Reducing Subsequent Poor Pregnancy Outcomes among Women in Michigan Division of Genomics, Perinatal...

Reducing Subsequent Poor Pregnancy

Outcomes among Women in Michigan

Reducing Subsequent Poor Pregnancy

Outcomes among Women in Michigan

Division of Genomics, Perinatal Health and

Chronic Disease Epidemiology

Division of Family & Community Health

CityMatCH PPOR Learning Network

July 22, 2008

State-level action and interaction for improving

preconception care in Michigan

State-level action and interaction for improving

preconception care in Michigan

Violanda Grigorescu, MD, MSPH

State MCH Epidemiologist, Director

Division of Genomics, Perinatal Health and Chronic Disease Epidemiology

Michigan Population Demographics 2006Michigan Population Demographics 2006

Total population: 10,095,643 - White: 82% - Black: 14.8% - Native Americans: 0.7% - Asian Pacific Islander: 2.5% Female: 50.8% - 18-44 yrs. old: 35.9% Live births (#): 127,537 Birth rate (live births per 1,000 population): 12.6 Fertility Rate (live births per 1,000 women 15-44):

61.8

Trend of Infant Mortality Rate in Michigan

Trend of Infant Mortality Rate in Michigan

0

5

10

15

20

25

Black MI 21.6 17.3 17.5 17.6 16.8 17.9 18.2 16.9 18.4 17.5 17.3 17.9 14.8

Black US 18.0 15.1 14.7 14.2 14.3 14.6 14.0 14.0 14.4 14.1 13.8

White MI 7.9 6.2 6.0 6.1 6.3 5.9 6.0 6.1 6.0 6.7 5.2 5.5 5.4

White US 7.6 6.3 6.1 6.0 6.0 5.8 5.7 5.7 5.8 5.8 5.7

1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006Infa

nt

Mo

rta l

ity

Ra t

e

Basic Health Indicator:

Infant Mortality Rate (IMR): number of infant deaths per 1,000 live births

Perinatal Periods of Risk:New Approach to Infant Mortality

Perinatal Periods of Risk:New Approach to Infant Mortality

6 KEY STEPS FOR PPOR1. Engage community

partners 2. Map feto-infant

mortality3. Focus on overall rate4. Examine potential

opportunity gaps 5. Target further

efforts6. Mobilize for

sustainable systems change

500- 1499g

1500g

Fetal NeonatalPost

neonatal

Maternal Health/ Prematurity

Newborn Care

Age at Death

Birth

we

igh

t Maternal Care

Infant Health

PPOR Findings: Eleven Communities with High Infant Mortality (1998-2002)

PPOR Findings: Eleven Communities with High Infant Mortality (1998-2002)

0

1

2

3

4

5

6

7

8

9

10

Berrie

n

Detro

it

Gen

esee

Ingha

m

Kalam

azoo

Kent

Mac

omb

Oak

land

Out

-Way

ne

Sagin

aw

Was

htena

w

IH MH/P

IMR

Dif

fere

nc e

IMR difference: Black IMR compared to reference group

Prenatal care Race Maternal age Parity Multiple Pregnancy STD/Bacterial Vaginosis Previous preterm births Unintended pregnancyUnintended pregnancy Smoking/Alcohol/drug use Maternal health conditions

Gestational age Referral system Mother transfer Infant transfer Perinatal care Neonatal conditions Pay source Maternal complications

Birth weight Distribution (VLBW Births)

Birth weight- Specific Mortality Rates

Maternal Health/Prematurity

CDC / CityMatCH: PPOR - PC

Unintended vs. Intended PregnanciesCurrent Definitions

Unintended vs. Intended PregnanciesCurrent Definitions

Intended pregnancies: reported to have happened at the "right time" or later than desired (because of infertility or difficulties in conceiving).

Unintended (unplanned) pregnancies: reported to have been either unwanted (i.e., they occurred when no children, or no more children, were desired) or mistimed (i.e., they occurred earlier than desired).

Important: All of these definitions assume that pregnancy is a conscious decision.

Trend of Unintended Pregnancies in Michigan, 1990-2003, PRAMSTrend of Unintended Pregnancies in Michigan, 1990-2003, PRAMS

0

10

20

30

40

50

60

70

80

90

100P

erce

nt (

%)

% Unintended 43.49 43.05 42.52 44.5 38.14 42.92 43.13 44.29 42.64 40.63 41.18 40.58 43.15 40.51

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001* 2002 2003

Prevalence of Intended and Unintended Pregnancies, 2003, PRAMS

Prevalence of Intended and Unintended Pregnancies, 2003, PRAMS

Profile of Women having an Unintended Pregnancy in Michigan

Profile of Women having an Unintended Pregnancy in Michigan

The overall prevalence of unintended pregnancies in Michigan in 2003 was 40.5%

In 2003, the prevalence was highest in:Black womenFemales less than 18 years of ageWomen with less than a HS diploma/GEDWomen who are not marriedWomen with no insuranceWomen on Medicaid, andWomen with an annual household income of

$10,000 or less2003 Michigan PRAMS

Data – Driven Interventions:From Identifying to Understanding & Doing


Identify critical information in key areas Assure participating communities

understand the data/information Assess current intervention strategies and

compare to evidence-based strategies Revise or develop new plan based on

community assessment, intervention strategy assessment or other information

Preconception Care and Pregnancy Planning: Voices of African American women

Preconception Care and Pregnancy Planning: Voices of African American women

Renée B. Canady, PhDDeputy Health Officer,

Ingham County Health DepartmentAdjunct Assistant Professor,

MSU College of Nursing



Not everything that can be counted counts, and not everything that counts can be counted.

Albert Einstein

BackgroundBackground In order to improve the knowledge, attitudes, and behaviors of

women related to preconception health, more must be understood about the idea of planning as related to pregnancy and conception.

For the clinical or public health professional, “planned pregnancy” is a term commonly used with clients, yet it is unclear if women's perceptions and understanding of family planning coincide with those of professionals.

Since African American women are nearly twice as likely to experience a poor pregnancy outcome as white women, the project was intended to build the understanding of pregnancy experiences of African American women in order to make needed changes in the health care system to support better outcomes.

ObjectivesObjectives

This study endeavors to further elaborate information that is vital to our understanding of preconception issues in two ways:

1) by generally evaluating women's understanding of the concept of planned pregnancies, and by

2) interpreting those findings through the experiences of African American women who are especially at risk for poor pregnancy outcomes.

MethodsMethods

In the summer of 2005 the Michigan Department of Community Health conducted 19 focus groups with 168 African American women across 10 counties identified as having the highest African American infant mortality rates in the state of Michigan.

Focus Group EmphasesFocus Group Emphases

To elicit feedback within the context of three key stages of the pregnancy experience:– Preconceptional – Prenatal– Post-partum

Because of our specific interest in the experiences of Black women, we also sought to extract information on the role of race and economics as factors in the pregnancy experience

Focus Group ProtocolFocus Group Protocol

The idea of having a “planned pregnancy” is often discussed as part of studies of women’s health and pregnancy outcomes. Please tell us how you would define the term “planned pregnancy

Would you describe your last pregnancy as a planned pregnancy?

What steps did you take to prepare for your pregnancy?

Please describe a time when you think your race or ethnicity / financial situation affected your ability to get the health care information or services you needed before becoming pregnant?

Participant DemographicsParticipant Demographics

County Total Berrien Gensee Ingham K’zoo Kent Macmb Oakl. Sagnaw Wash. Wayne

# Sessions 19 2 2 2 3 2 1 1 2 2 2

Number 168 23 25 15 22 24 6 7 15 16 15

Race: % Black 95 % 100% 80% 73% 96% 100% 100% 100% 100% 100% 100%

Age:MeanRange[>40]

3115-82[32]

3117-52[4]

2016-34[3]

2216-50[1]

4419-82[6]

3419-50[6]

3529-41[0]

3618-60[3]

2315-40[0]

3121-45[2]

3823-65[7]

%Pregnant 14% 1% 30% 13% 5% 22% 16% 0% 21% 13% 20%

# ChildrenRange

3 0-11

30-10

10-3

20-5

31-11

31-7

32-5

21-5

20-5

31-7

31-7

Results/Findings: Six interacting themesResults/Findings: Six interacting themes

Theme 1: Preconception care: An unfamiliar concept

Theme 2: Planning for pregnancy: A continuum of responses.

Theme 3: Psychology of conception-Attitudes, beliefs, and behaviors.

Theme 4: The shared nature of planning: It takes two to plan a pregnancy.

Theme 5: Birth control: The means to an end.

Theme 6: The context of preconception care: The big picture

Theme 1: Seeing a health care provider BEFORE a pregnancy occurs is foreign concept to many women


This theme raises a direct contradiction to the current preconception goals of health care providers and agencies.

Women associated seeing a provider with “health problems” and since they “didn’t have any health problems at the time” they did not perceive the need for care before conception.

“What’s the question again?”

“It’s time to hang up the party dress and get to work”

– Pregnancy readiness vs. pregnancy planning



Theme 2: Planning as a continuumTheme 2: Planning as a continuum

Definitions of “Planning” represented a continuum versus a unilateral definition.

1) Deliberate and informed “Everything is secured. You’re secure in

your home, financial wise; ain’t that what a planned pregnancy is?”


2) Conscious but not deliberate

“Me and my husband (sic), we planned to get married, we planned to have children, but we didn’t sit down and decide ‘OK, we’re going to have a baby”


3) Absence of Planning “It was stupid. I knew I was going to get

pregnant. I just didn’t prepare NOT to get pregnant”

“It wasn’t planned but since I didn’t use protection, I guess that would be planned, huh?”

Theme 3: The Psychology of Planning; Attitudes, Beliefs, and Behaviors


Many women expressed a level of fatalism or resignation about their ability to influence pregnancy planning.

“Sometimes it’s a whole lot of maybe’s. Maybe I won’t get pregnant this time”



“I just thought I couldn’t get pregnant, because I had one tube, but I guess I got fooled.”

“When I was 28 I had a miscarriage. From then on, I never got pregnant. I was planning my 40th birthday party and found out I was pregnant.”

Theme 4: The Shared Nature of PlanningTheme 4: The Shared Nature of Planning

It takes two to plan a pregnancy. – Often preconception care is focused solely

on women.

“You mean the girl planned or the guy planned or they both planned, or what?”

“But he was there for me. He, you know, stayed by me. So it was a planned pregnancy, and yet, it wasn’t…so…”

Theme 5: The Means to an EndTheme 5: The Means to an End

Women continue to face challenges in selecting and using appropriate birth control

This remains a barrier to managing preconception care and negotiating planning

Theme 5: The Means to an EndTheme 5: The Means to an End

Many women believed their birth control “just didn’t work.”

“…I don’t think I would have had the last baby if I could have found a birth control

without side effects.”

Theme 6: The context of preconception care – The Big Picture


Contextual issues affecting preconception care. Preconception care is more than physical, it has social, psychological and spiritual components – Fertility norms and behaviors are culturally

and socially defined (Geronimus, 2003)

Inquiry re: role of race and economics yielded less about discrimination and more about the context of women’s lives



“I know a lot of white people do (plan pregnancy). By the time I hit 30, get my career or whatever, then plan (a pregnancy).”

Another woman said: “Some people that have a career, they like to start it first or, you know, like a career mother, she like to start a job first before she plan.”



“I never, even in a middle class way of thinking, you know, that---because that is a middle-class way of thinking, you know. So those of us that have not obtained that status, doesn’t---it isn’t that. It’s just that, okay, you got pregnant and, you know, baby ain’t going to starve, you know;” or “I just thought once you get married, you’re supposed to start a family.”

Programmatic/Clinical ImplicationsProgrammatic/Clinical Implications

1. Preconception interventions should be developed with the input of women. Women have a consciousness about their readiness for pregnancy which should inform preconception planning.

2. Knowledge dissemination is only one aspect of preconception care or intervention; it is necessary to incorporate affective and behavioral needs of women, recognizing the importance of culture.

3. Include men as well as women in preconception interventions. Reinforce the idea that planning a pregnancy is in the control of both the woman and the man.

4. Selection of birth control methods should be tailored to individuals with an appreciation of their personality, life style, and potential side effects.

5. Preconception care for vulnerable populations requires the strengthening of cultural commitment and social justice activities of nurses and healthcare professionals through partnerships, advocacy, and dissemination of information.

State-local partnership: Steps to program

development

State-local partnership: Steps to program

development

Cheryl Lauber, RN, MSN, DPAConsultant – Infant Mortality

Initiative

Primary Goals for Reducing Infant Mortality

Primary Goals for Reducing Infant Mortality

Improve maternal preconception healthImprove access to healthcare for

mothers and infantsEliminate the racial disparity in infant

mortality ratesImprove infant health and safety

Key Objectives by Period of RiskKey Objectives by Period of Risk

Maternal Health/Prematurity– Support healthy lifestyles for women of childbearing age– Target women with poor outcomes for interconception care – Assure access to primary care for women– Reduce unintended pregnancy

Maternal Care– Assure early entry to prenatal care with assessment of risk – Provide in-home/in-community supports to at risk women

Newborn Care– Assure high risk pregnancy delivery at NICU hospital – Provide early identification of problems and link to services

Infant Health– Assure access to primary care for infants– Reduce SIDS & other infant death– Improve resources for risk conditions & develop delay

Steps to Program DevelopmentSteps to Program Development

Analysis of data – Maternal Health & Prematurity– Infant Health – Racial disparity

Identified 11 communities with highest black IMR

Secured funding through Healthy Michigan Fund


Local coalition development (2004-2005)– Contracts with local health departments– Hired independent consultants to provide

technical assistance Communication

– Coalition Coordinators Network meets monthly

– Written and oral communication with health officers

– 3 deliverables due in 2005


Goals of local coalitions– Identify access and service system barriers– Identify needed prevention, primary care

and support activities and services– Develop, implement, evaluate a community-

wide plan– Produce annual report on the community’s

infant mortality status


MCH program review– MIHP redesign– Unintended pregnancy– Family Planning– WIC

Cultural Competency– Voices of the Women

Literature review – Preconception Care

Michigan Interconception Care ProgramMichigan Interconception Care Program

Identify at least 25 women with a poor pregnancy outcome – hospital discharge– other health department programs.

Nursing/medical/genetic risk assessment Provide grief support if indicated Contraception access Access to a medical home Promote 18 month interpregnancy interval Perinatal high risk case management for up to 24

months

Performance Against GoalsPerformance Against Goals Goal: to field test an Interconception Care strategy

for African- American women who experienced:– Preterm birth– Low birth weight birth– Fetal or neonatal death

Actual: 104 women have been recruited from communities and have reported data– 65 Preterm birth/Low birth weight birth – 24 Fetal or neonatal death– 14 Miscarriage

Project PlanningProject Planning What was good about the plan?

– Logical path from data to action– Phased approach– Evidence based intervention

What was missing from the plan?– Specific protocol for the home visiting– Staff support for more local training

Was the plan realistic?– Time to make this change was limited– Funding was not guaranteed

How did the plan evolve over time?– Began with local organization, education & assessment– Evolved to service delivery options & intervention strategies

Key areas for improvement:– Make very specific recommendations.

Project Management Project Management Project Direction Team met monthly

– Project Manager; Program Consultants; Division Managers; Epidemiologist

– Good idea sharing. Necessary for keeping locals focused. Planned for each Network meeting.

Communication by email, letter, Network meetings– Not consistent people initially caused some

communication problems. Network meetings face-to-face were costly. Relied on emails to local contacts.

Database tracked community achievements– Unable to keep database current. Used verbal

reports at meetings.

Quality Assurance & SupportQuality Assurance & Support

Product quality measured by conformity to annual expectations. Model reports provided.– Provided minimum of information initially but

adequate to understand performance Products compared to goals;

– Coalitions, health education and focus groups met expectations.

– Implementation of ICP intervention was new experience and slow in accomplishment.

Quality issues addressed through information/teaching and consultation.

Support/resources for ICP intervention has grown and programs all enrolling clients. Local site visits, phone consultation and quarterly meetings.

Outcome IndicatorsOutcome Indicators

Preterm births Low birth weight Unintended pregnancy rate Family planning access Intergestation timeframes

Evaluation ElementsEvaluation Elements

Mother’s Information– DOB– Residence– Race– Education– Marital Status– Source of Primary Care– Pregnancy History

Index Pregnancy Info– Outcome– Delivery Date– Birth Weight– Gestational Age– NICU Admission– PNC Started – Number PNC Visits– Maternal Age– Source of Payment


Index Pg Risk Factors– Prepregnancy Weight– Infection History– Alcohol Use– Tobacco Use– Street Drug Use– Domestic Violence– Mental Health Problems– Chronic Illness– Unplanned Pregnancy

Subsequent Pg Info– Outcome– Delivery Date– Birth Weight– Gestational Age– NICU Admission– PNC Started (weeks)–Number of PNC Visits–Maternal Age–Source of Payment


ICC Program Information– Eligibility– Enrollment date– Recruitment source– # Home visits made– Referrals completed– Assessment completed

– Family planning– Nutrition– Mental Health– Substance Abuse– Bereavement

Support– Discharge date– Type of provider

Key Lessons LearnedKey Lessons Learned

What Went RightWhat Went Right

Partnership with state programs

– WIC; MIHP; FP; Healthy Start Local coalition building

– Good local awareness

– Local partnerships started Able to pilot interconception care in

variety of settings

What Went WrongWhat Went Wrong Local willingness to develop an intervention

project– LHDs are less involved in direct service– More comfortable with education campaign

Funding stability– State fiscal crisis– Little commitment from legislature

Project management– Hiring new staff was delayed– Trouble mandating qualified local staff

Preliminary Data Preliminary Data Pregnancy Outcome for women recruited

N=104

– #/% fetal deaths 15 (14%)– #/% neonatal death 9 (9%)– #/% preterm birth 62 (60%)– #/% miscarriages 14 (14%)

Characteristics of women– mean age 22.7 (14 <18 yrs)– #/% African American 75 (72%)– #/% High School educ 60 (71%)– #/% married 21 (20%)– #/% Medicaid eligible 76 (84%)

Preliminary DataPreliminary Data Index Pregnancy Information

– mean birth weight 1698 g– mean Gestation Age 27.5 wks– #/% NICU adm 52 (54%)– mean # PNC visits 4.9 visits– #/% PNC 1st trimester 54 (79%)

Program Information– recruitment sources: MIHP, FIMR, Healthy

Start, SIDS Program, Hospital social

worker, Birth certs, flyers, Early On, WIC, NFP

More Action NeededMore Action Needed Identify women and intervene in existing

programs, WIC, MIHP, Family Planning. Revise program policy to include these goals. Target women eligible for Medicaid. Focus FIMR data collection on fetal death,

pre-term and low birth weight births. Provide training for program staff. Educate private ob-gyn providers on inter-

conception standard of care.

Questions & CommentsQuestions & Comments

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