Healthy Babies are Worth the Wait®: Preventable Preterm Births Katrina Thompson, Karla Damus, Dr. Diane Ashton, Dr. Ruth Ann Shepherd

Preterm Birth Rates United States, 1983, 1993, 2003, 2006 > 1 out of 8 births or 520,000 babies born preterm in 2005 Percent >30% Increase The rate of preterm birth has increased by over 30% over the past two decades, reaching an all-time high of 12.7% (or more than 1 in 8 babies) in 2005 (the latest year for which final data are available). Each year, the rate of preterm birth gets farther and farther away from the Healthy People 2010 objective of 7.6%. HP 2010 Objective Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, final natality data Prepared by March of Dimes Perinatal Data Center, 2005

Late preterm infants are more likely than term infants to have: Focus on Late PTB Percentage Distribution of Preterm Births by Gestational Age, US, 2004 (<28 wks) Late preterm infants are more likely than term infants to have: -Depression at birth (low Apgar scores) -Respiratory distress, respiratory failure -Hypoglycemia -Feeding problems -Temperature Instability -Apnea -Hyperbilirubinemia -SIDS -ADHD -Behavior problems (28-31 wks) (36 wks) (32 wks) (33 wks) Over 70% of all preterm births are late preterm births (34-46 weeks). Although these babies may appear as big as term babies, they are at risk of a wide range of health problems. (34 wks) (35 wks) Source: NCHS, 2004 natality file Prepared by the March of Dimes Perinatal Data Center

Development of the Human Brain through Gestation Lower functions mature first Cortex is last to develop Brain at 35 wks weighs only 2/3 what it will weigh at term In addition, the brain of a 35 week infant is only 2/3 the size of that of a full-term infant. During the last six weeks of pregnancy, In the last 6 weeks of pregnancy, a baby’s brain adds connections needed for balance, coordination, learning and social functioning. Babies born early have more learning and behavior problems in childhood than babies born at 40 weeks. Babies born early are more likely to have feeding problems because they can’t coordinate sucking, swallowing and breathing as well as full-term babies.

A Collaborative Partnership The “Prematurity Prevention Partnership”: March of Dimes Johnson & Johnson Pediatric Institute Kentucky Department for Public Health Kentucky Chapter Professional Organizations (ACOG, AAP, AWHONN) Kentucky Perinatal Leaders In response to all of these issues, the March of Dimes and J&J formed an alliance called the Prematurity Prevention Partnership. The Partnership is working closely with the KY Department for Public Health and other leaders in KY on an intervention program called Healthy Babies are Worth the Wait.

Healthy Babies are Worth the Wait® Prevent “preventable” preterm births in target areas of Kentucky Three-year Initiative (2007-2009) in partnership with Johnson & Johnson Pediatric Institute and Kentucky Department for Public Health Evidence-based interventions -clinical -public health Focus on late preterm birth (34-36 weeks) Targets both perinatal providers and childbearing women System of collaboration between clinical and public health leadership The March of Dimes, Johnson & Johnson Pediatric Institute and the Kentucky Department for Public Health are partnering on a pilot program to reduce preterm births in targeted intervention areas in Kentucky. The three-year program began in January 2007. Kentucky was chosen from among several states under consideration because it best met criteria for the program design and implementation. The program “bundles” the best available evidence-based knowledge in both clinical practice and public health into a single intervention. Specific interventions include promoting standard clinical guidelines for use of folic acid, smoking cessation, and progesterone, linking families with needed public health services, and providing patient and provider education on the importance of preventing non-medically indicated preterm births. Education materials focus specifically on preventing late preterm births that are not medically indicated.

Healthy Babies are Worth the Wait® Hospital Sites Intervention sites are shown in red, comparison sites are in blue. Sites were chosen to represent a variety of geographic areas of the state. King’s Daughter’s and Lake Cumberland are located in the East, UK and Norton are academic centers located in urban areas in the center of the state, and Trover Clinic and Western Baptist are located in the west, near the Tennessee border.

Interventions “Bundled” Evidence-Based Interventions Linked elements of clinical care, public health and consumer education: Consumer Awareness and Education Health literacy in context of prenatal care Community outreach Professional Continuing Education Grand Rounds & Training Public Health Intervention Augmenting existing services for case management, screening & referral Clinical Intervention in Prenatal Period Standard clinical guidelines (folic acid, smoking cessation, progesterone) Patient safety HBWW takes a “bundling” approach: combining the best available evidence-based intervention in clinical care and public health. The Initiative attempts to link families with the public health services they need, enhancing synergies between public health and clinical care.

What Pregnant Women Can Do to Help Prevent Preterm Birth Messages for pregnant women (and women of childbearing age) Some preterm births—especially late preterm—could be prevented if all pregnant women: Get early, regular prenatal care Quit smoking or at least cut back and avoid secondhand smoke Avoid all alcohol Take folic acid daily before, during and between pregnancies Pay careful attention to good nutrition and eat a balanced diet with lots of fruits and vegetables Gain only the weight recommended by your health care provider Receive timely and appropriate treatment for existing medical conditions such as diabetes, high blood pressure, thyroid disease, addictions, and all infections including STIs Take good care of their teeth--brush, floss, and visit a dentist regularly Try to avoid stress and ask for help from their health care provider or support person to manage stressful situations in your life Question the reason to schedule any delivery before 39 weeks unless there are medical reasons for an early delivery Avoid elective induction or elective cesarean delivery including cesarean delivery on maternal request before 39 weeks Talk to their doctor if you have a history of spontaneous preterm labor or birth and are carrying a single baby about possible receiving progesterone to help prevent another preterm delivery

What Communities Can Do to Help Prevent Preterm Birth Messages for the community Preterm birth has consequences for many facets of our communities, including school systems, employers and insurers Make preventing preterm birth a priority in each community, as it will result in healthier babies, children, future parents and less chronic disease in all residents Visit and use materials from the Healthy Babies Are Worth the Wait website www.prematurityprevention.org Do not smoke around pregnant women, babies or children Host a Healthy Babies Are Wroth the Wait Prematurity Prevention awareness session where participants learn about preterm birth and how they can help to make a difference in their community Raise awareness of services and resources available to pregnant women and their families from the local clinical sites and the health department Work together on this leading public health problem as everyone can make a difference for the health of families in Kentucky

Barriers (due to dynamic conditions contributing to preterm birth) high rates of high risk factors (such as smoking, abuse of pain medication/oxycodone, illicit drug use, stress, infections, obesity) significant changes in the culture of childbearing by pregnant women (scheduling deliveries, CDMR) significant changes in obstetrical management with more inductions, cesareans and other procedures contributing to higher rates of iatrogenic late preterm birth changes in health care delivery systems, reimbursement structures and a litigious environment for obstetrical care These barriers are being overcome by successful implementation of the components of HBWW and with the close collaboration and guidance of key leadership in clinical, public health and communications/media. A focus on patient safety protocols is being implemented in year 2.

Consumer Survey: Methodology Snapshot KAB (knowledge, attitudes, beliefs/reported behaviors) survey 39-item core questionnaire 14-item optional supplement Questions from PRAMS, BRFSS, and MOD surveys Original questions specific to needs of HBWW interventions Focus groups and pilot testing Anonymous, voluntary, convenience sampling Analysis done in SPSS® WHO? Pregnant women presenting for prenatal care WHAT? Questions assessing KAB regarding pregnancy and childbirth WHERE Intervention and comparison sites (clinics, centering classes, private offices) WHEN? January-May, 2007

RESULTS Baseline consumer surveys Site Core Supplemental Int. Site 1 289 278 Int. Site 2 337 101 Int. Site 3 139 23 Comp. Site 1 93 88 Comp. Site 2 151 63 Comp. Site 3 57 48 Total 1066 601 English: 91.8% Spanish: 8.2%

Demographic Characteristics HBWW Consumer Survey Respondents Marital Status Married 54% Single/partner 20% Single 22% Maternal Education <HS 18% HS 26% Some College 38% Bachelors 14% Payor Medicaid 50% Private 35% Self 3% Maternal Age <20 years 14% 20-34 years 77% 35+ years 6% mean +/- sd 25.3 +/- 5.401 range 14-45  Race White 80% Black 9% Hispanic Ethnicity Yes

Obstetrical-Related Factors HBWW Consumer Survey Respondents Previous C/S None 63%  1 21% 2 7% 3+ 2% range 0-4  Inductions 42% 38% 2+ 10%  0-6 Trimester 1st 9% 2nd 28% 3rd 59% Planned Preg 39% Previous Births None 41% 1 31% 2 16% 3+ 11% mean +/- sd 1.02 +/- 1.129 range  0-6 Previous Preterm 71% 17% 2+ 7% 0.35 +/- 0.709  0-5  Multiple Birth 2.5% Of the 24% of pregnant women who had a previous preterm birth, 13% reported that their providers had discussed progesterone with them in their current pregnancy. Of women in their 3rd trimester, 66% reported that their hcp had discussed the signs and symptoms of preterm labor with them.

Prematurity KAB High risk conditions (38%) High risk behaviors (25%) How serious is preterm birth in your community? Very serious 14% Somewhat serious 23% Not at all 7% Not sure 54% How serious if your baby is born 3 weeks early? 2% Serious 11% 41% Not really 42% 79% could give an acceptable answer on how to explain prematurity to a friend Causes of preterm birth? High risk conditions (38%) High risk behaviors (25%) Stress (9%)

Periconceptional Vitamin Use by Women of Childbearing Age Percent HBWW Consumer Survey 2007

Behavioral Risk Factors: Smoking by Women of Childbearing Age Percent HBWW Survey 38% of respondents reported that at least 1 smoker lived in their home www.marchofdimes.com/peristats

Other Risk Factors for Preterm Birth Percent HBWW Consumer Survey, 2007

Cesarean Delivery KAB 30 35 33 Percent HBWW Consumer Survey, 2007

Goal: reduction of singleton PTB rate by 15% in Intervention Sites Reduction of singleton LPTB rate Reduction in elective inductions and sections conducted prior to 39 weeks gestation Increase in baby’s average days of gestational age and birth weight Reduction in neonate’s length of hospital stay Reduction in hospital cost / charges associated with preterm births Positive change in consumer and provider knowledge, attitudes, and behaviors regarding PTB More information: www.prematurityprevention.org The goal of the Initaitve is a 15% reduction in the rate of preterm births (among singletons only) in the Intervention sites over the 3 year period. Other objectives include demonstrating a reduction in late preterm births, a reduction in non-medically indicated early cesareans and inductions, and a reduction in hospital costs associated with prematurity. We will also be looking at changes in both patient and provider knowledge, attitudes and behaviors around prematurity. If the program is successful in reducing rates of preterm birth, this model could be replicated in other communities across the U.S. For more information, you can visit the project website, prematurityprevention.org. The site contains project information as well as free patient and provider educational resources.

Singleton Preterm Birth Rates by Hospital of Delivery, Kentucky, 2004 Graphic representation of HBWW Goal. First three bars show baseline prematurity rates in each of the intervention sites, and the fourth bar shows the aggregated baseline rate. The final bar represents success: a 15% reduction in the overall rate. This translates into 100 babies born at term that would have been born preterm without the project. Source: KY Dept pf Health Prepared by the March of Dimes Perinatal Data Center, 2007

www.prematurityprevention.org Prematurity prevention dot org is the publicly available website for HBWW. It includes resources for all members of the community: pregnant women, healthcare professionals, media professionals, and the general public.

Several original patient education materials have been developed, including this brochure on the importance of “going full term” (left), and this piece about the fetal brain development that occurs during the last few weeks of pregnancy (right).

Take Home Message- You Can Prevent Some Preterm Births The overall message is that despite years of research and programs to attempt to reduce preterm birth, the rates continue to rise reaching an all time high of 12.7% for the US and 15% for KY in 2005. However, since most of this increase is due to the rising rates of late preterm birth (34-36 weeks) a thorough understanding of contributing modifiable risk factors and an innovative program to address local issues driven by timely local information can begin to reduce these seemingly run away rates and in doing improve health by decreasing morbidity and mortality for infants, children and ultimately adults.

“Because this is a real-world model, and focuses on education and enhancing existing systems of care, we anticipate that it will be feasible to implement the lessons learned statewide. We are confident this initiative will improve the lives of mothers and babies.” Dr. Ruth Ann Shepherd Director, Adult and Child Health Improvement Kentucky Department for Public Health