Preventive Interventions May Reduce Preterm Births by 58,000

Troy Brown

November 17, 2012

Implementing the 5 most effective preventive interventions will reduce the preterm births in the highest-income countries by just 5% — a relatively small reduction, but one that would prevent 58,000 preterm births and result in a $3 billion total cost savings each year.

Hannah H. Chang, MD, PhD, a consultant at Boston Consulting Group in Massachusetts, and colleagues report their findings in an article published online November 16 in the Lancet in anticipation of World Prematurity Day, observed November 17.

In May 2012, the World Health Organization published "Born Too Soon: The Global Action Report on Preterm Birth," which outlined evidence-based interventions for preventing preterm birth.

"[O]ur aim was to do a multicountry analysis of the trends in preterm birth rates for 2000–10 in countries with more robust data, and to estimate the potential reduction in preterm birth with full implementation of currently proven interventions. A secondary objective was to consider the setting of a preterm birth reduction target for these countries," Dr. Chang and colleagues write.

The authors estimated the potential effect of these interventions (decreasing non–medically indicated caesarean deliveries and induced labor, limiting multiple embryo transfers in assisted reproductive technology, smoking cessation, progesterone supplementation, and cervical cerclage) in 39 highest-income countries.

Implementing the interventions in those countries could result in an estimated 5% relative reduction in preterm birth rates, which corresponds to an absolute preterm birth rate change from 9.6% to 9.1%.

The largest effect would be seen with the reduction of non–medically indicated caesarean delivery and induction of labor, which would account for about half of the decrease.

The researchers found significant variability across countries studied in the absolute effect (about 1% to roughly 8% relative reduction) as well as the relative effect of single interventions. They note that although reducing non–medically indicated caesarean delivery and labor induction would have the highest effect in the United States, its effect would negligible in Sweden. Conversely, cervical cerclage for women with previous preterm delivery and a short cervix would have the largest effect in Sweden.

The authors estimate that a relative reduction of 5% in preterm births in the countries studied would prevent approximately 58,000 preterm births each year and result in about $3 billion in total economic cost savings. They recommend aiming for a preterm birth rate reduction target of 5% by 2015.

"This projected cost savings is significant but still leaves a major cost and burden, highlighting the need for novel preventive interventions against preterm birth with greater impact," the authors write.

Prevention Difficult

In an accompanying editorial, Jane E. Norman, MBChB, MD, a professor of maternal fetal health at Tommy's Centre for Maternal and Fetal Health at the University of Edinburgh in the United Kingdom, and Andrew H. Shennan, MD, from the Women's Health Academic Centre and a professor of obstetrics at King's College London in the United Kingdom, address the difficulty of preventing preterm births. The pathophysiology of preterm birth is poorly understood, and the knowledge that we do have does not necessarily lead to effective interventions, they write.

"[A]lthough intrauterine infection is the most widely accepted cause of idiopathic preterm labour, preventive antibiotic therapy is ineffective and in some circumstances harmful," the commentators write.

In addition, available therapies do not work for all women, they note. "[W]hereas progesterone and cervical cerclage are effective in selected women with singleton pregnancy, they are both ineffective in multiple pregnancy, and cerclage can even be harmful."

Improved biomarkers are also needed. "The best current biomarkers (fetal fibronectin in cervicovaginal fluid and short cervical length) are useful but need improvement, since their likelihood ratios for prediction of preterm birth are lower than 10," the commentators note.

The long-term effects of new preventive measures on babies will also have to be established, they conclude.

The time of Dr. Chang and 2 coauthors was funded by the March of Dimes and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. One coauthor's time was funded by a grant from the Bill & Melinda Gates Foundation to Save the Children’s Saving Newborn Lives programme. One coauthor's time was funded by a grant from the Bill & Melinda Gates Foundation to the Child Health Epidemiology Reference Group. March of Dimes, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, and the Global Alliance to Prevent Prematurity and Stillbirth all receive grants from government, foundations and charitable organizations for research into preterm birth prevention. The authors have disclosed no relevant financial relationships. Dr. Norman has acted as an unpaid consultant to Hologic and provided paid expert testimony on drugs for prevention of preterm birth. Dr. Shennan is a paid consultant for GlaxoSmithKline, an unpaid adviser to Hologic, has received funds for research (paid to institution) from Alere and Hologic, and has received funds from Hologic, Alere, and Ferring for educational purposes.

Lancet. Published online November 16, 2012. Article summary, Editorial extract