PRAMS: A Tool to Understanding and Addressing Prematurity

1
PRAMS A Tool to Understanding and Addressing
Prematurity

• Preterm Birth in Utah
• Nan Streeter
• Utah Department of Health

2
Preterm Birth in Utah Compared to National Data

• Preterm birth birth prior to 37 completed weeks
  of gestation

3
Preterm Birth in Utah Compared to National Data

• Preterm birth birth prior to 37 completed weeks
  of gestation
• Utah PTB rate 9.5 (2003)
• 40 increase since 1992

4
Preterm Birth in Utah Compared to National Data

• Preterm birth birth prior to 37 completed weeks
  of gestation
• Utah PTB rate 9.5 (2003)
• 40 increase since 1992
• U.S. PTB rate 12.1 (2002)
• 13 increase since 1992

5
Utah and National Rates
Utah Source Utah Department of Health. Center
for Health Data. (2003). Indicator-Based
Information System (IBIS) for Public Health.
Birth Certificate Data. U.S. Source National
Center for Health Statistics, final natality
data. Retrieved from www.marchofdimes.com/peristat
s 1 Preterm is defined as less than 37 completed
weeks of gestation. Rates are based on clinical
estimate of gestation. 2 Preterm is defined as
less than 37 completed weeks of gestation. Rates
are based on NCHS methodology using LMP.
Utah Source Utah Department of Health. Center
for Health Data. (2003). Indicator-Based
Information System (IBIS) for Public Health.
Birth Certificate Data. U.S. Source National
Center for Health Statistics, final natality
data. Retrieved from www.marchofdimes.com/peristat
s 1 Preterm is defined as less than 37 completed
weeks of gestation. Rates are based on clinical
estimate of gestation. 2 Preterm is defined as
less than 37 completed weeks of gestation. Rates
are based on NCHS methodology using LMP.
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Sequelae of Prematurity

• Leading cause of perinatal death in otherwise
  normal newborns

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Sequelae of Prematurity

• Leading cause of perinatal death in otherwise
  normal newborns
• In Utah, 80 of infants who died during the
  neonatal period were born prematurely in 2002

8
Sequelae of Prematurity

• Major cause of suboptimum long-term outcomes

ACOG Perinatal care at the threshold of
viability. In Practice Bulletin-Clinical
Management Guidelines for Obstetrician-Gynecologis
t. ACOG. Washington DC, 2002, pp. 1-8.
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Sequelae of Prematurity

• Major cause of suboptimum long-term outcomes
• Disabilities in 50 of survivors of extreme
  prematurity at 30 months of corrected age

ACOG Perinatal care at the threshold of
viability. In Practice Bulletin-Clinical
Management Guidelines for Obstetrician-Gynecologis
t. ACOG. Washington DC, 2002, pp. 1-8.
10
Sequelae of Prematurity

• Major cause of suboptimum long-term outcomes
• Disabilities in 50 of survivors of extreme
  prematurity at 30 months of corrected age
• mental/psychomotor development

ACOG Perinatal care at the threshold of
viability. In Practice Bulletin-Clinical
Management Guidelines for Obstetrician-Gynecologis
t. ACOG. Washington DC, 2002, pp. 1-8.
11
Sequelae of Prematurity

• Major cause of suboptimum long-term outcomes
• Disabilities in 50 of survivors of extreme
  prematurity at 30 months of corrected age
• mental/psychomotor development
• neuromotor function or sensory

ACOG Perinatal care at the threshold of
viability. In Practice Bulletin-Clinical
Management Guidelines for Obstetrician-Gynecologis
t. ACOG. Washington DC, 2002, pp. 1-8.
12
Sequelae of Prematurity

• Major cause of suboptimum long-term outcomes
• Disabilities in 50 of survivors of extreme
  prematurity at 30 months of corrected age
• mental/psychomotor development
• neuromotor function or sensory
• communication function

ACOG Perinatal care at the threshold of
viability. In Practice Bulletin-Clinical
Management Guidelines for Obstetrician-Gynecologis
t. ACOG. Washington DC, 2002, pp. 1-8.
13
Outcomes of Very Low Birth Weight Infants in Utah

• Utah Department of Healths Neonatal Follow-up
  Program - 1986 - 2000

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Outcomes of Very Low Birth Weight Infants in Utah

• Utah Department of Healths Neonatal Follow-up
  Program - 1986 - 2000
• 545 babies born at ? 26 weeks gestation

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Outcomes of Very Low Birth Weight Infants in Utah

• Utah Department of Healths Neonatal Follow-up
  Program - 1986 - 2000
• 545 babies born at ? 26 weeks gestation
• Average birth weight
• 728 grams
• range 436 - 1500 grams

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Outcomes of Very Low Birth Weight Infants in Utah

• Utah Department of Healths Neonatal Follow-up
  Program - 1986 - 2000
• 545 babies born at ? 26 weeks gestation
• Average birth weight
• 728 grams
• range 436 - 1500 grams
• Gestational age ranged from 21 - 26 weeks
• 21-23 weeks 60 babies 11
• 24-26 weeks 485 babies 89

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Outcomes of Very Low Birth Weight Infants in Utah

• Average hospital stay - 107 days
• Range of 41 - 278 days

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Outcomes of Very Low Birth Weight Infants in Utah

• Average hospital stay - 107 days
• Range of 41 - 278 days
• Intraventricular hemorrhage
• 50 (271/545) all grade of IVH
• 20 (109/545) grade III and IV bleed

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Outcomes of Very Low Birth Weight Infants in Utah

• Average hospital stay - 107 days
• Range of 41 - 278 days
• Intraventricular hemorrhage
• 50 (271/545) all grade of IVH
• 20 (109/545) grade III and IV bleed
• Retinopathy of prematurity
• 80 (436/545) all stages of ROP
• 34 (183/545) ROP stage 3 and higher

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Outcomes of Very Low Birth Weight Infants in Utah

• Cerebral Palsy
• 18 (99/545)

21
Outcomes of Very Low Birth Weight Infants in Utah

• Cerebral Palsy
• 18 (99/545)
• Home on supplemental oxygen
• 68

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Utah Preterm Birth Study
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Utah Preterm Birth Study

• Utah Department of Health
• Lois Bloebaum BSN, (MPA Candidate)
• Laurie Baksh MPH
• Joanne Barley BS
• Nan Streeter MS, RN
• Peter Barnard CNM, MS

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Utah Preterm Birth Study

• Utah Department of Health
• Lois Bloebaum BSN, (MPA Candidate)
• Laurie Baksh MPH
• Joanne Barley BS
• Nan Streeter MS, RN
• Peter Barnard CNM, MS
• University of Utah
• Michael Varner MD
• Yvette LaCoursiere MD, MPH

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Utah Preterm Birth Study

• Study Question
• What are the significant factors associated with
  preterm births in Utah?

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Utah Preterm Birth Study

• Methodology
• Linked birth certificate and PRAMS data
• (1999-2001)
• Multiple gestations excluded from analysis

27
Utah Preterm Birth Study

• Methodology
• Linked birth certificate and PRAMS data
• (1999-2001)
• Multiple gestations excluded from analysis
• Dataset divided into two mutually exclusive
  categories

28
Utah Preterm Birth Study

• Methodology
• Linked birth certificate and PRAMS data
• (1999-2001)
• Multiple gestations excluded from analysis
• Dataset divided into two mutually exclusive
  categories
• Chi-square tests identified significant variables

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Utah Preterm Birth Study

• Study divided premature births into two categories

30
Utah Preterm Birth Study

• Study divided premature births into two
  categories
• Indicated preterm birth

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Utah Preterm Birth Study

• Study divided premature births into two
  categories
• Indicated preterm birth
• Spontaneous preterm birth

32
Utah Preterm Birth Study

• Definitions
• Indicated preterm birth associated with
  pregnancy complications requiring obstetric
  intervention for early delivery or led to preterm
  labor resulting in preterm birth

33
Utah Preterm Birth Study

• Definitions
• Indicated preterm birth associated with
  pregnancy complications requiring obstetric
  intervention for early delivery or led to preterm
  labor resulting in preterm birth
• Spontaneous preterm birth - one in which the
  underlying cause was not clinically evident
• From Kristensen J, Langhoff-Roos J,
  Kristensen F. Implications of Idiopathic Preterm
  Delivery for Previous and Subsequent Pregnancies.
  Obstet Gyn. Vol. 86, No. 5, Nov. 1995.

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Utah Preterm Birth Study

• Indicated preterm births - factors identified
  from birth certificate

35
Utah Preterm Birth Study

• Indicated preterm births - factors identified
  from birth certificate
• Maternal medical and/or obstetric risk factors

36
Utah Preterm Birth Study

• Indicated preterm births - factors identified
  from birth certificate
• Maternal medical and/or obstetric risk factors
• Complications of labor and delivery

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Utah Preterm Birth Study

• Indicated preterm births - factors identified
  from birth certificate
• Maternal medical and/or obstetric risk factors
• Complications of labor and delivery
• Congenital anomaly of the child

38
Utah Preterm Birth Study

• Indicated preterm births - factors identified
  from birth certificate
• Maternal medical and/or obstetric risk factors
• Complications of labor and delivery
• Congenital anomaly of the child
• Induction (elective or therapeutic)

39
Utah Preterm Birth Study

• Indicated preterm births - factors identified
  from birth certificate
• Maternal medical and/or obstetric risk factors
• Complications of labor and delivery
• Congenital anomaly of the child
• Induction (elective or therapeutic)
• Elective cesarean section
• (excludes PPROM)

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Utah Preterm Birth Study

• Spontaneous preterm births - those births that
  did not meet the criteria for indicated category
• category includes PPROM

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Utah Preterm Birth Study

• This study identified significant factors
  associated with both indicated and spontaneous
  premature births during 1999-2001.

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Utah Preterm Birth Study

• Indicated preterm births n5,700 (53)
• Mean gestational age - 33.8 wks.

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Utah Preterm Birth Study

• Indicated preterm births n5,700 (53)
• Mean gestational age - 33.8 wks.
• Spontaneous preterm births n5,100 (47)
• Mean gestational age - 34.5 wks.

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Utah Preterm Birth Study

• Indicated preterm delivery was significantly
  higher among women who

45
Utah Preterm Birth Study

• Indicated preterm delivery was significantly
  higher among women who
• Had a previous preterm infant

46
Utah Preterm Birth Study

• Indicated preterm delivery was significantly
  higher among women who
• Had a previous preterm infant
• Were other than white

47
Utah Preterm Birth Study

• Indicated preterm delivery was significantly
  higher among women who
• Had a previous preterm infant
• Were other than white race
• Smoked during last trimester

48
Utah Preterm Birth Study

• Indicated preterm delivery was significantly
  higher among women who
• Had a previous preterm infant
• Were other than white race
• Smoked during last trimester
• Were aged 20 24 years

49
Utah Preterm Birth Study

• Indicated preterm delivery was significantly
  higher among women who
• Had a previous preterm infant
• Were other than white race
• Smoked during last trimester
• Were aged 20 24 years
• Had lt high school education

50
Utah Preterm Birth Study

• Indicated preterm delivery was significantly
  higher among women who
• Had a previous preterm infant
• Were other than white race
• Smoked during last trimester
• Were aged 20 24 years
• Had lt high school education
• Earned lt 15,000 per year

51
Utah Preterm Birth Study
P-value lt0.001
52
Utah Preterm Birth Study
P-value lt0.01
53
Utah Preterm Birth Study
P-value lt0.05
54
Utah Preterm Birth Study
P-value lt0.05
55
Utah Preterm Birth Study
P-value lt0.05
56
Utah Preterm Birth Study
P-value lt0.05
57
Utah Preterm Birth Study

• Spontaneous preterm delivery was significantly
  higher among women who

58
Utah Preterm Birth Study

• Spontaneous preterm delivery was significantly
  higher among women who
• Had a previous preterm infant

59
Utah Preterm Birth Study

• Spontaneous preterm delivery was significantly
  higher among women who
• Had a previous preterm infant
• Used fertility drugs to conceive the pregnancy

60
Utah Preterm Birth Study

• Spontaneous preterm delivery was significantly
  higher among women who
• Had a previous preterm infant
• Used fertility drugs to conceive the pregnancy
• Had some college education

61
Utah Preterm Birth Study

• Spontaneous preterm delivery was significantly
  higher among women who
• Had a previous preterm infant
• Used fertility drugs to conceive the pregnancy
• Had some college education
• Had a prepregnancy BMI categorized as either
  under- or over-weight

62
Utah Preterm Birth Study

• Spontaneous preterm delivery was significantly
  higher among women who
• Had a previous preterm infant
• Used fertility drugs to conceive the pregnancy
• Had some college education
• Had a prepregnancy BMI categorized as either
  under- or over-weight

63
Utah Preterm Birth Study
P-value lt0.001
64
Utah Preterm Birth Study
P-value lt0.05
65
Utah Preterm Birth Study
P-value lt0.01
66
Utah Preterm Birth Study
P-value lt0.05
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Summary of Study Findings

• Indicated preterm births were slightly higher
  perhaps due to

68
Summary of Study Findings

• Indicated preterm births were slightly higher
  perhaps due to
• Technological advances that permit early delivery
  to protect mother/infant

69
Summary of Study Findings

• Indicated preterm births were slightly higher
  perhaps due to
• Technological advances that permit early delivery
  to protect mother/infant
• Preconceptional health issues chronic disease,
  poverty (health access), tobacco use

70
Summary of Study Findings

• Indicated preterm births were slightly higher
  perhaps due to
• Technological advances that permit early delivery
  to protect mother/infant
• Preconceptional health issues chronic disease,
  poverty (health access), tobacco use
• Iatrogenic contribution, such as induction

71
Summary of Study Findings

• Spontaneous preterm births accounted for almost
  half of preterm births, yet no identifiable
  medical risk factor was identified

72
Summary of Study Findings

• Spontaneous preterm births accounted for almost
  half of preterm births, yet no identifiable
  medical risk factor was identified
• Preterm birth was 5x greater with previous history

73
Summary of Study Findings

• Spontaneous preterm births accounted for almost
  half of preterm births, yet no identifiable
  medical risk factor was identified
• Preterm birth was 5x greater with previous
  history
• Demographic characteristics resemble general
  population

74
Summary of Study Findings

• Spontaneous preterm births accounted for almost
  half of preterm births, yet no identifiable
  medical risk factor was identified
• Preterm birth was 5x greater with previous
  history
• Demographic characteristics resemble general
  population
• Contribution of prepregnancy weight and fertility
  drug use

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Summary of Study Findings

• Both indicated and spontaneous preterm deliveries
  were significantly higher among women with
  history of previous preterm birth

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Study Limitations

• Limitations
• Use of birth certificate data, with
  under-reporting and/or inaccurate reporting of
  medical risk factors

77
Study Limitations

• Limitations
• Use of birth certificate data, with
  under-reporting and/or inaccurate reporting of
  medical risk factors
• Use of self-reported PRAMS data is subject to
  recall bias

78
Study Limitations

• Limitations
• Use of birth certificate data, with
  under-reporting and/or inaccurate reporting of
  medical risk factors
• Use of self-reported PRAMS data is subject to
  recall bias
• Methodology did not separate primiparous and
  multiparous women

79
Study Conclusions

• Conclusions
• Strongest risk factor - previous preterm birth
  screening and education critical

80
Study Conclusions

• Conclusions
• Strongest risk factor - previous preterm birth
  screening and education critical
• Improved preconceptional counseling and care
  (smoking cessation, chronic disease management,
  and weight control)

81
Study Conclusions

• Conclusions
• Strongest risk factor - previous preterm birth
  screening and education critical
• Improved preconceptional counseling and care
  (smoking cessation, chronic disease management,
  and weight control)
• Need for continued research periodontal disease,
  use of prophylactic progesterone in women with
  previous history of preterm birth

82
Future Studies

• Additional studies could focus on
• Separate analysis of primiparous and multiparous
  women

83
Future Studies

• Additional studies could focus on
• Separate analysis of primiparous and multiparous
  women
• Identifying a third group - PPROM

84
Future Studies

• Additional studies could focus on
• Separate analysis of primiparous and multiparous
  women
• Identifying a third group - PPROM
• Further logistic regression analysis to study
  interactions between variables

85
What Can We Take Home?

• Accurate data on birth certificates is important
  to conducting studies, especially report of
  medical risk factors

86
What Can We Take Home?

• Accurate data on birth certificates is important
  to conducting studies, especially report of
  medical risk factors
• Maternal birthing history is important in
  determining potential for repeating birth outcomes

87
What Can We Take Home?

• Accurate data on birth certificates is important
  to conducting studies, especially report of
  medical risk factors
• Maternal birthing history is important in
  determining potential for repeating birth
  outcomes
• PTB is a multifactoral, complex problem

88
Contact Information

• Nan Streeter, MS, RN
• MCH Bureau Director
• Utah Department of Health
• PO Box 142001
• Salt Lake City, UT 84114-2001
• 801-538-9963
• nanstreeter_at_utah.gov