Mission Possible: Reducing Disparities in Preterm Births in the United States

In 2001, a woman was transported to a Georgia hospital in preterm labor. She delivered a baby boy at 34 weeks gestation, six weeks before her due date. However, before this baby’s early birth, she was given medications to help her baby’s lungs mature more rapidly, and to slow down the labor. After her baby boy was delivered, his breathing was normal and he went home with his parents five days later. His name is Joseph, and he is my first son, born to my husband, Joe, and me.

Modern medical technology contributed to my successful preterm delivery outcome, but despite a wealth of medical resources, the United States has relatively high rates of preterm birth. Recently we’ve been losing ground in the fight to reduce preterm births, particularly among infants that are born late preterm (between 34-36 weeks gestation).

In 2017, overall preterm rates for non-Hispanic black (13.92%) and Hispanic (9.61%) women were higher than births to non-Hispanic white women (9.06%). [i] The high burden of preterm birth among black women creates greater challenges for survival, as non-Hispanic black infants have an infant mortality rate twice as high than that of non-Hispanic white infants.[ii] Approximately 44% of infant deaths among non-Hispanic black infants are related to being born preterm.[iii]

Disparities in the occurrence of preterm birth have both immediate and long-term consequences for families. Preterm birth is a major cause of infant death – but increased risk of infant death is not the only impact of preterm birth. A developing baby goes through important growth in the final months and weeks of gestation. For example, the brain, lungs, and liver fully develop in the final weeks of pregnancy. When a baby is born too early, this critical developmental period is missed. Thus, preterm babies who survive are at risk for breathing problems, feeding difficulties, intellectual and developmental disabilities, and vision and hearing problems. Some of these problems may not emerge for several years. These health concerns place increased social and financial burdens on families and our country. The annual economic burden associated with preterm birth in the U.S. was estimated to be at least $26.2 billion, according to a 2005 estimate from the Institute of Medicine.[iv] In 2017 US dollars (inflation adjusted from 2005 cost estimates using Gross domestic product [GDP] price index), the cost would be $32.4 billion.

We in public health can continue to work together with other partners to bring down preterm birth rates. There are several important factors that contribute to preterm birth for which we can focus our efforts. We can improve preconception health so women go into pregnancy as healthy as possible. We can prevent teen and unintended pregnancies and improve pregnancy spacing. We can help to reduce the risk of higher-order multiples in fertility therapies. We can also improve systems of care that ensure facilities have appropriate staffing, equipment, and experience to match patient needs. Pregnant women and newborns will benefit from receiving the right care, at the right place, and the right time. Lastly, we can ensure providers are aware of the variety of public health resources available to support postnatal infant development, particularly for low-income families through programs like breastfeeding support, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), early intervention services, Healthy Start, Home visitation programs, Head Start, and literacy initiatives (e.g., Reach Out and Read). These interventions, with a consideration for health equity and in collaboration with other stakeholders, will improve the health of women before, during, and after pregnancy and reduce death and disability among newborns.[v]

I’m proud of the work that the Division of Reproductive Health is doing to reduce preterm birth rates. Collective work with partners and other Federal agencies has had an impact on preterm birth rates. One example of the collective work is the support we provide to state-based Perinatal Quality Collaboratives (PQCs), which are state or multi-state networks of teams working to improve the quality of care for mothers and babies. PQCs address a range of perinatal health issues, among them: the use of antenatal steroids to reduce morbidity (as was the case with my pregnancy); the use of postpartum long-acting reversible contraception (LARC) to address short inter-pregnancy intervals, which are associated with preterm birth; and the use of 17 alpha-hydroxyprogesterone caproate (17-P) to prevent preterm birth in high risk women. One of our partners, the Ohio Perinatal Quality Collaborative, has implemented a Progestin Project, which uses quality improvement methods to identify eligible pregnant women and remove treatment barriers. In particular, the Ohio PQC project found sustained reductions in births before 32 weeks of gestation to women with prior preterm birth (decreased by 20.5%), with declines noted in African American women (20.3%) and women on Medicaid (17.1%).[vi] This model could help reduce disparities in preterm birth by improving outcomes among women at highest risk.

November marks National Prematurity Awareness Month. Our mission of improving birth outcomes for all is possible with the help of improved data, surveillance, and further research to understand the causes of preterm birth. More action is needed. We can ensure equitable access to medical care and prevention, create stronger public health partnerships, and eliminate the conditions that drive up rates of preterm birth. CDC will continue to work with partners across the country to improve quality of care, especially for the populations most impacted, while strengthening community partnerships to develop effective strategies to achieve equity in preterm birth.

Today, I gratefully watch a 17- year-old Joseph run track and play the cello. However, I still remember how hard it was to deal with the uncertainty and fear in those weeks immediately following his arrival. My hope, as a public health professional, a physician, and a mother, is that fewer women will have to experience that anxiety. Let’s continue to work together to ensure successful outcomes for all woman and their babies.

What actions do you see in your community that can help reduce disparities in preterm birth?

Special thanks to RADM Barfield for contributing this blog in recognition of National Prematurity Awareness Month and as part of the celebration of the 30^th anniversary commemoration of CDC’s Office of Minority Health and Health Equity. Our theme for the 30^th anniversary commemoration is Mission: Possible. We believe “healthy lives for everyone” is possible and a goal that resonates in public health.   

Sources:

[i]Hamilton BE, Martin JA, Osterman MJK, Driscoll AK, Rossen LM. Births: Provisional data for 2017. Vital Statistics Rapid Release; no 4. Hyattsville, MD: National Center for Health Statistics. May 2018. Available from: https:// www.cdc. gov/nchs/data/vsrr/report004.pdf. 8.

[ii] National Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-term Trends in Health. Hyattsville, Maryland. 2017.

[iii] Mathews TJ, MacDorman MF, Thoma ME. Infant mortality statistics from the 2013 period linked birth/infant death data set. National vital statistics reports; vol 64 no 9. Hyattsville, MD: National Center for Health Statistics. 2015.

[iv] Institute of Medicine. 2007. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: The National Academies Press. https://doi.org/10.17226/11622.

[v] Barfield, WD. Public Health Implications of Very Preterm Birth. Clinics in Perinatology September 2018. 45(3):565-577.

[vi] J.D. Iams, M.S. Applegate, M.P. Marcotte, et al. A statewide progestogen promotion program in Ohio. Obstet Gynecol, 129 (2017), pp. 337-346.