'I know I failed all the tests and never handed in any finished assignments. So what's your point?'Resident – You know that girl who just found out that she was pregnant and came to us around 26 weeks

Me: Yeah

Resident: Well she has a Hemoglobin A1C (measure of long term blood sugar control) of 11. Turns out she has undiagnosed diabetes.

Me: (Sigh) Go ahead and call high risk OB

The March of Dimes gave Alabama an F in the prevention of pre-term birth. That is not surprising in and if itself. We always get an F. In 2006, when 1 in 5 infants in Alabama were born before 37 weeks, we got a “low F.” At least this year, it was only 1 in 7. I guess that is an F+. In the United States as a whole, the number is a little over 1 in 10, putting us up there with Sierra Leone and Ghana and well below that of Cuba. Best state is California with a preterm birth occurring every 1 in 15 times. “Best practice” countries (the Scandinavian countries are the ones that do it best) have a preterm birth rate of about 1 in 20. The Alabama county with the highest (Bullock, 1 in 4, as a country would be worst in the world), through no coincidence, only has 4 primary care doctors, 2 dentists, and no obstetricians or hospitals that provide care for pregnant women.

Why does preterm birth matter? The vast majority of infants that die are delivered before 37 weeks; some die for no apparent reason. The more births beyond 37 weeks gestation, the lower the infant mortality. In addition, these infants are more likely to be admitted to a neonatal intensive care unit. March of Dimes anticipates that if Alabama were good at preventing preterm birth, we could save almost $500 million, most of it Medicaid.

You ask, why not just do what it takes? Saving half a billion dollars, improving the lives of almost 10,000 children in Alabama. Who could be against it?

Funny story, that. It was during the 1980s in the Bush 41 administration when we as a country identified infant mortality as a problem. Nationally, about 4 in every 1000 newborns were dying in the period of time between birth and 1 month of age. Some great thinkers and law makers got together and suggested that a lack of access to healthcare was a reason that these women were having early and unhealthy babies. In 1986, Congress passed, George HW Bush signed and Alabama Republican Governor Guy Hunt accepted a Medicaid expansion to provide care to pregnant mother because, well, “Won’t somebody please think of the children?” Today, almost 80% of pregnant Alabamians get prenatal care in the first trimester and 49 in 50 receive some type of prenatal care.

Fast forward 30 years later. We now know that, as I told my resident who presented this patient, by the time the woman presents for prenatal care, the horse is out of the barn. About half of all pregnancies are unplanned. Many women suffer from poorly controlled chronic illness that, should they become pregnant, can worsen pregnancy outcomes. Many woman are making lifestyle choices that can cause unintentional harm to their yet-to-be conceived infant but can be changed in a positive manner. To reduce preterm births we need to focus on pregnancy spacing, pre-conception counseling, addressing lifestyle choices that lead to poor outcomes, and planning pregnancy for those with chronic illnesses such as diabetes. There is a term “strong for surgery” that is gaining traction. Women also need to be “strong for pregnancy.”

This is a problem of primary care. We should provide preconception counseling to all women of child bearing age when given the opportunity. We as a society should provide access to primary care for all women of reproductive age (especially those with chronic conditions), and provide outreach to those with conditions related to poor behaviors to correct the behaviors before pregnancy. Our current President, a Democrat, gave us one of the tools (Medicaid expansion to women prior to conception) that is necessary if we want an A. It would still take a lot of work to get that A, as it almost always does. Just by accepting the expansion, we could easily get a gentleperson’s “C.” I suspect instead we’ll take the “F” in hopes that the next test will be on something easier, like football.