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The Changing Epidemiology of Preterm Birth in the U.S.

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Title: The Changing Epidemiology of Preterm Birth in the U.S.


1
The Changing Epidemiology of Preterm Birth in the
U.S.
  • Nancy S. Green, MD
  • Medical Director
  • National March of Dimes
  • White Plains, NY
  • ngreen_at_marchofdimes.com
  • Associate Professor of Pediatrics
  • Assistant Professor of Cell Biology
  • Albert Einstein College of Medicine, N.Y.

2
March of Dimes Birth Defects Foundation
  • Mission
  • To improve infant health by preventing infant
    mortality and birth defects
  • The Continuum of Reproductive Health
  • Determinates of infant health
  • The entire spectrum of reproductive health
    extends from pre- conception through 1st year of
    infants life and throughout the womans
    childbearing years
  • Pre-conceptional health as the cornerstone

3
Preterm Birth/Prematurity
  • 1 cause of perinatal mortality (28 weeks
    gestation - 6 days life) in US ( 75 of these
    losses)
  • 1 cause of neonatal mortality (0-27 days) in US
  • 2 cause of infant mortality (lt1 year) in US
  • 1 cause of infant mortality for black infants in
    the US
  • Major determinant of neonatal and infant illness
  • Neuro-developmental handicaps (CP, Mental
    Retardation)
  • Chronic respiratory problems
  • Intraventricular hemorrhage, Periventricular
    leukomalacia
  • Infection
  • Necrotizing enterocolitis
  • Neurosensory deficits (hearing, visual)

4
www.marchofdimes.com or peristats.modimes.org
5
Infant MortalityUnited States, 1915-2001
Rate per 1,000 live births
Source National Center for Health Statistics,
final mortality data Prepared by March of Dimes
Perinatal Data Center, 2002
6
Selected Leading Causes of Infant Mortality
United States, 1990 and 2000
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
7
Overlap in LBW, Preterm and Birth Defects U.S.
(2002)
Low Birthweight Births 7.8
Preterm Births 12.0
Among LBW 2/3 are preterm Among preterm almost
50 are LBW (some preterm are not LBW)
Birth Defects 3-4
8
Current Definitions
  • Birth Weight
  • Low Birth weight (LBW) - lt 2500 grams or 5.5 lbs
  • Very low birth weight - (VLBW) lt 1500 grams or
    3.3 lbs
  • Gestation Length
  • Premature (preterm delivery, PTD)- lt 37 weeks
  • Early preterm delivery - lt 32 weeks
  • Growth Restriction
  • lt 10th percentile for gestational age
  • IUGR - intrauterine growth restricted applies to
    fetuses
  • SGA - small for gestational age applies to
    neonates

9
Preterm BirthsUnited States, 1981, 1991, 2001,
2002
Percent
Healthy People Objective
March of Dimes Objective
27 Percent Increase 1981-2001
Source National Center for Health Statistics,
final natality data Prepared by March of Dimes
Perinatal Data Center, 2003
10
U.S. Preterm Birth by State (2001)
US Total 11.9
11
Percent Change in Preterm Birth Rate By State,
United States, 1991 to 2001
Note Value in ( ) number of states (includes
District of Columbia) Value ranges are
based on equal counts Source National Center for
Health Statistics, final natality data Prepared
by March of Dimes Perinatal Data Center
12
Distribution of Live Births by Gestational
Age United States, 1990 and 2001
2001 Live Births n 3,986,102
1990 Live Births n 4,111,396
Not Preterm (88.4)
Not Preterm (89.4)
Very Preterm (1.9)
Moderately Preterm (8.7)
Moderately Preterm (10.0)
Very Preterm (1.9)
Total Preterm 10.6
Total Preterm 11.9
Note Live births with missing gestational age
data were excluded from the analysis.
Source National Center for Health Statistics,
final natality data Prepared by March of Dimes
Perinatal Data Center, 2003
13
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
14
Preterm Births (lt37 weeks)by Maternal
Race/Ethnicity, US, 2001
Percent
Preterm is less than 37 weeks gestation Hispanics
can be of any race Source National Center for
Health Statistics, 2000 final natality
data Prepared by March of Dimes Perinatal Data
Center, 2002
15
Distribution of Live and Preterm Birthsby
Race/Ethnicity, US, 2001
Percent of Preterm Births (more than 476,000)
Percent of All Live Births (more than 4 million)
Source National Center for Health Statistics,
2001 final natality data Prepared by March of
Dimes Perinatal Data Center, 2003
16
Types of Preterm Birth
Spontaneous Preterm Labor
Spontaneous Premature Rupture of the Membranes
Preterm Birth
Medical Intervention
While this suggests distinct pathways, many of
the risk factors for all 3 are similar
17
Risk Factors for Preterm Labor/Delivery
  • The best predictors of having a preterm birth
    are
  • current multifetal pregnancy
  • a history of preterm labor/delivery or prior low
    birthweight
  • mid trimester bleeding (repeat)
  • some uterine, cervical and placental
    abnormalities
  • Other risk factors
  • low pre-pregnant weight
  • obesity
  • infections
  • bleeding
  • anemia
  • major stress
  • lack of social supports
  • tobacco use
  • illicit drug use
  • alcohol abuse
  • folic acid deficiency
  • multifetal pregnancy
  • maternal age (lt17 and gt35 yrs)
  • black race
  • low SES
  • unmarried
  • previous fetal or neonatal death
  • 3 spontaneous terminations
  • uterine abnormalities
  • incompetent cervix
  • genetic predisposition

18
Factors that Contribute to Increasing Rates of
Preterm Birth
  • ? rates of births to women gt35
  • ? rates of multiple births
  • Indicated deliveries
  • Induction - enhanced management of maternal and
    fetal conditions
  • Patient preference/consumerism
  • Substance abuse
  • Tobacco
  • Alcohol
  • Illicit drugs
  • Infections
  • Increased stress (?) (catastrophic events, DV,
    racism)

19
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
20
Preterm Birthsby Maternal Age, United States,
2000
Percent
Preterm is less than 37 competed weeks
gestation Source National Center for Health
Statistics, 2000 final natality data Prepared by
March of Dimes Perinatal Data Center, 2002
21
Very Preterm (lt32 wks) by Maternal Age United
States, 1999-2001 average
22
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
23
Multiple Birth Ratios by RaceUnited States,
1980-2001
Ratio per 1,000 live births
Race of child from 1980-1988 Race of mother
from 1989-2001 Source NCHS, final natality data,
1980-2001 Prepared by March of Dimes Perinatal
Data Center, 2003
24
Higher Order Birth Ratios by RaceUnited States,
1980-2001
Ratio per 100,000 live births
Race of child from 1980-1988 Race of mother
from 1989-2001 Source NCHS, final natality data,
1980-2001 Prepared by March of Dimes Perinatal
Data Center, February 2003
25
Risks of Adverse Pediatric Outcomes with ART
  • Multiples
  • Twins - 10-35 Triplets - 0.5-9.3
  • Prematurity
  • Low birth weight
  • Birth Defects? Complicated analysis
  • Maternal Low birth weight, Birth defects
  • Paternal Chromosomal abnormalities
  • Procedures ??

26
Singletons Preterm Delivery United States,
1991-2001
US Singleton PTB increase 6.1
27
Total and Primary Cesarean and VBAC Rates United
States, 1989-2002
28
Singleton Preterm Births by Delivery
Method United States, 1990 and 2000
Percent
29
Thank you for your attention
this continuing education presentation is
sponsored by the March of Dimes - Johnson
Johnson Pediatric Institute Grand Rounds Program
as part of the March of Dimes National
Prematurity Campaign
Additional Resources askus_at_marchofdimes.com
www.marchofdimes.com
www.jjpi.com
30
(No Transcript)
31
March of Dimes National Prematurity Campaign
  • Nancy S. Green, MD
  • Medical Director
  • National March of Dimes
  • White Plains, NY
  • ngreen_at_marchofdimes.com
  • Associate Professor of Pediatrics
  • Assistant Professor of Cell Biology
  • Albert Einstein College of Medicine, N.Y.

32
(No Transcript)
33
March of Dimes National Prematurity
Campaign2003-20075 year 75 million
initiativeNational Partners ACOG,
AAP,AWHONNand many national professional health
group alliances
34
Campaign Goals
  • 1. Increase public awareness of the problems of
    prematurity to at least 60
  • Annual survey 38 baseline
  • 2. Decrease the rate of preterm birth in the U.S.
    by at least 15
  • 2001 rate 11.9 (to lt10.1)

35
Preterm BirthsUnited States, 1981, 1991, 2001,
2002
Percent
Healthy People Objective
March of Dimes Objective
27 Percent Increase 1981-2001
Source National Center for Health Statistics,
final natality data Prepared by March of Dimes
Perinatal Data Center, 2003
36
March of Dimes Prematurity Campaign2003-2007
  • 5 Campaign Aims
  • 1. Raise public awareness
  • 2. Educate women as to signs of premature labor
  • 3. Assist practitioners
  • 4. Invest to identify causes and promising
    interventions
  • 5. Seek guaranteed access to health care

37
Outreach
  • Public
  • Media (PSAs, etc.), Print, Web
  • Pregnant women
  • Signs and symptoms of preterm labor and actions
  • Risk reduction (pre-conception and prenatal care,
    healthy lifestyles, risk-appropriate care
  • NICU family support
  • Health care providers
  • Grand Rounds, Curricula, patient ed materials,
    journal articles, PERIstats website

38
March of Dimes


www.marchofdimes.com askus_at_marchofdimes.com
39
Premature BirthThe answers cant come soon
enough
40
Thank you for your attention
this continuing education presentation is
sponsored by the March of Dimes - Johnson
Johnson Pediatric Institute Grand Rounds Program
as part of the March of Dimes National
Prematurity Campaign
Additional Resources askus_at_marchofdimes.com
www.marchofdimes.com
www.jjpi.com
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