elizabeth mcintosh chawla, ms4 georgetown university school of medicine 2009 advocacy project,...

Elizabeth McIntosh Chawla, MS4Georgetown University School of Medicine

2009 Advocacy Project, Education of Resident Physicians on Late Preterm Birth,

with the March of Dimes Maryland-National Capital Area Chapter

Premature Birth Rates in the United States

One of the goals of US Healthy People 2010 is to REDUCE the preterm* birth rate in the US to 7.6% by 2010

But rates have been INCREASING over the last decade

9.1 % in 1981 11.6% in 1998 12.3% in 2003 12.7% in 2005

* Preterm Births refers to all infants born with <37 fully completed weeks.

http://www.math.uni-luebeck.de/safir/Projects/Draeger/draeger.shtml

Late Preterm Birth Rates Of all preterm births, Late Preterm Births, 34 to 36 weeks,

are both the largest and fastest growing subgroup

Since 1990, the rate of Very Preterm Birth (<32 weeks) has remained stable at 2% of live births

But between 1990 and 2003, Late Preterm Birth increased more than 20%, from 7.3% to 8.8% of live births, accounting for the majority of the increase in preterm birth rates over the last two decades1

As of 2005, Late Preterm Births represent 9.1% of live births

Based on 2005 Data from the CDC on singleton births, Late Preterm Births made up about 72% of all preterm births 2

1National Center for Health Statistics. 2003 final natality data. Data prepared by the March of Dimes Perinatal Data Center, 2005.

22008 NCHS Data Brief: Recent Trends in Infant Mortality in the US

Increase Most Striking in Late-Preterm Group

25% increase in Late Preterm Group

Slide courtesy of Dr. Tonse Raju, 2007 presentation

2002 US DataPercent of Preterm Singleton Live Births

(<37 wks) by Week of Gestation

7%

5%

14%

13%

22%

40%<32 weeks32 weeks33 weeks34 weeks35 weeks36 weeks

Source: NCHS, final natality dataPrepared by March of Dimes Perinatal Data Center, April 2006.

75% of singletonpreterm births

36 wks

35 wks

34 wks


District of Columbia Preterm Birth Rates In D.C., the rate of preterm births in 2005 was 15.9%,

far above the national average of 12.7% 1

The rate of Late Preterm Births was 10.4%, also far above the national average, which was 9.1% for this subgroup 1

Disparities exist among population subgroups: Race: preterm birth rates were highest for African Americans

(18.2%) Age: preterm birth rates were highest for women ages 40 and

older (19.8%), followed by women under age 20 (17.6%)

1National Center for Health Statistics, final natality data. Data prepared by the March of Dimes Perinatal Data Center, 2005.www.marchofdimes.com/peristats

http://www.marchofdimes.com/peristats

Preterm Births as a Percent of Live Births, by race and ethnicity, 1992 to 2003. SOURCE: CDC (2004a).

Institute of Medicine, Report Brief: Preterm Birth: Causes, Consequences, and Prevention. July 2006

**The District of Columbia mirrors disparities seen across the United States:

“Educating professionals includes enabling them to educate the public and patients. We need to begin by teaching what we now know with regard to preterm risks: maternal age, parity, prior preterm labor, multiple gestations, and behavioral (i.e., substance abuse/use, violence in patient’s life) and psychosocial factors. Professionals should understand why preterm birth is an important problem. All types of clinicians must be knowledgeable about core preterm birth issues because patient contacts with pediatricians, cardiologists, pharmacists, dental professionals, and others represent prevention and intervention opportunities. Health sciences curricula should be targeted to the discipline. The curricula for the clinicians and public health professionals responsible for primary and reproductive health care will need to be more comprehensive.”

Statement from Report of the Surgeon General’s Conference on the Prevention of Preterm Birth, June 16-17, 2008

Morbidity and Mortality is higher for infants born between 34-36 weeks as compared to term infants.1

In many cases, these complications can be prevented.

If you are a Pediatrician… Infants born after 37 weeks have better overall outcomes. As physicians, it is your

responsibility to advocate for your future patients, to give them the best chance at a healthy start and a healthy childhood. A few words of guidance to Mom at a well child visit can make a big difference!

If you are an OB/GYN… The increase in rates of Late Preterm Births has been linked to rising rates of early

induction of labor and c-sections. 1 For the health of your patient, and her unborn baby, keep in it there a little longer!

If you are a Family Physician… For the health of both of your patients, Mom and baby, help them hang in there as

long as possible. Full gestation is 40 weeks!

If you are a Medical Student… Whether you are interested in perinatal outcomes or not, more knowledge makes you

a better well-rounded physician, and more valuable to your patients.

And to everyone, knowledge is power, educate your patients on the facts!

1 National Center for Health Statistics. 2002 period linked birth/infant death data. Data prepared by the March of Dimes Perinatal Data Center, 2005.

Term – 370/7 to 416/7 weeks gestation

“Near Term” – terms such as near term, early term, moderate preterm, mild preterm, borderline preterm, etc. have been used in the past to describe infants born anywhere between 32-37 weeks

Late Preterm - NICHD [National Institute of Child Health and Human

Development] Workshop 2005 recommended the use of “Late Preterm” to describe infants born between 340/7 to 366/7 weeks, or 239—259 days counting from the first day of the LMP. They also recommended discontinuing the use of the term “Near Term”.

Late Preterm Infant Assessment Guide, Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

First day of LMP

1

0/7

Day #

Week #

259

36 6/7

294

416/7

Preterm

Term Post term

239

340/7

Late Preterm

*

Preterm: Prior to completion of 37th week (36 6/7 weeks; on or before 259th day)

Drawing courtesy: William Engle, MD, Indiana University

20 0/7

Late Preterm: Between 34 0/7 through 36 6/7 weeks (239-259 days)

* Raju TNK., Higgins RD, Stark AR, Leveno KJ Optimizing Care and Outcome of the Late Preterm (Near-Term) Pregnancy and the Late Preterm Newborn Infant. Pediatrics , 2006;118 1207-14


“Near-Term” conveys that these infants are almost term and therefore almost mature. This may lead to false sense of security: less rigorous assessment in first hours of life, early discharge when infant is still at risk, inadequate follow-up plans. “Late Preterm” conveys the sense that they still premature and still vulnerable .

“All definitions are arbitrary, since maturation is a continuum”

* Raju TNK., Higgins RD, Stark AR, Leveno KJ Optimizing Care and Outcome of the Late Preterm (Near-Term) Pregnancy and the Late Preterm Newborn Infant. Pediatrics , 2006;118 1207-14

Medical Intervention: Early Induction of Labor and C-Sections Incorrect assumption that 34-36 weeks is “close

enough” given our current technological advances Errors in dating of Gestational Age (women are poor

historians), so “early” induction is accidental Growing culture of the “patient as customer” –

inductions and c-sections for non-medical reasons

Pre-term Labor: Spontaneous Premature Labor and PPROM Can be due to maternal or fetal health complications Increasing maternal age Increases in multiples with modern fertility treatments

Cesarean Section and Labor Induction Rates among Singleton Live Births by Week of Gestation

United States, 1992 and 2002.

Late Preterm

Source: NCHS, final natality dataPrepared by March of Dimes Perinatal Data Center, April 2006.

2002 Induction

2002 C-S

1992 C-S

1992 Induction


Singleton Preterm Live Births: Reasons for Delivery from Birth Certificates

0

10

20

30

40

50

60

70

PROM Med.Interventions

19922002

68%57%

29%

41%

2.2%3%

Spontaneous


Medical Intervention: Early Induction of Labor and C-Sections Correct dating of Gestational Age with early ultrasound – encourage

prenatal care from the beginning of the pregnancy Patient education about importance of continuing pregnancy until full

term is reached – even if inconvenient to patient Advocacy of OB/GYN residents to their colleagues – longer pregnancy

has better maternal and fetal outcomes

Pre-term Labor: Spontaneous Premature Labor and PPROM Smoking, alcohol, or drug use – cessation during pregnancy Diabetes, hypertension – tight control, starting BEFORE conception Infections – good prenatal care, treatment of active infection Birth Defects – folic acid supplementation, proper immunization of Mom Hx of preterm labor or preterm birth – good OB/GYN care, medical or

surgical interventions if needed Multiples – judicious use of assisted reproductive therapies (ART) Social – decreasing stress, appropriate child spacing, avoiding extremes

of maternal age, <20 years or >40 years

Source: Report from the Surgeon General’s Conference on the Prevention of Preterm Birth, June 16-17, 2008

Transitional Respiratory Distress (RDS) Temperature Instability Hypoglycemia Feeding difficulties

First Week Neonatal jaundice Apnea Infection rate

Later Neonatal Period Poor feeding and

dehydration Readmission to hospital

Early Infancy SIDS risk

Later Outcomes Learning difficulties &

School failures Behavior problems

1 Late Preterm Birth: Every Week Matters, Medical Perspectives on Prematurity. Prepared by the Office of the Medical Director, March of Dimes. March 2006.2 Late Preterm Infant Assessment Guide, Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) 3 NICHD Workshop: Optimizing Care and Long-term Outcome of Near-termPregnancy and Near-term Newborn Infant. July 18-19. Bethesda, MD, 2005.

The infant mortality rate among late preterm infants (7.7 per 1,000 live births) is three times higher than the rate among term infants (2.5 per 1,000 live births). [However, some of these higher rates are due to complications necessitating early delivery, including some birth defects, rather than due to early delivery itself.]

Late preterm infants incur greater costs and longer lengths of stay in neonatal intensive care units (NICU) and experience higher rates of re-hospitalization after neonatal discharge, as compared to term infants.

Children born in the late preterm phase have a greater risk of developmental delay, such as poor reading and math scores in elementary grades, need for special education, and retention in kindergarten than their full term counterparts.

1 Late Preterm Birth: Every Week Matters, Medical Perspectives on Prematurity. Prepared by the Office of the Medical Director, March of Dimes. March 2006.

2 2008 NCHS Data Brief: Recent Trends in Infant Mortality in the US

3 Chyi, L. et al. School Outcomes of Late Preterm Infants: Special Needs and Challenges for Infants Born at 32 to 36 Weeks Gestation. Journal of Pediatrics, July 2008.

Lisa J. Chyi, MD, Henry C. Lee, MD,MS, Susan R. Hintz, MD, MS, Jeffrey B. Gould, MD, MPH,

and Trenna L. Sutcliffe, Md, MS

Journal of Pediatrics, 2008

Data Source◦ Publicly available ECLS-K dataset from the United

States Department of Education [Early Childhood Longitudinal Study-Kindergarten Cohort]

Sample Group◦ Moderate Preterm: 32 to 33 weeks gestation (n=203)◦ Late Preterm: 34 to 36 weeks gestation (n=767) ◦ Excluded children with any known complication at birth

Comparison group◦ Age equivalent classmates◦ Full Term: 37 to 41 weeks gestation (n=13,671)

Outcome Measures

• 1) Reading and Math scores on Educational Tests (Including Peabody Tests and Woodcock Johnson Tests)

• 2) Teachers Evaluation of the student’s Reading and Math abilities as compared to peers. Scored on a 5-point scale.

(Most teachers unaware of students’ prematurity status)

• 3) Presence of IEP or participation in Special Education Services, information provided by the schools

Evaluation• Outcomes were evaluated at K, 1st, 3rd, and 5th grade

Results: Distribution of Late Preterm Vs. Full Term across outcome categories

Outcome Grade Late Preterm

(N=767)

Full term

(N=13,671)Educational Testing: Reading

K 50.2* 51.1

Testing: Math K 50.6 51.0

Teacher Evaluation: Reading

K 3.32* 3.39

Teacher Eval: Math K 3.49* 3.56

Presence of an IEP K 8.04% 6.18%

Special Education K 6.66%* 3.14%

* Values with P < .05Outcomes in Kindergarten



(N=767)

Full term


1st 50.2* 51.0

Testing: Math 1st 50.5 50.9


1st 3.36* 3.47

Teacher Eval: Math 1st 3.41* 3.48

Presence of an IEP 1st 10.54%* 7.48%

Special Education 1st 6.27%* 4.28%

* Values with P < .05Outcomes in 1st Grade



(N=767)

Full term


3rd 51.2 51.0

Testing: Math 3rd 50.9 51.0


3rd 3.29 3.34

Teacher Eval: Math 3rd 3.10 3.12

Presence of an IEP 3rd 12.12% 10.72%

Special Education 3rd 9.15% 7.52%

* Values with P < .05Outcomes in 3rd Grade



(N=767)

Full term


5th 51.7 51.3

Testing: Math 5th 51.8 51.4


5th 3.37* 3.46

Teacher Eval: Math 5th 3.41 3.43

Presence of an IEP 5th 12.19% 11.32%

Special Education 5th 10.28% 8.24%

* Values with P < .05Outcomes in 5th Grade

Standardized Educational Tests◦ LP infants scored lower than FT infants for Reading in K

and 1st grade, but not for Math Teacher Evaluated Abilities as Compared to

Peers◦ Reading: LP infants scored significantly lower in K, 1st ,

and 5th grades.◦ Math: LP infants significantly lower in K, 1st grade, with

comparable math abilities in later grades Special Education and IEPs

◦ IEP: Greater % of LP infants required IEP in K and 1st grade, versus FT infants

◦ Special Education: Greater % of LP infants in Special Education in K and 1st grade as compared to FT infants

Brain Development is a Continuum:At 34-35 weeks gestation, a baby’s brain is only 2/3 the size and maturity of full term.

Healthy Moms make Healthy Babies, before, during, and after pregnancy!

Identify and Counsel patients (or Moms of your patients) on the preventable causes of Late Preterm Birth

Encourage Mom to plan ahead – the best prevention starts BEFORE conception: Proper birth spacing improves perinatal outcomes Get diabetes, hypertension, and other medical conditions

under tight control BEFORE conception Establish healthy weight, healthy diet, and supplementation

with at least 400 mcg folic acid BEFORE conception Talk to MD about immunizations and other preconception

health recommendations BEFORE getting pregnant

Reproductive Life Plan

For more information about a Reproductive Life Plan and other counseling topics, please see www.physicianclassroom.org

http://www.physicianclassroom.org/

Healthy Moms make Healthy Babies, before, during, and after pregnancy!

Encourage Mom to see MD for good Prenatal care DURING pregnancy for best outcomes: Correct gestational dating with early ultrasound Help with managing infections or other health conditions that can

put the infant at risk of complication Start smoking cessation program, stop alcohol or drug use

[or at least cut down as much as possible] during pregnancy Learn the symptoms of preterm labor and seek help when

necessary Educate Mom about risks of late preterm birth, and what she can

do for her part to ensure a full 40 weeks of gestation

Encourage good communication between Mom and healthcare providers AFTER birth to ensure good follow-up care for herself and the infant.

Understand and watch for specific medical complications in late preterm infants Respiratory Distress Hypoglycemia Temperature instability/hypothermia Feeding difficulties Jaundice/hyperbilirubinemia Keep a low threshold for NICU transfer

Prevent Re-hospitalization Thoroughly evaluate infant before sending home Anticipate possible complications Arrange for appropriate follow-up Appropriately Educate Parents of Late preterm Infants on

special health considerations and what to watch for

Segment of Patient handout found at www.awhonn.org

http://www.awhonn.org/

DRAFT

More Examples of Patient Handouts:

This and other patient handouts available through your local March of Dimes office.

“There are misconceptions outside of the OB/GYN community that preterm birth (especially late preterm) is not a major problem; therefore, content on preterm birth risks and the consequences of preterm birth needs to be included in the curricula of all medical specialties, as well as in training for allied health and public health professionals.”

[Statement from Report of the Surgeon General’s Conference on the Prevention of Preterm Birth, June 16-17, 2008]

Knowledge is Power

Educate yourselves

Educate your colleagues

Educate your patients

Together we can make a big impact on the number of late preterm infants

born in the United States with just a little knowledge and prevention…

March of Dimes Foundation Dona Dei, RN, MSN Dr. Tonse N. K. Raju, MD, DCH Dr. Matthew Levy, MD, MPH

National Center for Health Statistics. 2002-2005 final natality data. Data prepared by the March of Dimes Perinatal Data Center, 2005.

2008 NCHS Data Brief: Recent Trends in Infant Mortality in the US.

Institute of Medicine, Report Brief: Preterm Birth: Causes, Consequences, and Prevention. July 2006.

Report from the Surgeon General’s Conference on the Prevention of Preterm Birth, June 16-17, 2008.

Late Preterm Infant Assessment Guide, Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

Late Preterm Birth: Every Week Matters, Medical Perspectives on Prematurity. Prepared by the Office of the Medical Director, March of Dimes. March 2006.

Raju TNK., Higgins RD, Stark AR, Leveno KJ Optimizing Care and Outcome of the Late Preterm (Near-Term) Pregnancy and the Late Preterm Newborn Infant. Pediatrics , 2006;118 1207-14

Chyi, L. et al. School Outcomes of Late Preterm Infants: Special Needs and Challenges for Infants Born at 32 to 36 Weeks Gestation. Journal of Pediatrics, July 2008

Raju TN. Epidemiology of late preterm (near-term) births. [Review] [53 refs] Clinics in Perinatology. 33(4):751-63; 2006 Dec.

Jain S. Cheng J. Emergency department visits and rehospitalizations in late preterm infants. [Review] [16 refs] Clinics in Perinatology. 33(4):935-45; 2006 Dec.

Adamkin DH. Feeding problems in the late preterm infant. [Review] Clinics in Perinatology. 33(4):831-7; 2006 Dec.

Fuchs K. Wapner R. Elective cesarean section and induction and their impact on late preterm births. Clinics in Perinatology. 33(4):793-801; 2006 Dec.

Websites• www.marchofdimes.com• www.awhonn.org• www.marchofdimes.com/peristats• www.iom.edu• www.surgeongeneral.gov• www.cdc.gov/nchs

elizabeth mcintosh chawla, ms4 georgetown university school of medicine 2009 advocacy project,...

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