Tennessee Connections for Better Birth Outcomes

Preterm births (PTBs) are the leading cause of death in infants under the age of one.
Tennessee (TN) is one of the lowest ranking states in the US for rates of PTBs (46th) and
infant mortality (48th). Costs for neonatal care increase exponentially with decreasing
gestational age, and there are lifelong consequences for families and communities. Despite
medications and improved diagnostic tools, a 27% increase in PTBs has occurred in the past
20 years. With a history of one PTB, the probability of another PTB is approximately 30%.
The risk of having another PTB rises to almost 70% if the woman has a history of more than
one PTB. Relationships between a variety of factors (e.g., African American race, smoking,
short interval between pregnancies, socio-environmental stressors) likely contribute to TN's
high rate of PTBs. Several interventions have been identified to reduce PTBs and improve
maternal and infant health indicators but with varying success; administering intramuscular
injections of progesterone between 16 and 36 weeks gestation, providing some prenatal care
in the home of women with a high risk pregnancy, increasing the interval between
pregnancies, and reducing social factors that negatively impact health, such as smoking,
substance abuse and stress.

The overall purpose of this study was to determine if a combined medical and biobehavioral
intervention would prevent PTBs and reduce healthcare costs in a sample of women who have
had a prior PTB. The medical intervention was conventional prenatal and postpartum clinic
care. The biobehavioral intervention included certified nurse midwife home visitors who
engaged women in an integrated System of Care (SOC) during their prenatal care. Care
continued during the first 18 months of the infant's life by maternal-child nurse visitors.
Home visits were in addition to regularly scheduled conventional prenatal and postpartum
clinic care. Main study questions were:

Is there a difference in: 1) the length of gestational age of infants of high-risk pregnant
women who receive the medical intervention and high-risk pregnant women who receive the SOC?
2) in health care costs between women who receive the medical intervention and the SOC? 3)
intervals between the current pregnancy and a subsequent pregnancy across groups? and 4) in
length of gestational age of current infant with gestational age of index prior preterm
birth?

Inclusion Criteria:

- Documented history of previous preterm delivery. Defined as delivery from 20 weeks to
36 weeks 6 days gestation.

- Proven pregnancy

- Reside in Davidson County, Tennessee (TN) or surrounding county in 90 mile driving
radius.

- Less than 24 weeks gestation at enrollment

- Will receive prenatal care at a Vnderbilt University Medical Center (VUMC) clinic

- Willing to accept nurse home visits and be randomly assigned to conventional care or
care with home visits

- Speaks and understands English

- Between the ages of 18 and 40 years.

Exclusion Criteria:

- Known fetal anomaly that can not be managed conservatively or fetal demise

- Maternal medical or obstetrical complications including:

- Current or scheduled cervical cerclage

- PROM in current pregnancy prior to enrollment

- Participation in an antenatal study in which the clinical status or intervention may
influence gestational age at delivery

- Profound mental dysfunction or under guardianship