Healthy Babies are Worth the Wait

®: Preventable Preterm Births

Katrina Thompson, Karla Damus, Dr. Diane Ashton, Dr. Ruth Ann Shepherd

15 10

Preterm Birth Rates United States, 1983, 1993, 2003, 2006

9.6

11.0

12.3

12.8

> 1 out of 8 births or 520,000 babies born preterm in 2005 7.6

>30% Increase 5 0 1983 1993

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, 2005

2003 2006 HP 2010 Objective

Focus on Late PTB

Percentage Distribution of Preterm Births by Gestational Age, US, 2004 Late preterm infants are more likely than term infants to have:

(36 wks)

Depression at birth (low Apgar scores) -Respiratory distress, respiratory failure -Hypoglycemia -Feeding problems -Temperature Instability -Apnea -Hyperbilirubinemia -SIDS -ADHD -Behavior problems 37.1

21.1

(<28 wks)

6

(35 wks)

10

Source: NCHS, 2004 natality file Prepared by the March of Dimes Perinatal Data Center

(28-31 wks)

5 12.9

(32 wks)

7.6

(33 wks) (34 wks)

Development of the Human Brain through Gestation

• Lower functions

mature first

• Cortex is last to

develop

• Brain at 35 wks

weighs only 2/3 what it will weigh at term

A Collaborative Partnership

The “Prematurity Prevention Partnership”:

– March of Dimes – Johnson & Johnson Pediatric Institute – Kentucky Department for Public Health

Kentucky Chapter Professional Organizations (ACOG, AAP, AWHONN) Kentucky Perinatal Leaders

Healthy Babies are Worth the Wait

®

• Prevent “preventable” preterm births in target areas of

Kentucky

• Three-year Initiative (2007-2009) in partnership with

Johnson & Johnson Pediatric Institute and Kentucky Department for Public Health

• Evidence-based interventions

-clinical -public health

• Focus on late preterm birth (34-36 weeks) • Targets both perinatal providers and childbearing women • System of collaboration between clinical and public

health leadership

Healthy Babies are Worth the Wait

®

Hospital Sites

Interventions

“Bundled” Evidence-Based Interventions Linked elements of clinical care, public health and consumer education:

– Consumer Awareness and Education • Health literacy in context of prenatal care • Community outreach – Professional Continuing Education • Grand Rounds & Training – Public Health Intervention • Augmenting existing services for case management, screening & referral – Clinical Intervention in Prenatal Period • Standard clinical guidelines (folic acid, smoking cessation, progesterone) • Patient safety

•

What Pregnant Women Can Do to Help Prevent Preterm Birth

Messages for pregnant women (and women of childbearing age)

Some preterm births—especially late preterm—could be prevented if all pregnant women:

– Get early, regular prenatal care – Quit smoking or at least cut back and avoid secondhand smoke – Avoid all alcohol – Take folic acid daily before, during and between pregnancies – Pay careful attention to good nutrition and eat a balanced diet with lots of fruits and vegetables – Gain only the weight recommended by your health care provider – Receive timely and appropriate treatment for existing medical conditions such as diabetes, high blood pressure, thyroid disease, addictions, and all infections including STIs – Take good care of their teeth--brush, floss, and visit a dentist regularly – Try to avoid stress and ask for help from their health care provider or support person to manage stressful situations in your life – Question the reason to schedule any delivery before 39 weeks unless there are medical reasons for an early delivery – Avoid elective induction or elective cesarean delivery including cesarean delivery on maternal request before 39 weeks – Talk to their doctor if you have a history of spontaneous preterm labor or birth and are carrying a single baby about possible receiving progesterone to help prevent another preterm delivery

What Communities Can Do to Help Prevent Preterm Birth

Messages for the community

• Preterm birth has consequences for many facets of our

communities, including school systems, employers and insurers

• Make preventing preterm birth a priority in each community, as it

will result in healthier babies, children, future parents and less chronic disease in all residents

• Visit and use materials from the

Healthy Babies Are Worth the Wait

website

• Host a

www.prematurityprevention.org

• Do not smoke around pregnant women, babies or children

Healthy Babies Are Wroth the Wait

Prematurity Prevention awareness session where participants learn about preterm birth and how they can help to make a difference in their community

• Raise awareness of services and resources available to pregnant

women and their families from the local clinical sites and the health department

• Work together on this leading public health problem as everyone

can make a difference for the health of families in Kentucky

Barriers

(due to dynamic conditions contributing to preterm birth)

• high rates of high risk factors (such as smoking, abuse of pain

medication/oxycodone, illicit drug use, stress, infections, obesity)

• significant changes in the culture of childbearing by pregnant

women (scheduling deliveries, CDMR)

• significant changes in obstetrical management with more inductions,

cesareans and other procedures contributing to higher rates of iatrogenic late preterm birth

• changes in health care delivery systems, reimbursement structures

and a litigious environment for obstetrical care

• These barriers are being overcome by successful

implementation of the components of HBWW and with the close collaboration and guidance of key leadership in clinical, public health and communications/media. A focus on patient safety protocols is being implemented in year 2.

Consumer Survey: Methodology Snapshot KAB (knowledge, attitudes, beliefs/reported behaviors) survey

– 39-item core questionnaire – 14-item optional supplement

Questions from PRAMS, BRFSS, and MOD surveys Original questions specific to needs of HBWW interventions Focus groups and pilot testing Anonymous, voluntary, convenience sampling Analysis done in SPSS®

WHO?

WHAT?

WHERE WHEN?

Pregnant women presenting for prenatal care Questions assessing KAB regarding pregnancy and childbirth Intervention and comparison sites (clinics, centering classes, private offices) January-May, 2007

RESULTS Baseline consumer surveys

Site Int. Site 1 Int. Site 2 Int. Site 3 Comp. Site 1 Comp. Site 2 Comp. Site 3 Total Core 289 337 139 93 151 57 1066 English: 91.8% Spanish: 8.2% Supplemental 278 101 23 88 63 48 601

Demographic Characteristics HBWW Consumer Survey Respondents <20 years Maternal Age 20-34 years 35+ years mean +/- sd 14% 77% 6% 25.3 +/- 5.401

range 14-45 Race White Black 80% 9% Hispanic Ethnicity Yes 9% Marital Status Married Single/partner Single Maternal Education

Obstetrical-Related Factors HBWW Consumer Survey Respondents Previous C/S None 63% 1 2 21% Of the 24% of pregnant women who had a 3+ 2% previous preterm birth, range 0-4 13% reported that their Inductions providers had None 1 discussed 42% 38% progesterone with 2+ 10% them in their current range pregnancy.

0-6 1st 2nd 3rd 9% 28% 59% Planned Preg Previous Births 39% None 41% 1 31% Of women in their 3 rd 2+ mean +/- sd range Multiple Birth 11% 17% 7% 0.35 +/- 0.709

0-5 2.5%

Prematurity KAB

•79% could give an acceptable

answer on how to explain prematurity to a friend

•Causes of preterm birth? • High risk conditions

(38%)

• High risk behaviors

(25%)

• Stress (9%)

How serious is preterm birth in your community?

Very serious Somewhat serious 14% 23% Not at all 7% Not sure 54% How serious if your baby is born 3 weeks early?

Very serious Serious Somewhat serious Not really 2% 11% 41% 42%

Periconceptional Vitamin Use by Women of Childbearing Age 76 80 Preconception During this Pregnancy 60 44 40 24 20 0 Daily 6 5 Weekly 14 6 A Few Times/Wk 4 Never

HBWW Consumer Survey 2007

Behavioral Risk Factors: Smoking by Women of Childbearing Age 35 30 25 20 15 10 5 0 34 Preconceptional 21 Prenatal HBWW Survey 32 22 KY (2005) US (2005) 38% of respondents reported that at least 1 smoker lived in their home

www.marchofdimes.com/peristats

Other Risk Factors for Preterm Birth

Feel blue, stressed, depressed 1+ days/wk Teeth need work or in poor condition Provider did not say avoid alcohol Did not see a hcp in year before pregnancy At least one service needed 28 34 47 60 40 0 10 20 30 40 50 60 70 Percent

HBWW Consumer Survey, 2007

Cesarean Delivery KAB

C/S is usually safer than vaginal delivery.

6 24 30 It is a good idea to schedule your delivery at 35-36 wks 13 22 Women have more problems later in life if they have vaginal (instead of C/S) births.

4 29 33 0 5 10 15 20 25 30 35 Percent HBWW Consumer Survey, 2007 35 True Not sure

Goal: reduction of singleton PTB rate by 15% in Intervention Sites

• • • • • •

Reduction of singleton LPTB rate Reduction in elective inductions and sections conducted prior to 39 weeks gestation Increase in baby’s average days of gestational age and birth weight Reduction in neonate’s length of hospital stay Reduction in hospital cost / charges associated with preterm births Positive change in consumer and provider knowledge, attitudes, and behaviors regarding PTB More information: www.prematurityprevention.org

Singleton Preterm Birth Rates By Hospital of Delivery, Kentucky, 2004

Percent of Singleton Live Births

15.4

15 14.3

15.5

15.0

15% reduction 12.8

10 5 0 King's Daughte r's M e d Ctr Re gional M e d Ctr Hopkins County Univ of KY Hospital Inte rv e ntion Hospital T otal Proje ct Goal

Source: KY Dept pf Health Prepared by the March of Dimes Perinatal Data Center, 2007 Prepared by the March of Dimes Perinatal Data Center, 2007

www.prematurityprevention.org

Take Home Message You Can Prevent Some Preterm Births

The overall message is that despite years of research and programs to attempt to reduce preterm birth, the rates continue to rise reaching an all time high of 12.7% for the US and 15% for KY in 2005. However, since most of this increase is due to the rising rates of late preterm birth (34-36 weeks) a thorough understanding of contributing modifiable risk factors and an innovative program to address local issues driven by timely local information can begin to reduce these seemingly run away rates and in doing improve health by decreasing morbidity and mortality for infants, children and ultimately adults.

“Because this is a real-world model, and focuses on education and enhancing existing systems of care, we anticipate that it will be feasible to implement the lessons learned statewide. We are confident this initiative will improve the lives of mothers and babies.”

Dr. Ruth Ann Shepherd Director, Adult and Child Health Improvement Kentucky Department for Public Health