BUILDING HEALTH EQUITY: CREATING CHANGE FOR

IMPROVED MATERNAL AND BIRTH OUTCOMES

Kweli Rashied-Henry Nicole Wong

Director, Health Equity Manager, Supportive

Pregnancy Care

Fiorella Horna & Danielle Little

NC Preconception Health Campaign

MARCH OF DIMES NORTH CAROLINA PRECONCEPTION HEALTH CAMPAIGN

• A statewide initiative aimed at improving birth outcomes in NC by reaching out

to women with important health messages before they become pregnant

• Goals of the Campaign are to reduce infant mortality, birth defects, premature

birth, and chronic health conditions in women, while also aiming to increase

intended pregnancies in NC

• Seeks to raise awareness and inspire positive action among the general

public, health care professionals, and community agencies

• Formerly functioned as the NC Folic Acid Campaign

This training was developed by the March of Dimes North Carolina

Preconception Health Campaign, under a contract and in collaboration with

the North Carolina Division of Public Health, Women’s Health Branch.

Wake AHEC for their support in providing continuing education credit for

this webinar

ACKNOWLEDGEMENTS

The presenters have no relationship with commercial companies that

could be perceived as a conflict of interest.

Nicole Wong, as Manager, Supportive Pregnancy Care of the March of

Dimes has received grant funding from United Healthcare, State of

Tennessee, AMAG Pharmaceuticals, Cigna and Health New England to

design and implement Supportive Pregnancy Care across the country

DISCLOSURES

Obtaining continuing education certification:

▪ If attending as a group, everyone must sign-in the Wake

AHEC Roster and email it TODAY to:

shismithgeorge@wakeahec.org

▪ Must be present 100% of the training

▪ Complete Survey up on receipt

Questions

HOUSEKEEPING

Nursing: 1.5 Contact Hours

Wake AHEC, Nursing Education, is an approved provider of Continuing nursing education by the North Carolina

Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on

Accreditation.

Wake AHEC CEU: Wake AHEC will provide 0.2 CEU to participants upon completion of this activity.

National Association of Social Workers (NASW)

NC AHEC is a 2018 NASW-NC approved provider of distance continuing education. This program has been

approved for 1.5 contact hours

A participant must attend 100% of the webinar to receive credit. Partial session credit will not be awarded.

Contact Hours: Wake AHEC will provide up to 1.5 Contact Hours to participants.

Wake AHEC is part of the North Carolina AHEC Program.

CREDITS

OBJECTIVES

Utilize data from the March of Dimes Prematurity Report Card to identify inequities among marginalized communities and recognize the relationship between the Social Determinant of Health and Maternal Health outcomes

Discuss Supportive Pregnancy Care as an evidence-based, client-centered, culturally-responsive intervention to prevent preterm birth and maternal mortality

Consider incorporating these approaches and the NC MOD Preconception Health Circle of Care approach in their practice when counseling on reproductive life planning to promote early, effective, and continual care

SOCIAL DETERMINANTS OF HEALTH AND MATERNAL HEALTH OUTCOMES

North Carolina Preconception Health Campaign Webinar Series (2018-19)

January 16, 2018

DATA

UNITED STATES

9.9%

PRETERM BIRTH RATE

C

GRADE

Premature birth and its complications are the largest contributors to infant death in the U.S., and a major cause of long-term health problems in children who survive. March of Dimes aims to

reduce preterm birth rates and increase equity, and monitors progress through Premature Birth Report Cards. Report Card grades are assigned by comparing the 2017 preterm birth rate in a

state or locality to March of Dimes’ goal of 8.1 percent by 2020. Report Cards provide county and race/ethnicity data to highlight the importance of addressing equity in areas and populations

with elevated risk of prematurity. March of Dimes is working to expand solutions to help all mothers and babies have healthy, full-term births.

Pe

rce

nta

ge

of

live

bir

ths

tha

t a

re p

rete

rm

2007 2017

10.4 10.4 10.1 10.0 9.8 9.8 9.6 9.6 9.6 9.8 9.9

Preterm is less than 37 weeks gestation based on obstetric estimate.

Source: National Center for Health Statistics, 2007-2017 natality data

2018 PREMATURE BIRTH REPORT CARD

MARCHOFDIMES.ORG/REPORTCARD

RACE & ETHNICITY IN UNITED STATES

In United States, the preterm birth rate

among black women is 49% higher than the rate among all other women.

13.4

10.8

9.2

8.9

8.6

0 2 4 6 8 10 12 14

Percentage of live births in 2014-2016 (average) born preterm

Ra

ce

/Eth

nic

ity

Asian/Pacific Islander

White

Hispanic

American Indian/Alaska Native

Black

Preterm is less than 37 weeks gestation based on obstetric estimate.

Race categories include only women of non-Hispanic ethnicity.

Source: National Center for Health Statistics, 2014-2016 natality data

2018 PREMATURE BIRTH REPORT CARD

MARCHOFDIMES.ORG/REPORTCARD

Hispanic

RACE & ETHNICITY DISPARITY BY STATE The March of Dimes disparity ratio measures and tracks progress towards the elimination of racial/ethnic disparities in preterm birth. It is based on

Healthy People 2020 methodology and compares the group with the lowest preterm birth rate to the average for all other groups. Progress is evaluated by comparing the current disparity ratio to a baseline disparity ratio. A lower disparity ratio is better, with a disparity ratio of 1 indicating no

disparity.

Gestational age is based on obstetric estimate.

Race categories include only women of non-Hispanic ethnicity.

Source: National Center for Health Statistics, 2014-2016 natality data

2018 PREMATURE BIRTH REPORT CARD

MARCHOFDIMES.ORG/REPORTCARD

U.S. DISPARITY RATIO

1.24The U.S. disparity ratio has

Worsenedfrom baseline

Highest disparity

Disparity rationot available

Lowest disparity

LEVEL OF OVERALLDISPARITY

Health equity means that

everyone has

a fair and just

opportunity to be

as healthy as

possible

Disparities are

costly in so

many ways for

our

communities,

our states, our

nation.

Achieving equity

is essential to

improving the

health of all

moms and

babies.

2018 PREMATURE BIRTH REPORT CARD

MARCHOFDIMES.ORG/REPORTCARD

NOT A “THOSE PEOPLE” PROBLEM, BUT AN “US” PROBLEM

16

17

Pregnancy-related mortality ratio is the number of pregnancy-related deaths per 100,000 live births. A pregnancy-related death is the death of a woman during pregnancy or within

one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of

pregnancy. Source: CDC, 1987-2013 (https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html)

Prepared by March of Dimes Perinatal Data Center, March, 2018.

TREND IN MATERNAL MORTALITY

Pregnancy-related death has more than doubled over the past 25 years.

DISPARITIES IN MATERNAL DEATH

Pregnancy-related mortality ratio is the number of pregnancy-related deaths per 100,000 live births. A pregnancy-related death is the death of a woman during pregnancy or within

one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of

pregnancy. Source: CDC, 2011-2013 (https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html)

Prepared by March of Dimes Perinatal Data Center, February 2018.

20#BlanketChange#BlanketChange

DISPARITIES IN PRECONCEPTION

HEALTH INDICATORS, BRFSS 2013-15

21

TABLE 1. Prevalence of preconception health indicators among nonpregnant reproductive-aged women (18–44 years), by age group, race/ethnicity, and insurance — Behavioral Risk Factor Surveillance System, United States, 2013–2015*

Characteristic Depression†

(2014–2015)Diabetes†§

(2014–2015)Hypertension†§¶

(2013, 2015)Current cigarette

smoking**(2014–2015)

Normal weight††

(2014–2015)Recommended

physical activity¶§§

(2013, 2015)

% (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)

Race/Ethnicity¶¶

White 27.0 (26.5–27.6) 2.6 (2.4–2.8) 10.2 (9.8–10.5) 21.1 (20.6–21.6) 49.0 (48.3–49.6) 53.8 (53.2–54.4)

Black 16.2 (15.1–17.2) 4.5 (4.0–5.1) 18.3 (17.3–19.3) 15.6 (14.5–16.7) 30.0 (28.6–31.5) 42.8 (41.3–44.3)

Hispanic 15.5 (14.6–16.4) 3.6 (3.2–4.1) 9.5 (8.7–10.3) 8.9 (8.2–9.6) 37.2 (35.9–38.6) 46.0 (44.6–47.4)

Other 14.8 (13.6–16.1) 2.4 (1.9–2.8) 8.0 (7.1–9.0) 11.3 (10.3–12.4) 57.6 (55.6–59.6) 50.3 (48.2–52.4)

Reference: Robbins C, Boulet SL, Morgan I, et al. Disparities in Preconception Health Indicators —Behavioral Risk Factor Surveillance System, 2013–2015, and Pregnancy Risk Assessment Monitoring System, 2013–2014. MMWR Surveill

Summ 2018;67(No. SS-01):1–16. DOI: http://dx.doi.org/10.15585/mmwr.ss6701a1

SOCIAL AND STRUCTURAL DETERMINANTS

• Social, behavioral and

environmental factors account for

60% of poor health and early death.

• Behavioral factors are largely

influenced by policy, systems and

environmental change.

THERE ARE MANY DETERMINANTS OF HEALTH

Schroeder, New England Journal of Medicine, 2007 23

Genetic predisposition

, 30%

Social circumstance

s, 15%

Behavioral patterns, 40%

Environmental exposure, 5%

Health care, 10%

“The social determinants of health are the contexts of our lives… the determinants of health which are outside of… individual behaviors and beyond individual genetic endowment.”

Jones et al, 2009

SOCIAL DETERMINANTS OF HEALTH

SURVEY OF PHYSICIAN ATTITUDES ON SOCIAL DETERMINANTS (SOCIAL NEEDS)

25

SOCIAL DETERMINANTS OF HEALTH can explain INEQUITY and undermineEQUITY

According to Collins (2011), a lifetime residence in a high-income neighborhood resulted in higher risk of preterm birth among African American women, in comparison to white women, even after controlling for age, prenatal care, education and smoking.

26

RACIAL DISCRIMINATION can contribute to HIGHER RATES of preterm birth and chronic disease

• Chronic everyday discrimination has been associated with giving birth to a low birthweight infant (Williams & Mohammed, 2013).

• Everyday and lifetime racism are associated with a woman’s increased risk for developing type 2 diabetes (Bacon et al, 2017).

• Diabetes, a major chronic disease that contributes to poor maternal health is related to pregnancy-related death.

• Chronic stress of lifelong minority status in a society characterized by historical and enduring racism is hypothesized to be an underlying social determinant of racial disparities in adverse birth and maternal health outcomes.

SOLUTIONS

FROM THE VOICES OF BLACK WOMEN

➢ Greater attention to birth plans

➢ Better communication among multiple healthcare

providers

➢ More careful listening to patients during clinical

encounters

➢ Increased support for social programs

29

Reference: Setting the Standard for Holistic Care of and forBlack Women, Black Mamas Matter Aliiance, Black Papger, April 2018, Accessed: http://blackmamasmatter.org/wp-

content/uploads/2018/04/BMMA_BlackPaper_April-2018.pdf

McLemore MR, Altman MR, Cooper N, Williams S, Rand L, and Franck L. Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth. Soc Sci Med. 2018;201:127-135

ACOG COMMITTEE OPINION:SOCIAL DETERMINANTS OF HEALTH

Key practices to address the social determinants of health:

➢ Hire multilingual staff

➢ Provide adequate interpreter services

➢ Engage in medical-legal partnerships

➢ Linkages with community resources

30

Potential Health Equity Solutions

• Community Partnerships / Community Engagement

• Addressing the Social Determinants of Health

• Addressing Racism

• Health in All Policies

• Diversity in Leadership

NATIONAL PREMATURITY COLLABORATIVE

PREMATURITY COLLABORATIVE

GOAL: To achieve equity and

demonstrated improvements in

preterm birth

PURPOSE: To engage diverse

organizations, drawing on their unique

expertise problem solve together

using collective action, shared strategy

and metrics.

35

GOAL: Establish key equity terms and concepts for all Collaborative members to use to guide their work

Subgroup of Health Equity workgroup convened to discuss structure, content and format of document.

Document builds on 2017 Robert Wood Johnson Foundation report, “What is Health Equity?”

GUIDING

PRINCIPLESMARCHOFDIMES.ORG/COLLABORATIVE

CONSENSUS STATEMENT

GOAL: Share the value and contributions of the social sciences to understanding and potential solving the problem of birth inequities.

Document includes:

1. Core values

2. Call to Action

Sign-on at:

marchofdimes.org/collaborative

NEW! SDOHSCREENING TOOL

GOAL: Joint workgroup activity with Collaborative Clinical and Public Health Workgroup to provide resource to health professionals on screening and referrals for the social and structural determinants of health

Director of Health Equity

(919) 424-2158

krashied-henry@marchofdimes.org

To join the Prematurity Campaign Collaborative visit marchofdimes.org/collaborative

Kweli Rashied-Henry, MPH

SUPPORTIVE PREGNANCYCARE

Building Health Equity

January 16, 2019

WHAT CAN WE DO TO ACHIEVE EQUITY AND IMPROVE THE HEALTH OF MOMS AND BABIES?

Accelerate the expansion

of group prenatal care,

particularly

Supportive

Pregnancy Care

GROUPPRENATAL CARE…

• Reduces premature birth

▪ 41% reduction among Black women

▪ 33% reduction among participants of all

races/ethnicities

• Improves psychological outcomes like readiness for labor

and delivery

• Empowers women and increases their satisfaction with

their health care

• Increases breastfeeding

• Reduces health care costs by avoiding NICU admissions

• Improves health care provider satisfaction

Multisite randomized controlled trial

Atlanta, GA (n=546) and New Haven, CT (n= 503)

Young women ages 14-25 years presenting for prenatal care

653 participated in group prenatal care (intervention)

394 participated in individual care (control)

Ickovics et al, Obs & Gyn 2007;110:330-339.

Qualitative research – interviews with women and providers

Carried out in Calgary, Alberta, Canada

Group prenatal care was implemented to address high rates of adverse perinatal outcomes in certain regions of the city

WHAT IS GROUP PRENATAL CARE?

• Medical care + prenatal education, childbirth

preparation, and postpartum care

education…in a GROUP!

• Group size 8-12 women

• About ten 90-120 minute sessions during a

typical pregnancy, monthly or bimonthly

• Two facilitators

1. Physician, midwife, or nurse practitioner

2. Other health care professional

50

Over $13 million—including funding from the

Anthem Foundation—over more than a decade to

support the start-up of the CenteringPregnancy

model nationwide

Funding from UnitedHealth Group to develop an

additional group prenatal care model, March of

Dimes Supportive Pregnancy Care

Leading efforts to get Medicaid and other

insurance to pay a higher fee for group prenatal

care

MARCH OF DIMES INVESTMENT IN GROUP PRENATAL CARE

SUPPORTIVEPREGNANCY CARE

CONCEPTUAL FRAMEWORK

Fosters

By addressing

And is an

approach that isIs flexible

LOGISTICAL FRAMEWORK OF A SESSION

PROGRAM

PRODUCTS &

SERVICES

• Implementation and Session Guides

• On-site training

• Becoming a Mom/Comenzando bien

curriculum and handouts

• Bilingual My 9 Months patient magazine

• Patient recruitment materials

• Technical assistance

• Data analysis

Training videos

• Why Group Prenatal Care? The Evidence

• What Does SPC Look Like? Implementation

Overview

• How do I Plan and Implement Supportive Pregnancy

Care?

• How to be a Good Facilitator

• How to Facilitate a Supportive Pregnancy Care

Group: Engaging Participants

Social media platform for women

ONLINE PRODUCTS

SOCIAL MEDIA GROUPS FOR PARTICIPANTS

CONSUMER RESOURCES

Becoming a Mom/Comenzando bien® prenatal

education curriculum and patient handouts

FORMS AND TOOLS

PLANNING

• Organization readiness assessment

• Organization clinic information

• 6-month planning checklist

• List of equipment and materials

FOR FACILITATORS

• Implementation and Session Guides

• Facilitator self-assessment

• Facilitator self-reflection

• Facilitator debrief worksheet

IMPLEMENTATION and EVALUATION

• Patient recruitment script

• Marketing materials

• Confidentiality agreement

• Group data worksheet

• Certificate of completion

Can JOIN A GROUP even if

entering care in second or third

trimester

MORE ACCESS to community

resources

Can join a group regardless of RISK FACTORS

Allows attendance of SMALL

CHILDREN

BENEFITS TO PATIENTS

Appeals to OBSTETRICIANS, MIDWIVES

AND NURSE-PRACTITIONERS

PROVIDER-driven and FLEXIBLE

implementation

• Group composition

• Co-facilitators

• Length of sessions

• Content of sessions

ONLINE ACCESS to resources

BENEFITS TO PROVIDERS

SMARTER, HEALTHIER health plan members

LOWER healthcare COSTS

Increased member SATISFACTION WITH CARE

BENEFITS TO PAYERS

PROGRAM EXPANSION

• Group technical assistance

• Data analysis

• Online access to materials

• Online access to training modules

• Online access to all materials

• PDFs of co-branded patient recruitment materials for print

• Optional in-person training (for purchase)

• In-person training

• Individualized technical assistance

• Printed co-branded patient recruitment materials

• Becoming a Mom curriculum

• Patient Education Materials

FULL SERVICE PACKAGE

SELF-IMPLEMENTATION

PACKAGE

65

HOW TO LEARN MORE

• Visit our website: marchofdimes.org/supportivepregnancycare

• Read our FAQs

• Email SPC@marchofdimes.org or speak to your local March of Dimes staff member

66

THANK YOUNicole Wong

Manager, Supportive Pregnancy Care

For more information, please email SPC@marchofdimes.org

North Carolina Preconception Health Campaign: Circle of CareDanielle Little

Eastern Regional Coordinator

“Opportunistic” Care

• “Every woman, every time”

• Preconception care is for every woman of childbearing age every time she is seen

• Interconception health, is the health of a woman between her pregnancies

CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules

Moos, MK. Connecting the Dots: Health Status Before Pregnancy and Pregnancy Outcomes. 2011

From Linear Care…

* *

Opportunistic

preconception

health care

Improved

preconception

health

Early

prenatal

care

Healthy

outcomes

Transition to

medical home

…to a Circle of Care

The IMPLICIT interconception health toolkit focuses on modifiable health behaviors by incorporating brief screenings and interventions that can take place during a well child visit targeting:

- Tobacco use

- Depression risk

- Contraception use

- Multivitamin with folic acid intake

IMPLICIT Interconception Care Toolkit

IMPLICIT ICC MODEL

✓ Repeatedly screen mothers during WCVs from 0-24 months of age for behavioral risk factors

✓ Assess current risks at each WCV 0-24 mo

✓ Reinforce desired behaviors

✓ Connect with primary providers or community resources to address risks

✓ Provide prescriptions and/or free MVIs as needed

✓ Collect and analyze data

✓ Develop strategies to improve care delivery and patient outcomes

IMPLICIT ICC

Download the ICC Toolkit:✓ https://prematurityprevention.org/Toolkits-

Reports/IMPLICIT-interconception-care-toolkit

Contact us:

✓ implicitinfo@fmec.net

✓ http://www.fmec.net/implicitnetwork.htm

✓ https://www.marchofdimes.org/professionals/implicit-interconception-

care-toolkit.aspx

74

Care that addresses the gaps

must become the norm and not

a set-aside program. Care that

addresses the gaps for Black

women looks like centering us

in its creation…. It is the only

way forward.”

– Dr. Joia Crear-Perry

Questions? Comments?

For more information about the Campaign and other preconception health topics visit: EveryWomanNC.org and at Latinasana.org

Find us on Facebook: http://www.facebook.com/everywomannc

Follow us Twitter: @everywomannc

Thank you!