State Works to Improve Birth Outcomes
When the March of Dimes released the first of what will become an annual Premature Birth Report Card1
last November, it became apparent that no state passed with flying colors and many flatly failed their youngest and most vulnerable citizens. With more than 543,0002
babies born prematurely each year, no state is immune to the issue of poor birth outcomes.
As has been widely reported, Tennessee was among the 18 states plus Puerto Rico that received an "F" on the report card. Only Vermont earned honor roll status with a "B" while eight others scored a "C" and 23 states received a "D."
- Preterm: less than 37 completed weeks of pregnancy;
- Late Preterm: between 34-36 completed weeks of gestation;
- Very Preterm: less than 32 completed weeks of gestation;
- Low Birthweight: less than 2500 grams (5 pounds, 8 ounces);
- Very Low Birthweight: less than 1500 grams (3.5 pounds).
The preterm birth objective for National Healthy People 2010 is a rate of no more than 7.6 percent of all live births. Based on the 2005 data used in the March of Dimes report card, the national rate was 12.7 percent, and Tennessee came in at 14.7 percent – 2.4 percent deemed "very preterm" and 12.3 percent "moderately-to-late preterm."
In an average week in 2005, 1,572 babies were born in Tennessee of which 230 were premature and 149 had low birthweight. Of the live births, 31.1 percent were cesarean deliveries, and nearly 8 percent of infants were born to mothers who had received late prenatal care (third trimester) or none at all.
Not only is premature birth the leading cause of death for newborns, it is also a major cause of lifelong disability resulting in a large physical and financial toll on families, states and the nation. In July 2006, the Institute of Medicine reported preterm births cost the country more than $26 billion annually.
To improve outcomes, Tennessee will have to buck a national trend which has seen more than a 20 percent increase in the preterm birth rate since 1990 … and a 36 percent jump since the early 1980s. Updated data from the National Center for Health Statistics, released last month, attributed much of the increase in preterm birth rates to children being born between 34-36 weeks of gestation.
Finding effective solutions to help Tennessee's tiniest residents is a clear priority for the state's Department of Health. One year ago, Veronica L. Gunn, MD, MPH, stepped into her role as chief medical officer and brought with her a passion born of a career focused on children. The board-certified pediatrician came to the Department of Health from the Tennessee Governor's Office of Children's Care Coordination where she oversaw efforts to improve birth outcomes and screening rates.
She readily admits Tennessee's numbers are not good.
"We're consistently in the bottom 5-10 percent. Historically, we've been 46th for birth outcomes in general," she said.
Gunn noted updated figures for 2007 are fairly consistent with what was seen in 2006. For example, the low birthweight rate was 9.4 percent in 2007 as compared to 9.5 percent the previous year. Following national trends, Tennessee has seen stability in the rate of very early preterm births but a jump in the number late preterm births.
As with many complex issues, there are likely a number of factors that contribute to the state's overall poor birth outcomes. Although some have speculated enhanced fertility methods resulting in the birth of multiples might be part of the problem, Gunn thinks the impact is fairly minimal and probably not a driver of the issue.
Of greater concern, she said, "The rate of cesarean section has increased concomitantly with those increases in low birthweight and prematurity."
Gunn added the American College of Obstetricians and Gynecologists has stressed for years that c-sections should not be performed before 39 weeks except in emergency situations. However, concern lingers that an increasing number of cesareans are being scheduled for convenience.
Still, she continued, it is her belief that poor birth outcomes "are primarily attributable to preconception care … the health of the mother before she ever conceives." Many of these issues, Gunn noted, are outside the typical scope of a family practitioner yet directly impact health outcomes.
To find viable interventions for problems that extend past the traditional borders of medicine, Gunn and other health officials have reached out to local community organizations, state partners and non-governmental agencies.
The Department of Health has embraced a number of programs that use a home visiting model to assist pregnant women and their young children such as Tennessee Connections for Better Birth Outcomes, which is spearheaded by Vanderbilt School of Nursing in Nashville. Help Us Grow Successfully (HUGS) is one of the department's largest endeavors and connects women and children to the numerous services and resources that exist in the state.
Another part of the solution, according to Gunn, is to recognize that different regions require different approaches. "The problem of poor birth outcomes … those exist across the state. However, there are certainly areas where problems are worse than others," she acknowledged, adding that the drivers also vary by geographic location.
"Shelby County is one example which is frequently used in the media," she continued. "We have had consistently high poor birth outcomes for decades."
In Upper East Tennessee, there are lower rates of infant mortality than in Memphis, she continued, but the numbers are on the rise. Gunn said poor prenatal care seems to be a driving force in the west and is being addressed through community activation. However, the underlying factor to the east seems to be tied to higher smoking rates. "Efforts there are more focused on smoking cessation rather than community support," she noted.
Reaching out to partners outside the Department of Health, Gunn continued, is "an acknowledgement that while we at the state have resources – some dollars, some staff – we are not the community, and we're not necessarily the trusted resource for health information for the individual. And that's OK as long as we get the right message through the right messenger to the right population. I think that's the difference now. We're trying not to make one model fit everyone."
No matter what approach is taken, however, Gunn said the state and its partners are looking to the literature as a guide to what works.
"The state, in general, has moved to evidence-based or evidence-informed models whenever possible," she stressed.
"Because so many factors are outside the traditional health purview, it may take a generation to see significant improvements," Gunn continued, "but I think we can see measurable improvements in specific communities within the next five, six, seven years."
Although there are different steps providers could take to help in the fight, there is one that research deems crucial to improving birth outcomes … and that's tobacco cessation.
"People are more likely to quit smoking if advised to do so by a trusted health professional," Gunn noted.
"Are you smoking? Can I help you quit?"
These two questions, she continued, can make a real difference. Yet, a recent survey in Tennessee indicated most providers are not routinely asking patients about tobacco habits.
"If every health provider could do that, we would go a long way in not only improving poor birth outcomes but health outcomes in general," Gunn concluded. For more information, go to www.marchofdimes.com/PeriStats.
2 National Center for Health Statistics, "Births: Final Data for 2006," National Vital Statistics Reports; Vol. 57, No. 7.