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Policy Brief: Reducing Preterm Births in the United States – AAN Expert Panels on Maternal Infant Health (MIH), Child, Adolescent & Family (CAF), and Women’s Health (WH)

There is an alarming rate of preterm births (PTB) (less than 37 weeks gestation) in the United States that has escalated in recent years and brought with this rise the associated public health problems of infant mortality and morbidity. While the richest country in the world, the U.S. ranks among the top 10 nations on preterm births. What is most troubling is that premature births were declining in the last decade, however more recently, in three consecutive years, preterm births have been steadily increasing to more than 400,000 U.S. babies born prematurely in 2016. The corollaries of PTB are associated with wider use of assisted reproductive technologies and clear racial and economic disparities. Representatives of the Expert Panels of the American Academy of Nursing including Maternal Infant Health (MIH), Child, Adolescent and Family (CAF), and Women’s Health (WH) convened and developed a Policy Brief on Reducing Preterm Births in the United States, published in the September/October issue of Nursing Outlook.

We asked Carole Kenner, the Carol Kuser Loser Dean and Professor in the School of Nursing, Health, and Exercise Science at the College of New Jersey to offer insights into this problem. She served as co-chair of the group of authors of the Policy Brief in Nursing Outlook. Their brief supports the evidence from several Institute of Medicine (IOM) reports relating the complex interplay of social, economic and environmental influences on maternal health in general and the rise of preterm childbirth specifically. In addition to limited access of maternal child health services, the brief includes discussion around the multiple underlying causes of preterm birth related to changes in obstetrical practices including increased rates of elective cesarean births, delayed childbearing, greater use of infertility treatments, illicit drug use, tobacco use, maternal mental health, maternal co-morbidities and chronic illnesses like diabetes, obesity, and hypertension. Although survival of premature infants has improved, morbidity has not followed. Babies born prematurely have a higher likelihood to have increased health-related and neurodevelopmental delays. These are shameful problems that our nation should address in a constructive way to find solutions.

The Policy Brief describes the problems and contributing factors of PTB and proposes policy recommendations with specific interventions that include advocacy for continuation of Medicaid to support maternal child health and action to support of the PREEMIE Reauthorization Act of 2018, with guidance from the March of Dimes. The American Academy of Nursing finds the rising prematurity rates in the U.S. unacceptable and urges the health care providers, policy makers, and the public to focus attention and resources to address this national health issue.

Contributors include (Maternal Infant Health Expert Panel Members): Carole Kenner, PhD, RN, FAAN, FNAP, ANEF, Co-Chair and Deborah S. Walker, PhD, CNM, FAAN, FACNM, Co-Chair; Kristin Ashford, PhD, RN, WHNP-BC, FAAN; Lina Kurdahi Badr, DNSc, RB, CPNP, FAAN; Beth Black, PhD, RN, FAAN; Joan Bloch, PhD, CRNP, FAAN; Rosalie Mainous, PhD, APRN, NNP-BC, FAAN, FAANP; Jacqueline McGrath, PhD, RN, FAAN, FNAP; Shahirose Premji, PhD, RN, FAAN; Susan Sinclair, PhD, RN, MPH, FAAN; Mary Terhaar, DNSc, RN, FAAN, ANEF; M. Terese Verklan, PhD, RNC, CCNS, FAAN; Marlene Walden, PhD, APRN, CCNS, NNP-BC, FAAN; Rosemary White-Traut, PhD, RN, FAAN; SeonAe Yeo, PhD, RNC, FAAN; Linda B. Zekas, MSN, APRN, NNP-BC, CPNP-PC, CWON, FAAN.

Joint expert panel contributors include: Elizabeth A. Kostas-Polston, PhD, APRN, WHNP-BC, FAANP, FAAN, Co-Chair, Women’s Health Expert Panel; Cindy Smith Greenberg, DNSc, RN, CPNP-PC, FAAN, Co-Chair, Child, Adolescent & Family Expert Panel, and Marina Boykoba, PhD, RN.

Acknowledgement: The authors of the Policy Brief wish to thank the members of the Maternal & Infant Health Expert Panel, Ellen Olshansky, PhD, RN, WHNP-BC, FAAN, American Academy of Nursing board liaison to the Maternal & Infant Health Expert Panel, Cheryl Sullivan, Chief Executive Officer, American Academy of Nursing, and Kim Czubaruk, Esq., American Academy of Nursing staff liaison to the Maternal & Infant Health Expert Panel.

We interviewed Dr. Kenner, the Carol Kuser Loser Dean and Professor of the School of Nursing, Health, and Exercise Science at the College of New Jersey, focusing on the policy brief that she co-chaired, to speak about the brief using our 3 Questions format!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

We invite commentary that is thoughtful and provocative! Join the online dialogue!

 

Carole Kenner, PhD, RN, FAAN, FNAP, ANEF

Carol Kuser Loser Dean/Professor
School of Nursing, Health, and Exercise Science, The College of New Jersey

 

Question 1. Why are the preterm birth rates rising in a high resourced country such as the U.S.?

Well first of all, thank you for the opportunity to share a topic that I feel very passionate about. I’ve been a neonatal nurse in maternal child for a lot of years and do a lot of global work. It’s very concerning to me (and I have to say the opinions that I’m going to express here are mine and not the American Academy of Nursing from my background and expertise) but it’s a real concern to me that we look more like low resource or developing countries in terms of our prematurity rate and especially with the rise in prematurity births, preterm births in the last two years in this country. As far as why – I think there is a multitude of factors. I think it’s the structure of our insurance coverage for women in this country. And I think it’s certainly the rise in delayed childbirth, the use of assistive reproductive technologies in this country. But the other thing is the fact that we have underrepresented women that don’t have access to care; don’t have access to maternity leave if they have jobs necessarily; and they, unfortunately, as our policy briefs mentions, in thirteen states in particular really represent the bulk of the premature births.

That’s a concern! So I think it’s insurance coverage, coverage access to care, a use of reproductive technologies, as well as the fact that we have underserved, underrepresented populations that continues to show disparities in in this area. And the lack of maternity leave – I can’t stress that enough – that women get very stressed in thinking about the fact that they have no maternity leave; and some women would normally take and start taking leave prior to a delivery, and now they’re working up to the time of a delivery. Well you might say, why does that contribute to preterm birth that they’re working up to delivery? – Because they’re delivering early because they know they might not even have any kind of leave available to them after the birth at all.

 

Question 2. What strategies can we use to raise awareness of the problem of an escalating rate of preterm births?

I think building on what the March of Dimes started several years ago when they created the campaign around “every pregnancy and every baby deserves a full 40 weeks.” It really was one of those awareness campaigns that grabs the attention of people across the spectrum – meaning from lay public through to professionals and to legislators. I believe that we have to do the same thing here with preterm births. People in general don’t realize the dangers that occur even with having late preterms – that means that babies that are born at 34 to 36 weeks gestation out of a 40 week pregnancy – that those babies act much more like preterm babies than they do term babies. And yet for a number of years we’ve thought in this country “Oh! We’ve got all the neonatal intensive care units! We’ve got all the technology to support these babies!” But the truth of the matter is: they may have some life-long problems. Not all, we have done a good job of providing neonatal care. But the families also have burdens, not only of just the stress of having a baby that’s born preterm, but the fear – even if everything worked out all right – of what’s going to happen with that baby and how that financially may impact them (again, depending on how much insurance or what kinds of insurance coverage – if any that they have).

So, strategies! Strategies are creating that awareness. Every time that I go to speak someplace, I always bring up the fact: Did you know that the US is really up there with India in the top ten countries in the world that have prematurity rates that do not compare with other high resourced, well developed countries? Bringing those key messages to legislators anytime we have the opportunity! Not waiting for an Op Ed! Not waiting for this blog (which is a great way to do it to raise the awareness!) Getting things out in social media now, and using that to see how impactful just key awareness statements are! When you say that there are research studies that support that paid maternity leave does impact preterm birth rates, that’s insightful! But we always tend to wait until we can write a full blown paper to get this out in the literature.

And instead, I think, we have to go the opposite and strategize around getting the message – that means that we also (those of us that were involved in writing the policy brief in particular) have an obligation now to work with other organizations. To partner. To make sure that this is integrated into conferences, into workshops, into blogs, into other areas, so that you’re hitting with as much impact as you can – hitting all levels of stakeholders. And I think that something that we haven’t really been good at in the past in terms of looking at different modalities of getting that word out: going to for example, that I have done, to Women League of Voters and talked about some reproductive issues – talked about some neonatal issues. Not just talked about voting issues! Bringing up some of the successes that other countries have had when they have put more funding behind maternal and infants’ health.

And also recognizing that this is an area of great opportunity for researchers to look at what are the strategies around combating preterm birth rates. So why is that a strategy in terms of raising awareness? Because in the research community, at some of our research meetings – our regional nursing meetings and other research meetings – we should be bringing up this topic within the context, especially those of us that do maternal-child research! Bring up this rising prematurity rate within the context of our research and the gaps that are out there!

 

Question 3. Your group proposed that targeted campaigns should be a high priority to protect those that are most vulnerable, pregnant women and children. What does this mean for nursing?

I would definitely say to nurse leaders, nurse educators and nurse researchers that we need to know the data. We need to bring those data to the awareness of the stakeholders in our organizations. So as an educator, right now, I work with public health undergraduate students, I work with nursing students and graduate nursing students. And I have said, “you know … this is a real problem!” With my maternal child faculty, we’ve had discussions about this and the fact that we need to begin to talk about the US’s role in contributing to preterm birth rates globally and also contributing to neonatal mortality globally. These are not conversations that we normally have. Nursing leadership, both in the practice side, in the education and in the research side needs to know this. We tend to gloss over this if you’re not very intimately involved in maternal child. We know that we’ve got increasing disparities in this country in terms of women’s health and concern over the cuts (the proposed cuts) for funding for women’s health services and what that might do – but not generally looking: is there a linkage with preterm birth rates and what that may do if they continue to rise? – why it’s an embarrassment, in my view, for the US with all the resources we have, to be in this position of one of the top 10 countries in the world with rising preterm birth rates.

So again, nursing has probably the greatest opportunity to impact this problem by working within some many of our own specialty organizations, but also, now that nurses are on many interdisciplinary boards, bringing that to the attention of those boards and saying “this is the time when we need to band together to play together in terms of a strategy.” This is not a strategy that nursing in and of itself can take on. This is a strategy that should involve insurance agencies or Centers for Medicare Medicaid Services (CMS) for the legislators to be involved, such as a passage, just now, of the Preemie Re-Authorization Act – iIt has gotten through the Senate; it now has to go through the House) to begin to strategize together with nursing taking the leadership, because we’re at the grassroots we’re at the bedside! we’re in the NICUs! we’re in the prenatal areas! The nurse midwives, they are seeing, also, complications in their practice and know how important it is to do good pre-conceptional and pre-prenatal discussions about the risks – raising the awareness at every level and then encouraging our researchers, especially our nurse researchers, to look more closely in terms of even health services research; looking at health systems, and how that could impact the preterm birth rate and what that could mean for us.

So, I really believe that nursing is at the (what I always say) is “at the bleeding edge” because we become the interface between policy issues and the public that we serve. We also become the interface between taking our stories of what it’s like to have a family that you are working with that experiences a preterm birth and everything that goes along with it, as well as the journey of the child, because I believe it’s the stories that grabs the public’s attention and grabs the legislator’s attention. It’s not about just data. We have to have the data; we can’t just have the passion. But we have to bring to the table the stories, so that we can advocate and be actively involved in reversing this course.