By Christina Gebel, MPH, LCCE, Birth Doula

Introduction

Today, November 17^th is World Prematurity Day, and all of November is Prematurity Awareness month. According to the March of Dimes, preterm birth, defined as a baby being born before the completion of 37 weeks gestation, affects nearly one in ten people. There are also varying levels of preterm such as extremely preterm, being born at less than 28 weeks; very preterm, 28 to less than 32 weeks, and moderate to late preterm, 32 to less than 37 weeks. This is in additional to ACOG's redefinition of term, including early term, born between 37 weeks 0 days, and 38 weeks 6 days; full term, born between 39 weeks 0 days, and 40 weeks 6 days; late term, born between 41 weeks 0 days, and 41 weeks 6 days; and post-term, born between 42 weeks 0 days and beyond.

Prematurity Report Card

Each year, the March of Dimes publishes a Prematurity Report Card, which uses the most recent and completed preterm birth data to give a "grade" from A-F, based on the percentage. This year's 2016 Prematurity Report Card for the United States, which uses completed birth data from 2014, reports that 9.63% of babies were born preterm, before 37 weeks. For the first time in eight years, the preterm birth rate has worsened. Compared to the 2015 report card, an additional 2,000 babies were born preterm. Preterm birth remains a too-common reality in the United States.

Even more concerning, not only has the preterm birth rate increased, but the gap in disparities of preterm birth among racial populations widened. According to the most recent March of Dimes analysis, the preterm birth rate among Black women according to the 2016 report card is 13.3%, which is 48% higher than the rate among all other women. The rate for Hispanic and American Indian Alaska/Native women were also statistically higher.

More questions than answers

All of these alarming rates raise a lot of questions: Why did the rate go up? Is this a part of normal variation in rates, which will reverse itself next year, or is this the beginnings of a larger increase over the course of the future? Furthermore, why is the racial disparities gap widening, and what can be done to reverse its course? Amid all the questions, one thing is clear: it is time to double down in finding answers. Preventing prematurity can also reduce serious health problems for the baby, including short term consequences of preterm birth, like respiratory distress, and long-term consequences, like developmental delays.

While many risk factors for premature birth are known and can be modified by interventions such as smoking cessation, elimination of early elective deliveries, and encouraging women to not get pregnant again until at least 18 months after giving birth, a large portion of spontaneous premature births have no known biological cause.

Prematurity Research Centers

This is why the March of Dimes launched a collaborative of five Prematurity Research Centers across the United States in 2010. Using a transdisciplinary model, these centers focus intensively on provocative hypotheses using the most promising and emerging fields in contemporary research. One such hypothesis is how altered bacteria in the microbiome surrounding the cervix can trigger preterm birth. This work catches the momentum of the microbiome in bio-medical research today and the attention towards topics like vaginal seeding. Other projects includes how the uterus may have its own pacemaker of sorts. This is the focus of researchers at Washington University in St. Louis, who hope to create imaging of the uterus, much like imaging that currently exists for the heart, to be able to determine the electrical properties of uterine contractions, much like an EKG.

While the potential of these findings is intriguing, questions simultaneously arise as to how to interpret these findings in light of disparate rates of prematurity across different racial and ethnic populations. For instance, if the altered microbiome does influence changes in the cervix, the question remains as to what initiates that trigger. Causes could include smoking, diet, or even stress, which is already a known risk factor for preterm birth. Once "the trigger to the trigger" is identified additional questions arise as to whether various racial populations carry an excess burden of risk factors that may trigger these changes on a biological and micro-level.

Certainly, these questions are in the beginning stages of speculation, but answers may include the social determinants of health, which like the microbiome in the medical research community, has gained much ground in the public health research community. Social determinants of health, defined by the World Health Organization as "the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life," have become the focus of various maternal and child health initiative across the country such as IM CoIIN, which seeks to lower infant mortality nationwide and improve birth outcomes.

Still work to be done

As we observe Worldwide Prematurity Day today, there are reasons for concern as well as hope. The March of Dimes momentum and increased attention to the very basic conditions in which people live, work and age may yield some of the surprising and promising findings that will help in solving one of health's most complex questions. With so much left unknown, the key to predicting preterm birth may be in the synergy that the public health and medical research worlds can offer.

What the educator can do

Childbirth educators are an integral part of fighting prematurity, too. Here are some ways the March of Dimes can support educators in doing so:

• Talking to your class about how to reduce known risk factors for preterm birth such as not smoking, reducing stress, and addressing chronic health conditions.
• Referring women to the March of Dimes website or the Spanish-language site, nacersano.org, to receive tons of free information. Childbirth educators can also order bilingual materials to be handed out in class.
• Supporting families who have had a preterm birth by referring them to the March of Dimes online community for parents who have had children with complications or have experienced infant loss, called "Share Your Story."
• Educating families about signs of preterm labor, and what the parent and baby's experiences and emotions may be like in the immediate hours after delivery, as well as likely interventions to help baby get the best care.

About Christina Gebel

Christina Gebel holds a Master of Public Health in Maternal and Child Health from the Boston University School of Public Health. She is a birth doula and Certified Lamaze Childbirth Educator as well as a freelance writer, editor, and photographer. She currently resides in Boston working in public health research and premature birth prevention. You can follow her on Twitter:@ChristinaGebel and contact her through her website duallovedoula.com

Published: November 17, 2016

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