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 Infant Mortality Low Birth Weight Low Birth Weight Maternal Mortality Maternal Mortality Access to Care Access to Care

Core Functions of Public Health AssessmentAssurancePolicy

Assessment Analysis of birth certificate data Analysis of birth certificate data Fetal and Infant Mortality Review (FIMR) Fetal and Infant Mortality Review (FIMR) Child Fatality Review Child Fatality Review Pregnancy Risk Assessment Monitoring System (PRAMS) Pregnancy Risk Assessment Monitoring System (PRAMS) Maternal Death Review 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

National and Virginia Infant Mortality by Race

National and Virginia Infant Mortality Rates by Race and Ethnicity

Trend in infant mortality over the last five years

Virginia rates of infant mortality, preterm births, and fetal deaths

Leading causes of infant death Prematurity/low weight birth Prematurity/low weight birth Sudden Infant Death (SIDS) Sudden Infant Death (SIDS) Birth defects Birth defects Complications of pregnancy Complications of pregnancy

Neonatal Deaths Early Infant Deaths (< one day) All Neonatal Deaths (0-27 days) Blacks Whites Other Total 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 Virginia is working toward the goal to reduce its infant death rate to 7.0 per thousand live births by This would surpass the Healthy People 2010 goal of reducing the infant mortality rate to 7.2 per thousand. 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. 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

Low Birth Weight is associated with multiple factors: Medical Risk Factors Medical Risk Factors - High parity - Chronic diseases - Previous Low Birth Weight infants - 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 Demographic Risk Factors - Age 34 years - African-American race - Low socioeconomic status - Unmarried - Low education Behavioral Risk Factors 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 Neurologic disorders Learning disabilities Learning disabilities Delayed development Delayed development

The populations at highest risk of infant deaths and low birth weight African American African American Unmarried Unmarried Low income Low income Less than a high school education Less than a high school education Enter prenatal care late or not at all Enter prenatal care late or not at all Many smoke and have poor nutrition Many smoke and have poor nutrition

National Fetal-Infant Mortality Review (NFIMR) Program Established in 1990 Established in 1990 Public-private partnership 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 Community-based, action-oriented process Early warning system that describes health care Early warning system that describes health care Method of continuous quality improvement Method of continuous quality improvement Means to implement core public health functions 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. 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. Describe significant social, economic, cultural and systems factors that contribute to mortality. Design and participate in implementing community-based interventions determined from review findings. Design and participate in implementing community-based interventions determined from review findings.

Assessment (continued) Child Fatality Review Child Fatality Review PRAMS PRAMS

Maternal Mortality Has Not Changed Since 1982 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 Sulfa and antibiotic drugs Decrease infections secondary to illicit abortions Decrease infections secondary to illicit abortions Availability of banked blood Availability of banked blood Safer surgical procedures, including Cesarean 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 Hemorrhage, including ectopic pregnancy Pregnancy-Induced Hypertension Pregnancy-Induced Hypertension Pulmonary Embolism Pulmonary Embolism

Maternal Mortality Ratios CDC Expanded Definition (21 natural) (13 natural) (32 natural)

Components of maternal death reviews Investigation of individual maternal death Investigation of individual maternal death Multidisciplinary discussion of each case Multidisciplinary discussion of each case Recommendations to prevent future deaths 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

Assurance Prevention Efforts Prevention Efforts Safety Net Safety Net Setting Standards/Quality of Care 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 Targeting young men and women between the ages of Increase knowledge regarding the risks of nonmarital birth Increase knowledge regarding the risks of nonmarital birth Promote healthy attitudes and behaviors about marriage, family, and career Promote healthy attitudes and behaviors about marriage, family, and career

Preconception Prevention of birth defects Prevention of birth defects Treatment of chronic conditions Treatment of chronic conditions Promotion of healthy lifestyles (smoking, alcohol) 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 problems of infant mortality and morbidity address access to prenatal care address access to prenatal care conduct perinatal outreach education for professionals conduct perinatal outreach education for professionals

Programs (continued) Car seat program Car seat program Virginia Council on Folic Acid/VDH Campaign Virginia Council on Folic Acid/VDH Campaign Fetal Alcohol Spectrum Disorders (FASD) Task Force Fetal Alcohol Spectrum Disorders (FASD) Task Force

Safety Net Providers Prenatal care in local health departments Prenatal care in local health departments WIC in local health departments WIC in local health departments Community Health Centers 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 Lay home visitors who mentor pregnant teenagers Lay home visitors who mentor pregnant teenagers Decrease infant mortality and low weight births Decrease infant mortality and low weight births 25 contractors enrolling approximately 1100 newly pregnant teens per year in 88 Virginia localities 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 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 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: Case management and health education Case management and health education Registered nurses provide medical nursing care Registered nurses provide medical nursing care Registered dietitians provide medical nutrition therapy services Registered dietitians provide medical nutrition therapy services Resource Mothers (Community Health Workers) Resource Mothers (Community Health Workers) FIMR FIMR

Newborn Screening Coordinated and comprehensive system consisting of education, blood screening tests, follow-up and referrals, diagnosis, medical and dietary management, and treatment 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 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. 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 Neonatal Regulations Screening for domestic violence, perinatal substance use, and perinatal depression Screening for domestic violence, perinatal substance use, and perinatal depression Web-based training on Bright Futures and Perinatal Depression Web-based training on Bright Futures and Perinatal Depression Provision of culturally competent care Provision of culturally competent care

Policy and Planning Implementation of Codes Regarding Perinatal Substance Use: of the Code of Virginia Substance Use Screening in Prenatal Care of the Code of Virginia Substance Use Screening in Prenatal Care of the Code of Virginia Physician referral of Substance Exposed Newborns of the Code of Virginia Physician referral of Substance Exposed Newborns of the Code of Virginia Hospital Discharge Planning for Substance using Postpartum Women of the Code of Virginia Hospital Discharge Planning for Substance using Postpartum Women of the Code of Virginia Discharge Education on Postpartum Blues, Perinatal Depression, Shaken Baby Syndrome 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 Infant mortality Obesity Obesity Smoking Smoking

Conclusion Studies of underlying factors that contribute to morbidity and mortality are needed 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 Review of quality of health care and access to care for all women and infants is needed Racial/ethnic disparities need to be eliminated Racial/ethnic disparities need to be eliminated Research to determine effective public health programs to make a difference Research to determine effective public health programs to make a difference