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  1. The March of Dimes Prematurity Campaign & New Approaches to the Prevention of Preterm BirthWebcastThursday, November 20, 20083:00 – 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

  2. Continuing Medical Education (CME)This activity was planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the CDC, NACCHO, and CityMatCH. CDC is accredited by the ACCME to provide continuing medical education for physicians.The CDC designates this activity for a maximum of 1.5Category 1 credits toward the AMA Physician's Recognition Award. • Continuing Nursing Education (CNE)This activity for 1.5contact hours is provided by the CDC, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditations. • Continuing Education Contact Hours (CECH)The CDC is a designated provider of continuing education contact hours in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event to receive 1.5Category 1 contact hours in health education. The CDC provider number is GA0082. • Continuing Education Units (CEU)The CDC was reviewed and approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET). The CDC will award .15CEUs to participants who successfully complete this program.

  3. If you are interested in receiving continuing education units: • - Go to the CDC Training and Continuing Education Online at http://www.cdc.gov/tceonline. If you have not registered as a participant, click on New Participant to create a user ID and password; otherwise click on Participant Login and login. You will need to enter the following verification code: NACCITYIPV1 • - Once logged on to the CDC Training and Continuing Education Online website, you will be on the Participant Services page. Click on Search and Register. Use one of the 3 search options. Search for Course Number (EV1237) Click on View. • - Scroll down and click on the program title. Select the type of CE credit you would like to receive and then click on Submit. Three demographic questions will come up. Complete the questions and then Submit. A message will come up thanking you for registering for the course. • - If you have already completed the course you may choose to go right to the evaluation/posttest. Complete the evaluation/posttest and Submit. A record of your course completion and your CE certificate will be located in the Transcript and Certificate section of your record. • If you have any questions or problems please contact: • CDC Training and Continuing Education Online • 800-41TRAIN or 404-639-1292 • Email at ce@cdc.gov

  4. 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.

  5. 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.

  6. The March of Dimes Prematurity Campaign and Prematurity Awareness Activities Karla Damus, PhD MSPH RN FAAN Associate Professor Dept of Ob/Gyn and Women’s Health Albert Einstein College of Medicine, Bronx, NY National March of Dimes, White Plains, NY kdamus@marchofdimes.com 914 997 4463

  7. Preterm Birth RatesUnited States, 1983, 1993, 2003, 2006 > 1 out of 8 births or ~540,000 babies were born preterm in 2006 Percent HP 2010 Objective >30% Increase 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, 2008 3

  8. Leading Causes of Neonatal MortalityUnited States, 2004 Rate per 100,000 live births NCHS, Deaths: Leading Causes for 2003. National Vital Statistics Reports 55(10), March 2007.

  9. 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.

  10. Preterm Birth Rates by Race and Education, IOM 2006

  11. Prematurity Campaign Background Initiated in January 2003 Two goals: • 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 • Decrease the rate of preterm birth by at least 15% by 2010.

  12. Campaign Goal I: Raise awareness of the problems of prematurity 64% Percent saying premature birth is a very or extremely serious pr oblem 60% 55% 54% 56% 53% 51% 50% 41% 47% 44% 44% 40% 42% 34% 41% 41% 35% Total Women 18-44 20% 2001 2002 2003 2004 2005 2006 2007 Prematurity Campaign:Prematurity Awareness

  13. Prematurity Campaign: Prematurity Rates U.S. Babies Born Preterm, 2000-2006 *2006 preliminary birth data provided by the National Center for Health Statistics; Source: National Center for Health Statistics

  14. 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: • 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

  15. Prematurity Campaign II Worldwide Problem of Preterm Birth 136 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, 2005 Note: Prematurity estimates are based on developed countries

  16. 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

  17. Prematurity Campaign II 3. Focus on three critical investment opportunities and intervention targets with a three year horizon

  18. Prematurity Campaign IIFocus on Critical Investments Accelerate 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

  19. Prematurity Campaign IIFocus on Critical Investments Expand 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

  20. Prematurity Campaign IIFocus on Critical Investments Implement 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

  21. National March of Dimes Preterm Birth Initiatives Preconceptional 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 Initiative PAD- Prematurity Awareness Day- Prematurity Summits National and State PTB Report Cards, Preemie Petition

  22. www.surgeongeneral.gov

  23. 103,374 www.marchofdimes.com/petition

  24. 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

  25. We Need Your Support! Please visit marchofdimes.com and sign the Petition for Preemies

  26. 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.

  27. Preterm Birth Rates, US, 2005 US PTB 12.7% www.marchofdimes.com/peristats

  28. Preterm Birth Rates Compared to HP2010 Objective and 2005 US Rate HP2010 Objective PTB 7.6% 2005 US PTB 12.7% www.marchofdimes.com/peristats

  29. Premature Birth Report CardGrades - Methodology Based 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%

  30. 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

  31. 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

  32. Report Cards 2009 & Beyond • 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

  33. Smoking among women of childbearing age, US, 2007 US 21.2% Uninsured women: US, 2005-2007 Avg US 20.1% 3 Major Factors Affecting Preterm Birth Rates: Late Preterm Births, Smoking, and Uninsured Women of Childbearing Age, Late preterm: US, 2005 US 9.1%

  34. Preterm Births by Gestational Age Category United States, 1990, 1995, 2000, 2005 12.7 11.6 11.0 10.6 71% Late Preterm Percent Source: NCHS, Prepared by Perinatal Data Center, March of Dimes

  35. Preterm Births by Week of GestationUnited States, 2004 Late preterm 71% Source: National Center for Health Statistics, 2004 final natality data Prepared by March of Dimes Perinatal Data Center, 2007 6

  36. Peak Shifted: 40 to 39 weeks Gestational Age-Specific DistributionSingleton Live Births, US, 1992, 1997, 2002 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.

  37. Rates of Late Preterm Births (34-36 wks)for All States, 2005 Which state had the largest increase in rates of late preterm birth in the past decade (1995-2005)? 2005 US Late Preterm Birth Rate 9.1% Source: March of Dimes Peristats Source: www.marchofdimes.com/peristats

  38. 5 States with Greatest Increase in Total and Singleton Late Preterm Births, 1995-2005

  39. 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)

  40. 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

  41. 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

  42. Total and Primary Cesarean and VBAC United States, 1993 - 2005 Percent Source: NCHS, final natality data, 1993-2003 and 2004 preliminary data Prepared by March of Dimes Perinatal Data Center, 2006

  43. Cesarean Delivery Rates by Maternal Age Categories, US, 1990-2005 Source: CDC/NCHS, National Vital Statistics System

  44. Rates of Total Cesareans for All States, 2005 2005 US Total Cesarean Rate 30.3% Source: March of Dimes Peristats Source: www.marchofdimes.com/peristats

  45. Preterm Birth Rates by Delivery Method US, 1996 and 2004 60,000 additional singleton preterm births 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.

  46. Infant Mortality among Late Preterm and Term Singletons, United States, 1995 - 2002 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, 2007 18

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