Broadening the Work of Prematurity and Infant Mortality Partnerships to Address Preconception Health: the Kentucky Experience Ruth Ann Shepherd, MD, FAAP Director, Division of Maternal and Child Health Kentucky Department for Public Health Connie Gayle White, MD, MS, FACOG Women’s Health Consultant Founding Member, Every Woman Southeast

KY Partnerships on Prematurity Kentucky Folic Acid Partnership Since 1998; partnership with March of Dimes Over 100 members, 80 agencies across the state Prematurity Toolkit, HBWW project name Prematurity activities since 2005 (278,000 individual, 1.7M media) Prematurity Summits- MOD and KPA – spring and fall 2004: “Prematurity, the Scope of the Problem” Frank Boehm 2005: “The Prematurity Problem: The Kentucky Data” 2006: “The Infant Born at 36 weeks is still Preterm” Kentucky Perinatal Association HPEP – Health Professional Education on Prematurity HPEP I - Pathways to Prematurity - 2005 HPEP II – Late Preterm Infants – 2007 HPEP III – Progesterone – 2009 National Perinatal Association Awards to KPA Innovation Award 2006 Best Chapter 2009 Pilot Projects: PRAMS, FIMR, GIFTS

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A Collaborative Partnership The Prematurity Prevention Partnership March of Dimes Johnson & Johnson Pediatric Institute Kentucky Department for Public Health Kentucky March of Dimes Chapter Professional organizations (ACOG, AAP, AWHONN) Kentucky perinatal leaders 4

Media Launch in Louisville, KY March 2007 Dr. David Smith, Dr. Jennifer Howse, Governor Ernie Fletcher, Dr. Steven Shelov, Mr. Shawn Crabtree

Overview HBWW® is a three year (2007-2009) pilot program that aims to reduce “preventable” preterm births at three Intervention Sites in Kentucky Goal: 15% reduction in the rate of singleton preterm births at the intervention sites Mixed ecological “real world” design Focus on late preterm birth (34-36 weeks) Collaboration between hospitals, obstetricians, and public health professionals and the local community Provides education for pregnant women, the community and perinatal providers Essential for HBWW interventions, implementation and evaluation include the: collaboration between each clinical intervention site and the local Kentucky Departments of Health (DOH) that provide services for pregnant women in each intervention site’s catchment area partnership between the clinical teams and their hospitals’ public relations teams for media outreach 6

These are the 3 intervention and 3 comparison sites in eastern, central and western Kentucky Sites were chosen to represent a variety of geographic areas of the state ~12,000 live births to be included in the study, from all 6 Sites Comparison Sites Geographically disparate to minimize contamination Somewhat comparable with respect to baseline data Provided a mechanism to track temporal changes in policies and practices Baseline and follow up consumer/provider surveys, annual epidemiological policy interviews, and perinatal program surveys 7

HBWW Advisory Council Biannual Site Council Meetings with leaders representing: Participating agencies in KY (DPH: Commissioner, Director MCH, HANDS Coordinator, State Epidemiologist, etc.) Perinatal professional organizations in KY (ACOG, AWHONN, KPA) State March of Dimes Intervention sites (both hospital and health dept each site) Executive Program Board (national partners and project PI) Clinical experts in ob/gyn, maternal fetal medicine, neonatology, pediatrics, family medicine, oral health, smoking cessation Communications/media experts Working Groups Intervention, Evaluation, Communication, ad hoc

Healthy Babies are Worth the Wait Interventions “Bundled” Evidence-Based Interventions Linked elements of clinical care, patient support, and public education: Partnerships Advisory Council, Local Implementation Teams, Local meetings with office managers, etc. Professional Education & Action Grand Rounds & Training Standard clinical guidelines (folic acid, smoking cessation, progesterone, screenings) Patient safety protocols Patient Education and Action Augmenting existing services for case management, screening & referral Health Literacy in the context of prenatal care Public/ Community Education and Action Community Toolkit Media toolkit Web site 9

HBWW® Health Messages See the doctor BEFORE & DURING pregnancy Don’t smoke or use alcohol while pregnant Take folic acid every day Brush, floss and visit the dentist Avoid scheduled delivery before 39 weeks Babies’ brains grow a lot between 35 and 40 weeks These concise messages were created for additional products (next slides)

HBWW® Materials Oral Health Products Stamped with website URL Message Pens Magnetic Photo Frames Message Totes Incentives for follow-up consumer survey

HBWW® Materials Brain Card Not to be distributed directly to patients Utilized by providers to facilitate communication with patients

This Late Preterm Brain Development card is available from the March of Dimes and is for use by health care providers (e.g. physicians, midwives, nurses, physician assistants). It is designed to present a graphic representation of fetal brain growth and maturation in the last month of pregnancy. Specific information is summarized in the 5 bulleted points describing some of the increased risks for late preterm compared to term infants. As clearly stated at the end of the card, it is strictly informational and not intended to be used as medical advice. The card also encourages the pregnant woman to discuss concerns with her health care provider. It is important that the card be used in the context of a discussion with a provider. The card should not be simply passed out to pregnant women. A consumer brochure will soon be available to provide additional information about late preterm birth which can be given to pregnant women and interested consumers. 13

State and National Outreach - 26 state professional meetings Community Outreach Education & Action Community Toolkit (KFAP) Message: Preventing Prematurity saves babies lives and improves the future for families and for communities. Fact Sheets, Handouts, Powerpoint, Instructions for Activities, Reporting form, evaluation English and Spanish Media in Intervention Communities Media Toolkit for traditional media Hospital and health department media teams Digital media interventions www.prematurityprevention.org Facebook, Twitter State and National Outreach - 26 state professional meetings - 12 national meeting presentations - nearly 100 media coverages

Web-based Resources: www.PrematurityPrevention.org Jan. 2008-Mar. 2009 Total visitors: 36,334 Most materials available for download from website Also available for free download is a Pregnancy Diary computer program from JJPI; It is a fun, interactive way to track pregnancy

Provider “Grade Card” sample Summary of Inductions and Scheduled C/S of Infants prior to 39 wks GA PHYSICIANS Total Medical Indication Medical Indication Rate Infants Admitted to NICU Who Were Induced or Sectioned Without Medical Indication Doc A 5 100% Doc B 3 1 33% Doc C 2 Doc D 66% 16

Late Preterm Birth Monthly Comparisons (percent of deliveries) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YR Avg 2006 11 10 18 13 20 8 16 2007 14 21 12 7 9 2008 2009 6 19

Partnership Example Initial Grand Rounds included information on periodontal disease and prematurity Discussions with providers  no local dentists would see pregnant women From HBWW Advisory Committee, national oral health expert (Dr. John Novak) agreed to provide educational session HBWW team and Local Dental Society partnered to sponsor combined educational session for medical and dental providers

After the educational session, some local dentists more willing to accept pregnant patients HBWW team meeting with OB office managers got feedback that only some dentists were participating HBWW team followed up with each local dentist, providing additional materials and answering remaining questions about dental care for pregnant women Additional dentists in the area agreed to provide dental care for pregnant women Office mangers now reporting they are able to get women in for dental care most of the time.

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