Transcript Slide 1

The March of Dimes Prematurity Campaign &
New Approaches to the Prevention of Preterm Birth
Webcast
Thursday, November 20, 2008
3:00 – 4:30 pm (Eastern)
Sponsored by Health Resources and Services
Administration Maternal and Child Health Bureau & CDC
National Center on Birth Defects and Developmental
Disabilities Prevention
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New Approaches to the Prevention of
Preterm Birth
Learning Objectives:
 Participants will learn about the medical perspectives of preterm
birth, the complexity of the problem and a summary of
Prematurity Awareness activities.
 Participants will come away knowing what the March of Dimes is
continuing to do to address the growing crisis of preterm birth.
 Participants will learn about new approaches to the prevention of
preterm birth; as well as how March of Dimes chapters and these
MCH experts are addressing the growing crisis in their states in
and with “real” communities.
 Participants will learn about new educational tools and resources
for addressing preterm birth interventions.
Disclaimer
CDC, our planners, and our presenters wish to disclose they
have no financial interest or other relationships with the
manufacturers of commercial products, suppliers of
commercial services, or commercial supporters.
Presentations will not include any discussion of the
unlabeled use of a product or a product under
investigational use.
The March of Dimes
Prematurity Campaign
and Prematurity
Awareness Activities
Karla Damus, PhD MSPH RN FAAN
Associate Professor
Dept of Ob/Gyn and Women’s Health
Albert Einstein College of Medicine, Bronx, NY
National March of Dimes, White Plains, NY
[email protected] 914 997 4463
Preterm Birth Rates
United States, 1983, 1993, 2003, 2006
15
12.3
12.8
11.0
10
> 1 out of 8 births or
~540,000 babies were
born preterm in 2006
9.6
Percent
7.6
5
0
1983
1993
2003
>30% Increase
Preterm is less than 37 completed weeks gestation.
Source: National Center for Health Statistics, final natality data
Prepared by March of Dimes Perinatal Data Center, 2008
2006
HP 2010
Objective
3
Leading Causes of Neonatal Mortality
United States, 2004
Rate per 100,000 live births
116.2
Preterm / LBW
97.8
Birth Defects
Maternal Preg
Complications
41.4
Placenta, Cord,
Membrane
Problems
28.5
0
20
40
NCHS, Deaths: Leading Causes for 2003. National
Vital Statistics Reports 55(10), March 2007.
60
80
100
120
140
Institute of Medicine Report, 2007
The IOM estimates the
total national cost of
premature births to be
at a minimum $26.2
billion. This estimate
includes many costs,
such as in-patient
hospital costs, lost
wages and productivity
and early intervention
programs.
Preterm Birth Rates by
Race and Education, IOM 2006
Years of
Ed
NonHisp
Black
NonHisp
White
Asian
Pacif Isl
Amer
Indian
Hispanic
<8
19.6
11.0
11.5
14.8
10.7
8-12
16.8
9.9
10.5
11.8
10.4
13-15
14.5
8.3
9.1
9.9
9.3
>16
12.8
7.0
7.5
9.4
8.4
Prematurity Campaign Background
Initiated in January 2003
Two goals:
1. Increase public awareness of the problems of
prematurity to at least 60% for women of child
bearing age, and 50% for the general public by
2010
2. Decrease the rate of preterm birth by at least
15% by 2010.
Prematurity Campaign:
Prematurity Awareness
Campaign Goal I:
Raise awareness of the problems of prematurity
64%
Percent saying premature birth is a very or extremely serious problem
60%
53%
55%
54%
50%
41%
40%
56%
51%
47%
41%
42%
44%
44%
34%
41%
35%
Total
Women 18-44
20%
2001
2002
2003
2004
2005
2006
2007
Prematurity Campaign:
Prematurity Rates
550,000
U.S. Babies Born Preterm, 2000-2006
543,000
520,000
508,356
500,000
499,008
480,812
467,201
476,250
450,000
2000
2001
2002
2003
2004
*2006 preliminary birth data provided by the National Center for
Health Statistics; Source: National Center for Health Statistics
2005
2006
Prematurity Campaign II
The March of Dimes Board of Trustees met in March
2008 and agreed to the extension of the Prematurity
Campaign. They unanimously agreed the March of
Dimes should:
1. Declare “Prematurity Prevention” a global
campaign, and extend to 2020. Retain the goals
of 15% reduction in rate and increased awareness
for the U.S. Set global targets by 2010
Prematurity Campaign II
Worldwide Problem of Preterm Birth
136 million births worldwide*
An estimated 6-12% of births are preterm
27% of infant deaths are
due to prematurity
Disproportionate burden of
mortality on developing countries
* WHO World Health Report, 2005
Note: Prematurity estimates are based on developed countries
Prematurity Campaign II
2. Assume a more outspoken public stance on issues
directly related to prematurity prevention
–
–
–
Create a more powerful Prematurity Awareness Month in
November. A national Prematurity Report Card will be
developed in 2008 to put a spotlight on the incidence of
prematurity
Target big drivers of preterm birth such as rising rates of
C-sections and certain ART practices
Use Surgeon General’s Conference , June 2008, as a
platform for launch of Prematurity Campaign 2020
Prematurity Campaign II
3. Focus on three critical investment
opportunities and intervention targets
with a three year horizon
Prematurity Campaign II
Focus on Critical Investments
Accelerate research:
– Expand Prematurity Research Initiative (PRI) to
determine underlying causes of preterm birth
(currently $3.5M per annum)
– Assist the WHO consortium to identify financial
support to analyze worldwide genetic
associations to preterm birth
– Identify additional private funding partners
Prematurity Campaign II
Focus on Critical Investments
Expand direct service to NICU affected families:
– These families will help to build a constituency
for the campaign
– Increase the number of NICU Family Support
Programs to at least 100 sites by 2010, and
develop new models for extending this program
Prematurity Campaign II
Focus on Critical Investments
Implement Community Programs based on the
findings Healthy Babies Are Worth the Wait Project
– Identify best practices that will help to define effective
strategies for community-based regional interventions to
decrease premature birth
– MOD chapters will be encouraged to develop local,
regional, or statewide programs to decrease prematurity
through partnering with professional groups, consumer
organizations, and public health professional departments
National March of Dimes
Preterm Birth Initiatives
Preconceptional Summits- June 2005 and Oct 2007(www.marchofdimes.com)
– Expert Panel Recommendations, MMWR Apr 2006
– Work Groups (Clinical Care, Consumer, Public Health, Policy and Finance)
– NICHD Preconception Research Meeting, April 14-15, 2008
Late Preterm Conference- July 2005
– Seminars in Perinatology Supplements (Vol 1 and 2, 2006)
– Clinics in Perinatology (Dec 2006)
Institute of Medicine (IOM)
– Environmental Toxicants and PTB, 2001
– Preterm Birth Causes, Consequences, and Prevention, 2007
PREEMIE Law - Surgeon General’s Conference June 16-17, 2008
PREBIC (Preterm Birth International Collaborative)
KY Prematurity Prevention Partnership to reduce singleton PTB (HBWW)
MOD national grand rounds program
Family Medicine CQI PTB/LBW Initiative
PAD- Prematurity Awareness Day- Prematurity Summits
National and State PTB Report Cards, Preemie Petition
www.surgeongeneral.gov
103,374
www.marchofdimes.com/petition
Petition – Advocacy Elements
• A bipartisan effort to elevate the problem of
preterm birth onto the health care agenda of
our new President and Congress
• Inform legislators and regulators about the
serious issue of preterm birth in order to
drive policy changes at federal and state
levels
We Need Your Support!
Please visit marchofdimes.com
and sign the Petition for Preemies
National Report Card Release
NATION GETS A “D”
MARCH OF DIMES RELEASES
PREMATURITY REPORT CARD
18 States, Puerto Rico and DC Failed
Nov 12, 2008, WHITE PLAINS, NY – The United States hasn’t
quite failed preterm infants, but it came close, according to
the March of Dimes.
In the first of what will be an annual report card on preterm
birth, the nation received a “D” and not a single state earned
an “A,” when March of Dimes investigators compared actual
preterm birth rates to the national Healthy People 2010 goal.
Preterm Birth Rates, US, 2005
US PTB 12.7%
www.marchofdimes.com/peristats
Preterm Birth Rates Compared to
HP2010 Objective and 2005 US Rate
HP2010 Objective PTB 7.6%
2005 US PTB 12.7%
www.marchofdimes.com/peristats
Premature Birth Report Card
Grades - Methodology
Based on distance from Healthy People 2010 goal – measured in
standard deviations.
A Less than or equal to 7.6%
B Between 7.6% and 1 standard deviation above
C Greater than 1, but less than 2 standard deviations above
7.6%
D Greater than 2, but less than 3 standard deviations above
7.6%
F 3 or more standard deviations above 7.6%
Goals of the Report Card
To create an awareness of the increase in incidence of preterm
births as a nation and as individual states
To addresses issues related to prematurity including :
- Access to quality healthcare
– Research into the causes and factor related to prematurity
– Prevention of preterm births in pregnant women, through
knowledge and intervention
– Advocate for work policies that accommodate pregnancy
Report Card – Advocacy Elements
• Access to health coverage for women of childbearing age
– Maximize Medicaid & SCHIP eligibility
– Medicaid targeted case management (TCM)
– Family planning waiver
• Tobacco related initiatives
–
–
–
–
–
Medicaid coverage for smoking cessation
Funding for 5”As” provider education
Smoke-free initiatives
Tobacco tax
Health warning signs
Report Cards 2009 & Beyond
• Report cards will be issued annually for at least
the next 3 years
• Future report cards will highlight improvement or
decline in rates from the previous year
• Work has begun on a global report on preterm
birth rates – goal is to release on Oct. 4, 2009 in
New Delhi
• Exploratory conversations have been held with
U.K. organizations about a global Prematurity
Awareness Day
3 Major Factors Affecting Preterm Birth Rates:
Late Preterm Births, Smoking, and Uninsured
Women of Childbearing Age,
Late preterm: US, 2005
US 9.1%
Smoking among women of
childbearing age, US, 2007
US 21.2%
Uninsured women:
US, 2005-2007 Avg
US 20.1%
Preterm Births by Gestational Age Category
United States, 1990, 1995, 2000, 2005
15
12.7
Percent
10.6
11.6
11.0
10
9.1
7.3
7.7
8.2
3.3
3.3
3.4
3.6
1990
1995
2000
2005
Preterm
5
0
less than 34 weeks
Late Preterm (34 0/7-36 6/7 weeks)
Source: NCHS, Prepared by Perinatal Data Center, March of Dimes
71% Late
Preterm Births by Week of Gestation
United States, 2004
16%
<32 weeks
37%
5%
32 weeks
33 weeks
Late preterm
71%
8%
34 weeks
35 weeks
36 weeks
13%
21%
Source: National Center for Health Statistics, 2004 final natality data
Prepared by March of Dimes Perinatal Data Center, 2007
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Gestational Age-Specific Distribution
Singleton Live Births, US, 1992, 1997, 2002
Peak Shifted:
40 to 39 weeks
30%
Percent
25%
20%
15%
10%
1992
1997
2002
5%
0%
28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
Gestational Age (weeks)
Davidoff MJ, Dias, T, Damus K, Russell R, Bettegowda VR, Dolan S, Schwarz RH,
Green NS and Petrini J. Changes in the gestational age distribution among U.S.
singleton births: Impact on rates of late preterm birth, 1992 to 2002. Seminars in
Perinatology 2006;30:8-15.
Rates of Late Preterm Births (34-36 wks)
for All States, 2005
Source: March of Dimes Peristats
Which
state
theBirth
largest
in
2005 US
Latehad
Preterm
Rate increase
9.1%
rates of late preterm birth in the past
decade (1995-2005)?
Source: www.marchofdimes.com/peristats
5 States with Greatest Increase in Total and
Singleton Late Preterm Births, 1995-2005
Late Preterm Births
Singleton Late Preterm
1995
2005
%
Change
MA
5.8
8.0
37.9
WV
7.0
9.7
38.6
WV
7.8
10.7
37.2
MA
5.0
6.7
34.0
KY
8.2
11.0
34.1
KY
7.5
9.9
32.0
AK
6.1
8.1
32.8
SD
6.1
7.9
29.5
MS
10.2
13.2
29.4
SC
7.7
9.9
28.6
State
%
State 1995 2005 Change
Why are Late Preterm Rates Rising?
Changing culture of childbearing
• More high risk pregnancies
– advanced maternal age, advanced paternal age
– more complications such as infections, high blood pressure,
gestational diabetes, obesity
– more multiple births
– women unable to get pregnant before now conceive
– more women now pregnant with serious health problems advised not
to get pregnant in the past
– high risk behaviors including substance abuse (smoking, drinking,
illicit drug use)
• Public preferences/autonomy
– date of delivery scheduled for convenience
– cesarean delivery on maternal request (CDMR)
Why are Late Preterm Rates Rising?
Changing culture of obstetrical practice
• Clinical management (more interventions)
–
–
–
–
more provider suggested scheduled deliveries
escalating rates of labor inductions
escalating rates of cesarean deliveries
if cesarean rates increase, rates of late preterm birth
usually increase
• Litigious environment, defensive medicine
– 9 out of 10 obstetricians named in at least one law suit
– on average 2.6 suits/career
• 2006 ACOG liability survey
– earlier delivery to prevent adverse outcomes such as fetal
demise
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Why are Late Preterm Rates Rising?
Changing culture of obstetrical practice
• Few evidence-based interventions after 34 weeks
– window to administer antenatal steroids to women in
preterm labor is 24-34 weeks
– increase in neonatal survival to almost 100% at 34 weeks
• Health care delivery system issues
– reimbursement based on provider performing the delivery,
not necessarily the provider of the prenatal care
– inadequate coverage of anesthesia or other staff during
some days of the week
– administrative or defensive medicine driven decisions
to not offer procedures such as vaginal birth after cesarean
(VBAC)
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Total and Primary Cesarean and VBAC
United States, 1993 - 2005
35
30
Percent
25
20
15
10
5
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Total
Primary
Source: NCHS, final natality data, 1993-2003 and 2004 preliminary data
Prepared by March of Dimes Perinatal Data Center, 2006
VBAC
Cesarean Delivery Rates by Maternal Age
Categories, US, 1990-2005
Source: CDC/NCHS, National Vital Statistics System
Rates of Total Cesareans
for All States, 2005
2005 US
Total
Cesarean
Rate 30.3%
Source:
March
of Dimes
Peristats
Source: www.marchofdimes.com/peristats
Preterm Birth Rates by Delivery Method
US, 1996 and 2004
60,000 additional singleton preterm births
Vaginal
Cesarean section
1996
2004
Absolute
difference
263,520
268,172
4,652
Total births
2,944,204
2,802,472
-141,732
Preterm
birth rate
9.0%
9.6%
0.6%
Preterm
1996
2004
Absolute
difference
91,477
145,882
54,405
722,756 1,071,082
12.7%
13.6%
348,326
0.9%
Infant Mortality among Late Preterm and Term
Singletons, United States, 1995 - 2002
Rate per 1,000 live births
10
9.5
8.9
8.7
8.3
8
7.8
8.1
7.6
7.9
6
4
3.0
2.9
2.8
2.7
2.6
2.6
2.5
2.4
1995
1996
1997
1998
1999
2000
2001
2002
2
0
Late-Preterm Infants
Term Infants
Late preterm is between 34 and 36 weeks gestation
Source: National Center for Health Statistics, period linked birth/infant death data
Prepared by March of Dimes Perinatal Data Center, 2007
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ACOG Committee Opinion # 404
Late Preterm Infants
April 2008
•Late preterm infants often are mistakenly believed to be as
physiologically and metabolically mature as term infants.
•Compared with term infants, late–preterm infants are at higher risk
than term infants of developing medical complications, higher rates of
infant mortality, higher rates of morbidity, and higher rates of hospital
readmission in the first months of life.
•Preterm delivery should occur only when an accepted
maternal or fetal indication for delivery exists.
•Collaborative counseling by both obstetric and neonatal
clinicians about the outcomes of late–preterm births is
warranted unless precluded by emergent conditions.
Statement developed jointly with AAP Committee on Fetus & Newborn
Clark SL, et al. AJOG, 2008;199:105.e1-105.e7.
•For the first time in many years, the primary cesarean delivery rate in our system in 2006 fell
significantly (Fig 5, P .001), despite the tolerance of a liberal general approach to operative delivery
•Appears to be attributable to fewer cesareans for oxytocin-induced fetal heart rate abnormalities
associated with the universal implementation in 2006 of a uniform, checklist-based system for
oxytocin administration.
•In our large system, this translates annually into the avoidance of tens of thousands of primary and
future repeat cesarean deliveries.
Clark SL, et al. AJOG, 2008;199:105.e1-105.e7.
OUTCOMES
l
Preterm Labor / pPROM
PRETERM BIRTH
FACTORS
Psychosocial
Medical Conditions
Nutrition
Medical Interventions
External Environment
Green NS, Damus K, Simpson JL, et al. AJOG 193:626-35, 2005.
Bleeding / Thrombophilias
Im mune Status
Maternal / Fetal Stress
Behaviors
Inflammation / Infection
Genetics / Family History
Abnormal Uterine Distention
Racial / Ethnic Disparities
YS
A
W
TH
A
P
Others: Hormones? Toxins?
ta
Fe
th
ow
Gr
Life Course Perspective
Poor Nutrition
Stress
Abuse
Tobacco, Alcohol, Drugs
Poverty
Lack of Access to Health Care
Exposure to Toxins
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes:
a life-course perspective. Matern Child Health J. 2003;7:13-30.
Special Supplement on the
Clinical Content of Preconception Care
Guest Editors: Brian Jack and Hani Atrash
1. Editorial - M Curtis
2. Where is the “W”oman in MCH? - H Atrash, B Jack, MK Moos, D Coonrod,
P Stubblefield,
R Cefalo, K Johnson, K Damus, et al
3. Clinical content of preconception care: an overview - Brian Jack, Hani Atrash, D Coonrod,
MK Moos, P Stubblefield, R Cefalo, K Johnson et al 4.
4. Preconception Health Promotion - MK Moos, A Dunlop, B Jack, L Nelson, D Coonrod, R Long,
K Boggess, P Gardner et al
5. Immunizations - D Coonrod, B Jack, J Iams, P Stubblefield, J Conroy, M Lu, L Hillier, A Dunlop
et al
6. Infectious Disease - D Coonrod, B Jack, J Iams, P Stubblefield, J Conroy, M Lu, L Hillier, A
Dunlop et al
7. Medical Conditions - A Dunlop, B Jack, P Bernstein, C Ruhl. M Lu, R Cefalo, S Shellhass, M
Beckman, L. Nelson, M McDiarmid, B Solomon, J Bottalico, J Iams, et al
8. Parental Exposures - L Floyd, B Jack, Jean Mahoney, R Cefalo, YF Johnson, et al
9. Family and Genetic History - Authors: G Ferro, B Soloman, et al
10. Nutritional Status - Authors: P Gardner, L Nelson, C Shellhass, A Dunlop, C Hogue, et al
11. Environmental Exposures - Authors: M McDiarmid, P Gardner, B Jack, et al
12. Psychosocial Risks - L Klerman, L Floyd, B Jack, D Coonrod, M Lu, et al
13. Medications - A Dunlop, P Gardner, C Shelhaas, M Mcdiarmid, et al
14. Reproductive History - P Stubblefield, U Reddy, W. Nicholson, D Coonrod, R Sayegh et al
15. Special Populations - C Ruhl et al
16. Fathers - K Frey, M Lu, et al
17. Psychiatric conditions - Frieder, Dunlop, Bernstein, Culpepper
Prevent the Preventable
Ø Unintended pregnancies
Ø Short interpregnancy intervals
Ø Folic acid deficiency
Ø Alcohol
Ø Tobacco
Ø Illicit drugs
Ø Infections (UTIs, STIs, periodontal disease)
Ø Extremes of weight
Ø Some medications (Rx, OTC, home remedies)
Ø Environmental toxins
Ø Known genetic/familial risks
Ø Unnecessary interventions resulting in preterm birth
Promote appropriate level designation
and regionalization
It is post time/term to redefine
prenatal care based on a life course
perspective and until then
at least--
do no harm
support stronger, healthier babies
…born in a nation and state that makes
the grade and gets an “A”
for preventing preterm birth