to hold his head up safely for the full 90 minutes of the test. In addition, he had jaundice. He spent four days in the neonatal intensive care unit before he was ready to go home.
Like many preterm babies, he had problems feeding. "Because he was preterm, he didn't have the strength to stay awake long enough to get enough milk," says Kuelz. "I called it 'falling asleep at the switch.'" So she learned to fill a syringe with her breast milk, and then let him latch onto her breast alongside a tiny tube running from the syringe to his mouth, supplementing what he was able to suck.
Not so long ago, people thought that 37 weeks gestation could be considered full-term, close enough to the 40 weeks of a typical pregnancy to call it good. "For most of my career, the goal line had been 37 weeks," says Edward McCabe, medical director of the March of Dimes. That thinking led some women to request and some physicians to schedule inductions or C-sections one, two or three weeks before a woman's due date for convenience, not medical urgency.
"Now 37 and 38 weeks is called early term," says McCabe. "Even at that point, the risk of a baby dying is 1.5 times as great as full term. Why put the baby at risk?" The American Congress of Obstetricians and Gynecologists recommends a policy called hard stop at 39 weeks. It means no elective inductions or C-sections should be planned before 39 weeks gestation.
For the developing fetus, every week counts. A study by Intermountain Health Care , a health care system that performs 30,000 deliveries a year in its Utah and Southeast Idaho hospitals, found that respiratory problems were 22.5 times higher in infants delivered at 37 weeks and 7.5 times higher in infants delivered at 38 weeks than in infants delivered at 39 weeks.
Recent research shows that the final stretch of the long haul of pregnancy is a time when important organ development occurs in the lungs, eyes, ears and brain, and that late preterm infants -- those born just one to three weeks too soon -- are also at greater risk for later learning and behavioral problems .
The costs to society of preterm births in 2006, when the number peaked at 12.5 percent of all births, was $26.2 billion, according to a report by the Institute of Medicine. The number is dropping, down to 11.7 percent in 2011, the lowest rate in a decade, according to the March of Dimes , which, in partnership with the U.S. Department of Health and Human Services, is working with hospitals and health educators to raise awareness about the importance of carrying pregnancies to no less than 39 weeks
"So far, it appears that the attempt to reduce prematurity is also reducing C-sections," says McCabe. While surgical deliveries still account for almost a third of births in the United States, the numbers have remained steady since 2009, following 12 years of consecutive increases. Costs differ dramatically across the country, but the average hospital cost of vaginal delivery without complications in the United States is $2,900, while the average cost of a C-section without complications is $4,700, according to the Agency for Healthcare Research and Quality. Complications for mother or baby, NICU stays and additional hospital days add to the price, as do physician fees.
The rate of premature birth is still too high. The goal set by the March of Dimes in 2012 of no more than a 9.6 percent premature birth by the year 2020, so far has been met by only four states: Vermont, New Hampshire, Maine and Oregon.
Good medical reasons exist for both C-sections and early induction of labor. Women with gestational diabetes, high blood pressure and other medical complications, or a fetus showing signs of distress, can mean an early delivery is medically necessary.
But impatience with the discomforts of pregnancy, out-of-town grandparents eager to buy plane tickets, or physicians' vacations are among the motives for scheduling early deliveries. "Scheduling a birth because in-laws are in town, or some other reason for convenience, isn't wise," says Dr. Jane Dimer, chief of Women's Health and Maternity Child Clinical Services for Group Health Cooperative in Seattle, Wash.
Some insurers are beginning to try to lower rates of both premature birth and elective C-sections by penalizing doctors and hospitals for delivering babies earlier than 39 weeks without a medical reason. Medicare, which covers disabled women, now requires hospitals to report their rate of elective deliveries before 39 weeks. In 2015, the federal insurer will fine hospitals whose rates continue to be high, according to Kaiser Health News.
Other insurers are following suit. South Carolina, for example, had a premature birth rate of 14.1 percent in 2010. So last year, both its Medicaid program and the state's largest insurer, Blue Cross Blue Shield of South Carolina, stopped paying for elective deliveries prior to 39 weeks gestation.
Hospitals around the country are gearing up for the change. A recent survey reported by ACOG in May found that two-thirds of hospitals handling non-emergency deliveries have instituted policies to eliminate elective deliveries prior to 39 weeks gestation. Within HCA Holdings, the nation's largest for-profit hospital chain, 90 percent of the hospitals don't allow elective deliveries before 39 weeks. In Washington state hospitals, after a statewide education effort on the risks of late pre-term birth, the percentage of babies born at 37 to 39 weeks due to early induction or scheduled C-section plummeted between 2010 and 2011 from 15.3 percent to 5.4 percent . Using the carrot of incentives, rather than the stick of penalties, the Washington state Medicaid program offers a 1 percent bonus to hospitals that reduce their rates of non-medical early delivery and C-section.
The nearer to 40 weeks that a fetus can remain safely within the perfect environment of the uterus, the better. The name of the March of Dimes' campaign on the issue sums it up: "Healthy Babies are Worth the Wait."