CHEROKEE, Iowa | Jezzika McKee's cell phone illuminates.
"Give it to Mummy. It's the hospital. Mummy needs to talk to them," McKee pleads with her daughter Neveya, who is clutching the device in her small hands and standing among a sea of stuffed animals scattered across the wood floor in their living room. A lighted Christmas tree sits in a corner.
McKee struggles to retrieve the phone from the soon-to-be 3-year-old while balancing her baby son, Samyuel, on her hip.
"Hello. ... Hi," she says, now sitting at the edge of a vintage gray and beige sofa with Samyuel in her lap. Neveya shrieks with laughter as a musical toy plays the Alphabet Song.
Neveya arrived a week after her due date. Samyuel was born more than 3 1/2 months early.
Now 15 months old, the 19-pound boy's weight continues to seesaw. He sees a pediatrician more than 50 miles away in Sioux City every other week. A nurse visits his family's apartment three times a week to weigh him and check his lungs.
"He's thrown up pretty much everything his whole life," McKee says of her son, who suffers from severe reflux and receives nourishment through a feeding tube inserted into his stomach.
Being born too early, before the 37th week of pregnancy, can cause short-term problems involving the lungs, heart, brain and immune system. But it may also lead to long-term complications impacting vision, hearing and learning. Preemies are also more likely than full-term infants to have chronic health issues such as infections, asthma and feeding problems.
In spite of these risks, the United States trails less developed countries at preventing preterm birth. The United States ranks 131st out of 184 countries behind Somalia, Turkey and Thailand, according to the March of Dimes.
For the first time in eight years, the nonprofit organization that works to improve the health of mothers and babies reports that preterm birth is on the rise in the United States, increasing from 9.57 to 9.63 percent of births. An additional 2,000 babies were born prematurely in the country in 2015. The March of Dimes gave the United States a "C" based on its preterm birth rate.
The state of Iowa received a "B," after improving its preterm birth rate from 9.3 percent to 9 percent over a year's time. Grades are assigned by comparing the 2015 preterm birth rate of a state or locality to the March of Dimes' goal of 8.1 percent by 2020.
Woodbury County maintained a "C," after seeing its preterm birth rate slightly increase from 9.7 percent to 9.8 percent in a year's time. Woodbury County and Polk County tied for the highest preterm birth rate among the state's six counties with the greatest number of births.
Al Fleming, a perinatologist at UnityPoint Health-St. Luke's, says any increase in the preterm birth rate isn't good, but he thinks the current rates at the local, state and national level are "pretty reasonable" given the national preterm birth rate hovered around 12 percent in 2013.
"If you look at the groups that are delivering preterm, the rates of prematurity are in a higher gestational age group relative to what it was before. That preterm group previously was less than 28 weeks," he says. "Now we're seeing the higher rates of prematurity are actually above 32 weeks, which is better than it was."
Who's at risk?
At the beginning of her pregnancy, McKee experienced mild spotting.
She says her doctor told her it wasn't anything to worry about, initially. When the spotting got worse, she was referred to Fleming, who detected a blood clot.
There are several risk factors -- maternal, fetal or a combination of both -- that lead to preterm birth.
Fleming says decidual hemorrhage, or bleeding, which is "very common," can change the environment inside the uterus and stimulate labor. Extra water in the uterus, carrying twins and fibroids -- abnormal growths that develop in the uterus -- can cause early labor.
"If you have continued bleeding like in the first 12 weeks and then into the second part of the pregnancy and that bleeding continues, then those patients are at very high risk for early labor and delivery," he says.
Women who smoke, use drugs or are overweight or underweight are at increased risk for preterm labor. When modifiable risk factors exist, physicians can intervene early on in the pregnancy to try to prevent preterm birth, but Fleming says the vast majority of women -- up to two-thirds -- don't have identifiable risk factors because they've never been pregnant before.
Preterm births are also more likely among teen moms and women over 40.
"We know there are many causes, but pinpointing who's at risk is the hard part," Fleming says. "The largest group of women who are at risk are those who've had a prior preterm delivery."
Patients at high risk for subsequent preterm labor can receive weekly injections of hydroxyprogesterone caproate or 17P to prevent it. The synthetic form of progesterone, a hormone vital to maintaining a pregnancy, gained FDA approval for prevention of preterm delivery in women with a history of it in 2011 under the brand name Makena.
A Christmas miracle
At 23 weeks gestation, McKee went into labor.
Paramedics drove her by ambulance to Methodist Women's Hospital in Omaha, Nebraska. There, doctors were able to delay her labor.
A week later, on July 25, while McKee was having lunch with Neveya and her husband, Ryley, at the hospital, she went into labor again. At 7 centimeters, Samyuel got stuck in the birth canal and McKee had to undergo a C-section. Samyuel weighed just 1 pound, 12 ounces at birth.
"He actually ended up getting really sick. He would drop down to 1 pound, 3 ounces," says McKee, who made the more than two-hour trip to Omaha with friends to visit Samyuel whenever she could. "I just kept that in my head, 'He's in a good place.'"
The Institute of Medicine reported in 2007 that premature birth in the United States costs $26.2 billion each year -- $1.9 billion in labor and delivery costs and $16.9 billion in medical and health care costs for the baby. Government assistance programs such as Medicaid and Supplemental Social Security Income can help cover the costs of a premature birth.
McKee says it was difficult caring for her daughter, working as a cashier at Fareway and then traveling to see her tiny son lying in an incubator hooked up to tubes and monitors. Samyuel spent 150 days in the neonatal intensive care unit.
"I was working to make ends meet, so we were able to pay bills. We couldn't afford rent, so we actually ended up moving," she says. "Back then we didn't have a working car."
On Dec. 21, McKee got her "Christmas miracle" -- Samyuel was finally released from the hospital. But caring for him was a big challenge. She had to feed her son every three hours and set an alarm to remind herself. She said there were many nights when she didn't get a wink of sleep.
"He was on a bottle for a while, but he ended up losing his sucking reflex, so he wouldn't take the bottle. We are just now getting him to eat food," she says. "Yesterday he weighed 19.1 (pounds), which is less than what he weighed the day before."
A couple months after Samyuel came home from the hospital, McKee, who was emotionally drained, quit her job. Disability benefits that Samyuel receives through Social Security help supplement the family's income.
"(Samyuel) kept going back into the hospital for things. It just got overwhelming. I just couldn't do it anymore," McKee says as Samyuel lets out a loud cry and kicks his stocking-clad feet.
Now, McKee is a full-time stay-at-home mom while her husband works as a subcontractor. This Christmas she's looking forward to putting presents underneath the tree for her children, something she couldn't afford to do last year.
"I strongly dislike it when people say they're ready for this baby to come and they're only like 30 weeks pregnant. Don't say that cause it could happen," she says.