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The National Prematurity Campaign: A Call to Action

The National Prematurity Campaign: A Call to Action. Karla Damus RN MSPH PhD Dept OB/GYN and Women’s Health Albert Einstein College of Medicine, Bronx, NY Office of the Medical Director National March of Dimes, White Plains, NY kdamus@marchofdimes.com 914 997 4463.

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The National Prematurity Campaign: A Call to Action

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  1. The National Prematurity Campaign:A Call to Action Karla Damus RN MSPH PhD Dept OB/GYN and Women’s Health Albert Einstein College of Medicine, Bronx, NY Office of the Medical Director National March of Dimes, White Plains, NY kdamus@marchofdimes.com 914 997 4463

  2. March of Dimes National Prematurity Campaign2003-20075 year $75 million initiative

  3. National Professional Partners • ACOG • AAP • AWHONN • Many national professional health group alliances

  4. Campaign Goals 1. Increase public awareness of the problems of prematurity to at least 60% 2. Decrease the rate of preterm birth in the U.S. by at least 15%

  5. March of Dimes Prematurity Campaign2003-2007 5 Campaign Aims: 1. Raise public awareness 2. Educate women as to signs of premature labor 3. Assist practitioners 4. Invest to identify causes and promising interventions 5. Seek guaranteed access to health care

  6. www.cdc.gov/brfss

  7. Preterm Birth/Prematurity • Single most important cause of perinatal mortality (28 weeks gestation through 6 days of life) in US (about 75% of these losses) • Leading cause of neonatal mortality (0-27 days) in US • Second leading cause of infant mortality in US • Leading cause of infant mortality in GA and leading cause of infant mortality for black infants in the US • Major determinant of neonatal and infant illness: • Neurodevelopmental handicaps (CP, mental retardation) • Chronic respiratory problems • Intraventricular hemorrhage • Periventricular leukomalacia • Infection • Retrolental fibroplasia • Necrotizing enterocolitis • Neurosensory deficits (hearing, visual)

  8. Prematurity Generates Enormous Health Care Costs • Average newborn hospital charges: $4,300 vs. $58,000 for a preterm baby* • Total U.S. hospital charges for infant stays due to prematurity/low birth weight: $11.9 Billion* • Maternity & related expenses: • Often the largest cost to employers’ health care plans * Source: Agency for Healthcare Research and Quality, 2000 Nationwide Inpatient Sample Prepared by March of Dimes Perinatal Data Center, 2003

  9. March of Dimes Birth Defects Foundation Mission: • To improve infant health by preventing infant mortality and birth defects The Continuum of Reproductive Health • Improving health of infants requires focusing on the entire spectrum of reproductive health which extends from prior to conception through the first year of an infant’s life and throughout the woman’s childbearing years • Preconceptional health is the cornerstone of healthy infants, children, families and communities

  10. Age at Loss Conception Fetal Infancy 20 wks 28 wks Birth 4 wks 1 Year Spontaneous Abortion Early Fetal Late Fetal Neonatal Postneonatal Infant Ectopic Feto-Infant I Perinatal II III

  11. 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

  12. Unintended Pregnancies United States, 1994 Percent Source: National Survey of Family Growth, 1995 Prepared by March of Dimes Perinatal Data Center, 2000

  13. www.marchofdimes.com or peristats.modimes.org

  14. www.health.state.ok.us

  15. Percent of Births by Race/Ethnicity Oklahoma and US 1999-2001 Average

  16. Infant MortalityUnited States, 1915-2000 Rate per 1,000 live births Source: National Center for Health Statistics, final mortality data Prepared by March of Dimes Perinatal Data Center, 2002

  17. Infant Mortality RatesOklahoma and US, 1990-2000 OK IMR decrease 31.4% US IMR decrease 25.0%

  18. Annual Black/White Infant Mortality Rate RatioUnited States, 1980-2000 Source: NCHS, final mortality data Alexander G., SACIM, 2001.

  19. 1995-97 Birth Weight-Specific Infant Mortality Rates by Race Source: NCHS, final mortality data Alexander G., SACIM, 2001.

  20. Selected Leading Causes of Infant Mortality United States, 1990and 2000 2000 Rank Rate per 100,000 live births 1 2 3 6 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

  21. Leading Causes of Infant Mortality Oklahoma and US, 2000

  22. IMR, PTB, and Adequate/+ PNCUS and OK, 1998-2000 avg and HP2010 State Rankings : 43 3241

  23. Overlap in LBW, Preterm and Birth Defects U.S. (2002) Low Birthweight Births 7.8% Preterm Births 12.0% Among LBW:2/3 are preterm Among preterm:almost 50% are LBW (some preterm are not LBW) Birth Defects ~3-4%

  24. Preterm BirthsUnited States, 1981, 1991, 2001, 2002 Percent March of Dimes Objective Healthy People Objective 27 Percent Increase 1981-2001 Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2003

  25. Preterm Births (<37 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

  26. Preterm Delivery (<37 wks) Oklahoma and US, 1991-2001 OK PTB increase 0.8% US PTB increase 10.2%

  27. Singleton Preterm Births by Race/Ethnicity United States, 1990 and 2000 Percent Source: National Center for Health Statistics, 1999 final natality data Prepared by March of Dimes Perinatal Data Center, 2002

  28. Very Preterm (<32 wks) by Maternal AgeOklahoma and US, 1999-2001 average

  29. Types of Preterm Birth Spontaneous Preterm Labor Spontaneous Premature Rupture of the Membranes Preterm Birth Medical Intervention While this suggests distinct pathways, many of the risk factors for all 3 are similar

  30. 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: • low pre-pregnant weight • obesity • infections • bleeding • anemia • major stress • lack of social supports • tobacco use • illicit drug use • alcohol abuse • folic acid deficiency • multifetal pregnancy • maternal age (<17 and >35 yrs) • black race • low SES • unmarried • previous fetal or neonatal death • 3+ spontaneous terminations • uterine abnormalities • incompetent cervix • genetic predisposition

  31. Folic Acid Deficiency • Predisposes to: • NTDs • Other birth defects (cleft lip/palate, cardiac, limb reduction, urinary tract, omphalocele, trisomies) • Early and recurrent pregnancy loss • Low birth weight and prematurity • ?Gestational hypertension • Atherosclerotic vascular disease (stroke, CAD) • Colorectal and cervical cancer • Acute Lymphocytic Leukemia • Alzheimer’s Disease

  32. Folic Acid Recommendations Prevent Recurrence, 1991 • All women with a previous NTD pregnancy should take 4 mg or 4000mcg interconceptionally Prevent Occurrence, USPHS September, 1992 • All women of childbearing potential should consume 0.4 mg (400 micrograms) of folic acid daily Food & Nutrition Board of IOM, 1998 • Men (14 yr & older) 400 µg any source • Women (14 yr & older) 400 µg synthetic + food • Pregnancy 600 µg synthetic + food • Lactation 500 µg any source

  33. www.cdc.gov/brfss

  34. Folic Acid Knowledge and Behavior 1995 and 2003 Percentage of women ages 18-45

  35. Reasons Why Women Do Not Take a Multivitamin DailyMarch of Dimes Folic Acid Survey, 2003

  36. Things Women Reported Might Encourage them to Take a Multivitamin DailyMarch of Dimes Folic Acid Survey, 2003

  37. 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 • Epidurals • Induction (What happened to labor support?) • 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)

  38. Percent of Births by Maternal AgeOklahoma and US 1999-2001 Average

  39. Multiple Birth Ratios Oklahoma and US, 1996-2001

  40. Multiple Birth Ratios by Race*United 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

  41. Multiple Birth Ratios by Maternal AgeOklahoma and US, 1999-2001 average

  42. Higher Order Birth Ratios by Race*United States, 1980-2001 Ratio per 100,000 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, February 2003

  43. Risks of Adverse Pediatric Outcomes with ART Multiples Twins - 20-40% Triplets - 0.5-9.3% • Prematurity • Low birth weight Birth Defects?Complicated analysis • Maternal: Low birth weight, Birth defects • Paternal: Chromosomal abnormalities • Procedures: ICSI - Imprinting defects ?

  44. Singletons Preterm Delivery Oklahoma and US, 1991-2001

  45. Total and Primary Cesarean and VBAC Rates, United States, 1989-2001

  46. All Delivery Methods CategoriesOklahoma and US, 2001

  47. Singleton Preterm Births by Delivery Method United States, 1990 and 2000 Percent

  48. All Substance Use CategoriesOklahoma and US, 2001

  49. 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 (RR=1.4-1.6) • Risk increases with increased amount smoked • Smoking during and after pregnancy increases risk for SIDS by 3-fold

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