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MATERNAL FETAL POPULATION HEALTH
MODULEIntegrating Population Health Inquiry Transforms (IPHIT)
Family Medicine
Northeast Education AfternoonDecember 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 1990 2000 2010 2020
OverarchingGoals
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
15 22 28 42*
# Objectives
226 312 467 > 580Slade-Sawyer, P, HHS Office of Disease Prevention and Health Promotion*39 Topic areas with objectives
2020 MATERNAL INFANT CHILD HEALTH METRICSSome 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 DATANational Vital Statistics Report
Volume 62, Number 1. June 28, 2013.
Pregnancy rates
Teen pregnancy rates
Cesarean delivery rates
Infant mortality rates
Series10.5
1
1.5
2
2.5
3
3.5
4
WhiteBlackLatinaOther
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 DATAexamples
Cesarean sections
Infant mortality
Premature Births
Sm
oking during pregnancy
LOCAL DATA
2013 Health Status Overview Report- www.publichealthmdc.com
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 (2011-12)
All 11.7% 8.4%
Black 16.7% 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
Mothers who smoked during pregnancy
NORTHEAST CLINIC AND UW- MADISON FAMILY MEDICINE RESIDENCY CLINICSThis data reflects deliveries in 2010-2013 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%
≤17 yo 18-34yo ≥ 35yo0%
5%
10%
15%
20%
25%
30%
Cesarean section rate by age
BellevilleNortheastVeronaWingra
White NH Black NH Other NH Hispanic Unknown0%
5%
10%
15%
20%
25%Cesarean section rate by race/ethnicity
BV
NE
Verona
Wingra
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)
≤17 yo 18-34yo ≥ 35yo0%
5%
10%
15%
20%
25%
Pregnancy smoking rate by age
BellevilleNotheastVeronaWingra
White NH Black NH Other NH Hispanic Unknown0%
10%
20%
30%
40%
50%
60%
70%
80%
Pregnancy smoking rate by race/ethnicity
BVNEVeronaWingra
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):527-535.
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
• MCH@WIC• 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?