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Born Too Soon: The Risks of Preterm Birth

Part one of a two-part series of conversations with leading prematurity experts as part of America’s Health Rankings® Public Health Legacy campaign.
By Anita Manning

A baby born before its time is at risk. Prematurity, birth before 37 weeks of gestation, places the newborn in danger of short- and long-term health problems.

In its just-released 2015 Premature Birth Report Card, the March of Dimes reports that 9.6% of babies born in the United States last year were premature, earning the nation only a “C” rating. The 8th annual report, for the first time, graded 100 cities and counties across the country, based on 2013 rates, the most recent year for which statistics were available, and found wide racial, ethnic and geographic disparities in preterm birth rates. Portland, Oregon, was out front with a preterm birth rate of 7.2% and Shreveport, Louisiana, the worst with a rate of 18.8%.

United Health Foundation’s America’s Health Rankings®, which measures states’ health by looking at a variety of health indicators, also reports wide racial and geographic differences in the rate of low birth weight babies. These babies may be small because they were born prematurely or for other reasons, such as inadequate prenatal care.

Newborn baby in incubator

November is Prematurity Awareness Month, when the March of Dimes releases its annual Report Card, and works with partner organizations to focus on protecting the health of babies by improving the numbers of those who are able to fully develop before birth. The agency is hosting the Prematurity Prevention Conference 2015: Quality improvement, evidence and practice this week in Crystal City, Virginia. A professional education conference, it will focus on the science of prematurity and interventions to prevent it. history-of-the-infant-incubator

United Health Foundation is currently partnering with Yale School of Public Health and the March of Dimes to pilot group prenatal care and to explore the eventual scale–up of group prenatal care nationally.

Here, two of the nation’s experts on prematurity reflect on how far we’ve come, and how much remains to be accomplished:

Dr. Edward R.B. McCabe, an international expert in pediatrics and genetics, Senior Vice President and Chief Medical Officer, March of Dimes.

The March of Dimes has set a goal of reducing the rate of preterm births in the U.S. to 8.1% by 2020 and to 5.5% by 2030. In the new Premature Birth Report Card, “we’re focusing on cities and counties with the highest volume of births as well as a disparity index for preterm births – we’re looking at the highest volume and the greatest burden,’’ says Dr. McCabe.

Racial and geographic differences highlighted in the report are not inevitable, McCabe says, citing new studies being published by Intergrowth 21s (The International Fetal and Newborn Growth Consortium for the 21st Century Project, a global collaboration in newborn health) that looked at women with no obvious high-risk factors – they don’t smoke or have other risky behaviors, have high socioeconomic status and access to prenatal care. “They found that in Sub-Saharan Africa and South Asia, when you get women with those characteristics, you get a 4.5-5.5% preterm rate,’’ he says.

In the U.S., some experts believe that because the population is so diverse, the preterm birth rate will never reach that of high-resource countries with more homogenous populations, but, “that’s not true,” McCabe says. Good prenatal care can protect against preterm birth, he says.

“I argue that we use diversity as an excuse, and we need to get over using it as an excuse,’’ he says. “We need to provide resources to the underserved in this country.’’

He points to cities that have opened prenatal clinics within communities where underserved women live, and also in settings in which these women receive group prenatal care.

In group prenatal care, “they’re learning that they can improve their health and their baby’s health by not smoking, taking drugs or drinking. They’re empowered and in control of their bodies. There is evidence that preterm birth may be induced by stress – and racism induces stress. And being empowered reduces that stress.’’

To turn things around will take national will, he says. Prematurity is “the leading cause of death in babies. We know we could prevent more than we’re preventing. California has an 8.3% rate and Mississippi has 12.9%. We should be doing better.’’

In 2006, the U.S. rate peaked and has declined since. “Because of this decline, 231,000 fewer babies have been born preterm,’’ he says. “We’re making a difference and we could make a bigger difference.’’

America’s Health Rankings® also reports geographic disparities among other birth-related health measures, such as the incidence of low birthweight. The Annual Report finds that the rate of low birthweight varies from a low of 5.7% of live births in Alaska to a high of 10% or more in Alabama, Mississippi, and Louisiana.

Dr. William Callaghan, Chief of the Maternal & Infant Health Branch within CDC’s Division of Reproductive Health.

Nurse weighing infant

Even with the best of medical technology, not all preterm babies will live, says Dr. Callaghan. “The focus should be on prevention,’’ he says. “Prematurity is the leading reason babies die in the first year of life… and the greater the preterm, the greater the risk.’’

There is some good news, he says. The rate of preterm births has been falling since 2006-07. “It had been going up, for reasons that are not totally clear,’’ he says. “We think some of the increase was due to a more cavalier attitude toward pregnancies that were approaching term.’’ The success of neonatology in keeping preemies alive led some new mothers to want to schedule elective C-sections or induction of birth at 36-38 weeks as a matter of convenience, but “it has become more clear in the last ten years that the best place for baby to be is inside, until he’s ready to come out,’’ Callaghan says. Recommendations against such early elective deliveries have led to a reduction in what is called “late preterm’’ birth.

The early preterm births are tougher. “We understand around three-quarters of those births occur because a woman spontaneously goes into labor, and we don’t have a lot to stop that,’’ he says. “The other quarter of very early preterm births occur because the fetus is in grave jeopardy of dying in utero, or the mother is in grave jeopardy of dying, so the only thing to do is deliver the baby.’’

Unfortunately, “we do not know how to totally prevent going into labor early,’’ he says. “The greatest risk factor for having a preterm baby is having had a preterm baby. So we have some medications that don’t help everybody, but help some.’’

Good prenatal care gives women access to those medications and allows the doctor to monitor blood pressure and other health measures. “Not having prenatal care is not good, but having prenatal care is no guarantee,’’ he says. Until more is known, he says, it’s important for women to stay healthy, have good nutrition, get flu shots, gain weight appropriately during the pregnancy and “be in touch with what’s going on with your body. It’s important to say, ‘I know my body, and this isn’t right,’’’ he says.

“Probably the way we attack prematurity will be through multiple methods, each of which will have small effects, but together will make a difference.’’

Science doesn’t have all the answers yet, he says, though lots of research is being done. “We all hope one day there will be a breakthrough announcement on prematurity,’’ he adds.

Part two of this series of conversations with leading prematurity experts can be viewed here, as part of America’s Health Rankings® Public Health Legacy campaign.

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