Measuring economic consequences of preterm birth - Methodological recommendations for the evaluation of personal burden on children and their caregivers

Socioeconomic disparities in the postnatal growth of preterm infants: a systematic review

OBJECTIVE

To determine the effect of parental socioeconomic status (SES) on the postnatal growth of preterm infants.

METHODS

A systematic review (PROSPERO registration CRD42020225714) of original articles from Medline, Embase, CINAHL Plus and Web of Science published 1946-2023 was undertaken. Studies were included if they reported anthropometric growth outcomes for preterm infants according to parental SES. Data extraction and assessments of bias and health equity impact were conducted using custom-designed forms.

RESULTS

A narrative synthesis of twelve included studies was performed. Most infants were moderate to late preterm. The settings, growth outcomes, timings of growth measurement, and SES measures were heterogenous. Six studies demonstrated an adverse effect of low parental SES on the extrauterine growth of preterm infants, five studies showed no effect, and one study showed a potentially beneficial effect. All studies had a high risk of bias, especially confounding and selection bias. The health equity impact of included studies was largely negative.

CONCLUSION

Limited and low-quality evidence suggests that socioeconomic minoritisation may adversely impact the growth of preterm infants, thereby widening existing socioeconomic health inequities. Observational studies informed by theorisation of the mechanistic pathways linking socioeconomic minoritisation to adverse postnatal growth are required to identify targets for intervention.

IMPACT

Limited evidence suggests low parental socioeconomic status (SES) adversely affects the postnatal growth of preterm infants across different settings. Early growth of preterm infants predicts neurodevelopmental outcomes and the risk of cardiovascular and metabolic disease in adulthood. Systematic screening of over 15,000 articles identified only twelve studies which reported postnatal growth outcomes for preterm infants according to parental SES. The health equity impact of the included studies was systematically assessed, and found to be negative overall. This study highlights limitations in existing evidence on the association between parental SES and postnatal growth, and delineates avenues for future research.

Costs of Neonatal Medical Complexity: Impact on New Parent Stress and Decision-Making

OBJECTIVE

Parents of children with medical complexity experience substantial financial burdens. It is unclear how neonatal intensive care unit (NICU) clinicians prepare new parents of medically complex infants for this reality. This study explored new parent awareness of health care costs, desire to discuss costs with clinicians, and impact of costs on parents' medical decision-making.

STUDY DESIGN

The study design comprised semistructured interviews and surveys of parents of infants with medical complexity currently or previously in a NICU. Conventional content analysis was performed on interview transcripts, and descriptive analyses were applied to surveys.

RESULTS

Thematic saturation was reached with 27 families (15 NICU families and 12 post-NICU families) of diverse race/ethnicity/education/household income. Most were worried about their infants' current/future medical expenses and approximately half wanted to discuss finances with clinicians, only one parent had. While finances were not part of most parent's NICU decision-making, some later regretted this and wished cost had been incorporated into treatment choices. The family desire to discuss costs did not vary by family financial status. Parents described their infant's health care costs as: "We are drowning"; and "We'll never pay it off."

CONCLUSION

Most parents were worried about current and future medical expenses related to their infant's evolving medical complexity. Many wanted to discuss costs with clinicians; almost none had. NICU clinicians should prepare families for the future financial realities of pediatric medical complexity.

KEY POINTS

· Many families want to discuss costs with NICU clinicians.. · Some families want costs to be a part of medical decisions.. · Few families currently discuss costs with NICU providers..

Women's experience of preterm birth in an East African context: a qualitative study

Background

Approximately 15 million children are born each year prematurely, representing more than 10 percent of all childbirths worldwide. Prematurity is an acute event and the leading cause of death among newborns and children under five. Sixty percent of these premature deaths occur in Sub-Saharan Africa and Southeast Asia.

Objective

The current study aimed to explore and understand women's experiences and perceptions regarding giving birth prematurely at the National Hospital of Muhimbili in Dar es Salaam, Tanzania.

Method

A qualitative method, using Interpretive Phenomenological Analysis approach was chosen to understand and describe the women's experiences. A semi-structured guide was used during the interviews. All interviews were audio-recorded and transcribed verbatim.

Findings

Eight in-depth interviews were conducted. The analysis revealed three superordinate themes: (a) Emotional turmoil: unmet expectations shattering maternal identity, emotional distress, and loss of hope; (b) Adapting to preterm birth and challenges: the unexpected situation, lack of proper care, strenuous breastfeeding routines, and socioeconomic challenges; (c) Significance of proper care and emotional support: good maternal care, mother-to-mother and family support.

Conclusion

This study provided a deeper understanding of women's experiences and perceptions of premature childbirth. The current study indicated the importance of caregivers' awareness of the women's emotional distress, their need to adapt to a sudden unexpected situation, and the necessity of emotional support.

Socioeconomic per-case costs of stroke, myocardial infarction, and preterm birth attributable to air pollution in Sweden

BACKGROUND

Incident cases of stroke, myocardial infarction, and preterm birth have established exposure-response functions associated with air pollution. However, there are no studies reporting detailed costs per case for these health outcomes that are adapted to the cost-benefit tools that guide the regulation of air pollution.

OBJECTIVES

The primary objective was to establish non-fatal per-case monetary estimates for stroke, myocardial infarction, and preterm birth attributable to air pollution in Sweden, and the secondary objective was to ease the economic evaluation process of air pollution morbidity effects and their inclusion in cost-benefit assessments.

METHODS

Based on recommendations from the literature, the case-cost analysis considered direct and indirect medical costs, as well as production losses and informal costs relevant for the calculation of the net present value. A literature search was conducted to estimate the costs of each category for each incident case in Sweden. Informal costs were estimated using the quality-adjusted life-years approach and the corresponding willingness-to-pay in the Swedish population. The total average per-case cost was estimated based on specific health outcome durations and severity and was discounted by 3.5% per year. Sensitivity analysis included varying discount rates, severity of health outcome, and the range of societal willingness to pay for quality-adjusted life years.

RESULTS

The average net present value cost estimate was €2016 460k (185k-1M) for non-fatal stroke, €2016 24k (16k-38k) for myocardial infarction, and €2016 34k (19k-57k) for late preterm birth. The main drivers of the per-case total cost estimates were health outcome severity and societal willingness to pay for risk reduction. Varying the discount rate had the largest effect on preterm birth, with costs changing by ±30% for the discount rates analysed.

RECOMMENDATION

Because stroke, myocardial infarction, and preterm birth have established exposure-response functions linking these to air pollution, cost-benefit analyses should include the costs for these health outcomes in order to adequately guide future air pollution and climate change policies.

Workplace Productivity Loss and Indirect Costs Associated With Preterm Birth in the United States

OBJECTIVE

To estimate workplace productivity loss and indirect costs in the year after birth among individuals who deliver preterm in the United States.

METHODS

This retrospective, observational cohort study estimated workplace productivity loss and indirect costs for individuals aged 18-55 years with an inpatient delivery between January 1, 2016, and September 30, 2021, using data from the Merative MarketScan Commercial Claims and Encounters database and the Health and Productivity Management database. Workdays lost and costs attributable to medical-related absenteeism, workplace absenteeism (defined as sick leave, leave, recreational leave, Family Medical Leave Act); disability (defined as short-term and long-term disability), and aggregate workplace productivity loss, a combined outcome measure, were compared between propensity-score-matched birth cohorts: preterm birth (before 37 weeks of gestation) and full-term birth (at or after 37 weeks of gestation). Outcomes were also compared between the full-term birth cohort and preterm birth subgroups (before 32 weeks of gestation and before 34 weeks of gestation). Estimations of indirect costs assumed an 8-hour workday. Costs were inflated to December 2021 U.S. dollars.

RESULTS

In total, 37,522 individuals were eligible for medical-related absenteeism, 1,028 for workplace absenteeism, 7,880 for disability, and 396 for aggregate workplace productivity loss after propensity score matching. Compared with full-term birth, preterm birth was associated with more workdays lost and costs in the year after childbirth attributable to medical-related absenteeism (differences of 4.2 days and $1,045, P <.001) and disability (differences of 2.8 days and $422, P <.001). Preterm birth was not associated with workplace absenteeism (differences of 1.4 days and $347, P =.787) and aggregate workplace productivity loss (differences of 5.2 days [ P =.080] and $1,021 [ P =.093]). Numerical differences were greater in magnitude and inversely related to gestational age at birth across outcomes.

CONCLUSION

Preterm birth was associated with medical-related absenteeism, disability claims, and indirect costs in the year after birth compared with full-term birth.

Identification of biochemical biomarkers associated with premature cervical shortening in high-risk, asymptomatic pregnant women: a retrospective data analysis

Reliably predicting spontaneous preterm birth remains challenging, therefore it persists as a major contributor to perinatal morbidity and mortality. The use of biomarkers to predict premature cervical shortening, a recognised risk factor for spontaneous preterm birth, is yet to be fully explored in current literature. This study evaluates seven cervicovaginal biochemical biomarkers as possible predictors of premature cervical shortening. Asymptomatic, high-risk women (n = 131) presenting to a specialised preterm birth prevention clinic were analysed through a retrospective data analysis. Cervicovaginal biochemical biomarker concentrations were obtained, and the shortest cervical length measurement, up to 28 weeks' gestation, was recorded. Associations between biomarker concentration and cervical length were then analysed. Of the seven biochemical biomarkers, Interleukin-1 Receptor Antagonist and Extracellular Matrix Protein-1 had statistically significant relationships with cervical shortening below 25 mm. Further investigation is required to validate these findings and any downstream clinical utility, with intentions to improve perinatal outcomes.IMPACT STATEMENTWhat is already known on this subject? Preterm birth is a major cause of perinatal morbidity and mortality. A woman's risk of delivering preterm is currently stratified using historical risk factors, mid-gestation cervical length, and biochemical biomarkers such as foetal fibronectin.What do the results of this study add? In a cohort of high-risk, asymptomatic pregnant women, two cervicovaginal biochemical biomarkers, Interleukin-1 Receptor Antagonist and Extracellular Matrix Protein-1, displayed associations with premature cervical shortening.What are the implications of these findings for clinical practice and/or further research? Further investigation into the possible clinical utility of these biochemical biomarkers is warranted, with a view to improving preterm birth prediction and antenatal resource utilisation, thereby reducing the burden of preterm birth and its sequelae in a cost-effective manner.

Supporting Disclosure of Unmet Mental Health Needs among Parents of Critically Ill Infants

OBJECTIVE

To characterize (1) the prevalence of mental health discussion and (2) facilitators of and barriers to parent disclosure of mental health needs to clinicians.

STUDY DESIGN

Parents of infants with neurologic conditions in neonatal and pediatric intensive care units participated in a longitudinal decision-making study from 2018 through 2020. Parents completed semi-structured interviews upon enrollment, within 1 week after a conference with providers, at discharge, and 6 months post-discharge. We used a conventional content analysis approach and NVIVO 12 to analyze data related to mental health.

RESULTS

We enrolled 61 parents (n = 40 mothers, n = 21 fathers) of 40 infants with neurologic conditions in the intensive care unit. In total, 123 interviews were conducted with 52 of these parents (n = 37 mothers, n = 15 fathers). Over two-thirds of parents (n = 35/52, 67%) discussed their mental health in a total of 61 interviews. We identified two key domains when approaching the data through the lens of mental health: (1) self-reported barriers to communicating mental health needs: parents shared uncertainty about the presence or benefit of support, a perceived lack of mental health resources and emotional support, and concerns about trust; (2) self-reported facilitators and benefits of communicating mental health needs: parents described the value of supportive team members, connecting to peer support, and speaking to a mental health professional or neutral third party.

CONCLUSIONS

Parents of critically ill infants are at high risk of unmet mental health needs. Our results highlight modifiable barriers and actionable facilitators to inform interventions to improve mental health support for parents of critically ill infants.

Cervical Cerclage vs. Pessary in Women with a Short Cervix on Ultrasound

PURPOSE

In the present study we sought to compare the efficacy of cervical pessary to that of cerclage in terms of reducing preterm birth rates among women with a short (<25 mm) or ultra-short (<15 and <10 mm) cervix during the ultrasonographic second-trimester assessment.

METHOD

We retrospectively searched the hospital records for singleton pregnancies diagnosed with cervical insufficiency during the second trimester of pregnancy. The McDonald cerclage using a 5mm Mersilene tape was used in all women. An Arabin pessary was used uniformly. In all cases 80 mg of vaginal progesterone gel were administered daily until 37 weeks of gestation.

RESULTS

Overall, 294 women (124 (42.2%) with a McDonald cerclage and 170 (57.8%) with placement of an Arabin pessary) were selected for analysis. Preterm birth rates <37 weeks were similar in both groups (C: 30/122 vs. P: 35:165, p=.581) as well as PTB <34 weeks (C: 16/122 vs. 15/150, p=.278). Admission to the NICU and need for CPAP were more prevalent in the cerclage group (p<.001). Analysis of cases with a cervix <15 mm and <10 mm indicated that preterm birth rates remained equal among the groups, while an increased risk of NICU admission was seen in cases with a cervical length <10 mm that were treated with cerclage.

DISCUSSION AND CONCLUSION

Cervical pessary may be an alternative to cervical cerclage for women with second-trimester cervical shortening and its effect may persist even among cases with an ultra-short cervix. Future randomized trials are needed to ascertain these findings.

SuPreme Study: a protocol to study the neuroprotective potential of sulfate among very/extremely preterm infants

INTRODUCTION

Antenatal maternal magnesium sulfate (MgSO4) administration is a proven efficacious neuroprotective treatment reducing the risk of cerebral palsy (CP) among infants born preterm. Identification of the neuroprotective component with target plasma concentrations could lead to neonatal treatment with greater efficacy and accessibility.

METHODS AND ANALYSIS

This is a prospective observational cohort study, in three tertiary Australian centres. Participants are preterm infants, irrespective of antenatal MgSO4 exposure, born in 2013-2020 at 24+0 to 31+6 weeks gestation, and followed up to 2 years corrected age (CA) (to September 2023). 1595 participants are required (allowing for 17% deaths/loss to follow-up) to detect a clinically significant reduction (30% relative risk reduction) in CP when sulfate concentration at 7 days of age is 1 SD above the mean.A blood sample is collected on day 7 of age for plasma sulfate and magnesium measurement. In a subset of participants multiple blood and urine samples are collected for pharmacokinetic studies, between days 1-28, and in a further subset mother/infant blood is screened for genetic variants of sulfate transporter genes.The primary outcome is CP. Surviving infants are assessed for high risk of CP at 12-14 weeks CA according to Prechtl's Method to assess General Movements. Follow-up at 2 years CA includes assessments for CP, cognitive, language and motor development, and social/behavioural difficulties.Multivariate analyses will examine the association between day 7 plasma sulfate/magnesium concentrations with adverse neurodevelopmental outcomes. A population pharmacokinetic model for sulfate in the preterm infant will be created using non-linear mixed-effects modelling.

ETHICS AND DISSEMINATION

The study has been approved by Mater Misericordiae Ltd Human Research Ethics Committee (HREC/14/MHS/188). Results will be disseminated in peer-reviewed journal publications, and provided to the funding bodies. Using consumer input, a summary will be prepared for participants and consumer groups.

Preterm Birth Among Intrapartum Cesarean Deliveries at Public Hospitals in Southern Ethiopia: A Multicenter Retrospective Analysis of Risk Factors

Purpose

Although the underlying causes for preterm birth are thought to be multifactorial irrespective of delivery mode, no study investigated its risk factors amongst cesarean deliveries (CD). Thus, we aimed to identify potential risk factors for the occurrence of preterm birth (PTB) among intrapartum CD.

Methods

Data from 1659 singleton intrapartum CDs were retrospectively recruited using medical records and an obstetric database. Gestational age was calculated using the last menstrual period (LMP) and ultrasound report of early onset pregnancy. A multivariable logistic regression analysis was performed to identify potential risk factors associated with PTB. Odds ratios (ORs) and 95% confidence intervals (95% CI) were used. Statistical analysis was performed using SPSS version 26.0.

Results

In this study, the prevalence of PTB among intrapartum CD was 6.1% (95% CI: 4.9, 7.2%). In the multivariable logistic regression model; grand parity ≥5 (adjusted odds ratio (AOR) = 2.43, 95% CI: 1.72-4.73), maternal age <20 years (AOR=2.63, 95% CI, 1.03-6.71), maternal age ≥35 years (AOR=3.83, 95% CI, 1.49-5.35), cesarean section scar ≥2 (AOR=4.86, 95% CI: 2.68-8.94), antepartum hemorrhage (AOR=4.37, 95% CI: 2.22-8.63), pregnancy-induced hypertension (AOR=2.92, 95% CI: 1.41-6.04), and premature rupture of membranes (AOR=4.56; 95% CI: 1.95-10.65) were significantly associated with PTB.

Conclusion

The current study showed an association between PTB and a multitude of obstetric variables, including grand parity ≥5, CS scar ≥2, antepartum hemorrhage, pregnancy-induced hypertension, and premature rupture of the membrane. Understanding these factors could help to implement improved quality of obstetric and neonatal care to increase survival and reduce morbidity among preterm birth.

Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial: a protocol for a multicentre, stepped-wedge cluster randomized trial

BACKGROUND

Evidence-based Practice for Improving Quality (EPIQ) is a collaborative quality improvement method adopted by the Canadian Neonatal Network that led to decreased mortality and morbidity in very preterm neonates. The Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial aims to evaluate the impact of EPIQ collaborative quality improvement strategies in moderate and late preterm neonates in Alberta, Canada.

METHODS

In a 4-year, multicentre, stepped-wedge cluster randomized trial involving 12 neonatal intensive care units (NICUs), we will collect baseline data with the current practices in the first year (all NICUs in the control arm). Four NICUs will transition to the intervention arm at the end of each year, with 1 year of follow-up after the last group transitions to the intervention arm. Neonates born at 32 + 0 to 36 + 6 weeks' gestation with primary admission to NICUs or postpartum units will be included. The intervention includes implementation of respiratory and nutritional care bundles using EPIQ strategies, including quality improvement team building, quality improvement education, bundle implementation, quality improvement mentoring and collaborative networking. The primary outcome is length of hospital stay; secondary outcomes include health care costs and short-term clinical outcomes. Neonatal intensive care unit staff will complete a survey in the first year to assess quality improvement culture in each unit, and a sample will be interviewed 1 year after implementation in each unit to evaluate the implementation process.

INTERPRETATION

The ABC-QI Trial will assess whether collaborative quality improvement strategies affect length of stay in moderate and late preterm neonates. It will provide detailed population-based data to support future research, benchmarking and quality improvement.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT05231200.

The Prevalence of PTSD of Mothers and Fathers of High-Risk Infants Admitted to NICU: A Systematic Review

Admission of a preterm or sick full-term infant to the neonatal intensive care unit (NICU) is a stressful experience for parents. Indeed, the 'NICU experience' may constitute a traumatic event for parents, distinct from other birth-related trauma, leading to significant and ongoing posttraumatic stress disorder (PTSD) symptoms. However, the rates at which this outcome occurs are not well understood. This review aimed to identify the prevalence of PTSD in mothers and fathers of high-risk infants admitted to the NICU, specifically focusing on the NICU experience as the index trauma. The PRISMA-P: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols were used to conduct this review. We searched PsycINFO, PubMed, Scopus, EMBASE, Web of Science, ProQuest Dissertations and Theses databases, and reference lists of included articles (1980-2021). Two independent reviewers screened titles and abstracts and conducted the full-text screening assessment. Of the 707 records identified, seven studies met the inclusion criteria. In this systematic review, PTSD symptomatology was assessed by self-report measures rather than a clinical interview. We identified significant variations in the methodologies and quality between studies, with a wide variation of reported prevalence rates of PTSD of 4.5-30% in mothers and 0-33% in fathers. Overall, the findings indicate that up to one-third of parents experience PTSD symptomatology related to the NICU experience. These results emphasize the importance of universal routine antenatal and postnatal screening for symptoms of PTSD to identify parents at risk of distress during the NICU experience and after discharge.Trial registration: The study protocol was registered with Prospero registration number CRD42020154548 on 28 April 2020.

Pregnancy Outcomes in Women With Rheumatoid Arthritis: A Systematic Review and Meta-analysis

ABSTRACT

Rheumatoid arthritis (RA) is a chronic inflammatory rheumatic disease affecting multiple joints and can also be a systemic widespread, affecting major organs. Rheumatoid arthritis is associated with greater adverse maternal and neonatal outcomes in comparison to the general obstetric population. This systematic review and meta-analysis aims to investigate the pregnancy outcomes in RA patients in comparison to the general pregnant population.Nine studies involving 11,999 RA patients met the eligibility criteria with 9,921,808 controls. Rheumatoid arthritis patients were compared with their control counterparts according to random-effects model statistical analysis.We searched databases from inception to September 8, 2021. Eligible studies reported maternal outcomes (preeclampsia, cesarean delivery, and preterm delivery) and/or neonatal outcomes. Data were pooled across using random-effects model. Subgroup analysis was conducted on RA patients alone. The review was registered prospectively with PROSPERO (CRD42021250521).In terms of maternal outcomes, there was an increased rate of cesarean delivery (odds ratio [OR], 1.55), preeclampsia (OR, 1.61), and preterm delivery (OR, 1.83) in RA patients compared with their control counterparts. In terms of neonatal outcomes, a higher rate of lower gestational weight (mean difference [MD], -0.19 kg), requirement for neonate intensive care unit admission (OR, 1.34), and stillbirths (OR, 1.99) were observed in RA patients compared with the controls. A subgroup analysis of 4 studies involving only RA patients (n = 3761) was conducted. A total of 33.2% of patients had a cesarean delivery, 7.3% had preeclampsia, 14.8% had a preterm delivery, and 9.5% of neonates had low birth weight.Compared with the general pregnant population, women with RA tend to have a higher risk of maternal and neonatal complications. As a result, this study hopes to increase awareness into the importance of counseling and managing RA patients.

What influences the implementation of kangaroo mother care? An umbrella review

Background

Kangaroo mother care (KMC) is an evidence-based intervention that reduces morbidity and mortality in preterm infants. However, it has not yet been fully integrated into health systems around the world. The aim of this study is to provide a cogent summary of the evidence base of the key barriers and facilitators to implementing KMC.

Methods

An umbrella review of existing reviews on KMC was adopted to identify systematic and scoping reviews that analysed data from primary studies. Electronic English databases, including PubMed, Embase, CINAHL and Cochrane Library, and three Chinese databases were searched from inception to 1 July 2022. Studies were included if they performed a review of barriers and facilitators to KMC. Quality assessment of the retrieved reviews was performed by at least two reviewers independently using the Joanna Briggs Institute (JBI) critical appraisal checklist and risk of bias was assessed with the Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) tool. This umbrella review protocol was documented in the PROSPERO registry (CRD42022327994).

Results

We generated 531 studies, and after the removal of duplicates and ineligible studies, six eligible reviews were included in the analysis. The five themes identified were environmental factors, professional factors, parent/family factors, access factors, and cultural factors, and the factors under each theme were divided into barriers or facilitators depending on the specific features of a given scenario.

Conclusions

Support from facility management and leadership and well-trained medical staff are of great significance to the successful integration of KMC into daily medical practice, while the parents of preterm infants and other family members should be educated and encouraged in KMC practice. Further research is needed to propose strategies and develop models for implementing KMC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05163-3.

The amniotic fluid proteome predicts imminent preterm delivery in asymptomatic women with a short cervix

Preterm birth, the leading cause of perinatal morbidity and mortality, is associated with increased risk of short- and long-term adverse outcomes. For women identified as at risk for preterm birth attributable to a sonographic short cervix, the determination of imminent delivery is crucial for patient management. The current study aimed to identify amniotic fluid (AF) proteins that could predict imminent delivery in asymptomatic patients with a short cervix. This retrospective cohort study included women enrolled between May 2002 and September 2015 who were diagnosed with a sonographic short cervix (< 25 mm) at 16–32 weeks of gestation. Amniocenteses were performed to exclude intra-amniotic infection; none of the women included had clinical signs of infection or labor at the time of amniocentesis. An aptamer-based multiplex platform was used to profile 1310 AF proteins, and the differential protein abundance between women who delivered within two weeks from amniocentesis, and those who did not, was determined. The analysis included adjustment for quantitative cervical length and control of the false-positive rate at 10%. The area under the receiver operating characteristic curve was calculated to determine whether protein abundance in combination with cervical length improved the prediction of imminent preterm delivery as compared to cervical length alone. Of the 1,310 proteins profiled in AF, 17 were differentially abundant in women destined to deliver within two weeks of amniocentesis independently of the cervical length (adjusted p-value < 0.10). The decreased abundance of SNAP25 and the increased abundance of GPI, PTPN11, OLR1, ENO1, GAPDH, CHI3L1, RETN, CSF3, LCN2, CXCL1, CXCL8, PGLYRP1, LDHB, IL6, MMP8, and PRTN3 were associated with an increased risk of imminent delivery (odds ratio > 1.5 for each). The sensitivity at a 10% false-positive rate for the prediction of imminent delivery by a quantitative cervical length alone was 38%, yet it increased to 79% when combined with the abundance of four AF proteins (CXCL8, SNAP25, PTPN11, and MMP8). Neutrophil-mediated immunity, neutrophil activation, granulocyte activation, myeloid leukocyte activation, and myeloid leukocyte-mediated immunity were biological processes impacted by protein dysregulation in women destined to deliver within two weeks of diagnosis. The combination of AF protein abundance and quantitative cervical length improves prediction of the timing of delivery compared to cervical length alone, among women with a sonographic short cervix.

Investigating the Developmental Trajectory of Long-term Oral Feeding Problems in 'Healthy' Preterm Infants

PURPOSE

To investigate the occurrence of oral feeding problems in preterm infants up to one year after hospital discharge.

METHODS

Thirty-six infants born <34 weeks gestation were enrolled in a prospective exploratory longitudinal pilot study prior to hospital discharge. Parents of eligible infants completed telephone questionnaires at 3, 6, and 12 months corrected gestational age. The occurrence and type of feeding problems; medical problems; and rehabilitation services received were collected.

RESULTS

A total of 26 (72.2%) parents responded, with 11 (42%) identifying feeding problems that developed within the first year of life. Avoidant behavior (including crying, agitated/fussy, and refusing to eat) was the most common feeding problem that occurred.

CONCLUSION

Feeding problems in 'healthy' preterm infants may occur at any point in development within the first year of life. Increased screening after hospitalization is needed for early identification and to make appropriate referrals in a timely manner to prevent and/or reduce the severity of long-term feeding problems.

Evaluation of the InterRAI Early Years for Degree of Preterm Birth and Gross Motor Delay

Background

The interRAI 0-3 Early Years was recently developed to support intervention efforts based on the needs of young children and their families. One aspect of child development assessed by the Early Years instrument are motor skills, which are integral for the maturity of cognition, language, social-emotional and other developmental outcomes. Gross motor development, however, is negatively impacted by pre-term birth and low birth weight. For the purpose of known-groups validation, an at-risk sample of preterm children using the interRAI 0-3 Early Years was included to examine correlates of preterm risk and the degree of gross motor delay.

Methods

Participant data included children and families (n = 591) from 17 health agencies in Ontario, Canada. Data were collected as part of a pilot study using the full interRAI 0-3 Early Years assessment. Correlational analyses were used to determine relationships between prenatal risk and preterm birth and bivariate analyses examined successful and failed performance of at-risk children on gross motor items. A Kruskal-Wallis test was used to determine the mean difference in gross motor scores for children born at various weeks gestation.

Results

Correlational analysis indicated that prenatal and perinatal factors such as maternal nicotine use during pregnancy did not have significant influence over gross motor achievement for the full sample, however, gross motor scores were lower for children born pre-term or low birth weight based on bivariate analysis. Gross motor scores decreased from 40 weeks' gestation (mean rank = 310.77), to moderate to late preterm (mean rank = 258.96), and to very preterm (mean rank = 234.54), however extremely preterm (mean rank = 236.28) performed comparably to very preterm.

Interpretation

The interRAI 0-3 was evaluated to determine its efficacy and report findings which confirm the literature regarding delay in gross motor performance for preterm children. Findings confirm that pre-term and low birth weight children are at greater risk for motor delay via the interRAI 0-3 Early Years gross motor domain.

Preterm birth update in Australasia: A report of the international symposium of Preterm Birth International Collaborative-Australasia branch

Preterm birth (PTB) is one of the most important problems that pose dilemmas for both the obstetrician and neonatologist, placing a heavy burden psychologically and financially on the families involved, and triggering high socio-economic costs to the public healthcare. The rate of PTB in Asian countries has been ranked at top globally. To reduce the PTB rate, to promote the prevention and intervention for PTB, and to better understand the pathophysiology underlying PTB, the Preterm Birth International Collaborative Australia branch (PREBIC-AA) was launched in 2017. A series scientific activities including organizing annual research symposiums has been planned and organized among Australasian countries. Here we briefly updated the current progress in clinical management and translational research on PTB in Australasian countries that have been participated in PREBIC-AA.

The financial burden experienced by families of preterm infants after NICU discharge

BACKGROUND AND OBJECTIVES

Describe the financial burden and worry that families of preterm infants experience after discharge from the neonatal intensive care unit (NICU).

METHODS

We surveyed 365 parents of preterm infants in a cross-sectional study regarding socio-demographics, supplemental security income (SSI), and financial worry. We completed a multivariable logistic regression model to examine the adjusted association of financial worry with modifiable factors.

RESULTS

We found that 53% of participants worried about healthcare costs after NICU discharge. After adjusting for socio-demographic and infant characteristics, we identified that, aOR (95% CI), out-of-pocket costs from the NICU index hospitalization, 3.51 (1.7, 7.26) and durable medical equipment use, 2.41 (1.11, 5.23) was associated with increased financial worry while enrollment in SSI, 0.38 (0.19, 0.76) was associated with decreased financial worry.

CONCLUSIONS

We identified factors that could contribute to financial burden after NICU discharge that may advise future work to target financial support systems.

Impact of paternal presence and parental social-demographic characteristics on birth outcomes

OBJECTIVES

Maternal race, marital status, and social environment impact risk of preterm delivery and size for gestational age. Although some paternal characteristics such as age are associated with pregnancy outcomes, the influence of the paternal presence, race/ethnicity and adverse life events is not well known. The objective of the study was to assess birth outcomes in mothers with a paternal presence compared to those without during the post-partum period. The secondary aim was to determine whether paternal race is associated with birth outcomes.

METHODS

This was a cross-sectional study using parental surveys linked with birth certificate data from 2016 to 2018. Adverse birth composite outcomes (ABCO) including small for gestational age (SGA), prematurity or neonatal intensive care unit admission (NICU) were assessed.

RESULTS

A total of 695 parents were analyzed (239 single mothers and 228 mother-father pairs). Compared to mothers with a father present, mothers without a father present exhibited increased odds of ABCO, prematurity and NICU. Non-Hispanic Black fathers had increased odds of ABCO and NICU compared to Non-Hispanic Whites (NHW). Hispanic fathers had increased odds of NICU compared to NHW.

CONCLUSIONS

Paternal absence in the post-partum period and paternal race were both independently associated with ABCO and NICU. Assessment of paternal presence and paternal race in clinical practice may help identify opportunities for additional support necessary to optimize birth outcomes.

"What are you carrying?" Experiences of mothers with preterm babies in low-resource setting neonatal intensive care unit: a qualitative study

INTRODUCTION

Babies born preterm often have challenges in feeding, temperature control and breathing difficulty and are prone to infection during the neonatal period. These usually necessitate admission to the neonatal intensive care unit (NICU). Admission to NICU disrupts the mother-baby bonding.

OBJECTIVE

This study explored the lived experiences of mothers with preterm babies admitted to NICU in a low-resource setting.

STUDY DESIGN

This was a qualitative study where 16 participants took part in indepth interviews and 35 in focus group discussions. We included mothers who delivered and were caring for preterm babies at the NICU of Mulago National Referral Hospital.

STUDY SETTING

Data were collected from a public hospital, which works as a district and national referral hospital located in the capital of Uganda.

PARTICIPANTS

Fifty-one mothers with preterm babies in the NICU were sampled and recruited after informed consent. Data were analysed using manual thematic analysis.

RESULTS

There were six themes on the experiences of mothers of preterm babies in NICU: constant worry and uncertainty about the survival of their babies, baby feeding challenges, worries of discharge, communication gaps between mothers and nurses, community acceptability and disdain for preterm babies, and financial challenges.

CONCLUSIONS AND RECOMMENDATIONS

Mothers of preterm babies admitted to NICU in a low-resource setting still need a lot of support other than the medical care given to their babies. Support groups in the hospital and community are recommended to help in dealing with these challenges.

Hospital antenatal admissions for threatened preterm labor: how long should we be "observing"?

PURPOSE

We sought to describe temporal trends in hospital admissions for threatened preterm labor (TPTL) and to examine hospital admission duration among women delivered or discharged undelivered.

METHODS

We carried out a cohort study on all TPTL admissions among pregnancies with a live singleton fetus and intact membranes between 1999 and 2015 using the United States' Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. ICD-9 codes were used to identify women with TPTL. Duration of antenatal admission length of stay was calculated in days following admission to hospital until delivery ("Delivery Admission") or undelivered discharge ("Observation Admission"). Analyses included evaluating trends of birth admissions over total admissions, identifying predictors of delivery using logistic regression, and measuring risk for delivery with increasing duration of antepartum hospitalization.

RESULTS

Of 15,335,288 pregnancy admissions, 1,089,987 admissions were for TPTL, with 61.8% being 'Delivery Admissions". During the 16-year study period, overall rates of TPTL admissions declined with a rising proportion of admissions being "Delivery Admissions". "Delivery Admissions" were more common among patients who were older, non-Caucasian, obese, or who had placental abruption. "Observation Admissions" were more common among admissions for antepartum hemorrhage or antepartum spotting. Among all "Delivery Admissions" for TPTL, 89% had delivered within 2 days, 7% delivered within 3-6 days, and 5% delivered beyond 6 days.

CONCLUSION

Overall admissions for TPTL declined over the study period with increasing proportions being "Delivery Admissions". Protocols taking into consideration declining risk of preterm birth among patients undelivered after 2 days may be helpful in reducing unnecessary prolonged observation admissions.

Preterm birth lifetime costs in the United States in 2016: An update

The societal cost of preterm birth indicates potential economic gains from interventions that reduce the incidence of preterm birth. Changes in the epidemiology of preterm birth and healthcare costs require periodic updates to cost estimates. Previously reported incremental cost estimates for the United States in 2004 were updated. The discounted present value of the excess cost associated with prematurity for the 2016 US birth cohort was estimated to be $25.2 billion: $17.1 billion for medical care of persons born preterm, $2.0 billion for delivery care, $1.3 billion for early intervention and special education, and $4.8 billion in lost productivity due to associated disabilities in adults. The nominal and inflation-adjusted incremental costs per preterm birth increased by 26% and 4%, respectively, during 2004-2016. The aggregate cost decreased by 4%, associated with declines in overall births and the preterm birth rate and changes in the distribution by gestational age.

Preventing early births in a regional tertiary maternity unit: Evaluating preterm and early term birth rates before and after implementation of the Preterm Birth Prevention Initiative in the Australian Capital Territory

BACKGROUND

A multifaceted preterm birth (PTB) prevention initiative was launched in the Australian Capital Territory (ACT) in 2019. The aim of this initiative was to safely lower the rate of early births across the ACT and the surrounding areas in New South Wales. Modelled on the Western Australian PTB Prevention Initiative, the program included new clinical guidelines and a new PTB prevention clinic at the main tertiary hospital.

AIM

To evaluate the initiative and its effects on preterm and early term birth rates at the main tertiary hospital after 16 months of implementation.

MATERIALS AND METHODS

A before and after intervention study was conducted. Rates of preterm and early term birth before (previous five years) and after 16 months of implementation of the ACT PTB Prevention Initiative were evaluated.

RESULTS

At the main tertiary hospital in The Canberra Hospital, the rate of PTB was significantly reduced by 10% after 16 months of implementation of the initiative. Rates of PTB were lower than any of the preceding five years and resulted in 45 averted or delayed PTBs. The number of planned early term births with no medical indication was significantly reduced by 34.5% and resulted in 77 averted or delayed early term births.

CONCLUSIONS

The multifaceted PTB Prevention Initiative safely lowered the rates of early birth in the ACT context. These results highlight the importance of prioritising early birth prevention, education, research and expanding the initiative nationwide.

Corticosteroids in Pregnancy for Preventing RDS: Overview of Systematic Reviews

The objective of this study was to analyze the available evidence of systematic reviews that evaluated the efficacy of antenatal corticosteroids in order to contribute to a reduction in magnitude and transcendence of respiratory distress syndrome of the newborn (RDS). Thus, an overview was conducted including all systematic reviews of randomized controlled trials (RCTs) that evaluated women who received corticosteroid treatment during pregnancy to prevent RDS. Therefore, a search strategy was developed using the terms "respiratory distress syndrome, newborn," "corticosteroids," "perinatal death," "neonatal death," "neonate," and "pregnancy." The electronic databases searched were MEDLINE, EMBASE, Cochrane Library, LILACS, and Google Scholar, for studies published until June 2020. We identified 354 references, 38 of which were relevant after the initial screening. Ten systematic reviews met the inclusion criteria. For RDS, 1522 cases occurred in the control group composed of 8716 participants, while in the intervention group was 1088 in 8740 participants (RR = 0.67, 95% CI 0.60-0.75). For neonatal death, 343 cases occurred in 5248 participants of the control group, while in the intervention group, there were 227 cases in 5246 participants (RR = 0.66, 95% CI 0.56-0.78). For perinatal death, there were 344 cases in 3345 participants in the control group, while in the intervention group, the number of cases was 264 in 3384 participants (RR = 0.72, 95% CI 0.58-0.89). Thus, the use of corticosteroids during pregnancy in women at risk of preterm birth is effective for the prevention of RDS in neonates and reducing the number of neonatal and perinatal deaths in preterm. PROSPERO protocol no: CRD42017074604.

The Potential of Metabolomic Analyses as Predictive Biomarkers of Preterm Delivery: A Systematic Review

SCOPE

as the leading cause of perinatal mortality and morbidity worldwide, the impact of premature delivery is undisputable. Thus far, non-invasive, cost-efficient and accurate biochemical markers to predict preterm delivery are scarce. The aim of this systematic review is to investigate the potential of non-invasive metabolomic biomarkers for the prediction of preterm delivery.

METHODS AND RESULTS

Databases were systematically searched from March 2019 up to May 2020 resulting in 4062 articles, of which 45 were retrieved for full-text assessment. The resulting metabolites used for further analyses, such as ferritin, prostaglandin and different vitamins were obtained from different human anatomical compartments or sources (vaginal fluid, serum, urine and umbilical cord) and compared between groups of women with preterm and term delivery. None of the reported metabolites showed uniform results, however, a combination of metabolomics biomarkers may have potential to predict preterm delivery and need to be evaluated in future studies.

Burden of prematurity-associated recurrent wheezing: caregiver missed work in the D-Wheeze trial

OBJECTIVE

This study describes the burden of prematurity-associated wheezing in black infants with respect to caregiver missed work.

STUDY DESIGN

We analyzed data from the D-Wheeze trial (ClinicalTrials.gov identifier NCT01601847). Black infants between 28-0/7 to 36-6/7 weeks' gestational age at birth receiving <28 days of supplemental oxygen were enrolled. The primary outcome was missed work to care for the infant in the first year.

RESULTS

147/277 (53.1%) infants had caregivers who reported time off. In an adjusted model, vitamin D supplementation (OR 0.52 [95% CI 0.30-0.89]; P = 0.018), recurrent wheeze (OR 2.26 [95% CI, 1.15-4.44]; P = 0.018), and other children in the household <5 years old (OR 0.45 [95% CI 0.26-0.78]; P = 0.004) were significantly associated with caregiver missed work.

CONCLUSIONS

Black premature infants had a significant burden of caregiver missed work, emphasizing the impact of prematurity-associated wheezing.

Sonographic Assessment of Fetal Growth Abnormalities

Fetal growth abnormalities have significant consequences for pregnancy management and maternal and fetal well-being. The accurate diagnosis of fetal growth abnormalities contributes to optimal antenatal management, which may minimize the sequelae of inadequate or excessive fetal growth. An accurate diagnosis of abnormal fetal growth depends on accurate pregnancy dating and serial growth measurements. The fetal size at any given stage of pregnancy is either appropriate or inappropriate for the given gestational age (GA). Pregnancy dating is most accurate in the first trimester, as biologic variability does not come into play until the second and third trimesters. The authors describe the determination of GA with use of standard US measurements and how additional parameters can be used to confirm dating. Once dates are established, serial measurements are used to identity abnormal growth patterns. The sometimes confusing definitions of abnormal growth are clarified, the differentiation of a constitutionally small but healthy fetus from a growth-restricted at-risk fetus is described, and the roles of Doppler US and other adjunctive examinations in the management of growth restriction are discussed. In addition, the definition of selective growth restriction in twin pregnancy is briefly discussed, as is the role of Doppler US in the classification of subtypes of selective growth restriction in monochorionic twinning. The criteria for diagnosing macrosomia and the management of affected pregnancies also are reviewed. The importance of correct pregnancy dating in the detection and surveillance of abnormal fetal growth and for prevention of perinatal maternal and fetal morbidity and mortality cannot be overstated. The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Hospitalization charges for extremely preterm infants: a ten-year analysis in Shanghai, China

OBJECTIVES

Extreme prematurity exerts a substantial economic burden on families and societies worldwide, especially in developing countries with limited healthcare resources. This study aimed to estimate initial hospitalization charges after extremely preterm birth in China over the previous decade.

METHODS

A retrospective study was conducted in the largest tertiary neonatal intensive care unit in Shanghai, China, including 441 extremely preterm infants (gestational age <28 weeks) discharged between 2010 and 2019. Hospitalization data and medical charges were obtained from electronic inpatient medical records. Subgroup analysis was conducted to examine how the charges and length of stay varied by gestational age, discharge year, survival status, and major morbidities.

RESULTS

The median total hospitalization charge was $20,770.70 with a median length of stay of 70.0 days. Total and daily charges declined as gestational age increased. A rising trend was found over time for overall and daily medical charges. Compared with decedents, survivors had a longer length of stay and higher total hospitalization charges, but their charge per day was lower. Total hospitalization charges were significantly higher in infants with necrotizing enterocolitis (Stage II-III), bronchopulmonary dysplasia, and sepsis when compared with neonates of the same gestational age without these co-morbidities. Charges for treatments accounted for the highest proportion (31.3%).

LIMITATIONS

Local statistics collected retrospectively might limit generalizability to other regions. Long-term medical charges were not reported.

CONCLUSION

Economic burden of the initial hospitalization for extremely preterm infants was substantial in China. Such economic factors should be fully taken into account for perinatal consultations, medical insurance policy-making, and clinical decisions.

Trends in Perinatal Practices and Neonatal Outcomes of Very Low Birth Weight Infants during a 16-year Period at NEOCOSUR Centers

OBJECTIVE

To describe trends in mortality, major morbidity, and perinatal care practices of very low birth weight infants born at NEOCOSUR Neonatal Network centers from January 1, 2001, through December 31, 2016.

STUDY DESIGN

A retrospective analysis of prospectively collected data from all inborn infants with a birthweight of 500-1500 g and 23-35 weeks of gestation.

RESULTS

We examined data for 13 987 very low birth weight infants with a mean birth weight of 1081 ± 281 g and a gestational age of 28.8 ± 2.9 weeks. Overall mortality was 26.8% without significant changes throughout the study period. Decreases in early onset sepsis from 6.3% to 2.8% (P <.001), late onset sepsis from 21.1% to 19.5% (P = .002), retinopathy of prematurity from 21.3% to 13.8% (P <.001), and hydrocephalus from 3.8% to 2.4% (P <.001), were observed. The incidence for bronchopulmonary dysplasia decreased from 17.3% to 16% (P = .043), incidence of severe intraventricular hemorrhage was 10.4%, necrotizing enterocolitis 11.1%, and periventricular leukomalacia 3.8%, and did not change over the study period. Administration of antenatal corticosteroids increased from 70.2% to 82.3% and cesarean delivery from 65.9% to 75.4% (P <.001). The use of conventional mechanical ventilation decreased from 67.7% to 63.9% (P <.001) and continuous positive airway pressure use increased from 41.3% to 64.3% (P <.001). Survival without major morbidity increased from 37.4% to 44.5% over the study period (P <.001).

CONCLUSIONS

Progress in perinatal and neonatal care at network centers was associated with an improvement in survival without major morbidity of very low birth weight infants during a 16-year period. However, overall mortality remained unchanged.

Three biomarker tests to help diagnose preterm labour: a systematic review and economic evaluation

BACKGROUND

Preterm birth may result in short- and long-term health problems for the child. Accurate diagnoses of preterm births could prevent unnecessary (or ensure appropriate) admissions into hospitals or transfers to specialist units.

OBJECTIVES

The purpose of this report is to assess the test accuracy, clinical effectiveness and cost-effectiveness of the diagnostic tests PartoSure™ (Parsagen Diagnostics Inc., Boston, MA, USA), Actim^® Partus (Medix Biochemica, Espoo, Finland) and the Rapid Fetal Fibronectin (fFN)^® 10Q Cassette Kit (Hologic, Inc., Marlborough, MA, USA) at thresholds ≠50 ng/ml [quantitative fFN (qfFN)] for women presenting with signs and symptoms of preterm labour relative to fFN at 50 ng/ml.

METHODS

Systematic reviews of the published literature were conducted for diagnostic test accuracy (DTA) studies of PartoSure, Actim Partus and qfFN for predicting preterm birth, the clinical effectiveness following treatment decisions informed by test results and economic evaluations of the tests. A model-based economic evaluation was also conducted to extrapolate long-term outcomes from the results of the diagnostic tests. The model followed the structure of the model that informed the 2015 National Institute for Health and Care Excellence guidelines on preterm labour diagnosis and treatment, but with antenatal steroids use, as opposed to tocolysis, driving health outcomes.

RESULTS

Twenty studies were identified evaluating DTA against the reference standard of delivery within 7 days and seven studies were identified evaluating DTA against the reference standard of delivery within 48 hours. Two studies assessed two of the index tests within the same population. One study demonstrated that depending on the threshold used, qfFN was more or less accurate than Actim Partus, whereas the other indicated little difference between PartoSure and Actim Partus. No study assessing qfFN and PartoSure in the same population was identified. The test accuracy results from the other included studies revealed a high level of uncertainty, primarily attributable to substantial methodological, clinical and statistical heterogeneity between studies. No study compared all three tests simultaneously. No clinical effectiveness studies evaluating any of the three biomarker tests were identified. One partial economic evaluation was identified for predicting preterm birth. It assessed the number needed to treat to prevent a respiratory distress syndrome case with a 'treat-all' strategy, relative to testing with qualitative fFN. Because of the lack of data, our de novo model involved the assumption that management of pregnant women fully adhered to the results of the tests. In the base-case analysis for a woman at 30 weeks' gestation, Actim Partus had lower health-care costs and fewer quality-adjusted life-years (QALYs) than qfFN at 50 ng/ml, reducing costs at a rate of £56,030 per QALY lost compared with qfFN at 50 ng/ml. PartoSure is less costly than Actim Partus while being equally effective, but this is based on diagnostic accuracy data from a small study. Treatment with qfFN at 200 ng/ml and 500 ng/ml resulted in lower cost savings per QALY lost relative to fFN at 50 ng/ml than treatment with Actim Partus. In contrast, qfFN at 10 ng/ml increased QALYs, by 0.002, and had a cost per QALY gained of £140,267 relative to fFN at 50 ng/ml. Similar qualitative results were obtained for women presenting at different gestational ages.

CONCLUSION

There is a high degree of uncertainty surrounding the test accuracy and cost-effectiveness results. We are aware of four ongoing UK trials, two of which plan to enrol > 1000 participants. The results of these trials may significantly alter the findings presented here.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42017072696.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Association of Summer Heat Waves and the Probability of Preterm Birth in Minnesota: An Exploration of the Intersection of Race and Education

Preterm birth (PTB) is common and has negative impacts on infant health. While some maternal risk factors have been identified, including age under 20 or over 40, substance abuse, low BMI, and racism, less is known about the impact of environmental exposures like high heat. We combined 154,157 records of live births occurring in Minnesota between 2009 and 2015 with hourly weather records collected from the Minneapolis–St. Paul airport. We tested if maternal heat wave exposure (a seven-day period with a mean daily high temp of 37 °C) immediately prior to birth leads to a higher risk of preterm birth. Additional covariates included maternal age, race/ethnicity, educational status, and residence in the seven-county Minneapolis–St. Paul metro area. Pregnant women exposed to a seven-day heat wave of 37 °C or higher experienced a higher relative risk of PTB compared to women who did not experience a heat wave (1.14 risk ratio (RR), 1.0–1.3 95% confidence interval (CI)). The result is robust to controls for a woman’s age, race/ethnicity, educational attainment, place of residence, and year of the birth. Children born to Black women with college degrees who are exposed to heat waves experience a higher relative risk of PTB compared to White women with college degrees in a heat wave (2.97 RR, 1.5–6.1 95% CI). Summer heat waves are associated with higher risk of PTB in late-term pregnancies in Minnesota.

From structural modalities in perinatal medicine to the frequency of preterm birth

Preterm birth is a global health problem that affects 11% of all live births: it remains a significant cause of death and an important cause of long-term loss of human potential among survivors all around the world. In the last decade, many developed countries have seen an increase in the rate of infants born preterm. Various theoretical and practical concepts have been discussed that aim to optimize the perinatal care of preterm infants and their mothers. These include the definition of hospitals with different levels of care, the regionalization of care, the creation of large care units with high case numbers, and a high level of expertise. This review article focuses on the connection between health care structures and different aspects of preterm birth. Furthermore, this review article highlights the fact that preterm birth is a heterogeneous syndrome with many underlying pathologies and that the causality for a large number of cases remains unexplained. There is still a significant knowledge gap concerning the actual drivers of spontaneous preterm birth, and future research particularly in parturition immunology as well as genetics of prematurity will be essential to identify new targets for therapy.

The effect of antenatal screening for depression on neonatal birthweight and gestation

BACKGROUND

Antenatal depression has been associated with poor perinatal outcomes such as preterm birth and low birth weight. Universal screening of perinatal depression has been recommended to improve maternal and pregnancy outcomes.

HYPOTHESIS AND AIM

We hypothesise that screening for antenatal depressive symptoms may reduce the risk of preterm birth and low birth weight. To assess the hypothesis, we explore the association between antenatal depression screening using the Edinburgh Postnatal Depression Scale and neonatal outcomes.

METHODS

A retrospective analysis of state-wide population-based health administrative data. Inclusion criteria were pregnant women who gave birth to a singleton in Queensland in the second half of 2015 (29,543 women). Logistic regression analyses were run in 27,817 women with information in all variables. Main outcomes were preterm birth (<37 weeks of gestation) and low birth weight (<2500 grs).

RESULTS

Women who did not complete the screening had increased odds of preterm birth (AOR, 1.56; 95% CI, 1.39-1.74; p < 0.001) and low birth weight (AOR, 1.48; 95% CI, 1.30-1.68; p < 0.001) before and after adjustments for relevant confounders when compared to women who completed the screening. Sensitivity analyses performed in women with spontaneous labour and in women without a diagnosis of depression showed similar results.

CONCLUSION(S)

We found an association between screening for depressive symptoms during pregnancy and better neonatal outcomes. However, this result does not necessarily infer causality. Any association may represent a previously unknown benefit to screening, which could support the case for universal antenatal depression screening.

Magnitude of Preterm Birth and Its Associated Factors: A Cross-Sectional Study at Butajira Hospital, Southern Nations, Nationalities, and People's Region, Ethiopia

BACKGROUND

Preterm birth infants are at a greater risk of mortality and a variety of health and developmental problems; reliable data support that this rate is increasing in almost all countries. The purpose is to find the magnitude of preterm birth and its associated factors among newborns delivered at Butajira Hospital, Southern Nations, Nationalities, and People's Region, Ethiopia.

METHODS

This hospital-based cross-sectional study was carried out on 304 maternity cards using the systematic sampling method during May 1_21 in 2019. The data collection was performed using a structured case record form. The data were entered into EpiData software (version 3.1) and analyzed using SPSS software (version 21). Binary and multivariable logistic regression analyses were computed to identify the associated factors at 95% CI.

RESULTS

Overall magnitude of preterm birth was observed to be 15.5%. The factors significantly associated with the preterm birth were preeclampsia (AOR = 4.0; 95% CI: 1.6-10.0), and premature rupture of fetal membranes (AOR = 4.2; 95% CI: 1.4-12.9).

CONCLUSION

Preterm birth is still public concern in the study area. The concerned administrative body should implement health education programs and improve the quality of health care delivered to pregnant mothers to control these associated factors and, consequently, promote public health in the study area.

Presence of amniotic fluid sludge and pregnancy outcomes: A systematic review

INTRODUCTION

Several studies acknowledge that the presence of amniotic fluid sludge (AFS) is an independent predictive factor for preterm birth. In the present systematic review, we summarize research that focuses on the comparison of pregnancy outcomes among women with and without AFS.

MATERIAL AND METHODS

Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar databases were systematically searched from inception. Both observational and randomized controlled studies were considered eligible provided that they reported data on pregnancy outcomes among women with and without AFS. Outcomes were not meta-analyzed because of the high heterogeneity in terms of selected population and outcome reporting.

RESULTS

Seventeen studies of 2432 women were included in this review. Six studies evaluated women at high risk for preterm birth. Pregnancies complicated by AFS had a lower gestational age at delivery and increased incidence of preterm delivery at <37 weeks. Neonatal death rates and admission to the Neonatal Intensive Care Unit were also increased. Evidence in low-risk women, those with signs of preterm labor, in those carrying twins, and in women with cervical cerclage or Arabin pessary was extremely limited.

CONCLUSIONS

Women with AFS seem to deliver at an earlier gestational age, and preterm birth rates are also increased. Limited data seem to point to neonatal morbidity and mortality being increased. However, the presence of a direct association should not be assumed because the evidence is not adjusted for the presence of confounders.

Commentary on a combined approach to the problem of developing biomarkers for the prediction of spontaneous preterm labor that leads to preterm birth

INTRODUCTION

Globally, preterm birth has replaced congenital malformation as the major cause of perinatal mortality and morbidity. The reduced rate of congenital malformation was not achieved through a single biophysical or biochemical marker at a specific gestational age, but rather through a combination of clinical, biophysical and biochemical markers at different gestational ages. Since the aetiology of spontaneous preterm birth is also multifactorial, it is unlikely that a single biomarker test, at a specific gestational age will emerge as the definitive predictive test.

METHODS

The Biomarkers Group of PREBIC, comprising clinicians, basic scientists and other experts in the field, with a particular interest in preterm birth have produced this commentary with short, medium and long-term aims: i) to alert clinicians to the advances that are being made in the prediction of spontaneous preterm birth; ii) to encourage clinicians and scientists to continue their efforts in this field, and not to be disheartened or nihilistic because of a perceived lack of progress and iii) to enable development of novel interventions that can reduce the mortality and morbidity associated with preterm birth.

RESULTS

Using language that we hope is clear to practising clinicians, we have identified 11 Sections in which there exists the potential, feasibility and capability of technologies for candidate biomarkers in the prediction of spontaneous preterm birth and how current limitations to this research might be circumvented.

DISCUSSION

The combination of biophysical, biochemical, immunological, microbiological, fetal cell, exosomal, or cell free RNA at different gestational ages, integrated as part of a multivariable predictor model may be necessary to advance our attempts to predict sPTL and PTB. This will require systems biological data using "omics" data and artificial intelligence/machine learning to manage the data appropriately. The ultimate goal is to reduce the mortality and morbidity associated with preterm birth.

Experiences of mothers with preterm babies at a Mother and Baby Unit of a tertiary hospital: A descriptive phenomenological study

Aim

To describe the lived experiences of mothers with preterm babies at a Mother and Baby Unit (MBU) of a tertiary hospital.

Design

A descriptive phenomenological approach.

Method

Ten mothers were purposively sampled during the month of May, 2017 to describe their experiences of having preterm babies. Recorded in-depth individual interviews were transcribed verbatim; codes were generated and inductively organised into themes.

Results

Four themes were actively generated: 'Emotional experiences of mothers', 'Mother-baby interaction', 'Perception on care and support' and 'Challenges within Mother and Baby Unit environment'. Mothers were anxious about the premature delivery and were afraid of possible infant's death. They cherished interactions with their babies during kangaroo mother care and breastfeeding. Mothers applauded the nurses for their professional competence. They expressed concerns about inadequate accommodation, high cost of care, the frequency and duration of mother-baby interactions.

Association of WIC Participation and Growth and Developmental Outcomes in High-Risk Infants

The objective of this study was to describe the association of enrollment in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), the Supplemental Nutrition Assistance Program (SNAP), and infant growth and neurodevelopmental outcomes. Z scores and Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) and Vineland Adaptive/Behavior Scale-II (VABS-II) scores represented primary outcomes. We conducted bivariate analyses and linear regression. Children who were enrolled in WIC or WIC/SNAP had weight z scores U (95% confidence interval [CI]) that were 1.32 (0.42-2.21) or 1.19 (0.16-2.23) units higher. Enrollment in WIC or WIC/SNAP was associated with a higher score (95% CI) of 11.7 U (1.2-22.2 U) or 11.5 (0.1-22.9) for Bayley-III cognitive score and 10.1 U (1.9-19.1 U) or 10.3 (0.9-19.7) for the VABS-II composite score. These findings support increased advocacy for participation in WIC or WIC/SNAP for families with high-risk infants.

A Prospective Study of Parent Health-Related Quality of Life before and after Discharge from the Neonatal Intensive Care Unit

OBJECTIVE

To determine how infant illness and parent demographics are associated with parent health-related quality of life (HRQL) during and 3 months after hospitalization in the neonatal intensive care unit (NICU). We hypothesized that parents of extremely preterm infants would report lower NICU HRQL than other parents, and that all parents would report improved HRQL after discharge.

STUDY DESIGN

This prospective study of parent-infant dyads admitted to a level IV NICU for ≥14 days from 2016 to 2017 measured parent HRQL before and 3 months after discharge using the Pediatric Quality of Life Inventory Family Impact Module. Multivariable regression was used to identify risk factors associated with HRQL differences during hospitalization and after discharge.

RESULTS

Of the 194 dyads, 167 (86%) completed the study (24% extremely preterm; 53% moderate to late preterm; 22% term). During the NICU hospitalization, parents of extremely preterm infants reported lower adjusted HRQL (-7 points; P = .013) than other parents. After discharge, parents of extremely preterm infants reported higher HRQL compared with their NICU score (+10 points; P = .001). Tracheostomy (-13; P = .006), home oxygen (-6; P = .022), and readmission (-5; P = .037) were associated with lower parent HRQL 3 months after discharge, adjusted for NICU HRQL score.

CONCLUSIONS

Parents of extremely preterm infants experienced a greater negative impact on HRQL during the NICU hospitalization and more improvement after discharge than parents of other infants hospitalized in the NICU. Complex home care was associated with lower parent HRQL after discharge. The potential benefit of home discharge should be balanced against the potential negative impact of complex home care.

Viewpoints from families for improving transition from NICU-to-home for infants with medical complexity at a safety net hospital: a qualitative study

Background

We have limited information on families’ experiences during transition and after discharge from the neonatal intensive care unit.

Methods

Open-ended semi-structured interviews were conducted with English or Spanish- speaking families enrolled in Medicaid in an urban high-risk infant follow up clinic at a safety-net center, which serves preterm and high-risk term infants. We generated salient themes using inductive-deductive thematic analysis.

Results

Twenty-one participants completed the study. The infant’s median (IQR) birth weight was 1750 (1305, 2641) grams; 71% were Hispanic and 10% were Black non-Hispanic; 62% reported living in a neighborhood with 3-4th quartile economic hardship. All were classified as having chronic disease per the Pediatric Medical Complexity Algorithm and 67% had medical complexity. A conceptual model was constructed and the analysis revealed major themes describing families’ challenges and ideas to support transition centered on the parent-child role and parent self-efficacy. The challenges were: (1) comparison to normal babies, (2) caregiver mental health, (3) need for information. Ideas to support transition included, (1) support systems, (2) interventions using mobile health technology (3) improved communication to the primary care provider and (4) information regarding financial assistance programs. Specific subthemes differed in frequency counts between infants with and without medical complexity.

Conclusions

Families often compare their preterm or high-risk infant to their peers and mothers feel great anxiety and stress. However, families often found hope and resilience in peer support and cited that in addition to information needs, interventions using mobile health technology and transition and financial systems could better support families after discharge.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1604-6) contains supplementary material, which is available to authorized users.

Impact of Respiratory Syncytial Virus-Confirmed Hospitalizations on Caregivers of US Preterm Infants

This study assessed the impact of respiratory syncytial virus-confirmed hospitalizations (RSVH) on caregivers of high-risk preterm infants. Caregivers for infants born at 29 to 35 weeks' gestational age and hospitalized for confirmed RSV disease responded to measures of self-rated and perceived infant stress (1-7; 7 = very stressful), perceived infant health (0-100; 100 = best imaginable health), and productivity impairment. Data were collected at hospital discharge through 1 month post-discharge. Caregiver responses indicated high stress levels, poor health, and productivity loss were reported at discharge; however, steady improvements were seen through 1 month post-discharge: caregiver-rated stress (from 6 to 2), infant stress (5 to 1), caregiver-perceived infant health (64 to 84), and productivity loss (mothers: 91% to 31%; fathers: 81% to 18%). Qualitative results indicated emotional impact, family routine disruption, financial concerns, and medical concerns persisted at 1 month post-discharge. This study found the caregiver burden of RSVH persists at least 1 month beyond discharge.

Cost of preterm birth during initial hospitalization: A care provider's perspective

Preterm birth incidence has risen globally and remains a major cause of neonatal mortality despite improved survival. Demand and cost of initial hospitalization has also increased. This study assessed the cost of preterm birth during initial hospitalization from care provider perspective in neonatal intensive care units (NICU) of two hospitals in the state of Kedah, Malaysia. It utilized universal sampling and prospectively followed up preterm infants till discharge. Care provider cost was assessed using mixed method of top down approach and activity based costing. A total of 112 preterm infants were recruited from intensive care (93 infants) and minimal care (19 infants) units. Majority were from the moderate (23%) and late (36%) preterm groups followed by very preterm (32%) and extreme preterm (9%). Median cost per infant increased with level of care and degree of prematurity. Cost was dominated by overhead (fixed) costs for general (hospital), intermediate (clinical support services) and final (NICU) cost centers where it constituted at least three quarters of admission cost per infant while the remainder was consumables (variable) cost. Breakdown of overhead cost showed NICU specific overhead contributing at least two thirds of admission cost per infant. Personnel salary made up three quarters of NICU specific overhead. Laboratory investigation was the cost driver for consumables. Gender, birth weight and length of stay were significant factors and cost prediction was developed with these variables. This study demonstrated the inverse relation between resource utilization, cost and prematurity and identified personnel salary as the cost driver. Cost estimates and prediction provide in-depth understanding of provider cost and are applicable for further economic evaluations. Since gender is non-modifiable and reducing LOS alone is not effective, birth weight as a cost predictive factor in this study can be addressed through measures to prevent or delay preterm birth.

Environmental extreme temperature and daily preterm birth in Sabzevar, Iran: a time-series analysis

Objectives

Most of the studies on the effect of heat stress on preterm birth (PTB) are conducted in temperate climates. Evidence on this effect in hot and arid countries with low and middle income is limited. This paper describes the short-term effect of exposure to the hot and cold environment on a daily number of PTB in Iran.

Methods

The daily number of PTB was obtained from all hospitals of the city. Meteorological and air pollution data from 2011 to 2017 were obtained from a metrological station in the city. A semi-parametric generalized additive model following a quasi-Poisson distribution with the distributed lag non-linear model was selected as a modeling framework for time-series analysis to simultaneously model the short-term and lagged effect of heat stress on PTB in the Sabzevar city.

Results

The minimum and maximum daily temperature were − 11.2 and 45.4 °C respectively. The highest risk estimate at extreme cold temperature was found for apparent temperature (relative risk (RR) 1.83; 95% CI 1.61: 2.09). This pattern was seen for both models. For extreme hot temperatures, the model with mean temperature showed the highest risk increase for both the main model and air pollution adjusted model (RR 1.36; 95% CI 1.25: 1.49). The lowest risk estimate in extremely cold conditions was found in the model with mean temperature. However, for extremely hot temperature conditions, the lowest risk estimate was found for both maximum and apparent temperature.

Conclusion

Obstetricians working in semi-arid areas should be aware of the influence of environmental extreme temperature on the incidence of PTB.

Electronic supplementary material

The online version of this article (10.1186/s12199-018-0760-x) contains supplementary material, which is available to authorized users.