1. Infant Death Related to Teen Mothers
Krystenn Fowler
Tracy Gregory
Nanci Klein
Elizabeth McManus
Janice Pappas
In its 10-year agenda for improving the nation’s health, the United States Department of Health and Human Services (HHS), Healthy People 2020 (2011) seeks to improve the health and well-being of women, infants, children, and families by reducing the risk of maternal and infant mortality and pregnancy-related complications and encouraging healthy birth outcomes. To achieve this lofty goal, HHS, Healthy People 2020 (2011) addresses both the physical and social determinants of maternal health as it calls for both the increase in number of women initiating prenatal care in the first trimester of pregnancy, and increased access to early prenatal care.
Increasing prenatal care initiation during the first trimester of pregnancy for the adolescent population of Kent County, Michigan is the focus of this group community change project being completed by BSN student nurses.

2. Teen Pregnancy & Infant Death Rates in the United States
Each year approximately 1 million adolescent females become pregnant, accounting for 13% of all births annually. (Harkness and DeMarco, 2012)
In 2011 alone a total of 329,797 babies were born to women aged 15–19 years. (CDC, 2011)
This is a record low for U.S. teens in this age group, and a drop of 8% from (CDC, 2011)
Infant mortality 6.1 deaths per 1000 live births
Michigan Public Health Institute. (2012). Kent County 2012 community health improvement plan. Retrieved from
Here are the teen pregnancy and infant death rates in the United States. Although there has been an 8% drop since 2010, approximately 1 million adolescents become pregnant, which is still a huge number. Approximately 6000 of these adolescent mothers will lose their infant.

3. Teen Pregnancy & Infant Death Rates in Michigan
Teen pregnancy rate 53.6/1000
Infant mortality rate 7.1 infant deaths per 1000 live births
Michigan Public Health Institute. (2012). Kent County 2012 community health improvement plan. Retrieved from
Michigan has a higher rate of infant deaths per 1000 live births than the United states average. Therefore, this is a statistic that should not go un-noticed.

4. Teen Pregnancy & Infant Death Rates in Kent County
Teen pregnancy rate is 61.5/1000
Rates in Kent County are higher than state
and national averages
Michigan Public Health Institute. (2012). Kent County 2012 community health improvement plan. Retrieved from
When we narrow it down to Kent County, Kent County rates higher than both the United States and Michigan averages. This is why we chose this subject for our project. With further education and resources, these numbers of teen pregnancy and infant deaths can be decreased.

5. Overview
“Improving the well-being of mothers, infants and children is an important public health goal for the United States. Their well-being determines the health of the next generation and can help predict future public health challenges for families, communities, and the health-care system” (Healthy People 2020, 2012, para. 1).
Healthy People (2013). Maternal, infant, and child health. Retrieved from

6. Current Pregnancy Programs that Promote Prenatal Care in Kent County
Maternal and Infant Health Program (MIHP): The Maternal and Infant Health Program is a program for all Michigan women with Medicaid health insurance who are pregnant and all infants with Medicaid.
MIHP Services Include:
Maternal infant health and psychosocial assessment.
Beneficiary care plans.
Referral to local childbirth education or parenting classes.
With Kent County haver higher than national averages with teen pregnancy and infant death, they already provide some excellent services to not only teenage mothers but all mothers. One program is the Maternal and Infant Health Program. This program provides support to promote healthy pregnancies, good birth outcomes, and healthy infants. Many of the excellent services provided are stated in the cloud bubbles.
Home or office visits.
Transportation services.
Referrals made to local community services

7. Current Pregnancy Programs that Promote Prenatal Care in Kent County
Healthy Women’s Resource Guide
This guide has been created in an effort to improve infant health in Kent County. This guide includes information for women who:
Are Pregnant
The Healthy Women’s Resource Guide is another program that Kent County offers. This guide educates all mothers on what they need to know before, during, and after pregnancy to have the best possible outcomes. The link to this guide is provided at the bottom of this slide.
Trying to get pregnant
Had a Baby
Might Be Pregnant
Link to the Healthy Women’s Resource Guide:

8. Kent County Community Problem Statement
Risk of infant mortality among infants born to adolescent mothers of Kent County, Michigan related to lack of entry into first trimester prenatal care.

9. Kent County Prenatal Care in First Trimester

10. Benefits to Early Prenatal Care
Provide Necessary Education
Counsel on risky behaviors
Information about physiological changes
Accurately determine gestational age
Poor nutrition associated with preterm delivery
Reduces infant mortality rate
Identify conditions associated with maternal and perinatal morbidity and mortality
Improved Birth Rate
Decreased Preterm Labor
Kirkham, C., Harris, S., & Grzybowski, S. (2005, April 1). Evidence-based prenatal care: part I. Generic prenatal care and counseling issues. American Family Physicians, 71(7),

11. Pregnancy Health and Behaviors
Healthy People 2020
Pregnancy Health and Behaviors
Increase the proportion of females delivering a live birth receiving prenatal care beginning in the first trimester from 70.8% to 77.9%.
MICH-10.1 Increase the proportion of pregnant women who receive prenatal care beginning in first trimester
MICH-10.2 Increase the proportion of pregnant women who receive early and adequate prenatal care
Healthy People (2013). Maternal, infant and child health objectives. Retrieved from:

12. Barriers to Care Unaware of pregnancy until past 1st trimester
Hiding pregnancy - fear of disclosing pregnancy
Lack of knowledge of importance of prenatal care - belief prenatal care is unnecessary
Fear of medical procedures
Lack of support - lack of a trusted adult figure
Availability of reproductive health care
Finances/money/insurance
Transportation issues
Clinic hours, long waits
Perceived discrimination - attitude of care providers r/t teen pregnancy
Michigan Public Health Institute. (2012). Kent County 2012 community health improvement plan. Retrieved from

13. Prenatal Care Best Practice
•Peer review studies reiterate early and regular prenatal care is a strategy to improve outcomes
•Pregnant women should be counseled early to identify and educate against high risk behaviors
•Allows for early and ongoing monitoring of maternal health
•Reduces the risk of adverse outcomes for mother and baby
•Early assessment identifies potential complications and allows treatment of underlying health issues
•Caregiver continuity is associated with reduced interventions during labor
U.S. Department of Health and Human Services Health Resources and Service Administration. (n.d.). Prenatal-first trimester care access. Retrieved from
Kirkham, C., Harris, S., & Grzybowski, S. (2005, April 1). Evidence-based prenatal care: part I. Generic prenatal care and counseling issues. American Family Physicians, 71(7),

14. The Ecological Model (Harknss & DeMrco, 2012)
Focuses on both population-level and individual-level determinants of health and interventions
Considers issues that are community-based and not just individually focused
Health is determined by influences at multiple levels (e.g., public policy, community, institutional, interpersonal, and intrapersonal factors
Recognizes that examining the ecological niche - the family, the community, the political and social environments—in which the person lives is essential in helping to understand and prevent health problems
Harkness, G. A., & DeMarco, R. F. (2012). Community and public health nursing. Philadelphia, Pa: Wolters Kluwer Health- Lippincott Williams & Wilkins.

15. Ecological Model Adolescent Prenatal Care
Individual
Sex, Age, Health
Female, adolescent, pregnant
The direct environment, the setting in which we have direct social interactions with people in our lives.
Microsystem
Relationships, Family, Peers
Mesosystem
The connection between the structures of the microsystem
The connections/interactions of family structure, family function, family adaptation, and school
Harkness, G. A., & DeMarco, R. F. (2012). Community and public health nursing: Evidence for practice. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.
Exosystem
Formal and Informal Social Structures
Health care system. Education systems. Policy makers.
Macrosystem
Attitudes and ideologies of the culture
The personal set of values and beliefs that shape and influence how events are interpreted

16. Ecological Model
The Ecological Model applied to adolescent health is a product of the factors that are occurring and interacting at individual, interpersonal, community and societal levels (Sword, 1999).
Individual Level
biological and personal history factors; developmental stage
Interpersonal Level
relationships with family, friends, and peers
Community Level
where teens live, attend school, and work
Societal Level
social, economic, political and cultural systems
These relationships are multi-directional meaning each level is influencing the other levels at any given time.
Considering social determinants of health and the influences of where teens live, learn, work, and play will help to better understand the factors and underlying causes of why teens are not initiating early prenatal within the context of each community (JSI, 2012).
JSI Research & Training Institute. (2012). Assisting organizations to address social determinants of health that impact teen pregnancy. Retrieved from
Sword, W. (1999). A socio-ecological approach to understanding barriers to prenatal care for women of low income. Journal Of Advanced Nursing, 29(5), doi: /j x

17. Pregnant Adolescent Students School based health clinic
WHO
WHERE
Pregnant Adolescent Students
School based health clinic
WHAT
WHY
To ensure pregnant adolescents receive proper prenatal care and resources
Receive all routine prenatal care
WHEN
HOW
Clinic nurse staff member will be assigned as OB case manager for each pregnant student
After school clinic hours

18. Goals/Objectives to Reduce Disparities in Adequacy of Prenatal Care
Kent County
Goals/Objectives to Reduce Disparities in Adequacy of Prenatal Care
Ensure all women receive prenatal care in the first trimester
Ensure pregnant women have referral and navigation support to get their first prenatal appointment right away
Ensure all women receive an adequate number of prenatal care visits
Educate community on the availability of prenatal care resources, insurance eligibility, and other support services
Reduce disparities in the provision of prenatal care.
Identify funding for a coordinated “early and often” prenatal care message and a social marketing campaign
Promote planning for pregnancy and recognizing pregnancy early
Ensure providers screen pregnant women for social determinants of health and provide referrals to appropriate resources and services
Michigan Public Health Institute. (2012). Kent County 2012 community health improvement plan. Retrieved from

19. Kent County 2012 Objectives Addressed
Description
Kent County 2012 Objectives Addressed
S4. Strengthen and expand comprehensive school-based health services, including primary care services where appropriate (i.e. school nurses, school-based health centers).
S12. Expand the models of prenatal care that are available within Kent County, such as Midwifery care and Centering
Primary Intervention: Onsite Prenatal Care
Students can receive all routine prenatal care one designated Kent County school based health clinic. Students who need additional services can receive assistance in coordinating and scheduling appointments and transportation.
In an analysis comparing teens receiving reproductive health care, with or without access to a school clinic, Ethier, et al. (2011) found that those with access to an SBHC had increased odds of having received pregnancy care (p. 563).
Ethier, K. A., Dittus, P. J., DeRosa, C. J., Chung, E. Q., Martinez, E., & Kerndt, P. R. (2011). School-based health center access, reproductive health care, and contraceptive use among sexually experienced high school students. Journal of Adolescent Health, 48, doi: /j.jadohealth
Michigan Public Health Institute. (2012). Kent County 2012 community health improvement plan. Retrieved from

20. Interventions Addressing Prenatal Care Best Practices by Increasing Prenatal Care Access in the First Trimester
Existing school based onsite health clinics will extend existing reproductive health care services to provide an obstetrics care coordination program that will provide comprehensive and culturally sensitive prenatal care, education, support, and community resource referrals to pregnant students.
Goal S5. Educate community on availability of prenatal care resources, insurance eligibility, and other support services.
Goal S3. Ensure pregnant women have referral and navigation support to get their first prenatal appointment right away.
The National Association of School Nurses (NASNa, 2011), a professional nursing organization, discussed characteristics of a SBHC in its position statement regarding the role of the SBHC nurse. NASN’s definition of a SBHC is a primary care clinic housed on primary and secondary school campuses in the United States generally operated as a partnership between the school district and community health organizations, such as a community health center, hospital, or the local health department (p. 196). The clinics are designed to overcome barriers that inhibit students from getting needed health care, including lack of confidentiality or fear that confidentiality will not be maintained, transportation problems, fear that parents will be notified by insurer, inconvenient appointment times, costs, and apprehension about discussing personal health problems (NASN, 2011a, p.197). With an emphasis placed on prevention and early intervention, NASN (2011a) further explains that the services provided by a SBHC are a combination of primary care, mental health care, substance abuse counseling, case management, dental health, reproductive health services and counseling, nutrition education, health education and health promotion (p. 196).
Michigan Public Health Institute. (2012). Kent County 2012 community health improvement plan. Retrieved from
National Association of School Nurses. NASN position statement: The role of the school nurse and school-based health centers. (2011a). NASN School Nurse, 26(3), doi: / X
S8. Ensure pregnant women are screened for social determinants of health and provide referrals to appropriate resources and services.
Goal S1. Promote planning for pregnancy and recognizing pregnancy early.

21. How It Works - OB Case Manager
Upon diagnosis or confirmation of pregnancy, a clinic nurse staff member will be assigned as OB Case Manager for that student.
The OB Case Manager will:
Meet with each student individually once or twice a month throughout the pregnancy to assess needs, coordinate services, and provide one -on-one education on a variety of topics related to pregnancy.
Provide support and guidance for teens experiencing difficulty communicating with family members about the pregnancy.
Ensure students questions are asked, answered, and understood.
Connect and refer to appropriate established resources within the community, including MIHP a WIC, .
Coordinate visits and consults at the school whenever possible.
Introduce and help transition the student into the existing school Teen Parenting Program.
SBHC nursing is a specialized practice of professional nursing and plays a pivotal role in serving as a liaison between school personnel, family, community and healthcare providers to advocate for health care and a healthy school environment (NASN, 2011b). Using clinical knowledge and nursing judgment, the SBHC nurse provides direct health care to students and staff, performs health screenings, and collaborates with other members of the health care team to coordinate referrals to the medical, home, or private healthcare provider. (American Nurses Association [ANA] 2011). Immersed in the environment of the targeted population, the SBHC nurse is able to continuously assess the needs and available community resources to develop care plans and evaluate the effectiveness of those plans. In this safe, convenient, non-judgmental environment, the SBHC nurse utilizing her clinical knowledge and nursing judgment, can provide direct health care to students by performing screening to obtain an early pregnancy diagnosis. Once the diagnosis is made, the SBHC nurse collaborates with other members of the community and health care team to coordinate care resources starting with a rapid referral to an appropriate prenatal care provider.
This role addresses both the physical and social determinants to both increased and early access to prenatal care at the individual and local community level.
American Nurses Association and National Association of School Nurses (2011). School nursing: Scope and standards of practice. Retrieved from
National Association of School Nurses. (2011b). Role of the school nurse. Retrieved from

22. Evaluation
Participants enrolled in the program will be categorized using the Kotelchuck Index to assess adequacy of prenatal care.
This index incorporates how early women enter prenatal care and the number of prenatal care visits they receive. The index categorizes adequacy of prenatal care as follows:
• Adequate Plus Prenatal Care - Prenatal care begun by the 4th month and 110% or more of recommended prenatal visits were received
• Adequate Prenatal Care - Prenatal care begun by the 4th month and 80% to 109% of recommended prenatal visits were received
• Intermediate Prenatal Care - Prenatal care begun by the 4th month and 50% to 79% of recommended prenatal visits were received
• Inadequate Prenatal Care - Prenatal care begun after the 4th month or less than 50% of recommended prenatal visits were received
Michigan Public Health Institute. (2012). Kent County 2012 community health improvement plan. Retrieved from

23. Frequency of evaluation.
Eval (CONT)
OB Case Managers will provide a synopsis on utilization of program resources from their cases. This report will include assessment of currently identified social determinants, barriers, and coordination of care efforts, challenges and successes.
Frequency of evaluation.
Data will be obtained/compiled from the School-Based Health Clinics during the school year at the following points:
at students entrance the program
monthly during the pregnancy through OB Case Manage synopsis reports
at the time of delivery

24. References
Harkness, G.A. & DeMarco, R.F. (2012). Community and Public Health Nursing Practice: Evidence for Practice. Wolters Kluwer/Lippincott, Williams & Wilkins: Philadelphia
Healthy Women’s Resource Guide (2008). What You Need to Know Before, During, and After Pregnancy. Retrieved from:
MDCH. Department of Community Health (2013). Maternal Infant Health Program (MIHP). Retrieved from
Michigan Public Health Institute. (2012). Kent County 2012 Community Health Improvement Plan. Retrieved from
Kirkham, C., Harris, S., & Grzybowski, S. (2005, April 1). Evidence-based prenatal care: part I. Generic prenatal care and counseling issues. American Family Physicians, 71(7),

25. What Else Is Neeed? Funding
The HHS validates the governments belief in the value and potential impact of the SBHC program when it reports “in an effort to address significant and pressing capital needs to improve delivery and support expansion of services at SBHCs, the Affordable Care Act is providing $200 million in funding for 2010 through 2013” (HHS, Food and Drug Administration, 2013, para 3).
Department of Health and Human Services; Food and Drug Administration. (2013). Federal Funds Salaries and Expenses. Retrieved from