leveraging opportunities for prevention across the life-course: utilizing data to target risk...
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Leveraging Opportunities for Prevention across the
Life-Course: Utilizing Data to Target Risk Factors
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
Trend of Infant Mortality Rate in Michigan
0
5
10
15
20
25
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 5.5 5.4
White US 7.6 6.3 6.1 6.0 6.0 5.8 5.7 5.7 5.8 5.8 5.7
1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006Infa
nt
Mo
rta l
ity
Ra t
e
Basic Health Indicator:
Infant Mortality Rate (IMR): number of infant deaths per 1,000 live births
PPOR Findings: Eleven Communities with High Infant Mortality (1998-2002)
PPOR Findings: Eleven Communities with High Infant Mortality (1998-2002)
0
1
2
3
4
5
6
7
8
9
10
Berrie
n
Detro
it
Gen
esee
Ingha
m
Kalam
azoo
Kent
Mac
omb
Oak
land
Out
-Way
ne
Sagin
aw
Was
htena
w
IH MH/P
IMR
Dif
fere
nc e
IMR difference: Black IMR compared to reference group
Profile of Women having an Unintended Pregnancy in Michigan
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/GEDnot marriedno insuranceMedicaidannual household income of $10,000
or less
2004 Michigan PRAMS
Unintended Pregnancy is:3.9 times more likely if not receiving any
prenatal care2.8 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
Profile of Women having an Unintended Pregnancy in Michigan
Profile of Women having an Unintended Pregnancy in Michigan
Voices of the WomenVoices 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 WomenVoices 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
Primary Goals for Reducing Infant Mortality
Improve maternal preconception healthImprove access to healthcare for
mothers and infantsEliminate the racial disparity in infant
mortality ratesImprove infant health and safety
Steps to Program DevelopmentSteps 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 ProgramMichigan 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 GoalsPerformance 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 PlanningProject 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 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 IndicatorsOutcome Indicators
Preterm births Low birth weight Unintended pregnancy rate Family planning access Intergestation timeframes
Evaluation ElementsEvaluation 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 ElementsEvaluation 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 ElementsEvaluation 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 RightWhat 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 PartnershipsDeveloping Partnerships
Division of Chronic Disease ECIC Children’s Special Health Care Services Southeast Michigan Regional Infant
Mortality Task Force
What Went WrongWhat 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 Preliminary Data Pregnancy Outcome for women recruited
N=104
– #/% fetal deaths 15 (14%)– #/% neonatal death 9 (9%)– #/% preterm birth 62 (60%)– #/% miscarriages 14 (14%)
Characteristics of women– mean age 22.7 (14 <18 yrs)– #/% African American 75 (72%)– #/% High School educ 60 (71%)– #/% married 21 (20%)– #/% Medicaid eligible 76 (84%)
Preliminary DataPreliminary Data Index Pregnancy Information
– mean birth weight 1698 g– mean Gestation Age 27.5 wks– #/% NICU adm 52 (54%)– mean # PNC visits 4.9 visits– #/% PNC 1st trimester 54 (79%)
Program Information– recruitment sources: MIHP, FIMR, Healthy
Start, SIDS Program, Hospital social
worker, Birth certs, flyers, Early On, WIC, NFP
More Action NeededMore 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.
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