Content of prenatal care and spontaneous preterm birth: Findings from the 1988 National Maternal and Infant Health Survey

The purposes of this study were to examine (1) the relationship between selected components of the content of prenatal care and spontaneous preterm birth; and (2) the degree of comparability between maternal and caregivers' responses regarding the number of prenatal care visits, selected components of the content of prenatal care, and gestational age, based on analyses of the 1988 National Maternal and Infant Health Survey conducted by the National Centers for Health Statistics. Spontaneous preterm birth was subcategorized into very preterm and moderately preterm births, with term birth as the controls. The study population was limited to non-Hispanic Anglo- and African-American mothers. The racial differences in terms of birth outcomes were also compared.^ This study concluded that: (1) there was not a high degree of comparability (less than 80%) between maternal and prenatal care provider's responses regarding the number of prenatal care visits and the content of prenatal care; (2) there was a low degree of comparability (less than 50%) between maternal and infant's hospital of delivery responses regarding gestational age at birth; (3) there were differences in selected components of the content of prenatal care between the cases and controls, overall and stratified by ethnicity (i.e., hemoglobin/hematocrit test, weight measurement, and breast-feeding counseling), but they were confounded with missing values and associated preterm delivery bias; (4) there were differences in selected components of the content of prenatal care between Anglo- and African-American cases (i.e., vitamin/mineral supplement advice, weight measurement, smoking cessation and drug abuse counseling), but they, too, were difficult to interpret definitively due to item nonresponse and preterm delivery biases; (5) no significant predictive association between selected components of the content of prenatal care and spontaneous preterm birth was found; and (6) inadequate/intermediate prenatal care and birth out of wedlock were found to be associated with moderately preterm birth.^ Future research is needed to examine the validity of maternal and prenatal care providers' responses and identify the sources of disagreement between their responses. In addition, further studies are needed to examine the relationship between the quality of prenatal care and preterm birth. Finally, the completeness and quality of patient and provider data on the utilization and content of prenatal care needs to be strengthened in subsequent studies. ^

Progestational agents and preterm birth: An updated review of the literature

The preterm birth rate has been increasing over time in the United States, causing a large social and individual financial burden. Though the cause of preterm birth is now known, risk factors such as a previous preterm birth and a short cervical length have been identified as possible predictors. There are many contributing social and behavioral factors that play a role was well as medical problems that occur before and during pregnancy. Though there have been prevention methods identified, such as prenatal care, tocolytic therapy and cervical cerclage, none of these methods have shown to definitively prevent preterm birth over a long period of time. 17 alpha hydroxyprogesterone has been recognized as a possible prevention method for women at high risk for preterm birth. Three out of the five studies assessed in this review showed a significant reduction in preterm birth with administration of progesterone, both for women with a previous preterm birth and with a short cervical length. Currently there is no standard of care for those at high risk for preterm birth. More large clinical trials need to be conducted to determine if this progesterone for the prevention of preterm birth is effective. ^

Differences in small-for-gestational-age and preterm birth among Asian subgroups in relation to nativity status

This retrospective cohort study examined the association between nativity status and very preterm birth, preterm birth, and small-for-gestational-age (SGA) among Asian subgroups using Texas birth certificate data with no personal identifiers. A total of 877,322 birth certificates of Asian and US-born white women with a singleton birth in Texas from 2001-2004 were analyzed. Birth certificate records of US-born white, Chinese, Japanese, Korean, Vietnamese, Filipino, and Asian Indian women with a singleton birth were included in the analysis. Logistic regressions models were used to explore and understand the differences of the effect of nativity status on birth outcomes in Asian subgroups with US-born whites as the reference group. Most of the Asian subgroups had a lower risk of preterm births compared with US born whites, with reductions in risk ranging from 19% to 49% and the lowest risk of preterm birth observed among foreign-born Chinese mothers. Only Filipino mothers had a higher risk of preterm birth compared to US-born whites. Overall, foreign-born Asians had lower risks for very preterm birth and preterm birth than US-born Asians and US-born whites. US-born Asians were at higher risk for preterm birth than US-born whites. For SGA, all Asian subgroups and Asian subgroups by nativity status were at higher risk of SGA than US-born whites. Asian Indians and Japanese were at highest risk for SGA infants with 2.5 to 3 times the risk of SGA present in US-born whites. Foreign-born Asian women were at higher risk for SGA than their US-born counterparts. This study showed that health disparities among Asian subgroups are hidden by classifying Asians into a single group. By examining Asian subgroups separately and looking at nativity status, the differences in risk of SGA and preterm birth can be revealed so prevention efforts can focus on high risk groups. ^

PRETERM BIRTH AND OCCUPATIONAL PHYSICAL ACTIVITY: A CASE-CONTROL STUDY OF THE RELATIONSHIP BETWEEN LENGTH OF GESTATION AND THE PHYSICAL DEMAND OF U.S. ARMY MILITARY OCCUPATIONAL SPECIALTIES (UNITED STATES)

A case-control study has been conducted examining the relationship between preterm birth and occupational physical activity among U.S. Army enlisted gravidas from 1981 to 1984. The study includes 604 cases (37 or less weeks gestation) and 6,070 controls (greater than 37 weeks gestation) treated at U.S. Army medical treatment facilities worldwide. Occupational physical activity was measured using existing physical demand ratings of military occupational specialties.^ A statistically significant trend of preterm birth with increasing physical demand level was found (p = 0.0056). The relative risk point estimates for the two highest physical demand categories were statistically significant, RR's = 1.69 (p = 0.02) and 1.75 (p = 0.01), respectively. Six of eleven additional variables were also statistically significant predictors of preterm birth: age (less than 20), race (non-white), marital status (single, never married), paygrade (E1 - E3), length of military service (less than 2 years), and aptitude score (less than 100).^ Multivariate analyses using the logistic model resulted in three statistically significant risk factors for preterm birth: occupational physical demand; lower paygrade; and non-white race. Controlling for race and paygrade, the two highest physical demand categories were again statistically significant with relative risk point estimates of 1.56 and 1.70, respectively. The population attributable risk for military occupational physical demand was 26%, adjusted for paygrade and race; 17.5% of the preterm births were attributable to the two highest physical demand categories. ^

Non-nutritive sucking and the preterm infant

Background. Preterm birth is major public health problem. Preterm infants face a post-natal environment that their under developed systems are inapt to manage. Developmentally supportive individualized care has demonstrated positive outcomes in minimizing resulting negative effects. Non-nutritive sucking (NNS) interventions are thought to promote the development of the suck-swallow-breathe mechanism and a calming tool. It is hypothesized that growth and development is maintained by strengthened sucking skills and stable behavioral states.^ Objective. To determine the importance of non-nutritive sucking (NNS) on outcomes that are clinically relevant to the preterm infant population.^ Methods. A computerized search of MEDLINE and PUBMED databases during the period of 1975 and May 2011 was conducted. Relevant articles were selected using published criteria for detecting clinically validated studies. The search yielded 10 randomized controlled studies relative to the outcomes of interest: weight gain, time to full feeds, time to discharge from hospital, and pain response.^ Results. NNS was found to decrease significantly the length of hospitalization in preterm infants. Although positive results were reported in some of the studies, the results did not show a consistent benefit of NNS with respect to other major clinical variables. NNS was shown to reduce distress following painful stimuli.^ Conclusion. Although NNS shows promise for the development of preterm infants, there is lack of agreement concerning some of the outcomes of interest. Evidence does support NNS's positive contribution to early hospital discharge and pain relief. Future research should focus on long-term, comparable outcomes. ^

An investigation of the pica practices of pregnant women in Houston and Prairie View, Texas

Pregnant African American women are at higher risk of having a preterm delivery and/or a low birthweight infant. Many factors are associated with adverse pregnancy outcomes but a food habit that deserves further study in the causal process is pica, a craving for, and ingestion of, nonnutritive substances such as laundry starch, clay, dirt, or ice. This food habit is more common in the African American population but has not been adequately studied in relation to preterm and/or low birth weight infants.^ Mothers (n = 281) with infants less than one year of age who participated in the Special Supplementary Food Program for Women, Infants, and Children (WIC) at clinics in Houston and Prairie View, Texas were interviewed regarding pica practices during pregnancy, dietary practices, and some demographic indices. Hospital records were abstracted for health information on the mothers and infants, including birthweight and gestational age at birth of the infant.^ The subjects were 88.6% African American, 6.8% Hispanic, and 4.6% Caucasian. Overall prevalence of pica was 76.5%. Pica prevalence by substance(s) was as follows: ice 53.7%; ice and freezer frost 14.6%; other substances such as baking soda, baking powder, cornstarch, laundry starch, and clay or dirt 8.2%; and 23.5% reported no pica. The women who reported ice/freezer frost pica had a higher percentage of illegal drug use and alcohol use during pregnancy. The women who reported other pica substances had the lowest mean educational level, highest gravidity, and a higher percentage smoked during pregnancy.^ There were no significant differences in nutrient intakes measured by the mean 24-hour dietary recalls between women who reported ice pica (n = 103) and women who denied pica (n = 50). The women who reported ice/freezer frost pica or other pica substances had more food cravings and food dislikes during pregnancy than those who reported ice pica or no pica.^ There were no differences in mean birthweight or mean gestational age at birth of infants born to mothers from the three pica groups and the no pica group but regression analyses revealed a possible relationship between pica, low maternal hemoglobin at delivery, and preterm birth. ^

A constellation of factors associated with premature births among African American women

A cohort, cross-sectional, historical study design was used to study factors related to spontaneous premature birth outcomes among African American women. The cohort consisted of 4,294 mothers drawn from the 1988 National Maternal and Infant Health Survey conducted by the National Center for Health Statistics. The objectives of the study were: (1) to examine the distribution of gestational ages of African American infants for selected variables reported for their families and (2) to describe risk factors associated with birth at 20–31 weeks of gestational age and at 32–36 weeks of gestational age. Risk factors examined include maternal age, maternal marital status, maternal living arrangements, maternal education, maternal work status, household income, gestational bleeding, month prenatal began, adequacy of prenatal care, parity, previous viable preterm birth, and behavioral factors of attitude toward pregnancy, smoking, drug, and alcohol use during pregnancy. Frequency distributions, cross tabulations, stratified analysis, and logistic regression analysis were used. ^ Risk factors associated with a 50 percent or more increase in preterm birth were cocaine use, low maternal education, teenaged mother, prenatal care deficits or overuse, and bleeding during the second half of pregnancy. The other risk factors of not living with the baby's father, smoking cigarettes and having a mistimed pregnancy carried statistically significance but lower strength of association. ^ Health care services, educational systems, and community organizations can develop and evaluate comprehensive health education and information campaigns that address preventable risk factors during pregnancy. Although preterm birth cannot always be prevented, preconception care can help identify and modify maternal risk and promote optimum health before conception. Quality care should include continued risk assessment, health promotion, and interventions. ^

Attention-Deficit/Hyperactivity Disorder and antidepressants and prescription medications: A pilot study

Background. Attention Deficit-Hyperactivity Disorder (AD/HD) diagnosis in children and adolescents has been on the rise over the last couple of decades and a multitude of studies have been conducted in an aim to better understand the disease. Literature has explored the role of several factors suspected of contributing to development of the disease, including: prenatal smoking exposures, environmental exposures, and low-birth weight. However, there is very limited reporting of fetal/infant exposure to antidepressants and prescription medications and the long-term behavioral outcomes, namely development of AD/HD. The purpose of this study was to evaluate the relationship between mother's exposure to prescription medications and/or antidepressants around the time of conception, during pregnancy, or while breastfeeding and the development of Attention-Deficit/Hyperactivity Disorder in offspring. Methods. Secondary analysis of data from a case-control study was performed. Exposure histories were collected for the mother and offspring. Data were collected using a secure, confidential, self-report, online survey to evaluate the relationship between antidepressant and/or prescription medication exposure and the development of AD/HD. The period of exposure to these drugs was defined as: around the time of conception, during pregnancy, or while breastfeeding. Cases were defined as a child who had been diagnosed with AD/HD. Controls were defined as a child who had not been diagnosed with AD/HD. Results. Prescription medication and antidepressant medication exposures around the time of conception, during pregnancy, or while breastfeeding were not associated with development of AD/HD. However, traumatic brain injury (OR=2.77 (1.61–4.77)) and preterm birth (OR=1.48 (1.04–2.12)) were identified as potential risk factors. These results support existing literature on AD/HD, but future work must be undertaken to better evaluate fetal/infant medication exposures and long-term behavioral outcomes.^

Epidemiology of isolated obstructive genitourinary defect in Texas: 1999--2003

Background. Obstructive genitourinary defects include all anomalies causing obstruction anywhere along the urinary tract. Previous studies have noted a large excess of males among infants affected by these types of defects. This is the first epidemiologic study focused solely on obstructive genitourinary defects (OGD). ^ Methods. Data on 1,683 mild and 302 severe cases of isolated OGD born between 1999 and 2003 and ascertained by the Texas Birth Defects Registry were compared to all births in Texas during the same time period. Adjusted prevalence odds ratios (POR) were calculated for infant sex, birth weight, gestational age, mother’s race/ethnicity, mother’s age, mother’s education, parity, birth year, start of prenatal care, multiple birth, and public health region of birth. Severe cases were defined as those cases that died prior to birth, died after birth, or underwent surgery for OGD in the first year of life. Cases of OGD that had other major birth defects besides OGD were excluded from this study. ^ Results. Severe cases of OGD were more likely than mild cases to have multiple obstructive genitourinary anomalies (37.8% vs. 18.9%) and bilateral defects (40.9% vs. 31.3%). Males had a significantly greater risk of OGD than females for both severe and mild cases: adjusted POR = 3.26 (95% CI = 2.45-4.33) and adjusted POR = 2.60 (95% CI = 2.33-2.90), respectively. Infants with both severe and mild OGD were more likely to be very preterm birth at birth compared with infants without OGD: crude POR of 16.19 (95% CI = 10.60-24.74) and 4.75 (95% CI = 3.54-6.37), respectively. Among the severe group, minority races had a decreased risk of OGD with an adjusted POR of 0.74 (95% CI = 0.55-0.98) compared with whites. Among the mild cases, increased rates of OGD were found in older mothers (adjusted POR = 1.10, 95% CI = 1.05-1.15), college/higher educated mothers (adjusted POR = 1.07, 95% CI = 1.01-1.13) and multiple births (adjusted POR = 1.28, 95% CI = 1.01-1.62). There was also a decreased risk of mild cases among black mothers compared to whites (adjusted POR = 0.63, 95% CI = 0.52-0.76). Compared to 1999, the prevalence of mild cases of OGD increased significantly over the 5 year study period with an adjusted POR of 1.10 (95% CI = 1.06-1.15) by 2003. ^ Conclusion. Risk factors of OGD for both severe and mild forms were male sex and preterm birth. Severe cases were more likely to have multiple OGD defects and be affected bilaterally. An increase in prevalence of mild cases of OGD over time and differences in rates of black, older, and higher educated mothers in mild cases may be attributed to ultrasound use. ^

The association between maternal use of selective serotonin reuptake inhibitors during pregnancy and adverse pregnancy outcomes

Maternal use of SSRIs for depression and anxiety during pregnancy has increased over the last decade. Recent studies have questioned the safety of these antidepressants when used in during pregnancy. The aim of this project is to assess the associations between maternal SSRI use and GH, SGA, and preterm birth using data from a U.S. population-based study with self-reported exposure information. ^ The study population is comprised of mothers of control infants from the NBDPS, an ongoing, multi-state, population-based case-control study. Mothers were asked about any use of medications during pregnancy, including the dates they started and stopped taking each medication. Maternal GH was self-reported, while gestational age and birth weight were calculated from information on birth certificates or medical records. ^ Our study found that women exposed to SSRIs in the first trimester and beyond had a higher odds of GH compared to unexposed women (aOR=1.96, 95% CI=1.02-3.74). Women who used SSRIs only in the first trimester had no increased odds of GH (aOR=0.77, 95% CI=0.24-2.50). Women who used SSRIs throughout their entire pregnancy had a two-fold increase in the odds of delivering an SGA infant compared to unexposed women (aOR=2.16, 95% CI=1.01-4.62), while women who reported SSRI use only in the first trimester had a decreased odds of delivering an SGA infant (aOR=0.56, 95% CI=0.14-2.34). Finally, both women who used SSRIs in the first trimester only (aOR=1.58, 95% CI=0.71-3.51) and women who used SSRIs in the first trimester and beyond (aOR=1.49, 95% CI=0.76-2.90) had an increased odds of delivering preterm compared to unexposed women. ^ Results from our study suggest that women who use SSRIs in the first trimester and beyond have an increased and significant odds of GH and SGA. An increase in the odds of preterm birth was also observed among women exposed in this period and is consistent with the results of previous studies which had much larger sample sizes. Women who use SSRIs only in the first trimester appear to have no increased odds of GH or SGA, but may have an increased odds of preterm birth. These findings are consistent with previous studies and highlight how exposure to SSRIs at different points in gestation may result in different risks for these outcomes. ^

A woman's right to know: A policy review of abortion legislation in Texas

Introduction: Despite its legalization, abortion remains a controversial issue, one that has many divided on either side of the political spectrum. While there have been several changes made to abortion policy over the past few decades, one that continues to have many asking questions is the Woman’s Right to Know Act, a piece of state imposed abortion legislation that has implemented strict restrictions and requirements of women seeking abortion, including pre-abortion mandatory counseling and a 24 hour waiting period. This project analyzed four controversial components of the mandatory counseling materials in Texas in an attempt to examine the scientific validity behind this legislation. Methods: In order to understand the scientific validity behind the content of the preabortion mandatory counseling, I conducted a systematic literature review to analyze: the purported link between abortion and breast cancer, the existence of fetal pain, the risk of abortion to future fertility, and the negative psychological effects of abortion. An electronic search in EBSCO and PubMed of review articles published between 1995 and 2010 resulted in fourteen reviews. Results: Results of the systematic review found (1) inconclusive evidence suggesting a link between abortion and breast cancer, (2) that fetal pain likely does not occur until the third trimester of pregnancy, (3) that associations exist between induced abortion and subsequent preterm birth and placenta previa, and (4) that there is mixed evidence relating to the negative psychological effects that exist among women having had an abortion and those who have not had abortion. Conclusion: Based on these conclusions, a recommendation was made to revise the current state mandated counseling materials to reflect more accurate and scientifically-based information about abortion and its potential risks.^

The epidemiology of left ventricular outflow tract obstruction defects in Texas, 2002-2008: An update and assessment of effect heterogeneity

Left ventricular outflow tract (LVOT) defects are an important group of congenital heart defects (CHDs) because of their associated mortality and long-term complications. LVOT defects include aortic valve stenosis (AVS), coarctation of aorta (CoA), and hypoplastic left heart syndrome (HLHS). Despite their clinical significance, their etiology is not completely understood. Even though the individual component phenotypes (AVS, CoA, and HLHS) may have different etiologies, they are often "lumped" together in epidemiological studies. Though "lumping" of component phenotypes may improve the power to detect associations, it may also lead to ambiguous findings if these defects are etiologically distinct. This is due to potential for effect heterogeneity across component phenotypes. ^ This study had two aims: (1) to identify the association between various risk factors and both the component (i.e., split) and composite (i.e., lumped) LVOT phenotypes, and (2) to assess the effect heterogeneity of risk factors across component phenotypes of LVOT defects. ^ This study was a secondary data analysis. Primary data were obtained from the Texas Birth Defect Registry (TBDR). TBDR uses an active surveillance method to ascertain birth defects in Texas. All cases of non complex LVOT defects which met our inclusion criteria during the period of 2002–2008 were included in the study. The comparison groups included all unaffected live births for the same period (2002–2008). Data from vital statistics were used to evaluate associations. Statistical associations between selected risk factors and LVOT defects was determined by calculating crude and adjusted prevalence ratio using Poisson regression analysis. Effect heterogeneity was evaluated using polytomous logistic regression. ^ There were a total of 2,353 cases of LVOT defects among 2,730,035 live births during the study period. There were a total of 1,311 definite cases of non-complex LVOT defects for analysis after excluding "complex" cardiac cases and cases associated with syndromes (n=168). Among infant characteristics, males were at a significantly higher risk of developing LVOT defects compared to females. Among maternal characteristics, significant associations were seen with maternal age > 40 years (compared to maternal age 20–24 years) and maternal residence in Texas-Mexico border (compared to non-border residence). Among birth characteristics, significant associations were seen with preterm birth and small for gestation age LVOT defects. ^ When evaluating effect heterogeneity, the following variables had significantly different effects among the component LVOT defect phenotypes: infant sex, plurality, maternal age, maternal race/ethnicity, and Texas-Mexico border residence. ^ This study found significant associations between various demographic factors and LVOT defects. While many findings from this study were consistent with results from previous studies, we also identified new factors associated with LVOT defects. Additionally, this study was the first to assess effect heterogeneity across LVOT defect component phenotypes. These findings contribute to a growing body of literature on characteristics associated with LVOT defects. ^

Use of empowerment evaluation to determine a sustainability plan for a community-based preconception care program

Women With IMPACT (WWI) is a community-based preconception care educational intervention. WWI is being implemented by the Impacting Maternal and Prenatal Care Together (IMPACT) Collaborative and targets zip codes in Harris County, Texas at high risk for infant mortality, low birthweight, and preterm birth. WWI started March 2012 and continues through August 2013. Three workshop series are planned. This study was conducted with participants and facilitators from the first workshop series. This study aimed to 1) evaluate the WWI program using empowerment evaluation, 2) engage all WWI stakeholders in an empowerment evaluation so the method could be adopted as a participatory evaluation process for future IMPACT activities, and 3) develop recommendations for sustainability of the WWI intervention, based on empowerment evaluation findings and results from the pre/post program evaluation completed by WWI participants. Study participants included WWI participants and facilitators and IMPACT Collaborative Steering Committee members. WWI participants were female, 18-35 year-old, non-pregnant residents of zip codes at high risk of adverse birth outcomes. All other study participants were 18 years or older. A two-phased empowerment evaluation (EE) was utilized in this study. Sessions 1-4 were conducted independently of one another – 3 with participants at different sites and one with the facilitators. The fifth session included WWI participant and facilitator representatives, and IMPACT Steering Committee members. Session 5 built upon the work of the other sessions. Observation notes were recorded during each session. Thematic content analysis was conducted on all EE tables and observation notes. Mission statements drafted by each group focused on improvement of physical and mental health through behavior change and empowerment of all participants. The top 5 overall program components were: physical activity, nutrition, self-worth, in-class communication, and stress. Goals for program improvement were set by EE participants for each of these components. Through thematic content analysis of the tables and observation notes, social support emerged as an important theme of the program among all participant groups. Change to a healthy lifestyle emerged as an important theme in terms of program improvement. Two-phased EE provided an opportunity for all program stakeholders to provide feedback regarding important program components and provide suggestions for program improvement. EE, thematic content analysis, pre/post evaluation results, and inherent program knowledge were triangulated to make recommendations to sustain the program once the initial funding ends. ^

Epidemiology of perinatal mortality: Birthweight, crown -heel length, gestational age, and weight -for -height

Studies suggest that slim infants (low weight-for-height) experienced higher mortality rates than average or high weight-for-height infants (Miller and Hassanein, 1973; Hoffman, Meirik, and Bakketeig, 1984). In this study, the 1980 National Natality Survey and the National Fetal Mortality Survey were used to examine the association of weight, height and perinatal mortality. All singleton births to white married mothers, between 18 and 34 years of age and of parity less than 4, for whom both mother's and hospital questionnaires were completed in those two surveys (3796 live births and 2043 fetal deaths) were selected for analysis. Overall, low weight and height infants had excess mortality rates. However, after adjustment for low birthweight and preterm birth status, low weight and height infants had only slightly higher mortality rates than their medium or high weight and height counterparts. The current study consists of relatively well-educated white married mothers of optimal reproductive age and low parity. Therefore, lower than expected mortality rates for slim infants may be attributed to these favorable demographic factors in this sample as compared with previous studies, or because of advances in perinatal medicine, slim infants may be prevented from achieving the high mortality seen in earlier studies. ^

Congenital diaphragmatic hernia in the preterm infant.

BACKGROUND: Congenital diaphragmatic hernia (CDH) remains a significant cause of death in newborns. With advances in neonatal critical care and ventilation strategies, survival in the term infant now exceeds 80% in some centers. Although prematurity is a significant risk factor for morbidity and mortality in most neonatal diseases, its associated risk with infants with CDH has been described poorly. We sought to determine the impact of prematurity on survival using data from the Congenital Diaphragmatic Hernia Registry (CDHR). METHODS: Prospectively collected data from live-born infants with CDH were analyzed from the CDHR from January 1995 to July 2009. Preterm infants were defined as <37 weeks estimated gestational age at birth. Univariate and multivariate logistic regression analysis were>performed. RESULTS: During the study period, 5,069 infants with CDH were entered in the registry. Of the 5,022 infants with gestational age data, there were 3,895 term infants (77.6%) and 1,127 preterm infants (22.4%). Overall survival was 68.7%. A higher percentage of term infants were treated with extracorporeal membrane oxygenation (ECMO) (33% term vs 25.6% preterm). Preterm infants had a greater percentage of chromosomal abnormalities (4% term vs 8.1% preterm) and major cardiac anomalies (6.1% term vs 11.8% preterm). Also, a significantly higher percentage of term infants had repair of the hernia (86.3% term vs 69.4% preterm). Survival for infants that underwent repair was high in both groups (84.6% term vs 77.2% preterm). Survival decreased with decreasing gestational age (73.1% term vs 53.5% preterm). The odds ratio (OR) for death among preterm infants adjusted for patch repair, ECMO, chromosomal abnormalities, and major cardiac anomalies was OR 1.68 (95% confidence interval [CI], 1.34-2.11). CONCLUSION: Although outcomes for preterm infants are clearly worse than in the term infant, more than 50% of preterm infants still survived. Preterm infants with CDH remain a high-risk group. Although ECMO may be of limited value in the extremely premature infant with CDH, most preterm infants that live to undergo repair will survive. Prematurity should not be an independent factor in the treatment strategies of infants with CDH.