Trends and predictors of extreme preterm birth: Western Australian population-based cohort study.

Brad M Farrant,Carrington C J Shepherd,Scott W White,Amy Metcalfe

doi:10.1371/journal.pone.0214445

Abstract

BackgroundThe preterm birth rate is rising in high-income countries and is associated with increased mortality and morbidity. Although the risks increase with greater prematurity and risk factors have been found to vary with gestational age and labour onset, few studies have focused on the myriad pathways to extreme preterm birth (20–27 weeks’ gestation). The current study investigated trends in extreme preterm birth by labour onset type and examined the antecedent risks to further our understanding around the identification of high-risk pregnancies.MethodsRetrospective cohort study including all singleton extreme preterm births in Western Australia between 1986 and 2010. De-identified data from six core population health datasets were linked and used to ascertain extreme preterm births (excluding medical terminations and birth defects) after spontaneous onset of labour, preterm pre-labour rupture of membranes, and medically indicated labour onset. Trends over time in extreme preterm birth were analysed using linear regression. Multivariable regression techniques were used to assess the relative risks associated with each salient, independent risk factor and to calculate Population Attributable Risks (PARs).ResultsThe extreme preterm birth rate including medical terminations and birth defects significantly increased over time whereas the extreme preterm birth rate excluding medical terminations and birth defects did not change. After medical terminations and birth defects were excluded, the rate of medically indicated extreme preterm births significantly increased over time whereas the rate of preterm pre-labour rupture of membranes extreme preterm births significantly reduced, and the rate of spontaneous extreme preterm births did not significantly change. In the multivariate analyses, factors associated with placental dysfunction accounted for >10% of the population attributable risk within each labour onset type.ConclusionsFirst study to show that the increase in extreme preterm birth in high-income jurisdiction is no longer evident after medical terminations and birth defects are excluded. Interventions that identify and target women at risk of placental dysfunction presents the greatest opportunity to reduce extreme preterm births.

Highlights

Research has demonstrated that the preterm birth (< 37 weeks gestation) rate is rising in highincome countries [1,2,3,4]
The extreme preterm birth rate including medical terminations and birth defects significantly increased over time whereas the extreme preterm birth rate excluding medical terminations and birth defects did not change
Factors associated with placental dysfunction accounted for >10% of the population attributable risk within each labour onset type

Summary

Introduction

Research has demonstrated that the preterm birth (< 37 weeks gestation) rate is rising in highincome countries [1,2,3,4]. Preterm birth is associated with marked increases in mortality and morbidity in the perinatal period, adverse outcomes throughout the lifecourse, and is the preeminent problem facing obstetricians and neonatologists in high-income countries [1]. A complex and inter-related range of risk factors for preterm birth have been identified in the extant literature. These include distal characteristics associated with sociodemographic circumstances, genetic traits, reproductive history and some maternal medical conditions, and factors that are more proximal to the birth—such as complications of pregnancy and delivery [6,7,8,9]. The preterm birth rate is rising in high-income countries and is associated with increased mortality and morbidity. The risks increase with greater prematurity and risk factors have been found to vary with gestational age and labour onset, few studies have focused on the myriad pathways to extreme preterm birth (20–27 weeks’ gestation). The current study investigated trends in extreme preterm birth by labour onset type and examined the antecedent risks to further our understanding around the identification of high-risk pregnancies

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