Melanie Lutenbacher, PhD, MSN, APRN, FAAN Infant Mortality Best Practices Forum August 31, 2011 Tennessee Connections for Better Birth Outcomes: Working to Improve Maternal and Infant Health
Transcript
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Melanie Lutenbacher, PhD, MSN, APRN, FAAN Infant Mortality Best
Practices Forum August 31, 2011 Tennessee Connections for Better
Birth Outcomes: Working to Improve Maternal and Infant Health
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Infant Mortality complex phenomenon societal issues lifestyle
choices biological factors indicator of overall maternal/child
health
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The Company We Keep Infant Mortality Rates
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Why Do Our Babies Die? congenital malformations &
chromosomal abnormalities short gestation and low birth weight
sudden infant death (SIDS) newborn affected by maternal
complications of pregnancy unintentional injuries Source: National
Vital Statistics Report 2006
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Acute Morbidity by Gestational Age Among Surviving Infants
Mercer BM Obstet Gynecol 2003;101:178 93. Results of a
community-based evaluation of 8523 deliveries, 19971998, Shelby
County, Tennessee
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Escalating Hospital Costs with Decreasing Gestational Age
(Phibbs and Schmitt, 2006 Journal of Early Human Development)
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One Premature Birth Significantly Increases the Likelihood for
Recurrence Adams, 2000
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Approaching the Problem
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Best Practices system of providing high quality care meets the
needs of patients and, is cost effective Evidence Based Practice
best available evidence, moderated by patient circumstances and
preferences, applied to improve the quality of clinical judgments
and, facilitate cost-effective care Translational Research
transforms scientific discoveries arising from laboratory,
clinical, or population studies into clinical applications to
reduce morbidity and mortality
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Synergistic Relationships Science Best Practice Evidence Based
Translational Research
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Preterm Birth Prevention we dont have all the answers BUT, we
know some of the factors that contribute to preterm births ANDwe
have some promising interventions.
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Modify Maternal Risk Factors Adequate health coverage Available
resources Multiple methods of service delivery *clinic *group
*texting *home visit *telephone *internet Pre-conception /
inter-conception care Early prenatal care Enhanced support through
pregnancy System of Care Stress Infections Domestic violence
Smoking Substance abuse Nutrition Dental Health Interpregnancy
intervals PTB Infant Mortality
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Tennessee Connections for Better Birth Outcomes Funded by BCBS
TN Health Foundation With support from: VU Clinical Translational
Science Award grant UL1 RR024975-01 from NCRR/NIH VU School of
Nursing Center for Research Development and Scholarship Translated
existing evidence into interventions Targeted modifiable risk
factors in pregnant women With history of at least one preterm
birth
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Melanie Lutenbacher, PhD, MSN, APRN, FAAN * Patricia Temple
Gabbe, MD, MPH, Pediatrician *+ William F. Walsh, MD, Neonatologist
Etoi Garrison, MD, High Risk Obstetrician Lavenia Carpenter, MD,
High Risk Obstetrician Mary S. Dietrich, PhD, Biostatistician *
Sharon Karp, PhD, MSN, CPNP * Deborah Narrigan, MSN, CNM Jennifer
Murray, PhD (c) * Appointments at Vanderbilt University Schools of
Nursing and Medicine *+ Appointment at Ohio State University
Schools of Nursing and Medicine BBO Research Team
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Study Goals improve maternal health in women with a history of
at least one prior PTB via evaluation of the feasibility and
efficacy of a system of care to reduce preterm births & the
associated health care costs
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Pregnant Women with Prior Preterm Birth Conventional Prenatal
& Postpartum Care (Control) BBO System of Care (Intervention)
Observational Group (decline main study) BBO Study Design Random
Assignment
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Who could participate? Confirmed pregnancy 18 40 years of age
History of preterm birth (Live birth > 20wks and
BBO Birth Outcomes Control (N=102) Intervention ( N=109) Term
birth (> 37 weeks)69 (67.6%)75 (68.8%) Gestational age (weeks)
Median=38 wk, 0 day (Min=25wk, 0 day) (Max=42wk, 1 day) Median=38
wk, 1 day (Min=23wk, 5 days) (Max=41wk, 5 days) Change in
gestational age from index birth (weeks) Median=3 wk, 5
daysMedian=4 wk, 2 days Birth weight (grams) Median=3131 (Min=435,
Max=4876) Median=3071 (Min=405, Max=4440)
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Disposition of Infant
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Maternal Length of Stay for Delivery
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Key Risk Factors Assessed # prior PTBs African American race
pregravid BMI smoked reported domestic violence # medical
conditions # prenatal hospitalizations Level of: depressive
symptoms maternal stressors social support sense of personal
mastery & control
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Women with Similar Clusters of Risk Factors exploratory method
of classifying cases on multiple dimensions helpful for seeing
patterns in complex data generates groups of cases with similar
patterns or characteristics into a cluster separates groups with
discrepant or inconsistent patterns defined groups can be used for
further analyses
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BBO Gestational Age by Risk Cluster (N = 188) Cluster
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Cluster 1 (N = 30) Cluster Compared to other clusters: Lowest %
smoke Healthy, normal BMI Lowest in stress & depressive
symptoms Higher sense of personal control
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Cluster Compared to other clusters: Higher % African American
Overweight Have more medical conditions including prenatal
hospitalization Higher stress, depressive symptoms, reports of DV
Cluster 2 (N = 59)
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Cluster Compared to other clusters: Healthy, normal BMI Lower
stress & depressive symptoms Lower sense of personal control
Cluster 3 (N = 33)
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Cluster Compared to other clusters: Higher % smoke Normal BMI;
healthy > number prior preterm births High social support and
sense of personal control Cluster 4 (N = 36)
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Cluster Compared to other clusters: Normal to low BMI Higher
stress & depressive symptoms levels Higher social support and
sense of personal control Cluster 5 (N = 30)
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Depressive Symptoms At study enrollment, 28% of women had high
depressive symptoms At 48 hours postpartum, after controlling for
baseline depressive symptoms: women in the intervention group had a
greater reduction in depressive symptoms than those in the control
group
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In Her Own Words
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Where Do We Go From Here? further examine women with specific
clusters of risk factors examine these clusters in relation to
amount and focus of home visits share lessons learned refine
intervention, study materials, and design test
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remember - prevention of infant mortality begins long before
the baby arrives educate yourself, family members, friends &
co-workers about risk factors for preterm birth use evidence to
guide your efforts to promote healthy behaviors support adequate
health care coverage & access get involved with efforts to
prevent preterm births What Can You Do?
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Tennessee Connections for Better Birth Outcomes Funded by