Transcript Slide 1

Alabama Perinatal Conference
Translating Recommendations
into Action
September 14. 2012
Lessons Learned from the Community-Based
Prematurity Prevention Pilot in Kentucky:
Preterm Births, Low Birthweight and Infant
Mortality
United States, 1981 - 2004
Percent
Rate per 1,000 live births
14
14
12
12
10
10
8
8
6
6
4
4
2
2
0
0
1981
1983
1985
1987
1989
Preterm Birth
1991
1993
Low Birthweight
1995
1997
1999
Infant Mortality Rate
Source: National Center for Health Statistics, final natality and mortality data
Prepared by March of Dimes Perinatal Data Center, 2007
2001
2003
Infant mortality rates excluding births at <22 weeks of
gestation, US and selected European countries, 2004
MacDorman,
NCHS, 2011
3
Three Leading Causes of Infant Mortality
United States, 1990 and 2007*
Rate per 100,000 live births
198.1
Birth Defects
134.9
96.5
Preterm / LBW
1990
112.7
2007
130.3
SIDS
57
0
50
100
Source: National Center for Health Statistics
Adapted from a slide Prepared by March of Dimes Perinatal Data Center, 2007
150
200
250
The Life Course Perspective of
Health Development
Critical
Periods
Cumulative
Effects
Interaction
with
Environment
Health
Equity
TIMING
TIMELINE
ENVIRONMENT
EQUITY
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.
5
Maternal Child Health J. 2003;7:13-30.
Life Course Health
Development
Poor Nutrition
Stress
Abuse
Tobacco, Alcohol, Drugs
Poverty
Lack of Access to Health Care
Exposure to Toxins
Poor Birth Outcome
Age
0
5
Puberty
Pregnancy
Birth Weight and
Insulin Resistance Syndrome
Barker Hypothesis
20
18
15
10
8.4
8.5
4.9
5
2.2
1
0
<5.5
5.6-6.5
6.6-7.5
7.6-8.5
Birthweight (lbs)
Barker 1993
8.6-9.5
>9.5
Birth Weight and
Coronary Heart Disease
Barker Hypothesis
1.75
1.5
1.5
1.25
1.15
1.25
1
1
0.9
0.7
0.75
0.5
0.25
0
<5.0
5.0-5.5
5.6-7.0
7.1-8.5
Birthweight (lbs)
Rich-Edwards 1997
8.6-10.0
>10.0
Fetal Origins of Disease
New York Times, Oct. 2, 2010
• “Perhaps the most striking finding is that a stressful
intrauterine environment may be a mechanism that
allows poverty to replicate itself generation to
generation. Pregnant women in low income areas
tend to be more exposed to anxiety, depression,
chemicals and toxins, more likely to smoke or drink…
the result is children who start life at a
disadvantage…”
Review of ORIGINS: How the Nine Months Before Birth Shape
the Rest of Our Lives. Annie Murphy Paul, 2010
9
Fetal Origins of Disease
Altered Gene Expression
• Jirtle & Waterland, Duke University
• Agouti mice
– Normally fat bodies, yellow fur, predisposed to diabetes and
cancer
– Appearance and physiology due to a specific gene
• Group of pregnant mice
– Half got regular diet, have got diet high in methyl groups (can turn genes off
or on)
– Pups from moms on regular diet looked just like their parents
– Pups from hi-methyl moms were SLENDER, BROWN FUR, NOT
PREDISPOSED TO DIABETES OR CANCER
Review of ORIGINS: How the Nine Months Before Birth Shape
the Rest of Our Lives. Annie Murphy Paul, 2010
10
A Community-Based Initiative to
Prevent Preterm Birth
CAN WE DO BETTER WITH WHAT WE KNOW NOW?
• A ‘real world’, ecological design using bundling of
evidence-based interventions in different health care
settings (academic, private, clinic-based)
• An innovative, multi-dimensional intervention
program designed to prevent “preventable” preterm
birth in subgroups of the population where
interventions have a likelihood of success in a
reasonable period of time
Dr. Karla Damus
July 2005June 2006
Baseline
CONCEPTS/DESIGN:
July 2006June 2007
Planning Training
July 2007-December 2009
Implementation
• Ecological “real world” design
•“Bundled” medical and public
health interventions
• Based on improving community
systems of care and support
• Targeting “preventable”
preterm birth
GOAL: 15% reduction in PTB in
intervention sites
18
13
Keys to Community-Based
Prematurity Prevention
• DATA
ACTION
• We know enough now to do better
• RESEARCH
“REAL WORLD”
• Implement Best Available Evidence
• SILOS
SYSTEMS
• Comprehensive, coordinated clinical and public health services
• MEDICAL MODEL
ECOLOGICAL MODEL
• Multiple determinants of health,Prematurity as a public health problem
• RELATIONSHIPS
• We can do better now
RESULTS
Data
Action
We know enough now to do better
Data
Action
• Data determines the focus
Late preterm was driving the increase PTB rates
• Develop the Data
Consumer & provider surveys, focus groups, ACOG survey, policy and
environment surveys
• Data quality matters
Data Definitions, consistent collection
• Local Data drives improvement
Don’t wait for vital statistics file
Use or adapt existing data sources
Percent of Live Births that were Preterm*;
Kentucky and U.S.
*Preterm birth is defined as any live birth
occurring <37 completed weeks gestation
Data Source: March of Dimes Peristats &
National Center for Health Statistics
Singleton Preterm Birth Rates
US and Kentucky, 1994-2004
Singleton Preterm Births
(<37wk)
Late Preterm Births
(34-36 wks)
Preterm Births by Week of Gestation
United States
Kentucky
16%
14.7%
<32 weeks
37%
5%
32 weeks
5.1%
39.1%
33 weeks
8%
6.9%
34 weeks
35 weeks
12.9%
36 weeks
<32 weeks
32 weeks
33 weeks
34 weeks
35 weeks
36 weeks
13%
21.4%
21%
Late preterm
71%
Source: National Center for Health Statistics, 2004 final natality data
Prepared by March of Dimes Perinatal Data Center, 2007
Late Preterm
73%
6
Preterm Births
• Term:
– about 40 weeks
• Preterm birth:
– <37 completed weeks
• Late preterm (near-term):
– 34 -36 weeks
• Very preterm:
– <32 weeks
Research
Real World
Implement best available evidence
Research
Real World
• State of the Science: Grand Rounds (quarterly), Resource centers:
Epidemology, latest research, Brain Growth, morbidity in LPTB
• ACOG Guidelines (induction, elective C/S, progesterone, cervical
length, antenatal steroids, etc.)
• Aggressive Treatment of Infections, STI, BV
• Patient Safety (Steve Clark, Kathleen Simpson)
• Quality Improvement, provider feedback
• Centering Pregnancy/ Group prenatal care
• Smoking Cessation (5A’s)
• Psychosocial screening & referral
• Oral Health Screening & referral
• Breastfeeding
• Evidence-based home visiting
•Reasons for singleton Preterm births in the U.S. 19892000
Anath CV et al, Obstet Gyecol 2005; 105:1084-91
Intervention
SPTL
PROM
NICHD Consensus Conference
July 2005
Morbidities Associatied with Late Preterm births:
Trying to separate causes and effects
Increased immediate morbidities:
 Respiratory distress
 Jaundice
 Feeding difficulties
 Hypoglycemia
 Temperature instability
 Sepsis
 Increased NICU use (and re-admissions)
 Increased cost
 Long term outcome - ???
The Late Preterm Morbidity:
HYPOGLYCEMIA
• Hypoglycemia is 3X more common in late
preterm infants
• “Unlike term infants, late preterm infants are
incapable of mounting an adequate mature
counter-regulatory response to
hypoglycemia”
– Gluconeogenesis, ketogenic responses to mobilize
alternate fuels is inadequate
– Glycogen reserves, adipose stores build up only in
late gestation
– Astrocytes in the glia are still immature
Garg M, Devaskar SU. Clin Perinatol 33:853-70, 2006.
Lung Transition to Life Outside the Womb
Onset of labor triggers
Decrease of Fetal lung
Fluid secretion
Mechanical Forces
“Vaginal Squeeze”
?
?
Transition from
Fluid-filled to
Air filled Lung
ENaC activation
Specificity,
number
Surfactant to
coat alveoli
Steroids before birth enhance maturation
Slide from L. Jain, Emory University, modified
Development of
the Human Brain
through Gestation
• The Brain is the
last major organ
system to
develop
• Lower functions
mature first,
cortex last
Brain at 35 wks
weighs only 2/3
what it will
weigh at term
Cowan WM. Sci Am 241:113,
1979
HBWW Consumer Surveys
Provided up-to-date, locally relevant KAB information from pregnant women, the target of the HBWW
Initiative
Based on findings, able to tailor educational materials and communication efforts of Initiative to community
needs
Results will be important for evaluation of the Initiative
(baseline vs. 3 year follow-up)
Concerns about Late Preterm Brain Development
And Potential Impact
“Because one out of 11 births in this country
is a late preterm birth, and
since the brain of the late preterm infant is
less mature than that of the term infant,
even a minor increase in the rate of
neurologic disability and scholastic failure in this
group can have a huge impact on the health care
and educational systems.”
Raju TNK. Epidemiology of Late Preterm Births. Clin
Perinatol 33 (2006) 751-763
Mortality in the Late Preterm
• Late preterm infants were 3 times more likely than term
infants to die in the first year of life
• Even excluding congenital anomalies, infant mortality rates
for late preterm infants were 2.6 times higher than in term
infants
• Early Neonatal (<7 days) 6X more likely to die
• Late Neonatal 3 X more likely
• Post Neonatal: 2X more likely
• Late preterm infants are 8.5 times more likely to die with a
diagnosis of respiratory distress in the early neonatal
period
• Late preterm infants are twice as likely as term infants to
die of SIDS
Tomashek, KM, Shapiro-Mendose CK, Davidoff MJ, Petrini JR. Differences in Mortality
between Late-Preterm and Term Singleton Infants in the United States, 1995-2002. J
Pediatr 2007:151:450-6
Late Preterm Infant Morbidity
in the Neonatal Period
• Late Preterms were 7X more likely to have newborn
morbidity than term infants. Newborn morbidity rate
doubled for each gestational week earlier than 38
weeks
• The independent effect of late preterm birth on
morbidity was 7X stronger than any of the selected
maternal conditions
• The proportion of morbidity among late preterm
infants was relatively high across the board, ranging
from 18.1% to 27.8%
Shapiro-Mendosa CK et al. Pediatrics 2008, 121:e223-e232
LATE PRETERM OUTCOMES
Compared to term infants, infants born in the
late preterm period have:
•
•
•
•
•
•
•
•
•
•
6X incr risk of dying in the first week of life
3X incr risk of dying in the first year of life
Increased risk of ADHD by 70%
Clinically significant behavior problems in 20%
Incr risk for special ed, cognitive and learning problems
2-4X increased risk for Cerebral Palsy
2-3X increased risk for IQ < 85
Increased risk for mental disorders/schizophrenia as adults
40% increased risk for medical disability that limits working capacity as
adults
Increased risk of long term neurodevelopmental handicap as young
adults
ACOG Committee Opinion # 22
• ACOG has cautioned against inductions
before 39 weeks in the absence of a medical
indication
• Since 1979
ACOG Committee Opinion # 404
Late Preterm Infants, April 2008
•Late preterm infants often are mistakenly believed to
be as physiologically and metabolically mature as term
infants. However, compared with term infants, late–
preterm infants are at higher risk than term infants of
developing medical complications, resulting in higher
rates of infant mortality, higher rates of morbidity
before initial hospital discharge, and higher rates of
hospital readmission in the first months of life.
Preterm delivery should occur only when
an accepted maternal or fetal indication
for delivery exists.
Statement developed jointly with AAP Committee on Fetus & Newborn
ACOG Practice Bulletin,
Number 107 August 2009
Induction of labor



Reinforced no elective induction or C/S
should be done prior to 39 weeks gestation
Specific criteria for establishing gestational
age should be followed
A mature fetal lung test result before 39
weeks of gestation, in the absence of
appropriate clinical circumstances, is not an
indication for delivery. (see Bates, 2009)
Elective cesarean
delivery before 39 weeks
is common (35.8%) and
is associated with
respiratory and other
adverse neonatal
outcomes, increased
risk 2-4X:
At 38 wks OR 1.2-2.1
At 37 wks OR 1.8-4.2
Complications of Non-medically Indicated
(Elective) Deliveries
Between 37 and 39 Weeks






Increased NICU admissions
Increased transient tachypnea of the newborn (TTN)
Increased respiratory distress syndrome (RDS)
Increased ventilator support
Increased suspected or proven sepsis
Increased newborn feeding problems and other
transition issues
See Toolkit for more data and full list of citations
Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997
NICU Admissions By Weeks Gestation
Deliveries Without Complications, 2000-2003
10%
8%
Percent
6.66%
NICU Admissions
6%
3.44%
3.36%
4%
2.47%
2.65%
39th Week
(33,185)
40th Week
(19,601)
4.26%
2%
0%
37th Week
(8,001)
38th Week
(18,988)
41st Week
(4,505)
42nd Week
(258)
Gestational Weeks
Oshiro et al. Obstet Gynecol 2009;113:804-811.
Preterm Births
Term: about 40 weeks (39-41):
• Early Term
– 37-38 weeks
Preterm birth: <37 completed
weeks
• Late preterm (near-term):
– 34 -36 weeks
• Very preterm:
– <32 weeks
Terminology
Late Preterm Early Term
First day of
LMP
Week #
0
20 0/7
340/7
Preterm
37 0/7 39 0/7
416/7
Term
Post term
The
“New”
Term
Modified from Drawing courtesy of William Engle, MD, Indiana University
Raju TNK. Pediatrics , 2006;118 1207. Oshiro BT Obstet Gynecol 2009;113:804
40
Rate of Scheduled Births
Available at:
http://opqc.net/presentations
at 360 - 386 Weeks’
Without Documented Indication
%
Observe
X 2 Months
Project begun 9-1-08
11-30-09
Clark SL, et al. AJOG, 2008;199:105.e1-105.e7. Improved
outcomes, lower C/S rates. Decr malpractice claims by half,
cost of claims by 5-fold
HCA Trial of 3 Approaches for
Reduction of Elective Deliveries <39 weeks
Hard Stop
Soft Stop/
Peer Rev
Education
Only
Consistent
reduction in
every hospital
Clark SL. et al. Am J Obstet Gynecol 2010;203:449.e1-6
Silos
Systems
“Comprehensive, coordinated, integration of
clinical and public health systems of care”
Silos
Systems
• Convene the Partners
– Hospitals and Health depts as community health leaders
– Don’t really know what services the other provides
• Describe best practices
– Don’t let perfect be the enemy of good
• Determine the gaps
– Prenatal classes, oral health, MNT, Substance abuse
• What can we do better now?
– Fax referral form, exchanging staff, co-locating services, consistent
information; referrals to health dept services
Healthy Babies are Worth the Wait
Oral Health
• ISW - Dental hygenist regular presenter in Centering
• Dental Chair in Women’s Center at hospital
– When moved to Health Dept a block away, patients did not go
• ISC - Improved coordination with dental school clinics
• increased emphasis with residents and nurses on oral screening
and care for patients
• ISE - No dentists in area would treat pregnant women
• Hosted regional meeting with area dentists and OB’s,
nationally known dentist as speaker
• Several local dentists then agreed to see pregnant women
referred by their obstetrician
Healthy Babies are Worth the Wait
Substance abuse prevention and management.
• ISW - Improved local access to substance-abuse treatment
for pregnant women
– began universal screening for substance abuse as part
of prenatal care; non-stigmatizing, non-punative
• ISC - Improved coordination with in-house detox unit for
managing substance abuse in pregnancy
– Implemented universal psychosocial screening
• ISE - Grand rounds on use of subutex by addiction
specialist for substance abuse in pregnancy
– Hospital social worker went to OB offices to see and
do brief intervention with substance-abusing patients
Evidence-Based Home Visiting
and Preterm Birth
Health Access Nurturing Development Services
Voluntary, intensive weekly home visitation
Overburdened, first time moms
or first time dads
Regardless of income
Prenatal to two years of age
Strengths-based, build resilience in families
Designed to improve both health & social outcomes
Mix of professionals and paraprofessionals
48
OUTCOMES
31% less Prematurity
33% less LBW
55% less VLBW
70% less Infant Mortality
50% less ER Usage
29-40% less Child Abuse and Neglect
26% improved/increased Education
Less developmental delays
Outside Evaluator
49
Social Determinants of Health
Kaplan, et al. (2000). A Multilevel Framework for Health in :Promoting Health. Washington, DC: National Academy Press
The basis for psychosocial screening
ACOG Committee Opinion # 343
Psychosocial Risk Factors: Perinatal Screening
and Intervention
• “Biomedical risks, such as complications of pregnancy,
concomitant maternal disease, infection, nutritional
deficiencies, and exposure to teratogens, are estimated
to account for approximately one half of the incidence of
low-birth-weight infants and of prematurity and their
postnatal sequellae. An important portion of the
remaining cases of these adverse pregnancy outcomes
may be attributable to psychosocial stress even after
controlling for the effects of recognized sociodemographic, obstetric, and behavioral risk factors.”
Medical Model
Ecological Model
Multiple Determinants of Health
Ecological Influences on Health
53
COMMUNITY MESSAGES
•
Full Term is about 40 weeks
•
Unless there are medical complications,
women should try to carry pregnancy
to a full 40 weeks, because….
•
Much of the brain development
happens in those last 4-6 weeks of
pregnancy
•
Preventing prematurity improves
the lives of families and communities
•
Available at www.kfap.org
(The KY Folic Acid Partnership)
Example billboard
What Do Women think is Term?
•
Goldenberg et al, 2009. Women’s Perceptions Regarding the Safety of
Birth at Various Gestational Ages. Obstet Gynecol 2009. 114:1254-8
• Survey of 650 women enrolled in an insurance plan
who had recently had a baby
“At what gestational age do you believe a baby is
considered full term:
– Responses of </=37 weeks
45.7%
– 38 weeks
29.1%
– 39-40 weeks (correct response) 25.2%
The Gestational Age that Women
Considered it “Safe to Deliver”
Obstet Gynecol 2009;114:1254
Relationships
Results
We can do better
Relationships
Results
• Relationships among
- Providers
- Agencies
- Clients
- Community partners
• Making a Difference motivates
• Small wins count
Intervention Implemented Across
All Sites
• The impact of the project, measured from 2007 through
2010, did meet the target of reducing preterm birth in the
intervention sites by 15%.
Preterm Birth Rates
Late Preterm Birth Rates
HBWW: Moving Forward
• In 2010 the 3 Kentucky control sites began
implementing HBWW
– Data has shown a decrease in preterm and late
preterm birth rates in these sites since
intervention implementation
• An additional 2 sites have been added to the
Kentucky program in 2011
• March of Dimes is expanding program sites
in New Jersey and Texas, with a goal of
reaching 20 sites by 2014
Community-Based Prematurity
Prevention
The Kentucky Experience
HRSA Regional Infant Mortality Summit
January 12-13, 2012
HRSA Collaborative Improvement
and Innovation Network (COIN)
Regions IV and VI Strategy Teams:
 Elective Deliveries < 39 weeks
 Perinatal Regionalization
 Medicaid policies for preconception/
interconception care
 Sleep related Infant Deaths
 Smoking in pregnancy
COIN Launch Meeting, July 23-24, 2012
STRONG START FOR MOTHERS AND NEWBORNS
• Grant opportunity from CMS Innovations Center
Medicaid finances about 40% of all births in US
Medicaid beneficiaries are at increased risk for
preterm birth
A. Promote awareness and spread best practices
through the Partnership for Patients Hospital
Engagement Networks (ED<39 weeks)
B. Funding opportunity to test the effectiveness of
new models of prenatal care that provide
comprehensive services/ enhanced prenatal care
1. Group Prenatal care (e.g., Centering
Pregnancy), providing peer support, health
assessment, and education
2. Comprehensive prenatal care at birth center; to include collaborative
practice, intensive case management, counseling
and psychosocial support services
3. Enhanced prenatal care at Maternity Care Homes, including
psychosocial support, education, and health promotion in addition to
traditional prenatal care
The National Infant Mortality
Initiative
And today I’m pleased to announce my
department will be collaborating in the
next year to create our nation’s first ever
national strategy to address infant
mortality.
Secretary Kathleen Sebelius
June 14, 2012
Keys to Community-Based
Prematurity Prevention
• DATA
ACTION
• We know enough now to do better
• RESEARCH
“REAL WORLD”
• Implement Best Available Evidence
• SILOS
SYSTEMS
• Comprehensive, coordinated clinical and public health services
• MEDICAL MODEL
ECOLOGICAL MODEL
• Multiple determinants of health,Prematurity as a public health problem
• RELATIONSHIPS
• We can do better now
RESULTS
This Continuing Professional Education Program is
generously supported by a March of Dimes Grant
from an Anonymous Donor
For additional online resources on preterm birth, please visit:
1. PrematurityPrevention.org Online source of information on prematurity. The
PPRC is primarily for professional use and includes current information on
interventions, research, advocacy, professional education, global initiatives,
teaching tools and resources to use with patients.
2. Elimination of Non-medically Indicated Elective Deliveries Before 39 Weeks
Gestational Age. Outlines successful initiatives and sample implementation
plan to reduce elective deliveries before 39 weeks at hospital, health system
and statewide levels. Free download: prematurityprevention.org or purchase:
marchofdimes.com/catalog
3. Toward Improving the Outcome of Pregnancy III. Explores the elements that
are essential to improving quality, safety and performance across the
continuum of perinatal care. prematurityprevention.org
4. Preterm Labor Assessment Toolkit – Provides standardized protocols for
assessing patients in preterm labor. prematurityprevention.org
5. Preterm Labor: Prevention and Nursing Management Nursing Module –
Discusses nursing management of women presenting in preterm labor. 3.9
Contact Hours available for RNs. marchofdimes.com/nursing