Preconception Health

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Preconception Health Were All in This Together
Womens Health Birth Risk Factors are a Major
Public Health Issue in Okanogan County
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Why Preconception Health Matters to Okanogan
County
Families In Poverty
Educational Attainment
Washington State Office of Financial Management
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Why Preconception Health Matters to Okanogan
County
Okanogan Co. Ranks 5th Overall in the of the
Population Receiving DSHS Services
Okanogan County State Ranks 7th in Food
Assistance 3rd in General Assistance 4th in
Medical Assistance 58 of Children live in High
Poverty neighborhoods 70 of births are
Medicaid
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Birth Risk Factors
Okanogan County Washington States Poster Child
for Birth Risk Factors
Economics of Preterm Births
PreTerm Births by County 2001-2006

• During the 10 yr period 1996-2005, 12 of the
  births in Okanogan County were premature, the 2nd
  highest rate in the state. During the period
  2000-2005 were and average of 68.6 premature
  births per year. Costs for premature births are
  approximately 10X greater than for normal term
  births
• A 2006 report published by the Institute for
  Medicine In 2005, preterm birth cost the United
  States at least 26.2 billion, or 51,600 for
  every infant born preterm.
• 16.9 billion (65) for medical care
• 1.9 billion (7) for delivery
• 0.7 billion (2) for early intervention
• 1.1 billion (4) for special education
• 5.7 billion (22) for lost productivity
• Using this data the costs of prematurity in
  Okanogan County are estimated at over
  3.54million per year.

Ferry 14.3 Asotin 13.7 Okanogan 13.1 Lincoln
13.1 Yakima 12.6
CDC estimates additional cost of 51,000 per pre
term over term delivery costs
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Birth Risk Factors
Birth Risk Factors in Okanogan County 2001-2005
Chlamydial infection 3rd Highest in
Washington Unmarried Moms 4th Highest
Adolescent Pregnancy 11th Highest Child
Mortality 10th Highest Low Birth
Weight 3rd Highest C sections 1st-2nd
Highest Preterm Delivery 2nd Highest
There were 529 births in Okanogan County during
2005 68 births were premature 34 births were
low birth weight babies 74 births were to moms
who smoked during pregnancy 21 births were to
moms less than 18 yrs old 259 births were to
unmarried moms 100 Births received inadequate
prenatal care CDC estimates additional cost of
51K per pre term over term delivery costs
68 pre-term births x 51,000 3.5 million
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Birth Risk Factors
Potential Factors Influencing PreTerm
Births Data is not case by case VARIABLE F
Value P Value CHLAMYDIA 17.34
.002 NOPRENATAL CARE 4.36 .066
LT25WGTG LIN 2.05 .186 SINGLEMOTHER
7.51 .023 SMOKE WHILE PG 9
6.4E-04 .980 LESS THAN 18YRS 6.36
.033 OF C-SECTIONS 10.07 .011
Chlamydia infection, Single mothers, age less
than 18yrs and C sections appear to be
significant factors associated with premature
birth
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STD Rates
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STD Rates
STD Rates 2001-2006 by COUNTY
Yakima 392 Pierce 362 Okanogan 315
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STD Rates
Rural Peers represent Adams, Columbia, Garfield,
Jefferson, Klickitat, Lincoln, Pacific, Wahkiakum
counties.
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STD Rates
Highest Rates Shortly After Leaving School
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STD Rates
Okanogan County STD cases by City 1999-2007, All
cases 896 Location Cases Percent Ave Annual
Rate Omak 351 39.2 523/100,000 Okanogan 144 16
.1 278 Brewster 138 15.4 412 Tonasket
91 10.2 179 Oroville 51 5.7 143 Nespelem
46 5.1 na Methow Valley 39 4.4
73 Coulee Dam 28 3.1 74 Pateros 7
0.8 108 STDS are the total number of cases, all
age groups listing an Okanogan County zip code
address. Okanogan represents Okanogan, Mallot,
Methow represents Twisp, Winthrop, Mazama
CarltonCoulee Dam Represents Electric City,
Elmer City, Coulee Dam No population data for
Nespelem was available Ave Annual Rate Average
number of cases/yr divided by zip code population
x 100,000
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Birth Risk Factors
Consequences of Chlamydia Pelvic Inflammatory
Disease
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Birth Risk Factors
Hospitalization for Urogenital Conditions
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Birth Risk Factors
1990 34.2 200548.9
Over the 10yr period form 1996-2005 Okanogan
County had the 4th highest rate of births to
unmarried mothers. During 1996-2005 here were
2160 births to unmarried moms in Okanogan County
out of 5139 births. A study by the Washington
State DOH Center for Health Statistics indicates
that unmarried moms are 1) more likely to smoke
during pregnancy2) more likely to have low birth
weight babies, 3) less likely to have a high
school education 4) receive later prenatal care
than married mothers.
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Birth Risk Factors
In 2006 Okanogan County Ranked 5th Highest in
Births to Moms lt20 and 7th Highest to In Births
to Moms lt 18 years of age
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Birth Risk Factors
31 births
27 Births
27 Births
21 Births
20 Births
17 Births
16 Births
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C-sections in Washington US first time, full
term, singleton, vertex presentation
Birth Risk Factors
C-section costs 5000 more than vaginal delivery
Healthy People 2010 goal
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Birth Risk Factors
Type of Delivery In Okanogan County
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spatial scan statistichigh primary c-section
regions
Birth Risk Factors
21 more c-section per year than expected
Excludes multiple births
2002-2004 for WA, OR military
Research Division Center for Health Statistics
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spatial scan statistichigh primary c-section
regions
Birth Risk Factors
Excluding any cases with hypertension, diabetes,
obesity or breech presentation
266 more c-section per year than expected
14 more c-section per year than expected
Excludes multiple births
2002-2004 for WA, OR military
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Birth Risk Factors
Okanogan County Has Higher Preterm Birth Rates
than our Rural Peers
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Long Term Effects of Preterm Birth are a Major
Factor in Educational Attainment for both Mother
and Child

• 80 increased rate of ADHD
• 20 risk of Significant Behavior problems at age
  8 yrs
• More likely to be diagnosed with developmental
  delay
• More likely to be referred for special needs in
  preschool
• More likely to have problems with school
  readiness
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  Twice as likely to die of SIDS
• Low Birth weight related to Diabetes issues
• Low Birth weight related to Coronary Artery
  Disease

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Birth Risk Factors
Hospitalization Rates for Perinatal Conditions
209 of State Rate
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For the period 2001-2005, Okanogan County had the
5th highest rate of Hospitalizations due to
Pregnancy Complications in Washington State.
Okanogan Countys rate was 977/100,000 compared
to 556/100,000 for the State of Washington.
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Additional Birth Risk Factors
Pregnancy Weight Issues
4.41 Underweight 57 overweight to obese
36 of Moms Exhibited less than adequate Weight
Gain (lt25lbs) during pregnancy 10th highest
rate in the State
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Additional Birth Risk Factors
Smoking while Pregnant Smoking rate declined for
both Okanogan County and Washington State over
the period of 1990-2000. After 2000 Okanogan
County rates appeared to increase and exceed the
state rate.
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Additional Birth Risk Factors
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Other Womens Health Issues
ACCESS TO HEALTHCARE
Access to Healthcare is a significant issue in
Okanogan County. Okanogan County ranks
significantly below State and National levels in
most measures of Healthcare Access. Of Okanogan
County residents 32 lack health care insurance
compared to 17 for the State. The 2006 BRFSS
data indicates that 14 of Okanogan County
residents could not see a Healthcare Provider due
to Cost. Okanogan County Ranks Last with
Respect to Breast Cancer Screening
Okanogan Co. Washington State Breast Cancer
screening 68 79 Adult Healthcare
Insurance 68 83 Adults with Personal
Healthcare Provider 71 78 Adults with Unmet
Medical Need 17 13 Ranked lowest in
Washington State 2nd Lowest in Washington
State Developed from 2006 BRFSS data for
Okanogan County N 527 The low rates of
screening or preventative measures is troubling
in light of hospitalization and mortality rates
for Okanogan County during the period
2001-2005. During that 5 yr period there were
175 cases, 74 hospitalizations and 41 deaths due
to Breast cancer. Cases Hospitalization
Mortality State Hosp. Rate .
Rate Rate Breast Cancer
175 74 63.4 41 35.0
41.0
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Our Public Health Goal is not just getting kids
through high school without a pregnancy or a STD
but preparing members of our communities to
attain healthy, successful lives and families.
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Partners in this Effort
Special Features
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Conflicts in Public Health Dogma Those
beliefs held as established or put forth as an
authoritative or expert opinion, often contained
in a secondary or tertiary source, but that have
little or no supportive empirical evidence from
primary sources. Medical dogma is usually derived
from unevaluated biological hypotheses and
uncritical observation or experience without
recognition of the effects of chance, natural
biological variation, and observer bias. An
unknown but significant portion of medical
practice falls into this category. Repetition
across secondary and tertiary sources or the
number of people, whatever their qualifications,
that hold this belief does not change the status
of such information. Belief The mental act or
state of mind of an individual after they accept
and internalize an external concept or idea,
which then becomes part of further thought
processes, often unrecognized, on related issues.
Internalized deeply, belief becomes part of
intuition. Belief can occur after deliberate,
systematic, critical thinking or can occur with
immediate, non-reasoned, uncritical acceptance.
Once a belief is accepted that is in error,
accepting a more correct belief becomes
considerably more difficult than if no previous
belief were held. Evidence-based
(population-based) medicine (EBM) "An approach
to practice in which the clinician is aware of
the evidence in support of their clinical
practice and the strength of that evidence"
(McMaster). EBM is the use of systematic
observation of the clinical patient and the rules
for empirical evidence to critically appraise and
interpret information from clinical research
(causation, prognosis, diagnostic tests, and
treatment strategies) to apply to that individual
patient. The goal of EBM is to increase the
likelihood of a better clinical outcome for an
individual patient because of making better
clinical decisions and doing so in a more
efficient, cost-effective manner. EBM goes beyond
the traditional focus on reasoning based on
microbiology, pathophysiology, and pharmacology,
beyond the traditional reliance on authority or
expert opinion (dogma) and beyond the traditional
use of uncritically and unsystematically
evaluated clinical experience (JAMA 2682420-2425
(1992), BMJ 3101122-1126 (1995), J Royal Soc Med
88620-624(1995)).
How do we make public health evidence based ?
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ALTERNATIVES ?
Other models for community health? Other funding
streams for public health?
If you put forth a hypothesis, you have a moral
obligation to test that hypothesis Bruce
Glick
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Production or Herd Health Models
Economic Losses
http//www.vetmed.wsu.edu/courses-jmgay/EpiMod2.ht
m
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Conflicts in Public Health
Financial A public health action may be have
both health and economic benefits but we lack the
financial resources to carry out that action.
Dogmatic Blockage Comprehensive Sex ED
HPV information Policy Issues The
health benefit to the community vs. the right of
the individual. Seat Belts Vaccinations Tobacco
Helmets Fluoridation IS THE CURRENT MODEL OF
PUBLIC HEALTH WORTH THE HASSLE? SHOULD WE THROW
THE BATH WATER OUT? THERE ARE OTHER MODELS OF
POPULATION EVIDENCE BASED MEDICINE
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HACCP PRINCIPLES HACCP is a systematic approach
to the identification, evaluation, and control of
food safety hazards based on the following seven
principles Principle 1 Conduct a hazard
analysis. Principle 2 Determine the critical
control points (CCPs). Principle 3 Establish
critical limits. Principle 4 Establish
monitoring procedures. Principle 5 Establish
corrective actions. Principle 6 Establish
verification procedures. Principle 7 Establish
record-keeping and documentation procedures.
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A Critical Control Point ?The adolescent stage
of development represents a window of opportunity
for positive as well as negative influences and
choices with life long consequences.
Healthy Kids -gt Healthy Adults - gtHealthy
Communities
Maxine Hayes, MD, MPH State Health
Officer September 2, 2008
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Preconception Health

• All women and men of childbearing age have a high
  awareness of risk factors related to childbearing
• All women have a reproductive life plan
• All pregnancies are intended and planned
• All women of childbearing age have health-care
  coverage
• All women screened prior to pregnancy for risk
  outcomes
• Women with previous high risk pregnancy outcomes
  have access to inter-conception care aimed at
  reducing risk

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PRECONCEPTION HEALTHCARE
Individual responsibility across the life
span Encourage each woman and every couple to
have a reproductive life plan. Consumer
awareness Using information and tools appropriate
across varying age, literacy, health
literacy, and cultural/linguistic contexts,
increase public awareness of the importance of
preconception health behaviors and increase
individuals use of preconception care
services. Preventive visits As part of primary
care visits, provide risk assessment and
counseling to all women of childbearing age to
reduce risks related to pregnancy
outcomes. Interventions for identified
risks Increase the proportion of women who
receive interventions as follow-up to
preconception risk screening, focusing on
high-priority interventions. Inter-conception
care Use the inter-conception period to provide
intensive interventions to women who have had a
prior pregnancy ending in adverse outcome (e.g.,
infant death, low birth weight or preterm birth).