March of DimesNYS Premature Birth

Report Card

Diane M. Ashton, MD, MPHDeputy Medical Director

March of Dimes National Officedashton@marchofdimes.com

Regional Perinatal ForumNovember 12, 2008

Preterm Birth(<37 completed weeks of gestation)

•Has increased 10% in the last decade and over 30% in the last 20 years

•#1 Perinatal Health Challenge

•Leading cause of infant mortality

•Leading cause of cerebral palsy, blindness, deafness, and retardation

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

Preterm Births, United States, 1983, 1993, 2003, 2006

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, 2006

9.611.0

12.3 12.8

7.6

0

2

4

6

8

10

12

14

1983 1993 2003 2006 2010

Percent

Healthy People

Objective30 Percent Increase

Preterm Births, US, 2000-2006

467,201

476,250480,812

499,008

508,356

520,000

543,000*

450,000

460,000

470,000

480,000

490,000

500,000

510,000

520,000

530,000

540,000

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

US PTB 12.7% NYS 12.1%

www.marchofdimes.com/peristats

Preterm Birth Rates, US, 2005

Premature Birth Report Card

• The March of Dimes is issuing a national and individual state Report Cards, giving the nation and each state a letter grade by comparing its preterm birth rate to the Healthy People 2010 goals

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.

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%

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

Preterm Birth Rates Compared toHP2010 Objective and 2005 US Rate

Report Card Key Messages

A – None.B – Vermont leads the nation, but can still do more to

prevent premature birth. (1)C – These states do better than most in preventing

prematurity but still have a long way to go to reach the Healthy People goals. (8)

D – These states lag behind in preventing premature birth – action is urgently needed to prevent more deaths and disabilities. (23)

F – These states face a crisis level of premature births that is driving up health care costs and special education budgets. We must act now to help moms go full term. (20)

NYS Preterm Birth Rates 1995-2005

•National Center for Health Statistics, final natality data.•Retrieved November 11, 2008, from www.marchofdimes.com/peristats.

Late preterm: US, 2005 US 9.1%NY 8.5%

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%

NYS Preterm Birth Rate by Race/Ethnicity 2003-2005 average

•National Center for Health Statistics, final natality data

.•Retrieved November 11, 2008, from www.marchofdimes.com/peristats.

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%

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

3.3 3.4 3.6

7.3 7.7 8.2 9.1

3.30

2

4

6

8

10

12

14

1990 1995 2000 2005

Year

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

71% Late

Preterm%

10.611.6

12.711.0

Consequences of Late Preterm Delivery

• Temperature instability• Hypoglycemia• Breathing difficulties• Feeding difficulties• Jaundice• Sepsis• 3 times as likely to die in first

year of life vs. term • Increased NICU use and

readmission• Increased cost• Long term outcomes – data

suggest problems

Kinney, 2006

Human Brain Growth by Gestation

Recent Studies

Clinical Outcomes:

Chyi, LJ, et al. School Outcomes of Late Preterm Infants: Special Needs and Challenges for Infants Born at 32-36 Weeks Gestation. Journal of Pediatrics, July, 2008

Lindstrom, K, et al.. Preterm Infants as Young Adults: a Swedish National Cohort Study. Pediatrics, July, 2007

Recent Studies

Findings:U.S.: 970 prematures compared to 13,671 full term infants

– Late preterm (34-36 wks.) are poorer readers with less math skills in early school years,

– With 1.6-2.1 times elevated risk for special education Sweden: 522,310 infants born 1973-1979 (23-29 y.o.)

– “Moderate” preterm (33-36 wks.) have lower chance of completing college, lower net salary, and increased risk for disability

Relevance:Late preterm infants have significant long term deficits

including learning problems, disability, and lower salaries

Infant Mortality among Singletonsby Gestational Age, 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, 2007

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. However, compared with term infants, late–preterm infants are at higher risk than term infants of developing medical complications, resulting in higher rates of infant mortality, higher rates of morbidity before initial hospital discharge, 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

ACOG Evidence Based Guidelines

No elective induction or elective cesarean delivery before 39 weeks unless evidence of fetal lung maturity

To assess fetal lung maturity an amniocentesis is usually done to collect amniotic fluid for testing– as for any invasive procedure there

are potential risks

ACOG Practice Bulletin No. 10, November, 1999.

www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=250148

As a result of these and other improvements, total maternal and neonatal variable costs decreased from $1,622 per case in January 2003 to $1,480 in the first half of 2004 (for uncomplicated deliveries resulting in normal newborns). This result was $300 better than expected based on historical trends, adjusted for producer price inflation.

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.

Work Policies That Support Maternal & Infant Health

• Provide preconception and pregnancy preparedness information to prospective parents, through classes, brochures, a library, e-mail or directed website(s)

• Provide information about healthy pregnancy and childbirth, that encourages early and continuing prenatal care and information about preterm birth prevention

• Ensure time off for prenatal appointments• Provide extra physical accommodation for pregnant

employees, such as a place where they can rest with their feet up, preferred parking in the last trimester, etc

• Engage other employees in creating a positive working environment for pregnant colleagues such as a smoke-, drug-, and toxin-free environment

Work Policies That Support Maternal & Infant Health (con’t)

• Ensure time off for pediatric appointments during first year of infancy

• Provide a private area where lactating women can pump and store breast milk

• Provide health insurance coverage that includes comprehensive preconception, prenatal, childbirth, and postnatal care, including immunizations or facilitate through a liaison the application for insurance through state or private agencies

• Access to flextime• Access to work from home/telecommuting• Access to Job Sharing• Offer an Employee Assistance Program • Offer discounts to gyms or fitness resources• Job protection for maternity leave that extends beyond

FMLA

www.marchofdimes.com/petition

Petition for Preemies

1. We urge the federal government to increase support for prematurity-related research and data collection as recommended by the Institute of Medicine and the Surgeon General’s Conference on the Prevention of Preterm Birth, to: (a) Identify the causes of premature birth; (b) Test strategies for prevention; (c) Improve the care, treatment and outcomes of preterm infants; (d) Better define and track the problem of premature birth

Petition for Preemies2. We urge federal and state policymakers to expand access

to health coverage for women of childbearing age and to support smoking cessation programs as part of maternity care

3. We call on hospitals and health care professionals to voluntarily assess c-sections and inductions that occur prior to 39 weeks gestation to ensure consistency with professional guidelines

4. We call on businesses to create workplaces that support maternal and infant health

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

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

…born in a nation and state that makes the grade and gets an “A” for preventing preterm birth

Support stronger, healthier babies

Questions? Comments?