Correspondence
In Reply
We are grateful for the high level of interest and for the numerous Letters to the Editor regarding our article (1). This underscores the importance of this topic for daily practice.
In international literature, the term “preterm birth rate” is understood to mean the rate of babies born preterm. The percentages given in our work, 9.38% for 2009 and 8.60% for 2017, are the correct preterm birth rates for Germany, taken from the Cross-sectoral Quality in Healthcare (SQG, Sektorenübergreifende Qualitätssicherung) federal evaluation and the IQTIG federal evaluation. The preterm birth rates are not specified in the IQTIG federal evaluations. Thus, our information could therefore be misinterpreted.
In the United States, the preterm birth rates were 10.44% in 2007, and 10.02% in 2018 (2). One cannot speak of a drastic reduction here.
Due to the limited scope of our article in the Deutsches Ärzteblatt and the large number of risk factors, we had to carefully select the risk factors based on their clinical relevance in practice and their ability to be influenced. We are aware that this selection cannot satisfy all readers. Undisputedly, a prior curettage (for miscarriage, abortion), anemia, gestational diabetes, and pre-eclampsia are other risk factors for preterm birth. A recently published, randomized placebo-controlled trial showed that, the rate of spontaneous preterm births can also be significantly reduced with low-dose aspirin as prophylaxis (3).
We thank you for pointing out that the risk factors should be given with respect to their prevalence in Germany. However, reliable data in this regard have so far been lacking.
Bacterial vaginosis is a significant risk factor for preterm birth. Nonetheless, a screening strategy (of vaginal pH measurement) only makes sense if evidence-based therapy is also available. Systemic or local administration of antibiotics is out of the question, as the PREMAVA trial recently showed (4). Antibiotics are highly potent drugs that can not only destroy the vaginal microbial flora, but also significantly affect the eubiosis of the maternal gut microbiome (for instance) and, as a result, can lead to diarrhea and abdominal complaints. Randomized controlled studies on other promising measures (especially displacement of pathogenic germs by promoting the physiological flora) in the prevention of preterm birth in bacterial vaginosis are not yet available.
The information on the possibility of lowering of the preterm birth rate through preconception measures could represent a worthwhile approach for future prospectively randomized prevention trials.
Our review was not about reducing iatrogenic preterm birth but rather about reducing spontaneous preterm birth.
Even if no significant reduction was observed for the preterm birth rate in Germany, it was important for us to demonstrate that the use of various preventive measures, such as progesterone, cerclage, and cervical pessary, can potentially reduce the risk of preterm birth (1).
DOI: 10.3238/arztebl.2020.0511b
On behalf of the authors
Prof. Dr. med. Richard Berger
Marienhaus Klinikum St. Elisabeth
Akademisches Lehrkrankenhaus
der Universitäten Mainz und Maastricht
Klinik für Gynäkologie und Geburtshilfe
Neuwied, Germany
richard.berger@marienhaus.de
Conflict of interest statement
Prof. Berger has been reimbursed for conference fees and travel expenses, and has received lecture honoraria, from Eickeler.
| 1. | Berger R, Rath W, Abele H, Garnier Y, Kuon RJ, Maul H: Reducing the risk of preterm birth by ambulatory risk factor management. Dtsch Arztebl Int 2019; 116: 858–64 VOLLTEXT |
| 2. | Statista: Percentage of preterm births in the United States from 1990 to 2018. www.statista.com/statistics/276075/us-preterm-birth-percentage/ (last accessed on 20 March 2020). |
| 3. | Hoffman MK, Goudar SS, Kodkany BS, et al.: Low-dose aspirin for the prevention of preterm delivery in nulliparous women with a singleton pregnancy (ASPIRIN): a randomised, doubleblind, placebo-controlled trial. Lancet 2020; 395: 285–93 CrossRef |
| 4. | Subtil D, Brabant G, Tilloy E, et al.: Early clindamycin for bacterial vaginosis in pregnancy (PREMEVA): a multicentre, double-blind, randomised controlled trial. Lancet 2018; 392: 2171–9 CrossRef |
