In an interview with Medical News Today, neonatologist Dr. Charleta Guillory speaks about her work looking after very small babies, how health inequity affects prematurity, and what public health measures she set up to counter these.
In the United States, around
While medical advances have ensured that many babies born prematurely survive and have good long-term outcomes, prematurity remains the
In this Special Feature interview, Medical News Today spoke to Dr. Charleta Guillory, an associate professor at Baylor College of Medicine and the Director of the Neonatal-Perinatal Public Health Program at Texas Children’s Hospital, both in Houston.
Dr. Guillory previously served as the Texas State prematurity campaign director for the March of Dimes. At the time of our interview, Dr. Guillory was on call at the Level 4 neonatal intensive care unit (NICU) at Texas Children’s and would be for the next 6 weeks.
Level 4 NICUs provide the highest level of care for premature and critically ill babies. This is where the smallest babies, those born before 32 weeks and weighing less than 1,500 grams, are looked after.
Dr. Guillory gave MNT some background information on prematurity and the known risk factors. She also explained how the care of premature babies had changed during her career and how her unit and the families she is working with have coped during the COVID-19 pandemic.
We spoke about the babies’ long-term outlook, how she talks to parents, and what support family and friends can offer.
Dr. Guillory also discussed how the social determinants of health affect prematurity and what public health measures she has developed to address these.
We have lightly edited the interview transcript for clarity.
MNT: What exactly do healthcare professionals mean when they say that a baby is premature?
Dr. Guillory: According to the American Academy of Pediatrics (AAP), preterm birth is the delivery of an infant before completion of 37 weeks gestation.
There are three categories of preterm births: Late preterm infants are born between 34 weeks and 36 weeks and 6 days of gestation, moderate preterm infants are born between 32 and 33 weeks gestation, and very preterm births are born at less than 32 weeks gestation.
In 2019, preterm birth affected 1 of every 10 infants born in the U.S., and this is alarming.
According to the
But, the rate of preterm births rose for the fifth year in a row in 2019. Importantly, there are still racial and ethnic differences in preterm birth rates.
The CDC explains that in 2019, the rate of preterm birth among African American women was 14.4%. This is [nearly] 50% higher than the rate of preterm birth among white women, where it is 9.3%, and Hispanic women, where it is 10%.
This trend is disconcerting. We must work, not only to decrease prematurity, but also, to decrease the gap between black infant prematurity rates and those of other races and ethnicities.
MNT: Are there any specific risk factors? Who is more likely to have a premature baby?
Dr. Guillory: There are multiple risk factors associated with preterm births.
These include maternal reproductive factors, such as a history of preterm birth and maternal age. Mothers who have a history of preterm birth are at high risk for repeat preterm deliveries. In addition, maternal age is associated with preterm births. Mothers younger than 18 years and those older than 35 years are at high risk of delivering their baby prematurely. Multiple gestation, having more than one baby, is another risk factor for early delivery.
Maternal health is also important. As we look at infection, anemia, hypertension, preeclampsia, eclampsia, cardiovascular, pulmonary disorders, and diabetes, all, if left untreated, can lead to an early delivery.
Then there, are maternal lifestyle issues, such as physical activity, history of substance abuse or smoking, diet, weight, and stress. All of these risk factors are modifiable.
There are also specific issues, such as cervical, uterine, and placental factors, including a short cervix, cervical surgery, uterine malformations, vaginal bleeding, and placenta previa or abruption, which can result in a preterm delivery.
And finally, fetal factors, such as the presence of congenital anomalies, growth restriction, fetal infections, and fetal distress, can play a role in delivering a baby early.
MNT: What do you think is behind this rise in prematurity rates?
Dr. Guillory: I think it’s multifactorial. The social determinants of health are beginning to play a major role, [particularly] access to healthcare. We have mothers who are not insured.
Access to healthcare [is] a big problem for our mothers. Without prenatal care we will not be able to address the many risk factors leading to more preterm births. We still see mothers today, who have no prenatal care.
Actually, I was looking at the data, and only 60% of our African American moms are not getting prenatal care in the first trimester.
We had opportunities to expand Medicaid, and in Texas, as in the U.S., Medicaid pays for 50% of deliveries.
Another reason prematurity is on the rise is that we have an increase of mothers over the age of 35. Some of these mothers utilize assisted reproductive technology, which can result in multiple gestations, another risk for premature births.
MNT: It seems very counterintuitive not to have prenatal care.
Dr. Guillory: Exactly! If you want a healthy nation: we always knew that infant mortality was the best barometer for measuring how well a nation is doing.
We know that premature babies have the highest morbidity and mortality, particularly those born at less than 32 weeks gestation.
MNT: How has the care of premature babies changed during your career?
Dr. Guillory: The major challenge initially was survival, primarily from respiratory distress syndrome.
Improvements in the NICUs with the advent of surfactant treatment and antenatal steroid therapy to prevent and treat neonatal respiratory distress resulted in decreased mortality rates of premature infants.
Now, we focus on other conditions, using a more active management approach to sepsis, necrotizing enterocolitis, etc. With the discovery of the benefits of [breast] milk, survival has improved significantly.
Today, we not only want to improve the survival of infants, but we want to focus on decreasing morbidity and improving long-term developmental outcomes.
MNT: Can you tell us a little bit more about how the focus has changed?
Dr. Guillory: There are two aspects to this. One before birth and one after.
The focused changes to improve outcomes have been both before birth (prenatally) after birth (postnatally). One important aspect prenatally is to make sure that these high risk pregnancies are cared for by obstetrician’s and/or maternal fetal medicine physicians that will deliver these high risk premature infants in designated NICU’s that can care for these infants.
We know that high risk premature infants born in the center of care (inborn) fair better than infants born outside the center (outborn).
Another important prenatal focus by our obstetrician partners is the use of maternal steroid treatment prior to delivery at 25–33 weeks of pregnancy and 24–48 hours prior to delivery of the pregnancy.
Steroids help to develop the lungs quickly, improving the premature infant’s survival. In addition, antenatal steroid treatment lowers the risk of intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC) in these infants. The use of antenatal steroids has advanced and improved the care of premature infants.
Once we were able to decrease the incidence of respiratory distress syndrome with antenatal steroids in the premature population, we turned our attention on how to improve outcomes within the NICU. Besides developing programs to decrease infections in the NICU and to decrease NEC using mothers’ own milk or donor milk, we looked at how to improve the outcomes of the smallest babies.
Small baby units are being developed within the Level IV NICU units across the country. Our unit specializes in caring for babies born after less than 28 weeks gestation or under 1,000 grams.
The small baby team consist of trained neonatologists, neonatal nurse practitioners, respiratory therapists, dietitians, pharmacists, social services, case management, and most of all, parents.
This multi-disciplinary collaboration, utilizing evidence-based medicine, develop guidelines, standardized and optimized care for this specialized group of babies. This family centered approach not only improves survival but decreases morbidity like NEC and IVH and improves neurodevelopmental outcomes.
MNT: How do you study the long-term outcomes for premature babies?
Dr. Guillory: It is crucial that we transition our premature NICU graduates to a medical home and to an NICU follow-up developmental program to monitor their medical and developmental milestones. The challenge for neonatal follow-up programs is competing with clinical services needed by the premature infants with available resources needed for long term outcomes of these infants.
A recent article by Jeffrey Hobar in Pediatrics uses the phrase ‘not only do you need to follow them up, you need to follow them through.’ I love that terminology.
He basically says that you have a responsibility to these babies, not only to help prevent premature births, but your role doesn’t end in the NICU providing the latest technology in patient care.
When you have a 23 or 24-weeker, you work hands-on providing “state of the art” care. You are part of the decision-making process, and you have an obligation to follow through. This means following through addressing the social determinants of health. Making sure we’re sending them to a medical home, where their developmental milestones are followed.
As for babies born at less than 32 weeks, they have an increased risk of neurodevelopment impairment; cognitive, the way they think; motor, the way they walk; emotional with [things such as] autism; and behavioral with attention deficit hyperactivity disorder (ADHD).
Sometimes these things aren’t identified until they are in school. Therefore, if you’re not able to follow them closely, you may miss the opportunity to intervene sooner.
For example, the AAP Texas Pediatric Society is fighting to make sure that the State legislators are allocating the funds that is needed for the Early Childhood Intervention (ECI) program.
One thing about taking care of premature babies is that you have to understand that your work extends beyond the hospital. We have to get out into the community, to improve the social determinants of health for our patients.
MNT: How do you talk to parents of premature babies?
Dr. Guillory: When you speak to families, you must speak honestly. You must speak candidly and with transparency. We really need to be open and listen.
You can’t hide anything; you need to tell them what you know. Being culturally appropriate in our [communication] is important. So when I talk, I’m honest with them, I’m candid with them, I’m transparent with them.
Here, where we have such a diverse population, it’s important for us to keep the lines of communication open. If we do not facilitate clear communication, [the families] are not going to understand us.
So, for example, if I have a family that speaks a different language, we need a validated medical interpreter. I need someone who knows my terminology.
Even today, I make sure that I have a medical interpreter as we discuss complicated issues and deliver difficult news.
I really depend on other members of the team that are specifically trained to help. We have to be careful what we’re saying and how it’s interpreted; it has to be culturally appropriate when we’re talking to our families.
The other thing is that in a Family-Centered Care Unit as we have in Texas Children’s, it is important that the parents are part of the discussion and part of the team.
So when we make rounds, they are our partners on the team. This is a team, where parents are shared decision makers about their child.
We make very serious life and death decisions every day, but the parents have to be in on it as partners. During the premature journey in the NICU, you will have good days, and you will have bad days and we walk by their side through both.
When we are talking to parents, we need to be there, always available to them. We have to be available during good times to talk to them, but especially in bad times. We need to make sure that we’re answering their questions and updating them when a baby really gets very sick.
They need to see we’re at the bedside 24/7, which we are in a Level 4 unit.
MNT: What can other family members do to support parents?
Dr. Guillory: That’s an interesting question. They need just to be there to support the parents the way the parents want to be supported.
The parents usually will identify what they need. You need to be the resource they need and that they identify. People can do different things, like, offer support by providing transportation, childcare for siblings, dinners, etc. Basically, ask what can I do to help and then respect their wishes.
Some of these [issues] are very personal. So I think you have to know your family. Family members should not impose themselves on the parents, but be there, just as family.
Be there to love them and listen to them, not always to give advice unless they ask for it. Be there in support of the family with whatever resources they need.
MNT: How have your parents coped with the restrictions put in place for COVID-19?
Dr. Guillory: [COVID-19] has made parental visits really challenging.
We had to impose very strict rules, sometimes with only one visitor being allowed. Can you imagine how that affected our parents?
It was one of the first things that we changed [once we were able to change.]
We have to be careful when we make these rules and decisions. We really need to understand not only how it impacts the whole hospital but how it impacts families.
During the time two visitors were allowed we utilized zoom and videos to communicate with extra family members.
[Interestingly,] nobody complained about the siblings not being able to come in. [Before the pandemic], we had a Child Life team caring for the siblings. We would talk to them about expectations for a big brother or big sister in sibling classes.
All of this was in place before COVID-19, and I can’t wait to get back to that again.
MNT: What public health measures or interventions will make a difference to the social determinants of health that affect prematurity?
Dr. Guillory: There are multiple interventions that can address the public health crisis of prematurity.
As a neonatologist, early on, I recognized the disproportionately high risks of preterm births in Black mothers. I knew that I had to address this issue before babies arrives in our NICU’s.
To help identify the problem and define the solutions, I prepared myself with a Robert Wood Johnson Health Policy Fellowship and a Master’s in Public Health (MPH). This led to the development of the Honey Child New Beginnings Project, which aims at decreasing the high risk of prematurity in the African-American community.
Honey Child New Beginnings is a faith based prenatal health education and mentorship program. The program addresses the specific needs of the African-American mothers combined with a culturally relevant curriculum with hands-on activities that support positive health behaviors. The program addressed five major interventions to decrease prematurity:
- Improved access to prenatal care with guidance provided by a coach
2. Increase fruit and vegetable intake, provide nutrition education, cooking class demonstrations, and provide grocery shopping tours to improve diet and obesity factors, which lead to prematurity. To counteract food deserts, the participants grew their own garden on the church grounds.
3. Provide exercise classes and relaxation techniques to help mothers to increase physical activity and decrease stress.
4. One-on-one mentoring to make sure they had appropriate housing.
5. Provide support for our students to ensure they did not get behind in school.
6. Provide an educational curriculum to include caring for their new infant.
So we developed a village of trust around our mothers. As this program was based in a church setting, unlike grants, there were no end dates. It became a mission of the church. This program decreased prematurity rates from 18% to 9% in Black mothers in Houston.
MNT: I imagine that your job is probably one of the toughest jobs in the world.
Dr. Guillory: I think you just have to have a strong faith, personally, to be able to do this on a daily basis.
We have an excellent NICU at Texas Children’s. The one thing that I see that is always comforting to me is when a mom says goodnight and knows she can walk away knowing that her baby is in good hands.
When I see a mom that can’t leave, and she is sleeping here day and night, then it’s our job to make sure that she knows [she can trust us.] That may not be us telling her; that is something that she has to see. So, we may have to work a little harder with that mother.
It’s a journey to have a premature baby that may be in the hospital for 3–6 months. You’re going to have some really good and bad days, you’re going to see smiles, you’re going to see tears. We have to adjust to that and be ready no matter what the day may bring.
MNT: What do you wish for parents with premature babies to know?
Dr. Guillory: The one thing I want them to know is they have a team of doctors, nurses, and allied health members, caring for their infant and that they, the parents, are also part of that team.
[The whole team] wants to give their child the best possible medical care technologically available. But they also want the best possible outcome for the child. And that’s what we work for day and night.
There are people that are pulling for them, that will walk with them through this very difficult walk. They’ll have that support from their medical team.
MNT: Is there anything else?
Dr. Guillory: I wrote an article 10 years ago. In it, it says, ‘I see on a daily basis the complications of being born prematurely. As physicians, we have to do more.’
[10 years later], I am saying the same thing.
MNT: I bet that you are doing all you can.
Dr. Guillory: Yes, but it’s not enough. If you still see one baby die, then it’s not enough.
Surprisingly, we managed to get through the whole interview without either of Dr. Guillory’s on-call phones ringing.
From speaking to Dr. Guillory, it is clear how deep her passion for caring for premature babies runs. She is a tireless advocate for babies, mothers, and their families, working towards the best possible long-term outcomes for premature babies.
With that, Dr. Guillory left to return to the ward to look after the small babies in her care.