Why are there so many preemies?

John Lantos, MD
John B. Francis Chair in Bioethics

For the last twenty years, rates of preterm birth have risen steadily in the United States. Doctors and policy makers used to think that they understood why.

The problem, according to a 1985 report by the prestigious Institute of Medicine, was that high-risk women did not have access to prenatal care. The IOM recommended expanding the Medicaid program and Congress responded. Millions more women became eligible for Medicaid.

Rates of prenatal care went up. Surprisingly, rates of preterm birth did not go down. In 1985, 8% of births were preterm. Today, it is 12%. What went wrong?

The answer reveals much about the complex interaction between biotechnology and people’s choices about how to live their lives. Better prenatal care made childbearing at older ages safer. The average age at which women have their first baby has risen from 23 to 27. Over half of births in the United States are now to women over 30.

Women in their thirties are much more likely to deliver preterm than are younger women, so people’s choices to postpone childbearing lead to many more preterm births. These decisions also lead to higher rates of infertility, the treatment of which also leads to higher rates of preterm birth.

At the same time, advances in neonatal care improve outcomes for preterm babies. Mortality used to be high for babies born a month early. Today, most such babies survive and thrive.

So we have more premature babies and lower infant mortality rates. Is this progress?

It depends upon the measure of progress. Higher preterm birth rates are the price we pay for enhanced reproductive freedom. If we want to lower our rates of preterm birth, we would have to lower the rates at which women over thirty have babies.

Now there’s a bioethical dilemma!

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