MATERNAL FETAL POPULATION HEALTH MODULE Integrating Population Health Inquiry Transforms (IPHIT) Family Medicine Northeast Education Afternoon December 17, 2013,

Objectives We will review what outcome measures (metrics) to consider applying We will review maternal fetal health population health data and try to drill down to a clinic level and consider health disparities We will look at some sample financial data as it relates to some of our inquiry today

Where to go when everything seems interesting?

Healthy People National agenda that communicates a vision and overarching goals, supported by topic areas and specific objectives for improving the population’s health and achieving health equity. The overarching goal of Healthy People 2020 is to attain high quality, long lives free of preventable disease, with a reduction in premature death and the second goal to achieve health equity, eliminating disparities and improving the health of all groups. Slade-Sawyer, P, HHS Office of Disease Prevention and Health Promotion

Evolution of Healthy People Target Year Overarching Goals Decrease mortality: infants-adults Increase independence among older adults Increase span of healthy life Reduce health disparities Achieve access to preventive services for all Increase quality and years of healthy life Eliminate health disparities Attain high quality, longer lives free of preventable disease… Achieve health equity, eliminate disparities… Create social and physical environments that promote good health… Promote quality of life, healthy development, healthy behaviors across life stages… Topic Areas * # Objectives > 580 Slade-Sawyer, P, HHS Office of Disease Prevention and Health Promotion *39 Topic areas with objectives

2020 MATERNAL INFANT CHILD HEALTH METRICS Some examples

Morbidity and Mortality MICH-7 Reduce cesarean births among low-risk (full- term, singleton, and vertex presentation) women MICH-7.1 Reduce cesarean births among low-risk women with no prior cesarean births Baseline: 26.5% of low-risk females with no prior cesarean birth had a cesarean birth in 2007 Target: 23.9% (10% improvement) MICH-7.2 MICH-7.2 Reduce cesarean births among low-risk women giving birth with a prior cesarean birth Baseline: 90.8% of low-risk females giving birth with a prior cesarean birth had a cesarean birth in 2007 Target: 81.7% (10% improvement) Data Source: National Vital Statistics System-Natality (NVSS-N), CDC/NCHS

Morbidity and Mortality MICH-1.3 Reduce the rate of all infant deaths ★ Leading Health Indicator ★ Baseline (2006): 6.7 infant deaths per 1000 live births Target: 6.0 infant deaths per 1000 live births (10% improvement) MICH-1.1: Reduce the rate of fetal deaths at 20 or more weeks of gestation MICH-1.2: Reduce the rate of fetal and infant deaths during perinatal period (28 wks gestation-7 days after birth) MICH-1.4: Reduce the rate of neonatal deaths (within the first 28 days of life) MICH-1.5: Reduce the rate of postneonatal deaths (between 28 days and 1 year of life)

Reduce total preterm births MICH-9.1 Reduce total preterm births ★ Leading Health Indicator ★ Baseline (2007): 12.7% of live births were preterm Target: 11.4% (10% improvement)

Pregnancy Health and Behaviors MICH-10.1 Increase the proportion of pregnant women who receive prenatal care beginning in first trimester Baseline: 70.8% of females delivering a live birth received prenatal care beginning in the first trimester in 2007 Target: 77.9% (10% improvement) MICH-11.1 Increase abstinence from alcohol among pregnant women Baseline: 89.4% of pregnant females aged 15 to 44 years reported abstaining from alcohol in the past 30 days in 2007–08 Target: 98.3 % (10% improvement) MICH-11.3 Increase abstinence from cigarette smoking among pregnant women Baseline: 89.6% of females delivering a live birth reported abstaining from smoking cigarettes during pregnancy in 2007 Target: 98.6% (10% improvement) MICH-11.4 Increase abstinence from illicit drugs among pregnant women Baseline: 94.8% pregnant females aged 15 to 44 years reported abstaining from illicit drugs in the past 30 days in 2007–08 Target: 100 percent (Total coverage) MICH-13 (Developmental) Increase the proportion of mothers who achieve a recommended weight gain during their pregnancies Data Source: Data Source: National Vital Statistics System-Natality (NVSS-N), CDC/NCHS ; National Survey on Drug Use and Health (NSDUH), SAMHSA (for MICH 11.4 only)

Other categories Preconception health and behaviors: Examples MICH-16.3: Increase the proportion of women* who did not smoke prior to pregnancy MICH-16.5: Increase the proportion of women who had a healthy weight prior to pregnancy Postpartum health and behavior Examples MICH-18: Reduce postpartum relapse of smoking MICH-19: Increase the proportion of women who attend a postpartum visit with a health care worker Infant care Example MICH-21.1 Increase the proportion of infants who are ever breastfed

NATIONAL DATA National Vital Statistics Report Volume 62, Number 1. June 28, 2013.

Pregnancy rates

Teen pregnancy rates

Cesarean delivery rates

Infant mortality rates

It’s not just early prenatal care Odds ratio for perinatal mortality >35,000 pregnancies followed – all had early prenatal care

Preterm birth rates

STATE DATA examples

Cesarean sections

Infant mortality

Premature Births

Smoking during pregnancy

LOCAL DATA

2013 Health Status Overview Report-

Preterm Births Delivery at less than 37 weeks gestation Nationally the preterm birth rate is declining Dane Black preterm continues to improve! U.S.Dane ( ) All11.7%8.4% Black16.7%10.9%

What maternal-fetal metrics is Healthydane.org measuring?

Mothers who smoked during pregnancy The Healthy People 2020 national health target is to decrease the percentage of women who gave birth and who smoked cigarettes during pregnancy to 1.4%.

Mothers who smoked during pregnancy

NORTHEAST CLINIC AND UW- MADISON FAMILY MEDICINE RESIDENCY CLINICS This data reflects deliveries in where the prenatal care was provided by our residency DFM clinics.

Northeast: Cesarean section rates Our cesarean section rate is 11% Belleville is 14% Verona is 13% Wingra is 14% 2020 Healthy People MICH-7 Reduce cesarean births among low-risk (full- term, singleton, and vertex presentation) women MICH-7.1 Reduce cesarean births among low-risk women with no prior cesarean births Baseline: 26.5% of low-risk females with no prior cesarean birth had a cesarean birth in 2007 Target: 23.9%

This is an interesting trend but notably for NE n=14 95% CI [5,51]; Wingra n=93 95% CI [7,22]; not statistically significant.

Northeast: Pregnancy smoking rates Our pregnancy smoking rate is 17% Belleville is 18% Verona is 11% Wingra is 18% 2020 Healthy People MICH-11.3 Increase abstinence from cigarette smoking among pregnant women Baseline: 89.6% of females delivering a live birth reported abstaining from smoking cigarettes during pregnancy in 2007 Target: 98.6% (i.e.1.4% smoking rate)

Northeast: Pregravid obesity rates Our pregravid obesity rate is 26%; excessive weight gain rate is 47% Belleville is 30%; 57% respectively Verona is 16%; 65% Wingra is 26%; 38% This data is more limited as it requires the clinician to input the pre- pregnancy weight

An example of cost implications

Cost of childbirth

Where to find hospital costs…

Kozhimannil KB, Law MR, Virnig BA. Cesarean Delivery Rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Affairs, 32, no.3 (2013):

COMMUNITY RESOURCES

Public Health Madison & Dane County (see handouts) Prenatal Care Coordination (PNCC)- Nurse Home Visit Program Nurse Family Partnership (NFP) – Nurse Home Visit Program First Breath/My Baby Fetal Infant Mortality Review (FIMR)

What more should we obtain/ask? We need to obtain clinic level Infant mortality data Preterm birth data Low birth weight data We should tie more specifically a cost analysis to analysis of metrics …so many intriguing questions to ask …and what should we do with the data?

Questions?