1. The Changing Epidemiology of Preterm Birth in the U.S.
Nancy S. Green, MD
Medical Director
National March of Dimes
White Plains, NY
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 infant’s life and throughout the woman’s childbearing years
Pre-conceptional health as the cornerstone
Since 1979, when the name of the Foundation was changed to the March of Dimes Birth Defects Foundation , our mission has been:
READ SLIDE
This is driven by the fact that the leading cause of infant deaths for the past 25 years has been birth defects (a term coined by the MOD in the 1950s) and about 3-4% of all live births have a serious birth defect, for which 2 out of 3 the cause is unknown. However, it has been known for decades the association of substance abuse with a number of birth defects to be mentioned subsequently. In addition, as we approach the next century with all the unsolved perinatal problems, research findings continue to identify the critical role that events prior to pregnancy play in pregnancy outcomes so that to effect change we must be committed to the importance of the continuum of reproductive health:

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 (<1 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 Mortality United 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
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 Gestation Length Growth Restriction
Low Birth weight (LBW) - < 2500 grams or 5.5 lbs
Very low birth weight - (VLBW) < 1500 grams or 3.3 lbs
Gestation Length
Premature (preterm delivery, PTD)- < 37 weeks
Early preterm delivery - < 32 weeks
Growth Restriction
< 10th percentile for gestational age
IUGR - intrauterine growth restricted applies to fetuses
SGA - small for gestational age applies to neonates

9. Preterm Births United States, 1981, 1991, 2001, 2002
Percent
March of Dimes Objective
Healthy People Objective
27 Percent Increase
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%
Percent of Live Births
12.7 to 17.0 (18)
11.2 to 12.7 (15)
8.2 to 11.2 (18)
It is evident that prematurity is a multi-factorial problem, and the risk factors associated with prematurity are not distributed evenly across the country. As you can see from this map, state rates of preterm birth vary substantially, with the highest rates in the south. -- Tertile Map, equal count distribution.

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
1990
Live Births
n = 4,111,396*
2001
Live Births
n = 3,986,102*
Not Preterm (89.4%)
Not Preterm (88.4%)
Moderately Preterm (8.7%)
Very
Preterm (1.9%)
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)
(<32 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 (<37 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 Births by Race/Ethnicity, US, 2001
Percent of All Live Births (more than 4 million)
Percent of Preterm Births
(more than 476,000)
Despite the increased African American risk of prematurity, since nearly 60% of all births are to white families, more than 50% of all premature babies are white. This means that prematurity is a serious health problem for all families, across all ethnic groups.
Source: National Center for Health Statistics, 2001 final natality data
Prepared by March of Dimes Perinatal Data Center, 2003

16. Types of Preterm Birth Preterm Birth Spontaneous Preterm Labor
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 (<17 and >35 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 >35
 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 Years United 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,
Prepared by March of Dimes Perinatal Data Center, 2003

20. Preterm Births by 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 (<32 wks) by Maternal Age United States, 1999-2001 average

22. Preterm Births by Plurality United States, 2001
Percent
Look at these numbers: while 1 in 10 singleton births are preterm, almost 60% of twins and over 90% of higher order multiples (triplets, quadrupulets, etc.) are born prematurely. More women are having twins and triplets – whether spontaneously, as is associated with pregnancy at an older age, or more importantly in the past decade through infertility management, including use of fertility drugs and assisted reproductive technology. Some of the increase in the U.S. rate of preterm birth is attributed to the increasing rates of these very high-risk multifetal pregnancies.
Enhanced ability to identify pregnancy complications that may require delivery before term have also contributed to the higher rates of preterm birth.
Source: National Center for Health Statistics, 2001 final natality data
Prepared by March of Dimes Perinatal Data Center, 2003

23. Multiple Birth Ratios by Race* United States, 1980-2001
Ratio per 1,000 live births
*Race of child from ; Race of mother from
Source: NCHS, final natality data,
Prepared by March of Dimes Perinatal Data Center, 2003

24. Higher Order Birth Ratios by Race* United States, 1980-2001
Ratio per 100,000 live births
*Race of child from ; Race of mother from
Source: NCHS, final natality data,
Prepared by March of Dimes Perinatal Data Center, February 2003

25. Risks of Adverse Pediatric Outcomes with ART
Multiples
Twins % Triplets %
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
Thank you for your attention

31. March of Dimes National Prematurity Campaign
Nancy S. Green, MD
Medical Director
National March of Dimes
White Plains, NY
Associate Professor of Pediatrics
Assistant Professor of Cell Biology
Albert Einstein College of Medicine, N.Y.

33. March of Dimes National Prematurity Campaign year $75 million initiative National Partners: ACOG, AAP,AWHONN and 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 <10.1%)
To move us towards the Healthy People 2010 goal, March of Dimes has set two campaign goals:
Read #1
The baseline awareness measure is 35% according to a March of Dimes survey conducted in 2002
Read #2
The rate in 2000 is 11.6 per 1,000 babies born are preterm. Our goal would be to have a rate of 9.9 by the year 2007.
Other ways to understand what this means:
Now approximately 1 in eight babies are born preterm. Our goal would be to have one in ten (or less)
A 15% reduction of the current 467,000 premature babies would mean that less than 400,000 babies are born premature each year

35. Preterm Births United States, 1981, 1991, 2001, 2002
Percent
March of Dimes Objective
Healthy People Objective
27 Percent Increase
Source: National Center for Health Statistics, final natality data
Prepared by March of Dimes Perinatal Data Center, 2003

36. March of Dimes Prematurity Campaign 2003-2007
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 (PSA’s, 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

39. Premature Birth: The answers can’t come soon enough
Read slide.

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
Thank you for your attention