Perinatal Programs: A Public Health Approach

1
Perinatal Programs A Public Health Approach

• November 19, 2007
• Virginia Commonwealth University
• Joan Corder-Mabe, RNC, M.S., WHNP
• Director, Division of Womens and Infants Health
• Virginia Department of Health

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Major Issues Regarding Maternal-Infant Health

• Infant Mortality
• Low Birth Weight
• Maternal Mortality
• Access to Care

3
Core Functions of Public Health

• Assessment
• Assurance
• Policy

4
Assessment

• Analysis of birth certificate data
• Fetal and Infant Mortality Review (FIMR)
• Child Fatality Review
• Pregnancy Risk Assessment Monitoring System
  (PRAMS)
• Maternal Death Review

5
Infant Mortality as a Measure of Health

• Infant death is a critical indicator of the
  health of the population. It reflects the overall
  state of maternal health as well as the quality
  and accessibility of primary health care
  available to pregnant women and infants. Despite
  steady declines in the 1980s and 1990s, the
  rate of infant mortality in the United States
  remains one of the highest in the industrialized
  world.
• Healthy People 2010 Report

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National and Virginia Infant Mortality Rates
1982-2005
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National and Virginia Infant Mortality by
Race1982-2005
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National and Virginia Infant Mortality Rates by
Race and Ethnicity1982-2005
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Trend in infant mortality over the last five years
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Virginia rates of infant mortality, preterm
births, and fetal deaths1982-2005
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Leading causes of infant death

• Prematurity/low weight birth
• Sudden Infant Death (SIDS)
• Birth defects
• Complications of pregnancy

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Neonatal Deaths
Early Infant Deaths (lt one day) All
Neonatal Deaths (0-27 days) Blacks 6.7
9.8 Whites 2.5 4.1 Other 1.4 2.3 Tota
l 3.3 5.1 Source 2005 Virginia
Center of Health Statistics
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Setting a Goal for Reduction of Infant Deaths

• Virginia is working toward the goal to reduce its
  infant death rate to 7.0 per thousand live births
  by 2008.
• This would surpass the Healthy People 2010 goal
  of reducing the infant mortality rate to 7.2 per
  thousand.
• In order to meet this goal, VDH needs to focus
  those populations with the highest risks,
  geographic areas and gestational periods with the
  highest number of deaths.

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Low Birth Weight Trend by Race1990-2005
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Low Birth Weight is associated with multiple
factors

• Medical Risk Factors
• - High parity
• - Chronic diseases
• - Previous Low Birth Weight infants
• - Genetic factors
• - Multiple gestation
• - Poor weight gain
• - Infection
• - Placental problems
• - Premature rupture of membranes
• - Fetal anomalies
• - Maternal stress

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Low Birth Weight (continued)

• Demographic Risk Factors
• - Age lt 17 years and gt 34 years
• - African-American race
• - Low socioeconomic status
• - Unmarried
• - Low education
• Behavioral Risk Factors
• - Smoking
• - Poor nutrition
• - Toxic exposure
• - Inadequate prenatal care
• - Substance abuse

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The etiology of preterm labor and premature birth
is unknown.
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Long-term effects of Low Birth Weight

• Neurologic disorders
• Learning disabilities
• Delayed development

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The populations at highest risk of infant deaths
and low birth weight

• African American
• Unmarried
• Low income
• Less than a high school education
• Enter prenatal care late or not at all
• Many smoke and have poor nutrition

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National Fetal-Infant Mortality Review (NFIMR)
Program

• Established in 1990
• Public-private partnership
• American College of Obstetricians and
  Gynecologists (ACOG)
• Maternal and Child Health Bureau
• March of Dimes Birth Defects Foundation

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FIMR is

• Community-based, action-oriented process
• Early warning system that describes health care
• Method of continuous quality improvement
• Means to implement core public health functions

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Objectives

• Initiate an interdisciplinary review of fetal and
  infant death from medical and social records and
  maternal interview.
• Describe significant social, economic, cultural
  and systems factors that contribute to mortality.
• Design and participate in implementing
  community-based interventions determined from
  review findings.

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Assessment (continued)

• Child Fatality Review
• PRAMS

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Maternal Mortality Has Not Changed Since 1982
Source Centers for Disease Control and
Prevention
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Maternal Mortality Rates,by Race of Mother 2000
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Reasons for reduction in maternal mortality

• Sulfa and antibiotic drugs
• Decrease infections secondary to illicit
  abortions
• Availability of banked blood
• Safer surgical procedures, including Cesarean

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The Year 2000 goal (3.3 maternal deaths per
100,000 live births) was not reached nationally
or in Virginia.
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The 3 leading causes of natural maternal death in
the United States and Virginia

• Hemorrhage, including ectopic pregnancy
• Pregnancy-Induced Hypertension
• Pulmonary Embolism

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Maternal Mortality Ratios
CDC Expanded Definition
2001 9 38 (21 natural)
2002 5 34 (13 natural)
2003 12 55 (32 natural)
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Components of maternal death reviews

• Investigation of individual maternal death
• Multidisciplinary discussion of each case
• Recommendations to prevent future deaths

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Team Purpose

• The Maternal Mortality Review Team reviews and
  analyzes maternal deaths in Virginia to develop
  an understanding of the causes of maternal death.
  We use the results to
• Educate colleagues and policymakers about these
  deaths and the need for changes in law and
  practice, and
• Recommend other improvements to reduce the number
  of preventable maternal deaths in Virginia.

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Public Health Approach to Infant Mortality
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Assurance

• Prevention Efforts
• Safety Net
• Setting Standards/Quality of Care

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Prevention
Preventing Unintended Pregnancy and Planning
Families Abstinence Education Teen Pregnancy
Prevention Girls Empowered to Make
Success Partners in Prevention Family
Planning Clinics
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Partners in Prevention Program (PIP)

• Targeting young men and women between the ages of
  20-29
• Increase knowledge regarding the risks of
  nonmarital birth
• Promote healthy attitudes and behaviors about
  marriage, family, and career

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Preconception

• Prevention of birth defects
• Treatment of chronic conditions
• Promotion of healthy lifestyles (smoking, alcohol)

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The improvement in infant mortality rates is not
an indicator that babies are healthier, but
medical technology is enabling sicker babies to
survive.
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Regionalization of perinatal care was successful
in the 1970s and 1980s by concentrating the
births of very low birth weight infants to the
tertiary centers.
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Regional Perinatal Councils (RPCs)

• Regional Perinatal Councils (RPCs) improve the
  infrastructure through which perinatal health is
  provided within the Commonwealth.
• Goals
• address problems of infant mortality and
  morbidity
• address access to prenatal care
• conduct perinatal outreach education for
  professionals

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Programs (continued)

• Car seat program
• Virginia Council on Folic Acid/VDH Campaign
• Fetal Alcohol Spectrum Disorders (FASD) Task Force

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Safety Net Providers

• Prenatal care in local health departments
• WIC in local health departments
• Community Health Centers

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Early and regular use of prenatal care is a
strong predictor of positive pregnancy outcomes.
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Early prenatal care is an indicator for access to
health care services.
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Resource Mothers Program

• Lay home visitors who mentor pregnant teenagers
• Decrease infant mortality and low weight births
• 25 contractors enrolling approximately 1100 newly
  pregnant teens per year in 88 Virginia localities
• Early and regular prenatal care, increased
  healthy behaviors, delay of repeat pregnancy,
  enrollment in school or employment, and creation
  of a stable home environment
• Staff aim to motivate program participants to
  stop smoking

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Loving Steps/Virginia Healthy Start Program

• Goal of reducing infant deaths and improving
  birth outcomes through early intervention
• Case management and health education
• Registered nurses provide medical nursing care
• Registered dietitians provide medical nutrition
  therapy services
• Resource Mothers (Community Health Workers)
• FIMR

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Newborn Screening

• Coordinated and comprehensive system consisting
  of education, blood screening tests, follow-up
  and referrals, diagnosis, medical and dietary
  management, and treatment
• Effective March, 2006, Virginia screens for 28
  disorders
• Since March 1, 2006, 8 infants have been
  identified with life-threatening rare disorders
  which would not have been identified before the
  expansion.

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Setting Standards/Quality of Care

• Neonatal Regulations
• Screening for domestic violence, perinatal
  substance use, and perinatal depression
• Web-based training on Bright Futures and
  Perinatal Depression
• Provision of culturally competent care

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Policy and Planning

• Implementation of Codes Regarding Perinatal
  Substance Use
• 54.1-2403.1 of the Code of Virginia Substance Use
  Screening in Prenatal Care
• 63.2-1509 of the Code of Virginia Physician
  referral of Substance Exposed Newborns
• 32.1-127 of the Code of Virginia Hospital
  Discharge Planning for Substance using Postpartum
  Women
• 32.1-134.01 of the Code of Virginia Discharge
  Education on Postpartum Blues, Perinatal
  Depression, Shaken Baby Syndrome
• Interagency Substance Exposed Newborn Workgroup
  (DMHMRSAS, DSS, DCJ)
• Analysis of proposed legislation
• Supports Governors task forces and commissions

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Governors Commission on Healthcare Reform

• Infant mortality
• Obesity
• Smoking

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Conclusion

• Studies of underlying factors that contribute to
  morbidity and mortality are needed
• Review of quality of health care and access to
  care for all women and infants is needed
• Racial/ethnic disparities need to be eliminated
• Research to determine effective public health
  programs to make a difference