WHAT YOU DO TO PREVENT PRETERM BIRTH

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Presentations text content in WHAT YOU DO TO PREVENT PRETERM BIRTH

Slide1

WHAT YOU DO TO PREVENT PRETERM BIRTHIN CLEVELAND AND CUYAHOGA COUNTY

Carol Gilbert, MS Health Data Analyst, CityMatCH

1

Slide2

Your Programs MomsFirst, Help Me Grow,

Lead Safe, Creating Healthy Communities, Produce Perks, Breast for Success, Place Matters, Baby Basics, and

CFHS

Your Expertise

Nursing

Perinatal health

Counseling

Health SystemsEducation SystemsHousing SystemsLaw enforcementJustice systemKnowledge of your clients

2

Slide3

….And you know Cleveland and Cuyahoga countyNeighborhoodsHistoryValues

Traditions3

Slide4

Services you provideHealth education

Health literacyPrenatal careBreastfeedingFamily planningInterconception care

ParentingSmoking CessationChild Health and Development

Case management

Obtaining medical insurance

Obtaining transportation to medical appointments

Screening and referral for perinatal depression

Connect parents to social supports, medical home

Health promotion

Assess and improve environmental, systems and policies to promote health

Lead abatement grants

Extra value for food stamp cards when used at farmers markets

Breastfeeding support

4

Slide5

Black birth outcomes (2010-2012 birth records)Teen pregnancy 17%Short birth spacing 36% (similar to reference group)

Late or no prenatal care 14% (none in the reference group)Very preterm birth 5% (vs 1% for reference group)Infant mortality rate

5

Slide6

In Cuyahoga County, the Black infant mortality rate is 2.5 times the White rate (2006-2010)

6

Slide7

Infant mortality is complexHealth care system

Built Environment

7

Important time periods

Preconception health

Prenatal

Neonatal

Post-neonatal

Goes beyond obstetrics

Chronic disease

Mental Health

Social determinants

Life course

Inter-generational

…and is an important indicator of population health

Slide8

What is the Perinatal Periods of Risk approach, or PPOR?An approach for helping cities and large communities to use

their own data to investigate the reasons for their high infant mortality rates and disparities

Uses Vital Records Data (birth and death

records)

Everyone is included

Available at local level

8

Slide9

What’s different about the PPOR analytic approach?Four periods of risk

Uses fetal death dataUses a reference group

Tailored to every community

9

Slide10

The PPOR “map” of fetal and infant mortality. Perinatal Periods of Risk are named to suggest the preventive areas

500-1499 g

1500+

g

Fetal Deaths

(>=24 wks)

9

10

11

12

13

14

15

16

Maternal Health / Prematurity

Maternal Care

Newborn

Care

Infant Health

Neonatal Deaths

(Birth – 27 days)

Postneonatal

Deaths

(28 – 364 days)

age

weight

Slide11

4.1

1.8

1.2

2.0

PPOR “maps” for Cuyahoga County

*

11

All

2006-2010

* PPOR Fetal and infant deaths per

1000 live births and fetal

deaths

7.3

2.7

1.3

2.9

NH Black 2006-2010

9.1

14.3

Slide12

But . . . What rates can we expect to see in each Period of Risk?”

PPOR answers this question using a reference group

, a real population

of mothers that experience best outcomes:

low fetal and infant mortality rates

12

Slide13

Ohio State Reference Group

PPOR MAP, 2006-2010

1.8

1.2

1.0

0.7

Reference Group Characteristics:

20+ years of age

16+ years of education

Non-Hispanic White

Resident of Ohio at the time of baby’s birth

13

Ohio State Reference Group Overall Rate = 4.7

*

per 1000 live births and fetal

deaths

Slide14

By using the reference group, PPOR helps measure “Inequity”Remember:

Inequity is a disparity that is unnecessary and unfair

Unnecessary deaths are those that could be prevented

In PPOR,

preventability

is estimated on a population basis by comparing the community’s outcomes to the outcomes of a real “

reference group

”14

Slide15

7.3

2.7

1.3

2.9

PPOR

for

Cuyahoga County

15

Black

2006-2010

*

per 1000 live births and fetal

deaths

1.8

1.2

1.0

0.7

Ref2 2006-2010

5

.5

1.6

0.4

2.2

Excess Mortality

14.3

4.7

9.6

Slide16

169

48

11

67

PPOR

for

Cuyahoga

County

Estimated excess deaths

2006-2010

16

Black NH

*

per 1000 live births and fetal

deaths

11

5

6

36

All others

295

59

Slide17

Cuyahoga County

(2006-2010)

17

From Kitagawa, 92% of the blue pie slice is due to too many babies born too small; County-wide,

44% of excess mortality is due to Black prematurity

Slide18

Infant Mortality

PPOR says:

Prematurity Prevention

Clear

F

ocus

Identifying Priorities

Next Step: Determine which risk factors are most important for Cuyahoga County Black births

End of today

Some of you saw this part of PPOR analysis before

Slide19

Risk Factors for Prematurity

Slide20

Potential impact of addressing … Maternal stress during pregnancy—pooled RR=1.50—prematurity defined as less than 37 weeks (Ding)

 Short cervix—RR=6.19 (lengths at or below the 10th percentile—prematurity defined as less than 35 weeks (Iams , 1996)

 Previous preterm birth—RR=1.5-2.0—prematurity defined as less than 32 weeks (Iams)

 

Diabetes (GDM)—RR=1.47—prematurity defined as less than 3.7 weeks (

Hedderson

)

 Inter-pregnancy interval—pooled adjusted RR=1.07-1.40 (<6 to 12-17mo)—preterm defined as less than 37 weeks (Conde-Agudelo)20

Slide21

Prematurity is dangerous! Ohio (2006-2010) It causes death…

Slide22

…prematurity also causes perinatal morbidity, and adverse childhood outcomes

Source: Mercer BM. Preterm premature rupture of the membranes.

Obstet Gynecol 2003;101:178-93. Reproduced with permission from Lippincott Williams & Wilkins.

Slide23

Risk factors for prematurity that we can’t measure from birth certificate data

Maternal stress during pregnancy and over the life courseAlcohol, prescription drugs, other drugs (even smoking is under-reported)Many congenital anomalies are not detected at birth

Environmental and occupational exposures (even strenuous work)

Periodontal disease

Generational effects (the grandparents’ health, the mother’s health at her own birth etc.)

23

Slide24

Risk factors on birth certificate

Not married at time of baby’s

birth (SES, social support)

Teen mom age<20

High school or less

education (indicator for SES)

Medicaid paid for

delivery (indicator for SES)

Received WIC during pregnancy

Twins, triplets etc.

Previous preterm birth

Birth spacing shorter than 18 months

Hypertension before or during pregnancy (includes eclampsia)

Overweight or obese prior to pregnancy

Diabetes before or during pregnancy

Smoking before or during pregnancy

Late or

no

prenatal

care (13 weeks or later)

STD (Syphilis, Chlamydia, or Gonorrhea)

24

Slide25

Determining importance of risk factors (PPOR Phase 2 analysis, continued):Is the risk factor more prevalent (more common) among Black mothers compared with the reference population?

Among Black mothers, does the factor have a high relative risk, i.e. is a woman more likely to have very preterm birth if she had the risk factor, compared to if she doesn’t?

If we could ELIMINATE the risk factor from this population, how much would the very preterm birth rate be reduced?

Population Attributable Risk Percent is a simple descriptive measure of potential impact.

It takes into account both “strength” (relative risk) and prevalence of the risk factor.

Interaction or overlap among factors is not addressed.

Slide26

Rare among Black Cuyahoga County Births

Not married at time of baby’s

birth (SES, social support)

Teen mom age<20

High school or less

education (indicator for SES)

Medicaid paid for

delivery (indicator for SES)

Received WIC during

pregnancy (protective)

Twins, triplets etc.

Previous preterm birth

Birth spacing shorter than 18 months

Hypertension before or during pregnancy (includes eclampsia)

Overweight or obese prior to pregnancy

Diabetes before or during pregnancy

Smoking before or during pregnancy

Late or

no

prenatal

care (13 weeks or later)

STD (Syphilis, Chlamydia, or Gonorrhea)

26

Slide27

Low RR for VPTB among Black CC

Not married at time of baby’s

birth (SES, social support)

Teen mom age<20

High school or less

education (indicator for SES)

Medicaid paid for

delivery (indicator for SES)

Received WIC during

pregnancy (protective)

Twins, triplets etc.

Previous preterm birth

Birth spacing shorter than 18 months

Hypertension before or during pregnancy (includes eclampsia)

Overweight or obese prior to pregnancy

Diabetes before or during pregnancy

Smoking before or during pregnancy

Late or

no

prenatal

care (13 weeks or later

)

[but underreporting]

STD (Syphilis, Chlamydia, or Gonorrhea)

27

Slide28

Little impact on Black prematurity in CC

Not married at time of baby’s

birth (SES, social support)

Teen mom age<20

High school or less

education (indicator for SES)

Medicaid paid for

delivery (indicator for SES)

Received WIC during

pregnancy (protective)

Twins, triplets etc.

Previous preterm birth

Birth spacing shorter than 18 months

Hypertension before or during pregnancy (includes

eclampsia

)

Overweight or obese prior to pregnancy

Diabetes before or during pregnancy

Smoking before or during pregnancy

Late or

no

prenatal

care (13 weeks or later)

STD (Syphilis, Chlamydia, or Gonorrhea)

28

Slide29

And the winners are:

Not married at time of baby’s

birth (SES, social support

)

Teen mom age<20

High school or less

education (indicator for SES)

Medicaid paid for

delivery (indicator for SES)

Received WIC during

pregnancy (protective)

Twins, triplets etc.

Previous preterm birth

Birth spacing shorter than 18 months

Hypertension before or during pregnancy (includes

eclampsia

)

Overweight or obese prior to pregnancy

Diabetes before or during pregnancy

Smoking before or during pregnancy

Late or

no

prenatal

care (13 weeks or later)

STD (Syphilis, Chlamydia, or Gonorrhea)

29

Slide30

Most important contributors to prematurity among Cuyahoga County Black mothers30

Black % with factor

Ref % with factor

RR for VPTB among Black

PAR for VPTB among Black

Not married at time of baby’s birth (SES, social support)

89

6

1.4

25%

Birth spacing shorter than 18 months

36

34

1.4

13%

High school or less education (SES)

58

N.A.

1.3

13%

Previous Preterm Birth*

8

2

3.0

13%

*not preventable, but predictive

Slide31

What you can do to prevent prematurityStrongest opportunities (based on birth certificate) : SES – mitigating the effects of low SES,

– reducing prevalence of low SESSocial support, strengthening familiesIncreasing birth spacing

31

Slide32

WIC 43%

Poverty is prevalent among Ohio mothers!

High school or less education 44%

Medicaid for Delivery 39%

ALL THREE indicators– 20% of births

AT LEAST ONE of the three indicators of poverty apply to 61% of births

Ohio births 2006-2010

Slide33

WIC 43%

Poverty is MORE prevalent among BLACK Ohio mothers!

High school or less education 58%

Medicaid for Delivery 64%

ALL THREE – 34%

AT LEAST ONE– 88%

Ohio births 2006-2010

Slide34

Approximate distribution of conditions leading to preterm birth

34

Screening to identify women at risk of spontaneous preterm labor:

Previous preterm

Short Cervix

10%

muti

-fetal pregnancy (twins, triplets)

contribute to all three parts

Slide35

One more potential direction

Having a previous preterm birth

35

Black % with factor

Ref % with factor

RR for VPTB among Black

PAR for VPTB among Black

Previous Preterm Birth

8%

2%

3.0

13%

This is an easily identified high-risk population that could potentially be treated with progesterone or 17p during pregnancy

.

In a population with history of spontaneous preterm birth, weekly injections of 17p reduced preterm birth by 33% (

Petrini

2005) Depending on current 17p use, we could expect up to 4% decrease in prematurity if all these women received appropriate treatment. If other high risk women could be identified, progesterone/17p could have more impact.

Slide36

36

Black%

Ref%

diff

RR

PAR

Not Married-Yes

83.80%

5.57%

78.23%

1.4

25%

Teen Mom-Yes

17.40%

1.0

0%

High School or Less-Yes

58.35%

1.3

13%

Medicaid-Yes

68.98%

4.15%

64.83%

1.2

12%

WIC-Yes

72.34%

5.35%

66.99%

0.7

-28%

Plurality-Yes

3.63%

5.07%

-1.44%

5.3

14%

PPB-Yes

7.82%

2.47%

5.35%

3.0

13%

Birth spacing <18 months

36.46%

34.34%

2.13%

1.4

13%

Hypertension-Yes

13.93%

6.11%

7.82%

1.6

7%

Overwt

/Obese-Yes

63.59%

42.60%

20.99%

1.1

7%

Diabetes-Yes

5.66%

5.46%

0.20%

1.4

2%

Smoke any-Yes

16.44%

4.66%

11.78%

1.3

4%

No/late Prenatal Care-Yes

14.27%

3.27%

11.00%

1.1

2%

STD-Yes

11.92%

0.26%

11.66%

1.0

1%

Slide37

Group prenatal care and Centering evidence

Slide38

Centering Healthcare™: The EvidenceYale University randomized control trial

1,047 women in public clinics Randomized to traditional or group care

33% reduction in preterm birth for women in Centering groupsOther outcomesIncreased satisfaction

with care

Increased

breast-feeding rates, and

Improved knowledge

and readiness for birth and parentingUniversity of Kentucky Centering Pregnancy Smiles programReduction in preterm births from 13.7% to 6.6%Saved ~$2.1 million in 2 years

38

Slide39

Centering delivers results:Less likely to delivery prematurely: to deliver prematurely (9.8 vs. 13.8 percent).

More likely to receive adequate prenatal care: CenteringPregnancy participants were less likely than those enrolled in usual care to receive inadequate prenatal care (26.6 percent of program participants received inadequate care, compared with 33 percent of those getting usual care)

Higher satisfaction with prenatal care

39

Slide40

Centering delivers resultsIncreased use of postpartum family planningHale N,

Picklesimer AH, Billings DL, et al. The impact of Centering Pregnancy Group Prenatal Care on postpartum family planning. Am J Obstet

Gynecol 2014;210:50.e1-7.Utilization of postpartum family-planning services was higher among women participating in GPNC than among women receiving IPNC (29%

vs

20% at 12 months postpartum, p<.05)

Slide41

Home Visitation: The EvidenceProgram dependenthttp://

homvee.acf.hhs.gov/programs.aspxhttp://homvee.acf.hhs.gov/EvidenceOverview.aspx

41

Slide42

Home visiting delivers resultsEvery Child Succeeds (ECS), an established, regional home visiting program in southwest

Ohio from 2007 to 2010Healthy Families America model of home visiting; program

goals are to (1) improve pregnancy

outcomes through

nutrition education

and substance use reduction

,

(2) support parents in providing children with a safe, nurturing,and stimulating home environment, (3) optimize child health and development,(4) link families to health care and other services, and

(

5) promote

economic self-sufficiency

. for at-risk, first-time mothers.

42

Slide43

Home visiting delivers resultsPediatrics. 2013 Dosage

effect of prenatal home visiting on pregnancy outcomes in at-risk, first-time mothers.Goyal NK1

et. alEvaluated the effect of home visiting dosage on preterm birth … in women

in southwest

Ohio.

Home

visits are

provided by social workers, child development specialists, nurses, or paraprofessionalsResults: ≥8 completed visits by 26 weeks reduced odds of preterm birth by about 2/3 (compared with <3 visits)

43

Slide44

Cuyahoga County

(2006-2010)

44

From Underlying Cause of Death, 62% of the green pie slice is due to sleep related deaths;

(Black Cleveland 2008-2010)

SUID rate was 2.2, should be <.5

Slide45

Causes of Sleep-related death

45

Source: Rachel Moon’s CDC Grand Rounds Presentation October 2012

Slide46

Back to sleep for every sleep Use a firm sleep surface Room-sharing without bed-sharing is recommended Keep soft objects and loose bedding out of the crib

Pregnant women should receive regular prenatal care Avoid smoke exposure during pregnancy and after birth Avoid alcohol and illicit drug use during pregnancy and after birth

Breastfeeding is recommendedPacifier for sleep

Avoid overheating

46

Source: Rachel Moon’s CDC Grand Rounds Presentation October 2012

Based on good and consistent scientific

evidence

Slide47

Relevant national initiativesCribs for Kids>300 partners nationally

Provide low-cost portable cribs to organizations, who then provide them free or at cost to parents who cannot afford a cribABCsAlone, on your Back, in a Crib

Baltimore City Health Department and othersSafe to SleepNICHD-led

public awareness campaign

Expands

focus from back sleeping only to ALL of the components of a safe sleep environment (position, bedding,

bedsharing

, sleep surface, etc.)47


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