Prematurity Campaign: Goals and Interventions

Mary LarsenRegional MCH Director

Midwest Region

5.5% - Proposed U.S. Preterm Birth Rate Goal for 2030 by March Of Dimes

Fighting for the Next Generation: US Prematurity in 2030

Edward R.B. McCabe, Gerard E. Carrino, Rebecca B. Russell and Jennifer L. Howse

Pediatrics; originally published online November 3, 2014

Prematurity Campaign Results

Since 2007 the prematurity rate has decreased to 9.6%• Fewer babies are now counted as preterm due to a change in

measurement by the National Center for Health Statistics (NCHS).

• Progress has been made in reducing preterm birth rates.

Progress is not victory• Despite progress, the U.S. preterm birth rate ranks poorly

among Very High Human Development Index (VHHDI) countries.

March of Dimes Board of Trustees Resets Goals

8.1% 2020 preterm birth rate goal for the U.S.

5.5% 2030 preterm birth rate goal for the US

March of Dimes 2015 Premature Birth Report Cards reset to the 8.1% target

New focus on high volume and high burden areas and populations in Report Cards.

Preterm birth rates

*2015 data are preliminary. LMP=gestational age based on date of mother’s last menstrual periodOE=gestational age based on obstetric estimate.2020 and 2030 goals based on OE gestational age.Preterm is less than 37 weeks gestation. Source: National Center for Health Statistics, 1990-2014 final and 2015 preliminary natality data.Prepared by March of Dimes Perinatal Data Center, June 2016.

10.611.0

11.6

12.7 12.8 12.712.3 12.2 12.0

11.7 11.5 11.4

9.57 9.62

8.1

5.5

4.0

5.0

6.0

7.0

8.0

9.0

10.0

11.0

12.0

13.0

14.0

1990 1995 2000 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* 2020Goal

2030Goal

Perc

en

tag

e o

f li

ve b

irth

s

LMP-based OE-based

United States, 1990, 1995, 2000, 2005-2015*

2003, 12.3%:March of Dimes

launches National

Prematurity Campaign

Preterm birth ratesUnited States,1990, 1995, 2000, 2005-2015*

Prematurity Campaign Roadmap

The Prematurity Campaign Roadmap sets out our plan for achieving the new 2020 and 2030 goals.

To achieve them, we must: Optimize existing interventions

Engage stakeholders.

Identify new treatments based on translation of discovery research.

March of Dimes investment in the Prematurity Research Centers

is essential to achieving 5.5% by 2030

March of Dimes Prematurity Research Network

Research essential to meeting goalsIdentify new treatments based on translation of discovery

research

CT

CA

NV

MT

UT

WY

CO

NMAZ

TX

OK

KS

NE

ND

SD

MN

WI

IL

IA

MO

AR

LA

AL

TN

MS

KY

IN

MI

OH

WV

GA

FL

SC

NC

VA

MDDE

VT

RI

NH

MA

ME

NY

PA NJ

WA

OR

ID

HI PR

AK

Regional Structure

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

115 Market Boards

Roadmap Targets 15 States and Puerto Rico

• Phase I: States and territories with highest rates 5 states and 1 territory in 2017

Alabama, Louisiana, Mississippi, Puerto Rico - Highest rates

Florida, Texas - Most populous high rate states

• Phase II: Additional states with large numbers of births 10 additional states with births >100,000

California, Georgia, Illinois,

Michigan, New Jersey, New York,

North Carolina, Ohio,

Pennsylvania, Virginia

Continue preterm birth prevention in ALL states

Racial Disparity in Preterm Birth

Martin JA, Hamilton BE, Osterman MKJ et al. Births: final data for 2013. Natl Vital Stat Rep 2015 Jan.

NH Black

NH White

Midwest Prematurity Rates and Goals

Number of Live

Births 2015

Number of

Preterm Births

2015

Prematurity

Report Card

Grade 2016

Preterm Birth

Rate 2015

Preterm Birth

Rate Goal 2020

Estimated Number

of Preterm Births

in 2020

If Goal is reached

Difference in

Number of

Preterm Births

(2015 - 2020)

Illinois 158,116 16,032 C 10.2% 8.1% 12,800 3,200

Indiana 84,040 8,055 C 9.6% 8.1% 6,800 1,200

Iowa 39,482 3,563 B 9.0% 8.1% 3,200 400

Kentucky 55,971 6,024 D 10.8% 8.1% 4,500 1,500

Minnesota 69,834 5,899 B 8.5% 8.1% 5,700 200

Missouri 75,061 7,476 C 10.0% 8.1% 6,100 1,400

Nebraska 26,679 2,623 C 9.9% 8.1% 2,200 500

Ohio 139,264 14,291 C 10.3% 8.1% 11,300 3,000

West Virginia 67,041 6,256 D 9.4% 8.1% 5,400 800

Wisconsin 19,805 2,226 C 11.3% 8.1% 1,600 600

Midwest Region Totals: 735,293 72,445 9.9% 8.1% 59,600 12,800

United States: 3,978,497 382,420 C 9.6% 8.1% 322,000 60,000

Midwest: Percent of

nation's preterm births 18.9%

Rounded Estimates

March of Dimes: 2016 Premature Birth Report Card

MinnesotaPreterm Birth

Rate

8.5% B

County Preterm Birth Rate Grade

Anoka 7.8% A

Dakota 9.5% C

Hennepin 8.4% B

Olmsted 6.4% A

Ramsey 8.6% B

Washington 8.4% B

March of Dimes Goal: 8.1% by 2020

12.0%9.6%

8.4%8.2%

8.0%

Native AmericanBlack

WhiteHispanic

Asian

Disparity Index

19

State Rank

15

Roadmap Interventions

Elimination of non-medically indicated early elective deliveries

Access to progesterone shots for women with a previous preterm birth

Smoking Cessation

Birth spacing and interconception care

Expanding group prenatal care

Low dose aspirin to prevent preeclampsia

Vaginal progesterone and cerclage for short cervix

Reduce multiple births conceived through Assisted Reproductive Technology

Target geographies and/or racial and ethnic groups with high rates and/or high birth volume.

Bundle interventions through the Healthy Babies are Worth the Wait® Community Program.

Preparing the Strategic Mission Investment Plan

Strategic Mission Investment Plan (SMI)

Focused, multi-year approach to program planning (2017-2020)

Data-driven decision-making

MCH Committee driven

Implementation fully utilizes all state mission resources to receive maximum return on investment.

SMI allows states to achieve greater impact, outcomes and visibility for mission activities.

The SMI approach allows for more flexibility, when necessary, in spending state community grant funds, to maximize impact.

Strategic Mission Investment

All states concentrate on robust Strategic Mission Investment Plans

and leveraging local partnerships:

Focus prematurity prevention activities

Maximize implementation with available resources

Engage local stockholders (e.g. State Health Officials)

Roadmap Interventions

Elimination of non-medically indicated early elective deliveries

Access to progesterone shots for women with a previous preterm birth

Smoking Cessation

Birth spacing and interconception care

Expanding group prenatal care

Low dose aspirin to prevent preeclampsia

Vaginal progesterone and cerclage for short cervix

Reduce multiple births conceived through Assisted Reproductive Technology

Reducing Non-medically Indicated(Elective/Planned) Deliveries

Inductions and caesarean sections scheduled before 39 weeks gestation without medical reason increase the risk of early term and late preterm birth and their health consequences.

Early Elective Deliveries

Percent of newborns with scheduled deliveries,

1-3 weeks early, without medical necessity (EED)

STATE PERCENT OF EED DELIVERIES

ILLINOIS 1%

INDIANA 1%

IDAHO 2%

MISSOURI 2%

MINNESOTA 3%

OHIO 3%

WISCONSIN 3%

NEBRASKA 4%

KENTUCKY 6%

WEST VIRGINIA 7%

Increasing Use of Progesteronefor Women with a History of Prior Preterm Birth

• Weekly progesterone injections for at-risk womenstarting at 16- 21 weeks gestation

• Proven to reduce preterm birth in women with a prior preterm birth

• Effective in preventing very early as well as later preterm birth

• Effective in both African American and non-African American women

17 alpha-hydroxyprogesterone caproate (17P)

ACOG Practice Bulletin, October 2012 One of the strongest clinical risk factors for preterm birth is a prior preterm birth.

Maternal history of preterm birth increased risk in a subsequent pregnancy

17P Synthetic form of progesterone given by injection

Reduces a woman’s risk of recurrent preterm birth by 33%

ACOG Committee Opinion, October 2012, Prediction & Prevention of preterm birth.

Smoking and Pregnancy Smoking can cause problems for a woman trying to become pregnant or who is already pregnant, and for her baby before and after birth.

Tobacco use is a well-documented risk factor for preterm birth and other adverse birth outcomes

One in ten women smokes while pregnant

• Educating women on the risk of smoking through the Becoming a Mom/Comenzandobien, Coming of the Blessing curriuculum

• Support smoking cessation programs through community grants including the 5 A’s, and SOPHE (SCRIPT) Program

• Advocate for Medicaid coverage of smoking cessation programs

• Consumer education materials

March of Dimes Action

Optimizing Birth Spacing

or Interpregnancy Interval

Time between one live birth and conception of next pregnancy.

Birth spacing of less than 18 months increases the risk of preterm birth, low birthweight, and small for gestational age.

33.1% of U.S. births have a short IPI (<18 months).

Risks increase as birth interval decreases, with birth spacing of less than 6 months having the highest risk.

Appropriate birth spacing would measurably reduce

national preterm birth rates.

For each month that birth spacing was less than 18 months,

Preterm births increased 1.9%

Low birthweight increased 3.3%

Poor intrauterine growth increased 1.5%

Conde-Agudelo JAMA 2006 295(15) 1809-23.

Expanding Group Prenatal Care

March of Dimes Support of group prenatal care

• Since 2005 March of Dimes has supported group prenatal care through community grants

• March of Dimes United Health Prenatal Care offers:- flexibility in group size

- possible reimbursement for services

Implement pilot taking place now, fall 2016.

March of Dimes & CenteringPregnancy®

March of Dimes chapters have been supporting the Centering model and/or directly supporting the establishment of Centering groups across the country since 2005.

2005 $200,0002006 $500,0002007 $800,0002008 $1.36 million2009 $1.27 million2010 $1.27 million2011 $1.85 million2012 $1.70 million2013 $1.49 million2014 $1.1 million2015 $1.39 million

Total of $12.93 million over the last 11 years (2005-2015)

Increasing Use of Low-Dose Aspirinto Prevent Preeclampsia

Preeclampisa involves high blood pressure

Can ultimately threaten the life or health of both mother and baby

Can only be cured by delivering the infant, regardless of the gestational age

The U.S. Preventive Services Task Force recommends all

at-risk women take a daily low-dose aspirin

ACOG: Treatment with Low Dose Aspirin

“For women with a medical history of early-onset preeclampsia and preterm delivery at less than 34 0/7 weeks of gestation or preeclampsia in more than one

prior pregnancy, initiating the administration of daily low dose (60 – 80 mg) aspirin beginning in the late first trimester is suggested.”

ACOG, Hypertension in Pregnancy, Taskforce on Hypertension in Pregnancy, 2013, page 28.

Advancing Interventions for WomenDiagnosed with a Short Cervix

Universal screening for short cervix can help identify women at risk for preterm birth

Allows women to take advantage of interventions like progesterone therapy and cerclage

Reducing Multiple Births Conceived through Assisted Reproductive Therapy

Women carrying twins or higher-order multiples are at high risk for preterm birth

Use of single embryo transfer can dramatically reduce the incidence of multiples conceived through ART

Last two interventions These interventions very clinical. National continues to work on the best promotion of these. States are not working specifically on these but MCH Directors

are aware of the interventions.

2016 PREMATURE BIRTH REPORT CARD

marchofdimes.org/reportcard

Nebraska 9.9%Preterm Birth Rate

CGrade

The March of Dimes Prematurity Campaign aims to reduce preterm birth rates across the United States. Premature Birth Report Card grades are assigned by comparing the 2015 preterm birth rate in a state or locality to the March of

Dimes goal of 8.1 percent by 2020. The Report Card also provides county and race/ethnicity data to highlight areas of increased burden and elevated risks of

prematurity.

2016 PREMATURE BIRTH REPORT CARD

marchofdimes.org/reportcard

Gestational age is based on obstetric estimate. Source: National Center for Health Statistics, 2015 natality data.

2016 PREMATURE BIRTH REPORT CARD

COUNTIES IN NEBRASKA

marchofdimes.org/reportcard

Counties with the greatest number of births are graded based on their 2014 preterm birth rates.

Counties Preterm birth rate Grade

Buffalo 9.4% C

Dodge 8.8% B

Douglas 9.8% C

Hall 6.9% A

Lancaster 8.9% B

Sarpy 10.6% D

Gestational age is based on obstetric estimate. Source: National Center for Health Statistics, 2014 natality data.

2016 PREMATURE BIRTH REPORT CARD

RACE & ETHNICITY IN NEBRASKA

marchofdimes.org/reportcard

Gestational age is based on obstetric estimate. Race categories include only women of non-Hispanic ethnicity.Source: National Center for Health Statistics, 2012-2014 natality data.

In Nebraska, the preterm birth rate

among black women is 45%

higher than the rate among all other

women.

2016 PREMATURE BIRTH REPORT CARD

marchofdimes.org/reportcard

Gestational age is based on obstetric estimate. Source: National Center for Health Statistics, 2015 natality data..

PRETERM BIRTH RATES AND GRADES BY STATE

March of Dimes Response

For these 8 interventions to reduce preterm birth

• Educating practitioners

• Inform women of child-bearing age

• Developing colloaborative efforts to implement interventions

• Increasing topic at March of Dimes’ conferences

• Provide grants to support interventions

Thank you!