# Presentation: 699303

## PRAMS: A Tool to Understanding and Addressing Prematurity

- Preterm Birth in Utah
- Nan Streeter
- Utah Department of Health

## Preterm Birth in Utah Compared to National Data

- Preterm birth – birth prior to 37 completed weeks of gestation

## Preterm Birth in Utah Compared to National Data

- Preterm birth – birth prior to 37 completed weeks of gestation
- Utah PTB rate 9.5% (2003)
- 40% increase since 1992

## Preterm Birth in Utah Compared to National Data

- Preterm birth – birth prior to 37 completed weeks of gestation
- Utah PTB rate 9.5% (2003)
- 40% increase since 1992
- U.S. PTB rate 12.1% (2002)
- 13% increase since 1992

## Utah and National Rates

- Utah Source: Utah Department of Health. Center for Health Data. (2003). Indicator-Based Information System (IBIS) for Public Health. Birth Certificate Data.
- U.S. Source: National Center for Health Statistics, final natality data. Retrieved from www.marchofdimes.com/peristats
- 1 *Preterm is defined as less than 37 completed weeks of gestation. Rates are based on clinical estimate of gestation.*
*2 Preterm is defined as less than 37 completed weeks of gestation. Rates are based on NCHS methodology using LMP.*

- Utah Source: Utah Department of Health. Center for Health Data. (2003). Indicator-Based Information System (IBIS) for Public Health. Birth Certificate Data.
- U.S. Source: National Center for Health Statistics, final natality data. Retrieved from www.marchofdimes.com/peristats
- 1 *Preterm is defined as less than 37 completed weeks of gestation. Rates are based on clinical estimate of gestation.*
*2 Preterm is defined as less than 37 completed weeks of gestation. Rates are based on NCHS methodology using LMP.*

## Sequelae of Prematurity

- Leading cause of perinatal death in otherwise normal newborns

## Sequelae of Prematurity

- Leading cause of perinatal death in otherwise normal newborns
- In Utah, ~ 80% of infants who died during the neonatal period were born prematurely in 2002

## Sequelae of Prematurity

- Major cause of suboptimum long-term outcomes

- ACOG: Perinatal care at the threshold of viability. *In *Practice Bulletin-Clinical Management Guidelines for Obstetrician-Gynecologist. ACOG. Washington DC, 2002, pp. 1-8.

## Sequelae of Prematurity

- Major cause of suboptimum long-term outcomes
- Disabilities in 50% of survivors of extreme prematurity at 30 months of corrected age

- ACOG: Perinatal care at the threshold of viability. *In *Practice Bulletin-Clinical Management Guidelines for Obstetrician-Gynecologist. ACOG. Washington DC, 2002, pp. 1-8.

## Sequelae of Prematurity

- Major cause of suboptimum long-term outcomes
- Disabilities in 50% of survivors of extreme prematurity at 30 months of corrected age
- mental/psychomotor development

- ACOG: Perinatal care at the threshold of viability. *In *Practice Bulletin-Clinical Management Guidelines for Obstetrician-Gynecologist. ACOG. Washington DC, 2002, pp. 1-8.

## Sequelae of Prematurity

- Major cause of suboptimum long-term outcomes
- Disabilities in 50% of survivors of extreme prematurity at 30 months of corrected age
- mental/psychomotor development
- neuromotor function or sensory

- ACOG: Perinatal care at the threshold of viability. *In *Practice Bulletin-Clinical Management Guidelines for Obstetrician-Gynecologist. ACOG. Washington DC, 2002, pp. 1-8.

## Sequelae of Prematurity

- Major cause of suboptimum long-term outcomes
- Disabilities in 50% of survivors of extreme prematurity at 30 months of corrected age
- mental/psychomotor development
- neuromotor function or sensory
- communication function

- ACOG: Perinatal care at the threshold of viability. *In *Practice Bulletin-Clinical Management Guidelines for Obstetrician-Gynecologist. ACOG. Washington DC, 2002, pp. 1-8.

## Outcomes of Very Low Birth Weight Infants in Utah

- Utah Department of Health’s Neonatal  Follow-up Program  -  1986 - 2000

## Outcomes of Very Low Birth Weight Infants in Utah

- Utah Department of Health’s Neonatal  Follow-up Program  -  1986 - 2000
- 545 babies born at  26 weeks’ gestation

## Outcomes of Very Low Birth Weight Infants in Utah

- Utah Department of Health’s Neonatal  Follow-up Program  -  1986 - 2000
- 545 babies born at  26 weeks’ gestation
- Average birth weight
- 728 grams
- range 436 - 1500 grams

## Outcomes of Very Low Birth Weight Infants in Utah

- Utah Department of Health’s Neonatal  Follow-up Program  -  1986 - 2000
- 545 babies born at  26 weeks’ gestation
- Average birth weight
- 728 grams
- range 436 - 1500 grams
- Gestational age ranged from 21 - 26 weeks
- 21-23 weeks		  60 babies	11%
- 24-26 weeks		485 babies	89%

## Outcomes of Very Low Birth Weight Infants in Utah

- Average hospital stay - 107 days
- Range of 41 - 278 days

## Outcomes of Very Low Birth Weight Infants in Utah

- Average hospital stay - 107 days
- Range of 41 - 278 days
- Intraventricular hemorrhage
- 50% (271/545) all grade of IVH
- 20% (109/545) grade III and IV bleed

## Outcomes of Very Low Birth Weight Infants in Utah

- Average hospital stay - 107 days
- Range of 41 - 278 days
- Intraventricular hemorrhage
- 50% (271/545) all grade of IVH
- 20% (109/545) grade III and IV bleed
- Retinopathy of prematurity
- 80% (436/545) all stages of ROP
- 34% (183/545) ROP stage 3 and higher

## Outcomes of Very Low Birth Weight Infants in Utah

- Cerebral Palsy
- 18% (99/545)

## Outcomes of Very Low Birth Weight Infants in Utah

- Cerebral Palsy
- 18% (99/545)
- Home on supplemental oxygen
-  68%

## Utah Preterm Birth Study

## Utah Preterm Birth Study

- Utah Department of Health
- Lois Bloebaum BSN, (MPA Candidate)
- Laurie Baksh MPH
- Joanne Barley BS
- Nan Streeter MS, RN
- Peter Barnard CNM, MS

## Utah Preterm Birth Study

- Utah Department of Health
- Lois Bloebaum BSN, (MPA Candidate)
- Laurie Baksh MPH
- Joanne Barley BS
- Nan Streeter MS, RN
- Peter Barnard CNM, MS
- University of Utah
- Michael Varner MD
- Yvette LaCoursiere MD, MPH

## Utah Preterm Birth Study

**Study Question**:
- What are the significant factors associated with preterm births in Utah?

## Utah Preterm Birth Study

- Methodology
- Linked birth certificate and PRAMS data
-      (1999-2001)
- Multiple gestations excluded from analysis

## Utah Preterm Birth Study

- Methodology
- Linked birth certificate and PRAMS data
-      (1999-2001)
- Multiple gestations excluded from analysis
- Dataset divided into two mutually exclusive categories

## Utah Preterm Birth Study

- Methodology
- Linked birth certificate and PRAMS data
-      (1999-2001)
- Multiple gestations excluded from analysis
- Dataset divided into two mutually exclusive categories
- Chi-square tests identified significant variables

## Utah Preterm Birth Study

- Study divided premature births into two categories

## Utah Preterm Birth Study

- Study divided premature births into two categories
- Indicated preterm birth

## Utah Preterm Birth Study

- Study divided premature births into two categories
- Indicated preterm birth
- Spontaneous preterm birth

## Utah Preterm Birth Study

- Definitions
- _Indicated preterm birth _– associated with pregnancy complications requiring obstetric intervention for early delivery or led to preterm labor resulting in preterm birth

## Utah Preterm Birth Study

- Definitions
- _Indicated preterm birth _– associated with pregnancy complications requiring obstetric intervention for early delivery or led to preterm labor resulting in preterm birth
- _Spontaneous preterm birth _- one in which the underlying cause was not clinically evident
-         From: Kristensen J, Langhoff-Roos J, Kristensen F.  Implications of Idiopathic Preterm Delivery for Previous and Subsequent Pregnancies.  Obstet & Gyn. Vol. 86, No. 5, Nov. 1995.

## Utah Preterm Birth Study

- _Indicated preterm births_ - factors identified from birth certificate

## Utah Preterm Birth Study

- _Indicated preterm births_ - factors identified from birth certificate
- Maternal medical and/or obstetric risk factors

## Utah Preterm Birth Study

- _Indicated preterm births_ - factors identified from birth certificate
- Maternal medical and/or obstetric risk factors
- Complications of labor and delivery

## Utah Preterm Birth Study

- _Indicated preterm births_ - factors identified from birth certificate
- Maternal medical and/or obstetric risk factors
- Complications of labor and delivery
- Congenital anomaly of the child

## Utah Preterm Birth Study

- _Indicated preterm births_ - factors identified from birth certificate
- Maternal medical and/or obstetric risk factors
- Complications of labor and delivery
- Congenital anomaly of the child
- Induction (elective or therapeutic)

## Utah Preterm Birth Study

- _Indicated preterm births_ - factors identified from birth certificate
- Maternal medical and/or obstetric risk factors
- Complications of labor and delivery
- Congenital anomaly of the child
- Induction (elective or therapeutic)
- Elective cesarean section
-    	(excludes PPROM)

## Utah Preterm Birth Study

- _Spontaneous preterm births_ - those births that did not meet the criteria for indicated category
- category includes PPROM

## Utah Preterm Birth Study

- This study identified significant factors associated with both indicated and spontaneous premature births during 1999-2001.

## Utah Preterm Birth Study

- _Indicated preterm births_: n=~5,700 (53%)
- Mean gestational age - 33.8 wks.

## Utah Preterm Birth Study

- _Indicated preterm births_: n=~5,700 (53%)
- Mean gestational age - 33.8 wks.
- _Spontaneous preterm births_: n=~5,100 (47%)
- Mean gestational age - 34.5 wks.

## Utah Preterm Birth Study

- I_ndicated_ preterm delivery was significantly higher among women who:

## Utah Preterm Birth Study

- I_ndicated_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant

## Utah Preterm Birth Study

- I_ndicated_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant
- Were other than white

## Utah Preterm Birth Study

- I_ndicated_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant
- Were other than white race
- Smoked during last trimester

## Utah Preterm Birth Study

- I_ndicated_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant
- Were other than white race
- Smoked during last trimester
- Were aged 20 – 24 years

## Utah Preterm Birth Study

- I_ndicated_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant
- Were other than white race
- Smoked during last trimester
- Were aged 20 – 24 years
- Had < high school education

## Utah Preterm Birth Study

- I_ndicated_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant
- Were other than white race
- Smoked during last trimester
- Were aged 20 – 24 years
- Had < high school education
- Earned < $15,000 per year

## Utah Preterm Birth Study

**P-value <0.001**

## Utah Preterm Birth Study

**P-value <0.01**

## Utah Preterm Birth Study

**P-value <0.05**

## Utah Preterm Birth Study

**P-value <0.05**

## Utah Preterm Birth Study

**P-value <0.05**

## Utah Preterm Birth Study

**P-value <0.05**

## Utah Preterm Birth Study

- _Spontaneous_ preterm delivery was significantly higher among women who:

## Utah Preterm Birth Study

- _Spontaneous_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant

## Utah Preterm Birth Study

- _Spontaneous_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant
- Used fertility drugs to conceive the pregnancy

## Utah Preterm Birth Study

- _Spontaneous_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant
- Used fertility drugs to conceive the pregnancy
- Had some college education

## Utah Preterm Birth Study

- _Spontaneous_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant
- Used fertility drugs to conceive the pregnancy
- Had some college education
- Had a prepregnancy BMI categorized as either under- or over-weight

## Utah Preterm Birth Study

- _Spontaneous_ preterm delivery was significantly higher among women who:
- Had a previous preterm infant
- Used fertility drugs to conceive the pregnancy
- Had some college education
- Had a prepregnancy BMI categorized as either under- or over-weight

## Utah Preterm Birth Study

**P-value <0.001**

## Utah Preterm Birth Study

**P-value <0.05**

## Utah Preterm Birth Study

**P-value <0.01**

## Utah Preterm Birth Study

**P-value <0.05**

## Summary of Study Findings

- Indicated preterm births were slightly higher – perhaps due to

## Summary of Study Findings

- Indicated preterm births were slightly higher – perhaps due to
- Technological advances that permit early delivery to protect mother/infant

## Summary of Study Findings

- Indicated preterm births were slightly higher – perhaps due to
- Technological advances that permit early delivery to protect mother/infant
- Preconceptional health issues: chronic disease, poverty (health access), tobacco use

## Summary of Study Findings

- Indicated preterm births were slightly higher – perhaps due to
- Technological advances that permit early delivery to protect mother/infant
- Preconceptional health issues: chronic disease, poverty (health access), tobacco use
- Iatrogenic contribution, such as induction

## Summary of Study Findings

- Spontaneous preterm births accounted for almost half of preterm births, yet no identifiable medical risk factor was identified

## Summary of Study Findings

- Spontaneous preterm births accounted for almost half of preterm births, yet no identifiable medical risk factor was identified
- Preterm birth was 5x greater with previous history

## Summary of Study Findings

- Spontaneous preterm births accounted for almost half of preterm births, yet no identifiable medical risk factor was identified
- Preterm birth was 5x greater with previous history
- Demographic characteristics resemble general population

## Summary of Study Findings

- Spontaneous preterm births accounted for almost half of preterm births, yet no identifiable medical risk factor was identified
- Preterm birth was 5x greater with previous history
- Demographic characteristics resemble general population
- Contribution of prepregnancy weight and fertility drug use

## Summary of Study Findings 

- Both indicated and spontaneous preterm deliveries were significantly higher among women with history of previous preterm birth

## Study Limitations

**Limitations:**
- Use of birth certificate data, with under-reporting and/or inaccurate reporting of medical risk factors

## Study Limitations

**Limitations:**
- Use of birth certificate data, with under-reporting and/or inaccurate reporting of medical risk factors
- Use of self-reported PRAMS data is subject to recall bias

## Study Limitations

**Limitations:**
- Use of birth certificate data, with under-reporting and/or inaccurate reporting of medical risk factors
- Use of self-reported PRAMS data is subject to recall bias
- Methodology did not separate primiparous and multiparous women

## Study Conclusions

**Conclusions:**
- Strongest risk factor - previous preterm birth 	screening and education critical

## Study Conclusions

**Conclusions:**
- Strongest risk factor - previous preterm birth 	screening and education critical
- Improved preconceptional counseling and care (smoking cessation, chronic disease management, and weight control)

## Study Conclusions 

**Conclusions:**
- Strongest risk factor - previous preterm birth 	screening and education critical
- Improved preconceptional counseling and care (smoking cessation, chronic disease management, and weight control)
- Need for continued research: periodontal disease, use of prophylactic progesterone in women with previous history of preterm birth

## Future Studies

- Additional studies could focus on
- Separate analysis of primiparous and multiparous women

## Future Studies

- Additional studies could focus on
- Separate analysis of primiparous and multiparous women
- Identifying a third group - PPROM

## Future Studies

- Additional studies could focus on
- Separate analysis of primiparous and multiparous women
- Identifying a third group - PPROM
- Further logistic regression analysis to study interactions between variables

## What Can We Take Home?

- Accurate data on birth certificates is important to conducting studies, especially report of medical risk factors

## What Can We Take Home?

- Accurate data on birth certificates is important to conducting studies, especially report of medical risk factors
- Maternal birthing history is important in determining potential for repeating birth outcomes

## What Can We Take Home?

- Accurate data on birth certificates is important to conducting studies, especially report of medical risk factors
- Maternal birthing history is important in determining potential for repeating birth outcomes
- PTB is a multifactoral, complex problem

## Contact Information

- Nan Streeter, MS, RN
- MCH Bureau Director
- Utah Department of Health
- PO Box 142001
- Salt Lake City, UT 84114-2001
- 801-538-9963
- _[nanstreeter@utah.gov](mailto:nanstreeter@utah.gov)_