Joia Crear-Perry was a 25-year-old medical school student when she gave birth to her son at just 22.5 weeks, despite her healthy habits.
Premature births are thought to be a leading cause of infants dying before they reach one year of life, and Louisiana is among the worst states in the nation in both categories. Some health care officials are celebrating the state's recent strides to reduce the number of infants who die here before they turn 1 year old, as the rate nose-dived by 25 percent between 2005 and 2014, the latest year for which the state has statistics on vital records.
But the state's numbers are still troubling. Although Louisiana averages 7.63 per 1,000 babies who die before they are 1 year old, the national average is 5.82 per 1,000.
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The news is even worse for Louisiana's black babies, who die at a rate of 11.28 per 1,000. Crear-Perry, who is black, did not fit the tropes often associated with women who have premature infants: She did not smoke, she was not obese and she was well-educated.
Yet her son, Carlos, weighed 1 pound when he came four months early. He needed heart surgery and a tube to breathe. But he survived and is now a 20-year-old whom his mother describes as "loved and loving and smart and kind."
Crear-Perry knew she wanted to become an OB-GYN before having him, but he inspired her to go full-force, and she now runs the New Orleans-based National Birth Equity Collaborative. Her group focuses on reducing black infant mortality and black maternal mortality with research, advocacy and more.
"Our black babies die at about twice the rate of white babies and are born at twice the rate of prematurity or more," said Louisiana Department of Health Secretary Rebekah Gee, who is also an OB-GYN.
Overall, the Annie E. Casey Foundation — which focuses on disadvantaged children — ranked Louisiana 46th for infant mortality rates in 2015.
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Gee, who frequently touts the benefits of Medicaid expansion, said the increased access to health care for 400,635 people in Louisiana also should make for healthier babies in the future. She and Crear-Perry said it's usually too late to make a woman become healthy once she's pregnant.
As the former director of the state's Birth Outcomes Initiative, Gee pointed to areas that she says helped contribute to the recent decline in the state's infant mortality rates. Among them are preventing premature births, teaching more people about safe sleeping habits for babies, visiting homes for first-time moms and administering a drug to women who previously have had premature births that can help reduce their chance at having another one.
Putting an end to elective early births and elective cesarean sections has been one of the state's most important steps, said Gee and Cheri Johnson, vice president of perinatal services at Woman's Hospital in Baton Rouge.
Campaigns called "Healthy Babies Are Worth the Wait" and "Go the Full 40" encouraged both women and their doctors to wait for their due dates rather than electing to schedule their birth at more convenient times for both the mother and the doctor.
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Gee said women are more prepared for vaginal deliveries, rather than C-sections, when they wait their full term. Babies' brains and lungs are also still developing late into a pregnancy.
Woman's Hospital started a policy in which women could not elect to deliver their babies before 39 weeks without a compelling medical reason, and it saw a 10 percent decrease of neonatal intensive care unit admissions between 2007 and 2010 for infants who were born between 36 to 40 weeks gestation. Baton Rouge General Medical Center said its policy is more or less the same.
"To get a mother to full term and having that healthy delivery takes a healthy nine months before delivery," said Louis Minsky, the chief of staff at Baton Rouge General and a family physician. "If you're complicated with medical problems like hypertension or diabetes or smoking, and the chances of going to term are less likely."
Parents of babies in the NICU at Baton Rouge General learn CPR for their infants, who are more likely to experience sudden infant death syndrome. And Woman's has placed more focus on breast-feeding, which Johnson said can lower the chances of SIDS.
The number of Woman's Hospital patients who breast-feed has ticked upward from 54.6 percent in 2002 to 72 percent in 2016, according to numbers the hospital provided. Louisiana ranked worst in the nation in breast-feeding on the CDC's 2014 report card but then leapfrogged over Mississippi and ranked 50 out of 51 in 2016.
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"I have always contended when we make big changes, it has the opportunity to affect our statewide numbers," said Johnson, who is a registered nurse in inpatient obstetrics. Woman's accounts for 13 percent of the births in the state.
Additionally, the hospitals teach safe sleeping practices so parents know that infants need to sleep on their backs in empty cribs to help prevent SIDS.
One important area where the state needs to improve, Gee said, is getting progesterone to women who previously have had a premature birth. The drug can reduce the chance of it happening. But Gee said just 10 percent of women on Medicaid in Louisiana are receiving the drug, partially because it's expensive and doctors rarely stock it.
Crear-Perry said it's not enough, though, for people to look only at the medical side of premature births and infant mortality. Her work focuses on policy, and she said people's mindsets about the causes of preterm births and infant mortality need to change.
"Most things we like to blame on personal responsibility," she said, but she pointed to the number of black babies who die early regardless of their mother's health or educational status. "That's what's hard for our country to grapple with at times."
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She said she believes people in certain communities, especially those who are poor and black, are plagued by problems like violence and racism and that the stress from those issues can take a toll on the health of someone's pregnancy and future child. Environmental factors can affect pregnancies as well, she said, and she pointed to pollution affecting poor communities that also can affect the health of a baby.
She and Gee also agreed on the importance of pregnant women feeling supported and even celebrated by the communities around them. For Crear-Perry, the idea translates into better leave policies from jobs. Gee said she would love to have the budget to send a nurse into the home of every mother to ensure a child is sleeping safely and the mother has the help she needs.
"We have to think outside the box and do whatever it takes," Gee said. "It's just heartbreaking when babies die too soon. We don't want any women here to go through that."