IN CLEVELAND AND CUYAHOGA COUNTY Carol Gilbert MS Health Data Analyst CityMatCH 1 Your Programs MomsFirst Help Me Grow Lead Safe Creating Healthy Communities Produce Perks ID: 756355
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WHAT YOU DO TO PREVENT PRETERM BIRTHIN CLEVELAND AND CUYAHOGA COUNTY
Carol Gilbert, MS Health Data Analyst, CityMatCH
1Slide2
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
2Slide3
….And you know Cleveland and Cuyahoga countyNeighborhoodsHistoryValues
Traditions3Slide4
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
4Slide5
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
5Slide6
In Cuyahoga County, the Black infant mortality rate is 2.5 times the White rate (2006-2010)
6Slide7
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 healthSlide8
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
8Slide9
What’s different about the PPOR analytic approach?Four periods of risk
Uses fetal death dataUses a reference group
Tailored to every community
9Slide10
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
weightSlide11
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
14.3Slide12
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
12Slide13
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
deathsSlide14
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
”14Slide15
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
9.6Slide16
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
59Slide17
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 prematuritySlide18
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 beforeSlide19
Risk Factors for PrematuritySlide20
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)20Slide21
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.)
23Slide24
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)
24Slide25
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)
26Slide27
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)
27Slide28
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)
28Slide29
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)
29Slide30
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 predictiveSlide31
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
31Slide32
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 2006-2010Slide33
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 2006-2010Slide34
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 partsSlide35
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 evidenceSlide38
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 outcomes
Increased 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
38Slide39
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
39Slide40
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
41Slide42
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.
42Slide43
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)
43Slide44
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 <.5Slide45
Causes of Sleep-related death
45
Source: Rachel Moon’s CDC Grand Rounds Presentation October 2012Slide46
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
evidenceSlide47
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 Sleep
NICHD-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