For decades now, the infant mortality rate in Georgia has ranked among the highest in the nation. Each year, thousands of babies are born prematurely or at a very low weight. Many of them die. While many of the causes are known, health experts are still searching for ways to prevent so many infant deaths. One key may be to bring a more personal touch to the care of mothers and babies.
They're Tiny and the Risk is Great
At the neonatal intensive care unit at Memorial Hospital in Savannah, 40 babies lie swaddled in small beds. Their tiny faces and scrawny limbs sprout an array of tubes and wires. Inside a climate-controlled plastic shell, a boy named Demario fights for his life. Born 3 months early, he's now 3 weeks old, and weighs only a pound and a half. He easily fits in the palm of a nurse's hand. As he recovers from a heart infection, a ventilator breathes for him, and an I.V. drips liquid food. He's not yet able to ingest the breast milk of his mother, who is 17.
His doctor, Linda Sacks, predicts what will come next.
"He'll probably have chronic lung disease. He'll have 2 hospitalizations his first year of life, be at risk for pulmonary infections, developmental delay, and neurological problems. He could die. He's very very high risk."
His mother is young, and she had Chlamydia while pregnant, two of several risk factors that often result in early death for infants. Dr. Sacks and her staff have saved many small and sick newborns like Demario. Advances in medical technology have made that possible, and are a major reason that infant mortality rates have decreased steadily statewide, and across the nation, since 1980. Georgia's infant mortality rate is still very high, in fact the 7th highest in the nation.
Dr. Sacks, "The fact is, we spend lots of research money and lots of real money taking care of these tiny little babies. And if we could just not have them, and prevent preterm delivery, we'd be so far ahead of the game."
Low Birth Weight and Prematurity Contribute to Infant Mortality
The two main causes of infant mortality are that babies are born prematurely or they don't weigh enough. Often, it's both. Birth defects, injuries, and Sudden Infant Death Syndrome are also leading causes. Babies born at a low birth weight - that is, five and half pounds or less - account for more than two-thirds of the state's infant deaths. And the percentage of babies born with low birth weight in Georgia has not decreased at all since 1990. On top of that, a disturbing racial disparity persists. African-American babies are twice as likely as white babies to be born at a low weight, and thus to die.
According to Sacks, "Almost any bad thing that can happen to a baby - being born early, being born small, dying before you're born, dying within the first 28 days of life, dying before the first year, is one and a half to three times higher for African-Americans. That's incredible."
The High Costs of Prematurity
What's also incredible is the financial cost of trying to save the lives of babies born too early. The average stay in a neonatal intensive care unit is more than $150,000 per infant, and can easily reach $500,000. Many of the babies die. Those who live often have cerebral palsy, retardation, and other serious conditions that require lifelong, costly care. That's opposed to a normal term birth, which costs a few thousand dollars. So, the primary goal among public health experts is to prevent so many preemies. To do that, they're honing in on minorities, and mothers most at risk.
PHP - A Prevention Strategy
One such program in southeast Georgia is showing some early success. Perinatal Health Partners (PHP) is a team effort by public health experts, doctors and hospitals to care for high-risk pregnant women. That includes women with serious medical conditions, as well as those with a history of preterm labor or miscarriages. Greta O'Steen is the manager of the program.
Says O'Steen, "The goal of this program is to take very good care of this mother, keep her medical issues under control, so that she can deliver at her local birthing hospital, and does not end up in an emergency situation, and everybody wins."
At the center of the program are nurses who make biweekly home visits to these expectant mothers. Whether the risk is diabetes, drug abuse, or a history of fetal death, the nurses come ready to assess their health and dispense advice.
A Perinatal Home Visit
Recently, nurse Julie Rowell and her assistant, Arnita Mooring, paid a visit to a young woman in Waycross who's an insulin-dependent diabetic. Etoya is 21 years old, and in her second trimester. She?s single, poor and lives with her grandmother. She no longer sees the child's father. Rowell is trying to help Etoya to maintain a good diet and to manage her diabetes. So far today, Etoya has eaten only a pop tart.
Etoya tells nurse Rowell, "I don't have an appetite. I feel full after eating popcorn. Everytime I eat something, I get full."
"When you're pregnant and your uterus grows, it makes your stomach seem smaller, so you fill up faster. That's normal. You eat a small amount, and you feel full. You might be full, but what about your baby?" replies Rowell.
As the conversation continues, Etoya discloses that her food stamps have been cut back. Mooring explains how she can reapply, and get more nutritious food. Then they check her vital signs, blood sugar, the proteins in her urine, and listen to the baby's heart.
"It sounds like a soldier."
"Perfect," says Rowell, "You think it sounds like a soldier? I'll have to use that one."
Promising Numbers
This program of intensive in-home case management by nurses has been operating in 10 counties in southeast Georgia for the past four years. Early data indicates that the intervention is helping. According to an analysis by Georgia Southern University, women enrolled in PHP are significantly less likely to give birth to a low weight baby, or to suffer an infant death, than women not receiving such care.
The numbers are especially promising for African-American and Hispanic mothers; the study shows that for the non-white women enrolled in the program, the odds of an infant death are 80 percent less likely. But this kind of care is labor-intensive, and not inexpensive. The PHP program, currently funded by state, federal and private grants, serves about 200 patients a year, at a cost of $350,000.
Program manager Greta O'Steen says that pales in comparison to the cost of caring for premature babies in a neonatal intensive care unit.
"The average stay is 52 days, and costs around $156,000 per infant. If we can just prevent 3 or 4 per year, in these 10 counties, it would more than pay for this program."
Medcaid Changes Threaten PHP
While public health officials are encouraged by the improved outcomes for mothers and babies in the Perinatal Health Program, the funding for it may run out. That's because of the state's move to privatize Medicaid. The new managed care companies are refusing to pay for the kind of in-home case management that the visiting nurses provide, which had been covered by Medicaid. The HMOs are opting instead to monitor high-risk pregnant women by telephone. Doctors say that's not an adequate way to deliver prenatal care, and will do little to reduce infant mortality.
