CLEVELAND, Ohio -- Cleveland's premature birth rate is the worst among 100 U.S. cities with the highest number of births, according to a new report from the March of Dimes released today.
The city's rate of 14.9 percent is more than two and a half times that of the best ranked city, Irvine, California, at 5.8 percent.
"The numbers in Cleveland are what you would see in developing countries," said Sam Mesiano, a professor in the department of reproductive biology at Case Western Reserve University School of Medicine and Obstetrics and Gynecology at University Hospitals who is studying the causes of preterm birth. "It's really unacceptable."
Preterm births occur before 37 weeks of pregnancy. They are the main reason for the United States' poor ranking in infant deaths compared to other developed nations.
In 2015, more than half of the babies born in Cuyahoga County who died before reaching a first birthday were born premature, and most of those infants were born so early they had almost no chance of surviving.
Cuyahoga County's premature birth rate of 12.1 percent is the highest of the six largest Ohio counties measured this year and again earned it a failing grade on the annual March of Dimes Premature Birth Report Card. The county's preterm birth rate increased from 11.8 percent in 2014. City and county report card data are from 2015, while state data reflects 2016 rates.
(Preliminary reports from 2017 indicate the county's preterm birth rate this year stands at 12 percent, a slight improvement.)
Ohio's grade dropped this year to a 'D' after remaining steady for two years at a 'C'. The drop reflects a slight rise in the overall state premature birth rate from 10.3 percent to 10.4 percent. The March of Dimes report grades are calculated by comparing a state's rate against the national goal of 8.1 percent.
The current national rate is 9.8 percent (up from 9.6 percent last year) and Ohio ranked 41st in the measure. Washington, Oregon, Vermont and New Hampshire were again the only four states to receive an 'A' in this year's report.
"It just breaks your heart to see these numbers," said Bernadette Kerrigan, executive director of the city-county infant mortality initiative First Year Cleveland. "But it also doubles down on the importance of our work, not only for the babies who are dying, but also for the babies born early who survive."
The causes of preterm birth are numerous, complex, and often not fully understood. They can be caused by risky behaviors like smoking, lack of prenatal care or elective cesarean deliveries, but about half of premature deliveries remain unexplained and occur in women who don't fall into any of these categories.
Dr. Brian Mercer, chair of the department of obstetrics and gynecology at MetroHealth Medical Center, said that Cuyahoga County's preterm birth rate has plateaued in recent years after dropping from a high of nearly 14 percent five years ago.
"What this tells us is that there's a lot more to do and that we're going to have to start focusing on the things that are harder to do," Mercer said. "We've done the things that are easier to do at the bedside. Many of the causes of preterm birth relate to things that we can't treat in the hospital."
One of those "bedside" interventions is a medication called hydroxyprogesterone caproate, or 17P, which reduces the risk of preterm birth by regulating levels of the hormone progesterone. It's given to women with a history of preterm birth, because they have an increased risk of delivering early again, and its use has been increasing across Ohio thanks to increased funding and concerted advocacy efforts from state and local health officials.
Mercer believes these efforts have already borne much of their fruit and it's time to turn to interventions "outside the medical model." These will have to address race, stress and racism if they are to make a difference.
In Ohio, the preterm birth rate among black women is 46 percent higher than the rate among all other women, according to the March of Dimes report. Asian/Pacific Islander women in the state have the lowest preterm birth rate, at 8.6 percent. Among black women, the rate is 13.9 percent.
Black women in Ohio are nearly four times more likely than white women to have a baby born between 16 and 22 weeks gestation, according to a study recently published in the American Journal of Obstetrics and Gynecology. Researchers don't yet understand why, though daily and inter-generational stress has been deemed a likely contributor.
"The stress that a woman undergoes during pregnancy, whether it's physical or perceived, may trigger preterm labor. We just don't understand the actual biology of the process and how that translates into a preterm birth," said Mesiano.
Much of the research to date on preterm birth and its causes has been focused on medical interventions, infections, and the biological mechanisms that cause early delivery, said Mesiano.
Less effort has been spent on figuring out how life outside the doctor's office influences births.
"That's probably why we haven't made major inroads into this," Mesiano said.
CenteringPregnancy, a group prenatal-care model, has been shown to reduce preterm births. It's now being offered locally to women at all major hospital systems and federally-qualified health centers thanks to a recent $1.5 million Ohio Medicaid grant.
Mesiano believes that interventions like Centering, which address "a sense of community and feeling like you're not alone" are where more research work needs to be done.
"Combining Centering with other therapies like progesterone may be part of the solution," he said.
Kerrigan agrees that investing in Centering and other community-building and community-driven programs will likely yield the best results. First Year Cleveland has helped secure state funding for more nurse and other home-visiting programs and for an innovative grassroots doula program in the Hough and Glenville neighborhoods called Birthing Beautiful Communities.
"In the end it's going to take more than just a magic bullet pill," Mesiano said. "It takes a community-based approach to look after pregnant women not just during pregnancy, but before conception."