The Cry of the Children
While we rant about our failing healthcare system and toss about muddy statistics on infant mortality as proof, we may be ignoring a pediatric crisis looming larger each year: the more than half a million babies coming into the world weeks to months before they should. Devoid of their mother's womb, these little ones, some smaller than the palm of your hand, confront risks and suffering simply not captured by the statistic released earlier this year: Preterm babies, those born six to 20 weeks too soon, make up over 12 percent of America's newborns.
Some of them die. But most do not, which creates an irony. In the face of a rising rate of preterm births, the infant mortality rate in this country is not rising but falling. It is because of an astonishingly capable level of healthcare. That care comes from neonatology, one of medicine's highest-tech, highest-touch specialties, nestled in the heart of our children's hospitals.
More than 40 years ago, neonatal intensive care units emerged to address the needs of sick newborns. Back then, all too many were robust 6-pounders born a month or two early, dying because of premature lungs. Our infant mortality rate was four times what it is now.
Advanced NICUs gradually emerged, geared to receiving large numbers of very sick babies from surrounding hospitals. These NICUs bring expertise and technology that other hospitals just can't provide. The ECMO system for oxygenation is a good example. In essence, it's an artificial lung, using tiny heart-lung bypass machines tailored to infants who can no longer breathe even with the best respirators.
Neonatologist Billie Lou Short, director of the NICU at Children's National Medical Center in Washington, D.C., pioneered ECMO there. She talks about one of her earliest "ECMO babies," now headed for medical school, who is enrolled in a study of long-term outcomes for NICU graduates. This has become a major research thrust; preemies often confront health problems later, like asthma or developmental disorders.
Short points out that in the early years, 2-pound babies barely had a chance, and now 95 percent survive to live full and happy lives. She is convinced that we will see similar success with micropreemies. These are babies who weigh less than a pound.
Despite the efforts of caring specialists, U.S. infant mortality, as noted, is not the lowest in the world. Also as noted, this fact is cited incessantly by politicians and pundits to attack U.S. healthcare. But it is a nonfact.
Count again. We report mortality rates based on World Health Organization guidelines for a live birth. A baby fully separated from the mother and showing any sign of life, even a single breath, counts as a newborn, regardless of other factors. Many developed countries with better infant mortality rates don't follow that to the letter. They purposely exclude deaths according to weight, degree of prematurity, or how long the baby lives.
Be serious—if you try to save sicker babies, you will have higher mortality. Some are catching on. In a recent study, researchers found that by correcting for weight, the mortality risk was the same in the United States as in Canada—and maybe even a bit better—despite our northern neighbor's welfare entitlements and universal healthcare system.
Saving premature infants is expensive. The United States spends $5.8 billion, about a quarter of all expenditures for pediatric hospitalizations, on care of neonates. On that, not surprisingly, we lead the world. But some argue we spend too much on neonatal care and not enough on prevention, which they maintain would reduce the number of preterm babies.
Granted, we must also focus on bringing babies to term and educating people about controllable risk factors that lead to problem pregnancies: smoking, uterine infection, and drug abuse. Pregnancy in the teen years and in middle age. And fertility treatments that increase the risk of twins and other multiples from a uterus designed for babies one at a time.
But how is this a case of either-or? We've had close to a doubling in the rate of twins since 1980 because of fertility drugs, and few people think of twin babies as sick and vulnerable. Yet half of them are premature and need intensive care. One of 6 of the infants who die in the first month is a twin. We can do better.
To paraphrase Elizabeth Barrett Browning: With their pale and sunken faces, we have heard our babies cry. As a nation, we have made a choice, as we have for our seniors, to support the care of the smallest and weakest. It's the right one.
This story appears in the September 3, 2007 print edition of U.S. News & World Report.