Transcript Late Preterm Birth – What YOU Need to Know

Elizabeth McIntosh Chawla, MS4
Georgetown University School of Medicine
2009 Advocacy Project, Education of Resident Physicians on Late Preterm Birth,
with the March of Dimes Maryland-National Capital Area Chapter

Premature Birth Rates in the United States
 One of the goals of US Healthy People 2010 is to REDUCE
the preterm* birth rate in the US to 7.6% by 2010
 But rates have been INCREASING over the last decade
 9.1 % in
 11.6% in
 12.3% in
 12.7% in
1981
1998
2003
2005
* Preterm Births refers to all infants born with
<37 fully completed weeks.
http://www.math.uni-luebeck.de/safir/Projects/Draeger/draeger.shtml

Late Preterm Birth Rates
 Of all preterm births, Late Preterm Births, 34 to 36 weeks,
are both the largest and fastest growing subgroup
 Since 1990, the rate of Very Preterm Birth (<32 weeks) has
remained stable at 2% of live births
 But between 1990 and 2003, Late Preterm Birth increased more
than 20%, from 7.3% to 8.8% of live births, accounting for the
majority of the increase in preterm birth rates over the last two
decades1
 As of 2005, Late Preterm Births represent 9.1% of live births
 Based on 2005 Data from the CDC on singleton births,
Late Preterm Births made up about 72% of all preterm births
2
1National
Center for Health Statistics. 2003 final natality data. Data
prepared by the March of Dimes Perinatal Data Center, 2005.
22008
NCHS Data Brief: Recent Trends in Infant Mortality in the US
Increase Most Striking in
Late-Preterm Group
25% increase in Late
Preterm Group
Slide courtesy of Dr. Tonse Raju, 2007 presentation
2002 US Data
Percent of Preterm Singleton Live Births
(<37 wks) by Week of Gestation
14%
5%
40%
75% of singleton
preterm births
36 wks
7%
34 wks
35 wks
13%
<32 weeks
32 weeks
33 weeks
34 weeks
35 weeks
36 weeks
22%
Source: NCHS, final natality data
Prepared by March of Dimes Perinatal Data Center, April 2006.
Slide courtesy of Dr. Tonse Raju, 2007 presentation

District of Columbia Preterm Birth Rates
 In D.C., the rate of preterm births in 2005 was 15.9%, far
above the national average of 12.7% 1
 The rate of Late Preterm Births was 10.4%, also far above
the national average, which was 9.1% for this subgroup 1
 Disparities exist among population subgroups:
 Race: preterm birth rates were highest for African Americans
(18.2%)
 Age: preterm birth rates were highest for women ages 40 and
older (19.8%), followed by women under age 20 (17.6%)
1National
Center for Health Statistics, final natality data. Data
prepared by the March of Dimes Perinatal Data Center, 2005.
www.marchofdimes.com/peristats
**The District of Columbia mirrors disparities seen across the United States:
Preterm Births as a Percent of Live Births, by race and ethnicity,
1992 to 2003. SOURCE: CDC (2004a).
Institute of Medicine, Report Brief: Preterm Birth:
Causes, Consequences, and Prevention. July 2006
“Educating professionals includes enabling them to educate
the public and patients. We need to begin by teaching
what we now know with regard to preterm risks: maternal
age, parity, prior preterm labor, multiple gestations, and
behavioral (i.e., substance abuse/use, violence in patient’s
life) and psychosocial factors. Professionals should
understand why preterm birth is an important problem. All
types of clinicians must be knowledgeable about core
preterm birth issues because patient contacts with
pediatricians, cardiologists, pharmacists, dental
professionals, and others represent prevention and
intervention opportunities. Health sciences curricula
should be targeted to the discipline. The curricula for the
clinicians and public health professionals responsible for
primary and reproductive health care will need to be more
comprehensive.”
Statement from Report of the Surgeon General’s
Conference on the Prevention of Preterm Birth,
June 16-17, 2008

Morbidity and Mortality is higher for infants born between 34-36 weeks as
compared to term infants.1

In many cases, these complications can be prevented.

If you are a Pediatrician…

If you are an OB/GYN…
 Infants born after 37 weeks have better overall outcomes. As physicians, it is your
responsibility to advocate for your future patients, to give them the best chance at a
healthy start and a healthy childhood. A few words of guidance to Mom at a well child
visit can make a big difference!
 The increase in rates of Late Preterm Births has been linked to rising rates of early
induction of labor and c-sections. 1 For the health of your patient, and her unborn baby,
keep in it there a little longer!

If you are a Family Physician…
 For the health of both of your patients, Mom and baby, help them hang in there as long
as possible. Full gestation is 40 weeks!

If you are a Medical Student…

And to everyone, knowledge is power, educate your patients on the facts!
 Whether you are interested in perinatal outcomes or not, more knowledge makes you a
better well-rounded physician, and more valuable to your patients.
1 National Center for Health Statistics. 2002 period linked
birth/infant death data. Data prepared by the March of Dimes
Perinatal Data Center, 2005.
 Term

– 370/7 to 416/7 weeks gestation
“Near Term” – terms such as near term, early term,
moderate preterm, mild preterm, borderline preterm,
etc. have been used in the past to describe infants
born anywhere between 32-37 weeks

Late Preterm - NICHD [National Institute of Child Health and Human
Development] Workshop 2005 recommended the use of
“Late Preterm” to describe infants born between 340/7
to 366/7 weeks, or 239—259 days counting from the
first day of the LMP. They also recommended
discontinuing the use of the term “Near Term”.
Late Preterm Infant Assessment Guide, Association of
Women’s Health, Obstetric and Neonatal Nurses
(AWHONN)
Late Preterm
First day
of LMP
Day # 1
Week # 0/7
239
20 0/7
340/7
Preterm
 Preterm: Prior to completion of
37th week (36 6/7 weeks;
on or before 259th day)
259
36
294
416/7
6/7
Term
Post term
 Late Preterm: Between 34 0/7
through 36 6/7 weeks
(239-259 days)
* Raju TNK., Higgins RD, Stark AR, Leveno KJ Optimizing Care and Outcome of the Late Preterm (Near-Term)
Pregnancy and the Late Preterm Newborn Infant. Pediatrics , 2006;118 1207-14
*
Drawing courtesy: William Engle, MD,
Slide courtesy of Dr. Tonse Raju,
2007 University
presentation
Indiana
 “Near-Term”
conveys that these infants
are almost term and therefore almost
mature.
 This may lead to false sense of security:
less rigorous assessment in first hours of life,
early discharge when infant is still at risk,
inadequate follow-up plans.
 “Late Preterm” conveys the sense that
they still premature and still vulnerable .
“All definitions are arbitrary, since
maturation is a continuum”
* Raju TNK., Higgins RD, Stark AR, Leveno KJ Optimizing Care and Outcome of the Late Preterm
(Near-Term) Pregnancy and the Late Preterm Newborn Infant. Pediatrics , 2006;118 1207-14
 Medical
Intervention:
Early Induction of Labor and C-Sections
 Incorrect assumption that 34-36 weeks is “close
enough” given our current technological advances
 Errors in dating of Gestational Age (women are poor
historians), so “early” induction is accidental
 Growing culture of the “patient as customer” – inductions
and c-sections for non-medical reasons
 Pre-term
Labor:
Spontaneous Premature Labor and PPROM
 Can be due to maternal or fetal health complications
 Increasing maternal age
 Increases in multiples with modern fertility treatments
Cesarean Section and Labor Induction Rates among
Singleton Live Births by Week of Gestation
United States, 1992 and 2002.
Late Preterm
2002 C-S
1992 C-S
2002 Induction
1992 Induction
Slide courtesy of Dr. Tonse Raju, 2007 presentation
Source: NCHS, final natality data
Prepared by March of Dimes Perinatal Data Center, April 2006.
Singleton Preterm Live Births:
Reasons for Delivery from Birth Certificates
70
68%
60
57%
50
41%
40
29%
1992
2002
30
20
10
3% 2.2%
0
PROM
Spontaneous
Med.
Interventions
Slide courtesy of Dr. Tonse Raju, 2007 presentation

Medical Intervention:
Early Induction of Labor and C-Sections
 Correct dating of Gestational Age with early ultrasound – encourage
prenatal care from the beginning of the pregnancy
 Patient education about importance of continuing pregnancy until full term
is reached – even if inconvenient to patient
 Advocacy of OB/GYN residents to their colleagues – longer pregnancy has
better maternal and fetal outcomes

Pre-term Labor:
Spontaneous Premature Labor and PPROM





Smoking, alcohol, or drug use – cessation during pregnancy
Diabetes, hypertension – tight control, starting BEFORE conception
Infections – good prenatal care, treatment of active infection
Birth Defects – folic acid supplementation, proper immunization of Mom
Hx of preterm labor or preterm birth – good OB/GYN care, medical or
surgical interventions if needed
 Multiples – judicious use of assisted reproductive therapies (ART)
 Social – decreasing stress, appropriate child spacing, avoiding extremes of
maternal age, <20 years or >40 years
Source: Report from the Surgeon General’s Conference
on the Prevention of Preterm Birth, June 16-17, 2008
 Later
 Transitional




Respiratory Distress (RDS)
Temperature Instability
Hypoglycemia
Feeding difficulties
 First
Neonatal Period
 Poor feeding and
dehydration
 Readmission to hospital
 Early
Infancy
 SIDS risk
Week
 Neonatal jaundice
 Apnea
 Infection rate
 Later
Outcomes
 Learning difficulties &
School failures
 Behavior problems
Late Preterm Birth: Every Week Matters, Medical Perspectives on Prematurity.
Prepared by the Office of the Medical Director, March of Dimes. March 2006.
2 Late Preterm Infant Assessment Guide, Association of Women’s Health,
Obstetric and Neonatal Nurses (AWHONN)
3 NICHD Workshop: Optimizing Care and Long-term Outcome of Near-term
Pregnancy and Near-term Newborn Infant. July 18-19. Bethesda, MD, 2005.
1

The infant mortality rate among late preterm infants (7.7 per 1,000
live births) is three times higher than the rate among term infants
(2.5 per 1,000 live births). [However, some of these higher rates are due to
complications necessitating early delivery, including some birth defects, rather than due
to early delivery itself.]


Late preterm infants incur greater costs and longer lengths of stay in
neonatal intensive care units (NICU) and experience higher rates of
re-hospitalization after neonatal discharge, as compared to term
infants.
Children born in the late preterm phase have a greater risk of
developmental delay, such as poor reading and math scores in
elementary grades, need for special education, and retention in
kindergarten than their full term counterparts.
Late Preterm Birth: Every Week Matters, Medical Perspectives on
Prematurity. Prepared by the Office of the Medical Director, March of
Dimes. March 2006.
1
2
2008 NCHS Data Brief: Recent Trends in Infant Mortality in the US
Chyi, L. et al. School Outcomes of Late Preterm Infants: Special
Needs and Challenges for Infants Born at 32 to 36 Weeks Gestation.
Journal of Pediatrics, July 2008.
3
Lisa J. Chyi, MD, Henry C. Lee, MD,MS, Susan R. Hintz,
MD, MS, Jeffrey B. Gould, MD, MPH,
and Trenna L. Sutcliffe, Md, MS
Journal of Pediatrics, 2008

Data Source
◦ Publicly available ECLS-K dataset from the United States
Department of Education
[Early Childhood Longitudinal Study-Kindergarten Cohort]

Sample Group
◦ Moderate Preterm: 32 to 33 weeks gestation (n=203)
◦ Late Preterm: 34 to 36 weeks gestation (n=767)
◦ Excluded children with any known complication at birth

Comparison group
◦ Age equivalent classmates
◦ Full Term: 37 to 41 weeks gestation (n=13,671)

Outcome Measures
• 1) Reading and Math scores on Educational Tests
(Including Peabody Tests and Woodcock Johnson Tests)
• 2) Teachers Evaluation of the student’s Reading and
Math abilities as compared to peers.
Scored on a 5-point scale.
(Most teachers unaware of students’ prematurity status)
• 3) Presence of IEP or participation in Special Education
Services, information provided by the schools

Evaluation
• Outcomes were evaluated at K, 1st, 3rd, and 5th grade
Results: Distribution of Late Preterm Vs. Full
Term across outcome categories
Outcome
Grade
Late Preterm
(N=767)
Full term
(N=13,671)
Educational Testing:
Reading
K
50.2*
51.1
Testing: Math
K
50.6
51.0
Teacher Evaluation:
Reading
K
3.32*
3.39
Teacher Eval: Math
K
3.49*
3.56
Presence of an IEP
K
8.04%
6.18%
Special Education
K
6.66%*
3.14%
Outcomes in Kindergarten
* Values with P < .05
Results: Distribution of Late Preterm Vs. Full
Term across outcome categories
Outcome
Grade
Late Preterm
(N=767)
Full term
(N=13,671)
Educational Testing:
Reading
1st
50.2*
51.0
Testing: Math
1st
50.5
50.9
Teacher Evaluation:
Reading
1st
3.36*
3.47
Teacher Eval: Math
1st
3.41*
3.48
Presence of an IEP
1st
10.54%*
7.48%
Special Education
1st
6.27%*
4.28%
Outcomes in 1st Grade
* Values with P < .05
Results: Distribution of Late Preterm Vs. Full
Term across outcome categories
Outcome
Grade
Late Preterm
(N=767)
Full term
(N=13,671)
Educational Testing:
Reading
3rd
51.2
51.0
Testing: Math
3rd
50.9
51.0
Teacher Evaluation:
Reading
3rd
3.29
3.34
Teacher Eval: Math
3rd
3.10
3.12
Presence of an IEP
3rd
12.12%
10.72%
Special Education
3rd
9.15%
7.52%
Outcomes in 3rd Grade
* Values with P < .05
Results: Distribution of Late Preterm Vs. Full
Term across outcome categories
Outcome
Grade
Late Preterm
(N=767)
Full term
(N=13,671)
Educational Testing:
Reading
5th
51.7
51.3
Testing: Math
5th
51.8
51.4
Teacher Evaluation:
Reading
5th
3.37*
3.46
Teacher Eval: Math
5th
3.41
3.43
Presence of an IEP
5th
12.19%
11.32%
Special Education
5th
10.28%
8.24%
Outcomes in 5th Grade
* Values with P < .05

Standardized Educational Tests
◦ LP infants scored lower than FT infants for Reading in K
and 1st grade, but not for Math

Teacher Evaluated Abilities as Compared to Peers
◦ Reading: LP infants scored significantly lower in K, 1st ,
and 5th grades.
◦ Math: LP infants significantly lower in K, 1st grade, with
comparable math abilities in later grades

Special Education and IEPs
◦ IEP: Greater % of LP infants required IEP in K and 1st
grade, versus FT infants
◦ Special Education: Greater % of LP infants in Special
Education in K and 1st grade as compared to FT infants
Brain Development is a Continuum:
At 34-35 weeks gestation, a baby’s brain is
only 2/3 the size and maturity of full term.
Healthy Moms make Healthy Babies, before, during,
and after pregnancy!

Identify and Counsel patients (or Moms of your patients) on
the preventable causes of Late Preterm Birth
 Encourage Mom to plan ahead – the best prevention starts
BEFORE conception:
Reproductive Life Plan
 Proper birth spacing improves perinatal outcomes
 Get diabetes, hypertension, and other medical conditions under
tight control BEFORE conception
 Establish healthy weight, healthy diet, and supplementation with
at least 400 mcg folic acid BEFORE conception
 Talk to MD about immunizations and other preconception
health recommendations BEFORE getting pregnant
For more information about a Reproductive Life Plan and other
counseling topics, please see www.physicianclassroom.org
Healthy Moms make Healthy Babies, before,
during, and after pregnancy!
 Encourage Mom to see MD for good Prenatal care
DURING pregnancy for best outcomes:
 Correct gestational dating with early ultrasound
 Help with managing infections or other health conditions that can
put the infant at risk of complication
 Start smoking cessation program, stop alcohol or drug use
[or at least cut down as much as possible] during pregnancy
 Learn the symptoms of preterm labor and seek help when necessary
 Educate Mom about risks of late preterm birth, and what she can do
for her part to ensure a full 40 weeks of gestation
 Encourage good communication between Mom and
healthcare providers AFTER birth to ensure good follow-up
care for herself and the infant.

Understand and watch for specific medical
complications in late preterm infants







Respiratory Distress
Hypoglycemia
Temperature instability/hypothermia
Feeding difficulties
Jaundice/hyperbilirubinemia
Keep a low threshold for NICU transfer
Prevent Re-hospitalization




Thoroughly evaluate infant before sending home
Anticipate possible complications
Arrange for appropriate follow-up
Appropriately Educate Parents of Late preterm Infants on
special health considerations and what to watch for
Segment of Patient handout found at www.awhonn.org
More Examples of
Patient Handouts:
This and other patient
handouts available through
your local March of Dimes
office.
“There are misconceptions outside of the OB/GYN
community that preterm birth (especially late
preterm) is not a major problem; therefore, content
on preterm birth risks and the consequences of
preterm birth needs to be included in the curricula
of all medical specialties, as well as in training for
allied health and public health professionals.”
[Statement from Report of the Surgeon General’s Conference on the
Prevention of Preterm Birth, June 16-17, 2008]
Knowledge is Power
Educate yourselves
Educate your colleagues
Educate your patients
Together we can make a big impact on the
number of late preterm infants born in the United States
with just a little knowledge and prevention…




March of Dimes Foundation
Dona Dei, RN, MSN
Dr. Tonse N. K. Raju, MD, DCH
Dr. Matthew Levy, MD, MPH






National Center for Health Statistics. 2002-2005 final natality data. Data
prepared by the March of Dimes Perinatal Data Center, 2005.
2008 NCHS Data Brief: Recent Trends in Infant Mortality in the US.
Institute of Medicine, Report Brief: Preterm Birth: Causes, Consequences, and
Prevention. July 2006.
Report from the Surgeon General’s Conference on the Prevention of Preterm
Birth, June 16-17, 2008.
Late Preterm Infant Assessment Guide, Association of Women’s Health,
Obstetric and Neonatal Nurses (AWHONN)
Late Preterm Birth: Every Week Matters, Medical Perspectives on Prematurity.
Prepared by the Office of the Medical Director, March of Dimes. March 2006.






Raju TNK., Higgins RD, Stark AR, Leveno KJ Optimizing Care and Outcome of
the Late Preterm (Near-Term) Pregnancy and the Late Preterm Newborn
Infant. Pediatrics , 2006;118 1207-14
Chyi, L. et al. School Outcomes of Late Preterm Infants: Special Needs and
Challenges for Infants Born at 32 to 36 Weeks Gestation. Journal of
Pediatrics, July 2008
Raju TN. Epidemiology of late preterm (near-term) births. [Review] [53 refs]
Clinics in Perinatology. 33(4):751-63; 2006 Dec.
Jain S. Cheng J. Emergency department visits and rehospitalizations in late
preterm infants. [Review] [16 refs] Clinics in Perinatology. 33(4):935-45;
2006 Dec.
Adamkin DH. Feeding problems in the late preterm infant. [Review] Clinics in
Perinatology. 33(4):831-7; 2006 Dec.
Fuchs K. Wapner R. Elective cesarean section and induction and their impact
on late preterm births. Clinics in Perinatology. 33(4):793-801; 2006 Dec.

Websites
•
•
•
•
•
•
www.marchofdimes.com
www.awhonn.org
www.marchofdimes.com/peristats
www.iom.edu
www.surgeongeneral.gov
www.cdc.gov/nchs