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

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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

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Mo

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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)

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Berrie

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Detro

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Gen

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Ingha

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Kalam

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Kent

Mac

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Oak

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Out

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Sagin

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IH MH/P

IMR

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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.