Public Health Feature - January 2010
Tex Med. 2010;106(1):41-46.
By Crystal Conde
It's not easy being a preemie. These tiny babies can have big problems.
They may be hooked up to monitors in the neonatal intensive care unit (NICU) for months, surrounded by physicians and nurses who watch closely for signs of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, and other complications of being born too soon.
Behind each of these diagnoses is a child, and behind each child are concerned and frightened family members who struggle to process the fact that their babies aren't perfectly healthy. Unfortunately for these families, the day their babies graduate from the NICU and head home doesn't signal the end of care.
Many require follow-up medical evaluation from occupational therapists, physical therapists, nutritionists, urologists, cardiologists, ophthalmologists, home nurses, social workers, speech and language therapists, and visits from home care medical supply companies. These high-risk infants may grow into high-risk children who suffer from asthma, poor cognitive ability and academic achievement, cerebral palsy, delayed motor skills, visual disability, and/or poor social adaptive functioning. Disabilities and health complications follow some into adulthood.
Huge expenses add to the crushing emotional, physical, and psychological toll preterm births can take on families.
Insurance plans for large employers paid an average $64,713 to cover the cost of inpatient and outpatient medical care and prescriptions for one preterm newborn (less than 37 completed weeks of gestation) and mother, according to 2008 figures from the March of Dimes. That figure doesn't include the cost of potential rehospitalization or long-term care and services. The Agency for Healthcare Research and Quality estimated in 2005 that on a national scale, private insurers and Medicaid each paid about $7.4 billion to cover preterm infants' inpatient hospital charges.
Charleta Guillory, MD, associate professor of pediatrics at Texas Children's Hospital Newborn Center and a member of Texas Medical Association's Committee on Maternal and Perinatal Health, becomes emotional when talking about the health challenges preterm infants endure. Dr. Guillory addressed the rising rate of prematurity at MedImmune's Premature Infant Summit, Collaborating for Preemies: Challenges & Changes, in Austin.
"I see on a daily basis the complications of babies being born prematurely. As physicians, we have to do more," she said.
Dr. Guillory points to the fact that among the leading causes of infant mortality in the United States - birth defects, preterm birth and low birth weight, sudden infant death syndrome, and respiratory distress syndrome - preterm birth and low birth weight are the only factors that haven't declined. (See " Selected Leading Causes of U.S. Infant Mortality, 1992 & 2006 .")
Adding to the burden is an increase in births identified as "late preterm," those that occur from 34 weeks to 36 weeks of gestation. Late preterm infants have a higher mortality rate - 7.7 per 1,000 births - than full-term babies - 2.5 per 1,000 births. They're also more likely than full-term infants to have temperature instability, hypoglycemia, respiratory distress, and clinical jaundice, and require intravenous infusion. Centers for Disease Control and Prevention (CDC) National Center for Health Statistics 2003 data show that 71 percent of preterm births occurred at 34, 35, and 36 weeks nationwide.
In mid-November, CDC reported that the proportion of babies born in the 34th through 36th weeks of pregnancy rose 20 percent between 1990 and 2006. More than 333,000 babies were born in this late preterm period in 2006, representing 8.1 percent of births. The CDC report says African-American mothers were about 50 percent more likely than white mothers and one-third more likely than Hispanic mothers to have a late preterm baby.
The American College of Obstetricians and Gynecologists (ACOG) calls the prevention of preterm births, including late preterm deliveries, a public health priority. ACOG and Dr. Guillory, along with other health care professionals who care for late preterm babies and their mothers, urge physicians to reduce the number of voluntary inductions and elective cesarean sections before 39 weeks of gestation for which no medical indication exists.
TMA's House of Delegates adopted a recommendation at TexMed 2009 to support the prevention of iatrogenic prematurity (caused by deliberately delivering a baby early) by physicians and others who attend at the delivery of infants. The recommendation, presented by TMA's Committee on Maternal and Perinatal Health, grew out of the March of Dimes' concerns that some iatrogenic prematurity may occur without good medical justification, such as at the request or convenience of the mother, or because of incorrect calculation of the gestational age of the fetus.
Room for Improvement
The United States ranks 30th among developed nations in infant mortality, with 6.9 deaths per 1,000 live births. Singapore ranks No. 1 with just 2.1 deaths per 1,000 live births. That's according to CDC National Center for Health Statistics 2005 data, the latest year for which the international ranking is available.
"You'd think with the United States' advances in technology, our country would rank well in infant mortality. That's not the case," Dr. Guillory said.
From 1990 to 2006, CDC National Center for Health Statistics data show the rate of preterm birth in Texas increased 22 percent, from 11.2 percent of live births in 1990 to 13.7 percent in 2006. The state saw a slight decrease of 1 percent from 2006 to 2007.
In 2007, the Institute of Medicine reported that the factors influencing the rise in preterm births include:
- Greater use of assisted reproductive technology, which increases the rate of multiple gestations;
- A rise in the proportion of births to women older than 35; and
- Changes in clinical practice, such as early induction of labor or a cesarean section close to, but not at, full term.
Primary risk factors contributing to preterm birth are:
- Current multifetal pregnancy;
- A history of preterm labor/delivery or prior low birth weight;
- Mid-trimester bleeding; and
- Some uterine, cervical, and placental abnormalities.
Some additional risk factors physicians have identified include obesity, tobacco use, alcohol abuse, illicit drug use, and folic acid deficiency.
Nevertheless, according to John C. Jennings, MD, an obstetrician-gynecologist and regional dean of Texas Tech University Health Sciences Center at the Permian Basin School of Medicine, modern medicine still doesn't have all the answers to what causes preterm births. He calls for expanded research into the causes of preterm birth. Additional measures he suggests to reduce a pregnant woman's chance of preterm delivery include developing and utilizing new modes of prenatal care and improving access to insurance coverage for women of childbearing age.
Michael E. Speer, MD, a Houston neonatal-perinatal specialist and chair of the TMA Board of Trustees, says lowering the pregnancy rate in teens would help reduce preterm births. That could be especially important in Texas because it has the third-highest rate of births to teen mothers nationally at 63.1 per 1,000.
Women younger than 18 have higher incidence of premature labor and delivery than mothers aged 20 to 39, Dr. Speer says. Teenage mothers also have a higher risk of complications during pregnancy, such as preeclampsia, he adds.
Dr. Jennings, chair of ACOG District XI, commends the March of Dimes for taking the lead in developing evidence-based group models of care for pregnant women. The organization's Centering Pregnancy program brings together pregnant women at risk of preterm birth.
In this group approach to prenatal care, at-risk expectant mothers with roughly the same due dates attend appointments together. An obstetrician facilitates the visit, gives advice based on participants' pregnancy concerns, and cares for each mother.
The March of Dimes also has a faith-based initiative targeted toward African-American pregnant women. The Honey Child Prenatal Education Program takes a culturally appropriate, spiritual approach to helping women aged 18 to 35 at risk of preterm birth have the healthiest possible pregnancy and birth outcomes.
Honey Child participants attend six sessions in which they learn about nutrition, relaxation and exercise, prenatal care, self-esteem, preterm birth, and labor and delivery. A mentor provides weekly one-on-one social support and reinforces the positive health behaviors discussed in the group.
In Texas, 18.7 percent of live births to African-American women are preterm, compared with 12.7 percent for white women, 13.3 percent for Hispanic women, and 11.3 percent for Asian women.
Dr. Guillory says the reason African-American women have a higher rate of preterm birth isn't known. However, she says collaborative innovations like those of the March of Dimes help physicians reduce preterm birth among this at-risk patient population.
Dr. Jennings advocates more research into new strategies for preventing preterm birth.
"Physicians know a lot about preterm birth, but we don't know everything," he said. "When I look at my old textbooks from the 1970s, I'm reminded that we were concerned about the high rate of preterm birth back then. Yet we haven't made the progress we'd like. That's not how it should be. We need to make expanded research and new interventions a priority to reduce the rate of preterm births."
One promising intervention is the use of 17 alpha-hydroxyprogesterone caproate during the second trimester in women who have had a previous spontaneous preterm birth before 37 weeks of gestation. The treatment reduces preterm birth in this population of high-risk women.
According to ACOG guidelines, physicians should consider weekly progesterone injections only for women who are at high risk for preterm labor.
Mike Nix, MD, a faculty member in the Obstetrics and Gynecology Department of Austin Medical Education Programs at University Medical Center Brackenridge, says the Seton Family of Hospitals, which leases Brackenridge from the City of Austin, has started a progesterone program for high-risk patients. Physicians with patients they've identified as high risk for preterm birth refer them to one of Seton's high-risk obstetrics clinic, where they receive weekly progesterone injections.
Dr. Nix says this specific hospital-level intervention seems to be effective in identifying and treating patients at risk for preterm birth.
But state-of-the art medical treatments aren't of much use if women can't access them. That's why Dr. Jennings says policies that increase access to health coverage for women of childbearing age are essential.
According to this year's U.S. Census Bureau figures, Texas still leads the nation in the percentage of uninsured residents. The bureau reports an uninsured rate of 25.1 percent, based on a two-year average for 2007-08.
The March of Dimes 2009 premature birth report card shows Texas' rate of uninsured women increased from 31.4 percent in 2006 to 32.2 percent in 2007. (See " Texas Flunks Preterm Birth Rate .") The organization encourages federal and state policymakers to expand access to health coverage for women of childbearing age and calls on employers to create workplaces that support maternal and infant health.
In Texas, Medicaid covers about half of all births annually. The Texas Health and Human Services Commission reports Texas Medicaid spent $408 million in 2007 for hospital costs associated with preterm births.
Community First Health Plans is a San Antonio-based nonprofit managed care organization that serves nearly half the Medicaid market share in the Bexar County area. Bexar County had the highest percentage of Texas Medicaid preterm and low-birth-weight deliveries in 2006 at 17 percent. Community First reports that 50 percent of newly enrolled women in Medicaid are in the program an average of only four months before giving birth.
Getting prenatal care late in the pregnancy places both mother and child at risk of preterm delivery, Dr. Jennings says.
"It's difficult to advocate for improved access to insurance coverage for women of childbearing age. Those who control health care policy look at what it costs on the front end. Physicians understand the tremendous costs that result from lack of access to services that improve health for uninsured women and their babies," Dr. Jennings said.
Reducing Preterm Births, Injuries
According to Dr. Jennings, about 80 percent of induced deliveries in late preterm have a medical justification. Induction may be necessary, for example, when a pregnant woman has hypertension or decreased amniotic fluid.
That leaves roughly 20 percent of late preterm births that don't have solid medical indications for delivery. Targeting those unnecessary interventions, he says, "could make a dent in some of the morbidity we see in late preterm babies."
Seton Family of Hospitals tackled the rising rate of preterm births and medically unnecessary inductions early on. In 2005, the entire system instituted a perinatal safety project that includes a policy prohibiting elective induction of labor before the 39th week of pregnancy.
Charles E.L. Brown, MD, MBA, obstetrics-gynecology residency program director and division chief of the Department of Obstetrics & Gynecology in the Austin Division of The University of Texas Medical Branch, says the guideline has effectively put a halt to elective inductions without a medical indication.
Getting buy-in for the policy among physicians and clinical staff members wasn't too difficult at University Medical Center Brackenridge, a teaching hospital. Focusing on the interests of residents in training made adopting the principle easier, says Dr. Brown, president of the Texas Association of Obstetricians and Gynecologists.
"Residents weren't always clear on why some women were induced. We needed a policy that was clear-cut," he said. "Internally, we all agreed not to do inductions before 39 weeks unless there was a good indication. Because adoption of the standard was driven by a desire to teach residents, it was easier for everyone to embrace."
Seton's elective induction guideline is but one component of its perinatal safety initiatives. The hospital system also developed protocols for using oxytocin, a drug commonly used for induction and augmentation of labor, and requires physicians and nurses to jointly review and discuss fetal monitor strips and reach joint interpretations of them to reduce errors.
Frank Mazza, MD, executive chair of the perinatal safety project, chief patient safety officer, and associate chief medical officer for Seton, says the hospital system relies on standardized protocols and simulation training using high-fidelity mannequins programmed to mimic various crises during labor and delivery.
"It's all about process," Dr. Mazza said. "Highly standardized protocols that are specific are a well-known, well-established element that you have to do any time you want to change a complex system and make it better."
Seton also uses the Situation, Background, Assessment, and Recommendation (SBAR) patient safety tool to improve communications in critical situations. SBAR is a highly structured, terse method of communicating critical information quickly. Seton drilled its labor and delivery personnel extensively on SBAR in its simulation labs.
Seton says it has seen dramatic improvements in quality of care from its perinatal safety processes and procedures. Seton averages about 9,700 births each year. As of June 30, Seton's birth trauma rate was 0.2 per 1,000 live births, compared with a rate of 3 per 1,000 live births for fiscal year 2001 to fiscal year 2003. That's a 93-percent reduction in birth trauma.
The hospital system's average length of stay for infants admitted to the NICU has declined by 79 percent -- from 15.8 days for fiscal year 2001 to fiscal year 2003, to 3.4 days for 2004 to 2007.
In addition, Seton has witnessed a huge decrease in total hospital billed charges for NICU care for birth injury infants -- down from about $4.5 million for fiscal year 2001 to fiscal year 2003, to $66,321 for 2004 to 2007.
The hospital system's perinatal safety efforts have earned it acclaim. The Joint Commission in 2007 awarded Seton its Codman Award, presented annually to hospitals that achieve exceptional performance improvement. And Childbirth Connection, a national nonprofit organization focused on improving the quality of maternity care, awarded Seton its inaugural Maternity Quality Matters Award. The distinction honors entities that have achieved significant improvement in the care provided to childbearing women and newborns.
Dr. Speer says the Seton system has adopted visionary policies to reduce the rate of preterm births. He hopes other hospitals will follow their example.
"The benefits of their policies are many: decreased hospitalization of these preterm infants in special care and NICU, improved neurodevelopment for the baby, and decreased costs for everyone," he said.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
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Texas Flunks Premature Birth Rate
The March of Dimes has slapped Texas with an F once again on the organization's 2009 premature birth report card. The state scored an F in 2008, as well. The nation got a D for its rate of preterm births, 12.7 percent.
The March of Dimes grades states annually by comparing each state's rate of premature birth to the nation's objective of 7.6 percent or less by 2010. March of Dimes also awarded a star when the rate for one of the selected contributing factors - uninsured women, women smoking, late preterm birth - moved in the right direction.
The organization admits health care professionals and researchers don't yet understand all the factors that contribute to premature birth. But it calls on the nation to continue to make progress on research to identify causes and prevention strategies, improve the outcomes of preterm infants, and better define and track the problem.
Although the report card came out in 2009, the result is based on data from 2007, which indicates Texas' preterm birth rate was 13.6 percent. The state's 2006 rate was 13.7 percent. States scoring an F have a preterm birth rate greater than or equal to 13.2 percent.
Eighteen states and Puerto Rico scored an F. The only state to receive a B was Vermont, with a preterm birth rate of 9.2 percent. No states received an A.
The March of Dimes gave Texas a star for reducing the rate of women who smoke from 18.1 percent in 2006 to 15.8 percent in 2007. The state also improved its rate of late preterm birth, decreasing from 9.8 percent in 2006 to 9.7 percent in 2007. March of Dimes dinged Texas for moving in the wrong direction on its rate of uninsured women, which increased from 31.4 percent in 2006 to 32.2 percent in 2007.
March of Dimes encourages federal and state policymakers to expand access to health coverage for women of childbearing age and calls on employers to create workplaces that support maternal and infant health.
To view state report cards and read a report on the global and regional toll of preterm birth, visit the March of Dimes Web site .
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