They are fragile creatures who venture prematurely from the womb into the blazing lights and antiseptic world of the intensive care unit for newborns.
Their hands are as small as pennies, their heads no bigger than tennis balls. When they cry, they make no sound as they grimace and stretch, reaching vainly for the walls of the womb.
Each tiny body is wired to a respirator, heart monitor and a host of life-support apparatus fueled by a dozen electrical outlets. Their beds are the most expensive in the hospital, running about $2,000 a day in Los Angeles County public medical centers.
One in three of these infants could well have been born perfectly healthy--if only Los Angeles County had ensured that their mothers received adequate prenatal care. Instead, the county's hospitalization costs for such sick infants are spiraling upward, while funds for preventive prenatal care lag far behind the growing need.
And the problem is worsening as more and more babies are being born to mothers in Los Angeles County who receive no prenatal care. Doctors say that good prenatal care consists of between 10 and 13 medical checkups beginning early in the pregnancy and includes tests that monitor the health of the mother and fetus.
At the county's 39 public health clinics, record numbers of pregnant women are seeking medical attention. And while more than ever are getting checkups, more than ever also have been turned away or kept waiting for weeks for an appointment.
At some clinics, women must spend a whole day on the phone simply trying to get through to make an appointment. Many clinics are booked for weeks--and the wait can be as long as four months, one survey found.
"I know many women who can't get an appointment until after their due date!" said Kathy West who surveyed 13 clinics for the Southern California Child Health Network.
The tragic result is that more babies than ever are being born needing extraordinary medical attention--at an average cost 20 times higher than the prenatal care that might well have prevented their early arrival in the first place.
"By shifting more resources to prenatal care, it will pay off in reducing these long-term medical problems," said Dr. Irwin Silberman, director of maternal health and family planning for Los Angeles County. "No one denies you'd save considerable money."
The Institute of Medicine in Washington estimates that for every $1 spent in prenatal care, $3.38 can be saved in newborn intensive care costs. An additional $6 is saved when all costs associated with caring for permanently disabled children are included, according to other studies.
But political concerns, as much as medical considerations, determine public health funding priorities. And prenatal care has not become a pivotal political rallying point.
Meanwhile, dramatic medical advances are enabling doctors to save infants born as early as the fifth month of pregnancy, weighing little more than a pound.
The cost of rescuing these infants is astronomical. Across the nation, as much as $3.3 billion is spent each year in intensive care for infants, according to a study prepared last year for the American Academy of Pediatrics. The brunt of the expense is borne by the taxpayers. And this is expected to increase as a growing number of medically uninsured women find themselves unable to pay for either prenatal care or their babies' medical bills.
The situation is especially acute in Los Angeles County, given the county's financial crunch, its birthrate, which is 18% higher than the national average, its large population of poor women and the increasing percentage of women who receive no prenatal care.
About 10,000 babies a year are born seriously underweight in Los Angeles County, requiring intensive care to survive. At one public hospital in Los Angeles, the cost of keeping an uncommonly small infant on a respirator for 18 months came to $1.5 million. It costs about $36 million a year to operate newborn intensive care units in the county's three biggest public hospitals. The county has set aside $15 million for prenatal care in its $1.3-billion health care budget.
Since 1981, when the county's public clinics began charging fees of $25 for prenatal checkups, the number of women receiving absolutely no prenatal care during their pregnancies has almost doubled. And the percentage of women who began their care during the first critical trimester has declined. The sharpest drop--about 13%--has been among black women.
The most recent statistics compiled for the Los Angeles County Department of Health Services illustrate the close connection between poverty, lack of prenatal care and the high risk of babies being born seriously underweight or dead.