Maternal & Perinatal Health: An Overview

1. Maternal & Perinatal Health: An Overview Anne Lang Dunlop, MD, MPH, FAAFP Emory University School of Medicine Department of Family & Preventive Medicine, and WHO Collaborating Center in Reproductive Health July 19, 2007

2. Maternal Terminology • Maternal death: any death to a woman while pregnant or up to 42 days post-partum from any cause (except accidental). • CDC also considers “late” maternal deaths to include any death to a woman while pregnant or up to 1 year post-partum from any cause.

3. Maternal Terminology (continued) • Maternal mortality rate = # maternal deaths x 1000 # women age 15 – 45 y • Maternal mortality ratio = # maternal deaths x 100,000 # livebirths • General fertility rate = # births x 1000 # women age 15 – 45 y • Total fertility rate = sum of age-specific fertility rates • Crude birth rate = # births x1000 total population

4. Perinatal Terminology • Infant period: from birth through one year of age. = Neonatal period + Post-neonatal period • Neonatal period: from birth through 28 days of life; divided into early (first 7 days) and late (days 8-28). • Fetal period: from 22 weeks’ gestation through birth. • Perinatal period: from 22 weeks’ gestation through first 7 days of life.

5. Conception 1 Year Birth Fetal Infancy 22 wks 28 wks 4 wks Spontaneous Abortion Early Fetal Late Fetal Neonatal Postneonatal Infant Feto-Infant I Perinatal II III

6. Perinatal Terminology (continued) • Preterm birth: birth before 37 completed weeks of gestation • Low birth weight (LBW):birth weight < 2500 grams (5.5 lbs) • Very low birth weight (VLBW):birth weight < 1500 grams (3.3 lbs)

7. Perinatal Terminology (continued) • Infant mortality rate = # deaths of infants < 1 yr x 1000 # live births • Feto-infant mortality rate = # stillbirths + # deaths of infants < 1 yr x 1000 total births (live births + stillbirths) • Neonatal mortality rate = # deaths of infants < 28 days x 1000 # live births • Perinatal mortality rate # deaths from 22 wks’ gestation through day 7 x 1000 total births (live births + stillbirths)

8. Maternal Mortality in the United States

9. Maternal Mortality in the United States • Causes: • Direct: occur only during pregnancy & peripartum • e.g., post-partum hemorrhage, eclampsia • account for 80% of maternal mortality • Indirect: diseases aggravated by pregnancy • e.g., diabetes, hepatitis, influenza, pyelonephritis • Timing of maternal mortality: “Rule of 2/3” • 2/3 of maternal deaths in the post-partum period • 2/3 of these in the first week post-partum • 2/3 of these in the first 24-48 hours post-partum • Specific causes of maternal mortality: • Hemorrhage • Sepsis/complications of unsafe abortion • Hypertensive disorders of pregnancy • Obstructed labor

10. Interventions to Reduce Maternal Deaths 4 main strategies: • Prevent unintended pregnancies • e.g. family planning services, access to abortions • Improve women’s preconception health by preventing diseases linked to increased maternal mortality • e.g. iron supplementation to prevent anemia • e.g. weight loss to prevent diabetes/gestational diabetes • Prenatal care to detect early signs of complications • e.g. screen for preeclampsia; induce labor if present • e.g. screen for anemia; treat if present • Treat complications with “essential obstetrical care” • Assisted vaginal delivery, manual removal of placenta, administration of abx & oxytocics & fluids, transport to facility to perform operative delivery if indicated.

11. Interventions to Reduce Maternal Deaths Basis for strategies: • Maternal mortality & morbidity rates increased for unintended vs. intended pregnancies; • Fewer pregnancies mean less exposure to ‘risk’; • Growing evidence that women’s preconception health • Prenatal care is important in detecting & treating two conditions that underlie direct medical causes of maternal death: anemia and hypertension.

12. Infant Mortality in the United States

13. Causes of Infant Mortality in the U.S.

14. Infant Mortality by Race, 1980-2000

15. Low Birth Weight† Delivery by Race † LBW: < 2500 grams (5.5 lbs)

16. Very Low Birth Weight† Delivery by Race † VLBW: < 1500 grams (3.3 lbs)

17. Interventions to Reduce LBW Rates • LBW rates are highest where women’s health status is poorest; • Estimated that up to 70% of feto-infant deaths could be prevented by interventions targeting women’s preconception health; • Application of the PPOR approach in three U.S. metropolitan areas finds that racial disparities in feto-infant mortality are largely related to racial differences in women’s health status prior to pregnancy. • Intensive prenatal care has been shown to improve LBW rates due to fetal growth restriction in cases of known underlying health conditions (e.g. maternal hypertension, diabetes, anemia) for medium LBW range (1500 – 2499 g) but NOT for VLBW range (< 1500 g). • No prenatal or obstetrical intervention has proven successful in reducing VLBW delivery. • Pilot study of interconception care delivered to women at Grady Memorial Hospital with an index VLBW delivery shows promise as a strategy for reducing unintended pregnancies, lengthening the interpregnancy interval, and decreasing subsequent adverse pregnancy outcomes.

18. Improving Women’s Preconception Health and Health Care A national strategy and action plan

21. Objectives • To examine the rationale and evidence supporting preconception health promotion and the delivery of specific preconception health care strategies; • To impart knowledge regarding preconception factors (medical, obstetrical, behavioral, and demographic) that increase a woman’s risk of adverse pregnancy outcomes and available tools for performing preconception risk assessment; • To review existing recommendations for delivering preconception health care.

22. Why focus on preconception care? • Poor pregnancy outcomes (for mother and child) occur at unacceptably high levels, with marked racial & SES disparities; • A high proportion of women enter pregnancy “at-risk” for adverse pregnancy outcomes; • There is evidence that intervening before pregnancy will help.

23. Why focus on preconception care? • Poor pregnancy outcomes (for mother and child) occur at unacceptably high levels, with marked racial & SES disparities; • A high proportion of women enter pregnancy “at-risk” for adverse pregnancy outcomes; • There is evidence that intervening before pregnancy will help.

24. Poor Pregnancy Outcomes Are Higher Than Acceptable

25. Low Birth Weight Births Have Increased ………………………….14.7% increase…………………………….

26. Preterm Births Have Increased ……………………………26% increase……………………………….

27. Historical Context:Limits of Prenatal Care • LBW and prematurity rates have increased simultaneously with increasing PNC utilization; • Racial and ethnic disparities in birth outcomes are increasing, while disparities in PNC are decreasing; • No compelling RCT literature linking comprehensive PNC with improved birth outcomes; • The late 20th Century consensus on comprehensive PNC programs as the public health strategy to improve birth outcomes and reduce disparities has ended.

28. Why focus on preconception care? • Poor pregnancy outcomes (for mother and child) occur at unacceptably high levels, with marked racial & SES disparities; • A high proportion of women enter pregnancy at-risk for adverse pregnancy outcomes; • There is evidence that intervening before pregnancy will help.

29. Risk Factors Are Prevalent Among Reproductive Age Women

30. Critical Periods of Development Critical Periods of Development Weeks gestation from LMP 4 5 6 7 8 9 10 11 12 Most susceptible Central Nervous System Central Nervous System time for major malformation Heart Heart Arms Arms Eyes Eyes Legs Legs Teeth Teeth Palate Palate External genitalia External genitalia Ear Ear Mean Entry into Prenatal Care Missed Period

31. Why focus on preconception care? • Poor pregnancy outcomes (for mother and child) occur at unacceptably high levels, with marked racial & SES disparities; • A high proportion of women enter pregnancy “at-risk” for adverse pregnancy outcomes; • There is evidence (of varying levels) that intervening before pregnancy can improve pregnancy outcomes.

32. Sources of Evidence for PCC • Johnson K, Posner SF, Biermann J, Cordero J, Atrash H, Parker CS, Boulet S, Curtis MG. Recommendations to improve preconception health and health care – United States. MMWR 2006; 55(No. RR-6): 1-23. • Korenbrot C, Steinberg A, Bender C, Newberry S. Preconception Care; a systematic review. Maternal Child Health Journal 2002.

34. Continued….

39. Integrating Preconception With Primary Care • Organizations advocating for preconception care, call for integration with primary health care. “Every woman, every time.” • Preconception care adds an anticipatory element to primary care – focusing on future pregnancy and the impact of pregnancy on maternal and infant outcomes. • Particularly important to integrate into primary health care given high rate of unintended pregnancies: • 49% of pregnancies are unintended; • Women with unintended pregnancies are notseeking a preconception care visit. • Henshaw SK. Unintended pregnancies in the U.S. Family Planning Perspectives 1998.

40. General Steps:Delivery of Preconception Care • Encourage women to plan & prepare for pregnancy; • Screen for those planning a pregnancy and at-risk for pregnancy • Educate re: importance of planning pregnancy with a health care provider • Optimize health of reproductive-age women: • Folic acid supplementation for all reproductive-age women; • Vaccination (rubella, varicella, HepB) for all reproductive-age women; • Counseling & screening for STI’s for reproductive-age women. • Perform thorough risk assessment: • Medical, obstetrical, & family history • Exposures: medications, supplements, environmental/occupational • Risk behaviors: substances, sexual practices • Establish effective treatment for chronic conditions; • Educate women about importance of disease control & medication changes; • Educate re: importance of planning pregnancy with a health care provider. • Counsel women to avoid use of non-essential medications if trying to conceive or at-risk for pregnancy.

41. 1. Plan & prepare for pregnancy • All women should be encouraged to discuss a reproductive life plan with a health care provider; • Providers should: • Ask women of reproductive age about their intentions to become pregnant in the next year; • Screen for those who are sexually active and not effectively contracepting; • Educate regarding how reproductive plans impact medical decision-making.

42. 2. Optimize health before conception • Measures for women of reproductive age: • Appropriate supplementation: Folic acid 400 mcg • Appropriate immunization: Rubella, Varicella, HepB • Counseling & screening for STI’s for reproductive-age women.

43. Folic Acid Supplementation • About 4000 neural tube defects (NTD) per year; • Folic acid can reduce risk of NTD: • 85% reduction in risk for primary prevention (0.4mg qd); • 71% risk reduction in recurrences (4mg qd). • Recommendation: All women of reproductive age should receive 0.4 mg qd. Women at increased risk (those with previous infant or family history of NTD, those taking carbamazepine or valproic acid, those with IDDM) should receive 4 mg qd.

44. Rubella (German measles) • Women who contract rubella during the 1st three months of pregnancy have a 1:4 chance of being born with one or more features of congenital rubella syndrome (heart defects, blindness, deafness, mental retardation); • Recommendation: All children receive primary immunization series; women of uncertain immunity should have Rubella IgG titre with booster dose of vaccine (if not pregnant & not planning to become pregnant within 3 months).

45. Varicella (Chickenpox) • Chickenpox can cause birth defects when contracted by the pregnant woman, although the risk is low; • Recommendation: Varicella vaccine should be considered in women who have not had chickenpox (90% of women are immune to chickenpox, even those who don't recall ever having the infection).

46. Hepatitis B • For acute hepatitis B during pregnancy, the risk of neonatal transmission ranges from 10% (1st trimester) to 90% (3rd trimester). • Chronic infection occurs in more than 90% of infected infants. Infants exposed to acute infection in utero are at increased risk for low birth weight and prematurity. • Recommendation: All high-risk women who have not been vaccinated should receive Hepatitis B vaccine before pregnancy; for those who are chronic carriers, they should be instructed on ways to prevent transmission to close contacts and how to prevent vertical transmission to their babies.

47. 3. Perform thorough risk assessment • American Family Physician article: • Brundage S. Preconception health care. Am Fam Physician 2002; 65: 2507-21. • March of Dimes website: • http://www.marchofdimes.com/files/preconception_tool_ed.pdf

49. Substance Use and Preconception Care • Screening for use and abuse with referral to treatment programs, as appropriate; • Patient education regarding the effects of substances on fetus; • Pregnancy may be a strong motivator for change!

50. Alcohol • Most common teratogen to which fetuses are exposed; Leading preventable cause of mental retardation; • Effects at all stages of pregnancy. No threshold has been identified for “safe” use in pregnancy. • Evidence-based guidelines for identifying and intervening with childbearing aged women who are engaging in risky drinking. • Recommendation: All women of childbearing age should be educated that no safe level of consumption has been established. Those with alcohol-related problem should be identified, educated as to the risks of alcohol consumption, and efforts to identify of programs that would help in cessation and long-term abstinence. USPSTF. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse. Ann Intern Med 2004.