Epidemiological characteristics and trends based on a joinpoint regression model of preterm birth with congenital heart disease in Changsha City, China, from 2011 to 2023
Highlight box
Key findings
• Our study observed that between 2011 and 2023, there was a slightly upward trend of the incidence of preterm birth (PTB) with congenital heart disease (CHD). The incidence of PTB with CHD was higher in rural areas than in urban areas (χ2=27.92, P<0.001). Compared with maternal age 25–29 years, the incidence of PTB with CHD was higher among babies of women of maternal age <25, 30–34, and ≥35 years.
What is known and what is new?
• Neonates with CHD had higher risk of PTB than the general population.
• Residence and maternal age were the determining factors for the incidence of PTB with CHD. The incidence of PTB with CHD in women of different residence and maternal age showed different trends.
What is the implication, and what should change now?
• Authorities and medical institutions should pay more attention to the prenatal diagnosis, and take a variety of measures to prevent CHD and PTB.
Introduction
Congenital heart disease (CHD) refers to a structural abnormality of the heart or an abnormal cardiovascular development that is present from birth (1). CHD is the most common birth defect and one of the main causes of neonatal death; the estimated prevalence of CHD among newborns worldwide was about 17–18 cases per 1,000 live births in 2017 (2), and the prevalence of CHD was approximately 17.3% in China in 2020 (3). Between 1970 and 2017, the prevalence of CHD worldwide steadily rose by 10% every five years, reaching a peak of 9.41 per 1,000 births (4). Compared with Europe and America, the prevalence of CHD in Asia was higher (4). The phenomenon of higher prevalence of CHD in advanced and developed regions in China (5) is due to that fact that advanced and developed regions have advanced prenatal screening and diagnostic technologies, thus the ability to detect CHD has been significantly improved.
Preterm birth (PTB) can easily result in complications during the perinatal period, including respiratory distress syndrome, cerebral hemorrhage, and infection (6,7). Prematurity complications are one of the leading causes of neonatal death and death among children under 5 years old (8,9). In 2020, it was estimated that there were approximately 13.4 million (9.9%) individuals worldwide who were born prematurely, with China contributing approximately 750,000 of these premature infants in and ranking fourth in the world (10).
PTB and CHD are major public health problems, and there are some associations among neonates between PTB and CHD (11,12). Previous studies have reported that neonates with CHD had higher risk of PTB than the general population (13-15); other studies have found that newborns of mothers with CHD were more prone to premature birth (16,17). A history of PTB has been reported to be a risk factor of CHD in the offspring of pregnant women (18), and premature infants face a higher risk of having severe CHD (19).
Therefore, we conducted a retrospective cohort study of neonates with CHD, who were born in Changsha City between 2011 and 2023, in order to analyze the epidemiology and trends of PTB with CHD, including different gender, residence, and maternal age. Our study aimed to reveal implications for clinical care, prevention, as well as contribute to the reduction of neonatal mortality rates. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-24-411/rc).
Methods
Data sources
We conducted a retrospective study of medical records. This paper used data from Birth Defects Surveillance System in Hunan Province, China, 2011–2023. Surveillance data included demographic characteristics such as maternal age, residence, the gender and birth weight of newborns, and other key information. Neonates with CHD reported by all obstetrics institutions in Changsha City between 2011 and 2023 were investigated. The research participants were required to meet the following criteria: the newborns were diagnosed with CHD within 7 days after birth, the delivery gestation was 28 weeks or above, and the pregnancy outcome was a single live fetus. PTB was defined as a newborn whose delivery gestational week should be in the interval from 28th week to the 37th week of gestation. Missing data were completed by searching the Hunan Primary Health Information System, and consulting the paper archive. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Ethics Committee of Changsha Hospital for Maternal & Child Health Care Affiliated to Hunan Normal University (No. EC-20240625-19) and the requirement for individual consent for this retrospective analysis was waived.
Data quality control
To standardize the monitoring of birth defects, the Health Commission of Changsha City organized at least one annual training session for monitoring personnel, and conducted comprehensive quality control inspections throughout the city. The data was collected and reported by experienced doctors, and reviewed by senior doctors. Then, the data were sent to maternal and child health institutions of county, municipal, and provincial level, and the National Center for Birth Defects Monitoring in turn. When errors were identified, the form was returned to the reporter for verification and amendment.
Statistical analysis
The incidence and 95% confidence interval (CI) of PTB with CHD were calculated with different gender, residence, and maternal age, respectively. Categorical data were shown as frequencies and percentages, and inter-group comparisons were conducted using the Chi-squared test. Joinpoint regression analysis was conducted of trends of PTB with CHD in total, and among women of different residence and maternal age, respectively. We examined the trends of PTB with CHD through the annual percentage change (APC) and the average annual percentage change (AAPC) in rates using Joinpoint 4.9.1.0 software (National Cancer Institute, Rockville, MD, USA). APC and AAPC were used to evaluate the trend of changes in each time period and throughout the entire period, respectively. APC <0 indicated a decreasing incidence rate annually, whereas APC >0 indicated an increasing incidence rate annually. If there was no connection point, indicating that APC = AAPC, the data was generally showing a monotonic downward or upward trend. A P value of less than 0.05 was considered significant.
Results
Epidemiological characteristics of PTB with CHD
A total of 6,559 neonates with CHD were included. Of those, 1,039 were born preterm. The overall incidence of PTB with CHD was 15.84%. There was no statistically significant difference in the incidence of PTB with CHD between male and female infants (χ2=0.318, P=0.57). The incidence of PTB with CHD was higher in rural areas than in urban areas (χ2=27.92, P<0.001). The analysis showed significant differences in different maternal age groups (χ2=73.417, P<0.001). Compared with maternal age 25–29 years, the rate of PTB with CHD was higher in maternal age <25 years [18.16% vs. 12.02%, odds ratio (OR) =1.63, 95% CI: 1.32–2.00], 30–34 years (16.60% vs. 12.02%, OR =1.46, 95% CI: 1.24–1.72), and ≥35 years (23.29% vs. 12.02%, OR =2.22, 95% CI: 1.84–2.69). Overall, the incidence of PTB with CHD in Changsha City between 2011 and 2023 was on the rise in general, but without statistically significant difference in the trend (AAPC =4.36%, P=0.09) (Tables 1,2).
Table 1
| Indicator | CHD (n) | PTB with CHD (n) | Incidence (95% CI) (%) | OR (95% CI) | χ2 | P value |
|---|---|---|---|---|---|---|
| Total | 6,559 | 1,039 | 15.84 (14.96–16.72) | – | – | – |
| Gender | ||||||
| Male | 3,520 | 566 | 16.08 (14.87–17.29) | 1.04 (0.91–1.19) | 0.318 | 0.57 |
| Female | 3,038 | 473 | 15.57 (14.28–16.86) | Reference | ||
| Unknown | 1 | 0 | – | – | – | – |
| Residence | ||||||
| Urban | 4,910 | 710 | 14.46 (13.48–15.44) | Reference | 27.92 | <0.001 |
| Rural | 1,649 | 329 | 19.95 (18.02–21.88) | 1.47 (1.28–1.70) | ||
| Maternal age (years old) | ||||||
| <25 | 859 | 156 | 18.16 (15.58–20.74) | 1.63 (1.32–2.00) | 73.417 | <0.001 |
| 25–29 | 2,746 | 330 | 12.02 (10.80–13.23) | Reference | ||
| 30–34 | 2,018 | 335 | 16.60 (14.98–18.22) | 1.46 (1.24–1.72) | ||
| ≥35 | 936 | 218 | 23.29 (20.58–26.00) | 2.22 (1.84–2.69) | ||
CHD, congenital heart disease; CI, confidence interval; PTB, preterm birth; OR, odds ratio.
Table 2
| Indicator | Year | APC (95% CI) (%) | AAPC (95% CI) (%) | P value |
|---|---|---|---|---|
| Gender | ||||
| Male | 2011–2023 | 5.32 (−0.89 to 11.91) | 5.32 (−0.89 to 11.91) | 0.09 |
| Female | 2011–2023 | 3.25 (−0.98 to 7.67) | 3.25 (−0.98 to 7.67) | 0.12 |
| Residence | ||||
| Urban | 2011–2023 | 6.64 (0.53 to 13.13) | 6.64 (0.53 to 13.13) | 0.04 |
| Rural | 2011–2023 | −1.39 (−5.38 to 2.77) | −1.39 (−5.38 to 2.77) | 0.47 |
| Maternal age (years old) | ||||
| <25 | 2011–2023 | 1.15 (−5.97 to 8.79) | 1.15 (−5.97 to 8.79) | 0.74 |
| 25–29 | 2011–2023 | 5.47 (−2.06 to 13.57) | 5.47 (−2.06 to 13.57) | 0.14 |
| 30–34 | 2011–2015 | 24.31 (4.26 to 48.21) | 4.92 (−1.25 to 11.46) | 0.12 |
| 2015–2023 | −3.62 (−9.29 to 2.42) | |||
| ≥35 | 2011–2016 | 25.49 (1.34 to 55.38) | 4.18 (−5.61 to 14.99) | 0.42 |
| 2016–2023 | −8.78 (−19.72 to 3.65) | |||
| Total | 2011–2023 | 4.36 (−0.74 to 9.72) | 4.36 (−0.74 to 9.72) | 0.09 |
AAPC, average annual percentage change; APC, annual percentage change; CHD, congenital heart disease; CI, confidence interval; PTB, preterm birth.
Trends of PTB with CHD according to residence
The incidence of PTB with CHD in urban areas of Changsha City between 2011 and 2023 showed an obvious upward trend, without a significant turning point (AAPC =6.64%, P=0.04). However, the incidence of PTB with CHD in rural areas between 2011 and 2023 showed a downward trend, without a statistically significant difference (AAPC =−1.39%, P=0.47) (Tables 2,3).
Table 3
| Year | Urban | Rural | Total | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| CHD (n) | PTB with CHD (n) | Incidence (95% CI) (%) |
CHD (n) | PTB with CHD (n) | Incidence (95% CI) (%) |
CHD (n) | PTB with CHD (n) | Incidence (95% CI) (%) |
|||
| 2011 | 424 | 42 | 9.91 (7.06–12.75) | 53 | 10 | 18.87 (8.33–29.40) | 477 | 52 | 10.90 (8.10–13.70) | ||
| 2012 | 395 | 34 | 8.61 (5.84–11.37) | 110 | 17 | 15.45 (8.70–22.21) | 505 | 51 | 10.10 (7.47–12.73) | ||
| 2013 | 388 | 20 | 5.15 (2.95–7.35) | 99 | 13 | 13.13 (6.48–19.78) | 487 | 33 | 6.78 (4.54–9.01) | ||
| 2014 | 373 | 55 | 14.75 (11.15–18.34) | 166 | 50 | 30.12 (23.14–37.10) | 539 | 105 | 19.48 (16.14–22.82) | ||
| 2015 | 458 | 47 | 10.26 (7.48–13.04) | 279 | 68 | 24.37 (19.33–29.41) | 737 | 115 | 15.60 (12.98–18.22) | ||
| 2016 | 234 | 54 | 23.08 (17.68–28.48) | 146 | 26 | 17.81 (11.60–24.01) | 380 | 80 | 21.05 (16.95–25.15) | ||
| 2017 | 502 | 90 | 17.93 (14.57–21.28) | 179 | 33 | 18.44 (12.75–24.12) | 681 | 123 | 18.06 (15.17–20.95) | ||
| 2018 | 316 | 63 | 19.94 (15.53–24.34) | 118 | 26 | 22.03 (14.56–29.51) | 434 | 89 | 20.51 (16.71–24.31) | ||
| 2019 | 310 | 71 | 22.90 (18.23–27.58) | 116 | 19 | 16.38 (9.64–23.11) | 426 | 90 | 21.13 (17.25–25.00) | ||
| 2020 | 299 | 48 | 16.05 (11.89–20.21) | 112 | 27 | 24.11 (16.19–32.03) | 411 | 75 | 18.25 (14.51–21.98) | ||
| 2021 | 351 | 56 | 15.95 (12.12–19.79) | 91 | 14 | 15.38 (7.97–22.80) | 442 | 70 | 15.84 (12.43–19.24) | ||
| 2022 | 474 | 67 | 14.14 (11.00–17.27) | 86 | 12 | 13.95 (6.63–21.28) | 560 | 79 | 14.11 (11.22–16.99) | ||
| 2023 | 386 | 63 | 16.32 (12.63–20.01) | 94 | 14 | 14.89 (7.70–22.09) | 480 | 77 | 16.04 (12.76–19.32) | ||
| Total | 4,910 | 710 | 14.46 (13.48–15.44) | 1,649 | 329 | 19.95 (18.02–21.88) | 6,559 | 1,039 | 15.84 (14.96–16.72) | ||
CHD, congenital heart disease; CI, confidence interval; PTB, preterm birth.
Trends of PTB with CHD according to maternal age
The incidence of PTB with CHD in Changsha City from 2011 to 2023 showed different trends in different maternal age groups. There were upward trends without a statistically significant difference between 2011 and 2023 in maternal age <25 years (AAPC =1.15%, P=0.74), 25–29 years (AAPC =5.47%, P=0.14), 30–34 years (AAPC =4.92%, P=0.12), and ≥35 years (AAPC =4.18%, P=0.42). However, the incidence of PTB with CHD in maternal age 30–34 years showed an obvious upward trend between 2011 and 2015 (APC =24.31, P=0.02), and showed a downward trend between 2015 and 2023 without a statistically significant difference (APC =−3.62, P=0.20). Meanwhile, the incidence of PTB with CHD in maternal age ≥35 years showed an obvious upward trend between 2011 and 2016 (APC =25.49, P=0.04), and showed a downward trend between 2016 and 2023 without a statistically significant difference (APC =−8.78, P=0.14) (Tables 2,4).
Table 4
| Year | <25 years old | 25–29 years old | 30–34 years old | ≥35 years old | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CHD (n) | PTB with CHD (n) | Incidence (95% CI) (%) |
CHD (n) | PTB with CHD (n) | Incidence (95% CI) (%) |
CHD (n) | PTB with CHD (n) | Incidence (95% CI) (%) |
CHD (n) | PTB with CHD (n) | Incidence (95% CI) (%) |
||||
| 2011 | 75 | 17 | 22.67 (13.19 to 32.14) |
246 | 19 | 7.72 (4.39 to 11.06) |
100 | 9 | 9.00 (3.39 to 14.61) |
56 | 7 | 12.50 (3.84 to 21.16) |
|||
| 2012 | 74 | 7 | 9.46 (2.79 to 16.13) |
230 | 18 | 7.83 (4.35 to 11.30) |
147 | 18 | 12.24 (6.95 to 17.54) |
54 | 8 | 14.81 (5.34 to 24.29) |
|||
| 2013 | 87 | 7 | 8.05 (2.33 to 13.76) |
215 | 7 | 3.26 (0.88 to 5.63) |
128 | 13 | 10.16 (4.92 to 15.39) |
57 | 6 | 10.53 (2.56 to 18.49) |
|||
| 2014 | 134 | 28 | 20.90 (14.01 to 27.78) |
240 | 39 | 16.25 (11.58 to 20.92) |
119 | 22 | 18.49 (11.51 to 25.46) |
46 | 16 | 34.78 (21.02 to 48.55) |
|||
| 2015 | 107 | 25 | 23.36 (15.35 to 31.38) |
399 | 40 | 10.03 (7.08 to 12.97) |
172 | 35 | 20.35 (14.33 to 26.37) |
59 | 15 | 25.42 (14.31 to 36.53) |
|||
| 2016 | 36 | 6 | 16.67 (4.49 to 28.84) |
184 | 33 | 17.93 (12.39 to 23.48) |
112 | 22 | 19.64 (12.28 to 27.00) |
48 | 19 | 39.58 (25.75 to 53.42) |
|||
| 2017 | 66 | 17 | 25.76 (15.21 to 36.31) |
310 | 42 | 13.55 (9.74 to 17.36) |
201 | 34 | 16.92 (11.73 to 22.10) |
104 | 30 | 28.85 (20.14 to 37.55) |
|||
| 2018 | 39 | 11 | 28.21 (14.08 to 42.33) |
163 | 26 | 15.95 (10.33 to 21.57) |
152 | 29 | 19.08 (12.83 to 25.33) |
80 | 23 | 28.75 (18.83 to 38.67) |
|||
| 2019 | 38 | 3 | 7.89 (−0.68 to 16.47) |
199 | 42 | 21.11 (15.44 to 26.78) |
122 | 29 | 23.77 (16.22 to 31.32) |
67 | 16 | 23.88 (13.67 to 34.09) |
|||
| 2020 | 46 | 9 | 19.57 (8.10 to 31.03) |
128 | 15 | 11.72 (6.15 to 17.29) |
174 | 33 | 18.97 (13.14 to 24.79) |
63 | 18 | 28.57 (17.42 to 39.73) |
|||
| 2021 | 47 | 9 | 19.15 (7.90 to 30.4) |
139 | 13 | 9.35 (4.51 to 14.19) |
183 | 32 | 17.49 (11.98 to 22.99) |
73 | 16 | 21.92 (12.43 to 31.41) |
|||
| 2022 | 65 | 9 | 13.85 (5.45 to 22.24) |
158 | 19 | 12.03 (6.95 to 17.10) |
228 | 35 | 15.35 (10.67 to 20.03) |
109 | 16 | 14.68 (8.04 to 21.32) |
|||
| 2023 | 45 | 8 | 17.78 (6.61 to 28.95) |
135 | 17 | 12.59 (7.00 to 18.19) |
180 | 24 | 13.33 (8.37 to 18.30) |
120 | 28 | 23.33 (15.77 to 30.90) |
|||
| Total | 859 | 156 | 18.16 (15.58 to 20.74) |
2,746 | 330 | 12.02 (10.80 to 13.23) |
2,018 | 335 | 16.60 (14.98 to 18.22) |
936 | 218 | 23.29 (20.58 to 26.00) |
|||
CHD, congenital heart disease; CI, confidence interval; PTB, preterm birth.
Discussion
We conducted a comprehensive analysis of the epidemiological characteristics of PTB with CHD in Changsha City from 2011 to 2023. The Chi-squared test was used to explore the influencing factors, and joinpoint regression model was used to explore the trends. This is the most recent retrospective study on PTB with CHD in China. Based on a representative sample size of the most recent decade of long-term CHD surveillance data, it is an important analysis on the epidemiology of PTB with CHD, and it provides unique and innovative contributions to the field.
The overall incidence of PTB with CHD in Changsha City (15.84%) from 2011 to 2023 was lower than that of the same population in other countries, for example, 23.21% in USA [2011–2016] (20), 18.9% in Canada [2008–2018] (21), but it was higher than that of the general population in Shanghai City (4.7%) between 2004 and 2020 (22), and worldwide (10.6%) in 2014 (23). This indicated that neonates with CHD would have a higher risk of PTB.
In our study, there was no significant difference between male and female infants in the incidence of PTB with CHD, which was consistent with previous studies (20,24). Our study found that the incidence of PTB with CHD was higher in rural areas than in urban areas. The finding was consistent with existing literature. For example, the incidence of PTB increased from 2008 to 2017 in Brazil, with small and rural municipalities frequently exhibiting higher rates than urban areas (25). This may be related to low-income groups who are deprived of resources, parental agricultural work, and lack of necessary prenatal testing (26). In our study, compared with maternal age 25–29 years, PTB with CHD was more common in maternal age <25 years, 30–34 years, and ≥35 years. Some previous studies have found that young and advanced-age mothers have higher risks of PTB (27-29). A potential explanation is that the young mothers were not yet physically or psychologically mature, were more likely to be primiparous, had achieved lower educational levels, and received insufficient prenatal care (29). Advanced-age mothers would have a higher risk of various internal, surgical, and gynecological diseases. In addition, factors such as decreased membrane tension and weakened cervical elasticity make it easy to induce premature delivery.
This study explores the trends in the incidence of PTB with CHD in Changsha City between 2011 and 2023, and the results showed different trends in total, residence, and maternal age. Overall, the incidence of PTB with CHD in Changsha City increased from 2011 to 2023 without a statistically significant difference in the trend. It is possible that although advanced medical technology leads to higher survival rates for PTB, people paid more attention to taking various measures to prevent PTB. The incidence of PTB with CHD in urban areas of Changsha City increased from 2011 to 2023, and showed an obvious upward trend. This may have been due to rapid economic development and advanced medical technology improving the survival rate of PTB. The incidence of PTB with CHD in maternal age 30–34 years increased obviously from 2011 to 2015, and decreased slightly from 2015 to 2023. Similarly, the incidence of PTB with CHD in maternal age ≥35 years increased obviously from 2011 to 2016, and decreased slightly from 2016 to 2023. This may be mainly associated with national policies, economic and medical conditions. For example, with the opening of the second-child policy and the third-child policy, the proportion of advanced maternal age increased. Government departments and medical institutions strengthened the health education of pregnant women and paid attention to antenatal examination. In turn, this led to early detection of pregnancy risk factors and timely treatment to reduce the occurrence of PTB.
Strengths
This study provided information on the incidence and trends of PTB (6,559 cases) with CHD in Changsha City over the past 13 years, which can provide a reference for preventing PTB with CHD.
Limitations
This study was based on existing database analysis and has not actively obtained other basic data and experimental results. This study only analyzed the incidence of PTB with CHD based on newborn gender, residence, and maternal age, without analyzing other influencing factors.
Conclusions
Overall, the incidence of PTB with CHD in Changsha City between 2011 and 2023 was below the national average, and it showed an upward trend. We found that PTB with CHD was more common in rural areas, as well as in maternal age <25, 30–34, and ≥35 years. There were obvious upward trends of the incidence of PTB with CHD in urban areas between 2011 and 2023, and in maternal age 30–34 years between 2011 and 2015, as well as in maternal age ≥35 years between 2011 and 2016. In the future, we need to pay more attention to neonates with CHD and reduce the incidence of PTB. Our findings contribute to clinical counseling and advancing research on the risk factors of PTB with CHD.
Acknowledgments
The author thanks all pregnant women and staff who participated in the collection and reporting of data on neonates with CHD between 2011 and 2023 in Changsha City.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-24-411/rc
Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-24-411/dss
Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-24-411/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-24-411/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Ethics Committee of Changsha Hospital for Maternal & Child Health Care Affiliated to Hunan Normal University (No: EC-20240625-19) and individual consent for this retrospective analysis was waived.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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(English Language Editor: J. Jones)
