Quality improvement to prevent prematurity: A report of a national symposium

In the United States, 12.7% of all live births (more than 546,000 in 2007 were preterm (i.e., less than 37 completed weeks' gestation).¹ This marks a 36% increase since the early 1980s. In 2006, prompted by the significant effect of prematurity on the health of America's children, the well-being of affected families, and society at large, the Institute of Medicine (IOM) issued Preterm Birth: Causes, Consequences, and Prevention, a report that describes preterm birth as a complex public health problem that requires multifaceted solutions.²

Preterm birth is associated with increased incidences of acute and lifelong disabilities, including cerebral palsy, mental retardation, blindness, deafness, and chronic respiratory and cardiovascular problems, and exacts a significant financial toll, with the annual societal economic burden totaling at least $26.2 billion in 2005, or $51,600 per preterm infant.² These figures represent the combined cost of maternal delivery and acute medical care required by premature infants at various stages, early interventions, special education, and lost productivity. In addition, the emotional consequences of preterm birth for parents and families are far reaching and should not be underestimated. The long-term emotional and societal costs can include increased family disruption, postpartum depression, and sometimes divorce.

Recent evidence suggests that the increase in preterm births is primarily due to the growing number of late preterm births, those between 34 0/7 and 36 6/7 weeks of gestation.¹ These infants account for more than 70% of all preterm births.³ Analysis of gestational age distribution of births in the United States between 1990 and 2006 reveals that the rates of late preterm births at 34 to 36 weeks' gestation and of early term births at 37 and 38 weeks' gestation have risen sharply, whereas for the rate of births occurring at 40 weeks' or more gestation has declined.¹

In 1986, ACOG instituted a Voluntary Review of Quality of Care program (VRQC) to assess and improve the quality of care provided by hospital departments of obstetrics and gynecology.⁶ These reviews document suboptimal compliance with ACOG guidelines for early induction without clinical indication.⁶

Not all trends associated with the increased number of preterm births are negative. Active obstetric management of preterm and early term pregnancies in recent years is associated with decreases in infant and fetal mortality.⁷ Since 1990, infant mortality has dropped 25%, from 9.2 to 6.9 per 1,000 live births, and fetal mortality (stillbirth) has dropped 17%, from 7.5 to 6.2 per 1,000 live births.^7-10

Before 2004, few experts recognized that the incidence of late preterm birth was increasing, but also-and more important-that late preterm infants are at risk for serious health problems. Compared with full-term infants, late preterm infants have higher rates of mortality and morbidities such as respiratory distress, apnea, hyperbilirubinemia, and feeding problems; they are more likely than term infants to need supplemental oxygen support and rehospitalization; and they require higher medical care expenditures.^11-18 In addition, data increasingly support the fact that early term births-infants born from 37 through 38 weeks' gestation-have higher rates of mortality and neonatal morbidity than infants born at 39 to 40 weeks.^16,18-20

Within the last 2 decades, interest in, and awareness of, the role of quality improvement programs in decreasing morbidity and mortality in clinical practice have increased dramatically. A series of reports from the IOM, including To Err Is Human: Building a Safer Health Care System and Crossing the Quality Chasm: A New Health System for the 21^st Century, brought critical attention to the high rate of preventable errors in hospitals and the concept that bad systems, not bad people, lead to the majority of errors and injuries.^21,22 The IOM reports spurred quality improvement initiatives nationwide, but only in recent years has interest in applying these concepts to the prevention of prematurity skyrocketed.