Transcript Perinatal Programs: A Public Health Approach

Perinatal Programs: A Public
Health Approach
November 19, 2007
Virginia Commonwealth University
Joan Corder-Mabe, RNC, M.S., WHNP
Director, Division of Women’s and Infants’ Health
Virginia Department of Health
Major Issues Regarding
Maternal-Infant Health
Infant Mortality
 Low Birth Weight
 Maternal Mortality
 Access to Care

Core Functions of Public Health
Assessment
Assurance
Policy
Assessment
Analysis of birth certificate data
 Fetal and Infant Mortality Review (FIMR)
 Child Fatality Review
 Pregnancy Risk Assessment Monitoring
System (PRAMS)
 Maternal Death Review

Infant Mortality as a Measure of
Health
“Infant death is a critical indicator of the health of the
population. It reflects the overall state of maternal health as
well as the quality and accessibility of primary health care
available to pregnant women and infants. Despite steady
declines in the 1980’s and 1990’s, the rate of infant
mortality in the United States remains one of the highest in
the industrialized world.”
Healthy People 2010 Report
National and Virginia Infant Mortality Rates
1982-2005
14
VA
12
US
8
6
4
2
Year
20
04
20
02
20
00
19
98
19
96
19
94
19
92
19
90
19
88
19
86
19
84
0
19
82
Rate/1000
10
National and Virginia Infant Mortality by Race
1982-2005
25
US
VA
White
20
Rate/1,000 live births
Black
15
10
5
0
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
Year
98
19
00
20
02
20
04
20
National and Virginia Infant Mortality Rates
by Race and Ethnicity
1982-2005
US
20
VA
Whit e, NH
18
Black, NH
Hispanic, Any r ace
14
12
10
8
6
4
2
Year
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
0
1982
Rate/1,000 live births
16
Trend in infant mortality over the
last five years
16
14
US
Rate/1,000 live births
12
VA
White, NH
10
Black, NH
Hispanic, Any race
8
6
4
2
0
2000
2001
2002
2003
2004
Year
2005
Virginia rates of infant mortality, preterm
births, and fetal deaths
1982-2005
Virginia's rate of infant mortality, preterm births, and fetal
deaths 1982 - 2005
14.0
12.0
8.0
6.0
4.0
Inf ant M ort alit y
Percent Pret erm
2.0
Percent f et al deat hs
Year
20
04
20
02
20
00
19
98
19
96
19
94
19
92
19
90
19
88
19
86
19
84
0.0
19
82
Rate
10.0
Leading causes of infant death
Prematurity/low weight birth
 Sudden Infant Death (SIDS)
 Birth defects
 Complications of pregnancy

Neonatal Deaths
Early Infant Deaths (< one day)
Blacks
6.7
Whites
2.5
Other
1.4
Total
3.3
All Neonatal Deaths (0-27 days)
9.8
4.1
2.3
5.1
Source: 2005 Virginia Center of Health Statistics
Setting a Goal for Reduction of
Infant Deaths



Virginia is working toward the goal to reduce its infant
death rate to 7.0 per thousand live births by 2008.
This would surpass the Healthy People 2010 goal of
reducing the infant mortality rate to 7.2 per thousand.
In order to meet this goal, VDH needs to focus those
populations with the highest risks, geographic areas and
gestational periods with the highest number of deaths.
Low Birth Weight Trend by Race
1990-2005
14.0
12.0
VA
8.0
White
Black
6.0
Hispanic
4.0
2.0
Ye ar
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
0.0
1990
Percent LBW
10.0
Low Birth Weight is associated with
multiple factors:

Medical Risk Factors
- High parity
- Chronic diseases
- Previous Low Birth Weight infants
- Genetic factors
- Multiple gestation
- Poor weight gain
- Infection
- Placental problems
- Premature rupture of membranes
- Fetal anomalies
- Maternal stress
Low Birth Weight (continued)

Demographic Risk Factors
- Age < 17 years and > 34 years
- African-American race
- Low socioeconomic status
- Unmarried
- Low education

Behavioral Risk Factors
- Smoking
- Poor nutrition
- Toxic exposure
- Inadequate prenatal care
- Substance abuse
The etiology of preterm labor and
premature birth is unknown.
Long-term effects of Low Birth
Weight
Neurologic disorders
 Learning disabilities
 Delayed development

The populations at highest risk of infant
deaths and low birth weight
African American
 Unmarried
 Low income
 Less than a high school education
 Enter prenatal care late or not at all
 Many smoke and have poor nutrition

National Fetal-Infant Mortality
Review (NFIMR) Program
Established in 1990
 Public-private partnership

– American College of Obstetricians and Gynecologists
(ACOG)
– Maternal and Child Health Bureau
– March of Dimes Birth Defects Foundation
FIMR is:
Community-based, action-oriented process
 Early warning system that describes health
care
 Method of continuous quality improvement
 Means to implement core public health
functions

Objectives:
Initiate an interdisciplinary review of fetal and
infant death from medical and social records and
maternal interview.
 Describe significant social, economic, cultural
and systems factors that contribute to mortality.
 Design and participate in implementing
community-based interventions determined from
review findings.

Assessment (continued)
Child Fatality Review
 PRAMS

Deaths per 100,000 Live Births
Maternal Mortality Has Not
Changed Since 1982
25
20
15
10
5
0
0
7
19
0
8
19
0
9
19
Year
Source: Centers for Disease Control and Prevention
Maternal Mortality Rates,
by Race of Mother: 2000
Reasons for reduction in maternal
mortality
Sulfa and antibiotic drugs
 Decrease infections secondary to illicit
abortions
 Availability of banked blood
 Safer surgical procedures, including
Cesarean

The Year 2000 goal (3.3 maternal
deaths per 100,000 live births) was
not reached nationally or in Virginia.
The 3 leading causes of natural maternal
death in the United States and Virginia
Hemorrhage, including ectopic pregnancy
 Pregnancy-Induced Hypertension
 Pulmonary Embolism

Maternal Mortality Ratios
CDC
Expanded
Definition
2001
9
38 (21 natural)
2002
5
34 (13 natural)
2003
12
55 (32 natural)
Components of maternal death
reviews
Investigation of individual maternal death
 Multidisciplinary discussion of each case
 Recommendations to prevent future deaths

Team Purpose:
The Maternal Mortality Review Team reviews and
analyzes maternal deaths in Virginia to develop
an understanding of the causes of maternal
death. We use the results to:
1. Educate colleagues and policymakers about
these deaths and the need for changes in law and
practice, and
2. Recommend other improvements to reduce the
number of preventable maternal deaths in
Virginia.
Public Health Approach to Infant
Mortality
Providing Access to Perinatal and Infant Care
Healthy Start
Reducing
Unintended
Pregnancy
Medicaid
&
SCHIP
Childhood
Immunization
Initiative
Reducing
Infant
Mortality
“Back to Sleep”
Campaign
Promoting healthy choices to reduce
mortality risks
MCH
Services
Reducing mother
to child HIV
transmission
Folic Acid
Campaign
Promoting research
to reduce infant
mortality
Assurance
Prevention Efforts
 Safety Net
 Setting Standards/Quality of Care

Prevention
Preventing Unintended Pregnancy and Planning Families
Abstinence Education
Teen Pregnancy Prevention
Girls Empowered to Make Success
Partners in Prevention
Family Planning Clinics
Partners in Prevention Program (PIP)
Targeting young men and women between
the ages of 20-29
 Increase knowledge regarding the risks of
nonmarital birth
 Promote healthy attitudes and behaviors
about marriage, family, and career

Preconception
Prevention of birth defects
 Treatment of chronic conditions
 Promotion of healthy lifestyles (smoking,
alcohol)

The improvement in infant
mortality rates is not an indicator
that babies are healthier, but
medical technology is enabling
sicker babies to survive.
Regionalization of perinatal care was
successful in the 1970s and 1980s by
concentrating the births of very low
birth weight infants to the tertiary
centers.
Regional Perinatal Councils (RPCs)
Regional Perinatal Councils (RPCs) improve the
infrastructure through which perinatal health is
provided within the Commonwealth.
Goals:
 address problems of infant mortality and morbidity
address access to prenatal care
 conduct perinatal outreach education for professionals

Programs (continued)
Car seat program
 Virginia Council on Folic Acid/VDH
Campaign
 Fetal Alcohol Spectrum Disorders (FASD)
Task Force

Safety Net Providers
Prenatal care in local health departments
 WIC in local health departments
 Community Health Centers

Early and regular use of prenatal
care is a strong predictor of
positive pregnancy outcomes.
Early prenatal care is an indicator
for access to health care services.
Resource Mothers Program
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Lay home visitors who mentor pregnant teenagers
Decrease infant mortality and low weight births
25 contractors enrolling approximately 1100 newly
pregnant teens per year in 88 Virginia localities
Early and regular prenatal care, increased healthy
behaviors, delay of repeat pregnancy, enrollment in
school or employment, and creation of a stable home
environment
Staff aim to motivate program participants to stop
smoking
Loving Steps/Virginia Healthy Start
Program
Goal of reducing infant deaths and improving
birth outcomes through early intervention:

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


Case management and health education
Registered nurses provide medical nursing care
Registered dietitians provide medical nutrition therapy
services
Resource Mothers (Community Health Workers)
FIMR
Newborn Screening



Coordinated and comprehensive system consisting of
education, blood screening tests, follow-up and referrals,
diagnosis, medical and dietary management, and
treatment
Effective March, 2006, Virginia screens for 28 disorders
Since March 1, 2006, 8 infants have been identified with
life-threatening rare disorders which would not have been
identified before the expansion.
Setting Standards/Quality of Care
Neonatal Regulations
 Screening for domestic violence, perinatal
substance use, and perinatal depression
 Web-based training on Bright Futures and
Perinatal Depression
 Provision of culturally competent care

Policy and Planning
Implementation of Codes Regarding Perinatal Substance Use:
 54.1-2403.1 of the Code of Virginia Substance Use Screening in
Prenatal Care
 63.2-1509 of the Code of Virginia Physician referral of Substance
Exposed Newborns
 32.1-127 of the Code of Virginia Hospital Discharge Planning for
Substance using Postpartum Women
 32.1-134.01 of the Code of Virginia Discharge Education on
Postpartum Blues, Perinatal Depression, Shaken Baby Syndrome
Interagency Substance Exposed Newborn Workgroup
(DMHMRSAS, DSS, DCJ)
Analysis of proposed legislation
Supports Governor’s task forces and commissions
Governor’s Commission on
Healthcare Reform
Infant mortality
 Obesity
 Smoking

Conclusion
Studies of underlying factors that contribute to
morbidity and mortality are needed
 Review of quality of health care and access to
care for all women and infants is needed
 Racial/ethnic disparities need to be eliminated
 Research to determine effective public health
programs to make a difference
