The Magnolia Project

Reducing Infant Mortality:

An Interconceptional Care Strategy

Carol Brady, MA, Executive Director

Northeast Florida Healthy Start CoalitionMCH Emerging Issues

A little history. . .

Duval was one of three counties in 1995-97 that had an infant mortality rate significantly higher than the state

Two factors contribute to higher infant mortality rates in Duval: Proportion of nonwhites in the population Poor outcomes among nonwhites

Infant Mortality Rates, Duval County, 1992-2001

10.6

8.99.6

10.29.5

10.8

7.86.8 7

5.9

7.7

14.715.3 15 15.5

9.6

89.4

6.4

7.87.3

8.2

12.7

10.812.5

12

14.4

0

2

4

6

8

10

12

14

16

18

1993 1994 1995 1996 1997 1998 1999 2000 2001

Total

White

Nonwhite

Why focus on well-women?

PPOR! Greatest racial disparities occurred in

Maternal Health and Maternity Care Disparities disappeared in the other

categories Kitagawa: too many black babies born

too soon and too smallFIMR!

Black & White Fetal-Infant Death RatesBy Period of Risk, Duval County 1995-97

500-

1499g

1500+g

Fetal(24+ Wks

Gestation) Neonatal Postneonatal

Maternal Health/PrematurityBlack 6.9 White 2.3

R= 3.01(2.14, 4.25 95% C.I.)

Maternal CareBlack 3.4 White 2.0

R=1.70(1.12, 2.58 95% C.I.)

Newborn CareBlack 1.5 White 1.2

R= 1.22(0.67, 2.20 95% C.I.)

Infant CareBlack 2.8 White 1.9

R= 1.44(.092, 2.24 95% C.I.)

Total Feto-Infant Deaths/1000 (Live Births + Fetal Deaths) =Black 14.6 White 7.4

R=1.96(1.59, 2.41 95% C.I.)

What do all the numbers mean?

Almost two-thirds of the mortality difference between black women and the internal reference group is due to birth weight distribution

The focus of efforts should be on Maternal Health and Prematurity as they account for 95% of the excess deaths.

Fetal & Infant Mortality Review (FIMR)

Information abstracted from birth, death, medical, hospital and autopsy records

Family interviewsACOG processCase review team determines medical,

social, financial and other issues that may have impacted on poor outcome

FIMR Process

142 fetal and infant cases reviewed by CRT since 1995 83 white 53 black 6 other

Systematic, not random, sample based on specific criteria

Linking FIMR to PPOR

Most Frequent FIMR Factors: Infections and STDs No Healthy Start screening Late/inadequate prenatal care Previous poor outcome Family planning problems General state of mother’s health Poor nutrition

From data to action

Used PPOR & FIMR findings to respond to federal Healthy Start RFP in 1999 to address racial disparities in birth outcomes

Funded for proposed a Pre- and Interconceptional Model

Initiated the Magnolia Project

The Magnolia ProjectArea accounts for

more than half of the Black infant mortality in the city

About 25,000 women age 15-44 years old live in the project area

• 85% African-American

The Magnolia Project

• Storefront site

• Collaborative effort:

Local Health Department

HS Coalition

Community agencies

The Magnolia Project

Interventions (1999): Enhanced clinical care Case management & risk reduction Outreach Community development

Additions (2001): Depression screening Health education

The Magnolia Project

Who Did We Serve?

Average age <25 years old80% single90% black40% less than HS education90% uninsured (but would be insured

if pregnant!)

The Magnolia Project

Clinic services Age 15-44 Resident of

target area Pregnant or able

to get pregnant Health exam > 1

year

Case management 15-44 and living in target area Not pregnant, but sexually

active 3 or more risk factors:

previous loss, repeated STDs, no family planning, substance abuse, pregnancy <15 yrs, mental health probs, protective services, no source of care

The Magnolia Project

Project experience (2002) 509 Women served

405 clinic104 case management (3+ months)

18% pregnant 3,137 clinic visits 762 pregnancy tests (70%

negative)

The Magnolia Project

Clinical Patient Profile 41% sexually active but not using

birth control 42% STDs 20% previous miscarriage or infant

death 27% poor nutrition

Clinic Services

Tailoring Care to the Community Evening clinic Magnolia for Men Walk-in Wednesdays Ryan White III partnership Group prenatal care??

Clinic Services

Birth Outcomes for Pregnant Clients (n=73) 77% began care in first trimester 15% LBW 4.1% VLBW 18% pre-term No infant deaths

The Magnolia Project

Risk Factors by Type 35.1% Medical 64.9% Social

Duration of Service (current participants) 59% >12 months 14% 9-12 months

Case Management

Case Management

100 served in 2002Average length of participation =

464 days60% referred by clinicAverage of 14.9 risk factors/patient

65% family planning issues 58% education/training 48% job placement 39% BV 32% repeat STDs

Case Management

30+ clients closed to service in 2002 45% were in case management for 1

year+ 83% completed referrals 86% of risks were resolved or managed

Outcome of next pregnancy?? MOD proposal.

Outreach

Project staff, partner agencies (Jp Ministries, HS/Grand Park Place, others) 8,000 contacts Street outreach, nightclubs, health fairs 300+ scheduled at Magnolia or linked to

another provider for care

Health Education

1,186 one-on-one counseling sessions on FIMR risks (STDs & infections, substance use, family planning, safe sex, douching)

100+ families participated in Cooking Among Sisters

90 community residents attended Women’s Community Health Conference

30 agencies, 300+ residents participated in Street Party

Infant Mortality Rates, Duval County, 1997-2002 (Preliminary)

12.715.3 16.2

9.3

21.319.9

16

22.1

15.214.7 12.511.2

9.710.29.89.6

15.6

12.1

0

5

10

15

20

25

NonwhiteTotal CountyMagnolia Target AreaLinear (Magnolia Target Area)

Impacting Women’s Health Before Pregnancy

Nearly half of all pregnancies are unplanned (mistimed or unwanted)

All women age 15 - 44 should be considered pre-/interconceptional!

ID opportunities for addressing pre-/interconceptional issues (FP, pediatrics, case management).