In July 2019, the Centers for Disease Control and Prevention (CDC) released data for 2018 that indicated a rise in preterm births (birth at <37 weeks' gestation). This increase marks the fourth consecutive year that the United States has seen an increase in infants born too soon or too small. The change is largely attributed to the rise in late preterm birth occurring between 34 and 36 weeks' gestation. Between 2014 and 2018, late preterm birth rates have escalated from 9.57% to 9.97%. The evidence demonstrates that about 72% of all preterm infants are born late preterm each year in the United States.1
March of Dimes examined these data for its annual report card. Released in November 2019—Prematurity Awareness Month—the report card gave the nation a “C” letter grade for this dismal outcome.2* Six states and Puerto Rico earned an “F” letter grade. Preterm birth rates worsened in 30 states since the 2018 report card that analyzed 2017 birth data. Only Oregon received an A score.3
This recent 4-year increase from 9.63% in 2015 to 10.02% in 2018 is startling, particularly since the rise in preterm birth coincides with an ongoing increase in severe maternal morbidity and pregnancy-related death. It is an urgent priority that healthcare professionals now must dig deeper into these statistics and identify solutions for reversing these trends.
NOT ONE CRISIS, BUT TWO
Recently, Americans have been rattled by stories in popular media about pregnancy-related deaths and near misses. Unfortunately, this trend is not new. Pregnancy-related death has more than doubled over the last 25 years.4,5† In the United States, 700 women die annually due to complications resulting from pregnancy; more than 60% of these deaths are preventable. Up to 50 000 women suffer from pregnancy complications.
AN INEQUITABLE BURDEN
More startling than the repeated increase in the overall preterm birth rate, and the ongoing threat to pregnant mothers, are the racial and ethnic disparities in the outcomes. Preterm birth rates remain much higher for black, American Indian, Alaskan Native, and Hispanic women than for white women. Women of color are up to 50% more likely to give birth prematurely. The rate of late preterm births among non-Hispanic black women is 35% higher than the rate among non-Hispanic white women.1 As for maternal outcomes, black, American Indian, and Alaska Native women are 2 to 3 times more likely to die from pregnancy-related causes than white women.6 These disparities are too large to be attributed to any single and one-dimensional causal factor. A growing body of evidence suggests that lifetime experiences of stress and racial discrimination are associated with the black-white disparity in preterm birth.7,8 The literature also supports a link between multiple adverse child experiences (ACEs) and pregnancy complications as well as poor birth outcomes.9 Racial and ethnic minorities report higher exposure to ACEs.10
March of Dimes is deeply committed to birth equity and addressing the injustices these disparities represent. Health outcomes at any one point in life are often the product not only of recent experiences but of experiences across the life course.11 That is why March of Dimes launched a Center for Social Science Research in 2018 to investigate the social and environmental factors that contribute to birth outcomes and identify clinical, programmatic, and policy interventions to address them. March of Dimes believes that all women and infants—regardless of race, ethnicity, culture, language, or national origin; poverty or socioeconomic status; gender identity or sexual orientation; disability; and region or place (urban and rural)—must have every opportunity for optimal maternal and birth outcomes. These disparities are unacceptable; tackling them drives the mission of the organization.
Preterm birth is a complex problem; individual and systems-level risk factors are at play. Research supports the relationship between preterm birth and the mother's health history, including prior maternal reproductive history (eg, previous preterm birth, repeat cesarean birth), nutritional status, and health behaviors, including physical activity and smoking and drug use during pregnancy.2 Modern-day trends, such as pregnancy later in life and chronic health conditions, are significant risk factors. Mothers with hypertension or diabetes, as well as those who are overweight or obese, are at an increased risk of giving birth before 37 weeks' gestation.
Access to quality healthcare also plays a role. More than 5 million women live in maternity care deserts—places that have no hospital offering obstetric care and no obstetric providers. An additional 10 million women live in counties with limited access to maternity care.12 Access to care across the life course, including the prenatal period,13 is crucial.
Finally, the evidence linking preterm birth to the social determinants of health is growing. That is, the conditions in which we are born, grow, live, work, play, and pray affect birth outcomes. Factors such as air pollution,14 homelessness,15 residential racial segregation,16 and housing quality17 are tied to preterm birth.
Not surprisingly, these risk factors for poor birth outcomes are similar to those that contribute to maternal death and morbidity. Those include access to quality healthcare, poor quality and differential treatment received by women of color, cesarean deliveries, maternal mental health and substance abuse, social determinants of health, and cumulative effects of stress.4,18,19
While healthcare professionals know more than ever about risk factors, there is a lack of information about how the complex combination of these risk factors affects the interplay between preterm birth and maternal outcomes. It is time for a new approach. As noted in Figure 1, the health impact pyramid, a framework for public health action, provides sound guidance for looking beyond individuals in order to identify population-level solutions to these crises.20
A PUBLIC HEALTH APPROACH IS NEEDED
At the top of the pyramid are interventions that require individual effort or clinical intervention. The United States has seen great progress in this area. For example, evidence shows that participants in group prenatal care have higher rates of breastfeeding initiation and duration and have infants who spend fewer days in the neonatal intensive care unit than those in traditional care. Although more evidence is needed, some studies show that participants in this group model may have a lower risk of preterm birth.21,22 The safe reduction of cesarean birth is a clinical intervention for reducing both preterm birth and pregnancy-related death.
In the middle of the pyramid are clinical interventions that require limited contact but confer long-term protection. A good example of progress in this space is long-acting reversible contraceptives. Because short (<12 months), very short (<6 months), and long (≥120 months) interpregnancy intervals are associated with increased odds of preterm birth,23 using this type of long-term contraceptive allows for optimal birth spacing. And since chronic disease (eg, hypertension, diabetes) and substance use disorder are linked to both preterm birth and poor maternal health outcomes, addressing modifiable risk factors (ie, via tobacco cessation programs) from the preconception through prenatal and interconception periods is critical.
Also in the middle of the pyramid are interventions that change the context to make individuals' default decisions healthy. Years ago, March of Dimes worked to spread the word about the importance of folic acid for women of childbearing age and helped bring about folic acid fortification of grains and cereals. We are committed to supporting such policy-driven efforts in order to drive changes at the systems level. Proven interventions include immunizations, smoke-free policies, and medically assisted treatment.
Finally, at the base of the pyramid are interventions with the greatest potential impact—those that address socioeconomic factors. At this level, cross-sector commitment from a range of stakeholders and a willingness to invest in long-term solutions are required. In developing his pyramid, former CDC Director Tom Frieden proposed that “interventions focusing on lower levels of the pyramid tend to be more effective because they reach broader segments of society and require less individual effort.”20(p90) March of Dimes is optimistic about the opportunities to make progress here in the new decade.
A CALL TO ACTION ON EQUITY
Implementing interventions at each level is needed to achieve the maximum possible sustained public health benefit. To that effect, March of Dimes is searching for solutions in the laboratory and in communities. As the next decade begins, the organization is more committed than ever.
March of Dimes has an 80-year legacy of scientific innovation. Since 2012, $100 million has been invested in partnerships with researchers across the United States and globally to uncover the causes of preterm birth and support novel discovery. In 2020, the lens will be expanded to include transdisciplinary clinical, social, and translational science.
At the top of the pyramid, the goal is to expand access to Supportive Pregnancy Care, a group prenatal care model that provides prenatal care, health education, and social support during pregnancy. The organization will also push for changes in the model of care delivery, such as utilization of and payment for doulas and midwives.24,25
As for changing the context, March of Dimes supports Medicaid expansion, which has been proven to close the racial/ethnic gap in birth outcomes,26 and backs creative, state-led efforts to expand and extend Medicaid to 12 months postpartum. The organization is launching implicit bias training to combat race and compliance stereotyping,27,28 acknowledging that implicit bias training is a first step to recognizing the role of bias during patient care encounters, and working to position health equity as a prominent feature in the systems' culture.
Beyond policies that fall explicitly under the scope of healthcare, the organization supports economic policies such as paid family leave, which improves maternal mental health29 and job security and labor market attachment30 and reduces mothers' risk of poverty following a birth, particularly among disadvantaged mothers.31
Finally, and at the base of the pyramid, March of Dimes is catalyzing communities to drive change and advance equity by partnering with 480 member organizations and 700 individuals to address racial and ethnic inequities in birth outcomes through our Mom and Baby Network. In 2020, this effort will be using a results framework to mobilize local partners across sectors. The results framework includes strategies and solutions for achieving equity in infant and maternal outcomes that will allow measurement and aligned action across partner organizations.
As the nation's leading organization fighting for the health of women and infants, March of Dimes turns to this new decade for population-level, sustained, scalable impact. The organization is committed to this multipronged strategy in order to reduce preterm birth, eliminate preventable pregnancy-related deaths, and achieve health equity.
1. Martin J, Hamilton B, Osterman M. Births in the United States 2018. Hyattsville, MD: National Center for Health Statistics; 2019. NCHS Data Brief No. 346. https://www.cdc.gov/nchs/data/databriefs/db346-h.pdf
. Accessed November 25, 2019.
2. McCabe ER, Carrino GE, Russell RB, Howse JL. Fighting for the next generation: US prematurity in 2030. Pediatrics. 2014;134(6):1193–1199.
3. March of Dimes. 2019 Report Card. https://www.marchofdimes.org/mission/reportcard.aspx
. Accessed November 25, 2019.
4. Petersen EE, Davis NL, Goodman D, et al. Vital Signs
: Pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017. MMWR Morb Mortal Wkly Rep. 2019;68(18):423–429. doi:10.15585/mmwr.mm6818e1.
5. Centers for Disease Control and Prevention. Pregnancy Mort-ality Surveillance System. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
. Published 2011–2015. Accessed November 25, 2019.
6. Petersen E, Davis N, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. MMWR Wkly. 2019;68(35):762–765. https://www.cdc.gov/mmwr/volumes/68/wr/mm6835a3.htm?s_cid=mm6835a3_w
. Accessed November 25, 2019.
7. Collins J, David R, Handler A, Wall S, Andes S. Very low-birth-weight in African American infants: the role of maternal exposure to interpersonal racial discrimination. Am J Public Health. 2004;94(12):2132–2138. doi:10.2105/ajph.94.12.2132.
8. Braveman P, Heck K, Egerter S, et al. Worry about racial discrimination: a missing piece of the puzzle of black-white disparities in preterm birth? PLoS One. 2017:12(10):e0186151. doi:10.1371/journal.pone.0186151.
9. Centers for Disease Control and Prevention. Early adversity has lasting impacts. https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/journal.html
. Accessed November 25, 2019.
10. Melissa M, Ford D, Ports K. Prevalence of adverse childhood experiences from the 2011–2014 Behavioral Risk Factor Surveillance System in 23 states. JAMA Pediatr. 2018;172(11):1038–1044. doi:10.1001/jamapediatrics.2018.2537.
11. McEwen B. Allostasis and the epigenetics of brain and body health over the life course: the brain on stress. JAMA Psychiatry. 2017;74(6):551–552. doi:10.1001/jamapsychiatry.2017.0270.
12. March of Dimes. Nowhere to go: maternity deserts across the U.S. https://www.marchofdimes.org/materials/Nowhere_to_Go_Final.pdf
. Published March 2018. Accessed November 25, 2019.
13. Leveno KJ, McIntire DD, Bloom SL, Sibley MR, Anderson RJ. Decreased preterm births in an inner-city public hospital. Obstet Gynecol. 2009;113(3):578–584. doi:10.1097/AOG.0b013e318195e257.
14. Stieb D, Chen L, Eshoul M, Judek S. Ambient air pollution, birth-weight and preterm birth: a systematic review and meta-analysis. Environ Res. 2012;117:100–111. doi:10.1016/j.envres.2012.05.007.
15. Clark R, Weinreb L, Flahive J, Seifert R. Infants exposed to homelessness: health, health care use, and health spending from birth to age six. Health Aff. 2019;38(5):721–728.
16. Anthopolos R, Kaufman J, Messer L, Miranda M. Racial residential segregation and preterm birth environment as a mediator. Epidemiology. 2014;25(3):397–405. doi:10.1097/EDE.0000000000000079.
17. Jacobs DE, Wilson J, Dixon SL, Smith J, Evens A. The relationship of housing and population health: a 30-year retrospective analysis. Environ Health Perspect. 2019;117(4):597–604.
18. Jain JA, Temming LA, D'Alton ME, et al. SMFM special report: putting the “M” back in MFM: reducing racial and ethnic disparities in maternal morbidity and mortality: a call to action. Am J Obstet Gynecol. 2018;218(2):B9–B17.
19. Leonard SA, Main EK, Carmichael SL. The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity
. BMC Pregnancy Childbirth. 2019;19(1):16.
20. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health. 2010;100(4):590–595. doi:10.2105/AJPH.2009.185652.
21. Ickovics JR, Kershaw TS, Westdahl C, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol. 2007;110(2, pt 1):330–339.
22. Ickovics JR, Earnshaw V, Lewis JB, et al. Cluster randomized controlled trial of group prenatal care: perinatal outcomes among adolescents in New York City health centers. Am J Public Health. 2016;106(2):359–365.
23. Conde-Agudelo A, Rosas-Bermudez A, Castano F, Norton MH. Effects of birth spacing on maternal, perinatal, infant, and child health: a systematic review of causal mechanisms. Stud Fam Plann. 2012;43(2):93–114. doi:10.1111/j.1728-4465.2012.00308.x.
25. March of Dimes. Position statement: midwifery and birth outcomes in the United States. https://www.marchofdimes.org/materials/Final%20midwifery%20position%20statement%20August%2029%202019.pdf
. Accessed November 25, 2019.
26. Brown CC, Moore JE, Felix HC, et al. Association of state Medicaid expansion status with low-birth-weight and preterm birth. JAMA. 2019;321(16):1598–1609. doi:10.1001/jama.2019.3678.
27. Cooper LA, Roter DL, Carson KA, et al. The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. Am J Public Health. 2012;102(5):979–987.
28. FitzGerald C, Hurst S. Implicit bias in health care professionals: a systematic review. BMC Med Ethics. 2017;18:19. doi:10.1186/s12910-017-0179-8.
29. Bullinger LR. Paid family leave and infant health: evidence from state programs. Paper presented at: the Association for Public Policy Analysis and Management 2015 Fall Conference; November 14, 2015; Miami, FL. https://appam.confex.com/appam/2015/webprogram/Paper13331.html
. Accessed November 25, 2019.
30. Jones K, Wilcher B. Maternal Labor Market Detachment: A Role for Paid Family Leave. American University Department of Economics Working Paper No 2019-07. https://econpapers.repec.org/paper/amuwpaper/2019-07.htm
. Accessed February 17, 2020.
31. Stancyzk A. Paid Family Leave May Reduce Poverty Following a Birth: Evidence From California. Chicago, IL: University of Chicago, The Employment Instability, Family Well-Being, and Social Policy Network; 2016. https://cpb-us-w2.wpmucdn.com/voices.uchicago.edu/dist/5/1068/files/2018/05/stanczyk_einetbrief-13l9z7e.pdf
. Accessed November 25, 2019.