PREMATURITY: A Public Health Problem

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PREMATURITY A Public Health Problem

• Charleta Guillory, MD, FAAP
• Associate Professor of Pediatrics
• Baylor College of Medicine
• Associate Director of Level II Nurseries and
• Director of Texas Childrens Hospital
• Neonatal-Perinatal Public Health Program

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Texas Childrens Hospital is No. 4 among the
nations pediatric hospitals and No. 3 in heart
and neonatology specialties. The hospital was
named the No. 1 pediatric hospital in the South
and Southwest.
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INFANT MORTALITYUNITED STATES, 1915-2001
Rate per 1,000 live births
Source National Center for Health Statistics,
final mortality data Prepared by March of Dimes
Perinatal Data Center, 2003
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INFANT MORTALITY

• The Center for Disease Controls National
  Center on Health Statistics recently reported
  that infant mortality increased from a rate of
  6.8 infant deaths per 1,000 live births in 2001
  to a rate of 7.0 per 1,000 births in 2002.
• The first year since 1958 that the rate has not
  declined or remained unchanged.

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Selected Leading Causes of Infant Mortality
United States, 1990 and 2000
Rate per 100,000 live births
Source National Center for Health Statistics,
1990 final mortality data and 2000 linked
birth/infant death data Prepared by March of
Dimes Perinatal Data Center, 2002
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CAUSES OF INFANT MORTALITY OKLAHOMA, 2001
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 INFANT MORTALITY RATES BY RACE/ETHNICITY OKLAHO
MA, 1999-2001 AVERAGE
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CURRENT DEFINITIONS

• Birth Weight
• Low Birth weight (LBW) - lt 2500 grams or 5.5 lbs
• Very low birth weight (VLBW) - lt 1500 grams or
  3.3 lbs
• Gestation Length
• Premature (preterm delivery, PTD) - lt 37 weeks
• Early preterm delivery - lt 32 weeks

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OVERLAP IN LBW, PRETERM AND BIRTH DEFECTS U.S.
(2002)
Preterm Births 12.1
Low Birthweight Births 7.8
Among LBW 2/3 are preterm Among preterm almost
50 are LBW (some preterm are not LBW)
Birth Defects 3-4
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PREMATURITY

• Premature birth is the 1 killer of newborn
  babies
• Leading cause of neonatal mortality (0-27 days of
  life) in U.S.
• Second leading cause of infant mortality in U.S.
• Major determinant of serious health problems
• Blindness
• Mental retardation
• Lung disease
• neurologic problems

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PREMATURITY AN AMERICAN CRISIS

• 480,812 babies/year born preterm in 2002
• Approximately 7,000 babies/year born preterm
  in Oklahoma (12.7 of live births)
• 100,000 babies/year end up with lifelong
  conditions

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PRETERM BIRTHSUNITED STATES, 1981, 1991, 2001,
2002
Percent
Healthy People Objective
March of Dimes Objective
27 Percent Increase 1981-2001
Source National Center for Health Statistics,
final natality data Prepared by March of Dimes
Perinatal Data Center, 2004
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Preterm Birth Rates by State United States, 2002
U.S Rate 12.1
Note Value in ( ) number of states (includes
District of Columbia) Value ranges are
based on equal counts Source National Center for
Health Statistics, 2002 final natality
data Prepared by March of Dimes Perinatal Data
Center, December 2003
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PRETERM BIRTHS (lt37 WEEKS)BY MATERNAL
RACE/ETHNICITY, US, 2001
Percent
Preterm is less than 37 weeks gestation Hispanics
can be of any race Source National Center for
Health Statistics, 2000 final natality
data Prepared by March of Dimes Perinatal Data
Center, 2002
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 PRETERM BIRTHSOKLAHOMA, 1993-2003
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 PRETERM BIRTHS BY RACE/ETHNICITY OKLAHOMA,
2002
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RISK FACTORS FOR PRETERM LABOR/DELIVERY

• The best predictors of having a preterm birth
  are
• current multifetal pregnancy
• a history of preterm labor/delivery or prior low
  birthweight
• mid trimester bleeding (repeat)
• some uterine, cervical and placental
  abnormalities
• Other risk factors

• multifetal pregnancy
• maternal age (lt17 and gt35 yrs)
• black race
• low SES
• unmarried
• previous fetal or neonatal death
• uterine abnormalities
• incompetent cervix
• genetic predisposition
• low pre-pregnant weight

• obesity
• infections
• bleeding
• anemia
• major stress
• lack of social supports
• tobacco use
• illicit drug use
• alcohol abuse
• folic acid deficiency

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FACTORS THAT CONTRIBUTE TO INCREASING RATES OF
PRETERM BIRTH

• Increasing rates of births to women 35 years of
  age
• Increasing rates of multiple births
• Indicated deliveries
• Induction
• Enhanced management of maternal and fetal
  conditions
• Patient preference/consumerism
• Substance abuse
• Tobacco
• Alcohol
• Illicit drugs
• Bacterial and viral infections
• Increased stress (catastrophic events, DV, racism)

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MULTIPLE BIRTH RATIOS BY RACEUNITED STATES,
1980-2001
Ratio per 1,000 live births
Race of child from 1980-1988 Race of mother
from 1989-2001 Source NCHS, final natality data,
1980-2001 Prepared by March of Dimes Perinatal
Data Center, 2003
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PRETERM BIRTHSAMONG MULTIPLE DELIVERIES
OKLAHOMA, 1992-2002
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SMOKING AMONG WOMEN OF CHILDBEARING
AGE OKLAHOMA, 1999-2003
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IMPACT OF SMOKING

• Smoking during pregnancy is responsible for
• 20 of all LBW
• 8 of preterm births
• 5 of all perinatal deaths
• Pregnant smokers compared to nonsmokers are
• 2.0-5.0 times as likely to experience PPROM
• 1.2-2.0 times as likely to deliver preterm
• 1.5-10 times as likely to deliver a SGA infant
• 1.5-3.5 times as likely to deliver a LBW infant
• Smoking increases risk of stillbirth (RR1.4-1.6)
• Risk increases with increased amount smoked
• Smoking during and after pregnancy increases risk
  for SIDS by 3-fold

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Prematurity Generates Enormous Health Care Costs

• Average lifetime medical expenses for a preterm
  baby 500,000
• The total national hospital bill for in patient
  hospital stays with any diagnosis of
  prematurity/low birthweight was estimated at
  13.6 Billion in 2001
• Hospital charges for all infants 29.3 Billion
  in 2001. Prematurity makes up almost half of all
  infant hospital costs
• The average hospital charge for a preterm baby is
  75,000 per stay, compared to 1,300 for an
  uncomplicated newborn stay.
• Maternity related expenses Often the largest
  cost to employers health care plans

Source Agency for Healthcare Research and
Quality, 2001 Nationwide Inpatient Sample
Prepared by March of Dimes Perinatal Data Center,
2003
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What are the adverse short and long-term outcomes
that these extremely immature infants are at risk
to develop?
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INFANTS BORN AT 22 25 WEEKS
New England Journal of Medicine 2000343378-84
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ODDS RATIO FOR ADVERSE OUTCOME
Variable Cerebral palsy Severe motor disability
Male 2.4 2.14
Vaginal breech 2.27 2.48
Systemic steroids 4.74 4.76
Abnormal HUS 5.17 6.94
O2 _at_ 36 wks 2.29 3.17
New England Journal of Medicine 2000343378-84
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OVERALL COGNITION
lt 23 wk 24 wk 25 wk
No disability 25 21 33
Mild disability 17 34 32
Moderate disability 33 18 19
Severe disability 25 27 17
New England Journal of Medicine 20053529-19.
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NEUROMUSCULAR
lt 23 wk 24 wk 25 wk
No disability 75 70 79
Abnormal signs, minimal functional loss 8 11 11
Cerebral palsy with disability, ambulatory 12 8 6
Cerebral palsy, non-ambulatory 4 11 4
New England Journal of Medicine 20053529-19.
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VISION DISABILITY
lt 23 wk 24 wk 25 wk
No disability 46 55 72
Squint, refractive error 38 34 24
Visually impaired, not blind 8 7 3
Severe blindness 8 4 1
New England Journal of Medicine 20053529-19.
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HEARING DISABILITY
lt 23 wk 24 wk 25 wk
No disability 88 85 93
Mild hearing loss 8 7 2
Hearing aid, but hears 0 3 3
Profound hearing loss 4 5 1
New England Journal of Medicine 20053529-19.
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LONG-TERM OUTCOMES

• Very Low Birth Weight (VLBW) infants have
  poorer cognitive and behavioral outcomes at
  school age compared to normal birth weight
  infants.

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COGNITIVE AND BEHAVIORAL OUTCOME OF SCHOOL AGED
CHILDREN BORN PRETERM A META-ANALYSIS
Bhutta, et al, JAMA, 2002

• Studies from 1980-2001- English language
  literature
• N 1556 preterm infants vs 1720 term controls
• Infants evaluated after age of 5 years
• Term controls had significantly higher cognitive
  scores than preterm infants
• Preterm born children showed more than twice the
  relative risk for developing ADHD.

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LONG-TERM OUTCOMES

• VLBW infants are associated with educational
  disadvantage that persists into early adulthood.

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Outcomes in Young Adulthood of Very Low Birth
Weight InfantsHack, et al. NEJM, 2002

• Cohort of 272 VLBW infants vs 233 control
  infants of normal birth weight
• Born 1977-1979 - Assessed at 20 yrs of life
• Fewer graduated from high school (74 vs 83)
• Lower mean IQ (87 vs 92) lower academic
  achievement scores
• Higher rates subnormal height (10 vs 5)
• More psychopathology among VLBW young adults
  than among control subjects

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The prevention or amelioration of disabilities in
survivors of extreme prematurity remains one of
the most important challenges in medicine!
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CAVEAT

• These results should be interpreted with the
  caution since neonatal care and outcomes for VLBW
  infants are different today than 20 years ago.
• However, the risk for potential impairments
  underscores the need for anticipatory guidance
  and early intervention in this population.

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CAN PRETERM LABOR BE PREVENTED?

• Primary prevention is the goal
• especially risk reduction in the preconceptional
  period and early in pregnancy
• Preterm prevention programs have focused on risk
  assessment or prediction of preterm labor
• risk assessment identifies only half of preterm
  births
• during pregnancy most biomarkers, even in
  combination with risk factors, do not have good
  positive predictive values
• Causation is the great unknown

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WHAT INTERVENTIONS MAY WORK?

• Most interventions designed to prevent
  preterm birth . . .are not universally effective
  and are applicable to only a small percentage of
  women at risk for preterm birth.
• A more rational approach to intervention will
  require a better understanding of the mechanisms
  leading to preterm birth.
• Goldenberg RL, et al. Prevention of preterm
  birth. NEJM 339 (5)313-20, 1998.

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POTENTIAL INTERVENTIONS

• Early, comprehensive, accessible, culturally
  sensitive prenatal care
• Educate all pregnant women about preterm labor
  signs and symptoms and what to do if they occur
• Screen and treat all UTIs and STIs
• Identify cigarette smokers and intervene (5As)
• Assess for alcohol use and intervene
• Identify illicit substance users and intervene
• Assess for domestic violence and intervene
• Eliminate folic acid deficiency
• Reduce major stress levels early and throughout
  pregnancy

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• . . . . . Although we have come a long way
  in understanding the mechanisms involved in the
  pathogenesis of prematurity, we have a long way
  to go.
• Lockwood CJ. Predicting premature
  delivery--No easy task. NEJM, 2002, 346
  (4)282-4.

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JANUARY 30, 2003MARCH OF DIMES PREMATURITY
CAMPAIGN

• Raise awareness
• Reduce rates of
• preterm birth

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PRETERM BIRTH LEGISLATION INTRODUCED

• PREEMIE Act, authorizes expansion of research
  into the causes and prevention of prematurity and
  increases federal support of public and health
  professional education as well as support
  services related to prematurity.

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MARCH OF DIMES National Prematurity Campaign
Thank you for your support!
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