Preterm Birth & Infant Mortality:
The Obstetrician’s Responsibility
ACOG District XII
Annual District Meeting
Jay D. Iams MD
The Ohio State University Wexner Medical Center
The Ohio Perinatal Quality Collaborative
August 16, 2014
Disclosures
Dr. Iams has contracts via Ohio State University with:
•NICHD for clinical research projects
•OPQC for quality improvement projects
•Elsevier for editorial & authorship roles in AJOG and
Creasy & Resnik’s MFM textbook
Objectives
At the close of this presentation, you
should want & be able to:
1. Accept Your Obstetrical Responsibility
to Reduce Infant Mortality.
2. Adopt 2 OB “Band-Aids®” to Do # 1.
•
Hint: Adopt systems to ensure 2 Rx’s
3. Embrace FPQC’s Projects in Your
Practice and in Your Hospital.
The Ohio Perinatal Quality Collaborative
Obstetrics
39-Week
Scheduled
Deliveries
without medical
indication
Neonatal
ANCS for women
at risk for preterm
birth
(240/7 - 33 6/7)
Done  Transition to
BC
Surveillance
2013-2015
Increase Birth
Data
Accuracy &
Online
modules
Spread to all
maternity
hospitals in
Ohio
BSI:
High
reliability of
line
maintenance
bundle
Progesterone
for Preterm
Birth Risk
Use of
human
milk in
infants 2229 weeks
GA
Neonatal
Abstinence
Syndrome
Prematurity is the Most Common Cause of Infant Mortality
34.3% of Infant Deaths Are Caused by Preterm Birth
2010 Infant Mortality Rates
March of Dimes 2013 Report Card
Premature Birth Rate
Rates of
Contributing Factors
2012
2013
Uninsured Women
Late Preterm Birth
Women Who Smoke
17.8%
8.2%
30.6%
17.0%
8.1%
27.3%
Grade



The Medical Model of Care for Preterm Birth
• Tertiary – After Parturition Starts
o Improve Outcomes in Preterm Infants Steroids
o No Effect on Incidence
• Secondary – Find & Reduce Risk
o Before and During Pregnancy
o In Individuals and Groups
• Primary - Prevention of Risk
o In Women, Before Pregnancy, Before Menarche
o In Systems
Care for Preterm Birth During Pregnancy
1985 - 2006
 Detection & Suppression of Contractions
 Detection & Suppression of Infections
 Detection & Replacement of Nutrients
 Calcium, Omega-3, Protein, Vitamins C + E
 Detection & Surgical Rx of Short Cervix
 Detection & Attention to Social Support
 Progesterone    ???
1996 - 2012
11.9%
11.7%
11.5%
2010
2011
2012
Who Decreased the Preterm Birth Rate?
• Obstetrician Gynecologists?
• Maternal Fetal Medicine Subspecialists?
• Midwives and Family Physicians?
•
•
• The Leadership Did It - Not the Research Program !
They Publicized Available Data
ASRM Statements On Fertility Care And
Twins, Triplets, & Higher Order Multiples
*
Report issued Nov 2011 by CDC – NCHS *
OPQC 39 Weeks Project in Sustain Phase
Decreasing Non-Medically Indicated
Scheduled Deliveries Between 37 and 39 Weeks Gestation
5% Goal
Data Is From All Ohio Maternity Hospitals
105 of 107 Hospitals Participated in the OPQC 39 Week Project
14
1996 - 2012
• Ultrasound Dating
• Fertility Rx
• Sched PTB > 34 wk
•  Fertility Rx
•  Sched Birth
• Progesterone?
11.9%
11.7%
11.5%
2010
2011
2012
Obstetricians
Have The Band Aids
• Antenatal Steroids
o Review Documentation of ANCS Use
o Systems Improvements in Birth Registry
o Publish Rates of Documented Use
• Progesterone Supplementation
o Women with a prior preterm birth
o Women with short cervix
in this pregnancy
Birth Registry Documentation of ANCS Use
Aggregate Rate in 19 OPQC Sites 2006 - 2014
Red Arrow:
Ohio Hospital
Compare
Blue Arrow:
OPQC ANCS
Project
Birth Registry Data 2006  2014
The Ohio OPQC Progesterone Project
• Goal: Reduce Ohio PTB & Related Infant Mortality
o Reduce Preterm Birth < 37 & 32 Weeks by 10% by 7-1-15
• Find Women with Prior Preterm Birth
• Find Women with Short Cervix
• Make it Easy to Prescribe and Rx Progesterone
o Protocols, Medicaid & Insurance Support, Navigators
• Outcome Measures
o Preterm Birth Rate
• Medicaid Data
• Birth Registry Data – Births < 32 & 37 Weeks
o Process Measures
o
The Infant Mortality Rate

Why?
Preterm Birth  Largest Contributor to Infant
Mortality
 Preterm Birth  Largest Driver of Disparity in PTB


Who?
Women with a Prior Preterm Birth
 Women with Very Short Cervical Length

How? Find & Rx Candidates for Progestogens
 When? ASAP – in Ohio & in Each Pregnancy

Find a Progesterone
Protocol You Like
And Use It.
Here’s One.
Find One
That Fits
Your
Practice.
Fundamental Principles
 Only You Can Prevent Preterm Birth
 Every Pregnancy Has Some Risk of PTB
 Preterm Parturition Starts Early in 1st or 2nd Trimester
 Short Cervix = Preterm Parturition
 Progesterone Can Slow Preterm Parturition



It does not prevent the process
Starting Progestogen Rx ASAP is Very Important
Finding & Treating Requires Time, So HURRY UP
What Formulations of Progestogens Should Be Used?
 Standard
Answers:
Hx SPTB: 17-OHPC 250 mg IM Q 7d 16  36 wks
 Short Cx ≤ 20 mm: Vag P, 200 mg QHS, Dx  36 wks

 But

Life is Not That Simple
17-OHPC – Manufactured vs. Compounded

Cost vs. Hassle
Vaginal P – multiple formulations - which to Rx?
 Who pays for what, when, & after how much hassle?


Initiate Progesterone ASAP for Hx SPTB
Accelerated 1st Prenatal Visit
 Presumptive Eligibility for Antenatal Care


Adopt a Local Management Protocol
For Hx SPTB
 For Short Cervix
 Test them via OPQC !


Make “Screen for PTB Risk” ≈ GBS, Rh, GDM
The Importance of Credentialing for Cervical Sonography
Iams JD et al. Am J Obstet Gynecol 2013
https://www.perinatalquality.org/C
LEAR/
http://www.fetalmedicine.com/fm
f/online-education/05-cervicalassessment/
OPQC’s Tasks:
Remove Administrative Barriers to Receiving
Progesterone Supplementation
Pharmacy Coordination
 Insurance / Medicaid Coverage & Protocols
 Delivery and Administration of 17 α- OHPC
 Use of Vaginal Formulations


Generic 200 mg capsules = cheapest & fastest Rx
Designate a Progesterone Coordinator
 Convene Participants to Assure Rx Received

Why Are We Missing P-Eligible Women?
What Have You Told OPQC About That?
• Do Providers Know About Progesterone? Yes.
• Do Providers Know What to Rx? Yes, mostly.
• Do Providers Know The Rx Gets to Patient?
Not So Much.
• Do Providers Know Why Women Don’t Seek
Care ‘til It’s Too Late? Yes, mostly.
•Do Providers Know What They Can Do To
Overcome That? Not So Much.
What Have Providers Done About Late for Care?
• No Appointment Needed!
– 1st Visits Welcomed Anytime in Cincinnati
• Community Open Houses with Food Prep
– “Moms2B” in Columbus Builds Social Networks
• Business Community Involvement
– Ohio Metro Counties Have High Infant Mortality
• High Infant Mortality = A Measure of Community Health
– Bring Your Business Here? No Way! Goin’ to Georgia!
• Hospital Geographic Responsibility for Health
Improving Access to Progesterone in Ohio
• Drive Community Changes to Increase
Awareness of PTB as Cause of Infant Mortality
• Increase Avenues to Enter Prenatal Care
• Recognize Candidates at First Contact
• Accelerate Appts & THEN get detailed OB Hx
• Track Receipt of Progesterone After Rx
• Think Outside the Medical Paradigm to Find
Eligible Women Late To Prenatal Care
Recommendations
• Publish The Data for Your County & Your State:
o Infant Mortality, Preterm Birth, & Smoking.
o Scheduled Births < 39 Weeks – 1% goal.
o Multi-fetal Pregnancy Rates.
o Antenatal Corticosteroids.
o Include Racial Disparity Rates for All the Above.
• Track All Over Time – Use Graphs, Not Tables.
• Promote Public Awareness
o Risks of Preterm Birth
o Prevention with Progesterone
o Availability of Cervical Ultrasound