The March of Dimes Prematurity Campaign &

New Approaches to the Prevention of Preterm Birth

WebcastThursday, 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 The March of Dimes Dimes Prematurity Prematurity Campaign and Campaign and Prematurity Prematurity Awareness Awareness ActivitiesActivities

Karla Damus, PhD MSPH RN FAANAssociate Professor

Dept of Ob/Gyn and Women’s Health Albert Einstein College of Medicine, Bronx,

NYNational March of Dimes, White Plains, NY

kdamus@marchofdimes.com 914 997 4463

9.611.0

12.3

7.6

12.8

0

5

10

15

1983 1993 2003 2006

Preterm is less than 37 completed weeks gestation.Source: National Center for Health Statistics, final natality dataPrepared by March of Dimes Perinatal Data Center, 2008

Pe

rce

nt

HP 2010 Objective>30% Increase

Preterm Birth RatesUnited States, 1983, 1993, 2003, 2006

> 1 out of 8 births or ~540,000 babies were born preterm in 2006

3

Leading Causes of Neonatal MortalityUnited States, 2004

28.5

41.4

97.8

116.2

0 20 40 60 80 100 120 140

Placenta, Cord,Membrane Problems

Maternal PregComplications

Birth Defects

Preterm / LBW

Rate per 100,000 live births

NCHS, Deaths: Leading Causes for 2003. National Vital Statistics Reports 55(10), March 2007.

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

47%44%44%

41%42%41%

35%

54%

64%

51%50%

55%53%

41%

20%

40%

60%

2001 2002 2003 2004 2005 2006 2007

Total Women 18-44

Campaign Goal I:Raise awareness of the problems of prematurity

Percent saying premature birth is a very or extremely serious problem

56%

34%

543,000

520,000

508,356

499,008

480,812

476,250467,201

450,000

500,000

550,000

2000 2001 2002 2003 2004 2005 2006

*2006 preliminary birth data provided by the National Center for Health Statistics; Source: National Center for Health Statistics

Prematurity Campaign: Prematurity Rates

U.S. Babies Born Preterm, 2000-2006

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 Birth136 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, 2005Note: 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 IIFocus on Critical InvestmentsAccelerate 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 IIFocus on Critical InvestmentsExpand 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 IIFocus on Critical InvestmentsImplement 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 InitiativesPreconceptional 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 InitiativePAD- Prematurity Awareness Day- Prematurity SummitsNational and State PTB Report Cards, Preemie Petition

www.surgeongeneral.gov

www.marchofdimes.com/petition

103,374

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.

US PTB 12.7%

www.marchofdimes.com/peristats

Preterm Birth Rates, US, 2005

HP2010 Objective PTB 7.6%2005 US PTB 12.7%www.marchofdimes.com/peristats

Preterm Birth Rates Compared toHP2010 Objective and 2005 US Rate

Premature Birth Report CardGrades - MethodologyBased 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 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

Report Cards 2009 & Beyond

Late preterm: US, 2005 US 9.1%

3 Major Factors Affecting Preterm Birth Rates:

Late Preterm Births, Smoking, and Uninsured Women of Childbearing Age,

Smoking among women of childbearing age, US, 2007US 21.2%

Uninsured women: US, 2005-2007 AvgUS 20.1%

Preterm Births by Gestational Age Category United States, 1990, 1995, 2000, 2005

3.3 3.4 3.6

7.3 7.7 8.29.1

3.3

0

5

10

15

1990 1995 2000 2005

less than 34 weeks Late Preterm (34 0/7-36 6/7 weeks)

71% Late

Preterm

Perc

en

t

10.611.6

12.711.0

Source: NCHS, Prepared by Perinatal Data Center, March of Dimes

Preterm Births by Week of GestationUnited States, 2004

8%

5%

16%

13%

21%

37% <32 weeks

32 weeks

33 weeks

34 weeks

35 weeks

36 weeks

Source: National Center for Health Statistics, 2004 final natality dataPrepared by March of Dimes Perinatal Data Center, 2007

Late preterm71%

6

Gestational Age-Specific DistributionSingleton Live Births, US, 1992, 1997, 2002

0%

5%

10%

15%

20%

25%

30%

28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44

Gestational Age (weeks)

Per

cen

t

1992 1997 2002

Peak Shifted: 40 to 39 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

Source: www.marchofdimes.com/peristats

2005 US Late Preterm Birth Rate 9.1%Which state had the largest increase in rates of late preterm birth in the past decade (1995-2005)?

Late Preterm Births   Singleton Late Preterm

State 1995 2005%

Change   State 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

5 States with Greatest Increase in Total and Singleton Late Preterm Births, 1995-2005

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

11

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)

12

0

5

10

15

20

25

30

35

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Total Primary VBAC

Source: NCHS, final natality data, 1993-2003 and 2004 preliminary dataPrepared by March of Dimes Perinatal Data Center, 2006

Total and Primary Cesarean and VBAC United States, 1993 - 2005

Per

cent

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

Source: March of Dimes Peristats

Source: www.marchofdimes.com/peristats

2005 US Total Cesarean Rate 30.3%

60,000 additional singleton preterm births

Preterm Birth Rates by Delivery MethodUS, 1996 and 2004

Vaginal Cesarean section

1996 2004

Absolute

difference 1996 2004

Absolute

difference

Preterm

263,520 268,172 4,652 91,477 145,882 54,405

Total births 2,944,204 2,802,472 -141,732 722,756 1,071,082 348,326

Preterm

birth rate

9.0% 9.6% 0.6% 12.7% 13.6% 0.9%

Bettegowda VR, Dias T, Davidoff MJ, Damus K, Callaghan WM, Petrini JR. The relationship between cesarean delivery and gestational age among US singleton births. Clinics in Perinatology. 2008;35: 309–323.

Infant Mortality among Late Preterm and Term Singletons, United States, 1995 - 2002

7.68.17.8

8.38.78.9

9.5

7.9

3.02.42.52.62.62.72.82.9

0

2

4

6

8

10

1995 1996 1997 1998 1999 2000 2001 2002

Late-Preterm Infants Term Infants

Rate per 1,000 live births

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, 200718

ACOG Committee Opinion # 404Late 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.

PATHWAYS

FA

CT

OR

S

External Environment

Immune Status

Nutrition

Behaviors

Medical Conditions

Medical Interventions

Psychosocial

Oth

ers: Ho

rmo

nes?

Toxin

s?

Bleed

ing

/ Th

rom

bo

ph

ilias

Ab

no

rmal U

terine D

istentio

n

Matern

al / Fetal S

tress

Inflam

matio

n / In

fection

PRETERM BIRTH

OUTCOMES

Preterm Labor / pPROM

Racial / Ethnic Disparities

Genetics / Family History

Fetal Growth

Green NS, Damus K, Simpson JL, et al. AJOG 193:626-35, 2005.

Life Course Perspective

Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30.

Poor NutritionStressAbuseTobacco, Alcohol, DrugsPovertyLack of Access to Health CareExposure to Toxins

Special Supplement on the Clinical Content of Preconception Clinical Content of Preconception

CareCareGuest Editors: Brian Jack and Hani Atrash

1. Editorial - M Curtis2. Where is the “W”oman in MCH? - H Atrash, B Jack, MK Moos, D Coonrod, P Stubblefield, R Cefalo, K Johnson, K Damus, et al3. 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 al8. Parental Exposures - L Floyd, B Jack, Jean Mahoney, R Cefalo, YF Johnson, et al9. Family and Genetic History - Authors: G Ferro, B Soloman, et al10. Nutritional Status - Authors: P Gardner, L Nelson, C Shellhass, A Dunlop, C Hogue, et al11. 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 al13. Medications - A Dunlop, P Gardner, C Shelhaas, M Mcdiarmid, et al14. Reproductive History - P Stubblefield, U Reddy, W. Nicholson, D Coonrod, R Sayegh et al15. Special Populations - C Ruhl et al16. Fathers - K Frey, M Lu, et al17. Psychiatric conditions - Frieder, Dunlop, Bernstein, Culpepper

Prevent the Preventable

Ø Unintended pregnanciesØ Short interpregnancy intervalsØ Folic acid deficiencyØ AlcoholØ Tobacco Ø Illicit drugsØ Infections (UTIs, STIs, periodontal disease)Ø Extremes of weightØ Some medications (Rx, OTC, home remedies)Ø Environmental toxinsØ Known genetic/familial risksØ Unnecessary interventions resulting in preterm birthPromote appropriate level designation

and regionalization

do no harmat least--

It is post time/term to redefine prenatal care based on a life course perspective and until

then

…born in a nation and state that makes the grade and gets an

“A” for preventing preterm birth

support stronger, healthier babies