[Show abstract][Hide abstract] ABSTRACT: To summarize some recent major epidemiological changes, evidence-based interventions, shifting paradigms, and national initiatives targeting the prevention of preterm birth in the United States.
Noteworthy epidemiological changes in preterm births include a shift from 40 to 39 weeks as the most common length of gestation for singleton births in the United States; significant jumps in late preterm births, which is the major contributor to increasing preterm rates: more multiple births with rates highest for non-Hispanic whites; dramatic increases in births to women of advanced maternal age; and substantial increases in cesarean births. Key paradigm shifts have also occurred such as considering most spontaneous preterm birth as a common complex disorder highlighting the importance of interactions of biological predispositions and environment; support for the fetal origins hypothesis requiring a life course perspective, including preconception health promotion to improve perinatal health and enhance equity; and a renewed focus on preventing recurrence. The March of Dimes National Prematurity Campaign, the National Institute of Child Health and Human Development leadership on late preterm birth, the 2006 Institute of Medicine's report on preterm birth, and passage of the Prematurity Research Expansion and Education for Mothers who Deliver Infants Early Bill with the resultant 2008 Surgeon General's Conference underscore the national resolve to prevent preterm births.
Despite the complex changing environment of perinatal care, shrinking resources and higher risk pregnancies, innovative strategies, expanded, interdisciplinary partnerships, a focus on perinatal quality initiatives, more evidence-based interventions, tools to better predict preterm labor/birth, dissemination of effective community-based programs, a commitment to enhance equity, promoting preconception health, translation of research findings from the bench to bedside to curbside, effective continuing education for busy clinicians and culturally sensitive, health literacy appropriate patient education materials can collectively help to reverse the increasing rates of preterm births.
Current opinion in obstetrics & gynecology 01/2009; 20(6):590-6. · 2.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Scientific evidence indicates that improving a woman's health before pregnancy will improve pregnancy outcomes. However, for many years, our efforts have focused primarily on prenatal care and on caring for infants after birth. The concept of preconception care has been identified repeatedly as a priority for improving maternal and infant health. Preconception care is not something new that is being added to the already overburdened healthcare provider, but it is a part of routine primary care for women of reproductive age. Many opportunities exist for preconception intervention, and much of preconception care involves merely the provider reframing his or her thinking, counseling, and decisions in light of the reproductive plans and sexual and contraceptive practices of the patient. With existing scientific evidence that improving the health of "W"omen will improve the health of mothers and children, we must focus on improving the health of "W"omen before pregnancy and put the "W" in Maternal and Child Health.
American journal of obstetrics and gynecology 01/2009; 199(6 Suppl 2):S259-65. · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The increasing trend of delivering at earlier gestational ages has raised concerns of the impact on maternal and infant health. The delicate balance of the risks and benefits associated with continuing a pregnancy versus delivering early remains challenging. Among singleton live births in the United States, the proportion of preterm births increased from 9.7% to 10.7% between 1996 and 2004. The increase in singleton preterm births occurred primarily among those delivered by cesarean section, with the largest percentage increase in late preterm births. For all maternal racial/ethnic groups, singleton cesarean section rates increased for each gestational age group. Singleton cesarean section rates for non-Hispanic black women increased at a faster pace among all preterm gestational age groups compared with non-Hispanic white and Hispanic women. Further research is needed to understand the underlying reasons for the increase in cesarean section deliveries resulting in preterm birth.
Clinics in Perinatology 07/2008; 35(2):309-23, v-vi. · 2.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to estimate national hospital costs for infant admissions that are associated with preterm birth/low birth weight.
Infant (<1 year) hospital discharge data, including delivery, transfers, and readmissions, were analyzed by using the 2001 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project. The Nationwide Inpatient Sample is a 20% sample of US hospitals weighted to approximately >35 million hospital discharges nationwide. Hospital costs, based on weighted cost-to-charge ratios, and lengths of stay were calculated for preterm/low birth weight infants, uncomplicated newborns, and all other infant hospitalizations and assessed by degree of prematurity, major complications, and expected payer.
In 2001, 8% (384,200) of all 4.6 million infant stays nationwide included a diagnosis of preterm birth/low birth weight. Costs for these preterm/low birth weight admissions totaled $5.8 billion, representing 47% of the costs for all infant hospitalizations and 27% for all pediatric stays. Preterm/low birth weight infant stays averaged $15,100, with a mean length of stay of 12.9 days versus $600 and 1.9 days for uncomplicated newborns. Costs were highest for extremely preterm infants (<28 weeks' gestation/birth weight <1000 g), averaging $65,600, and for specific respiratory-related complications. However, two thirds of total hospitalization costs for preterm birth/low birth weight were for the substantial number of infants who were not extremely preterm. Of all preterm/low birth weight infant stays, 50% identified private/commercial insurance as the expected payer, and 42% designated Medicaid.
Costs per infant hospitalization were highest for extremely preterm infants, although the larger number of moderately preterm/low birth weight infants contributed more to the overall costs. Preterm/low birth weight infants in the United States account for half of infant hospitalization costs and one quarter of pediatric costs, suggesting that major infant and pediatric cost savings could be realized by preventing preterm birth.
[Show abstract][Hide abstract] ABSTRACT: To review and report changes in genomic-based knowledge and care during the preconception and prenatal periods.
Integrative review of relevant medical and nursing literature.
Client education and counseling are needed to understand genomic information and provide guidance in interpreting this information and making decisions. The factors that influence decision-making about testing and acting on test results constitute a complex process that has not been well studied. Family history is an important tool for obtaining genomic information and can assist women and families in understanding risk preconceptionally and prenatally. Genomic research has enhanced understanding of the mechanisms of birth defects such as neural tube defect and will likely provide research opportunities to better understand complex perinatal outcomes such as preterm birth.
Research, education, advocacy, and anticipatory guidance are needed as women and families obtain more genetic and genomic information before and during pregnancy. All nurses will be involved in helping patients use genetic and genomic information to understand risk and to develop strategies to modify risk, and in translating the expanding array of genomic information to improve birth outcomes.
Journal of Nursing Scholarship 01/2007; 39(1):4-9. · 1.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study was undertaken to assess whether a surgical skills laboratory improves residents' knowledge and performance of episiotomy repair.
Twenty-four first- and second-year residents were randomly assigned to either a surgical skills laboratory on episiotomy repair or traditional teaching alone. Pre- and posttests assessed basic knowledge. Blinded attending physicians assessed performance, evaluating residents on second-degree laceration/episiotomy repairs in the clinical setting with 3 validated tools: a task-specific checklist, global rating scale, and a pass-fail grade.
Postgraduate year 1 (PGY-1) residents participating in the laboratory scored significantly better on all 3 surgical assessment tools: the checklist, the global score, and the pass/fail analysis. All the residents who had the teaching laboratory demonstrated significant improvements on knowledge and the skills checklist. PGY-2 residents did not benefit as much as PGY-1 residents.
A surgical skills laboratory improved residents' knowledge and performance in the clinical setting. Improvement was greatest for PGY-1 residents.
American journal of obstetrics and gynecology 12/2006; 195(5):1463-7. · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine whether current attitudes regarding the use of progesterone to prevent preterm birth have changed since our last survey in 2003.
We mailed a 20 question survey to 1264 board certified Maternal-Fetal Medicine specialists in the United States between February and March of 2005 asking about their use and attitudes regarding progesterone to prevent preterm birth.
Five hundred and seventy-two surveys were returned (response rate of 45%). In 2005, 67% of respondents used progesterone to prevent SPTB, compared to 38% in 2003 (P < .001). Among users, 38% recommended progesterone for indications other than previous SPTB. Users were more concerned about lack of insurance coverage compared to nonusers but nonusers were more concerned about safety, efficacy, need for more data, and long-term neonatal effects.
Although the use of progesterone to prevent PTB has increased significantly since our last survey, there remain a substantial number of nonusers. Among users, many are using it for indications not yet proven in clinical trials. Current nonusers have higher levels of concerns compared to nonusers in the first survey and their major concern is the need for more data.
American journal of obstetrics and gynecology 11/2006; 195(4):1174-9. · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess health care providers (HCP) knowledge and practices regarding folic acid (FA) use for neural tube defect (NTD) prevention.
Two identical surveys were conducted among 611 obstetricians/gynecologists (OB/GYNs) and family/general physicians (FAM/GENs) (2002), and 500 physician assistants (PAs), nurse practitioners (NPs), certified nurse midwives (CNMs), and registered nurses (2003) to ascertain knowledge and practices regarding FA. For analysis, T-tests, univariate and multivariate logistic regression modeling were used.
Universally, providers knew that FA prevents birth defects. Over 88% knew when a woman should start taking folic acid for the prevention of NTDs; and over 85% knew FA supplementation beyond what is available in the diet is necessary. However, only half knew that 50% of all pregnancies in the United States are unplanned. Women heard information about multivitamins or FA most often during well woman visits in obstetrical/gynecology (ob/gyn) practice settings (65%), and about 50% of the time during well woman visits in family/general (fam/gen) practice settings and 50% of the time at gynecology visits (both settings). Among all providers, 42% did not know the correct FA dosage (400 mug daily). HCPs taking multivitamins were more than twice as likely to recommend multivitamins to their patients (Odds Ratio [OR] 2.27 95%, Confidence Interval [CI] 1.75-2.94). HCPs with lower income clients (OR 1.49, CI 1.22-1.81) and HCPs with practices having more than 10% minorities (OR 1.46, CI 1.11-1.92) were more likely to recommend supplements. NPs in ob/gyn settings were most likely and FAM/GENs were least likely to recommend supplements (OR 3.06, CL 1.36-6.90 and OR 0.64, CL 0.45-0.90 respectively).
Knowledge about birth defects and the necessity of supplemental FA was high. Increasing knowledge about unintended pregnancy rates and correct dosages of FA is needed. The strongest predictor for recommending the use of FA supplements was whether the provider took a multivitamin.
Maternal and Child Health Journal 10/2006; 10(5 Suppl):S67-72. · 2.24 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is mounting evidence that infants born late preterm (34-36 weeks) are at greater risk for morbidity than term infants. This article examines the changing epidemiology of gestational length among singleton births in the United States, from 1992 to 2002. Analyzing gestational age by mode of delivery, the distribution of spontaneous births shifted to the left, with 39 weeks becoming the most common length of gestation in 2002, compared with 40 weeks in 1992 (P < 0.001). Deliveries at > or =40 weeks gestation markedly decreased, accompanied by an increase in those at 34 to 39 weeks (P < 0.001). Singleton births with PROM or medical interventions had similar trends. Changes in the distribution of all singleton births differed by race/ethnicity, with non-Hispanic white infants having the largest increase in late preterm births. These observations, in addition to emerging evidence of increased morbidity, suggest the need for investigation of optimal obstetric and neonatal management of these late preterm infants.
Seminars in Perinatology 02/2006; 30(1):8-15. · 2.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Preterm birth (PTB) is a common, serious, and costly health problem affecting nearly 1 in 8 births in the United States. Burdens from PTB are especially severe for the very preterm infant (<32 weeks' gestation), comprising 2% of all US births. Successful prevention needs to include newly focused and adequately funded research, incorporating new technologies and recognition that genetic, environmental, social, and behavioral factors interact in complex pathogeneses and multiple pathways leading to PTB. The March of Dimes Scientific Advisory Committee created this prioritized research agenda, which is aimed at garnering serious attention and expanding resources to make major inroads into the prevention of PTB, targeting six major, overlapping categories: epidemiology, genetics, disparities, inflammation, biologic stress, and clinical trials. Analogous to other common, complex disorders, progress in prevention will require incorporating multipronged risk reduction strategies that are based on sound scientific discovery, as well as on effective translation into clinical care.
American Journal of Obstetrics and Gynecology 10/2005; 193(3 Pt 1):626-35. · 3.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A multicenter, randomized placebo-controlled trial among women with singleton pregnancies and a history of spontaneous preterm birth found that weekly injections of 17 alpha-hydroxyprogesterone caproate (17P), initiated between 16 and 20 weeks of gestation, reduced preterm birth by 33%. The current study estimated both preterm birth recurrence and the potential reduction in the national preterm birth rate.
Using 2002 national birth certificate data, augmented by vital statistics from 2 states, we estimated the number of singleton births delivered to women eligible for 17P through both a history of spontaneous preterm birth and prenatal care onset within the first 4 months of pregnancy. The number and rate of recurrent spontaneous preterm births were estimated. To predict effect, the reported 33% reduction in spontaneous preterm birth attributed to 17P therapy was applied to these estimates.
In 2002, approximately 30,000 recurrent preterm births occurred to women eligible for 17P, having had a recurrent preterm birth rate of 22.5%. If 17P therapy were delivered to these women, nearly 10,000 spontaneous preterm births would have been prevented, thereby reducing the overall United States preterm birth rate by approximately 2%, from 12.1% to 11.8% (P < .001), with higher reductions in targeted groups of eligible pregnant women.
Use of 17P could reduce preterm birth among eligible women, but would likely have a modest effect on the national preterm birth rate. Additional research is urgently needed to identify other populations who might benefit from 17P, evaluate new methods for early detection of women at risk, and develop additional prevention strategies.
Obstetrics and Gynecology 03/2005; 105(2):267-72. · 4.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe changes in the epidemiology of multiple births in the United States from 1980 to 1999 by race, maternal age, and region; and to examine the impact of these changes on birth weight-specific infant mortality rates for singleton and multiple births.
Retrospective univariate and multivariable analyses were conducted using vital statistics data from the National Center for Health Statistics.
Between 1980 and 1999, the overall multiple birth ratio increased 59% (from 19.3 to 30.7 multiple births per 1000 live births, P <.001), with rates among whites increasing more rapidly than among blacks. Women of advanced maternal age, especially those aged 30-34, 35-39, and 40-44 experienced the greatest increases (62%, 81%, and 110%, respectively). Although all regions of the United States experienced increases in multiple birth ratios between 1991 and 1999, the Northeast had the highest twin (33.9 per 1000 live births) and higher order birth ratios (280.5 per 100,000 live births), even after adjusting for maternal age and race. Between 1989 and 1999, multiple births experienced greater declines in infant mortality than singletons in all birth weight categories. Consequently, very low birth weight and moderately low birth weight infant mortality rates among multiples were lower than among singletons.
It is important to understand the changing epidemiology of multiple births, especially for women at highest risk (advanced maternal age, white race, Northeast residents). The attribution of infertility management requires further study. The differential birth weight-specific infant mortality for singletons and multiples demonstrates the importance of stratifying by plurality when assessing perinatal outcomes.
Obstetrics and Gynecology 01/2003; 101(1):129-35. · 4.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: While overall infant mortality rates (IMR) have declined over the past several decades, birth defects have remained the leading cause of infant death in the United States. To illustrate how this leading cause of infant mortality impacts subgroups within the US population a descriptive analysis of the contribution of birth defects to infant mortality at the national and state level was conducted.
Descriptive analyses of birth defects-specific IMRs and proportionate infant mortality due to birth defects were conducted for the US using 1999 mortality data from the National Center for Health Statistics. In 1999, the change to ICD-10 impacted how cause-specific mortality rates were coded. Aggregated 1995-1998 state- birth defects infant death statistics were used for state comparisons.
In 1999, birth defects accounted for nearly 1 in 5 infant deaths in the US. Variation in birth defects-specific IMRs were observed by maternal race with black infants having the highest rates when compared with other race groups. However, among black infants prematurity/low birthweight was the leading cause of death, followed by birth defects. There is substantial variation in state-specific birth defects IMRs and the state-specific proportion of infant deaths due to birth defects.
Birth defects remain the leading cause of infant death in the United States, despite the changes that resulted in 1999 from an update in the coding of cause of death from ICD-9 to ICD-10. While birth defects-specific IMRs provide an overall picture of fatal birth defects and a gauge of the impact of life-threatening anomalies, they represent only a fraction of the impact of birth defects, missing those who survive past infancy and those birth defects related losses in the antepartum period. Expansion and support of effective birth defects monitoring systems in each state that include the full spectrum of perinatal outcomes must be a priority. However, paralleling these efforts, analyses of this leading cause of infant mortality provide critical insight into perinatal health and should continue, with appropriate adjustments for the 1999 classification changes.
[Show abstract][Hide abstract] ABSTRACT: Significant resources have been devoted to decreasing the rate of neural tube defects (NTDs) in the United States. Both surveillance data and birth records have strengths and limitations for evaluating the outcomes of this resource allocation. Cause-specific infant mortality data can be used as one measure to support evaluation efforts.
Using period linked birth/infant death data from the National Center for Health Statistics (NCHS), a retrospective analysis was performed to assess the NTD-specific IMR at the national, state, and regional level. NTD-specific IMRs for the United States were calculated from 1996 to 1998; stratified rates by race/ethnicity, maternal age, age at death, and gestational age and birthweight by type of NTD for the total US population were based on three-year aggregates (1996-98); state and regional rates were based on four-year aggregates (1995-98).
Annual US NTD-specific IMRs significantly decreased between 1996 and 1998. Black infants were significantly less likely to die from an NTD when compared to white infants, largely attributed to the high rate of NTD-specific deaths among white Hispanic infants. Infants born to women less than 20 years were more likely than infants born to women in other age groups to die from an NTD. Seventy-six percent of all NTD-specific deaths occurred in the first 23 hours of life. Seventy-four percent of NTD-specific infant deaths were low birthweight and 58 percent were preterm. The Midwest had the highest rate of NTD-specific infant deaths among US regions.
Enhanced prevention efforts are needed to address the disparities in infant deaths due to NTDs between Hispanics and other populations, as well as women under 20 years. Decreases in NTD-specific IMRs may have been impacted by fortification of enriched grain products with folic acid since these efforts were optional beginning in 1996. While there are limitations in cause-specific IMRs, NTD-specific IMRs can be used as one measure to assess the impact of public health interventions aimed at reducing NTDs, respectful of the relatively small numbers.
[Show abstract][Hide abstract] ABSTRACT: And his daughter-in-law, the wife of Phinehas, was pregnant near to giving birth, and got to hear the report that the ark of the true God was captured and that her father-in-law and her husband had died. At that she bowed herself and began giving birth, because her pangs came unexpectedly upon her.