Temporal trends in neonatal mortality and morbidity following spontaneous and clinician-initiated preterm birth in Washington State, USA: a population-based study

Abstract

ObjectiveAfter a decade of increase, the preterm birth (PTB) rate has declined in the USA since 2006, with the largest decline at late preterm (34–36 weeks). We described concomitant changes in gestational age-specific rates of neonatal mortality and morbidity following spontaneous and clinician-initiated PTB among singleton infants.Design, setting and participantsThis retrospective population-based study included 754 763 singleton births in Washington State, USA, 2004–2013, using data from birth certificates and hospitalisation records. PTB subtypes included preterm premature rupture of membranes (PPROM), spontaneous onset of labour and clinician-initiated delivery.Outcome measuresThe primary outcomes were neonatal mortality and a composite outcome including death or severe neonatal morbidity. Temporal trends in the outcomes and individual morbidities were assessed by PTB subtype. Logistic regression yielded adjusted odds ratios (AOR) per 1 year change in outcome and 95% CI.ResultsThe rate of PTB following PPROM and spontaneous labour declined, while clinician-initiated PTB increased (all p<0.01). Overall neonatal mortality remained unchanged (1.3%; AOR 0.99, CI 0.95 to 1.02), though gestational age-specific mortality following clinician-initiated PTB declined at 32–33 weeks (AOR 0.85, CI 0.74 to 0.97) and increased at 34–36 weeks (AOR 1.10, CI 1.01 to 1.20). The overall rate of the composite outcome increased (from 7.9% to 11.9%; AOR 1.06, CI 1.05 to 1.08). Among late preterm infants, combined mortality or severe morbidity increased following PPROM (AOR 1.13, CI 1.08 to 1.18), spontaneous labour (AOR 1.09, CI 1.06 to 1.13) and clinician-initiated delivery (AOR 1.10, CI 1.07 to 1.13). Neonatal sepsis rates increased among all preterm infants (AOR 1.09, CI 1.08 to 1.11).ConclusionsTiming of obstetric interventions is associated with infant health outcomes at preterm. The temporal decline in late PTB among singleton infants was associated with increased mortality among late preterm infants born following clinician-initiated delivery and increased combined mortality or severe morbidity among all late preterm infants, mainly due to increased rate of sepsis.

Accelerated fetal growth in early pregnancy and risk of preterm birth: a prospective cohort study

“…(7,17) Furthermore, the higher rates of medically induced preterm births observed in our study could re ect increasing rates of medical intervention over time, a trend that has also been reported in other settings. (18)(19)(20)(21) Although the exact pathophysiological mechanism behind our ndings still remains unknown, on the physiology of uterine contractions, it is thus reasonable to assume that accelerated fetal growth could increase the distension demands posed on the uterus to a greater degree than during normal fetal growth and subsequently trigger spontaneous preterm labor. The theory is also in line with the contrasting nding of preterm birth and delayed fetal growth.…”

Accelerated Fetal Growth in Early Pregnancy and Risk of Preterm Birth: A Prospective Cohort Study

“…(7,14) Furthermore, the higher rates of medically induced preterm births observed in our study could re ect increasing rates of medical intervention over time, a trend that has also been reported in other settings. (15)(16)(17)(18) Although the exact pathophysiological mechanism behind our ndings still remains unknown, a number of possible hypotheses associated to the onset of labor have been proposed. One of the theories to explain the timing of birth refers to prelabor mechanical distention and stretching of the myometrium.…”

Accelerated fetal growth in early pregnancy and risk of preterm birth: a prospective cohort study

“…(7, 17) Furthermore, the higher rates of medically induced preterm births observed in our study could re ect increasing rates of medical intervention over time, a trend that has also been reported in other settings. (18)(19)(20)(21) Although the exact pathophysiological mechanism behind our ndings still remains unknown, a number of possible hypotheses associated to the onset of labor have been proposed. One of the theories to explain the timing of birth refers to prelabor mechanical distention and stretching of the myometrium.…”