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."