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Photo by Tracie Morris/Young Studio
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This baby girl has bulked up to 3 pounds, 3 ounces.
That's a 7-ounce gain since Thanksgiving Day, her birthdate.
Compared to many of the other babies around her, this girl
is a giant. Each temperature-controlled crib contains a yellow sign giving the
infant's weight at birth. The surrounding infants were much smaller. One pound,
6 ounces, reads one sign. Two pounds exactly. One pound, 14 ounces.
Inside the incubator, her chest heaves as she sleeps. She's
clad only in a diaper. Her bare abdomen is dotted by three coin-size white patches.
Each patch is adhered to her skin and connected to a thin wire. As she inhales
and exhales, the three wires sway, monitoring her heart, her breathing and her
temperature.
This is the neonatal ward in the Medical Center of Louisiana,
which encompasses both Charity and University hospitals. Level I is the well-baby
nursery, where healthy babies only stay about three days before heading home
with their mothers. Level III holds the smallest and the most ill, the babies
requiring round-the-clock, one-on-one attention from nurses in the neonatal
intensive care unit (NICU). Level III infants stay in the hospital for a little
over a month on average, with costs estimated at around $500,000 per child.
Level II, called the step-down nursery, is for babies who don't necessarily
need 24-hour hands-on care but do need to be closely monitored. The stay in
Level II averages two and a half weeks.
Doctors here deliver 70 percent of the babies born in Orleans
Parish each year. Nearly every day of the year, one of those newborns will require
a stay in the NICU.
In 1994, Mariah Bickham, the second smallest live baby born
in the United States, was delivered here. She weighed 13 ounces, too small to
accommodate even the smallest breathing tube in the NICU. Gail Gibson, head
of Maternal Child Health for the hospital, remembers little Mariah well. Gibson
holds out one of her hands -- they're not large, but Mariah could easily fit
in one of them, she says. "We didn't know if she was going to make it," says
Gibson. "But she was a little tiger." Mariah is now a healthy young girl. A
photo of her as a newborn now hangs outside the NICU.
Mariah was unusual, but only by several ounces. One out of
10 babies born in this state is low birthweight -- less than 5.5 pounds. That's
the second-highest rate in the United States, according to the Kids Count data
book, published annually by the Annie E. Casey Foundation. The 2002 Kids Count
book compiles 1999 governmental birth, health and socio-economic data to rank
and profile each state on a number of factors that affect child health. Locally,
Agenda for Children is examining similar data at the parish level and will publish
a separate Louisiana Kids Count book early next year.
City-by-city Kids Count data shows that nearly one out of five
-- 17.4 percent -- of the 7,663 babies delivered in New Orleans were born before
37 weeks of pregnancy, which is considered full term. Preterm labor connects
closely with low birthweight, because premature babies emerge before they're
fully grown and thus are often small in size. Preemies are also more at risk
for a number of problems, including chronic lung disease, brain damage, mental
retardation, cerebral palsy and blindness. That's if they survive. According
to the National Center for Health Statistics, premature birth and unspecified
low birthweight are among the top causes of neonatal death, right behind birth
defects, which tops the list.
Yet even top experts are often perplexed about the causes for
early labor. "For nearly half of premature births, no reason can be found,"
says Gibson.
The young rapper Katana steps out onto the porch of the shotgun
house.
"It's hard being a young mama," she raps.
"All the pressure from the baby drama./ No more hanging out with your girlfriends./
A whole new world. A different outlook./ Everybody's tripping. Money's slipping./
Just like that you've grown./ One your own. No, never that./ Believe me girl,
you're not alone./ Pace yourself. Get it together./ Need help? Dial 1-800-251-BABY."
This is a television spot for Partners for
Healthy Partners, formed in 1993 to combat infant mortality in Louisiana. They
made the spot last year. Now, young women approach Karis Schoellman at health
fairs and sing the lyrics, written by Katana's friend Renard Johnson. "If I
went out on the street and sang it, young women would know it," says Schoellman,
the project director for Healthy Babies, an initiative of the state Office of
Public Health's Maternal and Child Program.
Schoellman's specialty is social marketing.
She teaches it at the Tulane School of Public Health and practices it in the
Office of Public Health, where she takes advertising and marketing techniques
and applies them to public-health campaigns.
The target of her efforts is young women ages
15 to 20. That's because Louisiana has one of the highest teen pregnancy rates
in the nation. In New Orleans, nearly 20 percent of all births are to teens.
Teens are more likely to go in late for prenatal care, partly because about
half of their pregnancies are unintended. They are also more likely to smoke
and less likely to gain enough weight during pregnancy. These factors can lead
to more low-birthweight babies and higher infant mortality.
Schoellman's focus is simple. "When a woman
is pregnant," she says, "we get her prenatal care. If she has bad behaviors,
we get her to change them."
Young women won't necessarily take a home-pregnancy
test and go straight to the doctor, she says. They need an intermediate step.
Which is where the Helpline (1-800-251-BABY) comes in. Older women use the Helpline
too, she acknowledges, but for very specific information. "Teens want it for
a friendly voice," she explains. "The people at the Helpline become kind of
a cheerleader, someone who coaches them through getting a doctor's appointment."
"Look at black women across geography. It
doesn't matter who they are or where they go," says Gail Gibson. Wherever you
find a black woman, she says, you will find a woman who is twice as likely as
a white woman to go into premature labor. This racial gap persists across all
ranges of age, education, prenatal care, and marital status.
Within the last few decades, experts in the
field looked at this situation and hypothesized that if more women had consistent
prenatal care, low birthweight numbers would drop. In 1986 and 1989, the federal
government expanded Medicaid to cover pregnant women at higher income levels.
Then in 1991, the U.S. Department of Health & Human Services announced a community-based
program, Healthy Start, to provide care beyond traditional medical services.
The intent of Healthy Start was to reduce
infant mortality by focusing on services for substance abuse, smoking, domestic
violence, mental health and early treatment of sexually transmitted diseases
and infections. Outreach workers would go into the community and find women;
case workers would then follow them through their pregnancy. Fifteen cities
with high rates of mortality were chosen to launch the program. New Orleans
was one of them.
Great Expectations, the Healthy Start project
designed in New Orleans, is praised in Reducing Infant Mortality: Lessons
Learned From Healthy Start, the federal government's six-year evaluation
of those first 15 cities. From 1991 to 1997, the number of pregnant New Orleans
women who had absolutely no prenatal care dropped from 7.3 to 2.2 percent. The
number of local women who received early -- first trimester -- prenatal care
rose from 67.2 to 77.3 percent. Infant mortality dropped by 38 percent. But
the low-birthweight number for Orleans Parish went nowhere. In 1991, it stood
at 12.8 percent. For 1999, it was 12.9 percent.
Across the country, infant mortality rates
have dropped greatly during the last two decades. In a large part this is because
of neonatal units. Between 1985 and 1995, the survival rate for the smallest
babies -- called "micro-preemies" -- rose by 50 percent. Still, the proportion
of low-birthweight babies in the United States has barely changed since the
1960s.
Gail Gibson knows about this first-hand. "My
first pregnancy, I had preterm labor from 29 weeks on," says Gibson. "I was
doing everything I was supposed to do and so they were able to start me on medication
and put me on bedrest." She ended up having a full-term baby.
Jenise Alexander was not so fortunate. Her
baby, Sharreiff, was born on Aug. 30 and admitted into NICU. He weighed 1 pound,
13 ounces. Right now, he tips the scale at 5 pounds, 5 ounces and is propped
up against her leg, feeding from a miniature bottle. Alexander wasn't able to
take him out of his crib and hold him like this until the beginning of November.
Alexander discovered she was in labor at 22
weeks, when she went to her regular prenatal appointment. "I went to the clinic
and the doctor told me that my water bag was bulging out," she says.
She'd had contractions, Gibson explains, but
hadn't recognized what they were. At the hospital, staff was able to delay Sharreiff's
arrival by three weeks. That isn't always the case. "Once the cervix starts
dilating, it's like stopping a train coming through a tunnel," says Gibson.
That's why it's vital that women learn what contractions feel like. If women
realize that they're in preterm labor, they can get help before it turns into
a preterm birth.
Maternal Child Health does lots of outreach
work through its Care Beyond Our Walls program. Gibson's staff speaks
at churches and schools, and they hold health fairs complete with an "Ask the
Doc" booth and a baby fair with trimester-specific education and lots of prizes.
Every Saturday, Operation Inoculation immunizes children for free.
Sometimes the solutions have nothing to do
with health care. Gibson recalls one patient, a pregnant 15 year-old. Teenagers
often want to stay slim and so it's hard to get them to gain the 25 to 35 pounds
recommended for average-size pregnant women. This young woman was not gaining
weight. Each time, the staff would talk with her about it and go over the four
food groups and proper nutrition. Still, no gain. So Gibson sat down with the
young woman and talked with her for awhile. "It turns out," she says, "that
they didn't have a refrigerator, just a small ice chest, so her mom could only
buy what fit in the ice chest." They got someone to donate a refrigerator, says
Gibson, and the young woman began to gain weight and had a full-term baby.
A happy ending, but one that illustrates that
some women's health behaviors are rooted elsewhere. "Sometimes there are other
social things going on," says Gibson.
At one point last summer, three cashiers in
a French Quarter grocery store were visibly pregnant. Two women went to term
and delivered healthy babies.
But Nicole Jackson went into premature labor
and was dilated enough upon her arrival at the hospital that she delivered two
months early. Her little girl, E'maja, weighed only 3 pounds, 6 ounces when
she was born. She spent about a month in the NICU at University Hospital before
coming home.
At her job, Jackson spends six hours on her
feet in front of a cash register, facing a continuous stream of customers. "My
life isn't really stressful," she says. "But it can be stressed in here." It
has crossed her mind, she says, that the fast pace and six-hour shifts might
have contributed to her baby's early arrival.
That makes sense, says Dawn Misra, an associate
professor of health behavior and health education at the University of Michigan.
Misra's research has primarily focused on poor and minority women and their
birth outcomes. She, like other researchers studying low birthweight and preterm
labor, is examining the role stress plays in pregnancy.
One of the big areas Misra is concentrating
on is racism. Some recent research suggests that low birthweight and preterm
labor are indeed a result of stress -- the stress of being a black woman. "Racism
may be even worse for a higher-educated, higher-income black woman," Misra contends,
"because she may be more likely to come into contact with the white world."
Poverty brings its own unique stress, a chronic
sort, she says. The studies she's done of low-income women consider the role
of spending-money. "We didn't just look at having enough money for heat and
hot water," Misra says, "but also what we called 'nonessentials' -- things like
having a little extra money to go out to dinner with. Having enough money to
save a little money. Being able to buy your child toys. For low-income women,
not having the extras was a factor that predicted preterm birth."
Misra and her colleagues are also examining
chronic disease -- asthma, hypertension, and diabetes -- and how it affects
the pregnancies of low-income African-American women, who experience those conditions
at higher rates than white or higher-income people. To combat this, the United
States could begin widespread well-women care, to improve women's health even
before they're pregnant, Misra says. "Baltimore was debating taking women who
had an infant death and providing them with primary care for the next year,"
she says.
At this point, very few low-income nonpregnant
women get Medicaid, says Misra. In Louisiana, as of Jan. 1, pregnant women in
this state are eligible for Medicaid even if they earn 200 percent of the federal
poverty level. Nonpregnant women are eligible only if they're much poorer. "It's
a slippery slope," says Misra. "Do we want to take care of women just because
they could be future child carriers? But if women are healthy from childhood
on, it would improve infant outcomes."
Typically, well-baby experts advocate some
physical activity during pregnancy. Misra and colleagues looked at what low-income
women did, physically. "We had a study that looked at what I call 'activities
of daily life,'" she says. They found that climbing stairs and "walking for
a purpose" -- to get to a bus because you didn't have a car or climbing the
stairs in your building -- seemed to increase risk of preterm birth. Leisure-time
physical activity such as dancing decreased the risk.
"One is a choice and one is not," Misra says.
"If the elevator isn't working in my building, I have to walk up the
stairs. When I use a stairclimber in the gym, it's on a day I feel good and
it's something I choose to do."
Should workplaces be more accommodating to
pregnant women? "Once again, it's a slippery slope," Misra says. She wouldn't
want to return to the workplace practices of the 1950s, when women were banished
from the workplace as soon as their pregnancy started to show.
Nicole Jackson's shift is over for the day.
Her feet are tired, she says, and she can hardly wait to sit down. She removes
her cash-register drawer and brings it to the back to count the money and reconcile
it with the receipts.
If she had it to do over, she says, she wouldn't
mind an adjustment of duties during her pregnancy. "Lighter work, yeah," she
says, counting a stack of one-dollar bills. "Lighter work, sitting down."
