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Mothers are at risk, too
“We have a terrible problem here in Tennessee,” said Chescheir. “Infant mortality is often a direct result of the treatment or care of women in this state. We do not do well right now with women’s health. When pregnant women suffer complications it’s bad for everybody – baby and mom too – and it’s terrible for the state.”

“We have high rates of diabetes, obesity, high blood pressure, smoking, substance abuse, poor nutrition,” chimes in Malee. “Mothers are at risk as well as babies. The maternal mortality rate in the U.S. is higher than that of many other countries in the world, maybe because mothers don’t get diagnosed. One serious societal problem is that while babies and children in Tennessee are well covered by TennCare, Tennessee’s Medicaid managed care program, their mothers are not. Anyone over age 18 is subject to recent cutbacks in the adult coverage of TennCare; so many mothers simply don’t have good care available to them before they become pregnant.”

The single greatest contributor to infant mortality is not the care of the infant, but the health and lifestyle of the mother before the baby is born. Focusing on saving babies once they are out of the womb is getting more expensive every year.

“Finding better, more effective treatments for prematurity was my goal for many years,” said William Walsh, M.D., chief of Nurseries at Children’s Hospital, who bends every ear he can find about his ‘million-dollar babies.’ “But I now realize that it would be better to focus research and energy on prevention of prematurity. The focus on prematurity has to be twofold. We know the money spent on one preemie could potentially prevent 10 preterm births. We are working hard to identify the factors responsible for prematurity. The best outcome is not a surviving preemie but a healthy term baby.”

Inborn vs. Outborn
One of the major issues the state is studying is the “inborn” versus “outborn” population in NICUs. “Inborn” babies are those whose mothers deliver at the same hospital where high level neonatal care is available, so that the prenatal and post-delivery care is as seamless as possible. “Outborn” babies are transported after delivery at another hospital to a hospital with a high level neonatal care, often necessitating separation of mother and baby and subjecting the infant to an ambulance or helicopter transport when the baby is in a tenuous medical condition.

Aschner says a critical factor in deciding where to deliver babies at high risk for surgical complications should be whether there are pediatric surgeons and pediatric anesthesiologists and an appropriate level NICU at the delivery hospital. But 42 percent of very low birth weight babies, and 45 percent of extremely low birth weight babies cared for at the Children’s Hospital are still outborn.

“And that percentage is increasing, which is very concerning, because babies who are brought in from elsewhere have significantly more complications and are less likely to survive than those who are inborn,” Aschner said.

Aschner is quick to point out that compared to other children’s hospitals that care for the sickest newborn patients, the complication and survival rates for all babies treated at the Monroe Carell Jr. Children’s Hospital NICU, regardless of where they were born, are among the best in the nation. That speaks well of the Children’s Hospital NICU and of the birth hospitals in the area, but there is a significant advantage for babies who are inborn and treated in one place, with the appropriate level of care and expertise. Aschner says it is important to explore ways the playing field can be leveled for all babies.

“We know, for example, in the extremely premature infants, bleeds in the brain are three times more common for outborn babies than for those who are inborn. Rates of surgery for potentially fatal gastrointestinal blockages and perforations are four times higher for outborn babies,” said Aschner.

Surgical repairs and post-surgery care are a huge contributor to health care costs, but even for premature or small babies who just need to be supported in a NICU (nurses call them “feeders and growers” because they are so small and underdeveloped), the cost of care runs quickly into the tens of thousands of dollars. In the U.S. the average cost for caring for a preterm infant in a NICU is $33,200.

For the Thurmans, another Bowling Green, Ky., family, it will be more. They are parents of premature twin baby girls, Grace Ann and Addyson Marie. The Thurmans, who have good health insurance, know they will likely never know the full cost of caring for their babies. Patty Thurman’s doctors knew early on that she would need care at the Vanderbilt Maternal-Fetal Care Center.

“My doctor in Bowling Green sent me down here to the Maternal-Fetal Care Center when I was 25 weeks along. He had noticed Grace Ann wasn’t growing like she should,” Patty Thurman said. Because Grace Ann had an underdeveloped placenta of unknown cause, there was no way to avoid a preterm delivery. The goal was simply to last as long as possible without compromising the health of either baby too much for the benefit of the other.

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