The best way to keep babies from being born dangerously early is to make sure women are as healthy as possible - and not just during pregnancy, according to an official with the March of Dimes.

Alabama's preterm birth rate ticked up in 2017, earning it an F rating from the national nonprofit, which works to prevent birth defects, premature birth and infant mortality.

"We don't make healthy babies in 9 months alone," said Dr. Paul Jarris, chief medical officer for March of Dimes National. If women aren't healthy going into a pregnancy, he said, it's more difficult to prevent complications and preterm birth.

Babies born preterm - at 37 weeks gestation or earlier - are more likely than full-term babies to die before their first birthday or face lifelong disabilities or chronic health conditions.

Preterm birth is the No. 1 reason babies die before their first birthday.

Alabama's preterm birth rate this year is 12 percent, third highest in the nation behind Mississippi and Louisiana. The preterm birth rate worsened in 43 states this year.

In many states, including Alabama, women who aren't low-income enough for Medicaid but can't afford health insurance can qualify for Medicaid once they become pregnant. It lasts throughout pregnancy and a few weeks after.

It's widely used; Medicaid pays for more than half of all births in Alabama.

But an insurance system that only insures women during their pregnancies "is not well thought out and contributes to unhealthy women, mothers and babies," said Jarris. "It's part of the reason the U.S. does much more poorly than other developed nations" in birth outcomes.

Access to affordable, quality healthcare for women is key, he said, to reducing preterm birth and infant mortality.

Alabama's preterm birth rate is up slightly from last year's 11.7 percent, but lower than its 10-year high of 13 percent in 2007. The March of Dimes' goal is 8.1 percent.

Out of Alabama's most populous counties, Montgomery County has the highest rate, at 14 percent, followed by Mobile and Madison Counties. Shelby County had the lowest of those counties, at just 7.8 percent.

The preterm birth rate in Alabama counties with the largest number of births. (Courtesy of the March of Dimes)

Race

One major predictor of a woman's likelihood of delivering a baby preterm is her race. The preterm birth rate is 49 percent higher for black women in Alabama than for white women. The infant mortality rate for black babies is three times as high.

Race or ethnicity doesn't cause preterm birth, said Jarris, but some racial and ethnic groups face challenges related to racism that have a profoundly negative impact on birth outcomes: inequities in health care, housing, jobs, neighborhood safety, food security and income.

"If you look at an African-American woman with more than a college education, her rate of preterm birth is still higher than a white woman with less than a high school education," he said. "We know that is not genetically predetermined, or simply choice of behavior.

"The stressors women of color are under in this country create changes physiologically," he said. For example, stress hormones can increase inflammation, and chronic stress can decrease the body's ability to fight infection.

"We have research demonstrating exposure to stressors - racism and others - can change the way genetics are expressed," he said. "Not the genes themselves, but the switches that regulate them."

Reducing racial inequality in housing, jobs and safety can improve outcomes for babies and mothers, he said.

Communities

Alabama's high rates of preterm birth and infant mortality aren't new problems. The state has multiple agencies and programs working to address at birth outcomes for mothers and babies.

Jarris said communities can play a role.

"There's a lot that can be done locally with community groups getting together for collective impact, looking at risks for pregnant women and babies, and trying to address those at a local level," he said.

Access to affordable, quality healthcare for women before, during and after pregnancy is key, he said. Women should be able to get treatment for chronic health conditions like high blood pressure, diabetes, depression and thyroid problems before ever getting pregnant. Transportation to medical offices is often an issue, particularly in rural areas.

Reducing smoking and drug use is important, as is having access to healthy food and safe neighborhoods in which to be active.

And because planned pregnancies are statistically healthier than unplanned pregnancies, Jarris said, women need access to birth control and family planning information.