Prematurity Infant Mortality: The Scourge Remains

1
Prematurity - Infant Mortality The Scourge
Remains!

• Diane Ashton, MD, MPH
• Associate Medical Director
• Office of the Medical Director
• National Office
• March of Dimes Birth Defects Foundation

2
(No Transcript)
3
Selected Leading Causes of Infant Mortality
United States, 1990 and 2002
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
4
Preterm Birth

• Single most important cause of perinatal
  mortality (28 weeks gestation through 6 days of
  life) in the U.S. (accounts for approx 75 of
  these losses)
• Leading cause of neonatal mortality (0-27 days)
  in U.S.
• Second leading cause of infant mortality in U.S.
• Leading cause of black infant mortality in U.S.
• Major determinant of neonatal and infant illness

5
Preterm BirthsUnited States, 1982, 1992, 2002,
2003
Percent
Healthy People Objective
30 Percent Increase
Preliminary Data, NCHS, 11/23/04. 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, 2004
6
Overlap in LBW, Preterm and Birth Defects U.S. ,
2002
Low Birthweight Births 7.8
Preterm Births 12.1
Among LBW 2/3 are preterm Among preterm almost
50 are LBW (some preterm are not LBW)
Birth Defects 3-4
7
Preterm Birth Rates by State United States, 2002
Percent of Live Births
Over 12.6
(17))
11
.4
to
12
.6
(16)
Under 11.4
(18)
Note Value in ( ) number of states (includes
District of Columbia) Value ranges are
based on equal counts Source National Center for
Health Statistics, 2002 final natality
data Prepared by March of Dimes Perinatal Data
Center, December 2003
U.S Rate 12.1
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
Risk Factors for Preterm Labor/Delivery

• The best predictor of having a preterm birth is
  multifetal gestation or history of preterm
  labor/delivery
• Other risk factors

• maternal age (lt17 and gt35 years)
• black race
• low SES
• unmarried
• previous fetal or neonatal death
• 3 spontaneous losses
• uterine abnormalities
• incompetent cervix
• genetic predisposition
• low pre-pregnancy weight

• obesity
• infections
• bleeding
• anemia
• major stress
• lack of social supports
• tobacco use
• illicit drug use
• alcohol abuse
• folic acid deficiency

10
Major Categories of Risk for Preterm Birth

• Extremes of maternal age
• Multiple gestations
• Unintended pregnancy
• 34, 35, 36 week gestations
• Maternal race

11
Preterm Birthsby Maternal Age, United States,
2001
Percent
Preterm is less than 37 completed weeks
gestation Source National Center for Health
Statistics, 2001 final natality data Prepared by
March of Dimes Perinatal Data Center, 2003
12
Live Births to Women ?30 YearsUnited States,
1980-2001
Rate per 1,000 women in specified group
95.2
61.9
41.3
19.8
8.1
3.9
Source NCHS, final natality data,
1980-2001 Prepared by March of Dimes Perinatal
Data Center, 2003
13
Preterm Births by PluralityUnited States, 2001
Percent
Source National Center for Health Statistics,
2001 final natality data Prepared by March of
Dimes Perinatal Data Center, 2003
14
Unintended Pregnancies United States, 1994
Percent
Source National Survey of Family Growth,
1995 Prepared by March of Dimes Perinatal Data
Center, 2000
15
All Preterm Births by Gestational Age, US, 2001
(36 Weeks)
(35 Weeks)
(lt32 Weeks)
(32 Weeks)
(34 Weeks)
(33 Weeks)
Source National Center for Health Statistics,
2001 natality file Prepared by the March of Dimes
Perinatal Data Center, 2003
71 of PTB occurs at 34, 35, 36 weeks
16
Preterm and Very Preterm BirthsUnited States,
1992-2002
Percent of live births
Objective
Preterm is less than 37 completed weeks
gestation. Very preterm is less than 32 completed
weeks gestation. Source National Center for
Health Statistics, final natality data Prepared
by March of Dimes Perinatal Data Center, 2004
17
Preterm Births (lt37 weeks)by Maternal
Race/Ethnicity, US, 2002
Percent
Preterm is less than 37 weeks gestation Hispanics
can be of any race Source National Center for
Health Statistics, 2004 final natality
data Prepared by March of Dimes Perinatal Data
Center, 2004
18
Disparities in Health and Health Care

• Disparities in health are defined as unequal
  burdens in disease morbidity and mortality rates
  experience by ethnic/racial groups as compared to
  the dominant group
• Causes may include poor education, health
  behaviors of the minority group, poverty, and
  environmental factors
• Disparities in health care are defined as racial
  or ethnic differences in the quality of health
  care that are NOT due to access-related factors
  or clinical needs, preferences or appropriateness
  of intervention
• Health care disparities relate to quality and
  include provider / patient relationships,
  provider bias and discrimination and patient
  variables such as mistrust of the health care
  system and refusal of treatment

19
How do disparities arise?

• Differences in the quality of care received
  within the health care delivery system
• Differences in access to health care including
  preventive and curative services
• Differences in social, political, economic, or
  environmental exposures which result in
  differences in underlying health status

20
Unequal Treatment, IOM Report, 2002

• Clearly documents the pervasiveness of racial and
  ethnic disparities in health care in the US
• Report commissioned by Congress 15 member
  Committee reviewed the literature, commissioned
  papers and gathered information with the use of
  workshops, focus groups and round table
  discussions
• Two major findings
• Racial and ethnic disparities in health care
  occur in the context of broader historic and
  contemporary social and economic inequality and
  evidence of persistent racial and ethnic
  discrimination in many sectors of American life
• Bias, stereotyping, prejudice and clinical
  uncertainty on the part of health care providers
  may contribute to racial/ethnic disparities in
  health care
• Within the context of the clinical encounter
  the IOM report suggests that major
  provider-client issues centered on health care
  provider prejudices, limited time frame with no
  time for processing information during the visit
  and mistrust and refusal on the part of patients

21
Changing Demographics

• If current birth and immigration trends continue,
  it is expected that by 2040 the
• Hispanic population will increase by 21
• Asian population will increase by 22
• African American population will increase by 12
• White population will increase by 2
• These changes combined with the fact that any
  minorities are overly burdened with disease
  suggests that the health care systems in the
  future will experience a much more diverse
  clientele and a sicker population

Source US Bureau of the Census, 2000
22
Population Projections by Race and Hispanic
Origin, US, 2000 - 2050
Percent of population
Includes American Indian and Alaska Native
alone, Native Hawaiian and Other Pacific Islander
alone, and Two or More Races Source US Census
Bureau Prepared by March of Dimes Perinatal Data
Center, 2005
23
Healthy People 2010 Goals

• Increase quality and years of healthy life
• Eliminate health disparities

24
Infant Mortality Rates by Maternal
Race/Ethnicity, US, 2002
Rate per 1,000 live births
People of Hispanic ethnicity may be any race all
other categories are non-Hispanic Source
National Center for Health Statistics, 2002
period linked birth/infant death data Prepared by
March of Dimes Perinatal Data Center, 2005
25
Infant Mortality by Maternal RaceUnited States,
1990 -2002
Rate per 1,000 live births
Objective
Source National Center for Health Statistics,
final mortality data Prepared by March of Dimes
Perinatal Data Center, 2003
26
Leading Cause-Specific Infant Mortality By
Maternal Race, US, 2002
Rate per 100,000 live births
Source National Center for Health
Statistics Prepared by March of Dimes Perinatal
Data Center, 2005
27
Preterm Rates by Maternal Race/Ethnicity, US,
1990-2000
Percent
Source National Center for Health Statistics
28
Major Categories of Risk for Disparities in Birth
Outcomes

• Attributed to maternal differences in
• Genetics
• Behaviors
• Prenatal Care
• SES
• Environmental

29
Racial Ethnic Disparities Birth Outcomes

• Race has no clear biologic or genetic basis
• Genetic diversity appears to be a continuum, with
  no clear breaks delineating racial groups.
• 
  Science 1998

30
Racial Ethnic Disparities Birth Outcomes

• Many birth outcomes have no clear genetic basis

31
Racial Ethnic DisparitiesInfant Mortality
Cigarette Smoking
NCHS 2002
African American
White
13.6
14.1
African American
9.3
White
5.8
32
Racial Ethnic DisparitiesInfant Mortality
Cigarette Smoking
13.2
9.2
NCHS 2002
33
Racial Ethnic DisparitiesInfant Mortality and
Maternal Education
African American
14.1
African American
74
Hispanic
Hispanic
51
5.7
NCHS 2002
34
Racial Ethnic DisparitiesInfant Mortality and
Maternal Education
10.2
6.8
NCHS 2002
35
Preterm Births by Maternal Education and
Race/Ethnicity, US, 2002
Percent
B/W gap
1.5
1.6
1.6
People of Hispanic ethnicity may be any race all
other categories are non-Hispanic Source
National Center for Health Statistics, 2002 final
natality data Prepared by March of Dimes
Perinatal Data Center, 2005
36
Racial Ethnic DisparitiesInfant Mortality
Household Income
16.6
11.2
37
Racial and Ethnic DisparitiesLife Course
Perspective

• Weathering Hypothesis
• The effects of social inequality on the health of
  populations may compound with age, leading to
  growing gaps in health status through young and
  middle adulthood that can affect fetal health.
• Geronimus AT (1996)

38
Physiologic Weathering

• Altered hormonal response to stress kindling
• Susceptibility to infection
• Impaired inflammatory response
• Vascular compromise

39
Life Course Perspective
White
Poor Nutrition Stress Abuse Tobacco, Alcohol,
Drugs Poverty Lack of Access to Health
Care Exposure to Toxins
African American
Poor Birth Outcome
0
5
Puberty
Pregnancy
Age
40
Barker HypothesisBirth Weight and Coronary Heart
Disease
Age Adjusted Relative Risk
Rich-Edwards 1997
41
Barker HypothesisBirth Weight and Hypertension
Law 1993
42
Barker HypothesisBirth Weight and Insulin
Resistance Syndrome
Odds ratio adjusted for BMI
Barker 1993
43
Racial and Ethnic Disparities

• Racial and ethnic disparities in birth outcomes
  are the consequences of disadvantages and
  inequities carried over a life course of
  differential exposures.
• Research needs to examine differential risk
  exposures not only during pregnancy, but over the
  life course.
• Dont look for a quick fix.

44
Life Course Perspective
White
African American
Primary Care for Children
Early Intervention
Prenatal Care
Prenatal Care
Internatal Care
Primary Care for Women
Poor Birth Outcome
0
5
Age
Pregnancy
Puberty
45
March of Dimes National Prematurity
Campaign2003-2010
46
www.marchofdimes.com/PeriStats
47
Prevention of Preterm Labor, Preterm Delivery and
Prematurity

• Primary prevention
• identifying and managing risks through
  preconception / interconception care services
• risk reduction approach and strategies to improve
  reproductive health
• prevent PTL
• Secondary prevention
• prevention of preterm delivery
• Tertiary prevention
• prevent / minimize complications of prematurity

48
Interventions that Help

• Preconception care
• Early, comprehensive, accessible prenatal care
• Educate all pregnant women about preterm labor
  signs and symptoms (Take Action MOD Video Tape)
• Eliminate folic acid deficiency
• Screen and treat UTIs and STIs
• Identify cigarette smokers and intervene (5As)
• Assess for alcohol use and intervene
• Identify illicit substance users
• Assess for domestic violence
• Identify major stress levels early and throughout
  pregnancy
• Cultural competency

49
Promising Research Directions

• Progesterone study (high risk by history)
• Multisite US, Meis, et, al MFMU-NICHD
  (preliminary)
• ? by 30
• da Fonesca (preliminary)
• ? by 50
• Stress research - CDC, MOD (PRI), Others

50
Addressing Racial/Ethnic Disparities in Health
Care

• Raising public and provider awareness of
  racial/ethnic disparities in health care
• Expanding health insurance coverage
• Improving the number and capacity of providers in
  underserved communities
• Improving quality of care
• Increasing the knowledge base on causes and
  interventions to reduce disparities.
• Kaiser Family Foundation Issue Brief
• www.kff.org/minorityhealth/7293.cfm

51
March of Dimes

www.marchofdimes.com askus_at_marchofdimes.com
52
Resources for Addressing Disparities

• http//www.cdc.gov/reach2010/index.htm CDC
  program Reach 2010 - racial and ethnic
  approaches to community health
• http//raceandhealth.hhs.gov/ DHHS initiative to
  eliminate racial and ethnic disparities in health
  
• http//www.omhrc.gov/ DHHS Office of Minority
  Health home page
• http//bhpr.hrsa.gov/MEDICINE-DENTISTRY/ACTPCMD/RE
  PORTS/ACTPCMDREPORT.HTM HRSA report on training
  primary care professionals to eliminate health
  disparities.
• http//www.omhrc.gov/CLAS/ Office of minority
  heath - Recommendations for national standards
  and an outcomes-focused research agenda in
  cultural competence in health care.

53
Resources for Addressing Disparities - 2

• http//www.census.gov/pubinfo/www/hotlinks.html
  U.S. Census Bureau provides racial/ethnic-specifi
  c population data.
• http//www.nap.edu/books/030908265X/html
  Institute of Medicine Report on Unequal
  Treatment - Unequal Treatment Confronting Racial
  and Ethnic Disparities in Health Care (March 20,
  2002)
• http//www.apha.org/NPHW/solutions/ APHA Health
  Disparities Community Solution Database. Can
  search for Health Disparities Projects and
  Interventions.
• http//www.newschool.edu/milano/Health/cbohealth/d
  isparitiesfin.pdf Robert Wood Johnson Foundation
  publication Addressing Health Disparities In
  Community Settings An Analysis of Best Practices
  in Community-Based Approaches.

54
Resources for Addressing Disparities - 3

• http//www.kff.org/whythedifference/index.htm
  Henry J. Kaiser Family Foundation and The Robert
  Wood Johnson Foundation's initiative to raise
  physician awareness about disparities in medical
  care, beginning with cardiac care.
• http//mchlibrary.info/KnowledgePaths/kp_race.html
  MCH Library knowledge path on racial and ethnic
  disparities in health. Provides multiple
  resources.
• http//gucchd.georgetown.edu//nccc/index.html
  National Center for Cultural Competence.
  Provides resources and tools to address health
  disparities through cultural competence.

55
Resources for Addressing Disparities - 4

• http//www.omhrc.gov/summit/summitoolkit.pdf
  Office of Minority Health's community tool kit
  designed for the national leadership summit on
  eliminating racial and ethnic disparities in
  health. Provides data and statistics, information
  on programs and initiatives, and federal, state
  and local contact information.
• http//www.astho.org/pubs/nabookfull.pdf ASTHO
  and NACCHO publication on health department state
  and local programs addressing ethnic and racial
  disparities in health.
• http//www.cdc.gov/omh/AMH/factsheets/infant.htm
  CDC Office of Minority Health initiative to
  reduce disparities in infant mortality.