Roll of the Dice — an excerpt from Baby E.R.

The flow of children into the Neonatal Intensive Care Unit is always constant — often a flood, seldom a trickle. There is a simple reason for this: One out of ten babies born in America are premature. One out of twelve newborns have dangerously low birth weights. One out of every ten infants will need a stay in NICU care, either because of prematurity, birth defects, infection or both. And these numbers are accelerating: More low-birthweight babies were born at the turn of the century than in any year past, which is one reason why America’s infant mortality rate is an abysmal 25th in the world.

It’s also why the nation’s network of 1,400 NICUs and 3,000 neonatologists is second to none: Supply follows demand. Neonatology, it seems, is a growth business, and likely to stay that way for the foreseeable future.

This is something most expectant parents understandably prefer not to think about, and something many hospitals (the ones with little or no neonatal capabilities) prefer to downplay. One reason for this silence is strictly economic: Most hospitals and HMOs want to deliver babies in-house, with all their glorious billables, without investing in a full-service neonatal intensive care unit or paying to have neonatologists on duty around the clock. The market for delivering the nation’s four million babies each year is among the most profitable in medicine’s beleaguered economic picture (which is why costly emergency rooms — the first and sometimes only option for medical care for the uninsured — are being shuttered all over America, while new and remodeled labor-delivery departments are being minted all the time). Luring pregnant mothers is big business: That’s why many hospitals market their luxurious birth suites and free HBO and gourmet meals, while neglecting to mention that they have little to offer those one out of ten babies who end up needing an NICU. Those children will have to waste precious minutes or hours being transported by ambulance, separated from parents and bumping through traffic instead of receiving life-saving care right where they were born.

This high-stakes gamble pays off for ninety percent of families — most will never know what they missed, or that they have rolled the dice with their babies’ lives, because the odds are with them. But those unfortunate ten percent — and in America, that adds up to more than forty thousand babies a year — find out the hard way that many hospitals boasting state-of-the-art facilities for delivering babies are not so good at handling them once they’re born. Most cannot put a breathing tube in a baby or provide mechanical ventilation when an infant’s lungs fail, and most lack the expertise to administer the gamut of life-saving drugs that are routine in a big, busy NICU — a Level III facility, to use the term of art neonatologists employ. Many hospitals with obstetrical wings may not have a pediatrician in the building around the clock, much less a neonatologist, and those that have them often provide inexperienced medical residents working unsupervised during those inconvenient late-night hours when babies most often seem to get born. It is a hard fact, but true, that seriously ill babies born in hospitals with large, full-service NICUs have a thirty-eight percent better survival rate than sick children born in hospitals with small or no neonatal programs.

Most expectant parents remain blissfully unaware of all this, unless the pregnancy happens to have been identified early on as high-risk, either because of the mother’s age, a medical condition, or a problem with the developing baby. The rest do not find out if they chose well — or chose badly — in their selection of hospitals until it is way too late to do anything about it. Which is why so many small patients arrive in the NICU via ambulance from other hospitals with their parents pale and terrified in the car behind them, unable to comprehend either their child’s illness or why they made the mistake of starting out at the wrong hospital in the first place. Invariably, among the first words out of these parents’ mouths — after, of course, How is our baby? — is: Nobody told us.

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