Leveraging Opportunities for Prevention across the Life-Course: Utilizing Data to Target Risk Factors

Cheryl Lauber, DPA, MSN Perinatal Consultant Michigan Department of Community Health

Trend of Infant Mortality Rate in Michigan

Basic Health Indicator: Infant Mortality Rate (IMR):

number of infant deaths per 1,000 live births 25 20 15 10 5 0 1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Black MI 21.6 17.3 17.5 17.6 16.8 17.9 18.2 16.9 18.4 17.5 17.3 17.9 14.8

Black US 18.0 15.1 14.7 14.2 14.3 14.6 14.0 14.0 14.4 14.1 13.8

White MI 7.9

6.2

6.0

6.1

6.3

5.9

6.0

6.1

6.0

6.7

5.2

White US 7.6

6.3

6.1

6.0

6.0

5.8

5.7

5.7

5.8

5.8

5.7

5.5

5.4

PPOR Findings: Eleven Communities with High Infant Mortality (1998-2002)

10 9 8 7 6

IH MH/P

5 4 3 2 1 0

B er rie n D et ro it G en es ee In gh am K al am az oo K en t M ac om b O ak la nd O ut -W ay ne S ag in aw W as ht en aw

IMR difference: Black IMR compared to reference group

Profile of Women having an Unintended Pregnancy in Michigan

 In 2004, the prevalence was highest in:  Black women  less than 18 years of age  less than a HS diploma/GED  not married  no insurance  Medicaid  annual household income of $10,000 or less 2004 Michigan PRAMS

Profile of Women having an Unintended Pregnancy in Michigan

 Unintended Pregnancy is:  3.9 times more likely if not receiving any prenatal care  2.8 times more likely if experiencing one or more stressors  2.2 times more likely if smoking during pregnancy  1.3 times more likely if LBW infant 2003 Michigan PRAMS

Voices of the Women

 Preconception health and concept of

planning

as related to pregnancy is not well understood.  An understanding of pregnancy experiences of African American women are needed to make changes in the health care system to support better outcomes.

Voices of the Women

 Women have a consciousness about their readiness for pregnancy which should inform preconception planning.

 Affective and behavioral needs of women must be incorporated in preconception care.

 Reinforce that planning a pregnancy is in the control of both the woman and the man.

 Strengthen cultural commitment of healthcare professionals through partnerships, advocacy, and information.

Primary Goals for Reducing Infant Mortality

 Improve maternal preconception health  Improve access to healthcare for mothers and infants  Eliminate the racial disparity in infant mortality rates  Improve infant health and safety

Steps to Program Development

 Goals of local coalitions – Identify access and service system barriers – Identify needed prevention, primary care and support activities and services – Develop, implement, evaluate a community wide plan – Produce annual report on the community’s infant mortality status

Michigan Interconception Care Program

       Identify 25 women with a poor pregnancy outcome – Hospital discharge – Other health department programs . Nursing/medical/genetic risk assessment Provide grief support if indicated Contraception access Access to a medical home – Chronic disease management – Target obesity, substance use, mental health Promote 18 month interpregnancy interval Case management up to 24 months

Performance Against Goals

 Goal: to field test an Interconception Care strategy for African- American women who experienced: – – Preterm birth or low birth weight birth Fetal or neonatal death  Actual: 104 women have been recruited from communities and have reported data – – – 65 Preterm birth/Low birth weight birth 24 Fetal or neonatal death 14 Miscarriage

Project Planning

    

What was good about the plan?

– Logical path from data to action – Phased approach – Evidence based intervention

What was missing from the plan?

– Specific protocol for the home visiting – Staff support for more local training

Was the plan realistic?

– Time to make this change was limited – Funding was not guaranteed

How did the plan evolve over time?

– Began with local organization, education & assessment – Evolved to service delivery options & intervention strategies

Key areas for improvement:

– Make very specific recommendations.

Project Management

    Project Direction Team meets monthly – Project Manager; Program Consultants; Division Managers; Epidemiologist – Sharing about issues, recent data, strategic plan accomplishments Communication – – Network meetings quarterly Conference calls as needed Database tracks client progress Meetings with broader perinatal program partners

Outcome Indicators

     Preterm births Low birth weight Unintended pregnancy rate Family planning access Intergestation timeframes

Evaluation Elements

 Mother’s Information – – – – – – – DOB Residence Race Education Marital Status Source of Primary Care Pregnancy History  Index Pregnancy Info – Outcome – – – – – – – – Delivery Date Birth Weight Gestational Age NICU Admission PNC Started Number PNC Visits Maternal Age Source of Payment

Evaluation Elements

 Index Pg Risk Factors – – – – – – – – – Prepregnancy Weight Infection History Alcohol Use Tobacco Use Street Drug Use Domestic Violence Mental Health Problems Chronic Illness Unplanned Pregnancy  Subsequent Pg Info – Outcome – – – – – Delivery Date Birth Weight Gestational Age NICU Admission PNC Started (weeks) – Number of PNC Visits – Maternal Age – Source of Payment

Evaluation Elements

 ICC Program Information – Eligibility – – – Enrollment date Recruitment source # Home visits made – – Referrals completed Assessment completed – – – – – Family planning Nutrition Mental Health Substance Abuse Bereavement – – Support Discharge date Type of provider

What Went Right

 Partnership with other state programs – WIC; MIHP; FP; Healthy Start  Local coalition building – Good local awareness – Local partnerships started  Able to pilot interconception care in variety of settings

Developing Partnerships

 Division of Chronic Disease  ECIC  Children’s Special Health Care Services  Southeast Michigan Regional Infant Mortality Task Force

What Went Wrong

 Local willingness to develop an intervention project – LHDs are less involved in direct service – More comfortable with education campaign   Funding stability – State fiscal crisis – Little commitment from legislature Project management – Hiring new staff was delayed – Trouble mandating qualified local staff

Preliminary Data

 Pregnancy Outcome for women recruited N=104 – #/% fetal deaths – – – #/% neonatal death #/% preterm birth #/% miscarriages 15 (14%) 9 (9%) 62 (60%) 14 (14%)  Characteristics of women – – – – – mean age #/% African American #/% High School educ #/% married #/% Medicaid eligible 22.7 (14 <18 yrs) 75 (72%) 60 (71%) 21 (20%) 76 (84%)

Preliminary Data

 Index Pregnancy Information – mean birth weight 1698 g – mean Gestation Age 27.5 wks – #/% NICU adm 52 (54%) – – mean # PNC visits #/% PNC 1 st trimester 4.9 visits 54 (79%)  Program Information – recruitment sources: MIHP, FIMR, Healthy Start, SIDS Program, Hospital social worker, Birth certs, flyers, Early On, WIC, NFP

More Action Needed

 Identify women and intervene in existing programs, WIC, MIHP, Family Planning.

 Revise program policy to include these goals.

 Target women eligible for Medicaid.

 Focus FIMR data collection on fetal death, pre-term and low birth weight births.

 Provide training for program staff.

 Educate private ob-gyn providers on life course perspective and inter-conception care.