preterm labor and prematurity
Mamas on Bedrest: My Little Lovely is 9 Today!
October 7th, 2011
My daughter is 9 years old today.
She awoke with an exuberance that has been bubbling up since we changed the calendar to October. This past Monday, she said to me, “Mama, it smells like October.”
“What does October smell like?” I asked.
“You know, like Fall and Halloween and….MY BIRTHDAY!!!!!!!!!!!“
She has literally been bouncing around all week in anticipation of her birthday festivities. And she has declared the entire month of October her birthday.
It absolutely blows my mind to see this person, who is a mere 6 inches shorter than me (but I’m only 5 ft tall so…), who has ever increasing curiosity about my make up and my jewelry, who is into all things girlie, pink and frilly and will who be a junior cheerleader tonight with a local high school squad emerge from the tiny 5lb 3 oz preemie who struggled to breathe at birth.
My daughter came into this world emergently and insistently on October 7th, 2002 at 8:03pm, 3 weeks and just under 4 hours shy of her due date. Hers was my most difficult pregnancy and one that on more than one occasion I feared wouldn’t survive. I spotted at about 18 weeks and we thought that I was miscarrying. I had “uterine irritability/preterm labor” around 20 weeks-then again at about 22 weeks and again at about 26 weeks. We batted around the idea of bed rest, but each time we got to that point, my daughter would settle down. It was so like her to want to do things in her own way; flopping around a bit as if searching for the exit, but then staying put. Not much has changed.
I am amazed at the bright-eyed girl who looks back at me with the same fixed gaze that she gave me the first time that I held her in the NICU. She looked at me then as if to say, “Oh, it’s you. Good to see you.” I am also amazed at the determination I see reflected back at me when we’re “locking horns”. She holds her ground and doesn’t back down to me or her father. Oh, she obeys what we say, but as she once told me, “Ya know Ma, when I’m older and all grown up, I’m not going to do this!” Of that I have no doubt. She knows what she wants and I am certain that she will get it!
It continues to be my joy and my honor to watch her grow and mature. (Some days more than others!) Watching her devour a burger and fries when she used to stop breathing when she first started nursing heartens me. To watch her tear out after her brother after all the nights I sat up giving her round the clock breathing treatments to ease her breathing and open her airways fills me with joy. To see her wearing one of my t-shirts and it only hanging just a little bit makes me smile because I remember how hard we worked (and how much I fretted) to get her to gain weight and grow for the first 2 years of her life.
I know now that my daughter never had (and doesn’t have) any doubt that she would (will) make it. It’s always been me who has doubted and believed all the negative news the doctors told me. When the neonatologist suggested that we insert a feeding tube down her nose to give her “an adequate amount of food”, my daughter gave him the same steely gaze she often gives me when she adamantly refuses to do something. Then she drank 40 cc of breast milk her very next feeding. “Take that up your nose!” she seemed to say to the neonatologist. And she was discharged 3 days later.
My daughter never ceases to amaze me and she most certainly inspires me. Happy Birthday My Little Lovely!
Bedrest Veterans, please share your stories of triumph. Mamas on Bedrest need to hear these stories and see our children to know that “good outcomes” really do happen. Share your stories below and give your support. Your story may be just what another mama needs to hold on for another day. Thank you!!
Mamas on Bedrest: Why I Can’t Tolerate The US Infant Mortality Rate
September 14th, 2011
Mamas on Bedrest, I can’t tolerate the fact that more black babies die in infancy than babies of other racial backgrounds. It sickens me. It angers me! It makes me want to cry. As a mama of two beautiful black children, the thought that simply by being African American their lives were at risk in their infancy is horrifying. I am lucky, I know. I have a husband who has single handedly supported our family financially while I was pregnant and beyond. I had the best healthcare. We live in a wonderful residential area and I don’t smoke or do drugs. Yet I still lost 2 children and my daughter was a preterm infant of low birth weight. What’s up?
September is Infant Mortality Awareness Month. We define infant mortality rate (IMR) as the number of deaths of infants under one year old per 1,000 live births. This rate is often used as an indicator of the level of health in a country. According to Index Mundi, the current IMR for the United States is 6.06/1000 live births. The breakdown is male: 6.72 deaths/1,000 live births, female: 5.37 deaths/1,000 live births and these numbers, from the CIA World Factbook, are accurate as of July 12, 2011.
Infant Mortality is often used as an indicator of the overall health of a nation. Looking at these numbers, things look pretty good for the US. But once you start looking “behind the numbers” things get a little sketchier. The United Nations lists infant mortality rates of most of the world’s countries. On this list, the US ranks 34th among nations of the world, and amongst industrialized nations and many of our “western” allies, we rank dead last. Suddenly things aren’t looking quite so rosy.
But we’ve improved. According to the Department of Health and Human Services,
“Overall, the nation’s infant mortality rate has fallen from 20 deaths per 1,000 live births in 1970 to 6.9 deaths in 2003 (preliminary data). The 2002 rate of 7.0 deaths, based on complete data, was higher than the 2001 rate (6.8), but has fallen 8 percent since 1995 and 24 percent since 1990. In 2002, the leading causes of infant mortality were congenital anomalies, disorders related to immaturity (short gestation and unspecified low birthweight), SIDS, and maternal complications.”
The most discouraging fact about infant mortality in the US is that it varies tremendously across racial groups. African American infants have an infant mortality rate of more than twice that of Caucasian and Hispanic infants. African American women, especially teenagers, are more likely to start prenatal care late in the first trimester or beyond and this is a known risk factor for increased infant mortality. The DHHS reports that for mothers 15 to 19 years of age, 29 percent received no early prenatal care in 2004.
According to the DHHS, there are 3 steps that we can implement now to lower infant mortality in the US and to narrow the gap amongst the racial groups.
- Promoting Access to Prenatal and Infant Care – Babies born to mothers who received no prenatal care are three times more likely to be born at low birth weight, and five times more likely to die, than those whose mothers received prenatal care. They also support a number of programs designed to improve access to care including Healthy Start, Medicaid/SCHIP programs, Prenatal care hotlines and immunization programs.
- Promoting Healthy Choices of Known treatments and behaviors that will lower infant risk – DHHS has promoted and implemented many programs proven to increase infant mortality. In particular, DHHS has be a staunch supporter of Maternal and Child Health Services (MCH) Block Grant (Title V). HRSA provides block grants to states to develop service systems to meet critical challenges in maternal and child health, including reducing infant mortality. These state efforts are developed with careful attention to Health Status Indicators and National Performance Measures, among them those that emphasize the importance of adequate prenatal care in improving the health of pregnant women and reducing infant mortality. In an average year, about 60 percent of U.S. women who give birth receive services through MCH programs.
- Increasing Research into the causes and potential cures of infant mortality – In addition to a myriad of research projects addressing specific causes of infant mortality, The Centers for Disease Control and Prevention is examining sociocultural, behavioral and environmental factors, including stress and social support, related to preterm births among African-American women in Harlem, N.Y., and Los Angeles, CA to try to get to the root issue causing the racial disparities in IMR.
Mamas on Bedrest are always in my mind when I read such reports because your pregnancy complications put you and your babies at risk. I think we all have to ask the questions, are we doing absolutely everything to ensure that pregnant women receive all the support and resources that they need to gestate and give birth to healthy babies? In my opinion, the answer is “No”. When a mama on bed rest has to worry about her job, feels forced to leave her bed and risk her child’s life in order to keep her job, is unable to meet her financial obligations and/or cannot access or afford much needed medical care for herself and her baby then we as a nation have failed her and her baby.
The US can redeem itself and lower its infant mortality rate. But it will require that we place the health and well being of mamas and babies before grandstanding, posturing and “political games of chicken” in our legislature. We have to impress upon our legislative leaders that our infant mortality rate is unacceptable and that disparities in IMR amongst infants of different racial backgrounds is also unacceptable. Speak up mamas! Your voices need to be heard! Your stories need to be told! Change will only happen when we demand it and refuse to settle for anything less than the absolute best for ourselves and our children. I won’t tolerate it. Will you?
References:
Preventing Infant Mortality: Fact Sheet The Department of Health and Human Services
Pregnancy Medical Home Program for Mamas on Bedrest?…
August 17th, 2011Not yet, but they would surely be a welcome addition to high risk pregnancy care.
The Pregnancy Medical Home Program is a program initiated in North Carolina that links payment incentives to prenatal care services-specifically those services and treatments shown to lower the incidence of premature birth and that lower maternal and infant morbidity and mortality. The program currently targets providers who care for women who are eligible for Medicaid.
The maternal mortality rate in the United States is abysmal and is far higher than most European Countries. According to statistics presented in a recent blog by Lee Partridge, Senior Health Policy advisor for the National Partnership for Women and Families,
In 1990 in the United States, 343 women died in childbirth; by 2007 that number had increased to 548. A report released July 6 by the National Institute of Child Health and Human Development documents some progress on reducing the incidence of preterm birth, down from 12.8 percent in 2006 to 12.2 percent in 2009. But that rate is still woefully behind the U.S. Healthy People 2010 target of 7.6 percent of all live births.
To date, little has been done that has had a significant impact on these statistics. With the Pregnancy Medical Home Program North Carolina hopes to reverse these turn statistics and turn the tide on maternal and infant mortality.
As previously stated, the Pregnancy Medical Home Program is an incentive program. Providers who wish to become Pregnancy Medical Home Centers agree to provide specific services and treatment during the perinatal period and in exchange, they will receive additional reimbursement, incentives, from Medicaid. The requirements and incentives are briefly outlined in the brochure put out by Community Care of North Carolina, the network of organizations that developed the program. But the aforementioned blog from the National Partnership for Women and Families gives a very good 4 point summary of the program:
Maternity care providers – obstetricians, family practitioners, nurse midwives, community clinics – can apply to be designated as a Pregnancy Medical Home. They must agree to do four things:
- At the first obstetric visit, administer a standardized pregnancy risk tool that provides not only clinical health history but other information about the woman and her situation that could indicate she is at risk of a poor outcome. The questions include poor nutrition, smoking status, use of alcohol or possible physical violence. If a women looks like a high risk, the provider must contact his or her CCNC network and arrange for care management services for that patient throughout her pregnancy. The provider and patient also develop a plan for managing her care.
- Ensure that none of the providers in the Pregnancy Medical Home perform “elective” deliveries – deliveries for which there is no medical reason to induce labor — prior to 39 weeks of gestation. Early deliveries increase the likelihood of infant death, admission to a Neonatal Intensive Care Unit, or life-long health problems for the child.
- Provide the drug 17 alpha hydroxyprogesterone caproate (commonly called 17P) to patients at risk of preterm delivery.
- Aim for a caesarean-section rate for low-risk, singleton births below 20 percent. C-sections expose both mother and child to surgical risk and possible infection, and can create complications for future pregnancies.
The program offers providers an additional $200/patient over and above the normal maternity fees to participate in the program. They receive the first $50 once they complete the initial pregnancy risk tool. The final $150 is paid after a woman has her final post partum visit which must include screening for depression, reproductive health and family planning and any referrals for ongoing care if necessary.
This is an amazing program! While I can appreciate the strategy of attacking the problem of maternal and infant morbidity and mortality in those who are often most vulnerable, women of low income and limited means/resources, I really wish that there had been at least a small portion of the program allotted to high risk pregnancy. I don’t really think that it would necessarily have to change the reimbursement incentives, but to include some provisions/requirements for care for women who do become high risk and require bed rest would have been nice. How about making sure that they have adequate resources for childcare of their existing children? How about at least asking if they are in danger of losing their jobs and assisting them to find resources to make ends meet? How about stress reduction? Maintaining physical strength and endurance while on bed rest? Okay, I am going a little bit off on a tangent, but once again I feel that high risk pregnancy and mamas on bed rest have been overlooked.
But there is a silver lining to this perceived dark cloud. This is the first program of its kind in this country. Other states are following. (See Washington State’s program here.) As a model, its not bad. Hopefully, as other states adopt and tweek the program for their citizens, they will remember the mamas on bed rest, at home (or in the hospital) silently waiting for help and assistance.
What would you add to the Pregnancy Home Program if you were to adapt it for Mamas on Bedrest? Share your comments below.
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