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The Problem of Prematurity

The Problem of Prematurity. Robert A. Kahle, MD California Association of Neonatologists California Premature Infant Health Coalition Catholic Healthcare West, Sacramento. Prematurity in California. Term pregnancy is greater than or equal to 37 weeks gestation.

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The Problem of Prematurity

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  1. The Problem of Prematurity Robert A. Kahle, MD California Association of Neonatologists California Premature Infant Health Coalition Catholic Healthcare West, Sacramento

  2. Prematurity in California • Term pregnancy is greater than or equal to 37 weeks gestation. • Prematurity is less than 37 completed weeks gestation.  • Moderate preterm is 32-36 weeks of gestation. • Very preterm is less than 32 weeks gestation.  • Extremely Preterm is less than 28 weeks gestation

  3. The Faces of Prematurity

  4. Why Prematurity?The incidence continues to increase.

  5. Why Prematurity? • 10% of all premature births in the U.S. happen here in California • Every five years we add more than a quarter of a million prematurely born children to our state’s population, with a great number of these children having multiple serious health and human service needs • Prematurity is currently estimated to costCalifornia’s health care system $4 billion

  6. Why Prematurity? As the incidence increases so does the cost. • Economic: • High risk OB and NICU care. • Long term health and development problems. • Societal: • Increased costs in education and care. • Lost wages and productivity of Parents. • Personal/Interpersonal: • Stress, disruption, time and travel. • Increased demands on entire family

  7. Complications of Prematurity: Ongoing Needs • Respiratory: • Chronic Lung Disease • Recurrent infections • Nutritional: • Failure to thrive • Feeding issues • Neurological: • Developmental delay • Cerebral Palsy • Mental retardation • Vision and hearing deficits

  8. Rural Areas and Prematurity

  9. Mono 14.9% Kern 12.9% Fresno 12.6% Inyo 12.6% Calaveras 12.2% Imperial 11.8% Kings 11.6% San Joaquin 11.4% Stanislaus 11.3% Madera 11.3% Sonoma 7.5% Sierra 8.1% Lassen 8.3% Yolo 8.4% Del Norte 8.45% Napa 8.6% Marin 8.7% Trinity 9.1% Tuolumne 9.1% San Luis Obsipo 9.2% Prematurity at the County LevelSome hit harder than others.

  10. Why is Prematurity Increasing? • Increasing distribution of Risk Factors • Racial and Ethnic factors • Age factors • Multiple Gestation Pregnancies • Health related conditions • Social factors • Environmental factors • Medical Intervention

  11. Prematurity: Racial and Ethnic Factors

  12. Prematurity: Age Related Factors

  13. Previous Pregnancies & Risk of Preterm Delivery • Carr-Hill; Kristensen et al.

  14. Prematurity and Multiple Gestational Pregnancies

  15. Prematurity • Health Related Conditions: • Obesity and Diabetes • Chronic Hypertension • Chorioamnionitis, sexually acquired infections • Societal Related Conditions: • Poverty, Violence and Other Stressors • Drug, Alcohol and Tobacco Use • Intrinsic lack of support

  16. Prematurity • Environmental Conditions: • Toxic exposures (insecticides, BPA) • Medical Intervention: • Cesarean sections • Induction of labor • Medical Legal Influence

  17. So how do we address the issue? • Improving women’s health through education and through appropriate access to healthcare (preconception, prenatal and interconception care) and the provision of high quality medical care of the mother and the infant offers the best chances of reducing prematurity and improving outcome and thereby reducing the economic, societal and personal burdens associated with prematurity. • Advocate, advocate, advocate!

  18. California Premature Infant Health Coalition “It is the vision of the California Premature Infant Health Coalition that all women receive the societal support and the ongoing health care necessary to prevent prematurity, when possible; and if not possible, that those infants born prematurely and their families receive the ongoing care and support necessary to ensure the best outcome.”

  19. Preconception Health Initiatives • Preconception Health Council of California • Everywomancalifornia.com • Promotes health of women of reproductive age

  20. Preconception Health Council of California Essential Components • Reproductive life plan • Healthy body • Healthy mind • Healthy environment

  21. Interconception Health Initiatives • WOW Program: WIC Offers Wellness • WIC provides Federal grants to States for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk. • The WOW Program is a prematurity prevention, interconception care MOD funded demonstration project.

  22. WOW Program Objectives: • To improve the health status of high-risk women who recently delivered a premature or low birth weight infant. • To increase pregnancy interval. • To increase the rates of planned pregnancy. • To reduce the incidence of repeat premature or LBW deliveries in low income women.

  23. WOW Program The project is designed to reduce the risk of a subsequent poor birth outcome through ….. • Enrolling mothers with recent premature infant • Providing 1:1 Counseling • Providing health and nutrition screening and assessment • Providing health education and promotion • Making referrals for psychosocial intervention services • Peer support groups

  24. Maternal Management Initiatives • March of Dimes Preterm Labor Assessment Toolkit • Appropriate evaluation and treatment of preterm labor • California Maternal Quality Care Collaborative (CMQCC) • Prevention of elective deliveries before 39 weeks • Prevention of maternal deaths related to post partum hemorrhage

  25. Neonatal Management Initiatives • California Perinatal Quality Care Collaborative (CPQCC) • Maintains database on all infants with birth weights under 1500g and on select group of others (Transports, Ventilator, Surgery, Infection, etc). • Provides risk adjusted outcome measures to all NICUs in California. • Provides Quality Improvement tools including Neonatal Care Collaboratives and NICU Toolkits

  26. California Perinatal Quality Care Collaborative (CPQCC) • California Perinatal Transport Service (CPETS): • Maintains database on all infant transports in the state, tracking response times and adequacy of support during transport. • CCS High Risk Infant Follow Up (HRIF): • Developed a High Risk Infant Developmental Follow Up Database tracking premature and other high risk infants to two years of age.

  27. Rural Issues • Lack of local resources • Inadequate access to specialists (Perinatal, Neonatal and Pediatric) • Appropriate transfer of care of high risk mothers • Appropriate center for delivery of preterm infants • Timeliness of maternal and neonatal transports • Adequate medical and developmental follow up • Increased need for rehospitalization • Access to rehabilitative therapies

  28. The Rural Response • Outreach Clinics • Intermittent availability • Telemedicine • Inpatient vs Outpatient • Maternal and Neonatal Transport • Coordination and timeliness issues • Family support • Family Voices • Friends of NICU

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