COVER STORY : Critica Care...
Isis Thomas lay cradled in her mother’s arms in the neonatal intensive care unit at Childrens Hospital, IV lines piercing her tiny arms and stomach and a breathing tube down her throat.
Every incubator and crib in the small 10-bed ICU is occupied with babies like Isis--underweight, underdeveloped infants, many born premature and with several complications.
In hospitals around Central Los Angeles, the vast majority of these tiny, sickly infants in neonatal intensive care units are born to economically and socially disadvantaged mothers, many of whom have limited access to or are unaware of the importance of proper prenatal care, doctors say.
Although drug abuse by pregnant women was once among the most common causes of infants in need of critical--and expensive--neonatal care, other factors are now becoming more prevalent in cases of severely ill newborns, some of whom will be afflicted with minor problems for most of their lives. And those factors--most of which are avoidable--are taking their toll on hospitals, taxpayers and, most important, young lives.
An approximate bill to care for one child for two weeks in a neonatal ICU in a Central Los Angeles hospital runs about $21,000, most of which is paid for by taxpayers because the majority of the parents are poor. While most of the neonatal ICU patients live long and somewhat normal lives, a good portion of them could have avoided ending up in the intensive care units had their mothers taken proper preventive care that costs thousands less, doctors and advocates say.
“There’s no doubt that if you’re underprivileged, you’re going to have a baby with a low birth weight and the chances of your baby going into ICU are going to be high,†said Dr. Gabriel Escobar of the Permanente Medical Group Division of Research in Oakland. “But the issues that lead up to that are not so black and white, there are many gray areas.â€
Isis falls into one of those gray areas. The baby was born full term, and doctors found problems while her mother, Clarice Thomas, was pregnant.
“They took an ultrasound and found out that the baby’s spine was crooked and that I would have to have a (Cesarean) section because she wouldn’t make it through the birth canal,†said Thomas, 39, of Watts.
Four-month-old Isis now suffers from a bad kidney and deformity of her right arm, among other ailments. She must be fed through a tube in her stomach and requires a tracheal tube to breathe, two of several problems that will remain with her for her entire life.
Dr. Arnold Platzker, head of neonatology and pediatric pulmonology at Childrens Hospital, said it is uncertain what could have caused so many complications in the baby. It is a rare case, he said. Most infants in neonatal intensive care units are born premature, with birth weights as low as 1 pound, 4 ounces and multiple problems that sometimes continue with them through life, Platzker said.
The reasons for prematurity in infants are myriad, doctors say, and are not genetically or ethnically dictated. It is partly attributable to lifestyle, poor diet, youth of mothers, drug abuse, health problems such as diabetes, rare genetic problems and lack of prenatal care.
Neighborhood health clinics and agencies face an uphill battle in spreading the word about the necessity of proper care.
Ana Bevilacqua, a health care worker at La Clinica Sunol in East Los Angeles, said the center has a constant flow of more than 200 women from the community who seek prenatal services, many of whom are illegal immigrants. However, Rodolfo Diaz, executive director of the Community Health Foundation of East Los Angeles, said it remains difficult getting some illegal immigrants to seek care because some believe that workers will turn them in to authorities.
Zola Jones of the Crenshaw-based Great Beginnings for Black Babies said that many of her predominantly African American clients who manage to make their way to one of her agency’s two locations often bring a deficient history of medical care with them.
“There is more of a lack of knowledge about prenatal providers,†Jones said. “Women, all women, who are without insurance or not accustomed to getting regular medical care don’t usually know where to turn.â€
Great Beginnings’ workers have started going door to door in neighborhoods, canvassing at-risk pregnant women at check-cashing shops and on the streets to get them to seek care.
“There are definitely people out there who need to come in for help, because the infant mortality rate is still too high,†Jones said. “So we’re trying to get the word out.â€
One recurrent problem is that mothers who are in pre-term labor often do not go to the hospital until it is too late to save the baby from serious complications, said Dr. Xylina Bean, a neonatologist and director of the Rosa Parks Neonatal Intensive Care Unit at Martin Luther King.-Drew Medical Center.
Others don’t seek care until they start showing, or they miss appointments. Neonatologists say even the most basic prenatal care--which includes proper diet, exercise and taking any necessary medication--could make a significant difference in a newborn. Behavior modification is also sometimes necessary to cut out damaging habits.
For example, alcohol and smoking are most detrimental to fetuses, sometimes even more so than drug abuse, doctors say. Women from poor, low-income households smoke more than three times as much as those who abuse drugs or alcohol, doctors say, citing reports from the American Lung Assn. and the U.S. Centers for Disease Control.
“The issue of drug babies is serious, but tobacco is even more severe,†Escobar said. “This is the major cause of low birth weight in the U.S. The combination of drugs or alcohol, tobacco and lack of access (to prenatal care) leads to high-risk indigent babies.â€
Statistics from the U.S. Centers for Disease Control show that low birth weight ranked as the principal cause of death among African American babies.
The department also noted that poverty is largely to blame for higher infant mortality rates among blacks, particularly among families who have limited access to medical care and are not covered by health insurance. In Central Los Angeles, the infant mortality rate for 1992, the most recent figures available, was 8.9 per 1,000 births, compared to 7.8 per 1,000 countywide.
The infant mortality rate is determined by the number of deaths from birth to age 1. It combines the neonatal rate, which includes babies who die between birth and 28 days, and the post-neonatal rate, which covers deaths between 28 days and 1 year.
Bean said a little-known cause of neonatal problems among immigrant mothers is difficulty in acclimating to new environments. The longer they live here, the more they suffer from the medical problems common among Angelenos.
“As you begin to take on the same patterns of behavior as the populations around you, then your risk tends to become the same as that population,†she said.
Bean said that although Latinos currently have a low rate of prematurity compared to African Americans, those numbers are likely to increase in future generations without greater access to prenatal care.
“Stress (in poor communities) has always been put forward as a major problem in the environment. Just the stress of living in a hostile environment clearly plays a role in producing premature labor,†she said. “But whatever the reason, the numbers of preemies is still high and it taxes our resources.â€
At Childrens Hospital, County-USC Women’s Hospital and King-Drew Medical Center, there is rarely a vacant bed among the 160 in their neonatal intensive care units, where 90% of the babies are from impoverished families.
At King-Drew, for example, of the approximately 9,000 babies born each year, about 500 end up in the neonatal ICU, where they are hooked up to ventilators, monitors and feeding tubes.
As she walked through the neonatal ICU at King-Drew, which opened in June, Bean playfully spoke to the dozens of infants and remarked on the progress and outcome of each. Only 18% to 20% of the babies in the unit are drug-exposed, she said.
Many of these tiny, sickly babies are born after just 23 to 26 weeks gestation. They arrive with problems including infections, brain damage and birth defects. And the price tag for care is expensive.
It costs an average of $1,500 to $2,000 a day to care for children in a neonatal intensive care unit. Full prenatal care for one mother would cost the same amount, said Diaz, of Community Health Foundation in East L.A.
The stays in neonatal ICUs range from three days to five months or longer. Many families, including Thomas and her husband, Prue, have to rely on Medi-Cal or Medicare to handle the exorbitant costs.
The Thomases had no medical insurance during the pregnancy or Isis’ birth and applied for Medi-Cal in December to cover the thousands of dollars it has cost and will cost to care for their daughter.
“The head of the (neonatal intensive care) unit said she’ll be having operations until she’s 16,†Clarice Thomas said of her daughter, who has been in the hospital since she was born Oct. 29. “I appreciate the taxpayers helping care for her.â€
Maria Barajas of South-Central relies on Medi-Cal and low-cost social service agencies to help cover the cost of doctors’ visits and a leg brace for her son, Rolando, 4.
Rolando was born five months into his mother’s pregnancy after she had a fall that induced labor. Rolando has trouble moving the right side of his body and was recently diagnosed with cerebral palsy, Barajas said.
With the exception of his leg brace and going to a special school, Rolando does not have extensive problems that require enormous amounts of medical care.
Once Isis goes home, she will need care around the clock, plus various medical machinery to keep her alive, Platzker said. Her parents are preparing their house and themselves for her release from the hospital, which is still uncertain.
“I hate that she’s so sick,†Clarice Thomas said. “I knew something was wrong, but I never anticipated it would be this bad.
“It hurts because I planned to have this baby,†she said. “I watched my health, went to the doctor, took my medication, was very careful. But it just seems it couldn’t have been helped.â€
Some cases are avoidable, doctors and health experts say. The best way is by increasing preventive education and access to medical and prenatal care.
“The portion of the health-care dollar consumed by preventive education programs like prenatal care is inconsequential in comparison to the resources required to care for a drug-impaired infant,†said Dr. Norman B. Duerbeck, director of maternal-fetal medicine at White Memorial Medical Center.
A report issued in December from the recently defunct National Commission to Prevent Infant Mortality said prenatal care is essential to solving the problem of neonatal care and infant mortality.
But the issue goes beyond increasing access to prenatal care, said Bean of King-Drew Medical Center.
“Increasing access alone doesn’t solve the problem,†she said. “It doesn’t allow you to reach the hard-to-reach, at-risk populations. You have to modify their behavior to how they approach health care.â€
Reaching these populations means finding ways to make them want to seek health care, either by bringing it into their housing projects or communities, or developing an incentive program that would encourage them to visit health clinics.
“Neonatal care is a service that is needed and will never go away, because there are those unavoidable incidents,†Bean added. “And disadvantaged families are always going to be around as long as there is a division between rich and poor.
“But there is a very possible way to reduce the number of disadvantaged infants that become part of the neonatal ICU patient list,†she said, “and we have to move in that direction soon or else our resources will be worn thin.â€
On the Cover
An infant is hooked up to a monitor in the Rosa Parks Neonatal Intensive Care Unit at Martin Luther King Jr.-Drew Medical Center. Of the 9,000 babies born at the hospital each year, 500 end up in the neonatal ICU. Many of their ailments could have been avoided, experts say.
“The issue of why there are premature babies and why there are sick babies that are born with multiple problems is not a simple answer,†said Dr. Xylina Bean, a neonatologist. “The important thing is knowing what are the components of the problem and beginning to address each one of those issues.â€
* IN VOICES: Dr. Xylina Bean, director of the Rosa Parks Neonatal Intensive Care Unit at Martin Luther King.-Drew Medical Center, discusses the tremendous need in South-Central Los Angeles for critical care for premature and very ill babies. 22
