Prematurity Awareness Day - 2008

Today is Prematurity Awareness Day. At a local press conference sponsored by the March of Dimes, I had the opportunity to discuss some of my thoughts on this subject with a reporter. When I started my residency, the prematurity rate sat between 8% and 9%. Today one in every eight babies (530,000 per year) in the U.S. is born prematurely and in my home state of South Carolina the rate is even higher – one in five to six babies. (Incidentally, during the same time period since my residency, cesarean delivery rates have gone from about 12% to 35%).

Complications related to prematurity now make it the leading cause of death among newborns and during the first year of life – now surpassing birth defects. This holds true despite the remarkable advances that have been made in neonatal care that have pushed survival into the range of 23 weeks gestation. In general, first year medical costs for preterm babies across the board are at least 10 times greater than that for babies born at term. The 2006 Institute of Medicine special report, “Preterm Birth: Causes, Consequences, and Prevention,” concluded preterm birth costs our nation $26 billion annually. Factoring in the continued rise in preterm birth as a percentage of all deliveries, the population increase, the immediate expense related to the acute care of extremely premature neonates (and the ongoing expenses due to complications of prematurity among survivors), the enormous number of late preterm deliveries (and their ongoing expenses due to complications of prematurity!), and the inflation in health care costs, I would wager that the total cost is now much more than twice that annually.

Despite the fact that we have a long list of factors that we know are associated with increased risk for preterm birth, we continue to lose ground in the battle against it. Funding for women’s health initiatives related to prenatal care is inadequate, educational programs that focus on planned pregnancy, preconceptional counseling and early entry to prenatal care, adequate nutrition and weight control, stress reduction, cessation of smoking and other substance abuse, are not widespread enough (nor begun early enough in life), and efforts to scrutinize and control the high rates of labor induction, as well as primary and repeat cesarean deliveries are thwarted by providers, hospitals, and patients themselves.

Especially frustrating to me are the factors over which we could have a significant impact, but where we are falling further and further behind: teen pregnancy rates are the highest they have been in years; obesity is morbidly epidemic and beginning younger and younger in life; patients in our area are presenting later for prenatal care (forget preconceptional care); racial disparities in preterm birth rates are widening; more than 20% of pregnant women in South Carolina continue to smoke; access to care is being deleteriously affected by Medicaid cuts, poorly-controlled Managed Medicaid programs, and a growing percentage of underinsured and completely uninsured women in their reproductive years; and reimbursement for providers of obstetrical care is inadequate to cover expenses when one factors the total amount of time required in patient management during the pregnancy, labor, and delivery and the liability risks and overhead costs associated with that care.

Personally, I support and applaud the efforts of the March of Dimes to address the many issues related to preterm birth. Since 2003, the organization has focused its attention on raising public awareness and expanding programs that provide information and support to families affected by preterm birth. But, this is an effort that will require support, financially and organizationally, at a much higher level if the dismaying trends are to be reversed and a true impact realized.

The first step in this is not necessarily underwriting large research programs to identify the ‘cause’ or a ‘treatment’ for preterm birth. Preterm birth is not a disease, it is the final common pathway of the many factors that variably contribute to it in different individuals. We must, however, continue the efforts by groups such as the March of Dimes to educate patients, providers, employers, and politicians regarding the extent of the problem and its long-term consequences on the health, healthcare costs, and welfare of our people. We must also focus our attention on preventive and ‘therapeutic’ programs to address some of the major issues mentioned above – programs that will improve the general health of women in their prereproductive and reproductive years – improving the prospects that their children will not be destined to repeat the cycles of the prior generations.