Prevention of Prematurity: Can We Do It in America?

(1)

310 PEDIATRICS Vol. 76 No. 2 August 1985 cialist and subspecialist is vital. If we can rein in

the neonatologists and confine their activity to

tertiary neonatal intensive care units and limit the

proliferation of intensivists, young pediatricians of

today and tomorrow are going to enjoy an

expan-sive, truly comprehensive, exciting practice,

partic-ularly if they organize group practices that can

generate the equilibrated time, motion, and

eco-nomics of office and community hospital practice.

The internist faces some of the same issues. The

practicing specialist in internal medicine,

inter-ested in general medicine, may utilize a university

teaching hospital on occasion. More likely, he or

she uses a community hospital for urgent illnesses.

The pediatrician contends with an additional

insti-tutional force, the children’s hospital. Most

univer-sity general hospitals are highly geared toward

aca-demia and the subspecialists on site emphasize

academic pursuits over practice. Some children’s

hospitals, for a variety of historical reasons and

issues of governance, are less academic and the

pediatric subspecialists emphasize clinical work,

draining clinical opportunities from the sphere of

the general pediatric specialist.

The time has come to expect more science and

discovery from the subspecialist and to prepare

these individuals for the rigor of this work. The

general pediatric specialist can fill the gap of

sec-ondary subspecialty care, where most subspecialty

care exists, if we press them vigorously and

com-prehensively during core residency training. If we

set the level of expected clinical intellectuality and

performance sufficiently high and ensure

profes-sional opportunity that will match that education

and capability, pediatrics will reach its fullest

expression. This goal is clearly feasible.

REFERENCES

JOSEPH W. ST GEME, JR, MD Department of Pediatrics

Harbor-UCLA Medical Center

UCLA School of Medicine

Torrance, California

1. Brownlee RC: Pediatric Resident Relocation, 1982-1983.

Chapel Hill, NC, American Board of Pediatrics, 1983 2. Muller 5, Gerberding WP, Alexander D et al: Physicians for

the Twenty-First Century: The GREP Report. Washington, DC, Association of American Medical Colleges, 1984 3. Brownlee RC: Definition of a Passing Candidate. Chapel

Hill, NC, American Board of Pediatrics, 1983

4. State Department of Health Services, California Children Services: Standard for Pediatric Intensive Care Units.

Bul-letin 82-00, 1982, chapt 3

Prevention

of Prematurity:

Can We Do It in America?

Everyone agrees that the solution to the problem

of prematurity would be to prevent preterm births.

The perinatal study in Haguenau’ is one of the

largest published studies (>16,000 live births) that

demonstrate that prevention of premature births is

possible. In a 12-year period (1971 to 1982),

Pa-piernik et al achieved a 31% reduction (5.4% to

3.7%) of premature births. In the first 3 years of

the study, they had essentially no change in the

incidence of prematurity. It is interesting to

spec-ulate what would have happened had this study

been performed in the United States. It probably

would have been abandoned. Our funding agencies

expect results in 2 years or else! One lesson we

should learn from this monumental study is that

any studies in which it is necessary to change

people’s life-styles take a long time.

Of special significance is that the prevention

program of Papiernik et al demonstrated a 67%

reduction ofbirths ofvery low-birth-weight (<1,500

g) and very premature infants (<32 weeks of

ges-tation) during this 12-year span. The beneficial

impact of preventing prematurity of the very

pre-mature infant is readily apparent when one

consid-ers that it is this infant who suffers the greatest

morbidity and mortality and who requires longer

intensive care.

These favorable results were replicated by

Pa-piernik at the Maternity Hospital of Clamart,

France, where the incidence of preterm births was

decreased by 42% during a 10-year period (6.46%

to 3.76%).23 The study in Clamart followed 18,815

pregnancies and deliveries. Similarly, on the French

island of Martinique, a reduction of prematurity by

27% during a 2-year period (6% to 4.4%) has been

realized, based on the methods of Papiernik et al.3’4 The overall impact of the prevention of prematurity

program in France has resulted in a national

de-crease of preterm births from 8.2% in 1972 to 5.3%

in 1982, a reduction of 35%#{149}3

Papiernik’s research objectives have been to

de-velop methods that predict and prevent preterm

labor.5 Previously established risk factors

associ-ated with premature labor cannot be changed (eg,

maternal age, height, education, history of previous

preterm birth). These factors have only been useful

to identify certain women at risk for premature

labor. Papiernik’s approach has been to define

American Academy of Pediatrics.

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(2)

COMMENTARIES 311

dictive risk factors that can be modified during the

course of pregnancy, specifically unhealthy

life-styles or habits, certain physical efforts, or other

stress that may enhance uterine contractility.

Pa-piernik-Berkhauer6 has incorporated the amenable

risk factors into a preterm birth risk assessment

score system. This scoring system correlates

de-mographic information with reproductive history,

life-style, and clinical signs during the current

preg-nancy.6 Use of this scoring system is widespread in

France. It has been modified and used successfully by Creasy et al7 in the United States and Lambotte8 in Belgium.

Predicting who is at risk for premature labor is a

necessary first step. However, identification of the

high-risk woman will not, by itself, prevent

pre-maturity. Pregnant women must be educated to

understand their own risks and to recognize early

any suspicious signs or symptoms associated with

premature labor, and to modify amenable risk

fac-tors (specific stresses, efforts, and activities)

asso-ciated with increased uterine activity and preterm

labor.

This degree of patient education and support

requires a commitment on the part of medical

professionals and providers of prenatal care to

pre-vent prematurity and to improve the content of

prenatal care. Prenatal care providers must be able

to recognize the presence and development of

preg-nancy factors that are associated with preterm

de-livery, to follow such patients more closely, to

ed-ucate their patients, to intervene by helping to

minimize the influence of any amenable risk

fac-tors, and to respond appropriately to early

indica-tions of preterm labor.

Why have the French been able to reduce the

incidence of prematurity? Can we do the same in

the United States? The French government

ac-cepted that it would be cost-effective and beneficial

to support a national scale program on prevention

of prematurity. There is no charge to the patient

for prenatal care or hospitalization. This is paid for

by the National Social Security System.2’5

Infor-mation about preterm birth and its prevention was

and is disseminated through France by the National

Health Authority via public media and magazines

to health professionals, women, employers, and the

general public. The groundwork was laid. Pregnant

women’s expectations of prenatal care and of their

own role in modifying risk factors were enhanced.

Obstetric providers in France utilize the risk

assessment score system throughout the course of

pregnancy. In France and continental Europe,

ex-amination of the cervix is part of the routine

ob-stetric assessment within each prenatal

consulta-tion. The value of cervical examinations has not

been fully appreciated in the United Kingdom or

the United States, where cervical examinations are

rarely performed as a part of routine prenatal care.

Papiernik,5 Wood et al,9 Anderson and Turnbull,’#{176}

and others”’3 have all demonstrated the increased

risk of preterm labor in the presence of precocious

maturation of the cervix. French obstetric providers also utilize and individualize interventions for high-risk patients.

The most frequently used intervention in the

French program for women identified as “high-risk”

is a reduction of physical exertion and stress. This

may be accomplished by a physician’s prescribing

an early work leave or modification of the work

load or schedule. This prescription must be honored

by employers under French law and accompanied

by full salary or equivalent public subsidy. If

house-hold help is necessary, support is elicited through

family, friends, and/or free domestic help through

the social service system. In addition, the prenatal

care system provides weekly follow-up care at home

by nurse midwives for patients found to be at high

risk for premature labor.

Clinical trials of predicting and preventing

pre-maturity within the United States have, within

recent years, revealed promising preliminary

re-sults. Herron et al’4 reported a reduction in preterm

deliveries from 6.7% to 2.4% during a 2-year period

in a project focused on intensive education of

high-risk patients and providers of prenatal care, early

self-detection of preterm labor, and early and

effec-tive long-term tocolysis. The results of this single

medical center are encouraging, but the number of

births is small (1,150). Presently, this project is

being expanded and continued as the March of

Dimes Multicenter Preterm Birth Prevention

Trial.3 The Los Angeles Prematurity Prevention

Program is a randomized trial to evaluate the effec-tiveness of different interventions designed to

pre-vent preterm labor, superimposed on educational

programs for both patients and providers of

pre-natal care. The results of this program are pending.3

For prevention of prematurity programs to be

effective throughout a regional or national level,

there must be an intensive education and

heightened awareness not only of health care

pro-viders and the pregnant population, but also of the

population in general, employers, and legislators

about the magnitude of the problem of low birth

weight/prematurity and the benefits of prevention

of prematurity. There must be a cooperative effort

among all parties involved to make prevention of

prematurity a reality. This includes the supportive and active participation of

pediatricians/neonatol-ogists. They are the professionals who must deal

with the failures of prevention. The precise extent

(3)

312 PEDIATRICS Vol. 76 No. 2 August 1985

of unavoidable premature births is not known,

a!-though it may be approximately 2% to 3% of all

deliveries.5 Therefore, with the persistent incidence

of preterm births in the United States estimated to

be 6% to 8% of all pregnancies,’5 our work in

preventing prematurity is not yet completed. It will

not be easy to prevent prematurity in the United

States. However, the effort appears worthwhile and

it certainly merits a trial.

CYNTHIA H. COLE, MD Department of Pediatrics

University of Vermont College of Medicine

Burlington

REFERENCES

1. Papiernik E, Bouyer J, Dreyfus J, et al: Prevention of preterm births: A perinatal study in Haguenau, France.

Pediatrics1985;76:154-158

2. Papiernik E: The very low birth weight problem, an imper-ative necessity for prevention. Padiatr Padol 1982;17:211 3. Committee to Study the Prevention of Low Birthweight,

Division of Health Promotion and Disease Prevention: Pre-venting Low Birthweight. Washington, DC, National Acad-emy Press, 1985

4. Goujon H, Papiernik E, Main D: The prevention of preterm delivery through prenatal care: An intervention study in Martinique.

mt

Gynaecol Obstet 1984;22:339-343

5. Papiernik E: Prediction of the preterm baby. Clin Obstet Gynecol 1984;11:315

6. Papiernik-Berkhauer E: Coefficient de risque d’accouche-ment premature. Presse Med 1969;77:793

7. Creasy RK, Gummer BA, Liggins GC: System for predicting spontaneous preterm birth. Obstet Gynecol 1980;55:692 8. Lambotte R: Preterm labour, in Anderson A, Beard R,

Brudnell JM, et al (eds): Proceedings of the 5th Congress of the Royal College of Obstetricians and Gynoecologists. Lon-don, 1977, pp 40-41

9. Wood C, Bannerman RH, Booth RT: Prediction of prema-ture labour by observation of the cervix and external tocog-raphy. Am J Obstet Gynecol 1965;91:396-402

10. Anderson AB, Turnbull AC: Relationship between length of gestation and cervical dilation: Uterine contractibility and

other factors during pregnancy. Am J Obstet Gynecol

1969;105:1207-1214

11. Schaffner F, Schanzer SN: Cervical dilatation in the early third trimester. Obstet Gynecol 1966;27:130-133

12. Pystynen P, Kaupilla 0, Terho J, et al: Der Zervixstatus und die subjectiven symptoms in der normalen Schwanger-schraft. Zentralb Gynakol 1975;97:1601-1606

13. Diener L: Die Veranderung des Zervixstatus wharend der Schwangerschraft (The change of the cervical state during pregnancy). Zentralb Gynakol 1979;101:224-230

14. Herron MA, Katz M, Creasy RK: Evaluation of a preterm birth prevention program: Preliminary report. Obstet Gyne-cot 1982;59:452

15. Creasy RK: Prevention of preterm birth. Birth Defects

1983;19:97-102

FOLLOW-UP

ON BABY

DOE

The Department of Health and Human Services announced the final rule on

the treatment of disabled infants on April 15, 1985. The final version, a vast

improvement over the earlier regulations, incorporates many of the concerns

the Academy expressed in its comments and more accurately reflects the spirit

and intent of the statute passed by Congress last year.

Pediatricians who care for newborns are urged to cooperate with child

protective services agencies in their states to establish the programs and

procedures to implement the new rule. Additional information has been sent to

Chapter Chairmen.

ROBERT J. HAGGERTY, MD

President

American Academy of Pediatrics

(4)

1985;76;310

Pediatrics

CYNTHIA H. COLE