Incorporating Preconception Health into MCH Services Emerging Issues in MCH Debra Bara MA Incorporating Preconception Health into MCH Services PPOR

Perinatal Periods of Risk Practice Collaborative Sponsored by CityMatCH, UNMC Partners included National Offices of March of Dimes Centers for Disease Control and Prevention

Practice Collaborative Members Teams from 16 cities that included: Policy Representative Data Representative Community Representative Met to “refine the practice” of PPOR and adapt for use in urban cities in industrialized country.

OVERVIEW Perinatal Periods of Risk Both a DATA ANALYSIS TOOL and an APPROACH to identify critical gaps in the maternal and child health system that lead to infant mortality.

OVERVIEW PPOR Differs from conventional analysis In addition to AGE AT DEATH, PPOR takes into account the BIRTH WEIGHT, an equally important predictor of survivability.

OVERVIEW PPOR differs from conventional analysis: Utilizes LINKED birth and death records, which allows investigators to sort and study variables on the birth certificates, which is generally more complete that death certificate records alone.

OVERVIEW PPOR differs from conventional analysis Combines fetal and infant deaths in a “feto-infant” death rate. Includes fetal deaths as over 24 weeks, live births greater than 500 grams, (excluding spontaneous and induced abortions) Ensures comparability of data (reference group)

OVERVIEW Feto-infant mortality rates are “mapped” according to the time of death and weight Age at death Fetal 24+ wks. Neonatal Postneonatal Birth Weight Maternal Health Maternal Care Newborn Care Infant Health

Maternal Health/ Prematurity DATA LEADS TO ACTION ! Maternal Health/ Prematurity Preconception Health Health Behaviors Perinatal Care Prenatal Care High Risk OB Referrals Insurance Coverage Maternal Care Perinatal Management Neonatal Care Pediatric Surgery These labels suggest preventive action. For Maternal Health and Prematurity, prevention may need to focus on preconceptional health, unintended pregnancy, smoking, drug abuse, and specialized perinatal care. For Maternal Care, prevention may need to focus on early continuous prenatal care, referral of high risk pregnancies and good medical management of diabetes, seizures, post maturity or other medical problems. For newborn care, the focus may need to be advanced neonatal care and treatment of congenital anomalies. And for infant health, communities may need to focus on SIDS prevention like sleep position or breast feeding, access to a medical home and injury prevention. Newborn Care Sleep Position Breast Feeding Injury Prevention Infant Health

Maternal Health Risk Factors Infection Stress and Work General state of health prior to pregnancy Injuries and abuse Family planning Nutrition Tobacco/alcohol/drug use Previous pregnancy outcomes

Maternal Care Risk Factors Tobacco/alcohol/drug use during pregnancy Lack of recognition of problems needing care Recognition/management of early labor Obesity Nutrition during pregnancy Late/inadequate PNC Treatment of infection Poor weight gain

Newborn Care Risk Factors Availability of neonatal intensive care Prevention of infection Recognition of emergency situation Obstetric expertise Pediatric expertise Regular newborn care including feeding/well baby care.

Infant Health Risk Factors Prevention & treatment of infection Recognition of birth defects/developmental anomalies Prevention/treatment of injuries Recognition of signs & symptoms of illness Failure to obtain well-child care or follow-up for illness SIDS prevention

What it tells us Opportunity gaps Uses a “comparison group” model to quantify the specific opportunity to improve United States “reference group” is white women, 13+ years of education, over 20 years of age, married.

Common Finding across Cities Maternal Health was greatest opportunity for improvement Infant Health was most frequent second opportunity Often documented racial disparity issues as occurring in Maternal Health Cell Maternal care in some area, newborn care in

National PPOR Rates by Race/Ethnicity, by Period of Risk Components, for Resident Mothers 20+ years age, 13+ years of education in US, 1998-2000 (Table 6.3)

Implications Changes in Practice Program & Policy

PRACTICE EXAMPLES-Integrating pre and interconceptional care into existing services Family Planning Clinics Home Visitation services Developing risk screening process for non-pregnant population of women Incorporating physical health assessment, screening for diabetes, high blood pressure

Program- EXAMPLE Healthy Start Home Visitation Services Risk assessment Women’s Health questionnaire-25 questions Access to Health Care, Maternal Infections, Baby Spacing Nutrition & Physical Activity Chronic Health Issues Stress & Mental Health Environmental Health Interventions Home Visitation Staff linking non-pregnant patients to: Smoking cessation services Domestic violence prevention, MH services, including drug treatment Health Care

Policy Answer questions “who do we serve & how?” What programs need to be organizationally connected for optimum service to women throughout the life span? Funding Implications Research Implications