COMMENTARY : No-Care Mothers / No-Hope Babies : Of all the barriers to prenatal care, lack of funding is the most indefensible, morally and economically.

Babies born premature or with life-threatening problems are rushed to the neonatal nursery. The specialized intensive-care unit resembles the set of a science-fiction movie. Encased in plastic isolettes, babies with needles in their bodies look like tiny visitors from another planet lost in a world of pain. It is eerily quiet; the babies’ cries are silenced by tubes in their tracheas. On some days the nursery is so crowded with NPCs--babies who had no prenatal care--that nurses and doctors wonder how much worse it has to get before society will act to end this epidemic of misery.

“These children didn’t ask to be born in a drug environment,” says Dr. William Swartz, who has delivered his share of no-care babies. He believes that society has a responsibility to intervene on behalf of such children, at least to the extent of ensuring that their mothers get prenatal care. “If we don’t, it’s going to hit us in the pocketbook--taxes and social programs. And there is clear data that an ounce of prevention is worth a pound of care.”

The cost of neonatal care for a severely underweight newborn averages $2,000 a day. Some babies remain hospitalized for six weeks. A miraculous survival may cost upwards of $100,000. The savings in prenatal care that keeps one child out of the neonatal nursery could pay for 60 more women to receive it. Dr. Frank Mannino, a neonatology specialist, questions whether society should take care of a sick baby born at 26 weeks’ gestation with a poor prognosis for survival when funds are lacking to provide prenatal care to all mothers. “It’s the wrong thing to do,” he concludes.

But who can look at the tiny girl born 14 weeks too soon, now lying face down in a maze of blinking monitors, sucking air from an oxygen pump, and not want her to pull through? Miracles are precisely what our high-tech health-care system is designed to perform. But it fails miserably to make basic prenatal care available to all women. If it did, it would have even more money to spend on miracles.

The barriers to prenatal care are myriad: lack of money or insurance, fear of being deported, hopelessly long waits, transportation problems, denial of being pregnant (especially among teens), even an inability to fill out forms. Behind these barriers are the formidable escarpments of the health-care system, where politicians argue over funding, lawyers cash in on the malpractice lottery and doctors shield themselves by refusing to treat poor women whose health complications may trigger lawsuits.

Just as the baby is totally dependent on the mother’s placenta for its food and oxygen, both mothers and babies are dependent on the health-care network for medical attention and, in the case of poor mothers, proper nutrition. California’s multi-billion-dollar health-care system--public and private--is larger than the economy of some Third World nations. Yet, mothers it fails to reach might as well be in Bangladesh.

The fertile crescent of California, where one of eight American children are born, is creating a birth-caste system. You can see the results in the neonatal intensive-care nursery. All children there receive the same skillful care, at astronomical cost. The privately insured 870-gram preemie (less than 2 pounds) with a snapshot of his family taped to the incubator was diagnosed early and saved. He will have every chance to lead a normal life. Nearby is a listless baby staring with half-lidded eyes; her mother had no medical care during her pregnancy, and the baby suffered brain damage in utero. Her life will be a tragedy of institutionalization.

They are both America’s children, our society’s future. But one was saved and the other doomed by a system that has its spending priorities backwards.

Prenatal care cannot, by itself, heal the widening rifts in our society. But the denial of prenatal care widens the gap and causes thousands more children to be born on the far side of neglect. Later, when these children are suffering or harming others, people will say, “If only we’d started earlier, this could have been prevented.”

Prenatal care is the paradigm of prevention. It is the cheapest, most effective way to help babies when they most need it--as their limbs are being developed and their minds and bodies are growing.

In this intrauterine environment, where social problems are often made manifest, lies the field of medical advancement that can begin to heal society. The obstetrical advances of the 1990s will be made in community-care clinics, by medical missionaries who will bring maternal health care to the neglected corners of our society, to East Los Angeles and Watts, to farm-worker camps and public housing projects.

Swartz didn’t start out to be a medical missionary. The Comprehensive Perinatal Program that he developed in San Diego started with his wish simply to give practical experience to medical-school interns who’d learned obstetrics on the blackboard. The program works like this: Established community clinics provide space for prenatal checkups by physicians and nurse-practitioners. The support team includes a social worker, a health educator and a nutritionist. The baby is delivered at the UC San Diego Medical Center.

The malpractice crisis is another barrier to making quality, low-cost prenatal care universally available. Malpractice insurance for obstetricians runs from $60,000 to $160,000 a year in California; a doctor would have to deliver a Medi-Cal baby every day for two months just to pay the low-end insurance rate. Tragically, million-dollar damage awards for a small number of babies who have been killed or maimed by poor-quality doctors have had the effect of restricting access for thousands of other babies.

The final barrier to care lies at the hospital. Public hospitals are overwhelmed, which puts a limit on how many women can enter prenatal care programs. That’s what gave Swartz the idea to add a birthing center near the teaching hospital. Now awaiting state approval, it would deliver low-risk mothers in an economical environment. High-risk mothers would go to the UC San Diego hospital.

“In the U.S., we have a pathological model,” Swartz says. “We prepare for each mother and baby as if birth is an impending disaster.” In other developed countries, he says, low-tech delivery is adequate for the vast majority of mothers, who also benefit from the less stressful atmosphere of a birthing center.

Model programs that remove the barriers to prenatal care in America are ready to be adapted and expanded. “Unless we act today, in the next 13 years we will lose more American infants that we have lost soldiers in all the wars fought by the nation in this century,” says a report by the National Commission to Prevent Infant Mortality. Knowing how beneficial and cost-effective prenatal care is, how can we accept that thousands of no-care babies are still being born?