Perinatal Programs: A Public Perinatal Programs: A Public Health ApproachHealth Approach

November 19, 2007November 19, 2007

Virginia Commonwealth UniversityVirginia Commonwealth University

Joan Corder-Mabe, RNC, M.S., WHNPJoan Corder-Mabe, RNC, M.S., WHNP

Director, Division of Women’s and Infants’ HealthDirector, Division of Women’s and Infants’ Health

Virginia Department of HealthVirginia Department of Health

Major Issues Regarding Major Issues Regarding Maternal-Infant HealthMaternal-Infant Health

Infant MortalityInfant Mortality Low Birth WeightLow Birth Weight Maternal MortalityMaternal Mortality Access to CareAccess to Care

Core Functions of Public HealthCore Functions of Public Health

AssessmentAssessment

Assurance Assurance

PolicyPolicy

AssessmentAssessment

Analysis of birth certificate dataAnalysis of birth certificate data Fetal and Infant Mortality Review (FIMR)Fetal and Infant Mortality Review (FIMR) Child Fatality ReviewChild Fatality Review Pregnancy Risk Assessment Monitoring Pregnancy Risk Assessment Monitoring

System (PRAMS)System (PRAMS) Maternal Death ReviewMaternal Death Review

Infant Mortality as a Measure of Infant Mortality as a Measure of HealthHealth

“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 1980’s and 1990’s, the rate of infant mortality in the United States remains one of the highest in the industrialized world.”

Healthy People 2010 Report

National and Virginia Infant Mortality Rates National and Virginia Infant Mortality Rates 1982-20051982-2005

0

2

4

6

8

10

12

14

Year

Rate

/1000

VA

US

National and Virginia Infant Mortality by RaceNational and Virginia Infant Mortality by Race1982-20051982-2005

0

5

10

15

20

25

Year

Ra

te/1

,00

0 liv

e b

irth

s

US

VA

White

Black

National and Virginia Infant Mortality Rates National and Virginia Infant Mortality Rates by Race and Ethnicityby Race and Ethnicity

1982-20051982-2005

0

2

4

6

8

10

12

14

16

18

20

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

Year

Ra

te/1

,00

0 liv

e b

irth

s

US

VA

White, NH

Black, NH

Hispanic, Any race

Trend in infant mortality over the Trend in infant mortality over the last five yearslast five years

0

2

4

6

8

10

12

14

16

2000 2001 2002 2003 2004 2005

Year

Ra

te/1

,00

0 liv

e b

irth

s US

VA

White, NH

Black, NH

Hispanic, Any race

Virginia rates of infant mortality, preterm Virginia rates of infant mortality, preterm births, and fetal deathsbirths, and fetal deaths

1982-20051982-2005Virginia's rate of infant mortality, preterm births, and fetal

deaths 1982 - 2005

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Year

Rate

Infant Mortality

Percent Preterm

Percent fetal deaths

Leading causes of infant deathLeading causes of infant death

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

Neonatal DeathsNeonatal Deaths

Early Infant Deaths (< one day) All Neonatal Deaths (0-27 days)

Blacks 6.7 9.8

Whites 2.5 4.1

Other 1.4 2.3

Total 3.3 5.1

Source: 2005 Virginia Center of Health Statistics

Setting a Goal for Reduction of Setting a Goal for Reduction of Infant DeathsInfant Deaths

Virginia is working toward the goal to reduce its infant Virginia is working toward the goal to reduce its infant death rate to 7.0 per thousand live births by 2008.death rate to 7.0 per thousand live births by 2008.

This would surpass the Healthy People 2010 goal of This would surpass the Healthy People 2010 goal of reducing the infant mortality rate to 7.2 per thousand.reducing the infant mortality rate to 7.2 per thousand.

In order to meet this goal, VDH needs to focus those In order to meet this goal, VDH needs to focus those populations with the highest risks, geographic areas and populations with the highest risks, geographic areas and gestational periods with the highest number of deaths.gestational periods with the highest number of deaths.

Low Birth Weight Trend by RaceLow Birth Weight Trend by Race1990-20051990-2005

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.01

99

0

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

Year

Pe

rce

nt L

BW

VA

White

Black

Hispanic

Low Birth Weight is associated with Low Birth Weight is associated with multiple factors:multiple factors:

Medical Risk FactorsMedical Risk Factors- - High parityHigh parity

- Chronic diseases- Chronic diseases - Previous Low Birth Weight infants- Previous Low Birth Weight infants

- Genetic factors- Genetic factors- Multiple gestation- Multiple gestation- Poor weight gain- Poor weight gain- Infection- Infection- Placental problems- Placental problems- Premature rupture of membranes- Premature rupture of membranes- Fetal anomalies- Fetal anomalies- Maternal stress- Maternal stress

Low Birth Weight (continued)Low Birth Weight (continued)

Demographic Risk FactorsDemographic Risk Factors- Age < 17 years and > 34 years- Age < 17 years and > 34 years

- African-American race- African-American race- Low socioeconomic status- Low socioeconomic status- Unmarried- Unmarried- Low education- Low education

Behavioral Risk FactorsBehavioral Risk Factors- - SmokingSmoking- Poor nutrition- Poor nutrition- Toxic exposure- Toxic exposure- Inadequate prenatal care- Inadequate prenatal care- Substance abuse- Substance abuse

The etiology of preterm labor and The etiology of preterm labor and premature birth is unknown.premature birth is unknown.

Long-term effects of Low Birth Long-term effects of Low Birth WeightWeight

Neurologic disordersNeurologic disorders Learning disabilitiesLearning disabilities Delayed developmentDelayed development

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

African AmericanAfrican American UnmarriedUnmarried Low incomeLow income Less than a high school educationLess than a high school education Enter prenatal care late or not at allEnter prenatal care late or not at all Many smoke and have poor nutritionMany smoke and have poor nutrition

National Fetal-Infant Mortality National Fetal-Infant Mortality Review (NFIMR) ProgramReview (NFIMR) Program

Established in 1990Established in 1990 Public-private partnershipPublic-private partnership

– American College of Obstetricians and Gynecologists (ACOG)

– Maternal and Child Health Bureau

– March of Dimes Birth Defects Foundation

FIMR is:FIMR is:

Community-based, action-oriented processCommunity-based, action-oriented process Early warning system that describes health Early warning system that describes health

carecare Method of continuous quality improvementMethod of continuous quality improvement Means to implement core public health Means to implement core public health

functionsfunctions

Objectives:Objectives:

Initiate an interdisciplinary review of fetal and Initiate an interdisciplinary review of fetal and infant death from medical and social records and infant death from medical and social records and maternal interview.maternal interview.

Describe significant social, economic, cultural Describe significant social, economic, cultural and systems factors that contribute to mortality.and systems factors that contribute to mortality.

Design and participate in implementing Design and participate in implementing community-based interventions determined from community-based interventions determined from review findings.review findings.

Assessment (continued)Assessment (continued)

Child Fatality ReviewChild Fatality Review PRAMSPRAMS

Maternal Mortality Has Not Maternal Mortality Has Not Changed Since 1982Changed Since 1982

0

5

10

15

20

25

Year

Death

s p

er

100,0

00 L

ive B

irth

s

Source: Centers for Disease Control and Prevention

Maternal Mortality Rates,Maternal Mortality Rates,by Race of Mother: 2000by Race of Mother: 2000

                                                                         

                 

Reasons for reduction in maternal Reasons for reduction in maternal mortalitymortality

Sulfa and antibiotic drugsSulfa and antibiotic drugs Decrease infections secondary to illicit Decrease infections secondary to illicit

abortionsabortions Availability of banked bloodAvailability of banked blood Safer surgical procedures, including Safer surgical procedures, including

CesareanCesarean

The Year 2000 goal (3.3 maternal The Year 2000 goal (3.3 maternal deaths per 100,000 live births) was deaths per 100,000 live births) was

not reached nationally or in Virginia.not reached nationally or in Virginia.

The 3 leading causes of natural maternal The 3 leading causes of natural maternal

death in the United States and Virginiadeath in the United States and Virginia

Hemorrhage, including ectopic pregnancyHemorrhage, including ectopic pregnancy Pregnancy-Induced HypertensionPregnancy-Induced Hypertension Pulmonary EmbolismPulmonary Embolism

Maternal Mortality RatiosMaternal Mortality Ratios

CDC

Expanded Definition

2001 9 38 (21 natural)

2002 5 34 (13 natural)

2003 12 55 (32 natural)

Components of maternal death Components of maternal death reviewsreviews

Investigation of individual maternal deathInvestigation of individual maternal death Multidisciplinary discussion of each caseMultidisciplinary discussion of each case Recommendations to prevent future deathsRecommendations to prevent future deaths

Team Purpose:Team Purpose:

The Maternal Mortality Review Team reviews and The Maternal Mortality Review Team reviews and analyzes maternal deaths in Virginia to develop analyzes maternal deaths in Virginia to develop an understanding of the causes of maternal an understanding of the causes of maternal death. We use the results to:death. We use the results to:

1.1. Educate colleagues and policymakers about Educate colleagues and policymakers about these deaths and the need for changes in law and these deaths and the need for changes in law and practice, andpractice, and

2.2. Recommend other improvements to reduce the Recommend other improvements to reduce the number of preventable maternal deaths in number of preventable maternal deaths in Virginia.Virginia.

Public Health Approach to Infant Public Health Approach to Infant MortalityMortality

Providing Access to Perinatal and Infant Care

Reducing Infant

Mortality

Healthy Start Medicaid

& SCHIP

Childhood Immunization

Initiative

Reducing Unintended Pregnancy

“Back to Sleep” Campaign MCH

Services

Folic Acid Campaign

Reducing mother to child HIV transmission

Promoting research to reduce infant

mortality

Promoting healthy choices to reduce mortality risks

AssuranceAssurance

Prevention EffortsPrevention Efforts Safety NetSafety Net Setting Standards/Quality of CareSetting Standards/Quality of Care

PreventionPrevention

Preventing Unintended Pregnancy and Planning Families

Abstinence Education

Teen Pregnancy Prevention

Girls Empowered to Make Success

Partners in Prevention

Family Planning Clinics

Partners in Prevention Program (PIP)Partners in Prevention Program (PIP)

Targeting young men and women between Targeting young men and women between the ages of 20-29the ages of 20-29

Increase knowledge regarding the risks of Increase knowledge regarding the risks of nonmarital birthnonmarital birth

Promote healthy attitudes and behaviors Promote healthy attitudes and behaviors about marriage, family, and careerabout marriage, family, and career

PreconceptionPreconception

Prevention of birth defectsPrevention of birth defects Treatment of chronic conditionsTreatment of chronic conditions Promotion of healthy lifestyles (smoking, Promotion of healthy lifestyles (smoking,

alcohol)alcohol)

The improvement in infant The improvement in infant mortality rates is not an indicator mortality rates is not an indicator

that babies are healthier, but that babies are healthier, but medical technology is enabling medical technology is enabling

sicker babies to survive.sicker babies to survive.

Regionalization of perinatal care was Regionalization of perinatal care was successful in the 1970s and 1980s by successful in the 1970s and 1980s by concentrating the births of very low concentrating the births of very low birth weight infants to the tertiary birth weight infants to the tertiary

centers.centers.

Regional Perinatal Councils (RPCs)Regional Perinatal Councils (RPCs)

Regional Perinatal Councils (RPCs) improve the infrastructure through which perinatal health is provided within the Commonwealth.

Goals:Goals: address problems of infant mortality and morbidityaddress problems of infant mortality and morbidity address access to prenatal careaddress access to prenatal care conduct perinatal outreach education for professionalsconduct perinatal outreach education for professionals

Programs (continued)Programs (continued)

Car seat programCar seat program Virginia Council on Folic Acid/VDH Virginia Council on Folic Acid/VDH

CampaignCampaign Fetal Alcohol Spectrum Disorders (FASD) Fetal Alcohol Spectrum Disorders (FASD)

Task ForceTask Force

Safety Net ProvidersSafety Net Providers

Prenatal care in local health departmentsPrenatal care in local health departments WIC in local health departmentsWIC in local health departments Community Health CentersCommunity Health Centers

Early and regular use of prenatal Early and regular use of prenatal care is a strong predictor of care is a strong predictor of

positive pregnancy outcomes.positive pregnancy outcomes.

Early prenatal care is an indicator Early prenatal care is an indicator for access to health care services.for access to health care services.

Resource Mothers ProgramResource Mothers Program

Lay home visitors who mentor pregnant teenagersLay home visitors who mentor pregnant teenagers Decrease infant mortality and low weight birthsDecrease infant mortality and low weight births 25 contractors enrolling approximately 1100 newly 25 contractors enrolling approximately 1100 newly

pregnant teens per year in 88 Virginia localitiespregnant teens per year in 88 Virginia localities Early and regular prenatal care, increased healthy Early and regular prenatal care, increased healthy

behaviors, delay of repeat pregnancy, enrollment in behaviors, delay of repeat pregnancy, enrollment in school or employment, and creation of a stable home school or employment, and creation of a stable home environmentenvironment

Staff aim to motivate program participants to stop Staff aim to motivate program participants to stop smokingsmoking

Loving Steps/Virginia Healthy Start Loving Steps/Virginia Healthy Start ProgramProgram

Goal of reducing infant deaths and improving Goal of reducing infant deaths and improving birth outcomes through early intervention:birth outcomes through early intervention:

Case management and health educationCase management and health education Registered nurses provide medical nursing careRegistered nurses provide medical nursing care Registered dietitians provide medical nutrition therapy Registered dietitians provide medical nutrition therapy

servicesservices Resource Mothers (Community Health Workers)Resource Mothers (Community Health Workers) FIMRFIMR

Newborn ScreeningNewborn Screening

Coordinated and comprehensive system consisting of Coordinated and comprehensive system consisting of education, blood screening tests, follow-up and referrals, education, blood screening tests, follow-up and referrals, diagnosis, medical and dietary management, and diagnosis, medical and dietary management, and treatmenttreatment

Effective March, 2006, Virginia screens for 28 disordersEffective March, 2006, Virginia screens for 28 disorders Since March 1, 2006, 8 infants have been identified with Since March 1, 2006, 8 infants have been identified with

life-threatening rare disorders which would not have been life-threatening rare disorders which would not have been identified before the expansion.identified before the expansion.

Setting Standards/Quality of CareSetting Standards/Quality of Care

Neonatal RegulationsNeonatal Regulations Screening for domestic violence, perinatal Screening for domestic violence, perinatal

substance use, and perinatal depressionsubstance use, and perinatal depression Web-based training on Bright Futures and Web-based training on Bright Futures and

Perinatal DepressionPerinatal Depression Provision of culturally competent careProvision of culturally competent care

Policy and PlanningPolicy and Planning

Implementation of Codes Regarding Perinatal Substance Use:Implementation of Codes Regarding Perinatal Substance Use: 54.1-2403.1 of the 54.1-2403.1 of the Code of Virginia Code of Virginia Substance Use Screening in Substance Use Screening in

Prenatal CarePrenatal Care 63.2-1509 of the 63.2-1509 of the Code of Virginia Code of Virginia Physician referral of Substance Physician referral of Substance

Exposed NewbornsExposed Newborns 32.1-127 of the 32.1-127 of the Code of Virginia Code of Virginia Hospital Discharge Planning for Hospital Discharge Planning for

Substance using Postpartum WomenSubstance using Postpartum Women 32.1-134.01 of the 32.1-134.01 of the Code of Virginia Discharge Education on Code of Virginia Discharge Education on

Postpartum Blues, Perinatal Depression, Shaken Baby SyndromePostpartum Blues, Perinatal Depression, Shaken Baby SyndromeInteragency Substance Exposed Newborn Workgroup Interagency Substance Exposed Newborn Workgroup

(DMHMRSAS, DSS, DCJ)(DMHMRSAS, DSS, DCJ)Analysis of proposed legislationAnalysis of proposed legislationSupports Governor’s task forces and commissionsSupports Governor’s task forces and commissions

Governor’s Commission on Governor’s Commission on Healthcare ReformHealthcare Reform

Infant mortalityInfant mortality ObesityObesity SmokingSmoking

ConclusionConclusion

Studies of underlying factors that contribute to Studies of underlying factors that contribute to morbidity and mortality are neededmorbidity and mortality are needed

Review of quality of health care and access to Review of quality of health care and access to care for all women and infants is neededcare for all women and infants is needed

Racial/ethnic disparities need to be eliminatedRacial/ethnic disparities need to be eliminated Research to determine effective public health Research to determine effective public health

programs to make a differenceprograms to make a difference