Preterm birth increases the risk for infant health problems, long-term developmental issues, and death.1 Because of glaring and avoidable geographic and racial disparities, the prevention of preterm births is an evidenced-based practice for promoting health equity. So far, only a few interventions have been found to effectively prevent such births among women with known risk factors. A synthetic form of progesterone, 17P, is one of these interventions. Unfortunately, access to 17P can be challenging, especially for those mothers who need it the most as the same societal factors that perpetuate disparities also inhibit access to this potentially lifesaving treatment. State and territorial health agencies can play a leadership role by identifying women who could benefit from this intervention, connecting them to care and treatment, facilitating Medicaid coverage, and delivering and administering injections in ways that improve accessibility.

Preterm Birth Is a Health Equity Issue

Nearly 1 in 10 infants is born preterm, defined as birth before 37 weeks of gestation, in the United States. Racial disparities in preterm birth are glaring: non-Hispanic white infants are born preterm far less often (at a rate of 10.2%) than African American and Hispanic infants (16.3% and 11.3%, respectively).2 Studies have linked premature birth with long-term medical conditions and declining social achievement such as delays in achieving higher education and obtaining a well-paying job.3 Preventing preterm birth is critical to supporting long-term infant health and development. Furthermore, 1 evidence-based public health and health care practice to promote health equity is to prevent preterm birth. Even after controlling for known preterm birth risk factors, disparities between white and black infants born preterm exist.4 Women who have already experienced preterm birth are more likely to have another preterm infant than women who have not.

Access to Progesterone Is a Health Equity Issue

Progesterone is a steroid hormone that plays an important role in preparing the uterus for pregnancy and maintaining a uterine environment that supports fetal growth once pregnancy is achieved. A synthetic form of progesterone administered through weekly injections, 17 [alpha]-hydroxyprogesterone caproate (17P), has been found to reduce the recurrence of preterm birth by 33%. Approximately 133 000 women are eligible for treatment with 17P each year, yet just a fraction of these women actually receive this treatment. One study found that, nationwide, 30% of women eligible for 17P either receive progesterone treatment that does not align with current clinical guidance or receive no progesterone supplementation at all (C. M. Rudolph, MPH, MCHES, Lumara Health data on file, e-mail communication, July 13, 2015).

Despite overwhelming evidence for its use, numerous challenges prevent some eligible women from receiving 17P treatment. Because 17P is a weekly injection and must be started between 16 and 21 weeks of gestation, treatment initiation and follow-through are more difficult for women without access to transportation, prenatal care, and paid leave. These challenges often have their roots in systemic inequities, and the women who are most at risk of preterm birth are not able to access 17P. Many pregnant women, particularly in the Medicaid population, first seek prenatal care after 21 weeks, the gestational age indicated for 17P treatment. When women do present for prenatal care early in their pregnancy, a lack of education that a prior preterm birth increases their risk for a recurrence may prohibit them from talking with their doctor about preterm birth prevention. Providers also face challenges to 17P administration including ordering, procuring, stocking, and storing the injections, and billing and payment.5

Recommendations

Focus on data for identification of vulnerable populations

State health agencies are poised to take a leadership role in collecting and analyzing data that can help with early identification of 17P-eligible women. Using data to encourage early identification of 17P-eligible women is critical to expanding risk screening and connecting women who are appropriate for 17P to case management and enhanced clinical and community services.6 Louisiana, North Carolina, Ohio, and Texas are engaged in efforts to enhance their early screening and ensure that more eligible women receive 17P or appropriate progesterone treatment through statewide data sharing.5

Partnerships with Medicaid for increased coverage

Since 45% of all births nationwide are covered by Medicaid,7 this publically financed payer is a critical partner for state health agencies interested in increasing 17P utilization. Each state Medicaid agency determines coverage for 17P differently. The cost of the name brand 17P formulation varies by state. The cost of the name brand drug is sometimes considered too expensive for state Medicaid agencies, so some state Medicaid agencies cover a compounded version of the drug. Quality concerns about the compounded version of the drug exist, and it is not Food and Drug Administration approved. The parent company of the name brand 17P formulation negotiates price directly with state Medicaid agencies to address cost barriers.5,8 State health agencies in Iowa, Louisiana, and Ohio work closely with their state Medicaid agencies to increase access to 17P.5 Louisiana was the first state to construct a pay-for-performance measure for Medicaid-managed care plans aimed at increasing access to progesterone. These plans are tasked with increasing the percentage of eligible women receiving the drug to 20%, up from the current 5%. Medicaid-managed care plans in the state have up to $2 million at stake if they do not meet this specific goal.9

Improving accessibility through delivery and administration

17P is delivered via weekly injections by a licensed health care provider, posing potential health equity barriers for women with limited access to child care, reliable transportation, and paid leave for medical appointments or personal time off. Some states, such as Iowa, Louisiana, and South Carolina are exploring home or alternate location administration to alleviate these issues so that women with transportation or personal leave issues are able to access 17P.5 Puerto Rico has been successful in delivering 17P to eligible women at home, at work, or at any convenient location. A public-private partnership in Puerto Rico that, among other efforts, made access to 17P easier for eligible women, resulted in 85% of eligible women receiving 17P in 2014.10

Conclusion

Preterm births can result in long-term medical and social consequences. While the cause of preterm birth is not always well understood, actions should be taken to mitigate known risk factors, especially for those most at risk. Disparities in poor birth outcomes have significant long-term implications for infants, their families, and the health of the nation. State health agencies are uniquely positioned to leverage strategic partnerships, intentionally utilize data, and increase access to 17P for all eligible women, and select state health agencies are already taking decisive action in these areas. Actions taken to increase utilization of 17P will work to reduce the number of preterm births and will ultimately increase the health of our nation as a whole.

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