Health care advocacy

Mamas on Bedrest: Early Prenatal Care Lowers the Risk of Preterm Birth

December 13th, 2013

Early initiation of progesterone prophylaxis is associated with a reduction in spontaneous preterm births among women with a history of preterm delivery, a new retrospective cohort study shows.

So Begins a recent study published by Kara B. Markham, MD, from the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Ohio State University. Interestingly, the more important piece of the article is,

Special efforts to promote timely access to care and initiation of progesterone treatment are likely needed to lower the rate of prematurity.

For me, this is the crux, the real nugget of truth to this article. When prenatal care is initiated early, many necessary treatments can be initiated at times when they may actually be effective.

So let’s look at the article.

The investigators analyzed data on women with a history of preterm birth attending the Prematurity Clinic at The Ohio State University Wexner Medical Center between January 1, 1998, and June 30, 2012. Clinicians started in 2004 to offer high-risk women routine progestin prophylaxis, delivered as weekly injections provided by a clinic staff member, and, starting in 2008, women could opt for daily, self-administered vaginal suppositories..The greatest reductions in preterm deliveries were observed in birth rates before 37 and 35 weeks of gestation. No significant difference was seen in the odds of birth at less than 32 weeks’ gestation, although the study was not statistically powered to detect a difference at that point in pregnancy.

According to the authors, Our report suggests that progestin prophylaxis can reduce the rate of recurrent spontaneous preterm birth when barriers to care and treatment are aggressively removed and that the gestational age at initiation may affect the success of progestin prophylaxis.”

This is great. Yet it has already been esstablished the progesterone therapy is effective in the prevention of preterm labor. (see our previous blog posts on 17OHP/Makena Injections) But the real gem of this article isn’t the progesterone therapy, but the realization by the authors that if prenatal care is initiated early, progesterone therapy can be initiated early and effectively prevent preterm births.

According to this publication, many of the women at risk for preterm delivery were Medicaid recipients. Because of the laws governing Medicaid in Ohio, there is a lag time between when a women is approved to receive Medicaid and eligible to receive Medicaid benefits (i.e. about to go for prenatal care). So in 2008,

the clinic started a program designed to identify and address obstacles to the timely initiation of progestin therapy, such as delayed entry to prenatal care, late identification of patients most in need of progestin prophylaxis, barriers to obtaining insurance, and safe administration of progestin injections. 

This action resulted in

the mean gestational age at the first clinic visit dropped from 19.6 weeks in 1998 to 2003, to 17.4 weeks in 2004 to 2008, and to 15.5 weeks after 2008, a statistically significant reduction (P < .01 for trend)Compared with the period from 1998 to 2007, the odds ratios of preterm birth in 2008-2012, adjusted for race, cerclage, smoking, and number of prior preterm births, were 0.75 at less than 37 weeks’ gestation (95% confidence interval [CI], 0.58 – 0.97), 0.70 at less than 35 weeks’ gestation (95% CI, 0.52 – 0.94), and 1.21 at less than 32 weeks’ gestation (95% CI, 0.83 – 1.76).

The authors note that the reduction in preterm births could be attributed to some unknown factor, but from what they observe, aggressively getting women (who need it) approved for Medicaid and in for their first prenatal visit early greatly enhanced the likelihood that they would start progesterone therapy at a time when it would be most effective.

This is truly remarkable work. Not only did the researchers find Progesterone therapy effective in preventing preterm births, they also found that early prenatal care also plays a role in reducing preterm births. Since women were seen and evaluated earlier, if any medical treatments or interventions were needed, they were started sooner rather than later.

Early intervention is the crux of most medical therapies; breast cancer campaigns, infant vaccination programs, diabetes treatments….Is it any wonder, then that early intervention is also beneficial when it comes to prenatal care? I was unaware that iniital prenatal visits have been pushed out to 10 weeks and beyond. It seems to me that earlier is better-allowing time to get baseline laboratories and to educate mamas on much needed prenatal information.

In my opinion, this is another example of how insurance coverage-money- is dictating medical care. And once again, this is proving to be an inappropriate standard by which to practice medical care. What is it going to take for us, as a society, to understand that sometimes faster, cheaper, leaner isn’t better? It certainly isn’t the case when it comes to health care and it most certainly isn’t best when it comes to prenatal care. We now have “evidence” to this, so in this era of “evidence based medicine”, isn’t it time to practice what we preach?

Reference

Markham, Kara B. MD; Walker, Hetty RNC-OB, CCRC; Lynch, Courtney D. PhD, MPH; Iams, Jay D. MD “Birth Rates in a Prematurity Prevention Clinic After Adoption of Progestin Prophylaxis”  Obstetrics & Gynecology., POST AUTHOR CORRECTIONS, 6 December 2013.