Preventing Preterm Births: When Little Things Matter Most

Ask parents about the cost of raising kids, and they’ll likely just roll their eyes. Yes, raising children is expensive, and those costs increase every year. Just having a child is costly, but when a baby is born prematurely, the costs rise dramatically and continue long after that infant goes home from the hospital.

The Centers for Disease Control and Prevention define premature (preterm) as a birth that occurs three or more weeks before the baby’s due date. The fetus develops tremendously in the last few weeks before birth and the more premature the birth, the more severe the baby’s health problems are likely to be. If the infant survives, he or she could face lifelong problems including neurological, cardio-vascular, gastro-intestinal, respiratory, and cognitive deficits — problems that result in high healthcare costs.

A look at the costs

Premature birth is one of the top catastrophic claim categories, accounting for nearly one-third of all claims over $1 million between 2010 and 2013. According to MHPA (The Medicaid Health Plans of America), preterm birth is the leading cause of infant morbidity and mortality, affecting 11.4% of births in the U.S. Preterm birth accounts for 50% of all pregnancy costs, largely due to neonatal admissions. In fact, the March of Dimes puts the costs of premature birth to employers alone at 12 times that of full-term births and those costs only increase the earlier in the gestation cycle the delivery occurs.

Medical technology can save the lives of infants born as early as 25 weeks, but that comes with a significant price tag.  According to the Committee on Understanding Premature Birth and Assuring Healthy Outcomes, “the annual societal economic burden associated with preterm birth in the United States was at least $26.2 billion in 2005, or $51,600 in ongoing costs per infant born preterm. Medical care services contributed $16.9 billion to the total cost and maternal delivery costs contributed another $1.9 billion. A “million dollar baby” has become the cost standard for pre-term births.

How big is the problem?

The rate of premature births in the United States dropped in 2013 to 11.5% (a 15-year low) but rated just a “C” on the March of Dimes Premature Birth Report Card. Why the mediocre score? That 11.5% was the highest rate among industrialized nations.

Premature births can result for myriad reasons, including:

• Premature rupture of membranes (PROM). PROM is associated with women who have in low socioeconomic status, low body mass index (BMI), use tobacco, have a history of preterm labor, develop urinary tract infection (UTI), experience vaginal bleeding at any time during the pregnancy, or undergoes amniocentesis.
• Medical indications. Medical reasons for early delivery include mateal illness and complications such as multiple fetuses, high blood pressure, preeclampsia, infections (such as urinary tract infections), advanced material age, rheumatoid arthritis, gestational diabetes, asthma, thyroid disease, and cardiac problems.
• Preterm labor (PTL). PTL can result from anatomical problems such as the mother having a short or weak cervix or atypical uterus, vaginal bleeding, or even depression and anxiety.
• Elective preterm delivery. Patient convenience, physician convenience, and even policy changes in the American College of Obstetricians and Gynecologists have all contributed to a one-week reduction in the national gestational age (i.e., 39 weeks rather than the full 40 weeks).

Prevention: Watching for the little things

What can be done to help prevent premature births? First and foremost, education and proper mateal care are imperative.

For example, providers can work to identify those mothers at greatest risk of complications, such as those experiencing vaginal bleeding, mothers pregnant with multiples (e.g., twins, triplets), and those who have chronic infections (e.g., UTIs or sexually transmitted diseases). In addition, working with mothers to maintain an appropriate BMI, control risk factors for diabetes and maintain a healthy blood pressure can increase the chance of healthy, full-term pregnancies.

Another factor in ensuring full-term pregnancies is reducing or eliminating elective preterm deliveries. According to the Hospitals & Health Networks (H&HN), evidence-based medicine shows that “elective delivery increases complications among babies and their mothers”.

In one initiative to reduce elective preterm deliveries, 400 participating hospitals reported a 42% drop in the volume of early elective deliveries. According to the H&HN website, “In the case of elective deliveries before 39 weeks, the evidence is strong — babies’ brains, lungs and livers aren’t fully developed until 39 weeks. Infants born earlier are more likely to require a neonatal intensive care unit [NICU] stay, to have difficulty keeping warm, to have a hard time eating and to have jaundice”. Similarly, the March of Dimes notes that “women undergoing induced labor are twice as likely to need a C-section”.

But what about unavoidable preterm deliveries?

In cases of PTL, drug interventions can help labor and extend the time before delivery. Tocolytic (anticontraction) medications, such as nifedipine (a calcium channel blocker), magnesium sulfate (MgSO₄), and beta-mimetics like terbutaline can delay delivery 24 to 72 hours, long enough for transport to a Level 3 NICU. In addition, corticosteroids can aid in fetal lung maturation, and MgSO₄ offers fetal neuroprotection, with several studies citing a reduction in the incidence of cerebral palsy.

Recently, hydroxyprogesterone caproate injection (Makena^®) received U.S. Food and Drug Administration (FDA) approval for use in pregnant women carrying a single fetus, with a study showing prolonged pregnancy for women treated with the drug. (This drug is not recommended for multiple fetuses.)

What can Insurers and Providers do?

Insurers and Providers can be valuable partners in helping to reduce preterm births by working together to develop proactive medical management plans for expectant mothers that can include:

• Screening, education, care coordination and streamlined prior authorization for preventive treatments.
• Education about risk factors to watch for at the onset of pregnancy.
• Risk factors to watch for during pregnancy.
• Reducing unwarranted early deliveries.

PartnerRe can assist our clients in implementing preterm medical management programs that are developed to help reduce preterm deliveries, improve clinical outcomes and manage medical cost.

For more information, contact the experts at PartnerRe online or by phone at (415) 354-1551 to participate in our upcoming webinar on “Preventing Preterm Births.”