Preterm Birth and Abortion 2 · 2017-07-25 · • Over the last two decades, the percentage of...

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The Burden of Abortion and the Preterm Birth Crisis MJ McCaffrey, MD, CAPT USN (Ret) Professor of Pediatrics Division of Neonatal-Perinatal Medicine Department of Pediatrics University of North Carolina School of Medicine Presented at Massachusetts Citizens for Life Convention, April 8, 2017

Transcript of Preterm Birth and Abortion 2 · 2017-07-25 · • Over the last two decades, the percentage of...

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TheBurdenofAbortionandthePretermBirthCrisis

MJMcCaffrey,MD,CAPTUSN(Ret)ProfessorofPediatrics

DivisionofNeonatal-PerinatalMedicineDepartmentofPediatrics

UniversityofNorthCarolinaSchoolofMedicine

PresentedatMassachusettsCitizensforLifeConvention,April8,2017

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Itinerary

• Thepretermbirthepidemic• Areallassociationsequalinthepretermbirthdiscussion?

– Smokingandsurgicalabortion• Theevidencefortheassociations• Istheabortionassociationmootinaneraofmedicalabortion?• Estimatingtheimpactofabortiononverypretermbirths• Countingthecostofabortion’simpactonVPB• Whatthen?

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ThePretermBirthCrisis• In2015,9.6%ofallbabiesbornintheUnitedStatesarebornpreterm• Overthelasttwodecades,thepercentageofpre-termdeliverieshasrisen20percent• PretermbirthvsLBW

– Prematurity,definedasabirthpriorto37weeks– LBW<2500gramsor5lbs 8oz

• .• In201563,000USbirthsareclassifiedasVeryPretermBirths(VPBs):<32weeks.• VPBsconstitute1.6%ofallbirthsintheUS• Thesebirthsassociatedwiththehighestriskfordeathandmorbidity

– RespiratoryDistressSyndromeandChronicLungdisease– Necrotizingenterocolitis– Intraventricular Hemorrhage(IVH)orbrainbleeding– Blindness– Hearingloss– Mentalretardation– CerebralPalsy

• TheestimatedannualcostforcareattributabletopretermbirthintheUnitedStatesis$26billion

InstituteofMedicine,NationalAcademyofScience,PretermBirth:Causes,Consequences,andPrevention,NationalAcademiesPress,WashingtonDC,2006.

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PretermBirthTrends

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IOMReportonPretermBirth:Causes,Consequences,andPrevention

• Establishedin1970bytheNationalAcademyofSciencestosecuretheservicesofeminentmembersofappropriateprofessionsintheexaminationofpolicymatterspertainingtothehealthofthepublic.

• TheIOMactsundertheresponsibilitygiventotheNationalAcademyofSciencesbyitscongressionalchartertobeanadvisertothefederalgovernment.

• ThemajorityofIOMstudiesandotheractivitiesarerequestedandfundedbythefederalgovernment.

InstituteofMedicine,NationalAcademyofScience,PretermBirth:Causes,Consequences,andPrevention,NationalAcademiesPress,WashingtonDC,2006.

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PerIOM:“ImmutableRiskFactors”AssociatedWithPretermBirth

• Previouslowbirthweightorpretermdelivery• Multiple2ndtrimesterspontaneousabortion• Priorfirsttrimesterinducedabortion• Familialandintergenerationalfactors• Placentalabnormalities• Cervicalanduterineanomalies• Inuterodiethylstilbestrolexposure• Multiplegestations• Infantsex• Shortstature• Lowprepregnancy weight/lowbodymassindex• Urogenitalinfections• Preeclampsia

InstituteofMedicine,NationalAcademyofScience,PretermBirth:Causes,Consequences,andPrevention.NationalAcademiesPress,WashingtonDC,2006:AppendixB,TableB-5,p625.

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PerIOM:PossiblyMutableRiskFactorsAssociatedWithPretermBirth

• Cigarettesmoking• Noorinadequateprenatalcareusage• Useofmarijuanaandotherillicitdrugs• Cocaineuse• Alcoholconsumption• Caffeineintake• Maternalweightgain• Dietaryintake• Sexualactivityduringlatepregnancy• Leisure-timephysicalactivities

InstituteofMedicine,NationalAcademyofScience,PretermBirth:Causes,Consequences,andPrevention,NationalAcademiesPress,WashingtonDC,2006.

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ReportoftheAdvisoryCommitteetotheSurgeonGeneraloftheUnitedStates:1964

“Fiveretrospectiveandtwoprospectivestudieshaveshownanassociationbetweenmaternalsmokingduringpregnancyandbirthweightoftheinfant.Womensmokingduringpregnancyhavebabiesoflowerbirthweightthannon-smokersofthesamesocialclass.Theyhavealsoasignificantlygreaternumberofprematuredeliveries(definedasbirthweightof2,500gramsorless)thanthenon-smokingcontrols.”

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CigaretteSmokingandPretermBirth:1985

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TheDataonSmokingandPretermBirth– A1984metaanalysiswhichexamined5studies,usedunadjustedoddsratios1– Sinceonesystematicreviewmetaanalysisofgoodquality2– Pooledpointestimateforanymaternalsmokingversusnomaternalsmokingwas1.27(95%

confidenceinterval,1.21-1.33)– Noneofthestudiesincludedpriorabortionasavariable– Heaviersmokingtrendedtoincreasedriskforpretermbirth– “Publicationbiasmayaffecttheresultsofthisstudy,butwebelieveitscontributionis

minimal…despitethepossibleexistenceofsomepublicationbias,thepooledestimateislikelyavalidestimateofthetrueunderlyingeffect.”

1.McIntoshID.Smokingandpregnancy.II.Offspringrisks.PublicHealthRev.1984;12:29–63.2.ShahNRandBrackenMB.Asystematicreviewandmeta-analysisofprospectivestudiesontheassociationbetweenmaternalcigarettesmokingandpretermdelivery.AmJObstet Gynecol.Feb2000;182(2):465–472.

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CigaretteSmokingandPretermBirth

• Cigarettesmokingisrecognizedtobeamongthemostprevalent,preventablecausesofadversepregnancyoutcomes.

• Smokingisstronglyrelatedtoplacentalabruption,reducedbirthweight,andinfantmortality

• “Therelationshipofcigarettesmokingtopretermbirthisrathermodestandnotentirelyconsistent.”

• Therangeofoddsratioforstudiesshowingsuchanassociationisfrom1.1-2.Thereareanumberofstudiesshowingnorelationship.Therearesomestudiesshowingaprotectiveeffectofsmoking.

InstituteofMedicine,NationalAcademyofScience,PretermBirth:Causes,Consequences,andPrevention,NationalAcademiesPress,WashingtonDC,2006.

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TheDataonAbortionandPretermBirth

• 145statisticallysignificantstudiesdemonstratingtheassociationofpretermbirthwithabortion(1963-Present)

• 26statisticallysignificantstudiesdemonstratingtheassociationofverypretermbirth(<32weeks)orverylowbirthweight(VLBW<1500grams)withabortion(1978-Present)

• Therearestudieswhichfailtoshowanassociationofabortionwithpretermbirthbuttheyaresmall

• Anylargestudywithatleast30,000mothersor500deliveries<33weeksshowsanassociationofabortionandpretermbirth

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TheSystematicReviewsandMetaAnalysesExaminingAbortionandPretermBirth

• SystematicReviewsinvolveadetailedandcomprehensiveplanandsearchstrategyderivedapriori,withthegoalofreducingbiasbyidentifying,appraising,andsynthesizingallrelevantstudiesonaparticulartopic.

• SystematicReviewsmayincludeameta-analysis(SRMA)componentwhichinvolvesusingstatisticaltechniquestosynthesizethedatafrommultiplestudiesintoasinglequantitativeestimateorsummaryeffectsize• Swingle HM,Colaizy TT,ZimmermanMB,Morriss FH.Abortionandtheriskofsubsequentpretermbirth:Asystematicreviewwithmeta-analyses.JRreproMed2009;54:95-108.

• ShahPS,Zao J.Inducedterminationofpregnancyandlowbirthweight andpretermbirth:asystematicreviewandmeta-analysis.BJOG2009;116:1425-1442.

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Meta-analysisbySwingle,etal2009

• Meta-analysesofliterature1995-2007• Pro-abortion&pro-lifeauthors• 7,891titles,349abstracts,130papers• 30abortion&26SABpapersincluded• Analyzeddatafrom12inducedand9SABpapers

SwingleHM,Colaizy TT,ZimmermanMB,Morriss FH.Abortionandtheriskofsubsequentpretermbirth:Asystematicreviewwithmeta-analyses.JReproMed2009;54:95-108.

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Meta-analysisbySwingle,etal2009

• Oneinducedabortionhada1.25adjustedOR[1.03-1.48]increasedriskpretermbirth<37weeks

• >1inducedabortion1.51OR[1.21-1.75]increasedriskpretermbirth<37weeks

• >1inducedabortionORof1.64[1.38-1.91]for<32weekdelivery(VPB)

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Meta-analysisbyShahetal2009

• Screened834papers• Excluded765forlackdata/objective• 69citationsreviewed• 32excluded,37included

ShahPS,Zao J.Inducedterminationofpregnancyandlowbirthweight andpretermbirth:asystematicreviewandmeta-analysis.BJOG2009;116:1425-1442.7

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Meta-analysisbyShah,etal2009:22PTBStudies

• Noabortionvs1Abortion• 22studies• 268,379patients• OR1.36[1.24-1.50]forPTB

• Noabortionsvs>1Abortion• 7studiesof22• 158,421patients• OR1.93[1.38-2.71]forPTB

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Watson,etal:Identifyingriskfactorsforverypretermbirth(20- 31⁶weeks)

• CasecontrolstudyfromAustralia;603casesand796controlsfrom2002-2004

• Findings:• 1abortionOR2.11(1.3,3.4)p<0.002;AOR2.02(1.2,3.3)p<0.004• >1abortionOR4.4(1.9,9.1)p<0.001;AOR3.50(1.6,7.9)p<0.002

Watson LF, Rayner J-A, Forster D. Identifying risk factors for very preterm birth: A reference for clinicians. Midwifery May 2013;29(5):434-439

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Hardyetal:Effectofinducedabortionsonearlypretermbirths

• 17,916patients• 2276(13%)hadundergoneonepriorinducedabortion,and862(5%)hadundergonetwoormorepriorinducedabortions.

• Womenwhoreportedonepriorinducedabortionweremorelikelytohaveprematurebirthsby32,28,and26weeks– ORwere1.45(95%CI1.11to1.90),1.71(95%CI1.21to2.42),and2.17(95%CI1.41to3.35),respectively

HardyG1,BenjaminA,Abenhaim HA.Effectofinducedabortionsonearlypretermbirthsandadverseperinataloutcomes.JObstet Gynaecol Can.2013Feb;35(2):138-43.

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Klemetti,etal:BirthOutcomesAfterInducedAbortion

• Nationwideregister-basedoutcomesoffirstbirthsinFinland;recordslinkedtooutcomes1996-2008;300,858firsttimemothers

• Controlledforcomorbidities:maternalage,maritalstatus,socioeconomicposition,urbanity,smoking,reproductivehistory;method,timingandindicationofabortion

• Increasedoddsforverypretermbirth(<28weeks)seeninallthesubgroupsexhibitedadose–responserelationship:OneIA1.19,twoIA’s1.69,threeIA’s2.78

Klemetti R, Gissler M, Niinimaki M, Hemminki E. Birth outcomes after induced abortion: a nationwide register-based study of first births in Finland. Human Reproduction 2012 August 29

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Klemetti,etal:BirthOutcomesAfterInducedAbortion

• “Intermsofpublichealthandpracticalimplications,healtheducationshouldcontaininformationofthepotentialhealthhazardsofrepeatIAs,includingverypretermbirthandlowbirthweightinsubsequentpregnancies.”

• “HealthcareprofessionalsshouldbeinformedaboutthepotentialrisksofrepeatIAsoninfantoutcomesinsubsequentpregnancy.”

• “Observationalstudieslikeours,howeverlargeandwell-controlled,willnotprovecausality.”

Klemetti R, Gissler M, Niinimaki M, Hemminki E. Birth outcomes after induced abortion: a nationwide register-based study of first births in Finland. Human Reproduction 2012 August 29

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AndtheSRMAsKeepComing• Lemmers etal.reviewed21studiesreportingon1,853,017womenwiththehistoryofa

dilatationandcurettage(D&C)procedureforeitherterminationofpregnancyorcompletionofmiscarriage.

• InwomenwithahistoryofD&Ccomparedwiththosewithnosuchhistory,theAORforPTBwas1.29[1.17;1.42],whileforVPBAORwas1.69[1.20-2.38].

• ForwomenwithahistoryofmultipleD&CscomparedwiththosewithnoD&C,theORforPTBwas1.74[1.10-2.76].

• WomenwithapreviousD&C,formiscarriageorterminationofpregnancyinthefirsttrimester,areatincreasedriskforPTBandespeciallyVPBincomparisontowomenwithoutapreviousD&C.

• “Thismeta-analysisshowsthatD&Cisassociatedwithanincreasedriskofsubsequentpretermbirth.TheincreasedriskinassociationwithmultipleD&Csindicatesacausalrelationship.Despitethefactthatconfoundingcannotbeexcluded,thesedatawarrantcautionintheuseofD&Cformiscarriageandterminationofpregnancy,themoresosincelessinvasiveoptionsareavailable.”

Lemmers M,Verschoor MA,HookerAB,Opmeer BC,Limpens J,Huirne JA,AnkumWM,Mol BW.Dilatationandcurettageincreasestheriskofsubsequentpretermbirth:asystematicreviewandmeta-analysis.HumReprod.2016Jan;31(1):34-45.

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AndtheSRMAsKeepComing• Saccone etal.included36studies(1,047,683women).• 31studiesonI-TOP,28included913,297womenwithahistoryofsurgicalI-TOP,3included10,253womenwithapriormedicalI-TOP.

• WomenwithapriorsurgicalI-TOPhadahigherriskofPTB(5.4%vs4.4%;OR,1.52,95%CI,1.08–2.16)

• MedicalI-TOPhadasimilarriskofPTBcomparedwiththosewhodidnothaveahistoryofI-TOP(28.2%vs29.5%;OR,1.50,95%CI,1.00–2.25)

• “PriorsurgicaluterineevacuationforeitherI-TOPorSABisanindependentriskfactorforPTB.Thesedatawarrantcautionintheuseofsurgicaluterineevacuationandshouldencouragesafersurgicaltechniquesaswellasmedicalmethods.”

SacconeG,PerrieraL,BerghellaV.Prioruterineevacuationofpregnancyasindependentriskfactorforpretermbirth:asystematicreviewandmetaanalysis.AmJObstet Gynecol.2016May;214(5):572-91.

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AbortionandPretermBirth

Ismedicalabortionassociatedwithpretermbirth?

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VirkJetal.:Medicalabortionandtheriskofsubsequentadversepregnancyoutcomes

• WomeninDenmarkhavingabortionfornonmedicalreasonsbetween1999-2004• Comparedsurgicaltomedicalfirsttrimesterabortion• 11,814pregnanciesinwomenwithpreviousfirst-trimestermedicalabortion(2710

women)orsurgicalabortion(9104women)– Nocontrolgroupwithoutanabortion– Didnotdescribethespecificsurgicalabortionmethod(surgicalripeningagentsornot)– DidnotanalyzedataforVPB

• “Wefoundnoevidencethatapreviousmedicalabortion,ascomparedwithaprevioussurgicalabortion,increasestheriskofspontaneousabortion,ectopicpregnancy,pretermbirth,orlowbirthweight.”

• Medicalabortionhasthesameriskforsubsequentpretermbirth.

VirkJ,ZhangJandOlsenJ.Medicalabortionandtheriskofsubsequentadversepregnancyoutcomes.NEngl JMed.2007Aug16;357(7):648-53.

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Liaoetal:RepeatedMedicalAbortionsandPTB

• Cohortstudy• 4yearsfromJanuary2006-December2009• Interviewbasedwithdeliveryoutcomes• 18,323women(19,527interviewed)(93.8%)• Dividedinto3comparisongroups:

– Nulliparouswomenwith1ormorefirsttrimestermedicalabortions(mifepristone)

– Nulliparouswithsurgicalabortions(elective)– Nulliparouswithnopreviousabortions

LiaoH,WeiQ,Duan L,GeJ,ZhouY,ZengW.Repeatedmedicalabortionsandtheriskofpretermbirthinsubsequentpregnancies.ArchGynecolObstet 2011;289:579-586

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Liaoetal:RepeatedMedicalAbortionsandPTB

• Exceptionalfollowup– 7,478withcompletefollowupinabortiongroupoutoforiginal7,558(98.9%)

– 10,546withcompletefollowupinnoabortiongroupoutoforiginal10,681(98.9%)

• FindingsOR1.4(1.1-1.8)pretermbirthwith1surgicalabortion• OR1.62(1.27-3.42)pretermbirth>3surgicalabortions(doseeffect)

• OR2.18(1.51-4.42)pretermbirthwithmedical&surgicalabortionsLiaoH,WeiQ,Duan L,GeJ,ZhouY,ZengW.Repeatedmedicalabortionsandtheriskofpretermbirthinsubsequentpregnancies.ArchGynecolObstet 2011;289:579-586

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Liaoetal:RepeatedMedicalAbortionsandPTB• OR1.03(0.53-1.63)noincreaseriskofpretermbirthwithmedicalabortions

comparedtonoabortionsbut…– OR1.4(1.1-1.8)pretermbirthwith1surgicalabortion– OR1.62(1.27-3.42)pretermbirth>3surgicalabortions(doseeffect)– OR2.18(1.51-4.42)pretermbirthwithmedical &surgicalabortions

• And…20.3%ofpatientsneededapost-abortionsuctioncurettage!– OR1.69(1.02-3.16)pretermbirthriskinwomenwithmedicalabortion<7weekswithcurettage

– ORfor<32weekdelivery(VPB)was3.61(1.43-4.93)with<7weekmedicalabortionwithcurettage(20%ofpatients)

• Didnotreporteitherofthesefindingsinabstract

LiaoH,WeiQ,Duan L,GeJ,ZhouY,ZengW.Repeatedmedicalabortionsandtheriskofpretermbirthinsubsequentpregnancies.ArchGynecolObstet 2011;289:579-586

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Oliver-Williamsetal:ChangesinAssociationbetweenPreviousTherapeuticAbortionandPretermBirthin

Scotland• Historicalcohortstudyof732,719firstbirths>24weeks• Pretermdelivery<37weeksdeclinedovertime• Surgicalwithoutuseofcervicalpre-treatmentdecreasedfrom31%to0.4%;medicalabortionsincreasedfrom18%to68%duringthisperiod

• Previousabortionassociatedwithpretermbirthmostprevalent1980-1983(OR1.32[1.21–1.43]);overallOR(1.12[1.09–1.16])

Oliver-WilliamsC,FlemingM,Monteath K.,WoodAM,SmithGCS.ChangesinAssociationbetweenPreviousTherapeuticAbortionandPretermBirthinScotland,1980to2008:AHistoricalCohortStudy.PLOSJuly2013;10(7:1-11)

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Oliver-Williamsetal:Changesinassociationofabortionandpretermbirth:Scotland1980-2008

Oliver-WilliamsC,FlemingM,Monteath K.,WoodAM,SmithGCS.ChangesinAssociationbetweenPreviousTherapeuticAbortionandPretermBirthinScotland,1980to2008:AHistoricalCohortStudy.PLOSJuly2013;10(7:1-11)

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Oliver-WilliamsC,FlemingM,Monteath K.,WoodAM,SmithGCS.ChangesinAssociationbetweenPreviousTherapeuticAbortionandPretermBirthinScotland,1980to2008:AHistoricalCohortStudy.PLOSJuly2013;10(7:1-11)

Oliver-Williamsetal:ChangesinAssociationofAbortionandPretermBirthinScotland

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Oliver-Williamsetal:Changesinassociationofabortionandpretermbirth:Scotland1980-2008

• “Wespeculate thatchangesinthemethodsusedtoachieveterminationofpregnancyarethemostplausibleexplanationforthelossoftheassociationbetweenpreviousabortionandthesubsequentriskofpretermbirth….Theaboveinterpretationassumesacausalassociationbetweensurgicalabortionwithoutcervicalpre-treatmentandpretermbirth,andthereareanumberofaspectsofthecurrentanalysisthataresupportiveofacausalrelation.”

• Theresearcherscouldnotdirectlytestwhetherthetrendstheynotewererelatedbecausetheydidnothaveinformationonthemethodofpreviousterminationlinkedtosubsequentbirthoutcomeforindividualwomen

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SoIsMedicalAbortionWithoutRiskForFuturePretermBirth?

• InSeptember2000,theU.S.FoodandDrugAdministrationapprovedmifepristonetobemarketedintheUnitedStatesasanalternativetosurgicalabortion.

• Whileadmittingthatsurgicalabortionincreasestheriskforpretermbirth,someproponentsofmedicalabortionadvancethetheorythatinjuryfromsurgicalabortionisthereasonabortionhasincreasedpretermbirthrisk

• Thisisanassumptionnotsupportedbycurrentresearch• Ifthisconclusionwastruewearestillleftwiththefactthat77%ofabortionsintheUnitedStatesin2011weresurgical

JonesRKandJerman J.AbortionincidenceandserviceavailabilityintheUnitedStates,2011.PerspectivesonSexualandReproductiveHealth,2014,46(1):3-14

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PathophysiologyofAbortionandPretermBirth

• Cervicaltraumaandinjury• Inductionoforpredispositiontoinflammation• Maternalstress• Unknownfactors

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ImpactofMedicalAbortion:MifepristoneandtheCervix

• SuddenlossofprogesteronefunctionuponRU486administrationdiffersfromthemoregradualwithdrawalofprogesteroneoccurringduringnormaltermbirth

• Up-regulateMetalMetalloprotein-9(MMP-9)release,degradesvascularbasementmembrane

• ThisinconjunctionwithreleaseofchemokinesincludingMCP-1andIL-8,favorsaccumulationofinfiltratingleukocytes,specificallyneutrophils,monocytesandmastcells

• ReleaseofcollagenasesMMP-1andMMP-8bystromalcellspromoteremodelingandlooseningofcervicalconnectivetissuestroma.

• ResultsinacombinationofprematureactivationofprocessesinvolvedintermripeningaswellasapartialactivationofresidentneutrophilsandmacrophagessimilartothePPrepairphaseofcervicalremodeling.

• MifepristoneinmousecervixupregulatesgenesincludingChi313,Ptgs1(Cox1)…genesofuncertainsignificancebutnotedtobeactiveininflammatorydisorders

1.DenisonFCetal.Theeffectofmifepristoneadministrationonleukocytepopulations,matrixmetalloproteinases andinflammatorymediatorsinthefirsttrimestercervix.Mol HumReprod.2000Jun;6(6):541-8.2.HoltRetal.TheMolecularMechanismsofCervicalRipeningDifferbetweenTermandPretermBirth.Endocrinology.Mar2011;152(3):1036–1046.

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ImpactofMedicalAbortion:MifepristoneandtheCervix

MifepristoneAdministration

✓

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RiskofChorioamnionitis AfterPriorAbortion

• Muhlemann etal.1– Athreefoldelevatedriskforbothinducedandspontaneousabortion

• Krohn etal.2– Womenwithspontaneousabortion(oddsratio=4.3;95%confidenceinterval2.9to6.4)orelectivetermination(oddsratio=4.0;95%confidenceinterval2.7to5.8)hadanincreasedriskofintraamnioticinfection.

1. Muhlemann K.etal.DoesanAbortionIncreasetheRiskofIntrapartum InfectionintheFollowingPregnancy?Epidemiology.1996:7(2):194-198.

2. Krohn M.etal.Priorpregnancyoutcomeandtheriskofintraamniotic infectioninthefollowingpregnancy.AmJObst Gyn.1998;178(2):381–385

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BradfordHillCriteria

• InhispresidentialaddressbeforetheRoyalSocietyofMedicinein1965,BradfordHillnotedthefollowing9conditionsthathelpstrengthencausalinferenceforanobservedassociation:strengthoftheassociation,consistency,specificity,temporality,doseresponse,plausibility,coherence,experiment,andanalogy.

• TheUSSurgeonGeneralappliedthenewlydevelopedBradfordHillcriteriaforcausalitytothecigarette-lungcancerlinkepidemiologicstudiestowarnthepublic

HillAB."Theenvironmentanddisease:associationorcausation?"inBullWorldHealthOrgan,volume83onpage796.

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BradfordHill:Abortion,SmokingandPretermBirth

• Timing:Abortionandsmokingoccurbeforepretermbirth• Doseeffect:Demonstratedforabortion,lessapparentforsmoking

• Consistencyofeffect:Yesforabortion,notsmoking– Repeatedlyobservedbydifferentinvestigatorsatdifferenttimes

• Strengthofassociation:Abortionhasaveryspecificassociationwithverypretermbirth

• Biologicalplausibility:Abortionyes,smokinguncertain

HillAB."Theenvironmentanddisease:associationorcausation?"inBullWorldHealthOrgan,volume83onpage796.

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AndCautionfromProfessorHill• “Noneofmynineviewpointscanbringindisputableevidencefororagainstthecause-and-effecthypothesisandnonecanberequiredasasinequanon.Whattheycando,withgreaterorlessstrength,istohelpustomakeupourmindsonthefundamentalquestion- isthereanyotherwayofexplainingthesetoffactsbeforeus,isthereanyotheranswerequally,ormorelikely,thancauseandeffect?”

• “Allscientificworkisincomplete– whetheritbeobservationalorexperimental.Allscientificworkisliabletobeupsetormodifiedbyadvancingknowledge.Thatdoesnotconferuponusafreedomtoignoretheknowledgewealreadyhave,ortopostponetheactionthatitappearstodemandatagiventime.“

• “Whoknows,askedRobertBrowning,buttheworldmayendtonight?True,butonavailableevidencemostofusmakereadytocommuteonthe8:30nextday.”

HillAB."Theenvironmentanddisease:associationorcausation?"inBullWorldHealthOrgan,volume83onpage796.

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AbidingtheWisdomofProfessorHill• Dr.JayIams:“Contrarytocommonbelief,population-basedstudieshavefoundthat

electivepregnancyterminationsinthefirstandsecondtrimestersareassociatedwithaverysmallbutapparentlyrealincreaseintheriskofsubsequentspontaneouspretermbirth.”1

• Dr.PhilSteer:“Akeyfindingisthatcomparedtowomenwithnohistoryoftermination,evenallowingfortheexpectedhigherincidenceofsocio-economicdisadvantage,womenwithjustoneTOP(terminationofpregnancy)hadanincreasedoddsofsubsequentpretermbirth.Wehaveknownforalongtimethatrepeatedterminationspredisposetoearlydeliveryinasubsequentpregnancy.Howeverthefindingthatevenoneterminationcanincreasetheriskofpretermbirthmeansthatweshouldcontinuetosearchforwaysofmakingterminationlesstraumatic.2

• OliverWilliamsetal.:“Inconclusion,wehaveshownthatpreviousabortionwasariskfactorforpretermbirthamongnulliparouswomeninScotlandpriorto2000.”3

1. IamsJDandBerghella V.Careforwomenwithpriorpretermbirth.AmJObstet Gynecol.2010;203(2):89–100.2. Steer,P.(2009),EditorsChoiceBJOG:AnInternationalJournalofObstetrics&Gynaecology.2009;116(11):i–ii.3. Oliver-WilliamsCetal.ChangesinAssociationbetweenPreviousTherapeuticAbortionandPretermBirthinScotland,1980to2008:AHistoricalCohort

Study.PLOSJuly2013;10(7:1-11)

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AbidingtheWisdomofProfessorHill

• CareofWomenRequestingInducedAbortion– RECOMMENDATION5.12:“Womenshouldbeinformedthatinducedabortionisassociatedwithasmallincreaseintheriskofsubsequentpretermbirth,whichincreaseswiththenumberofabortions.However,thereisinsufficientevidencetoimplycausality.”

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PlannedParenthood:RejectingHill’sWisdomandtheRightforWomentobeInformed

• “Therearemanymythsabouttherisksofabortion.Herearethefacts.Abortiondoesnotcausebreastcancer.Safe,uncomplicatedabortiondoesnotcauseproblemsforfuturepregnanciessuchasbirthdefects,prematurebirthorlowbirthweightbabies,ectopicpregnancy,miscarriage,orinfantdeath.”

http://www.plannedparenthood.org/health-info/pregnancy/pregnant-now-what/thinking-about-abortion

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ACOG:IgnoresHillCriteria

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Pediatrics:DismissingtheHillCriteria• “Theconsequencesofpretermdeliveryareoftensevere,andtheauthorsarepassionatein

theirplea,astheyhavebeeninmultipleotherpublicationsandinthelaypressinNorthCarolina.However,IamnotsurethatPediatricsisthebestforumtohighlighttheirconcerns.”

• “First,whiletheycite2well-donesystematicreviewsandmeta-analyses(Swingle 2009andShah2009),otherauthorscontendthatfirst-trimestersurgicalabortionsand(astheauthorsherealsostate)medically-inducedabortionsconferlittleriskoffuturepretermdeliveries(VirkandZhou).“

• “Anyapproachtohealththatreducesriskofpretermbirthisimportant.However,yourdiscussionappearstoassumethatwomenareroutinelyusingabortionasbirthcontrolwhichdemonstratesaprofoundmisunderstandingandlackofempathyregardingwomen¹sreproductivedecisionmaking.”

TheAbortion-PretermBirthAssociation:AnOpportunitytoReduceInfantMortality…2014

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Pediatrics:DismissingtheHillCriteria• "Therecommendationtolettheteenknowatthistimeaboutapossibleassociationof

abortionwithfuturepretermbirthandaboutallthepotentiallydireconsequencesofpretermbirth,hasastrongflavorofa‘righttolife’messagethatisnotrelevanttoorsupportiveoftheteen¹sdecisionmaking.“

• “Doyoubelievethatadiscussionaboutabortionrisksshouldbepartofroutinehealthmaintenancecounselingforteens?Manyproviderswouldrespectfullydisagree.Familiesandteensdonotneedtobeconvincedthatabortionisanegativechoice.TimeincounselingwouldlikelybebetterspentaddressingLARC(longactingreversiblecontraception),condomuse,andemergencycontraception,aswellasdatesafetyandintimatepartnerrelationships.”

• “Wedonotproscribewhatreviewersdointermsofbackgroundworkfortheirreview(nordootherpeerreviewjournalsasfarasIamaware)butasstatedpreviously,theissuesyouhaveraisedhavemadeandwillcontinuetomakeforimportanteditorialboarddiscussionsgoingforward.Thankyouagainforraisingtheseissuesforoureditorialboardtodiscuss.”

TheAbortion-PretermBirthAssociation:AnOpportunitytoReduceInfantMortality…2014

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AbortionDemographicsGuttmacher2014

https://www.guttmacher.org/fact-sheet/induced-abortion-united-states

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EstimatingImpactofAbortiononVPB• Nopubliclyavailablereportingofabortionhistorypriortobirth• Theimpactcanonlybeestimated• Calhounetal.reportedonthecostconsequencesofabortiononVPBin2007(for2002data)…31.5%ofVPBassociatedwithabortion

• Estimatenumbersofwomengivingbirthwithapriorabortion– Useknownabortionratesinapopulationwithhighlikelihoodoffuturepregnancy

– Estimate%ofthosewomenwithoneormultiplepriorabortions– AssignrelativeriskforfutureVPBforoneormultipleabortions– Calculate%ofVPBsbirthsimpactedbyabortion– Calculatesubgroupimpactsbasedonknowndifferencesinabortionratesinthosecommunities

• #VPBs,deaths,morbiditiesforverypretermbirths

CalhounBC,Shadigian E,RooneyB.JReprod Med.Costconsequencesofinducedabortionasanattributableriskforpretermbirthandimpactoninformedconsent.2007Oct;52(10):929-37.

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EstimatingImpactofAbortiononVPB• 2010aconveniencesampleyearbasedonareportissuedbyGuttamcherexaminingteenpregnancyoutcomesin2010.1

• AllestimationsarebasedonmodelofCalhounetal.2• In2010theaverageageoffirstbirthwas25.2years.Basedonthis,theabortionratefor15-24yearoldsisusedhereasconservativerepresentativeofthegroupofwomenmostlikelytohaveanabortionbeforealivebirth.

• Presumeallinducedabortionsaresurgicalinthisanalysis– Givenuntil2000,nomedicalabortions– MostUSabortionsstillsurgical(69%)perGuttmacher for2014– NotclearlyestablishedthatmedicalabortionimposeslessriskforafutureVPB– 2-5%ofinducedmedicalabortionsrequiresurgicalcompletion

1. Kost KandHenshawS.U.S.TeenagePregnancies,BirthsandAbortions,2010:NationalandStateTrendsbyAge,RaceandEthnicity.GuttmacherInstitute.May2014.

2. CalhounBC,Shadigian E,RooneyB.JReprod Med.Costconsequencesofinducedabortionasanattributableriskforpretermbirthandimpactoninformedconsent.2007Oct;52(10):929-37.

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EstimatingImpactofAbortiononVPB• 15-24yearoldexperiencingalivebirthwithatleastonepriorabortionisthesumof

thegroupratesexpressedasapercentage:5204/1000+130/1000=334/1000=33.4%

o Use30%asreasonableestimateforwomenhavingabirthafteranabortiono Acceptthatsignificantnumbersofwomenwilllaterhaveabortionswhichwillimpact

pretermbirthrisk• Thirtypercentistheestimateforthepercentofwomengivingbirthaftertwoormore

priorabortions.4• TheRRofVPBafter1abortionis1.691• TheRRofVPBafter2ormoreabortionsisestimatedas2.6(averageofHardyand

Martius)2,3• 70%ofwomenwithalivebirthhadnopriorabortionexposureand30%hadatleast

onepriorinducedabortion1. Swingle HM,Colaizy TT,ZimmermanMB,Morriss FH.Abortionandtheriskofsubsequentpretermbirth:Asystematicreviewwithmeta-analyses.JReproMed

2009;54:95-108.2. HardyG1,BenjaminA,Abenhaim HA.Effectofinducedabortionsonearlypretermbirthsandadverseperinataloutcomes..JObstet Gynaecol Can.2013

Feb;35(2):138-433. MartiusJA.isk factorsassociatedwithpreterm(<37+0weeks)andearlypretermbirth(<32+0weeks):univariateandmultivariateanalysisof106 345singleton

birthsfromthe1994statewideperinatalsurveyofBavaria.Eur JObstet Gynecol Reprod Biol.1998Oct;80(2):183-9.4.CohenS.GuttmacherPolicyReview.Spring2007,Volume10,Number25.,JonesRKetal.TrendsinAbortionintheUnitedStates.ClinicalObstetricsandGynecology.2009;52(2):119-129

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EstimatingImpactofAbortiononVPB• Ofwomenwithpriorabortionannuallygivingbirth,estimate30%hadtwoormore

priorabortions.Thisrepresents 9%ofthebirths(30%x30%).4• Theremainingwomenwithapriorabortionhadasingleterminationpriortobirth.This

numberis21% (30%-9%)ofthetotalnumberofbirthsafteranyabortion..• OverallexcessUSRRforaVPBattributabletoabortion=

(0.7x1.00)+(0.21x1.64)+(0.09x2.6)=1.28• Excess%ofUSVPBsattributabletopriorabortion=

100%x(1.28-1.0/1.28)=22%• Therewere64,604VPBsin2010,estimate14,212oftheseVPBs(22%)areattributable

toabortion• ExtrapolatingGuttmacher subgroupspecific15-19yo abortionrates,excessVPB%can

becalculated– Hispanicrate211/1000,whiterateof272/1000andblackrateof400/1000.– Usinglowestrateofexposure,Hispanicpregnancies(1x),asabaseline,whitepregnanciesfaceda1.29greaterlikelihoodofanabortion(1.29x)andblackteenpregnanciesa1.9greaterlikelihoodofpriorabortionexposure(1.9x)

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EstimatingImpactofAbortiononVPB• Applyingtheexcess%ofVPBduetoabortiontohistoricalnumbersofVPBs,thenumberofVPBsassociatedwithABforeachsubgroupcanbecalculated:

1x+1.29x+1.9x=14,212X=3,392

• Byrace,basedonbestestimatesand2010data,theannualnumberofabortionattributableexcessVPBs:

•TotalVPBs:14,212•HispanicVPBs:3,392(1X)•WhiteVPBs:4,376(1.2X)•BlackVPBs:6,445(1.9X)

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CountingtheCostofAbortionandVPB

• ThemortalityratereportedbytheNVSSfor2010forinfants<32weekswas16.7%

• ThenumberofdeathsresultingfromabortionattributableVPBs:– Totaldeaths:2,373(11,839survivors)– Hispanicdeaths:567(2,826survivors)– Whitedeaths:731(3,645survivors)– Blackdeaths:1076(5,369survivors)

NationalVitalStatisticsReports,Vol.61,No.1,August2012

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CountingtheCost• NewCerebralPalsyCasesin2010VPBsAttributabletoAbortion

•Totalinfantswithcerebralpalsy:1,657•Hispanicinfantswithcerebralpalsy:396•Whiteinfantswithcerebralpalsy:510•Blackinfantswithcerebralpalsy:752

NewSignificantMentalDelay(MDI<70)Casesin2010VPBsAttributabletoAbortion

•Totalinfantswithsignificantcognitiveimpairment:3,433•Hispanicinfantswithsignificantcognitiveimpairment:820•Whiteinfantswithsignificantcognitiveimpairment:1,057•Blackinfantswithsignificantcognitiveimpairment:1,557

Vohr BR,WrightLL,PooleWK,McDonaldSA.Neurodevelopmentaloutcomesofextremelylowbirthweightinfants<32weeks’gestationbetween1993and1998.Pediatrics.2005Sep;116(3):635-43.

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CountingtheCost

• NewBlindnessinatLeastOneEyein2010VPBsAttributabletoAbortion•Totalinfantswithblindness:118•Hispanicinfantswithblindness:28•Whiteinfantswithblindness:36•Blackinfantswithblindness:54

Vohr BR,WrightLL,PooleWK,McDonaldSA.Neurodevelopmentaloutcomesofextremelylowbirthweightinfants<32weeks’gestationbetween1993and1998.Pediatrics.2005Sep;116(3):635-43.

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CountingtheCostofVPBsCausedbyAbortionSince1973

625,328VPBsattributabletoabortion

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CountingtheCostofVPBsCausedbyAbortionSince1973

102,309Dead

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CountingtheCost:TheGruberCalculationofSavingsResultingfromAbortion

• “Wefindthatforthemarginalchildnotbornduetoincreasedabortionaccess…– “Theoddsoflivinginasingleparentfamilywouldhavebeenroughly70percenthigher…

– “Theoddsoflivinginpovertynearly40percenthigher…

– “Theoddsofwelfarereceipt50percenthigher…– “Fromtheseresults,weestimatethatthelegalizationofabortionsavedthefederalgovernmentover$14billioninwelfarepaymentsthrough1994.”

GruberJ,LevinePandStaiger D.AbortionLegalizationandChildLivingCircumstances:WhoistheMarginalChild?NationalBureauofEconomicResearchWorkingPaper6034,1997.

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CountingtheFinancialCostofAbortionResultingfromVPB

• 2010Costs(in2016$)forAbortionrelatedVPBinfanthospitalization:– Tricare2016DRGpayments(http://www.tricare.mil/drgrates/)

• Model1:Community(Non-Children’s,Non-ResidencyTrainingHospital)NICUCare

$981,142,551(hospitalcharges)+$245,285,638(profees)=$1,226,428,188• Model2:CommunityNICU(80%care)andChildren’sHospital(20%care)

$784,914,041(Community)+$283,053,772(Children’sHospital)+$266,991,953(profees)=$1,334,959,766

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CountingtheCostofAbortioninVPB

$22,600,000,000

$27,300,000,000

$47,000,000,000

$57,200,,000,000

0

50

100

150

200

250

300

350

Gruber"Benefit"ofAbortion1973-1994

HospitalCostofAbortionRelatedPretermBirth1973-1994

Gruber"Benefit"ofAbortion1973-2014

HospitalCostofAbortionRelatedPretermBirth1973-2014

Gruber"Benefit"ofAbortion1973-1994

HospitalCostofAbortionRelatedPretermBirth1973-1994

Gruber"Benefit"ofAbortion1973-2014

HospitalCostofAbortionRelatedPretermBirth1973-2014

GruberJ,LevinePandStaiger D.AbortionLegalizationandChildLivingCircumstances:WhoistheMarginalChild?NationalBureauofEconomicResearchWorkingPaper6034,1997.

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WhatNext?• Medicalprovidersneedtorecognizetheirdutytocreateaninformedconsentprocessfor

womenconsideringabortionthatstatestheriskinducedabortion,especiallysurgicalabortion,imposesforafutureVPB.

• Publichealthorganizationsneedtoaccepttheirresponsibilitytoinformthepublic,astheydidwithsmokinganditsassociationwithPTB,thatabortionismorehighlyassociatedandisacausalfactorforafutureVPB.

• Ideallywomenandmenwouldbemadeawareofthisassociationasapublicservicewhichwouldinformdecisionsbeingmadeprospectivelyregardingsexualactivityandcontraception

• StateandfederalDepartmentsofHealthandHumanServicesandEducationneedtoincorporateintopublicschoolsexeducationcurriculumstheevidencethatinducedabortionisamutableriskfactorforafuturePTB.

• TheCenterforDiseaseControl(CDC),asthestewardsofpublichealthforanationexperiencingapretermbirthepidemic,shouldacknowledgeandeducatethenationregardingtheestablishedscientificriskabortionposesforfuturepretermbirth.

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WhatNext?• TheMarchofDimesneedstoincludetheriskthatabortionposesforaVPBaspartoftheireffortsto

reducePTB.ThemissionoftheMarchofDimesis“Wehelpmomshavefull-termpregnanciesandresearchtheproblemsthatthreatenthehealthofbabies.”

• TheAmericanAcademyofPediatrics(AAP)BrightFuturesChildHealthPathwayshouldincludecounselingforadolescentsthatincludeseducationregardingtheriskabortionposesforafuturepretermbirth.

• TheAmericanCongressofObstetriciansandGynecologists(ACOG)shouldfollowtheexampleoftheRoyalCollegeofMedicineandrecognizetheabortion-VPBrisk.

• Researcheffortsarenecessarytoexaminethelongtermimpactofmedicalabortion,andspecificallymifepristone,oncervicalarchitectureandremodeling.

• ItshouldbearesearchprioritytoanalyzetherelationshipbetweenmedicalabortionandfuturePTBandVPB.

• Itshouldbearesearchprioritytoevaluatethepossibleroleof17Alpha-hydroxyprogesteronecaproate (17-P)inpreventingPTBwhenadministeredtomotherswithahistoryofapriorabortion.Thebeliefofsomethatapriorsurgicalabortionisan“immutable”riskfactorforafuturepretermbirthmaybeaninaccurateassumption.Itispossiblethatwith17-Pwemightbeabletomitigatetheriskforfuturepretermbirthforwomenwithanabortionhistory.

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RecommendedSources

• IssuesinLawandMedicinehttp://issuesinlawandmedicine.com/• AmericanAcademyofProlifeObGyns (AAPLOG)http://aaplog.org/

– AnnualBullfinchMeeting• September29,30andOctober1,2017• TheCenterforBioethicsandHumanDignity• TrinityInternationalUniversityCampus

• AmericanCollegeofPediatricshttps://www.acpeds.org/• HUSHhttp://hushfilm.com/

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“Additionalriskfactorsforpretermbirthreportedinthemedicalliteratureareuterineandcervicalabnormalities,smoking,alcoholconsumption,illicitdruguseduringpregnancyandtheperformanceofdilationandevacuationabortions.

“AccordingtoChapter10ofthemedicaltextbook“AClinician’sGuidetoMedicalandSurgicalAbortion,”theUSreportsthehighestrateofdilationandevacuationabortionsofanywhereintheworld.Dilationandevacuationabortionsaregenerallyconsideredtobesecondandthirdtrimesterprocedures(usedwhenthebabyislargerandthecervixneedstobedilatedwider).However,statestatisticsshowthousandsoffirsttrimesterdilationandevacuationsreportedinMaine,Pennsylvaniaandotherstatesduringthepasttwodecades.”

https://worcestermag.com/2014/05/22/epidemic-preterm-births/23540 LastaccessedApril5,2017.

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“Andthat’sasitshouldBe”IfAbortionsWereBananas…

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IOMReportonPretermBirth:Causes,Consequences,andPrevention

• “TheprojectthatisthesubjectofthisreportwasapprovedbytheGoverningBoardoftheNationalResearchCouncil,whosemembersaredrawnfromthecouncilsoftheNationalAcademyofSciences,theNationalAcademyofEngineering,andtheInstituteofMedicine.”

• “ThisstudywassupportedbyContractNo.N01-OD-4-2139,TaskOrderNo.145betweentheNationalAcademyofSciencesandtheNationalInstituteforChildHealthandHumanDevelopment,CentersforDiseaseControlandPrevention,HealthResourcesandServicesAdministration,EnvironmentalProtectionAgency,andNIHOfficeofResearchonWomen’sHealth.”

InstituteofMedicine,NationalAcademyofScience,PretermBirth:Causes,Consequences,andPrevention,NationalAcademiesPress,WashingtonDC,2006.

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Zhou:RiskFactorsforPPROMinChineseWomenfromUrbanCities.

Historyofadversepregnancyoutcomes

34-36Weeks PValue 28-33Weeks P Value <28Weeks PValue

1inducedabortion

1.03(0.93–1.16) 0.504 1.08(0.93–

1.26) 0.323 1.65(1.05–2.57) 0.029

2inducedabortions

1.17(1.07–1.29) 0.221 1.21(1.01–

1.33) 0.163 2.66(1.78–3.96) < 0.001

≥ 3inducedabortions

1.27(1.11–1.47) 0.051 1.37(1.12–

1.67) 0.002 2.75(1.66–4.56) < 0.001

ZhouQetal.RiskfactorsforpretermprematureruptureofmembranesinChinesewomenfromurbancities.Int JGynaecolObstet.2014Dec;127(3):254-9.

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Zhou:RiskFactorsforPPROM(<37Weeks)inChineseWomenfromUrbanCities.

• Population-based,prospectivestudywasundertakenin14citiesinChina2011-2012.Womenrecruitedattheirfirstprenatal-carevisit

• 112,439womenincludedinanalyses,3077(2.7%)hadPPROM• Didnotdiscriminatebetweenmedicalandsurgicalabortionbut• “Apossibleexplanationfortheassociationcouldbeatendencyforincreasedsystemicinflammationandstimulationoftheinfectionpathwayinwomenwhohavehadaninducedabortion.”

• LikelyatleasthalfofChineseabortionsnowmedical

1.ZhouQetal.RiskfactorsforpretermprematureruptureofmembranesinChinesewomenfromurbancities.Int JGynaecol Obstet.2014Dec;127(3):254-9.2.XiaW1,SheS,LamTH.MedicalversussurgicalabortionmethodsforpregnancyinChina:acost-minimizationanalysis.

GynecolObstet Invest.2011;72(4):257-63.


Placenta in Preterm Birth - IntechOpen

Placenta in Preterm Birth - IntechOpen

Preventing Preterm Birth Issue Brief

Preventing Preterm Birth Issue Brief

Care of Low Birth Weight (LBW) Babies - RMSC

Care of Low Birth Weight (LBW) Babies - RMSC

ABC of Preterm Birth

ABC of Preterm Birth

Preterm Birth and PPROM - mc.vanderbilt.edu€¦ · Spontaneous Preterm Birth: A Syndrome? •PTL, PPROM, and preterm cervical effacement and dilation without labor –One syndrome

Preterm Birth and PPROM - mc.vanderbilt.edu€¦ · Spontaneous Preterm Birth: A Syndrome? •PTL, PPROM, and preterm cervical effacement and dilation without labor –One syndrome

Preterm Birth Interventions_James Litch_10.16.13

Preterm Birth Interventions_James Litch_10.16.13

Preterm labour and birth - NICE

Preterm labour and birth - NICE

Epidemiology of preterm birth

Epidemiology of preterm birth

Predicting Preterm Birth - dangooreducation.com

Predicting Preterm Birth - dangooreducation.com

The impact of preterm birth

The impact of preterm birth

Preterm Birth - PatientPop

Preterm Birth - PatientPop

Original Article Addition of Cervical Elastography May ... · preterm birth,3 about 90% of pregnant women experience preterm birth without any history of preterm birth. Therefore,

Original Article Addition of Cervical Elastography May ... · preterm birth,3 about 90% of pregnant women experience preterm birth without any history of preterm birth. Therefore,

Preterm labour and birth (PDF) | Labour and birth ...

Preterm labour and birth (PDF) | Labour and birth ...

Kaiser Permanente: Preterm Birth Education Program Birth Education Program_tcm75...Preterm Birth . Education Program. healthy beginnings. The Preterm Birth Education Program provides

Kaiser Permanente: Preterm Birth Education Program Birth Education Program_tcm75...Preterm Birth . Education Program. healthy beginnings. The Preterm Birth Education Program provides

Learning disabilities among extremely preterm …...Extremely preterm birth (EP;

Learning disabilities among extremely preterm …...Extremely preterm birth (EP;

Preterm Labor and prevention of preterm birth

Preterm Labor and prevention of preterm birth

determinant of mortality among low birth weight (lbw)

determinant of mortality among low birth weight (lbw)

Reducing Preterm Birth - tommys.org

Reducing Preterm Birth - tommys.org

CONTINUUM OF CARE FOR THE PREVENTION OF PRETERM BIRTH ... · At the same time, low birth weight (LBW)—babies born weighing less than 2.5 kg—is a major contributor to newborn deaths

CONTINUUM OF CARE FOR THE PREVENTION OF PRETERM BIRTH ... · At the same time, low birth weight (LBW)—babies born weighing less than 2.5 kg—is a major contributor to newborn deaths

Preterm birth and the lungs

Preterm birth and the lungs