Hospitals Try New Ways to Lower Premature Birth Rates

Some hospitals are refusing to allow elective births earlier than 39 weeks -- and some insurers are refusing to pay for them.

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Babies born even a few days before 39 weeks gestation are at risk for health problems.

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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.

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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.

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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.

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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.


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