by Candi Helseth
Having lost four babies since her son was born eight years ago, April McFadden successfully carried Michael, now three, to full term and is currently in the third trimester of another pregnancy. McFadden gives credit to Best Babies, a program begun in 2006 to reduce preterm births in four rural southern Georgia counties designated as Health Professional Shortage Areas.
“I get gestational diabetes and other problems when I’m pregnant,” McFadden said. “The Best Babies nurse comes to my house and checks on all these things, like my blood sugar and blood pressure and the baby’s heart beat. This is the best pregnancy I’ve had yet.”
For the first time in three decades, preterm birth rates for women of all age groups declined from 12.8 to 12.3 percent of live births, according to National Center for Health Statistics (NCHS) data. From the early 1980s through 2006, preterm birth rates had risen by more than one-third, increasing risk of life-long disability and early death for infants.
March of Dimes began a national Prematurity Campaign in 2003 to reduce premature births. March of Dimes Deputy Director Diane Ashton said that the Institute of Medicine* report, Preterm Birth: Causes, Consequences and Prevention, and the Surgeon General’s Conference on Preterm Birth in 2008 also have contributed to a multi-focused effort to increase awareness and public education about the effects of preterm births.
“Our primary campaign has been heavily focused on educating women about the signs and symptoms of preterm birth,” Ashton said. “Many of our chapters work together with health care providers in their areas.”
Preterm births and infant mortality continue to be higher in rural areas. In the 2006 book, Rural Women’s Health, researchers attributed this problem to several rural lifestyle issues including smoking, obesity and exposure to chemicals, which are more prevalent in rural areas. Geographic isolation, lack of access to care, increased poverty and psychosocial factors related to rural living are also factors, according to its authors.
Another factor might be that fewer family practitioners are offering prenatal care in rural areas and prenatal visits in rural areas are 5.6 times more likely to occur with a family physician than an obstetrician, according to a 2009 study in the Annals of Family Medicine. When pregnant women have to travel great distances to get prenatal care, they are likely to make fewer visits, which could lead to poorer outcomes, according to the report’s authors.
But rural areas can bring attention to other factors that help reduce premature birth.
“We know smoking contributes to preterm birth and in rural areas, it tends to be almost double the rate of urban areas and even higher than that in some rural areas,” Ashton said. “Without additional expense, rural providers can counsel patients on smoking cessation. Ideally, it should begin before patients become pregnant and it should be a family intervention because of the effects of second-hand exposure. Another positive step that takes little resource investment is educating women prior to pregnancy about the importance of taking care of pre-existing conditions, such as diabetes and hypertension, and reducing obesity.”
Pregnancy Programs in North Carolina and Georgia
The Perinatal Quality Collaborative of North Carolina (PQCNC) launched an initiative, The 39 Weeks Project, last September to eliminate elective deliveries before 39 weeks of gestation. March of Dimes provided the 41 participating hospitals with staff training and educational materials to distribute to pregnant women explaining why the last weeks of pregnancy count. 39 Weeks Project Coordinator Kate Berrien said the initiative also targets providers and hospitals.
“Women who have an induction before the cervix is ready to dilate are more likely to have a C-section and these babies have a higher rate of complications and neonatal intensive care admissions,” Berrien said. “These health concerns were the impetus for this project. Hospitals have developed different action plans to make sure that safety and health of the baby drives the decision for an early delivery, not patient or physician convenience.”
At Wilkes Regional Medical Center in North Wilkesboro, scheduled inductions and C-sections were reduced by 8 to 10 percent within the first two months primarily by educating mothers and working with physicians to prevent elective deliveries, according to New Beginnings Birth Center Nurse Manager Debbie Mitchell.
Wilkes, which is among several participating rural hospitals, provides prenatal education, fitness classes and other instruction to help mothers and their babies have healthy outcomes.
“We assumed going in that this would be a greater challenge in rural settings because they have fewer resources but some of these rural hospitals are leading the way and have almost eliminated elective deliveries before 39 weeks,” Berrien said.
Six months into the project, data indicated an ongoing decline in elective deliveries less than 39 weeks. Final data will be compiled the end of August.
With enrollment in Georgia’s Best Babies, gestational age has increased to an average of 37.2 weeks, said Program Manager Greta O’Steen. Previous pregnancy data indicated a gestational age of 25.8 weeks for babies born in the four-county area to high-risk mothers. Best Babies provides prenatal intensive in-home case management, nursing assessment and care coordination.
“When you have problems, waiting a month to see your doctor can be too long,” said McFadden, who travels 80 miles round-trip to her doctor’s office. Only one of the counties that Best Babies covers has a hospital and OB/GYNs that deliver babies. Best Babies also helps women keep their prenatal appointments by providing childcare and transportation vouchers.
“This program is a partnership with a woman’s doctor to provide resources most OB offices don’t have time to do and to educate these women on how to reduce their risk of poor birth outcome,” O’Steen said. “Providing services in their homes ensures regular prenatal assessments and tells us a lot about the psychosocial dynamics taking place in that home.”
Following the baby’s birth, a perinatal health outreach worker (PHOW) is assigned to the family for two years. Because birth outcomes with high-risk mothers improve if pregnancies are at least two years apart, O’Steen said, the PHOW advises mothers on birth control methods. Babies are also regularly screened for appropriate development.
Assessing What Works
Preterm birth rates decreased in 41 states between 2007 and 2008, according to Ashton. March of Dimes linked many improvements to states that targeted three key risk factors for premature birth: smoking during pregnancy; lack of health insurance for pregnant women; and unnecessary or non-medically indicated inductions or cesarean sections done during the “late pre-term,” or between 34 to 36 weeks’ gestation. Thirty-three states and the District of Columbia reduced the number of women of childbearing age who smoke; 21 states and Washington, D.C. insured more women from 2007 to 2008; and 27 states, Washington, D.C. and Puerto Rico lowered the late pre-term birth rate.
March of Dimes is currently assessing the outcome of Healthy Babies are Worth the Wait, a three-year education-based program begun in 2007. March of Dimes partnered with the Kentucky Department for Public Health to provide moms-to-be with education and support to reduce preterm births and prevent unnecessary or non-medically indicated deliveries.
“We’re looking at rolling this program out on a larger basis,” Ashton said. “There were resources available that many providers in that area didn’t know about when we began this program. So I’d encourage rural providers to work closely with public health and look for other providers as partners.”
Ashton says the key to continuing to decrease preterm births begins with education, which has proven to be effective. The task ahead is still monumental. While the decrease is good news, March of Dimes’ statistics indicate 13 million babies are still born too early every year.
Resources on Women’s Health
For more information on women’s health and childbirth in rural areas, see the following Rural Health Information Hub resources:
RHIhub Topic Guides
- For general information on women’s health issues, see the RHIhub’s Women’s Health Topic Guide (No longer available)
- For publications indexed on the RHIhub website, see Documents search: maternal and child health care.
Back to: Summer 2010 Issue