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Improving Birth Outcomes Key to Improving Global Health

Improving Birth Outcomes Key to Improving Global Health Optimizing birth outcomes is critical to improving global health not only for children, but also for the mother and family. Children who are born small, which is common in preterm births and complicated pregnancies, have a higher risk of heart disease and diabetes later in life.1 Similarly, some pregnancy complications, such as preeclampsia, have been found to increase the risk of maternal cardiac disease.2 Improving birth outcomes by optimizing pregnancy, reducing pregnancy complications, and delivering at the appropriate time can improve lifelong health for the mother and child, thereby benefitting the family unit and the broader community. Only during the last decade have late preterm (delivery at 34-36 weeks’ gestation) and early term (delivery at 37-38 weeks’ gestation) birth been defined and routinely used.3 Before that time, advances in neonatal care allowed an almost cavalier attitude toward these deliveries for many years, as their outcomes generally were excellent. With time, however, it has become clear that this interval is critical, and allowing development to continue in vivo in an uncomplicated pregnancy is beneficial.4 Over the last decade, research has demonstrated that delivering even a few days early can have negative implications for neonatal health.5 These infants are at higher risk for thermal instability, hypoglycemia, hyperbilirubinemia, infections, and respiratory morbidities.5,6 These findings have led to national campaigns and even local, hospital-based efforts to reduce unindicated deliveries prior to term, defined as 39 weeks. In this issue of JAMA, Richards and colleagues7 report results of a population-based study of trends in late preterm and early term deliveries and their association with clinician-initiated obstetric interventions in 6 high-income countries (Canada, Denmark, Finland, Norway, Sweden, and the United States) between 2006 and 2010-2015. Late preterm birth rates ranged from 3.3% in Finland to 6.0% in the United States; early term birth rates ranged from 16.8% to 26.9%, respectively, in these countries. The rate of obstetric interventions among late preterm births was highest in the United States (44.1%), whereas the rate of obstetric interventions among early term births was highest in Canada (45.2%). Over the period of the study, late preterm and early term births declined in the United States and Norway; early term births also declined in Sweden. There was no association between late preterm birth rates and obstetric intervention in any of the countries. However, a decline in early term birth rates was associated with decreasing obstetric interventions in the United States. For the purposes of this study, clinician-initiated obstetric interventions were defined as labor induction or prelabor cesarean delivery. Deliveries in the late preterm and early term periods with obstetric interventions may or may not be indicated. The public health emphasis has been on reducing nonindicated deliveries, but the current analysis cannot directly evaluate the effect of these efforts. Although a nonindicated delivery would require one of these obstetric interventions, indicated deliveries also may require an obstetric intervention, and these cannot be separated out in this study because it relied on registries and administrative databases. Determining the proportion of nonindicated deliveries is not easy. A study using 2001 data found that 23% of late preterm births had no recorded indication; however, it is possible that this ratio has changed in the last decade.8 In a more recent Brazilian study, the authors were able to distinguish women who were less likely to have an indication for early delivery. They found that these women were more likely to have interventions if they received care from private services. They also observed that 40% of late preterm births to these low-risk women had obstetric interventions, and of these more than 90% were prelabor cesarean deliveries.6 The substantial variation in late preterm births (3.3% to 6.0%) and early term births (16.8% to 26.9%) reported in this study suggests that nonindicated deliveries are substantial proportions of early births in some countries, and additional progress in reducing preterm delivery is possible. The study by Richards and colleagues also found that the United States had the highest rates of obstetric interventions for late preterm births and the second highest rates of obstetric interventions for early term births, approximately 40% to 50%. In the Nordic countries included in the study, the range was between 20% and 40%. Both the United States and Canada had substantially higher rates of late preterm and early term births compared with the Nordic countries. Although the populations and health care systems of these countries are different, are these differences enough to double the rates of obstetric interventions? Or is there another factor that explains these findings? Canada, Finland, and Denmark had increases in their intervention rates over the years studied. However, the reasons for these increases cannot be determined based on the data available to the investigators, but if these increases in obstetric interventions continue at the current rate, the late preterm and early term delivery rates in these countries may increase to rival those of the United States. Reductions in early term births in the United States have been documented previously,9 and Richards and colleagues found an impressive decline in obstetric interventions among early term births from 48.9% in 2006 to 38.7% in 2014. This reduction may be due to national and local efforts to reduce nonindicated deliveries prior to 39 weeks. In contrast, the rates of obstetric interventions among late preterm births were relatively constant over the years studied. Although reducing preterm birth is a major goal, sometimes late preterm birth is the best outcome for the mother and/or fetus, and these deliveries would require an obstetric intervention.10 Thus, the constant rate of obstetric interventions among late preterm births may be associated with a relatively smaller number of nonindicated late preterm births. Richards and colleagues have provided a thoughtful multinational picture of late preterm and early term deliveries and their association with obstetric interventions. More data are needed to better understand the differences between countries and changes over time. Better tools and technologies to date pregnancies are now available, and, as studies continue to demonstrate, it is critical to wait until full term for delivery in uncomplicated pregnancies. However, physicians cannot become too devoted to decreasing late preterm and early term birth rates. For pregnancies in which there is a complication and when delivery will optimize the pregnancy outcome, delivery should occur and will require an obstetrical intervention. Back to top Article Information Corresponding Author: Catherine Y. Spong, MD, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 31 Center Dr, 2A03, Bethesda, MD 20892 (spongc@dir49.nichd.nih.gov). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. References 1. Smith CJ, Ryckman KK, Barnabei VM, et al. The impact of birth weight on cardiovascular disease risk in the Women’s Health Initiative. Nutr Metab Cardiovasc Dis. 2016;26(3):239-245.PubMedGoogle ScholarCrossref 2. Kessous R, Shoham-Vardi I, Pariente G, Sergienko R, Sheiner E. Long-term maternal atherosclerotic morbidity in women with pre-eclampsia. Heart. 2015;101(6):442-446.PubMedGoogle ScholarCrossref 3. Spong CY. Defining “term” pregnancy: recommendations from the Defining “Term” Pregnancy Workgroup. JAMA. 2013;309(23):2445-2446.PubMedGoogle ScholarCrossref 4. Kugelman A, Colin AA. Late preterm infants: near term but still in a critical developmental time period. Pediatrics. 2013;132(4):741-751.PubMedGoogle ScholarCrossref 5. Tita AT, Landon MB, Spong CY, et al; Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009;360(2):111-120.PubMedGoogle ScholarCrossref 6. Leal MdoC, Esteves-Pereira AP, Nakamura-Pereira M, et al. Provider-initiated late preterm births in brazil: differences between public and private health services. PLoS One. 2016;11(5):e0155511.PubMedGoogle ScholarCrossref 7. Richards JL, Kramer MS, Deb-Rinker P, et al. Temporal trends in late preterm and early term birth rates in 6 high-income countries in North America and Europe and association with clinician-initiated obstetric interventions. JAMA. doi:10.1001/jama.2016.9635Google Scholar 8. Reddy UM, Ko CW, Raju TN, Willinger M. Delivery indications at late-preterm gestations and infant mortality rates in the United States. Pediatrics. 2009;124(1):234-240.PubMedGoogle ScholarCrossref 9. Little SE, Zera CA, Clapp MA, Wilkins-Haug L, Robinson JN. A multi-state analysis of early-term delivery trends and the association with term stillbirth. Obstet Gynecol. 2015;126(6):1138-1145.PubMedGoogle ScholarCrossref 10. Spong CY, Mercer BM, D’alton M, Kilpatrick S, Blackwell S, Saade G. Timing of indicated late-preterm and early-term birth. Obstet Gynecol. 2011;118(2 Pt 1):323-333.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Improving Birth Outcomes Key to Improving Global Health

JAMA , Volume 316 (4) – Jul 26, 2016

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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2016.9851
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Abstract

Optimizing birth outcomes is critical to improving global health not only for children, but also for the mother and family. Children who are born small, which is common in preterm births and complicated pregnancies, have a higher risk of heart disease and diabetes later in life.1 Similarly, some pregnancy complications, such as preeclampsia, have been found to increase the risk of maternal cardiac disease.2 Improving birth outcomes by optimizing pregnancy, reducing pregnancy complications, and delivering at the appropriate time can improve lifelong health for the mother and child, thereby benefitting the family unit and the broader community. Only during the last decade have late preterm (delivery at 34-36 weeks’ gestation) and early term (delivery at 37-38 weeks’ gestation) birth been defined and routinely used.3 Before that time, advances in neonatal care allowed an almost cavalier attitude toward these deliveries for many years, as their outcomes generally were excellent. With time, however, it has become clear that this interval is critical, and allowing development to continue in vivo in an uncomplicated pregnancy is beneficial.4 Over the last decade, research has demonstrated that delivering even a few days early can have negative implications for neonatal health.5 These infants are at higher risk for thermal instability, hypoglycemia, hyperbilirubinemia, infections, and respiratory morbidities.5,6 These findings have led to national campaigns and even local, hospital-based efforts to reduce unindicated deliveries prior to term, defined as 39 weeks. In this issue of JAMA, Richards and colleagues7 report results of a population-based study of trends in late preterm and early term deliveries and their association with clinician-initiated obstetric interventions in 6 high-income countries (Canada, Denmark, Finland, Norway, Sweden, and the United States) between 2006 and 2010-2015. Late preterm birth rates ranged from 3.3% in Finland to 6.0% in the United States; early term birth rates ranged from 16.8% to 26.9%, respectively, in these countries. The rate of obstetric interventions among late preterm births was highest in the United States (44.1%), whereas the rate of obstetric interventions among early term births was highest in Canada (45.2%). Over the period of the study, late preterm and early term births declined in the United States and Norway; early term births also declined in Sweden. There was no association between late preterm birth rates and obstetric intervention in any of the countries. However, a decline in early term birth rates was associated with decreasing obstetric interventions in the United States. For the purposes of this study, clinician-initiated obstetric interventions were defined as labor induction or prelabor cesarean delivery. Deliveries in the late preterm and early term periods with obstetric interventions may or may not be indicated. The public health emphasis has been on reducing nonindicated deliveries, but the current analysis cannot directly evaluate the effect of these efforts. Although a nonindicated delivery would require one of these obstetric interventions, indicated deliveries also may require an obstetric intervention, and these cannot be separated out in this study because it relied on registries and administrative databases. Determining the proportion of nonindicated deliveries is not easy. A study using 2001 data found that 23% of late preterm births had no recorded indication; however, it is possible that this ratio has changed in the last decade.8 In a more recent Brazilian study, the authors were able to distinguish women who were less likely to have an indication for early delivery. They found that these women were more likely to have interventions if they received care from private services. They also observed that 40% of late preterm births to these low-risk women had obstetric interventions, and of these more than 90% were prelabor cesarean deliveries.6 The substantial variation in late preterm births (3.3% to 6.0%) and early term births (16.8% to 26.9%) reported in this study suggests that nonindicated deliveries are substantial proportions of early births in some countries, and additional progress in reducing preterm delivery is possible. The study by Richards and colleagues also found that the United States had the highest rates of obstetric interventions for late preterm births and the second highest rates of obstetric interventions for early term births, approximately 40% to 50%. In the Nordic countries included in the study, the range was between 20% and 40%. Both the United States and Canada had substantially higher rates of late preterm and early term births compared with the Nordic countries. Although the populations and health care systems of these countries are different, are these differences enough to double the rates of obstetric interventions? Or is there another factor that explains these findings? Canada, Finland, and Denmark had increases in their intervention rates over the years studied. However, the reasons for these increases cannot be determined based on the data available to the investigators, but if these increases in obstetric interventions continue at the current rate, the late preterm and early term delivery rates in these countries may increase to rival those of the United States. Reductions in early term births in the United States have been documented previously,9 and Richards and colleagues found an impressive decline in obstetric interventions among early term births from 48.9% in 2006 to 38.7% in 2014. This reduction may be due to national and local efforts to reduce nonindicated deliveries prior to 39 weeks. In contrast, the rates of obstetric interventions among late preterm births were relatively constant over the years studied. Although reducing preterm birth is a major goal, sometimes late preterm birth is the best outcome for the mother and/or fetus, and these deliveries would require an obstetric intervention.10 Thus, the constant rate of obstetric interventions among late preterm births may be associated with a relatively smaller number of nonindicated late preterm births. Richards and colleagues have provided a thoughtful multinational picture of late preterm and early term deliveries and their association with obstetric interventions. More data are needed to better understand the differences between countries and changes over time. Better tools and technologies to date pregnancies are now available, and, as studies continue to demonstrate, it is critical to wait until full term for delivery in uncomplicated pregnancies. However, physicians cannot become too devoted to decreasing late preterm and early term birth rates. For pregnancies in which there is a complication and when delivery will optimize the pregnancy outcome, delivery should occur and will require an obstetrical intervention. Back to top Article Information Corresponding Author: Catherine Y. Spong, MD, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 31 Center Dr, 2A03, Bethesda, MD 20892 (spongc@dir49.nichd.nih.gov). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. References 1. Smith CJ, Ryckman KK, Barnabei VM, et al. The impact of birth weight on cardiovascular disease risk in the Women’s Health Initiative. Nutr Metab Cardiovasc Dis. 2016;26(3):239-245.PubMedGoogle ScholarCrossref 2. Kessous R, Shoham-Vardi I, Pariente G, Sergienko R, Sheiner E. Long-term maternal atherosclerotic morbidity in women with pre-eclampsia. Heart. 2015;101(6):442-446.PubMedGoogle ScholarCrossref 3. Spong CY. Defining “term” pregnancy: recommendations from the Defining “Term” Pregnancy Workgroup. JAMA. 2013;309(23):2445-2446.PubMedGoogle ScholarCrossref 4. Kugelman A, Colin AA. Late preterm infants: near term but still in a critical developmental time period. Pediatrics. 2013;132(4):741-751.PubMedGoogle ScholarCrossref 5. Tita AT, Landon MB, Spong CY, et al; Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009;360(2):111-120.PubMedGoogle ScholarCrossref 6. Leal MdoC, Esteves-Pereira AP, Nakamura-Pereira M, et al. Provider-initiated late preterm births in brazil: differences between public and private health services. PLoS One. 2016;11(5):e0155511.PubMedGoogle ScholarCrossref 7. Richards JL, Kramer MS, Deb-Rinker P, et al. Temporal trends in late preterm and early term birth rates in 6 high-income countries in North America and Europe and association with clinician-initiated obstetric interventions. JAMA. doi:10.1001/jama.2016.9635Google Scholar 8. Reddy UM, Ko CW, Raju TN, Willinger M. Delivery indications at late-preterm gestations and infant mortality rates in the United States. Pediatrics. 2009;124(1):234-240.PubMedGoogle ScholarCrossref 9. Little SE, Zera CA, Clapp MA, Wilkins-Haug L, Robinson JN. A multi-state analysis of early-term delivery trends and the association with term stillbirth. Obstet Gynecol. 2015;126(6):1138-1145.PubMedGoogle ScholarCrossref 10. Spong CY, Mercer BM, D’alton M, Kilpatrick S, Blackwell S, Saade G. Timing of indicated late-preterm and early-term birth. Obstet Gynecol. 2011;118(2 Pt 1):323-333.PubMedGoogle ScholarCrossref

Journal

JAMAAmerican Medical Association

Published: Jul 26, 2016

Keywords: infant, premature,labor induction,world health,premature birth,elective cesarean delivery

References