The Consequences of Progress
Despite advances in neonatal and perinatal medicine, certain aspects of pregnancy and parturition continue to perplex physicians and researchers.
Of these, the biologic basis of preterm delivery remains particularly vexing. The rate of preterm birth in the United States continues to climb at an alarming rate despite substantial investment in high-level obstetrical care and good health conditions. The National Center for Health Statistics indicates that 12.8% of all births occur before 37 weeks, a 36 percent increase from the early 1980’s. The growing number of infants born between 32 and 34 weeks gestation, so-called late preterm infants accounts much of the increase during this time period.
The preterm birth rate is the most important epidemiologic factor contributing to infant mortality (death during the first 12 months of life). Even late preterm infants experience excess mortality risk compared to their term counterparts. Although key organ systems have matured to the point that survival is possible outside the uterus, crucial developmental processes continue. These include the formation of mature alveoli in the lung and substantial maturation of the brain, which doubles in
size between the 34th and 40th weeks of gestation. This development is supposed to take place in utero – and yet increasing numbers of babies complete the process outside the womb.
What Cost Survival
We have made tremendous progress in the care of these preterm infants. You will learn about some of these advances in the pages that follow. Chances for survival following a preterm delivery have never been better, but long-term complications after being born too soon remain a great concern to clinicians and families. Preterm infants bear a higher risk of developmental delay, poor growth, and chronic health problems such as asthma. As our efforts at improving survival bear fruit,
we need to refine our focus toward improving outcomes rather than simply measuring success through mortality statistics
Looking at Long-Term Outcomes
We have long appreciated that long-term neonatal outcomes are affected by events during pregnancy, or even before conception. However, the traditional focus of neonatology is restricted to events around the time of delivery and beyond. Similarly, the practice of obstetrics concentrates on prenatal care and the delivery of a healthy infant, but less so on longer-term neonatal outcomes. As we consider the challenge of a complex issue such as preterm birth, it becomes apparent that solutions require a fluid understanding of the continuum of fetal health from pre-conception to long-term postnatal outcomes. Doing so requires data linking mothers with their babies.
Information is Key
Advances in neonatal care have dramatically reduced mortality due to respiratory problems. As these outcomes have improved, obstetricians have become more comfortable effecting delivery prior to 40 weeks gestation. However, we know that neonatal morbidity and mortality increase as gestational age decreases from term. As the percentage of spontaneous vaginal deliveries declines in the United states, we must enhance our understanding of how obstetrical decision-making impacts important neonatal outcomes such as behavioral and neurodevelopmental status. In this issue you will read about how we are working to develop useful data repositories that should help us understand how important factors such as maternal health and obstetrical practice affect neonatal outcomes beyond the delivery room. The detailed interrogation of data sets linking mothers to their infants is needed to understand the impact of changes in pregnancy on the well-being of our children.
Ultimately, improvements in pregnancy outcomes will require careful integration of data from the mother, the fetus/neonate, and the community. The Cincinnati Children’s Perinatal Institute builds upon that concept by creating collaboration among clinicians, investigators, and community providers with the goal of achieving the best possible outcome for mothers and newborns.
