Foreword The Tug of War Between Stillbirths and Elective Early Births Lucky Jain, MD, MBA Consulting Editor In August of 1956, nearly four years before John F. Kennedy became president of the United States, Mrs Jacqueline Kennedy gave birth to a stillborn child. Arabella Kennedy was born lifeless at 36 weeks’ gestation; this event had a deep and lasting impact on Mrs Kennedy. It also impacted the actions and approach of her health care team in subsequent pregnancies (and her two preterm deliveries) since the fear of another stillbirth was foremost on Mrs Kennedy’s mind. This story, stripped of its celebrity overtones, is still played over and over again, all over the world. The tug of war between stillbirths and early deliveries continues! In the many decades since then, we have seen a remarkable reduction in perinatal mortality rates. These gains, as shown in Fig. 1, have come from a reduction in both still- births and infant deaths. 1 A further reduction in perinatal mortality could be reliably achieved if the 6000 or so stillbirths each year in the United Stated beyond 39 weeks’ gestation could be eliminated. However, that would require elective delivery of all women beyond 39 weeks’ gestation, an action that would surely have untoward conse- quences of its own. 2 Although multifactorial in its origin, there is no doubt that the trend toward higher early term births has contributed to additional short-term and long-term neonatal morbidity. 3,4 This is particularly important for elective cesarean births whereby early birth coupled with lack of labor has led to a higher incidence of neonatal transi- tional problems. 5 Perinatal quality initiatives by many states and campaigns for public awareness have led to a measurable decrease in early term cesarean sections. In one recent study, Oshiro and coworkers 6 implemented a rapid-cycle process improve- ment program in 26 participating hospitals to decrease elective scheduled early term deliveries. Over a 12-month period, elective scheduled early term deliveries decreased from 27.8% in the 1st month to 4.8% in the 12th month (Fig. 2). Several other states have implemented similar programs and are reporting considerable success. Clin Perinatol 40 (2013) xv–xviii http://dx.doi.org/10.1016/j.clp.2013.08.002 perinatology.theclinics.com 0095-5108/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved. Moderate Preterm, Late Preterm and Early Term Births
Transcript
Moderate Preterm, Late Preterm and Early Term Births
Foreword
The Tug of War Between
Sti l lbirths and Elective Early
Births
Lucky Jain, MD, MBA
Consulting Editor
In August of 1956, nearly four years before John F. Kennedy became president ofthe United States, Mrs Jacqueline Kennedy gave birth to a stillborn child. ArabellaKennedy was born lifeless at 36 weeks’ gestation; this event had a deep and lastingimpact on Mrs Kennedy. It also impacted the actions and approach of her healthcare team in subsequent pregnancies (and her two preterm deliveries) since the fearof another stillbirth was foremost on Mrs Kennedy’s mind. This story, stripped of itscelebrity overtones, is still played over and over again, all over the world. The tug ofwar between stillbirths and early deliveries continues!In the many decades since then, we have seen a remarkable reduction in perinatal
mortality rates. These gains, as shown in Fig. 1, have come from a reduction in both still-births and infant deaths.1 A further reduction in perinatal mortality could be reliablyachieved if the 6000 or so stillbirths each year in the United Stated beyond 39 weeks’gestation could be eliminated. However, that would require elective delivery of allwomen beyond 39 weeks’ gestation, an action that would surely have untoward conse-quences of its own.2 Although multifactorial in its origin, there is no doubt that the trendtoward higher early term births has contributed to additional short-term and long-termneonatal morbidity.3,4 This is particularly important for elective cesarean births wherebyearly birth coupled with lack of labor has led to a higher incidence of neonatal transi-tional problems.5 Perinatal quality initiatives by many states and campaigns for publicawareness have led to a measurable decrease in early term cesarean sections. Inone recent study, Oshiro and coworkers6 implemented a rapid-cycle process improve-ment program in 26 participating hospitals to decrease elective scheduled early termdeliveries. Over a 12-month period, elective scheduled early term deliveries decreasedfrom 27.8% in the 1st month to 4.8% in the 12th month (Fig. 2). Several other stateshave implemented similar programs and are reporting considerable success.
Clin Perinatol 40 (2013) xv–xviiihttp://dx.doi.org/10.1016/j.clp.2013.08.002 perinatology.theclinics.com0095-5108/13/$ – see front matter � 2013 Elsevier Inc. All rights reserved.
Fig. 1. Trends in late preterm birth, stillbirth, and infant mortality, United States, 1990–2004.The left axis shows trends in stillbirth and infant mortality rates; the right axis shows trends inlate pretermbirths (34–36wk). Late pretermbirth rates are shownper 100 live births; stillbirthrates, per 1000 total births; and infant death rates, per 1000 live births. (Source: Linked birthand infant death data, National Center for Health Statistics.) (FromAnanthC, Gyamfi C, Jain L.Characterizing risk profiles of infants who are delivered at late preterm gestations: does itmatter? Am J Obstet Gynecol 2008;199:329–31; with permission.)
Fig. 2. Scheduled elective singleton early term deliveries by delivery type (%). For each de-livery type, the number is the number of scheduled elective singleton early term deliveriesand the denominator is the number of all scheduled singleton early term deliveries. (FromOshiro B, Kowalewski L, Sappenfield W, et al. A multistate quality improvement program todecrease elective deliveries before 39 weeks of gestation. Obstet Gynecol 2013;121:1025–31;with permission.)
xvi
Foreword xvii
Yet another vexing issue is the complex relationship between the increase in latepreterm births and the seemingly symmetrical (and potentially causally related)decline in stillbirths shown in Fig. 1. In many countries, particularly the United Statesand Canada, there has been a significant rise in late preterm births over the lastseveral decades. One study showed that for births between 34 and 36 weeks’ gesta-tion, labor induction doubled and cesarean sections increased by 50% between 1990and 2006.7 An inevitable question associated with this trend is the potential protec-tive effect of indicated late preterm and early term births on the stillbirth rate. Aglimpse into this association was provided in a recent commentary by Kramer andcolleagues.2 As these authors point out, the benefit of reducing stillbirths throughearly iatrogenic delivery appears to be a logical conclusion; however, this epidemio-logic association is not backed by rigorous data. As in Fig. 3, a comparison of gesta-tional age–specific stillbirth rates 1992–1994 versus 2003–2005 shows that nearly allof the reduction in stillbirths in the United States appears to be due to a reduction instillbirths at 40 weeks or more; early scheduled births at less than 39 weeks should
Fig. 3. The rise in late preterm obstetric intervention: has it done more good than harm?(Adapted from Kramer MS, Zhang X, Iams J. The rise in late preterm obstetric intervention:has it donemore good than harm? Paediatr Perinat Epidemiol 2013;27:7–10; with permission.)
Forewordxviii
therefore get no credit for this observed improvement and may indeed have donemore harm than good.Dr Raju and I are delighted to have the opportunity (once again) to put together a
comprehensive review of late preterm and early term births for the Clinics in Perinatol-ogy. Themany well-written articles in this edition reflect a new level of understanding ofthis topic; they also reflect a remarkable level of collaborative work between obstetri-cians and neonatologists and their collective efforts to improve perinatal outcomes.
Lucky Jain, MD, MBADepartment of PediatricsEmory Children’s Center
Emory University School of Medicine2015 Uppergate Drive
1. Ananth C, Gyamfi C, Jain L. Characterizing risk profiles of infants who are deliv-ered at late preterm gestations: does it matter? Am J Obstet Gynecol 2008;199:329–31.
2. Kramer MS, Zhang X, Iams J. The rise in late preterm obstetric intervention: has itdone more good than harm? Paediatr Perinat Epidemiol 2013;27:7–10.
3. Ramachandrappa A, Rosenberg ES, Wagoner S, et al. Morbidity and mortality inlate preterm infants with severe hypoxic respiratory failure on extra-corporealmembrane oxygenation. J Pediatr 2011;159:192–8.
4. Williams BL, Dunlop AL, Kramer M, et al. Perinatal origins of first grade academicfailure: role of prematurity and maternal factors. Pediatrics 2013;131:693–700.
5. Tita A, Landon MB, Spong CY, et al, Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network. Timing of elective repeat cesarean delivery atterm and neonatal outcomes. N Engl J Med 2009;360:111–20.
6. Oshiro B, Kowalewski L, Sappenfield W, et al. A multistate quality improvementprogram to decrease elective deliveries before 39 weeks of gestation. ObstetGynecol 2013;121:1025–31.
7. Martin JA, Kermeyer S, Osterman M, et al. Born a bit too early: recent trends inlate preterm births. National Center for Health Statistics Data Brief 2009;(24):1–8.
