Why can't more American women access medications for preterm birth?

September 7, 2017 by Jodi Frances Abbott, The Conversation

There are two medications that prevent preterm birth, the most common cause of perinatal death in the U.S. One costs 16 cents a week, one US$285. Poor black women aren't getting either. Why?

In 2015, for the first time in eight years, the rate of preterm birth in the U.S. rose, despite increased understanding of preventative measures. By one estimate, preterm births cost us an estimated $26 billion per year.

Additionally, U.S. maternal death rates are the among the worst for economically similar countries, currently double that of Canada and Spain, and almost three times than for women in Japan. In Texas, they doubled in just over two years.

When the rates are examined more closely, they reveal an alarming narrative about differences in health outcomes that are systematic, avoidable and unjust.The increased burden of on low-income, urban and in America is 48 percent higher that of white women in every state.

As an obstetric provider for women with high-risk pregnancies at Boston Medical Center, the largest safety-net hospital in New England, I witness the tragic outcomes of these health inequities every day. As an investigator tasked with reducing them, I lead teams who have identified several important barriers to access.

Preventing spontaneous preterm birth

One potentially preventable cause of preterm is recurrent spontaneous preterm birth. That's when babies deliver early despite attempts to prevent it, to mothers who have a history of early deliveries from the same cause.

Both the Society of Maternal Fetal Medicine and the American College of Ob/Gyn recommend a specific progesterone preparation called 17P. This medication can reduce recurrent preterm birth in women with a history of spontaneous preterm birth.

Currently, it's available only at high cost, between $225 and $385 per week. The cost has profoundly impacted obstetric providers' ability to obtain 17P for all eligible women – and contributes to the increased incidence of spontaneous preterm birth in black women.

Most health insurers who enroll low-income and urban women – those seeking low-cost insurance through connectors – require prior authorization or numerous additional communications. These hurdles can be daunting, especially for anyone with competing financial needs and language or literacy challenges.

In Louisiana, a state with one of the highest rates of preterm birth in the U.S., only 5 percent of women who should be getting this medication are able to obtain it.

When we started a study at Boston Medical Center, we found that only 37 percent of our eligible patients received 17P. Our patients were not routinely informed that they had delivered preterm and were at risk of recurrence.

In fact, we found that none of our patients delivering preterm had documented counseling about their diagnosis or recommendations for future pregnancy during their hospitalization for that first . Without this information, they were unaware of the risk to their next pregnancy or that they could reduce risk by asking in prenatal care for 17P.

A cheaper treatment

17P is expensive, so perhaps it seems reasonable for insurers to restrict it – even from those who qualify for its benefit.

But what about other preventable causes of preterm birth? Maternal complications of high blood pressure, also known as preeclampsia, can also induce preterm birth.

Preeclampsia, a disease of constriction of small blood vessels, costs an estimated $2.1 billion per year in the U.S. This is at a time when the poorest women in America are at rising risk of maternal death, of which preeclampsia is a leading contributor.

The population at highest risk for preterm birth due to hypertensive disorders or placental insufficiency? Black women, especially those with a personal or family history of ; first-time mothers; and obese women with low socioeconomic status.

A medication that costs 16 cents a week is also unavailable to many of the women most likely to benefit. This magical treatment is low-dose or "baby" aspirin.

In 2014, the U.S. Preventive Services Task Force, a congressionally authorized independent group of national experts, officially recommended low-dose aspirin for pregnant women at high risk of preeclampsia.

Aspirin in highest-risk women may reduce preterm birth by 62 percent. It can also cut the overall incidence of hypertensive pregnancy complications in half.

Low-dose aspirin has been used safely for both mothers and babies for more than 80,000 pregnancies over 30 years. But our study showed that only 11 percent of high risk pregnant woman at Boston Medical Center received low-dose aspirin, when our goal is for 90 percent of qualified women to get this benefit. Why aren't women, especially high-risk women, getting this medication?

At Boston Medical Center, we are working to address our three specific identified barriers to access. Providers are reluctant to prescribe low-dose aspirin, pharmacists are reluctant to fill it, and, when prescribed, women are afraid to take it.

Though it hasn't been fully studied, reluctance on the part of providers and pharmacists likely stems from a lack of knowledge or acceptance about risk factors. Meanwhile, women, eager to have a safe pregnancy, are bombarded by mixed messaging when searching online for information about aspirin in pregnancy.

Changing the narrative

The medical community can do better to reduce this racial disparity, but doing so requires focused interventions directed toward those women most likely to benefit.

At our hospital, we were able to increase our patients' access rate to 17P to almost 90 percent. We focused on four specific barriers: lack of patient knowledge, lack of provider awareness, suboptimal communication in the electronic health record and insurance challenges in obtaining the medication. This subsequently reduced our preterm birth rate by 62 percent.

At a time when reproductive health care sites are being closed and preventative care restrictions on poor women are implemented daily, we need to prioritize every woman's access to interventions that reach high-risk in order to prevent infant mortality and preterm birth.

Explore further: Insomnia, sleep apnea nearly double the risk of preterm delivery before 34 weeks

Related Stories

Insomnia, sleep apnea nearly double the risk of preterm delivery before 34 weeks

August 9, 2017
Pregnant women who are diagnosed with sleep disorders such as sleep apnea and insomnia appear to be at risk of delivering their babies before reaching full term, according to an analysis of California births by researchers ...

Study finds variation of the interval between first and second pregnancy

February 2, 2015
In a study to be presented on Feb. 5 in an oral concurrent session at the Society for Maternal-Fetal Medicine's annual meeting, The Pregnancy Meeting in San Diego, researchers will report that the variation of interval from ...

Study looks at a new method for filtering results from genetic studies

January 23, 2017
In a study to be presented Thursday, Jan. 26, in the oral concurrent session, at the Society for Maternal-Fetal Medicine's annual meeting, The Pregnancy Meeting, researchers verified genetic results from one large study of ...

Study quantifies risk factors for preterm birth

August 17, 2016
A significant portion of preterm births might be avoided by reducing or eliminating three major risk factors.

Study finds residence in US a risk factor for preterm birth

February 9, 2012
In a study to be presented today at the Society for Maternal-Fetal Medicine's annual meeting, The Pregnancy Meeting, in Dallas, Texas, researchers will report findings that indicate that duration of stay in the United States ...

Mother's family history could pose risk for preterm birth

April 27, 2017
If a pregnant mother has a family history of premature birth, she is at risk for a preterm birth of her baby, according to a new study by researchers from Ben-Gurion University of the Negev (BGU) and Soroka University Medical ...

Recommended for you

Women taking probiotics during pregnancy might have lower pre-eclampsia and premature birth risk

January 24, 2018
Probiotics taken during pregnancy might help lower the risks of pre-eclampsia and premature birth, suggests observational research in the online journal BMJ Open. But timing may be crucial, the findings indicate.

Essure female sterilization device appears safe: study

January 23, 2018
(HealthDay)—Essure implants used in female sterilization have come under fire in recent years, with women reporting a wide array of problems to the U.S. Food and Drug Administration.

Premature births linked to changes in mother's bacteria

January 23, 2018
Changes to the communities of microbes living in the reproductive tract of pregnant women could help to spot those at risk of giving birth prematurely.

Study shows how fetal infections may cause adult heart disease

January 23, 2018
Recent studies have shown that infants born prematurely have a higher risk of developing heart disease later in life. Now, a study led by researchers at the University of Washington School of Medicine in Seattle shows that, ...

Rise in preterm births linked to clinical intervention

January 18, 2018
Research at the University of Adelaide shows preterm births in South Australia have increased by 40 percent over 28 years and early intervention by medical professionals has resulted in the majority of the increase.

New report calls into question effectiveness of pregnancy anti-nausea drug

January 17, 2018
Previously unpublished information from the clinical trial that the U.S. Food and Drug Administration relied on to approve the most commonly prescribed medicine for nausea in pregnancy indicates the drug is not effective, ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.