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

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:

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)

www.marchofdimes.com or peristats.modimes.org

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

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

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%

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

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

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.

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

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

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

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

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

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

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

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)

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, 1980-2001 Prepared by March of Dimes Perinatal Data Center, 2003

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

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

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

Multiple Birth Ratios by Race* United 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

Higher Order Birth Ratios by Race* United 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

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: ??

Singletons Preterm Delivery United States, 1991-2001 US Singleton PTB increase 6.1%

Total and Primary Cesarean and VBAC Rates United States, 1989-2002

Singleton Preterm Births by Delivery Method United States, 1990 and 2000 Percent

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@marchofdimes.com www.marchofdimes.com www.jjpi.com Thank you for your attention

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

March of Dimes National Prematurity Campaign 2003-2007 5 year $75 million initiative National Partners: ACOG, AAP,AWHONN and many national professional health group alliances

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

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

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

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

March of Dimes www.marchofdimes.com askus@marchofdimes.com

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

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@marchofdimes.com www.marchofdimes.com www.jjpi.com Thank you for your attention