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Preterm Births in Canada. Where do we go from here?
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G U E S T
The Society of Obstetricians and Gynaecologists of Canada
EDITORIAL
, , , , ,
Preterm Births in Canada. Where do we go from here?
COUNCIL MEMBERS 1998-1999 PRESIDENT Thomas Baskett, MB - Halifax PAST PRESIDENT Robert Reid, MD - Kingston PRESIDENT ELECT Robert Gauthier, MD - Montreal EXECUTIVE VICE-PRESIDENT Andre Lalonde, MD - Ottawa TREASURER Bryan MitcheII, MD - Edmonton VICE-PRESIDENTS Thirza Smith, MD - Saskatoon Thomas Mainprize, MD - Calgary REGIONAL CHAIRS & ALTERNATE CHAIRS WESTERN REGION Michael Bow, MD - Edmonton David Wilkie, MD - Vancouver CENTRAL REGION Marilyn Davidson, MD - Saskatoon Eric Stearns, MD - Winnipeg ONTARIO REGION Janice Ann Willett, MD - Sault Ste-Marie Guylaine Lefebvre, MD - Ottawa QUEBEC REGION Luc St-Pierre, MD - Victoriaville Vyta Senikas, MD - Montreal ATLANTIC REGION Garth Christie, MD - Fredericton Shelagh Connors, MD - Charlottetown OTHER REPRESENTATIVES JUNIOR MEMBER REPRESENTATIVE Debbie Penava, MD - London PUBLIC REPRESENTATIVE Yvonne Chiu, BSc - Edmonton ASSOCIATE MD REPRESENTATIVE Bruno Lemieux, MD - LaSalle ASSOCIATE MEMBERS (RN) REPRESENTATIVE Maureen Heaman, RN - Winnipeg APOG REPRESENTATIVE Daniel Blouin, MD - Sherbrooke NATIONAL OFFICE EXECUTIVE VICE-PRESIDENT Andre Lalonde, MD - Ottawa ASSOCIATE EXECUTIVE VICE-PRESIDENT J. Kenneth Milne, MD - Ottawa 774 Echo Drive Ottawa,Ontario K1S 5N8 tel: (613) 730-4192 or 1-800-561-2416 fax: (613) 730-4314
L
ast September, an international gathering at Maternite Port-Royal, in Paris, celebrated Emile Papiernik who dedicated 30 years of his career to reducing the rate of preterm births in France. The actual rate is 3.5 percent, less than half the rate in 1971. Professor Papiernik published a paper, about ten years ago, in the Journal of the SOGC on his community-wide approach to the prevention of preterm delivery.\ In Canada, in 1979. a consensus of priority health objectives was reached among the sixteen Jean-Marie Moutquin, MD, MSc, university departments of obstetrics, gynaecology FRCSC, Department 01 Obstetrics and Gynaecology, Unlversite and paediatrics, with the Association of ProfesLaval, Quebec City. sors of Obstetrics and Gynaecology together with the Canadian Medical Research Council. The best means to improve the health of Canadians was to prevent preterm deliveries. A group of scientists was given the mandate to plan two studies: prevention of preterm labour and its treatment. This group concluded rather quickly in 1982 that there was no medical intervention to prevent preterm labour that was worth investigating. Concurrently, a multicentre randomized controlled trial to arrest preterm labour with a betaadrenergic agent was launched. T ocolysis with this agent was ineffective in reducing perinatal mortality.: However, this trial, with a sampie size equivalent to the previous 16 published studies, brought a definitive answer: tertiary prevention with tocolysis delayed delivery by 48 hours, just the allocated time for lung mat-
uration and maternal transport, when needed.: Adrenergic agents were associated with serious cardiovascular side effects in one out of five treated mothers without improving neonatal morbidity substantially. This Canadian study had tremendous influence world wide, and influenced the FDA (US) to modify the approaches to tocolysis. Renewed interest was genera ted in the search for a tocolytic agent without maternal side effects. The preterm birth rate in Canada, 6.6 pereent in 1991, had not altered for years. In 1994, it suddenly jumped to 7.3 percent. ' This inerease, if sustained, will be alarming. Perinatal mortality will increase as 75 percent of this mortality is attributable to preterm births. Among the survivors, 25 pereent of children born before 37 weeks and up to 45 percent of those born before 32 weeks will require specialized edueation from their first year at primary schoo1. 4 For every surviving low birthweight « 2,500g) preterm infant, health eare costs, in the first year of life, are estimated to be around $50,000, or about $600 million for
JOURNAL SOGe
115
FEBRUARY 1999
, , , REFERENCES
all such children born in 1991. 5 About 3,000 will suffer long-term handicaps with a diminished quality of life for them and their families. At its 50th meeting, the SOGC put the prevention of preterm deliveries in Canada on its national priority agenda. A group of investigators associated with the Society has attempted on three occasions to obtain funding for a primary prevention trial; a population-oriented trial based on health promotion during pregnancy. We already knew that no more than 10 percent of pregnant women were aware of risk factors or symptoms of preterm labour. 6 In addition, secondary preventive strategies among high-risk pregnancies were demonstrated to be ineffective as identified risk factors (previous preterm deliveries, multiple pregnancy, uterine anomalies) could not be modified, and because the majority of preterm deIiveries were occurring among primiparas without any recognized risk factors at the beginning of their pregnancies. 7 Finally, the societal value granted to pregnancy in Canada couId be improved, especially for the working pregnant woman.; With the concerted efforts of the SOGC, obstetricians, paeditricians and other dedicated health care professionals in education or public health, there is a new ray of hope. A working group together with Health Canada established a consensus conference on new perspectives and strategies to reduce preterm deliveries. These recommendations were presented last June at the National Meeting of the Canadian Paediatrics Society amI the Society of Obstetricians and Gynaecologists of Canada." These statements emphasized future directions in basic and clinical research. In the clinical field, the preferred strategy shouId include a multidisciplinary approach of primary prevention addressed to every pregnancy. It is hoped that this consensus conference will result in numerous initiatives across Canada that will be funded by research agencies and supported by politicians. The French success story of the reduction of preterm births was the result of scientific studies but also of political action based on sound evidence. In Canada, it is now time to act to stop this increasing rate of prematurity, or else we might soon attain the preterm birth rate that France had in 1971. J SOC OBSTET GYNAECOL CAN
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Moutquin J-M, Papiernik E. Can we lower the rate of preterm birth? J Soc Obstet Gynaecol Can 1990;12:19-21. The Canadian Preterm Labour Investigators Group. Treatment of threatened preterm labor with the betaadrenergic agonist ritodrine. N Engl J Med 1992;327 :308-12. Joseph KS, Kramer MS. Recent trends in infant mortality rate and proportions of low birthweight live births in Canada. Can Med Assoc J 1997;157:535-41. Bouyer J, Isenman D. Long term development of preterms: the state of health at age 6 years. In: Papiernik E, Keith L, Bouyer J, Dreyfus J, Lazar P (Eds). Effective prevention of preterm birth: the French experience measured at Haguenau. March of Dimes. Birth Defects, original article series, White Plains, New York;1989; vo1.25; no 1:195-203. Lalonde A. Moutquin J-M. The cost of prematurity in Canada. J Soc Obstet Gynaecol Can 1999 (In Press). Labrecque M, Martin J, Moutquin J-M, Marcoux S, Gingras S. Connaissance des femmes enceintes sur la prematu rite au Quebec. Union Med Can 1993;122:347-52. Moutquin J-M, Milot-Roy V, lrion O. Preterm birth prevention: effectiveness of current strategies. J Soc Obstet Gynaecol Can 1996; 18:571-88. Moutquin J-M. A pledge to value the pregnant woman in Canada. Editorial. J Soc Obstet Gynaecol Can 1998;20:123-6. Preterm Birth Prevention Consensus Conference. Victoria, SOGC Annual Meeting and Hamilton Canadian Paediatric Society Annual Meeting 1998. Summary report available through both societies.
1999;21(2):12.15
JOURNAL SOGC
116
FEBRUARY 1999
G U E S T
The Society of Obstetricians and Gynaecologists of Canada
EDITORIAL
, , , , ,
Preterm Births in Canada. Where do we go from here?
COUNCIL MEMBERS 1998-1999 PRESIDENT Thomas Baskett, MB - Halifax PAST PRESIDENT Robert Reid, MD - Kingston PRESIDENT ELECT Robert Gauthier, MD - Montreal EXECUTIVE VICE-PRESIDENT Andre Lalonde, MD - Ottawa TREASURER Bryan MitcheII, MD - Edmonton VICE-PRESIDENTS Thirza Smith, MD - Saskatoon Thomas Mainprize, MD - Calgary REGIONAL CHAIRS & ALTERNATE CHAIRS WESTERN REGION Michael Bow, MD - Edmonton David Wilkie, MD - Vancouver CENTRAL REGION Marilyn Davidson, MD - Saskatoon Eric Stearns, MD - Winnipeg ONTARIO REGION Janice Ann Willett, MD - Sault Ste-Marie Guylaine Lefebvre, MD - Ottawa QUEBEC REGION Luc St-Pierre, MD - Victoriaville Vyta Senikas, MD - Montreal ATLANTIC REGION Garth Christie, MD - Fredericton Shelagh Connors, MD - Charlottetown OTHER REPRESENTATIVES JUNIOR MEMBER REPRESENTATIVE Debbie Penava, MD - London PUBLIC REPRESENTATIVE Yvonne Chiu, BSc - Edmonton ASSOCIATE MD REPRESENTATIVE Bruno Lemieux, MD - LaSalle ASSOCIATE MEMBERS (RN) REPRESENTATIVE Maureen Heaman, RN - Winnipeg APOG REPRESENTATIVE Daniel Blouin, MD - Sherbrooke NATIONAL OFFICE EXECUTIVE VICE-PRESIDENT Andre Lalonde, MD - Ottawa ASSOCIATE EXECUTIVE VICE-PRESIDENT J. Kenneth Milne, MD - Ottawa 774 Echo Drive Ottawa,Ontario K1S 5N8 tel: (613) 730-4192 or 1-800-561-2416 fax: (613) 730-4314
L
ast September, an international gathering at Maternite Port-Royal, in Paris, celebrated Emile Papiernik who dedicated 30 years of his career to reducing the rate of preterm births in France. The actual rate is 3.5 percent, less than half the rate in 1971. Professor Papiernik published a paper, about ten years ago, in the Journal of the SOGC on his community-wide approach to the prevention of preterm delivery.\ In Canada, in 1979. a consensus of priority health objectives was reached among the sixteen Jean-Marie Moutquin, MD, MSc, university departments of obstetrics, gynaecology FRCSC, Department 01 Obstetrics and Gynaecology, Unlversite and paediatrics, with the Association of ProfesLaval, Quebec City. sors of Obstetrics and Gynaecology together with the Canadian Medical Research Council. The best means to improve the health of Canadians was to prevent preterm deliveries. A group of scientists was given the mandate to plan two studies: prevention of preterm labour and its treatment. This group concluded rather quickly in 1982 that there was no medical intervention to prevent preterm labour that was worth investigating. Concurrently, a multicentre randomized controlled trial to arrest preterm labour with a betaadrenergic agent was launched. T ocolysis with this agent was ineffective in reducing perinatal mortality.: However, this trial, with a sampie size equivalent to the previous 16 published studies, brought a definitive answer: tertiary prevention with tocolysis delayed delivery by 48 hours, just the allocated time for lung mat-
uration and maternal transport, when needed.: Adrenergic agents were associated with serious cardiovascular side effects in one out of five treated mothers without improving neonatal morbidity substantially. This Canadian study had tremendous influence world wide, and influenced the FDA (US) to modify the approaches to tocolysis. Renewed interest was genera ted in the search for a tocolytic agent without maternal side effects. The preterm birth rate in Canada, 6.6 pereent in 1991, had not altered for years. In 1994, it suddenly jumped to 7.3 percent. ' This inerease, if sustained, will be alarming. Perinatal mortality will increase as 75 percent of this mortality is attributable to preterm births. Among the survivors, 25 pereent of children born before 37 weeks and up to 45 percent of those born before 32 weeks will require specialized edueation from their first year at primary schoo1. 4 For every surviving low birthweight « 2,500g) preterm infant, health eare costs, in the first year of life, are estimated to be around $50,000, or about $600 million for
JOURNAL SOGe
115
FEBRUARY 1999
, , , REFERENCES
all such children born in 1991. 5 About 3,000 will suffer long-term handicaps with a diminished quality of life for them and their families. At its 50th meeting, the SOGC put the prevention of preterm deliveries in Canada on its national priority agenda. A group of investigators associated with the Society has attempted on three occasions to obtain funding for a primary prevention trial; a population-oriented trial based on health promotion during pregnancy. We already knew that no more than 10 percent of pregnant women were aware of risk factors or symptoms of preterm labour. 6 In addition, secondary preventive strategies among high-risk pregnancies were demonstrated to be ineffective as identified risk factors (previous preterm deliveries, multiple pregnancy, uterine anomalies) could not be modified, and because the majority of preterm deIiveries were occurring among primiparas without any recognized risk factors at the beginning of their pregnancies. 7 Finally, the societal value granted to pregnancy in Canada couId be improved, especially for the working pregnant woman.; With the concerted efforts of the SOGC, obstetricians, paeditricians and other dedicated health care professionals in education or public health, there is a new ray of hope. A working group together with Health Canada established a consensus conference on new perspectives and strategies to reduce preterm deliveries. These recommendations were presented last June at the National Meeting of the Canadian Paediatrics Society amI the Society of Obstetricians and Gynaecologists of Canada." These statements emphasized future directions in basic and clinical research. In the clinical field, the preferred strategy shouId include a multidisciplinary approach of primary prevention addressed to every pregnancy. It is hoped that this consensus conference will result in numerous initiatives across Canada that will be funded by research agencies and supported by politicians. The French success story of the reduction of preterm births was the result of scientific studies but also of political action based on sound evidence. In Canada, it is now time to act to stop this increasing rate of prematurity, or else we might soon attain the preterm birth rate that France had in 1971. J SOC OBSTET GYNAECOL CAN
1. 2.
3.
4.
5. 6.
7.
8.
9.
Moutquin J-M, Papiernik E. Can we lower the rate of preterm birth? J Soc Obstet Gynaecol Can 1990;12:19-21. The Canadian Preterm Labour Investigators Group. Treatment of threatened preterm labor with the betaadrenergic agonist ritodrine. N Engl J Med 1992;327 :308-12. Joseph KS, Kramer MS. Recent trends in infant mortality rate and proportions of low birthweight live births in Canada. Can Med Assoc J 1997;157:535-41. Bouyer J, Isenman D. Long term development of preterms: the state of health at age 6 years. In: Papiernik E, Keith L, Bouyer J, Dreyfus J, Lazar P (Eds). Effective prevention of preterm birth: the French experience measured at Haguenau. March of Dimes. Birth Defects, original article series, White Plains, New York;1989; vo1.25; no 1:195-203. Lalonde A. Moutquin J-M. The cost of prematurity in Canada. J Soc Obstet Gynaecol Can 1999 (In Press). Labrecque M, Martin J, Moutquin J-M, Marcoux S, Gingras S. Connaissance des femmes enceintes sur la prematu rite au Quebec. Union Med Can 1993;122:347-52. Moutquin J-M, Milot-Roy V, lrion O. Preterm birth prevention: effectiveness of current strategies. J Soc Obstet Gynaecol Can 1996; 18:571-88. Moutquin J-M. A pledge to value the pregnant woman in Canada. Editorial. J Soc Obstet Gynaecol Can 1998;20:123-6. Preterm Birth Prevention Consensus Conference. Victoria, SOGC Annual Meeting and Hamilton Canadian Paediatric Society Annual Meeting 1998. Summary report available through both societies.
1999;21(2):12.15
JOURNAL SOGC
116
FEBRUARY 1999