Giving Infants a Stronger Start

The United States is spending roughly 18 percent of our gross domestic product on health care — more than twice than any other country — and yet we now rank 26th in life expectancy among developed nations, partly because of our growing rate of premature birth. One in 10 American infants is born prematurely, putting them at higher risk of death and lifelong health problems, according to the Centers for Disease Control and Prevention, and the rate is steadily increasing

Something is very wrong here. The rise in preterm births, due largely to declining health of young, childbearing women, represents the proverbial canary in the coal mine that calls out an urgent warning: The life expectancy of the youngest generation is shorter than that of their parents and grandparents.

There is no amount of conventional medical care that can reverse this alarming trend until we focus, as a nation, on the underlying socioeconomic conditions that are cutting short the lifespan of our next generation.

In the health care system, we call this the “social determinants of health.” The World Health Organization defines social determinants of health as the underlying drivers of the health conditions under which human beings “are born, grow, live, work, and age.” Research consistently estimates that these factors — such as low income, unemployment, unstable housing, unsafe neighborhoods and substandard education — account for 85 percent of health outcomes in a population, while medical care accounts for only 15 percent.

For those of us who treat and fight for premature infants every day, the pattern is frightening. Growing numbers of young mothers are giving birth while suffering from illness and trauma caused by socioeconomic burdens. This barrage of physiological stressors can create a hostile environment for the birth of a healthy baby.

Education level, ethnicity and income are major factors that accurately predict premature birth. Prematurity increases dramatically with lack of education, and the racial/ethnic disparities are equally striking: A white woman with just a high school diploma has a better chance of avoiding premature birth than an African-American woman with a doctorate.

Research also demonstrates that the richer you are, the less likely you will deliver preterm. We sometimes say that the likelihood of prematurity is less related to your genetic code than to your zip code.

Last month, approximately 1,400 of the world’s leading neonatologists and perinatologists gathered around Washington, D.C., for the research conference, Hot Topics in Neonatology, which we’ve convened for more than 30 years. Our agenda spotlighted everything the U.S. health system does right to care for mothers and infants, including amazing advances in complex fetal surgeries, genetic screening and other marvels of tertiary and quaternary care, but there is a gap that we cannot bridge with medical care alone.

Costly new drugs and advanced technologies alone won’t create healthier mothers who will carry their babies to full term and spare them from higher lifelong risk of neurodevelopmental issues, heart disease, asthma, obesity and more.

Beyond the disease burden, our failure to reduce preterm birth is also a financial disaster. From 2005 to 2016, the average cost of a preterm birth increased by 25 percent to $64,815.

Nationally, at least 1 out of every 3 dollars spent on preterm birth is on non-clinical services such as education, social services and labor market losses. While infant mortality is far too high, it also requires highly expensive lifelong treatment for countless premature babies consigned to this fate.

Demonstration models supported by the Center for Medicare & Medicaid Innovation are beginning to test whether we can save money and improve outcomes by connecting patients to social services that give them better access to stable housing, nutritious food and other vital services. This is an important step.

Our leaders on Capitol Hill and across the federal government need to help the health care community confront the question of why preterm births in the United States remain so much higher than in Canada, Great Britain, Western Europe and even Cuba. Together, we must consider ways to create a more holistic health system for mothers and infants by investing in high-quality prenatal and postpartum care for mothers.

This includes ensuring access to all the crucial services mothers need like mental health services, nutrition, housing and transportation. Beyond these basic needs, investments in early interventions such as better child care, early literacy promotion and parenting supports are critical to creating strong foundations for children to grow from.

We must also fully utilize the tools we have at our disposal. Even under current authority, Medicaid, which covers roughly half of all births, can help to address the social determinants of health.

State leaders need to ensure they are using their existing authority to maximize the benefits of their state-based programs for these populations. At the same time, Congress should ensure that the Department of Health and Human Services, including its Innovation Center, has the authority and funding to test novel cross-agency models that can help determine the best approaches to more seamlessly addressing the social and developmental needs.

We, as a nation, must seize the opportunity to change our outlook on health. We must prioritize federal policies and investments that support the health of pregnant women and children and increase training for providers on social determinants of health to help raise a healthier generation of Americans. 


Jay Greenspan, M.D., MBA, is a neonatologist and the chief executive of operations for Nemours Delaware Valley Operations across Delaware, Pennsylvania, New Jersey and Maryland, and he is the Robert L. Brent Professor of Pediatrics at Sidney Kimmel Medical College of Thomas Jefferson University.

Dr. Rahul Gupta, M.D., MPH, MBA, FACP, is the senior vice president and chief medical and health officer at March of Dimes, the nation’s leader in mom and baby health, and in his role, Gupta provides strategic oversight for March of Dimes medical and public health efforts to improve the health of all moms and babies.

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This op-ed has been updated with Dr. Rahul Gupta’s medical credentials.

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