COPH observes World Prematurity Day with reflection and optimism

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The March of Dimes marks its annual World Prematurity Day on Monday, Nov. 17. Notably, the USF College of Public Health is home to two leaders in prematurity research, Dr. William Sappenfield and Dr. Russell Kirby.

Sappenfield, professor and chair of the Department of Community and Family Health and director of the Lawton and Rhea Chiles Center for Healthy Mothers and Babies, is a recipient of the 2013 Roy Pitkin Award for Research Excellence. Kirby is Distinguished USF Professor and Merrill Endowed Chair in Community and Family Health.

The two got together recently with COPH writer David Brothers to discuss the history of World Prematurity Day, as well as their and COPH’s efforts at improving Florida’s prematurity statistics.

World Prematurity Day 2

Question: “Tell us about World Prematurity Day. How did it get started? How long has it been going on?”

Kirby: “It’s really been the March of Dimes Foundation that’s been pushing it, first in the United States, and then trying to build support for a focus on pre-term birth prevention internationally. They started funding research on prevention of pre-term birth in the 1990s, and in about 2000 or 2001, they decided to make prevention of prematurity the major focus of their efforts. Over time, they decided to identify a specific day for a focus on prematurity prevention.

“March of Dimes has also sponsored a series of international conferences to focus attention on prevention of birth defects and prematurity in developing countries. I went to one in 2011. They’ve been trying to bring together other NGOs, as well as World Health Organization in developing countries. It turns out that data on pre-term birth internationally are a little hard to come by. In some of the countries with the largest populations, it’s hard to get information on what the prevalence of prematurity really is.”

Sappenfield: “They can’t even give you the number of births very accurately, let alone what type of births they were.”

Q: “So, are we talking places like India?”

S: “Right … and Africa, Southeast Asia.”

K: “Exactly. We think that, while the United States has a high rate of prematurity compared to other developed countries, the rates are probably higher in the developing world setting, but we don’t have really concrete data on it.”

Q: “What is LRC’s role going to be in this?”

William M. Sappenfield, MD, MPH

William M. Sappenfield, MD, MPH

S: “The Chiles Center has been partnering with the March of Dimes for a long time. Here’s their report card: Florida gets a ‘D’ again in prematurity. The country as a whole gets a ‘C.’ There are places that actually get ‘A’s’ and ‘B’s’ in the United States. We have a very high rate of pre-term birth in this state, and there are several ways we can try to reduce that pre-term birth rate. The March of Dimes is highlighting uninsured women. Even though we get a star for slight improvement, Florida has one of the highest proportions of women who are uninsured. The state, as an option, chose not to go to Medicaid expansion to fill in ACA.

“So, Florida is one of the top five states in terms of uninsured women, which is hard on pre-term birth. We’re trying to say that women should be healthy before pregnancy, should get their medical conditions taken care of before pregnancy. When so many women have no insurance, that’s not necessarily an attainable goal. One of the other areas is that smoking continues to be an issue in Florida.

“The place where we’re plugging in is early elective delivery. We’re trying to stop babies from being unnecessarily delivered early. For a while in this country, we thought it was safe to deliver babies at 37 weeks. We now have data that show that every week matters up to 39 weeks. We’re inducing and doing cesareans early, and many times without indication, so the focus has been working with hospitals to reduce delivering babies early.

Q: “Where does Florida rank in early elective delivery?”

“Florida is 36th in the country in terms of early elective delivery. We still have about six percent of all pre-term births that are not medically indicated. Most states are down to about three percent. The national goal is to be under five percent. About 34 percent of the delivery hospitals in the state have rates higher than five percent; 17 percent have rates higher than 10 percent. We even have one hospital that is at almost 40 percent early deliveries without medical indication.”

39 weeks

Q: “Is the day more targeted organizationally, or is it more for public awareness? Do you think heightened public awareness can actually help anything improve?”

K: “That’s an interesting question. On one level, probably not. What is more important, probably, is having the day as a symbol to pull together people who are involved with organizations. Professionally, it helps to promote an atmosphere of awareness about the issue that over time potentially can have an effect.”

S: “It’s one component of a public relations campaign. It’s not in and of itself sufficient, but if we’re trying to get the issue out there of how important prematurity is and increase public awareness, it is one component of doing that. As Russ said, this rallies the troop around this issue and keeps it out in front of people, but it’s also part of that larger component. To be honest, this country is still political. We still under-invest our research dollars in pre-term research, but we know that, if we increase the importance of pre-term births in the United States, then we’ll put more funding toward both policies and research.”

K: “It’s one piece of the effort.”

S: “Right. It’s one piece of a larger strategy. The key, as in many things, is not to look at them in isolation, but look at them as a portfolio approach to try and do this.

“The estimated cost of pre-term births in the last [Institute of Medicine] report was $15.5 billion, and that’s per year. So, it has really long-term consequences, and we’re still trying to figure out how to prevent it.

“Here we are in a medical age when we can do a lot of things, and we’re really behind in understanding what causes pre-term births and how to prevent them. Russ and I have both spent a long time in a career where we’ve had many next-best solutions that have failed in terms of pre-term births. There’s a long list of what we thought the answers were, from cerclage to intensive prenatal care to special tocolytic agents to treating bacterial vaginosis to oral health disease. Almost all of the trials ultimately showed that what we thought were the magic answers haven’t worked, so this is why further research is really critical.”

K: “Right. There’s been quite a bit of investment in a number of different lines of inquiry, some more clinical, some more in the psycho-social arena, and there have been all sorts of interventions.

“The issue of prematurity has been a persistent one probably throughout the 20th century, but it only started to get attention around 1990, when, first of all, we became better able to measure it. In the earlier era, the vital statistics on weeks of gestation were not very good. They’ve gotten better over the last 15-20 years, and we started seeing the rates going up to the point where there’s quite a substantial increase over the period from 1990 to the mid-2000s, and that’s when it started to get more public attention. It looks like, in most places around the country, we’re starting to turn the tide a little bit, but we’ve still got a lot of work to do just to get the rate back down to what it was 20 years ago.”

S: “Russ and I have spent most of our careers trying to figure out why pre-term births were increasing all the way up to 2008, and if you asked us was it ever going to decrease, we would have said, ‘It doesn’t look like it.’ Because the trend was pretty consistent, and all of a sudden, it’s now turned, and people are saying, ‘So, why has it decreased?’ And we have probably as much evidence to explain why it decreased as why it increased.”

Russell Kirby, PhD, MS

Russell Kirby, PhD, MS

Q: “Besides early elective delivery, what are the best guesses?”

S: “While we do think reducing elective early delivery is important, I think it may be an over-attribution. In fertility treatment, for a long time we were planting multiple eggs in women who were trying to get pregnant, and it more than doubled our twinning rate in the country — and nearly half of all twins are born prematurely. So, now they’re cutting back on the number of implanted fertilized eggs, and that’s really helped reduce the twinning rate. Those are probably the two biggest explanations as to why it’s decreasing.”

Q: “What other related research is underway here?”

“We’re by no means the only people here working on this. Our new vice president [Dr. Charles Lockwood, head of USF Health] is a prematurity researcher and has brought his whole lab here. He’s bringing his whole lab and team with him.”

K: “That’s a good point. There’s a nurse midwife, Jessica Brumley, who’s on the staff of OB/GYN, and she’s been big on promoting group-model prenatal care, and there is research that suggests that group-model prenatal care can reduce the risk of pre-term birth.”

S: “And Cheryl Vamos and Ellen Daley are looking also at oral health disease in women, periodontal disease, and it’s been associated with pre-term birth, so they’re now trying to understand the literacy component for both providers and women as it relates to better treating and promoting the recommendations for addressing oral health disease.

Q: “Anything else either of you would care to add?”

S: “One final point, but it’s important to note that this is strictly conjecture on my part: Florida’s service-based economy may be playing a role in pre-term births, because it tends to produce a more stressful environment. We’re discovering more and more that it’s not just your income level, it’s the inequity in income that seems to be driving a lot of stress.

“If you look at infant mortality in the United States and some of the recent articles that have come out, we are getting worse than European countries, and if you break it out by more of the income basis, it is suggestive that it’s our income inequality. I would suspect that, in Florida, with its service-sector economy, we probably have more income inequality. With the recession, even though we’re adding more jobs in Florida, if you keep reading the paper, we’re not adding the higher-paying jobs, we’re adding even more lower-paying jobs. But that’s conjecture on my part. There’s no research to show that that’s why Florida is higher than most states in pre-term births.”