Thursday, July 20, 2006

Prematurity

A few days ago the Institute of Medicine released a report showing that there has been a 30% increase in the rate of premature birth in the U.S. since 1981. One of every eight babies born in the U.S. is born prematurely. The economic burden associated with it, that is, how much it costs to take care of these premies, is 26.2 billion dollars, or about $51,000 per premie. Obviously, the more premature you are, the greater the cost.

I haven't seen the actual report, just a news article about it, but for those of us who work in the field this is not a surprise. We've known for a number of years that the rate of prematurity is increasing. We've also known for a number of years that we don't know why the rate of prematurity is increasing, and we certainly don't know how to prevent it.

We know that certain infertility treatments increase the risk of multiple births, which increases the chance of premature delivery, but that accounts for just a small proportion of the increase. The report recommends that we take steps to decrease the number of multiple birth pregnancies - such as implanting only one or two embryos when doing in vitro fertilization - but that's just a drop in the bucket. For years, I've heard people saying we need more research into causes of prematurity, and we do. It just makes you feel a little impotent to be able to do nothing more about it besides call for more research.

Often reports like these are accompanied by hand wringing about how bad the U.S.'s infant mortality rate (IMR) is. We are far from first in the world in that measure of public health. I think we're around 20th, although I haven't looked it up recently. About now we will also likely hear statements meant to shame us that say the infant mortality rate in some of our inner cities is the same as that of some third world countries. These are bad things, but I'd like to point out one reason why our infant mortality rates will never be best in the world.

Blacks have a higher rate of premature birth than whites, 17.8% versus 11.5%. We don't know why that is, but it seems to be a biological phenomenon, and not just due to socioeconomic factors. Blacks of the same educational and economic levels as white counterparts still have more premature births. Since premature birth is one of the main contibutors to the infant mortality rate, countries that have more blacks are going to have a higher infant mortality rate. We are never going to be able to compete, in terms of infant mortality rate, with countries with more homogeneous populations like Japan (a perennial high achiever in IMR) and the Scandinavian countries.

I'm not saying we should be proud of our showing in the IMR rankings, or that we shouldn't try to improve it. I guess I'm just trying to point out that our high IMR is not a blanket indictment of our health system, as some would have it.

25 Comments:

Anonymous Angela said...

Ever consider the number of elective inductions and cesareans?? I can only imagine how that number would drop if the use of these elective procedures were curtailed. Ahhh, but that sure would make practicing OB a lot less cost effective... Seems like OB's are trying to keep you busy, NeoDoc.

4:12 PM  
Blogger Sarabeth said...

angela--the report wasn't about NICU stays increasing--it was about the number of premature births increasing. Since prematurity is definied as an infant born before 37 weeks, the statistic stated is not due to inductions or elective c-sections.

4:57 PM  
Anonymous Anonymous said...

I agree with the angela. It is insane how easy it is to elect a cesarean at any point after week 37. Given the +/- 2 to 4 weeks error rate with due dates, many supposed 38 and even 40 week babies are truly only 35 to 38 weeks. On top of that, induction for high AFI, low AFI, expected large baby and so on are not medically prudent for mom or baby (according to many recent studies in the journal of ob/gyn); but the practice of inducing or sectioning for these types of “problems” is growing at an alarming rate. If women could no longer elect to have a cesarean or induction, but rather only allow these things to happen when a true medically emergent issue arrives, the premature birth rate would decline drastically over the next two to three years. I speak from experience--Amy

5:01 PM  
Blogger Tanya said...

I think the topic angela was trying to discuss was iatrogenic prematurity, aka not waiting for the baby to decide when it is ready to be born. It is an increasing problem that the obstetrical community is not willing to admit. And iatrogenic prematurity is most certainly associated wtih inductions and elective c-sections.

5:03 PM  
Anonymous Anonymous said...

I forgot to mention the number of OBs and MWs who begin scraping membranes at 36 weeks and all the interventions that caregivers have started doing to "make sure" women don't get past 40 weeks. Given the fact that infant mortality has not declined with the vast number of interventions used these days, and that it is fairly consistent and sometime less with non-interventive MW care, it seems to me that leaving healthy women alone (including not doing even vag exams in the last 4 weeks of pregnancy) could reduce some of the premature birth problems in the us as well.--Amy

5:07 PM  
Anonymous Another Amy said...

sarabeth,

Elective inductions and cesareans could indeed have an effect on prematurity. Using the LMP to estimate a baby's due date is notorioudly inaccurate, as it assumes all women ovulate on Day 14 of their mentrual cycle, which we know NOT to be the case. If a woman ovulates much further along and she is seeing a practice that routinely induces at what they think is the 40-week mark, or the 41-week mark, or sooner, then there is a chance that the baby will be premature. There are also docs who induce for a suspected "big baby" even though ultrasound size estimation is also badly inaccurate, and many of them will induce as soon as what they think is 39 weeks-- again, if the LMP date was inaccurate, then the baby could be premature.

This is a very unscientific sample, but I teach in a school where 8 teachers either gave birth or their wives did. Out of the 8 pregnancies, two were scheduled cesareans, one at 34 weeks (twins) and one at 39 weeks (obese mother); two were inductions that ended in vaginal birth (both a few days shy of 40 weeks) and two were inductions that ended in cesareans, one at 38 weeks and one (mine) at 42 weeks. One was an "emergency" cesarean for PIH at 36 weeks. Only one was a spontaneous labor around the 41-weeks mark. All were first-time pregnancies, which traditionally has had an average gestation of 41 weeks 1 day-- but here the average was 38 weeks, 5 days. In 3 of the cases a NICU stay was indicated, and my daughter (not one of the NICU babies) required aggressive treatment for pathological jaundice rooming in with me and then at home.

Clearly something is awry here.

5:16 PM  
Blogger Sarabeth said...

Yes, all you say is true, however, those infants would still be categorized by the estimated gestational age, which would not influence these statistics.

8:13 PM  
Blogger Borneo Breezes said...

It should be relatively easy to determine if the cause is due to an increase in elective inductions or CS. I'm not up on the reading, (never a reason for not having an opinion tho') but there was a recent study in the Borneo Post about sex in the third trimester resulting in an increase in premmature babies.

9:23 PM  
Blogger La Lubu said...

Hmmm....

What about stress? Does stress play a role in premature birth? Are there any studies of this nature?

9:45 PM  
Blogger Sarabeth said...

The March of Dimes has a pretty good description of prematurity and what is known and not known.

10:45 PM  
Anonymous Anonymous said...

If a mom is not in labor the baby is not ready, whether it's 35, 38 or even 40+ weeks. Inductions and scheduled c-sections = a baby who isnt ready.

10:50 PM  
Anonymous Anonymous said...

Sarabeth,

The March of dimes is largely funded by ACOG (american college of OBGYN's) Do you really think they will have impartial information.

Also if a baby is born presenting as a premie they're age is adjusted. My Cousin was induced at 39wks it ended in a c-section. Her daughter was 4lbs 16oz, and had all the markers for a 35-36wk gestation infant. So you know what happened? they adjusted the babies age, and Her OB said "sometimes these things happen"

And let us not forget about those OB's who don't know how to handle relativly simple complications in a pregnant woman, swoop in declare an emergency at 24wks and section them on the spot.

Or those who make the decision to section a multiple pregnancy at a certain date because they think "no good will come out of remaining pregnant" instead of waiting it out. I mean come ON, elective c/s at 34wks, when twin pregnancies can and are often carried to 38,39,even 40wks without problem?

Or those who do routine vaginal exams at 35 or 36wks and "accidentaly" rupture a womans membranes.

If you don't beleive that "routine" pregnancy, and labor inductions intervetions produce premature babies thats fine, but for those of us on this side of the fence it's clear as day.

11:03 PM  
Blogger gamer boy said...

Hi i was wondering if you know jonathan L. held hes a neonatal doctor too

2:39 AM  
Blogger neonataldoc said...

Thanks for the comments. Could elective inductions be part of the cause for the increased premature birth rate? Maybe, but I'm not sure it's the major cause. I think we have to accept that for some reason moms are going into labor earlier.

La luba, yes, some people think stress does have a part in this. I don't know about studies of that, though.

8:22 AM  
Blogger Flea said...

ND,

I have seen the most recent data on IMR. The bulk of the causes are noted as consequences of extreme prematurity and congenital anomalies. IOW, we resuscitate micropremies and we don't abort abnormal fetuses. What's not to be proud of?

best,

Flea

8:52 AM  
Anonymous Dianne said...

Blacks have a higher rate of premature birth than whites, 17.8% versus 11.5%. We don't know why that is, but it seems to be a biological phenomenon, and not just due to socioeconomic factors. Blacks of the same educational and economic levels as white counterparts still have more premature births.

I don't think that you can safely conclude that the higher rate of prematurity in blacks is strictly a biological phenomenon from current evidence. Prejudice exists and it might affect rates of prematurity in a number of ways, even after correction for socioeconomic and educational status.

First, blacks are probably more chronically stressed than whites and relatively wealthy blacks, who probably have to deal with whites more often, may be stressed as much as poorer blacks. Every black person I know has a horror story of being stopped by the police for "walking while black" or being told "you only got into college because of affirmative action" or similar incidents. This has to take a toll on a person's health and reproductive ability.

Second, doctors may be prejudiced, whether they realize it or not and may not take complaints from their black patients as seriously as they take complaints from other patients. Again, the prejudice may not be concious, but even a subtle, unconcious prejudice can cause problems.

Third, black patients may be less willing to utilize medical care to the extent that other patients are. Everyone has heard of Tuskeegee.

Finally, there may be an interaction between biological factors and social factors that is disadventageous to blacks. In the past, the "normal" patient who was studied was generally a white man. Unsuprisingly, the techniques and medications developed using white men as the normal population work best on white men. In the OB population, of course, men weren't ever the norm but whites certainly were. Studies done on whites may not be applicable to blacks, hispanics, etc. This problem is being corrected--you can't get an NIH grant if you don't have a plan to study minority populations these days--but residual of past prejudice is still there.

There may be strictly biological reasons why more blacks have premature babies, but I don't think that it is proven at this point. And I don't think that we have to resign ourselves to higher neonatal death rates in blacks. With more study of the problem, better interventions may reduce the incidence.

4:21 PM  
Anonymous Anonymous said...

Is part of the reason that pregnancies that formerly resulted in later miscarriages are now being prolonged to result in a very premature baby?

3:55 PM  
Anonymous Christy said...

I think we have to accept that for some reason moms are going into labor earlier.

Yes. We also have to accept that the national induction rate is somewhere around 80%. EIGHTY! And our C-section rate is approx. 29.1%. I was sectioned for "suspected macrosomia" when I was estimated at between 39-41 weeks. My son was 8.8lbs and spent 9 days in the NICU for severe respiratory distress because of the c-section ( neonatal dr told us this ). He was also estimated at 36 ( THIRTY SIX ) weeks, instead of 39-41. Interesting huh?

Is it so incredibly shocking that the amount of premature births, and the amount of babies that spend time in the NICU is right around the same time that we have the HIGHEST induction and c-section rates? Does it really take a genius to put these two together? If the baby's not ready to be born, there is a high probable chance of baby not breathing well, which = NICU stay.

I'm not the smartest of people, but even I can see that.

7:08 PM  
Anonymous Bananarama said...

Dianne,
You sure do like to play the victim card.

4:07 AM  
Anonymous Dianne said...

we don't abort abnormal fetuses.

Flea, the US has one of the highest abortion rates of any country with legal abortion. If we've got a high rate of babies born with congential abnormalities because we don't abort abnormal fetuses as often as average, we must conceive them at an enormous rate.

11:25 AM  
Blogger stockingup99 said...

Banana - wrong

Diana - You made a very good point about how we treat others.

Not waiting for Baby to decide it's time is the reason for premies. 80% induction. A first time mom I know was just forced to induce at almost 41 weeks, or find a new practice. She went in for the induction -> C, no suprise.

How 'bout the court ordered C's. Did you know docs have called judges and gotten court orders to force a C against moms wishes?

If 40 weeks is the middle of the month long 95% confidence band, 42 weeks is well within expected bounds. The 'due date' is the center, two weeks plus or minus. There is no overdue, only induced.

12:24 PM  
Anonymous Anonymous said...

I am a Neonatal Transport Respiratory Therapist for 25 years, plus I also take high risk call for a rural hospital. I have seen the number of inductions rise considerably thus producing 35-38 wk infants who end up being transported for there need of surfactant. Some develope PPHN resulting in a very sick infant and exspensive stay.

3:27 AM  
Anonymous Anonymous said...

Odd. There has been a 50% (from 9% to 19.2%)rise in induction, a 30% rise in prematurity, and there is disturbing evidence that our maternal death rate may be on the rise as well. What could possibly be the cause?

8:23 PM  
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