Alabama Perinatal ConferenceTranslating Recommendations

into ActionSeptember 14. 2012

Lessons Learned from the Community-Based Prematurity Prevention Pilot in Kentucky:

Preterm Births, Low Birthweight and Infant Mortality

United States, 1981 - 2004

0

2

4

6

8

10

12

14

1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 20030

2

4

6

8

10

12

14

Preterm Birth Low Birthweight Infant Mortality Rate

Percent

Source: National Center for Health Statistics, final natality and mortality dataPrepared by March of Dimes Perinatal Data Center, 2007

Rate per 1,000 live births

Infant mortality rates excluding births at <22 weeks of gestation, US and selected European countries, 2004

3

MacDorman, NCHS, 2011

Three Leading Causes of Infant Mortality

United States, 1990 and 2007*

57

112.7

134.9

130.3

96.5

198.1

0 50 100 150 200 250

SIDS

Preterm / LBW

Birth Defects

19902007

Rate per 100,000 live births

Source: National Center for Health StatisticsAdapted from a slide Prepared by March of Dimes Perinatal Data Center, 2007

The Life Course Perspective of Health Development

Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Maternal Child Health J. 2003;7:13-30. 5

Critical Periods

Cumulative Effects

Interaction with

Environment

Health Equity

TIMING

TIMELINE

ENVIRONMENT

EQUITY

Life Course Health Development

Poor NutritionStressAbuseTobacco, Alcohol, DrugsPovertyLack of Access to Health CareExposure to Toxins

Poor Birth Outcome

0 5 Puberty PregnancyAge

Birth Weight and Insulin Resistance Syndrome

Barker Hypothesis

18

8.4 8.5

4.9

2.21

0

5

10

15

20

<5.5 5.6-6.5 6.6-7.5 7.6-8.5 8.6-9.5 >9.5

Odd

s r a

tio a

d jus

t ed

for B

MI

Barker 1993Birthweight (lbs)

Birth Weight and Coronary Heart Disease

Barker Hypothesis

1.5

1.251.15

10.9

0.7

0

0.25

0.5

0.75

1

1.25

1.5

1.75

<5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0 >10.0

Age

Adj

uste

d R

elat

ive

Ris

k

Rich-Edwards 1997

Birthweight (lbs)

Fetal Origins of DiseaseNew York Times, Oct. 2, 2010

• “Perhaps the most striking finding is that a stressful intrauterine environment may be a mechanism that allows poverty to replicate itself generation to generation. Pregnant women in low income areas tend to be more exposed to anxiety, depression, chemicals and toxins, more likely to smoke or drink… the result is children who start life at a disadvantage…”

9

Review of ORIGINS: How the Nine Months Before Birth Shape the Rest of Our Lives. Annie Murphy Paul, 2010

Fetal Origins of DiseaseAltered Gene Expression

• Jirtle & Waterland, Duke University• Agouti mice

– Normally fat bodies, yellow fur, predisposed to diabetes and cancer

– Appearance and physiology due to a specific gene• Group of pregnant mice

– Half got regular diet, have got diet high in methyl groups (can turn genes off or on)

– Pups from moms on regular diet looked just like their parents– Pups from hi-methyl moms were SLENDER, BROWN FUR, NOT

PREDISPOSED TO DIABETES OR CANCER

10

Review of ORIGINS: How the Nine Months Before Birth Shape the Rest of Our Lives. Annie Murphy Paul, 2010

A Community-Based Initiative to Prevent Preterm Birth

CAN WE DO BETTER WITH WHAT WE KNOW NOW?

• A ‘real world’, ecological design using bundling of evidence-based interventions in different health care settings (academic, private, clinic-based)

• An innovative, multi-dimensional intervention program designed to prevent “preventable” preterm birth in subgroups of the population where interventions have a likelihood of success in a reasonable period of time

Dr. Karla Damus

13

July 2005-June 2006

July 2006-June 2007

July 2007-December 2009

Baseline Planning - Implementation TrainingCONCEPTS/DESIGN:

• Ecological “real world” design

• “Bundled” medical and public health interventions

• Based on improving community systems of care and support

• Targeting “preventable” preterm birth

GOAL: 15% reduction in PTB in intervention sites

18

• DATA ACTION• We know enough now to do better

• RESEARCH “REAL WORLD”• Implement Best Available Evidence

• SILOS SYSTEMS• Comprehensive, coordinated clinical and public health services

• MEDICAL MODEL ECOLOGICAL MODEL• Multiple determinants of health,Prematurity as a public health problem

• RELATIONSHIPS RESULTS• We can do better now

Keys to Community-Based Prematurity Prevention

Data Action

We know enough now to do better

• Data determines the focusLate preterm was driving the increase PTB rates

• Develop the Data Consumer & provider surveys, focus groups, ACOG survey, policy and environment surveys

• Data quality mattersData Definitions, consistent collection

• Local Data drives improvementDon’t wait for vital statistics file

Use or adapt existing data sources

Data Action

Percent of Live Births that were Preterm*; Kentucky and U.S.

*Preterm birth is defined as any live birth occurring <37 completed weeks gestation

Data Source: March of Dimes Peristats & National Center for Health Statistics

Singleton Preterm Birth RatesUS and Kentucky, 1994-2004

Singleton Preterm Births (<37wk)

Late Preterm Births (34-36 wks)

Preterm Births by Week of GestationUnited States Kentucky

8%

5%

16%

13%21%

37% <32 weeks32 weeks33 weeks34 weeks35 weeks36 weeks

Source: National Center for Health Statistics, 2004 final natality dataPrepared by March of Dimes Perinatal Data Center, 2007

Late preterm71%

Late Preterm 73%

6

14.7%

5.1%

6.9%

12.9%

21.4%

39.1% <32 weeks32 weeks33 weeks34 weeks35 weeks36 weeks

Preterm Births• Term:

– about 40 weeks• Preterm birth:

– <37 completed weeks • Late preterm (near-term):

– 34 -36 weeks• Very preterm:

– <32 weeks

Research Real World Implement best available evidence

• State of the Science: Grand Rounds (quarterly), Resource centers: Epidemology, latest research, Brain Growth, morbidity in LPTB • ACOG Guidelines (induction, elective C/S, progesterone, cervical length, antenatal steroids, etc.)• Aggressive Treatment of Infections, STI, BV• Patient Safety (Steve Clark, Kathleen Simpson)• Quality Improvement, provider feedback• Centering Pregnancy/ Group prenatal care• Smoking Cessation (5A’s)• Psychosocial screening & referral• Oral Health Screening & referral • Breastfeeding• Evidence-based home visiting

Research Real World

Anath CV et al, Obstet Gyecol 2005; 105:1084-91

• Reasons for singleton Preterm births in the U.S. 1989-2000

Intervention

PROM

SPTL

Morbidities Associatied with Late Preterm births: Trying to separate causes and effects

4 Increased immediate morbidities:4 Respiratory distress4 Jaundice4 Feeding difficulties4 Hypoglycemia4 Temperature instability4 Sepsis

4 Increased NICU use (and re-admissions)4 Increased cost4 Long term outcome - ???

NICHD Consensus Conference

July 2005

The Late Preterm Morbidity:HYPOGLYCEMIA

• Hypoglycemia is 3X more common in late preterm infants

• “Unlike term infants, late preterm infants are incapable of mounting an adequate mature counter-regulatory response to hypoglycemia”– Gluconeogenesis, ketogenic responses to mobilize

alternate fuels is inadequate– Glycogen reserves, adipose stores build up only in

late gestation– Astrocytes in the glia are still immature

Garg M, Devaskar SU. Clin Perinatol 33:853-70, 2006.

Lung Transition to Life Outside the Womb

ENaC activationSpecificity,

number

Transition fromFluid-filled toAir filled Lung

Mechanical Forces“Vaginal Squeeze”

Onset of labor triggers Decrease of Fetal lung Fluid secretion

Surfactant to coat alveoli

? ?

Steroids before birth enhance maturationSlide from L. Jain, Emory University, modified

• The Brain is the last major organ system to develop

• Lower functions mature first, cortex last

Brain at 35 wks weighs only 2/3 what it will weigh at term

Development of the Human Brain

through Gestation

Cowan WM. Sci Am 241:113, 1979

HBWW Consumer SurveysProvided up-to-date, locally relevant KAB information from pregnant women, the target of the

HBWW InitiativeBased on findings, able to tailor educational materials and communication efforts of Initiative to

community needsResults will be important for evaluation of the Initiative (baseline vs. 3 year follow-up)

Materials for

Professionals

Concerns about Late Preterm Brain Development

And Potential Impact “Because one out of 11 births in this country

is a late preterm birth, and since the brain of the late preterm infant is

less mature than that of the term infant, even a minor increase in the rate of

neurologic disability and scholastic failure in this group can have a huge impact on the health care and educational systems.”

Raju TNK. Epidemiology of Late Preterm Births. Clin Perinatol 33 (2006) 751-763

Mortality in the Late Preterm • Late preterm infants were 3 times more likely than term

infants to die in the first year of life• Even excluding congenital anomalies, infant mortality rates

for late preterm infants were 2.6 times higher than in term infants

• Early Neonatal (<7 days) 6X more likely to die• Late Neonatal 3 X more likely• Post Neonatal: 2X more likely

• Late preterm infants are 8.5 times more likely to die with a diagnosis of respiratory distress in the early neonatal period

• Late preterm infants are twice as likely as term infants to die of SIDS

Tomashek, KM, Shapiro-Mendose CK, Davidoff MJ, Petrini JR. Differences in Mortality between Late-Preterm and Term Singleton Infants in the United States, 1995-2002. J Pediatr 2007:151:450-6

Late Preterm Infant Morbidity in the Neonatal Period

• Late Preterms were 7X more likely to have newborn morbidity than term infants. Newborn morbidity rate doubled for each gestational week earlier than 38 weeks

• The independent effect of late preterm birth on morbidity was 7X stronger than any of the selected maternal conditions

• The proportion of morbidity among late preterm infants was relatively high across the board, ranging from 18.1% to 27.8%

Shapiro-Mendosa CK et al. Pediatrics 2008, 121:e223-e232

LATE PRETERM OUTCOMES

Compared to term infants, infants born in the late preterm period have:

• 6X incr risk of dying in the first week of life• 3X incr risk of dying in the first year of life• Increased risk of ADHD by 70%• Clinically significant behavior problems in 20%• Incr risk for special ed, cognitive and learning problems • 2-4X increased risk for Cerebral Palsy• 2-3X increased risk for IQ < 85• Increased risk for mental disorders/schizophrenia as adults• 40% increased risk for medical disability that limits working capacity as

adults• Increased risk of long term neurodevelopmental handicap as young

adults

ACOG Committee Opinion # 22

• ACOG has cautioned against inductions before 39 weeks in the absence of a medical indication

• Since 1979

ACOG Committee Opinion # 404Late Preterm Infants, April 2008

• Late preterm infants often are mistakenly believed to be as physiologically and metabolically mature as term infants. However, compared with term infants, late–preterm infants are at higher risk than term infants of developing medical complications, resulting in higher rates of infant mortality, higher rates of morbidity before initial hospital discharge, and higher rates of hospital readmission in the first months of life.

Preterm delivery should occur only when an accepted maternal or fetal indication for delivery exists.

Statement developed jointly with AAP Committee on Fetus & Newborn

Reinforced no elective induction or C/S should be done prior to 39 weeks gestation

Specific criteria for establishing gestational age should be followed

A mature fetal lung test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery. (see Bates, 2009)

ACOG Practice Bulletin, Number 107 August 2009

Induction of labor

Elective cesarean delivery before 39 weeks is common (35.8%) and is associated with respiratory and other adverse neonatal outcomes, increased risk 2-4X: At 38 wks OR 1.2-2.1At 37 wks OR 1.8-4.2

Complications of Non-medically Indicated (Elective) Deliveries

Between 37 and 39 Weeks

See Toolkit for more data and full list of citationsClark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997

Increased NICU admissions Increased transient tachypnea of the newborn (TTN) Increased respiratory distress syndrome (RDS) Increased ventilator support Increased suspected or proven sepsis Increased newborn feeding problems and other

transition issues

NICU Admissions By Weeks Gestation Deliveries Without Complications, 2000-2003

2.47% 2.65%3.36% 3.44% 4.26%

6.66%

0%

2%

4%

6%

8%

10%

37th Week(8,001)

38th Week(18,988)

39th Week(33,185)

40th Week(19,601)

41st Week(4,505)

42nd Week(258)

Gestational Weeks

Perc

ent

NICU Admissions

Oshiro et al. Obstet Gynecol 2009;113:804-811.

Preterm BirthsTerm: about 40 weeks (39-41):• Early Term

– 37-38 weeks

Preterm birth: <37 completed weeks

• Late preterm (near-term): – 34 -36 weeks

• Very preterm:– <32 weeks

Terminology

First day of LMP

0Week # 37 0/7 416/7

Preterm Post term

340/7

Term

Modified from Drawing courtesy of William Engle, MD, Indiana University

20 0/7

Raju TNK. Pediatrics , 2006;118 1207. Oshiro BT Obstet Gynecol 2009;113:804

39 0/7

Late Preterm Early Term

The “New” Term

40

Rate of Scheduled Births at 360 - 386 Weeks’

Without Documented Indication

ObserveX 2 Months Project begun 9-1-08 11-30-09

%

Available at: http://opqc.net/presentations

Clark SL, et al. AJOG, 2008;199:105.e1-105.e7. Improved outcomes, lower C/S rates. Decr malpractice claims by half, cost of claims by 5-fold

Clark SL. et al. Am J Obstet Gynecol 2010;203:449.e1-6

Hard StopSoft Stop/Peer Rev

EducationOnly

Consistent reduction in every hospital

HCA Trial of 3 Approaches for Reduction of Elective Deliveries <39 weeks

Silos Systems

“Comprehensive, coordinated, integration of clinical and public

health systems of care”

• Convene the Partners– Hospitals and Health depts as community health leaders– Don’t really know what services the other provides

• Describe best practices– Don’t let perfect be the enemy of good

• Determine the gaps– Prenatal classes, oral health, MNT, Substance abuse

• What can we do better now?– Fax referral form, exchanging staff, co-locating services, consistent

information; referrals to health dept services

Silos Systems

Healthy Babies are Worth the Wait

Oral Health• ISW - Dental hygenist regular presenter in Centering

• Dental Chair in Women’s Center at hospital– When moved to Health Dept a block away, patients did not

go • ISC - Improved coordination with dental school

clinics • increased emphasis with residents and nurses on oral

screening and care for patients• ISE - No dentists in area would treat pregnant

women• Hosted regional meeting with area dentists and OB’s,

nationally known dentist as speaker• Several local dentists then agreed to see pregnant

women referred by their obstetrician

Healthy Babies are Worth the Wait

Substance abuse prevention and management.• ISW - Improved local access to substance-abuse

treatment for pregnant women

– began universal screening for substance abuse as part of prenatal care; non-stigmatizing, non-punative

• ISC - Improved coordination with in-house detox unit for managing substance abuse in pregnancy

– Implemented universal psychosocial screening• ISE - Grand rounds on use of subutex by addiction

specialist for substance abuse in pregnancy– Hospital social worker went to OB offices to see

and do brief intervention with substance-abusing patients

Evidence-Based Home Visiting

and Preterm BirthHealth Access Nurturing Development ServicesVoluntary, intensive weekly home visitationOverburdened, first time moms or first time dads Regardless of incomePrenatal to two years of ageStrengths-based, build resilience in familiesDesigned to improve both health & social outcomesMix of professionals and paraprofessionals

48

31% less Prematurity33% less LBW55% less VLBW70% less Infant Mortality50% less ER Usage29-40% less Child Abuse and

Neglect26% improved/increased EducationLess developmental delays

Outside Evaluator

OUTCOMES

49

Social Determinants of Health

Kaplan, et al. (2000). A Multilevel Framework for Health in :Promoting Health. Washington, DC: National Academy Press

The basis for psychosocial screening

ACOG Committee Opinion # 343Psychosocial Risk Factors: Perinatal Screening and Intervention• “Biomedical risks, such as complications of pregnancy,

concomitant maternal disease, infection, nutritional deficiencies, and exposure to teratogens, are estimated to account for approximately one half of the incidence of low-birth-weight infants and of prematurity and their postnatal sequellae. An important portion of the remaining cases of these adverse pregnancy outcomes may be attributable to psychosocial stress even after controlling for the effects of recognized socio-demographic, obstetric, and behavioral risk factors.”

Medical Model Ecological Model Multiple Determinants of Health

53

Ecological Influences on Health

COMMUNITY MESSAGES• Full Term is about 40 weeks

• Unless there are medical complications, women should try to carry pregnancy to a full 40 weeks, because….

• Much of the brain development happens in those last 4-6 weeks of pregnancy

• Preventing prematurity improves the lives of families and communities

• Available at www.kfap.org (The KY Folic Acid Partnership)

Example billboard

What Do Women think is Term?• Goldenberg et al, 2009. Women’s Perceptions Regarding the Safety of

Birth at Various Gestational Ages. Obstet Gynecol 2009. 114:1254-8

• Survey of 650 women enrolled in an insurance plan who had recently had a baby

“At what gestational age do you believe a baby is considered full term: – Responses of </=37 weeks 45.7%– 38 weeks 29.1%

– 39-40 weeks (correct response) 25.2%

The Gestational Age that Women Considered it “Safe to Deliver”

Obstet Gynecol 2009;114:1254

Relationships Results We can do better

• Relationships among- Providers- Agencies- Clients- Community partners

• Making a Difference motivates• Small wins count

Relationships Results

Intervention Implemented Across All Sites

• The impact of the project, measured from 2007 through 2010, did meet the target of reducing preterm birth in the intervention sites by 15%.

Preterm Birth Rates Late Preterm Birth Rates

HBWW: Moving Forward• In 2010 the 3 Kentucky control sites began

implementing HBWW– Data has shown a decrease in preterm and late

preterm birth rates in these sites since intervention implementation

• An additional 2 sites have been added to the Kentucky program in 2011

• March of Dimes is expanding program sites in New Jersey and Texas, with a goal of reaching 20 sites by 2014

Community-Based Prematurity Prevention

The Kentucky Experience

HRSA Regional Infant Mortality Summit January 12-13, 2012

HRSA Collaborative Improvement and Innovation Network (COIN)

Regions IV and VI Strategy Teams: Elective Deliveries < 39 weeks Perinatal Regionalization Medicaid policies for preconception/

interconception care Sleep related Infant Deaths Smoking in pregnancy

COIN Launch Meeting, July 23-24, 2012

STRONG START FOR MOTHERS AND NEWBORNS• Grant opportunity from CMS Innovations Center

Medicaid finances about 40% of all births in USMedicaid beneficiaries are at increased risk for

preterm birth

A. Promote awareness and spread best practicesthrough the Partnership for Patients Hospital Engagement Networks (ED<39 weeks)

B. Funding opportunity to test the effectiveness of new models of prenatal care that provide

comprehensive services/ enhanced prenatal care1. Group Prenatal care (e.g., Centering

Pregnancy), providing peer support, healthassessment, and education

2. Comprehensive prenatal care at birth center; to include collaborative practice, intensive case management, counseling

and psychosocial support services3. Enhanced prenatal care at Maternity Care Homes, including

psychosocial support, education, and health promotion in addition to traditional prenatal care

The National Infant Mortality Initiative

And today I’m pleased to announce my department will be collaborating in the next year to create our nation’s first ever national strategy to address infant mortality. Secretary Kathleen Sebelius

June 14, 2012

• DATA ACTION• We know enough now to do better

• RESEARCH “REAL WORLD”• Implement Best Available Evidence

• SILOS SYSTEMS• Comprehensive, coordinated clinical and public health services

• MEDICAL MODEL ECOLOGICAL MODEL• Multiple determinants of health,Prematurity as a public health problem

• RELATIONSHIPS RESULTS• We can do better now

Keys to Community-Based Prematurity Prevention

This Continuing Professional Education Program is generously supported by a

March of Dimes Grant from an Anonymous Donor

For additional online resources on preterm birth, please visit:

1. PrematurityPrevention.org Online source of information on prematurity. The PPRC is primarily for professional use and includes current information on interventions, research, advocacy, professional education, global initiatives, teaching tools and resources to use with patients.

2. Elimination of Non-medically Indicated Elective Deliveries Before 39 Weeks Gestational Age. Outlines successful initiatives and sample implementation plan to reduce elective deliveries before 39 weeks at hospital, health system and statewide levels. Free download: prematurityprevention.org or purchase: marchofdimes.com/catalog

3. Toward Improving the Outcome of Pregnancy III. Explores the elements that are essential to improving quality, safety and performance across the continuum of perinatal care. prematurityprevention.org

4. Preterm Labor Assessment Toolkit – Provides standardized protocols for assessing patients in preterm labor. prematurityprevention.org

5. Preterm Labor: Prevention and Nursing Management Nursing Module – Discusses nursing management of women presenting in preterm labor. 3.9 Contact Hours available for RNs. marchofdimes.com/nursing