Preconception

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Preconception Early Prenatal Care Examining
Evidence Based Practice Strategies for KS MLC
Project

• Ginger Breedlove PhD, CNM, ARNP, FACNM
• Assistant Professor, KU School of Nursing
• Nurse Midwifery Education Program Director

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What is this all about?
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Improving lives of women children in Kansas

• Birth rates for 15-19 year olds 2005/2006
• 41.4/1,000 and 42.0/1,000 respectively
• Birth rate for unmarried women ages 15-44 at all
  time high in U.S. 50.6
• In Kansas rate is 35 (all races)
• Number and percentage of preterm births in Kansas
  in 2006
• 4,824 and11.8 respectively
• NVSR, Vol 57, (7), January 7, 2009

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Objectives

• Discuss Evidence Based Practice (EBP) Best
  Practice Models
• Describe exemplary models of PNC in U.S.
• Define access outcomes issues
• Explore challenges
• Enhance concept development

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Adequacy of Prenatal Care (PNC) in KS - 2007

• Kansas reported 39,055 live births met
  definition of PNC
• 77 received adequate or better
• 23 received less than adequate
• Of this subset 16 received Inadequate PNC
• Kansas counties with highest percentage of
  Inadequate Prenatal Care (IPNC)
• Scott, Seward, Hamilton, average 38
• Significant clustering of IPNC in lower southwest
  KS counties
• Southeastern counties rate of IPNC
• Cherokee 31
• Other surrounding counties range 9 28
• Jefferson Shawnee counties rate of IPNC were
  11 and 14 respectively
• Urban county with largest index of IPNC
  Wyandotte, 29
• KS APNC Utilization Index, 2007, CHES/KDHE
  publication, http//www.kdheks.gov/ches/

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IPNC Percentage to People (2007)

• Kansas overall rate was 6,351 pregnant women
• Jefferson Shawnee counties 360 women
• Lower 8 counties in Southeast KS 230 women
• Wyandotte county 748 women

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U.S. Trends in PNC
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PNC by Race/Origin in U.S.
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Young women in their teens are by far the most
likely to receive late or no prenatal care
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Providers of PNC in KS

• OB/GYNs
• Family Medicine
• ARNPs
• CNMs
• WHNPs
• FNPs
• Physician Assistants
• Professional (lay) midwives
• Indigenous midwives

• Is it just a provider shortage issue? Discussion

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Benefits of PNC

• Early and ongoing PNC can improve pregnancy
  outcomes by
• Assessing health risks
• Providing health care advice
• Assisting in supportive services
• Managing chronic and pregnancy-related health
  conditions
• NVSR, Vol 57, (7), January 7, 2009

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What is EBM/EBP?

• Evidence based medicine is a systematic approach
  to clinical problem solving which allows the
  integration of the best available research
  evidence with clinical expertise and patient
  values.
• (Sackett DL, Strauss SE, Richardson WS, et
  al. Evidence-based medicine how to practice and
  teach EBM. London Churchill-Livingstone, 2000)

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An example in KS

• Hunter Health Clinic, Wichita
• Comanzando Bien prenatal care program with focus
  on Spanish speaking pregnant women diagnosed with
  Gestational Diabetes
• Funded by the KS Chapter MOD and other agencies
• Other EBP examples in Kansas?

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Five Step Model of Evidence-Based Practice

• Convert information needs into answerable
  questions
• Track down with maximum efficiency the best
  evidence with which to answer them
• Critically appraise that evidence for its
  validity and usefulness for your desired outcome
• Apply the results of this appraisal to your
  practice/project
• Evaluate your performance

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Create your Question

• How would you describe a group of patients you
  are interested in OR a particular problem of
  interest?
• What are the most important characteristics of
  the population?
• This may include the primary topic, or
  co-existing conditions.
• Consider how gender, age, race, payer status,
  religion, SES or other variables influence the
  desired outcome.

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Determine an intervention, prognostic factor or
exposure

• Which main intervention is most relevant?
• What do you want to do for the patient? Improve
  access? Improve outcomes? Provide minimal
  services?
• What factors may influence the outcome?
• Co-existing problems?
• Is there an influencing exposure delaying care?
• Substance abuse, others

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Comparisons of Interest

• What is the main alternative to compare with the
  intervention?
• Are you trying to decide between two outcomes
• an outcome with no intervention vs. usual care
• or two pilot interventions
• or between multi-site outcomes
• Your clinical question does not always need a
  specific comparison.

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Outcomes

• What can you hope to accomplish, measure, improve
  or affect?
• What are you trying to do for the patient?
• Relieve
• Reduce
• Improve

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So a question might be

• In pregnant patients with no insurance, is
  access to care through coordinated, regionalized
  services among LPHDs effective in reducing the
  rate of late entry into prenatal care?
• See worksheet FSU College of Medicine Library
• Question building

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What are AMCHP Best Practice Models? (2004)

• AMCHP defines best practices" as a continuum of
  practices, programs and policies ranging from
  promising to evidence-based to science-based.
• A best practice could focus on the health of
  women, adolescents, young children, families, or
  children with special health care needs.
• It could address mental health, data and
  assessment, financing, program integration,
  workforce development, emergency preparedness,
  family involvement, or a public health issue.

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Resources for MCH Best Practices

• MCH national database are materials published in
  2000 or later that are program practices
  evaluated to be effective, or best practices, in
  a variety of topics, including community
  programs, women's health, infant health, and
  others.
• http//www.mchlibrary.info/action.lasso?-database
  Biblio-layoutWeb-response/databases/BibLists/b
  ib_effective.html-MaxRecordsall-DoScriptauto_s
  earch_effective-search
• Sakala, C. Corry, M. P. Evidence-based
  maternity care What it is and what it can
  achieve. New York, NY Milbank Memorial Fund,
  2008,128 pp.
• http//www.milbank.org/reports/0809MaternityCare/0
  809MaternityCare.html

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MCH Preconception and PregnancyKnowledge Path
(April 2008)

• Maternal and Child Health Library at Georgetown
  University
• It offers a selection of current, high-quality
  resources that analyze perinatal health
  statistics, describe effective prenatal care
  programs, and report on research aimed at
  improving access to and quality of prenatal care
  and improving perinatal health outcomes.
• A separate section lists consumer health
  resources.
• Includes section of resources on specific aspects
  of preconception and pregnancy childbirth,
  depression, drug and alcohol use, environmental
  concerns, fertility and infertility, nutrition,
  oral health, and tobacco use.
• http//www.mchlibrary.info/

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Searching the Academic Literature

• There are literally millions of published
  reports, journal articles, correspondence and
  studies available to clinicians.
• Choosing the best resource to search is an
  important decision.
• Large search engines will give you access to the
  primary literature.
• CINNAHL, PubMed, OVID, MEDLINE
• The Cochrane Library database provides access to
  systematic reviews which help summarize the
  results from a number of studies.

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How to do an effective search

• If you are not familiar with searching PubMed,
  you may want to use the PubMed tutorial at
  http//www.nlm.nih.gov/bsd/pubmed_tutorial/m1001.h
  tml
• If you are not familiar with searching MEDLINE in
  OVID, you may want to use the OVID tutorial at
  http//www.mclibrary.duke.edu/training/ovid
• You can even try GOOGLE SCHOLAR as a search
  engine

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EBP Tools Hierarchy of rigor
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Guideline Recommendation and Evidence Grading
(GREG)

• Evidence grade
• I (High) the described effect is plausible,
  precisely quantified and not vulnerable to bias
• II (Intermediate) the described effect is
  plausible but is not quantified precisely or may
  be vulnerable to bias
• III (Low) concerns about plausibility or
  vulnerability to bias severely limit the value of
  the effect being described and quantified
• Recommendation grade
• A (Recommendation) there is robust evidence to
  recommend a pattern of care
• B (Provisional recommendation) on balance of
  evidence, a pattern of care is recommended with
  caution
• C (Consensus opinion) evidence being inadequate,
  a pattern of care is recommended by consensus

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Common reporting terms

• Confidence Intervals are calculated on the
  results of the data to show the strength or
  weakness of the evidence.
• A 95 CI range means that if you were to repeat
  the same clinical trial a hundred times you can
  be 95 sure that the data would fall within the
  calculated range.
• Odds Ratio describes the odds of an experimental
  patient suffering an adverse event relative to a
  control patient.

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and Definitions

• p Value refers to the probability that any
  particular outcome would have arisen by chance.
• The smaller the p value the less likely the data
  was by chance.
• Standard scientific practice, usually deems a p
  value of less than 1 in 20 (expressed as p.05)
  as "statistically significant"
• The smaller the p value the higher the
  significance.
• A p value of p.01 (less than 1 in 100) is
  considered "statistically highly significant"
• Relative Risk is the risk of developing a disease
  in the exposed group divided by the risk of
  developing the disease in the unexposed group.

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Article on PNC

• Early Access to Prenatal Care Implications for
  Racial Disparity in Perinatal Mortality
• Sub-analysis from large prospective RCT examining
  first and second trimester risk of Downs and
  NTDs
• Conclusions Racial disparities exist in
  perinatal outcomes despite early access and entry
  to PNC
• Healy, Malone, Sullivan, et.al. (2006) Obstetrics
  Gynecology, 107 (3), 625-31.

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Exemplary Models of PNC

• What are the characteristics of PNC believed to
  be of value for providers and consumers?
• Discussion

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LA, California

• Developed a Comprehensive Perinatal Collaborative
  Program in LA County
• Integrated a referral for perinatal services into
  the 2-1-1 system and serve as a main referral
  agency for entry into PNC
• Promote risk appropriate perinatal care in early
  pregnancy and beyond for seamless integration of
  services
• Developed Speakers Bureau
• Preconception Care Marketing Tools
• Reproductive Life Plan Toolkit
• Pregnancy and Family Friendly Workplace Policies
  Brief

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Indiana Perinatal Network (IPN)

• Indiana Access
• A Community Based Research Training Project
  designed to improve access to services for
  low-income pregnant women and children.

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IPN Background

• In 2002, after competing with more than 70 cities
  throughout the nation, Indianapolis was one of
  four chosen to participate in a community-based
  research project, known nationally as Friendly
  Access, and locally as Indiana Access.
• This community-based research project is governed
  by the principle that the way in which people are
  treated plays a role in whether they access and
  continue to participate in primary and preventive
  health services, including prenatal care.
• Based on the Disney Model for Customer Service

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Indiana Access Key Findings

• Handout from Indiana Perinatal Network Consumer
  Survey
• How does that impact what we do and might need to
  change in Kansas?
• Discussion

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Arizona Perinatal Health Initiative on early PNC

• A crucial step to improving prenatal care
  utilization is the identification of pregnant
  women early in the pregnancy (i.e. before
  conception or within the first trimester).
• Outreach efforts are also crucial to assure that
  pregnant women receive consistent prenatal care.
• Identification and outreach activities work
  hand-in hand.
• For example, identifying high-risk pregnancies
  and providing outreach activities to assure
  consistent prenatal care utilization among
  high-risk pregnancies will result in better birth
  outcomes.

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Arizona activities increase early access to PNC

• Funded 15 high priority health departments.
• LCHDs provide activities including pregnancy
  testing, community education, clinical services,
  information and referral
• County develops goals depending on needs
  identified by community members, service
  providers, and medical community

• Interventions include
• CHWs
• Baby Arizona, a public/private partnership
• Public awareness campaign
• Focus on early and consistent PNC
• http//www.azdhs.gov/phs/owch/cpbg.htm

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Resources from a non-profit, Public/private
collaborative

• Additional models of exemplary MCH practice

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Center for Health Care Inc. (CHCS) Strategies

• Improving the quality and cost-effectiveness of
  publicly financed health care
• Nonprofit health policy resource center dedicated
  to improving the quality and cost effectiveness
  of health care services for low-income
  populations and people with chronic illnesses and
  disabilities.
• CHCS works directly with states and federal
  agencies, health plans, and providers to develop
  innovative programs that better serve people with
  complex and high-cost health care needs.

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CHCS Toward Improving Birth Outcomes A BCAP
Toolkit

• Toolkit provides a step-by-step, practical
  approach for improving birth outcomes among
  Medicaid and SCHIP enrollees.
• It includes a simple process improvement model to
  consistently follow including
• strategies for identification, stratification,
  outreach, and intervention, including case
  studies and communications tactics for creating
  change
• http//www.chcs.org/publications3960/publications_
  show.htm?doc_id212947

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Access

• What are some provider and service-related
  issues, barriers, and variables related to EARLY
  access to prenatal care?

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What about maternal characteristics?

• Marital Status
• For each maternal age group, unmarried status
  increase risk for LBW babies
• Father acknowledging his child early in
  pregnancy
• Adolescent Pregnancy
• Increased risk for PTB, LBW, and infants die in
  first 12 months
• Socioeconomic Status
• Increases risk suboptimal outcome, particularly
  with PTB
• Substance Abuse
• Virtually EVERY illicit recreational drug
  associated with adverse pregnancy outcomes
• Stress
• Amount of education
• Culture and Tradition
• Pregnancy Wantedness
• Interpregnancy Interval Highest Rate Late Entry
  PNC

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Association of Preconception Care and Early PNC

• 2006 Article by Liu and Li (China)
• How might incorporation of an annual
  preconception health care appointment impact
• Services
• Billing
• Staff
• Educational Resources
• Reduction of poor perinatal outcomes
• Earlier entry into PNC
• MOD Preconception Screening (See Tool)

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Trust for Americas Health Healthy Women,
Healthy Babies

• An ISSUE BRIEF, June 2008
• The leading document on improving outcomes
  through incorporation of universal preconception
  care
• ITS BEEN DONE A CERTAIN WAY FOR 40 YEARS.
  EVERY WOMAN IS SUPPOSE TO SEEK CARE DURING THE
  FIRST 3 MONTHS OF PREGNANCY. WHAT WE HAVE
  LEARNED IS THAT THIS IS GOOD -- BUT ITS NOT GOOD
  ENOUGH!
• Magda Peck ScD, CityMatch
• http//healthyamericans.org/reports/files/BirthOu
  tcomesLong0608.pdf

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Factors Influencing Outcomes!
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Outcome Measures Common Concerns

• Where do you find reliable measures?
• What is a comparable benchmark?
• How long should it take?
• What if I cant replicate the same interventions?
• It might cost more than the accessible funds
  available.
• The stakeholders might not be interested.
• We dont have enough human resources to conduct
  the project.

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Creating Process/Outcome Measures

• Seek usefulness, not perfection.
• Use small or repeated samples.
• Measure over specified time and over a wide range
  of conditions.
• Include quantitative and qualitative measures

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PNC Determinants Outcomes

• Goals of 90 percent have been set both for care
  beginning in the first trimester of pregnancy and
  for early and adequate prenatal care, as part of
  the Healthy People 2010 program.
• No goal has been set for reducing late or no
  prenatal care.

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Are outcomes just about Entry/Access of PNC?

• Preconception and Family Planning
• Scope of services
• Provider collaborative
• Awareness campaign
• Educational and supportive services
• Community engagement and business partners

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Challenges ahead
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Expecting Trouble The Myth of Prenatal Care in
America (2000)

• by Thomas Strong, MD, MFM University of Arizona
• What is ADEQUATE PNC?

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Obvious challenges

• Time
• Money
• Human and Nonhuman Resources
• Geographic Distance
• Required Partnerships
• Issue and Outcome Measures
• Provider types services
• Population demographics

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not so obvious challenges

• Leader/Follower styles
• Authority line
• Hidden Influencers
• Priority setting
• Commitment
• Consensus
• Collegiality
• Common end GOAL

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Comments from Rural KS

• I am from a small town in rural KS which has
  a huge population of people without insurance. I
  recently worked at a hospital where women
  frequently came in to labor with no prenatal care
  whatsoever. This was because they could not
  afford insurance. Some had no complications, but
  many had complications that could have been
  prevented. Many just needed medications and could
  not afford them. How can this be happening to
  women and babies in America? This is a HUGE
  problem that needs to be addressed and changed.
• Masters student in NRSG 835 Spring, 2009 online
  Primary Care of Women Course, KUMC/KUSON

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Next Steps

• State the problem or outcome and construct your
  clinical question(s)
• Determine the main interventions are you
  considering
• Reflect on Greatest Impact -- Percentages and
  People
• Investigate evidence based intervention, exposure
  or actions addressing your defined
  question/outcomes
• Implement and monitor your intervention
• Evaluate your outcomes
• Consider comparison data

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Discussion and Questions