The Interpregnancy Care ProgramThe Interpregnancy Care Program

Interpregnancy Primary Care and Social Support for African-American Women at risk for recurrent

very-low-birthweight delivery:A Pilot Evaluation

Accepted for Publication - July, 2007 in

Maternal and Child Health Journal

Background

• Georgia’s infant mortality declined by 50% from 1975 to 1996, primarily due to improved survival of low birth weight (LBW; < 2500 gm) infants;

• The largest contributor to Georgia’s infant mortality rate is the birth of LBW and VLBW (< 1500 gm) infants:

% of Births % of Infant Deaths

< 2500 g 11% 70%

< 1500 g 2% (~2500 births) 50%

Background

• African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality (1).

• Survival of VLBW infants has significantly improved in the last 25 years, but the prevalence of cerebral palsy has not changed.

Background

• No obstetrical or prenatal assessment or intervention has been successful in predicting or preventing a woman’s first preterm/LBW delivery (4);

• The single best predictor of a preterm/VLBW delivery is a history of a previous preterm/VLBW delivery (5).

• White women – 8%

• African-American women – 13%

Background

• Experience and a growing body of evidence link the delivery of a VLBW infant to aspects of a woman's health status, including (1):

– Unrecognized and poorly-controlled medical problems;

– Reproductive tract infections (including BV and STI’s);

– Substance abuse disorders;– Periodontal disease;– Psychosocial factors including psychological stress

and domestic violence.

Background

• Short interpregnancy intervals increase the risk of preterm/LBW delivery (2, 3),

• the critical interval varies by race (4):

– 9 months for African-American women;

– 3 months for white women.

Background

• Pregnancy is too late to initiate

prenatal care if the mother has had

a previous VLBW infant.

Interpregnancy Care

• Primary health care from delivery of one child until conception of the next.

Study Team

Principal Investigator:

• Alfred W. Brann, Jr, MD

Co-principal Investigator:• Anne Lang Dunlop, MD,

MPH

Co-investigators:• Denise Raynor, MD• George Bugg, MD, MPH

Study Coordinator:• Cynthia Dubin, CNM, FNP

Case Manager:• Michelle Cox, RN

Resource Mother:• Patricia Ward

IPC Intervention Package

• Definition of an individualized IPC plan based on assessments of medical and social risks for subsequent poor pregnancy outcomes;

• Provision of comprehensive and integrated primary health care and dental services in accordance with the individualized IPC plan for 24 months;

• Assistance in developing and achieving her reproductive goals, that may include child spacing (at least 9 months and preferably 18 months);

• Community outreach via a trained Resource Mother and nurse case manager.

Provision of IPC

• Contact with a multidisciplinary team, including a nurse-midwife, family physician, periodontist, nurse case manager, social worker, and Resource Mother;

• Primary care visits occur every 1 -3 months (dependent upon extent of health problems) principally in a group setting with integration of group educational experiences according to the Centering Pregnancy Model for delivery of prenatal care;

• Home visits and telephone contact by the Resource Mother monthly to address psychosocial issues.

IPC: Participant Selection

• 47 consecutive women delivered VLBW infants during the enrollment period:– 9 not offered enrollment because not African-

American;• 38 otherwise eligible to enroll:

– 4 declined to sign permission-to-contact;– 2 unable to be contacted after discharge; – 1 moved out of town;– 2 (with stillborn infants) left hospital prior to

notification of nurse case manager.• 29 women ultimately recruited and enrolled into IPC

intervention cohort.

Comparison Group: An Historical Cohort from GMH

• A comparison group constructed from consecutive VLBW deliveries at GMH during an 18-month period preceding initiation of the IPC program (06/2001 through 12/2002);

• Matched to IPC intervention group on two variables:– African-American ethnicity;– Census tract.

Demographic Description Prior to Index VLBW Delivery

CharacteristicIPC Intervention Cohort

(n = 29)Historical Control Cohort

(n = 58)

Age: Teenagers (< 20 years) Women age 20 – 35 yrs Women age ≥ 35 yrsGravidity Range MedianParity Primiparous Prior preterm delivery Prior term delivery Prior spontaneous ab

7/29 (24.1%)18/29 (62.1%) 4/29 (13.8%)

1-13 pregnancies 2 pregnancies

15/29 (51.7%)*12/29 (41.4%)12/29 (41.4%)15/29 (51.7%)

12/58 (20.7%)43/58 (74.1%)) 3/58 (5.2%)

1-8 pregnancies 2 pregnancies

14/58 (24.1%)*19/58 (32.8%)36/58 (62.1%) 30/58 (51.7%)

* p-value for Fisher’s exact test = 0.0154

Description of Birthed Index VLBW Infants

CharacteristicIPC Intervention Cohort Historical Control Cohort

Birth weight

Multiple gestation

Stillborn

944 g (520-1490)

7/29 women (24.1%)*

4/37 infants (10.8%)3/4 (75%) macerated

1023 g (520-1480)

3/58 women (5.2%)*

4/61 infants (4.9%)3/4 (75%) macerated

* p-value for Fisher’s exact test = 0.0140

Underlying Categorical Cause of Preterm Delivery

UnderlyingCause

IPC Intervention Cohort Historical Control Cohort

Infectious

Vascular

Infect + Vasc

Unexplained

Iatragenic

15/29 (51.7%)*

3/29 (10.3%)

2/29 (6.9%)

4/29 (13.8%)

5/29 (17.2%)**

12/58 (20.7%)*

11/58 (18.9%)

7/58 (12.1%)

11/58 (17.2%)

17/58 (32.8%)***

* p-value for Fisher’s exact test = 0.0061

Result of Placental Pathologyfor Iatragenic Preterm Deliveries

Iatragenic PTDIPC Intervention Cohort

Iatragenic PTDHistorical Control Cohort

5/29 (17.2%)

- 2 for maternal preeclampsia showed pathology of UTP*- 1 for fetal anomalies showed no specific pathol. process- 2 for growth-discordant twins showed no specific pathol. process

17/58 (32.8%)

- 15 for preeclampsia showed pathology of UTP*- 2 for IUGR/oligohydramnios showed pathology of UTP*

* Uteroplacental insufficiency

Participation in IPC

• During Initial 12 months of IPC Program:– 21/29 (72.4%) actively participating;– 8/29 (27.6%) not actively participating:

• 2 moved out of state;• 3 electively disenrolled (2 prior to 1st IPC visit; 1 after single visit);• 3 become lost to follow-up (2 prior to 1st iPC visit; 1 after single visit).

• During Second 12 months of IPC Program:– 16/29 (55.2%) completed follow-up;– 13/29 (44.8%) not actively participating:

• In addition to 8 described above,• 1 disenrolled (working with health insurance benefits);• 4 lost to follow-up.

Impact of IPC: Health Outcomes

Health status of 7 women with chronic disease before and since enrollment:

1. Valvular heart disease; hepatitis C Valve replacement surgery, on-going evaluation by infectious disease;

2. Sickle cell disease, severe anemia with non-compliance Compliance with daily multivitamin and folic acid;

3. Hypertension, Diabetes, Asthma with non-compliance Improved compliance with simplified medication regimen;

4. SLE, Hypertension, Renal insufficiency Improved blood pressure control, re-established link with rheumatology clinic;

5. Pituitary tumor (prolactinoma) Planned surgical resection;

6. Cardiac arrhythmias, panic attacks Medical management;

7. Generalized anxiety disorder, depression, multi-substance abuse patient lost to follow-up.

Impact of IPC: Health Outcomes

During the interpregnancy period:

• 15 of 21 women diagnosed and treated for reproductive tract infections;

• 5 of 21 women diagnosed and treated iron-deficiency anemia;

• 7 of 15 women fully evaluated and treated for oral infections

and periodontal disease; • 8 of 21 women screened positive for post-partum depression

and linked to appropriate psychiatric evaluation and psychological support services.

Impact of IPC: Health Outcomes

12 of 29 participants with substance abuse problems:

• Tobacco alone – 3 (1 has quit)

• Tobacco, alcohol – 1 (reduced alcohol; uses tobacco)

• Street drugs, tobacco, alcohol – 8 (3 lost to follow-up, 3 completed outpatient rehab, 2 completed residential rehab)

Impact of IPC: Birth Planning

• Reproductive plans development:

– 21/21 women stated a reproductive plan for themselves.

• Reproductive plans attainment:

– 21/21 women provided with a contraceptive method of their choosing.

Impact of IPC: Conception within 9-months

* p-value for Fisher’s exact test = 0.0002

Outcome IPC Intervention Cohort

GMH Historical Cohort

Proportion of women who conceived ≥ 1 pregnancy within 9-mo of index VLBW delivery

0/29 (0%)* 18/58 (31%)*

Impact of IPC: Conception within 18-months

* p-value for Fisher’s exact test = 0.0026

Outcome IPC Intervention Cohort

GMH Historical Cohort

Proportion of women who conceived ≥ 1 pregnancy within 18-mo of index VLBW delivery

5/29 (17.3%)* 29/58 (50%)*

Impact of IPC: No. pregnancies within 18-months

No. of pregnanciesIPC

Intervention Cohortn = 29

GMH Historical Cohort

n = 58

0 24 29

1 3 22

2 2 7

Average per woman 0.241* 0.621*

* cohort A 61.2% reduction in the average no. of pregnancies within 18-months for women in the IPC; p-value (Poisson regression) = 0.0222.

Conclusion: Women in the historical cohort had 2.57 (95% CI: 1.14 – 5.78) times as many pregnancies within 18-months of the index VLBW delivery as women in the IPC cohort, on average.

Impact of IPC: Subsequent pregnancy outcomes

IPC Intervention Cohort:7 pregnancies within 18 months

GMH Historical Cohort:36 pregnancies within 18 months

3/7 (42.8%) with adverse outcome: - 1 liveborn, intermed. LBW (1500-2499g); - 2 spontaneous abortions (< 20 wks’). 3/7 (42.8%) liveborn, ≥ 2500 g; 1/7 (14.3%) electively aborted.

21/36 (58.3%) with adverse outcomes: - 7 liveborn, intermed. LBW (1500-2499g); - 3 liveborn, VLBW (< 1500 g); - 4 stillborns; - 3 ectopic pregnancies; - 3 spontaneous abortions (< 20 wks’); - 1 molar pregnancy. 8/36 (22.2%) liveborn, ≥ 2500 g; 6/36 (16.7%) electively aborted; 1/36 (2.7%) unknown outcome (delivered outside GMH).

Impact of IPC: No. adverse pregnancy outcomes

No. adverse outcomesIPC

Intervention Cohortn = 29

GMH Historical Cohort

n = 58

0 27 41

1 1 13

2 1 4

Average per woman 0.103* 0.362*

* A 71.5% reduction in the average no. of adverse outcomes of pregnancies for women in the IPC cohort; p-value (Poisson regression) = 0.0424.

Conclusion: Women in the historical cohort had 3.51 (95% CI: 1.04 – 11.73) times as many adverse pregnancy outcomes for pregnancies conceived within 18-months of the index VLBW delivery than did women in the IPC cohort, on average.

Impact of IPC: Social Outcomes

The Resource Mother assisted participants in:

improving educational attainment

employment acquisition

housing

Lessons Learned:Impact of Interpregnancy Care

For women who have had a VLBW delivery, the provision of IPC facilitated:

• the availability of primary care that permitted the identification and management of a relatively high prevalence of unrecognized and/or poorly managed acute and chronic conditions epidemiologically-linked to LBW and preterm delivery;

Lessons Learned:Impact of Interpregnancy Care

For women who have had a VLBW delivery, the provision of IPC facilitated:

• the development of a personal reproductive plan by participating women;

• the achievement of a 9-month interpregnancy intervals;

Lessons Learned:Impact of Interpregnancy Care

For women who have had a VLBW delivery, the provision of IPC facilitated a reduction in:

the average number of pregnancies conceived within 18 months, and

the average number of adverse pregnancy outcomes

Lessons Learned:

Impact of Interpregnancy Care for Women who Have a VLBW Delivery:

• The receipt of health care services for themselves is less of a priority than is securing income/employment, and this influences their health care seeking behaviors.

Cost-Benefit Analysis of an 18-month IPC Program for 450 African-American Women with an Index VLBW Birth

Cost of WC with no IPC

$0 $1,530,000 Cost of WC with IPC

Cost of OB/NIC/CP

$2,496,000 $870,000 Cost of OB/NIC/CP

Total Cost without IPC

$2,496,000 $2,400,000 Total Cost With IPC

+ $96,000Estimated Cost Benefit

Objective 1

• Describe a new indicator for the status of health of a community.

LBWR – Low Birth Weight Rate

Objective 2

• List the largest contributor to infant mortality. LBWB – Low Birth Weight

Birth

Objective 3

• Describe the public health approach of dealing with an identified and quantified recurrent public health risk.

• Define the risk

• Institute strategies that eliminate the risk Interpregnancy Care Public education on

reproductive awareness

Risk-Specific Interpregnancy Care

1. Establish risk categories from previous pregnancy

o pre-term / LBW birtho diabetic pregnancyo Preeclampsia/eclampsiao substance abuseo HIV/AIDSo women less than 19 years without their GED

(continued)

Risk-Specific Interpregnancy Care

(continued from previous slide)

• Initiate primary care after routine postpartum check

• Develop risk-specific process for Interpregancy Care

• Continue to refine risk categories

Number of Live Births less than 1500 gm.by Census Tract

1994-1998 Georgia and Public Health Districts

Number of Live Births less than 1500 gm.by Census Tract

Neighborhood view in Fulton County

Objective 4

QUESTIONS• Do you plan to become pregnant in the

coming year?• If the answer is NO, what are you doing to

prevent pregnancy?• Are you taking medicines, alcohol, or

drugs that may harm your fetus if you are pregnant and do not yet know it.

Influence of Early-Life Events on Human Capital, Health Status and Labor Market Outcomes

Rucker C. Johnson, Goldman School of Public Policy, UC Berkeley and Robert F. Schoeni, ISR, Ford School of Public Policy, and Department of Economics, University of Michigan (January 2007).

National Poverty Center Working Paper Series #07-05February, 2007

This paper is available online at the National Poverty Center Working Paper Series index at:http://www.npc.umich.edu/publications/working_papers

Negative reinforcing of intergenerational transmission of disadvantage within the family

• Parental economic status influences birth outcomes

• Birth outcomes have long-reaching effects in adulthood on health & economic status

• This in turn leads to poor outcomes for one’s own children

(From NPC Working Paper Series #07-05, Feb. 2007)

(1) Georgia Perinatal Task Force Report, 1998. (2) Adams, M. M., K. M. Delaney, P. W. Stupp, B. J.

McCarthy and J. S. Rawlings. "The relationship of interpregnancy interval to infant birthweight and length of gestation among low-risk women, Georgia." Paediatric and Perinatal Epidemiology 1997, 11(Suppl 1): 48-62.

(3) Klerman, L. V.; S.P. Cliver; R.L. Goldenberg. The impact of short interpregnancy intervals on pregnancy outcomes in a low-income population. American Journal of Public Health 1998, 88, 1182-1185.

(4) Rawlings, J. S., V. B. Rawlings and J. A. Read. "Prevalence of low birth weight and preterm delivery in relation to the interval between pregnancies among white and black women." NEJM 1995, 332: 69-74.

(5) Goldenberg, R. L. and D. J. Rouse. "Prevention of premature birth." New England Journal of Medicine 1998, 339(5): 313-20.

(6) Adams, M. M., L. D. Elam-Evans, H. G. Wilson and D. A. Gilbertz. "Rates of and factors associated with recurrence of preterm delivery." JAMA 2000, 283(12): 1591-6.

References

Socio-Demographic

GroupCharacteristics Births

% Total Births

Feto-infant Deaths

% Total Deaths

FIMRExcess FIMR

 

1981 - 1983  

White NH Grp 1 Age 20+, Educ. 13+ yrs 47,402 18.4% 608 9.6% 12.8 8.5  

White NH Grp 2 Age 20+, Educ. <13 yrs 89,653 34.8% 1681 26.6% 18.8 14.5  

White NH Grp 3 Age <20, Educ. <13 yrs 25,868 10.0% 679 10.7% 26.2 21.9  

Black NH Grp 1 Age 20+, Educ. 13+ yrs 15,547 6.0% 442 7.0% 28.4 24.1  

Black NH Grp 2 Age 20+, Educ. <13 yrs 53,539 20.8% 1914 30.2% 35.7 31.4  

Black NH Grp 3 Age <20, Educ. <13 yrs 25,742 10.0% 1007 15.9% 39.1 34.8  

Total 257,751  6,331 24.6  20.3

2001-2003  

White NH Grp 1 Age 20+, Educ. 13+ yrs 115,183 34% 534 16.2% 5.1 0.8  

White NH Grp 2 Age 20+, Educ. <13 yrs 105,562 22% 979 20.4% 9.8 5.5  

White NH Grp 3 Age <20, Educ. <13 yrs 25,344 6% 299 6.8% 12.3 8.0  

Black NH Grp 1 Age 20+, Educ. 13+ yrs 47,501 15% 549 16.2% 11.5 7.2  

Black NH Grp 2 Age 20+, Educ. <13 yrs 54,915 17% 999 29.4% 18.0 13.7  

Black NH Grp 3 Age <20, Educ. <13 yrs 20,675 6% 373 11.0% 17.9 13.6  

Total 322,596 3,398 10.5 6.2 

Table 1. Births and feto-infant mortality by sociodemographic group for Georgia, 1981-83, 2001-03