Improving Pregnancy Outcomes through Community Engagement

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Improving Pregnancy Outcomes through Community
Engagement

• Meena Abraham, DrPH
• MedChi, The Maryland State Medical Society

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Historical Trends in Infant Mortality, Baltimore
City
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Infant Mortality as a Measure of Community
Well-being

• Infant Mortality
• Is a measure of economic development, healthcare
  systems, and access to care
• Is a measure of a societys ability to care for
  its most vulnerable populations
• Can be compared over time and across regions

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Partners

• Baltimore City Health Department
• Baltimore City Healthy Start, Inc.
• Maryland Chapter March of Dimes
• United Way of Central Maryland
• Family League of Baltimore City
• Center for Maternal and Child Health, Maryland
  State Health Department

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Resources

• Committed leadership State and Cityfunding,
  visible advocacy and support for efforts
• Expertiseinstitutions, highly trained clinical
  professionals, school of public health
• Community-based initiatives partnered with public
  and institutional efforts
• Medical Societyaccess to physician community,
  venue for advocacy

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Baltimore City Population

• Population Size632,680
• Racial Composition
• 67 African American
• 31 White
• 2 Other
• Poverty
• 24 live at or below poverty in Baltimore.
• 9 live at or below poverty in Maryland.

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Infant Mortality Rates by Race Baltimore City,
2001-2005
Source Md Vital Statistics Administration
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Initiative in Baltimore City

• BackgroundHigh rates fetal-infant mortality
• PurposeTo improve services to women at risk for
  a poor pregnancy outcome
• Tools for Assessment/MonitoringFIMR, PPOR
• Objectives
• To identify women at risk for fetal-infant
  mortality, poor pregnancy outcome
• To identify strategies for improving services,
  particularly to reach women at greatest risk

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PPOR Analysis

• What is the distribution of birth weight and
  mortality in our population?
• Are there differences within our population?
• What are the reasons for the disparity in birth
  outcomes?
• Who is at increased risk?

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PPOR Findings

• Greatest disparity is in maternal health/
  prematurity and maternal care
• Infant deaths lt1500 g and fetal deaths
• 90 of excess mortality is due to birthweight
  distribution.
• Only 10 to birthweight-specific mortality good
  systems for infant care.

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Multi-variate Analysis

• Outcome VLBW live births lt1500g
• Findings
• African American women 2.7 times risk
• Maternal age 30-39 lowest risk for whites but
  highest risk for African Americans
• Maternal education not significant for whites,
  lt12 yrs increased risk AA
• Parity first birth increased risk AA

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Multi-variate Analysis

• Prenatal Care none is high risk for all
• Medicaid no effect for whites, not enrolled and
  enrollment pending increased risk for AA
• Hypertension, multiple gestation, and other
  complications all precipitate preterm delivery
  and increase risk

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Fetal Infant Mortality Review

• Examines the How? and Why? from an individual
  poor pregnancy outcome to improve systems of care
• Activities
• Compiled case histories from birth and death
  certificates, medical records, other sources
• Conducted maternal interviews
• Reviewed cases and develop recommendations with a
  multi-disciplinary board
• Worked with partners/stakeholders to implement
  recommendations

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Characteristics of Women with Losses

• Majority African American, ages 20s and 30s
• Pregnancy Hx 21 first preg, 43 repeat loss,
  49 terminate
• Infections 23 STI, 46 perinatal infection
• Health Conditions 3 diabetes, 27 hypertension
• Complications 14 placental abruption, 32 PROM
• No prenatal care 13
• Multiple gestation pregnancy 10
• Substance use28 smoke, 10 alcohol, 25 drugs
  39 any
• Domestic violence9 (not routinely screened)

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Key Findings

• Women have multiple risk factors for poor
  pregnancy outcome.
• Women are not always aware of their risks or ways
  to reduce them.
• Providers and pregnant women are often not aware
  of support services and community resources.
• Opportunities exist to improve services and
  increase awareness of ways to reduce risks.

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Priority Areas for Action

• Care of Women Following a Perinatal Loss or VLBW
  Birth to prevent repeated poor outcomes
• Family Planning and Preconception/Inter-conception
  Care to plan/prepare for pregnancy
• Perinatal Infection repeated screening to
  identify new infection/re-infection
• Adequate and Early Utilization of Prenatal Care
  for improved management of risks to pregnancy

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Community Action Getting the Word Out

• Work with institutional and community-based
  stakeholders to
• Educate community members
• Educate providers serving members of the
  community at greatest riskAn effective
  community education strategy targets community
  members as well as the providers who serve them.
  The latter is especially powerful (and
  cost-effective) because providers serve a large
  number of community members over time.

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Provider Education

• Trainings were developed to
• Disseminate FIMR and PPOR findings.
• Increase awareness of factors contributing to
  poor pregnancy outcomes in communities at
  greatest risk.
• Educate providers of tools and resources to
  facilitate working with at-risk communities.

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Provider Education Activities

• Grand Rounds and Seminars Obstetric and
  Pediatric Clinicians in Baltimore City Hospitals
• MCH Trainings Nursing, Social Work, Case
  Management Staff from hospitals, Healthy Start,
  Maternal and Infant Nursing, and other home visit
  programs
• DSS Trainings Staff from Department of Social
  Services (Training adapted to incorporate key
  healthy pregnancy messages for their interactions
  with families.)

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Community Education Activity

• Healthy Pregnancy Community Fair
• Designed to raise awareness among Baltimore City
  residents living in high-risk communities of the
  factors associated with poor pregnancy outcomes
  and the steps they can take to prevent them.
• Incorporated interactive presentations and
  information booths to address the four priority
  areas.

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Community Education Materials

• Resources developed and distributed to providers
  to share with clients
• Report of program findings and recommendations
  (Shared Goals Partnering to Give Baltimores
  Babies the Best Start)
• Baltimore City Family Resource List
• Refrigerator Magnet with signs of risk during
  pregnancy

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Shared Learning for Community Action

• Work with stakeholders to identify priority areas
  and strategies to improve pregnancy outcomes.
• To promote collaboration with community resources
  and understanding of healthy pregnancy-related
  issues, findings need to be shared with
• Community Providers (Clinicians, case management
  staff, home visit staff, social workers).
• Community Members.

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Impact on Outreach and Case Management Services

• Incorporated FIMR, PPOR findings into strategic
  planning.
• Restructured services to target women with
  losses, VLBW to prevent repeat losses.
• Added in-home STD screening and family planning
  services.
• Developed protocol for hospitals to assess and
  refer women with poor outcome for
  inter-conception care.

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Making a Difference

• Review data to understand the what associated
  with poor outcomes.
• Work with stakeholders to understand the why
  and issues specific to community being served.
• Engage stakeholders to take action.
• Use all available resources.

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