MCHB Programs In Support of the Preemie Act Hani K MCHB Programs In Support of the Preemie Act Hani K. Atrash MD, MPH Director Division of Healthy Start and Perinatal Services (DHSPS) Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB) Meeting of the Secretary’s Advisory Committee on Infant Mortality, August 10-11, 2015 Washington, DC

The PREEMIE Reauthorization Act Reauthorizes… the Secretary of HHS to conduct demonstration projects related to preterm births …. to test and evaluate various strategies .. on: (1) the core risk factors for preterm labor and delivery, (2) medically indicated deliveries before full term, (3) the importance of preconception and prenatal care, (4) treatments and outcomes for premature infants, (5) meeting the informational needs of families during the stay of an infant in a neonatal intensive care unit, and (6) utilization of evidence-based strategies to prevent birth injuries.

Preconception / Interconception health Life-course approach HRSA Approaches to Improving Pregnancy Outcomes Preconception / Interconception health Life-course approach Collaborative Innovation Networks (COINS) Collective impact Backbone organizations

Improving Pregnancy Outcomes – Levels of Support National: Secretary’s Advisory Committee on Infant Mortality (SACIM) National Maternal Health Initiative Guidelines for Well Woman Care Title V Transformation / Collaborative Improvement and Innovation Network (COIN) State/Regional: Maternal, Infant and Early Childhood Home Visiting Local/Community: National Healthy Start Program

MCHB supports SACIM’s National Strategy to Reduce Infant Mortality: the 6 Big Ideas (1/2013) Improve the health of women Ensure access to a continuum of safe and high quality, patient-centered care Redeploy key evidence-based, highly effective preventive interventions to a new generation Increase health equity and reduce disparities by targeting social determinants of health through investments in high-risk communities and initiatives to address poverty. Invest in adequate data, monitoring, and surveillance systems to measure access, quality, and outcomes. Maximize the potential of interagency, public-private, and multi-disciplinary collaboration.

Title V Block Grant Transformation Reduce burden Reducing data reporting by prepopulating from federal sources Simplifying/clarifying and reducing the number of forms; streamlining narrative and application Maintain flexibility Choice in national performance measures (8 of 15) State-specific performance measures (3 to 5) State-developed evidence-based/informed strategy measures Improve accountability and document impact Fewer performance measures directly tied to Title V activities New framework that tracks performance in relation to activities

Performance Measure Domains Women’s / Maternal Health Perinatal/Infant Health Child Health Adolescent Health CSHCN Cross-cutting / Life Course

Title V Performance Measures Related to Prematurity Well Woman Visit: Past-year preventive visit among women ages 18-44 (%) (PM 1) Low-risk Cesarean: Cesarean among nulliparous, term, singleton, vertex live births (%) (PM 2) Adolescent Well Visit: Past-year preventive visit among adolescents ages 12-17 (%) (PM 4) Smoking during pregnancy (%) (PM 14 A)

Title V Outcome Measures Related to Prematurity First trimester prenatal care entry Severe maternal morbidity Infant outcomes: Preterm birth  (<37 weeks gestation); Early preterm birth (<34 weeks gestation); Late preterm birth (34-36 weeks gestation); and, Early term birth (37,38 weeks gestation) Early elective deliveries (37, 38 weeks gestation) Mortality (infant): Perinatal mortality rate; Infant mortality rate; Neonatal mortality rate; and, Preterm-related mortality rate

Women’s Health Preventive Services Guidelines for Well Women Care Support the development of clinical preventive health guidelines for well woman visit Compile the guidelines into a succinct resource Disseminate these guidelines and promote their adoption into standard clinical practice among women’s health care providers

National Maternal Health Initiative Goal: Promote coordination and collaboration within HRSA, across HHS agencies and with professional and private organizations. Priorities: Improving women’s health before, during, and after pregnancy Improving systems of maternity care including clinical and public health systems Improving public awareness and education Improving research and surveillance Improving the quality and safety of maternity care

National Maternal Health Initiative Alliance for Innovation on Maternal Health (AIM) A four year $4 million cooperative agreement with the “Council on Patient Safety in Women’s Health Care” supported by the American Congress of Obstetricians and Gynecologists (ACOG) Goal: to prevent 100,000 severe complications during delivery hospitalizations and 1,000 maternal deaths by 2018   Approach: the development and rollout of evidence-based patient-safety bundles

National Maternal Health Initiative Alliance for Innovation on Maternal Health (AIM) Supports harmonized data-driven continuous quality improvement processes Provides evidence-based implementation resources to streamline bundle implementation Leadership team, in addition to ACOG, includes more than 25 organizations and agencies Continuous quality improvement efforts are data driven

National Maternal Health Initiative Alliance for Innovation on Maternal Health (AIM) Safety bundles include: Obstetrical Hemorrhage Severe Hypertension/Preeclampsia Prevention of Venous Thromboembolism Support for Intended Vaginal Birth Reduction of Peripartum Racial Disparities Standards of Care for the Interconception/Postpartum Visit AIM facilitates multidisciplinary and interagency collaboration between states and hospitals

The Infant Mortality CoIIN The Collaborative Improvement & Innovation Network to Reduce Infant Mortality Designed to help States innovate and improve their approaches to improving birth outcomes Initiated March 2012 as a mechanism to support the adoption of collaborative learning and quality improvement principles and practices to reduce infant mortality and improve birth outcomes

Regions IV and VI CoIIN: Strategies & Structure 5 Strategy Teams Reducing elective deliveries <39 weeks (ED); Expanding interconception care in Medicaid (IC); Reducing SIDS/SUID (SS); Increasing smoking cessation among pregnant women (SC); Enhancing perinatal regionalization (RS). Teams 2-3 Leads (Content Experts); Method Experts Data Experts Shared Workspace Data Dashboard

Non-Medically Indicated Early Term Deliveries Among Singleton, Term Deliveries* 30% total decline translating to ~85,000 early elective deliveries averted since 2011 Q1 5 states met aim of 33% reduction 11 states had declines of 20%+ * Based provisional birth certificate data; denominator excludes women with medical indications present prior to and during pregnancy

Smoking During Pregnancy* 12% total decline translating to ~18,000 fewer women smoking in pregnancy since 2011 Q1 6 states met aim of 3% reduction * Based on provisional birth certificate data reflecting smoking in any trimester

National CoIIN 58 States & Jurisdictions 6 Strategy Teams Safe sleep Smoking Cessation Social Determinants Preconception/Interconception Care Prevention of Preterm and Early-Term Births Perinatal Regionalization 19

Preconception/Interconception Health n=29 LEGEND Learning Network Chosen = Puerto Rico

Prevention of Preterm & Early Term Births n=21(Progestogens & EED) LEGEND Learning Network Chosen = Puerto Rico

Perinatal Regionalization n=14 LEGEND Learning Network Chosen = Puerto Rico

Smoking Cessation n=21 LEGEND Learning Network Chosen = Puerto Rico

Social Determinants of Health n=23 LEGEND Learning Network Chosen = Puerto Rico

THE NATIONAL HEALTHY START PROGRAM History Established in 1991 as a presidential initiative Provides funding and supports communities with high infant mortality rates and other adverse perinatal outcomes Focused on community innovation and creativity and encouraged communities to do what was best for them Today, HRSA supports 100 healthy start projects in 37 States and Washington, DC 25

Main Changes to Healthy Start Healthy Start Approaches Improve Women’s Health Promote Quality Services Strengthen Family Resilience Achieve Collective Impact Increase Accountability through Quality Improvement, Performance Monitoring, and Evaluation

The Federal Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) Provide voluntary, evidence-based home visiting services to pregnant women and families with young children Budget grew from $100 million in 2010 to $400 million in 2014 In 2014, MIECHV supported 685 unique Local Implementing Agencies (LIAs) serving 115,500 parents and children in 787 counties in 50 states, DC and 5 territories The program reaches those at the highest need (79% below poverty level, 34% of adults had less than high school education, and 67% were racial and ethnic minorities)

The Federal Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) 8 of the 17 evidence-based models target pregnant women: Early Head Start Early Intervention Program for Adolescent Mothers Healthy Families America Maternal Early Childhood Sustained Home Visiting Program Minding the Baby Nurse Family Partnership Oklahoma’s Community-Based Family Resource and Support Program Parents as Teachers In 2014, 27% of newly enrolled households included pregnant teenagers

For More Information Hani Atrash, MD, MPH Director, DHSPS 5600 Fishers Lane, Room 13-91 Rockville, MD 20857 Office: 301-443-0543 Direct: 301-443-7678 Email: hatrash@hrsa.gov