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Infant Mortality, Premature Babies Subject of House Hearing

On May 12, the House Energy and Commerce Subcommittee on Health held a hearing, “Prematurity and Infant Mortality: What Happens When Babies are Born too Early?”

Chair Frank Pallone (D-NJ) said, “While much advanced research has been conducted and continues today, researchers are still trying to understand why preterm labor occurs. However, we do know that there are a set of factors that put women at higher risk of having a premature baby. Some known factors include: carrying more than one baby, having a previous preterm birth, high blood pressure, and diabetes. In addition, we know that there are also external factors that occur either alone or in combination with other individual characteristics. These include age, race, poverty, marital status, stress, environmental chemicals, and many others. I am interested to hear from our witnesses today how these factors intertwine and what we can do moving forward to limit their effects.” Rep. Pallone added, “While not directly linked to prematurity, I am particularly interested to hear today about the prevalence of stillbirths and Sudden Unexpected Infant Death (SUID) within the infant mortality rate in the United States. Like preterm birth, stillbirth has some risk factors and causes, such as maternal medical conditions, fetal factors, umbilical cord problems, and placental abnormalities. However, despite these known risk factors there is no known cause for as many as half of all stillbirths, leaving many parents without answers to the reasons for these deaths. No parent should have to endure the pain of losing a child, especially without knowing why that child was taken from them so soon.”

Dr. William Callaghan, acting chief of the Maternal and Infant Health Branch in the Division of Reproductive Health at the Centers for Disease Control and Prevention (CDC), said, “The death of an infant is a tragedy. Deaths are relatively easy to measure. Hence, we put a lot of emphasis on the outcome of infant mortality. However, while most infant deaths have at least an association with being born preterm, most preterm infants do not die. One reason for this is the great strides that have been made in the intensive care of these smallest of newborns. Another reason, not wholly unrelated, is that most preterm infants are born at the high end of the preterm gestational age range, (i.e., late preterm). Although these infants have a higher infant mortality rate than term infants, deaths during the first year of life are much lower than those born earlier in pregnancy. Hence, we need to think beyond infant mortality when we discuss prematurity as a public health problem. Preterm birth is a leading cause of neurological disability, such as cerebral palsy and intellectual disabilities, in children. It can also result in blindness and chronic lung problems. We are only now beginning to understand the lifelong impact that being born too small and too early has on the individual and their families. Premature births extract a huge financial toll on our healthcare resources – in 2005 it was estimated that medical care, early intervention services, special education services and lost productivity associated with preterm birth cost $26.2 billion. There is also an emotional toll. Taken together, it is clear that preterm delivery is a public health priority.”

Dr. Catherine Spong, branch chief of the National Institute of Child Health and Human Development (NIHCD) at the National Institutes of Health (NIH), said, “Research supported by the NICHD has indicated that spontaneous preterm birth has a number of possible causes. These include intrauterine infection/inflammation, uterine bleeding, excessive uterine stretch, maternal psychosocial stress, and fetal physiological stress. Certain causes are more prominent during certain stages of pregnancy. For example, intrauterine infection is associated more often with an early (less than 34 weeks) than a late (34-36 weeks) spontaneous preterm delivery. The physiological processes underlying these causes are currently an area of intense study. The main pregnancy complications leading to a medically-induced preterm delivery are preeclampsia, fetal distress, and fetal growth restriction. Notably, preeclampsia is a major focus of research supported by NICHD since it is the primary reason for a medically-indicated, preterm delivery, accounting for approximately 40 percent of all medically-induced preterm births. Preeclampsia is a pregnancy-specific, hypertensive disorder and occurs in about four percent of all live-birth pregnancies. Researchers supported by the NICHD have shown that this disease is associated with abnormal development of the placenta, which results in reduced blood flow between the mother and the fetus.”

In discussing some of the causes for preterm birth, Dr. Alan Fleischman, senior vice president and medical director for the March of Dimes Foundation, highlighted the impact of fertility treatments, saying, “An additional factor contributing to the high preterm birth rate is the increasing problem of multiple births primarily due to assisted reproductive technologies and the use of fertility drugs. Fertility drugs are used to stimulate a woman’s ovaries to increase the maturity and production of eggs. This causes a high percentage of multiple births. According to a study published in the American Journal of Epidemiology by authors from the Centers for Disease Control and Prevention (CDC) and the March of Dimes, controlled ovarian hyperstimulation (COH) drugs account for four times more live births than assisted reproductive technologies (ART), such as in vitro fertilization. The study found that 4.6 percent of live births in 2005 resulted from fertility drug use – a figure four times higher than the 1.2 percent of births resulting from ART. Approximately 88,000 babies born preterm annually are multiple births. About 60 percent of twins, more than 90 percent of triplets, and virtually all quadruplets and higher-order multiples are born prematurely compared to 11 percent of singleton births. In addition to the increased risks associated with multiple birth, studies have also suggested that even infants born singly, but conceived with ART, are at increased risk for preterm delivery than naturally-conceived single births. Present practices and voluntary professional guidelines have not been sufficient to date to limit this problem.”

Dr. Charles S. Mahan, dean and professor emeritus of the University of South Florida College of Public Health, Lawton and Rhea Chiles Center for Healthy Mothers and Babies, discussed the disparities in infant mortality rates for black and white babies and offered immediate and short-term recommendations to help improve mortality rates for babies in low-income families. He recommended that the Medicaid program “stop paying for elective inductions and elective cesareans at any stage of pregnancy – even 39 weeks and above” and that “true informed consent be given to pregnant patients at the beginning of the third trimester to be read and discussed at least eight weeks before the due date. These should especially highlight the dangers of elective induction and cesarean to the baby.” Dr. Mahan also recommended that “tiered financial incentives for providers in insurance programs to encourage VBAC [vaginal birth after cesarean] since babies are healthier after VBAC than repeat cesarean.” Dr. Mahan’s short-term recommendations include: “encouraging new pregnancy provider models” that include midwives and doulas. This recommendation includes providing equal pay for midwives, who perform the same duties as obstetricians; encouraging group prenatal care instead of individual visits; training “maternal-fetal specialists” that can assist midwives; and encouraging women to give birth in “out-of-hospital birth centers.” He also recommended that the Maternal and Child Health Bureau “outline quality standards for perinatal care and encourage states to use them to build their own state perinatal quality improvement initiatives. (Ohio, California, North Carolina, and Florida have already begun this process.) This should include a list of procedures Medicaid will pay for (medical or OB high risk) and those they will not pay for (elective procedures).”

Dr. Hal Lawrence, III, vice president of Practice Activities at the American College of Obstetricians and Gynecologists (ACOG), highlighted ACOG’s Making Obstetrics and Maternity Safer (MOMS) Initiative. He said, “Due the magnitude of the problem, it is essential that we address the issue in a comprehensive manner. We must make well-informed and targeted investments to help lower the rate of prematurity, and remember that the health of every baby starts with the health of its mother. For this reason, ACOG developed our MOMS Initiative, a legislative proposal to improve maternal and infant health outcomes through:

  • Maternal/infant health research at the NIH to reduce the prevalence of premature births and to focus on obesity research, treatment, and prevention;
  • Maternal/infant health research and surveillance at the CDC to assist states in setting up maternal mortality reviews; modernize state birth and death records systems to the 2003‐recommended guidelines; and improve the Safe Motherhood Program to better understand maternal deaths;
  • Maternal/infant health programs at HRSA [Health Resources and Services Administration] to continue the Fetal and Infant Mortality Review (FIMR) which brings together local ob‐gyns and health departments to solve a community’s problems related to infant mortality; and improve the Maternal Child Health Block grant, the only federal program that exclusively focus on improving the health of mothers and children;
  • Comparative effectiveness research into interventions for preterm birth;
  • Disparities research into maternal outcomes, preterm birth and pregnancy‐related depression;
  • The development, testing, and implementation of quality improvement measures and initiatives; [and]
  • The testing of an obstetric medical home model.”