WHAT YOU DO TO PREVENT PRETERM BIRTHIN CLEVELAND AND CUYAHOGA COUNTY Carol Gilbert, MS Health Data Analyst, CityMatCH
Your Programs Your Expertise Nursing Perinatal health Counseling Health Systems Education Systems Housing Systems Law enforcement Justice system Knowledge of your clients • MomsFirst, • Help Me Grow, • Lead Safe, • Creating Healthy Communities, • Produce Perks, • Breast for Success, • Place Matters, • Baby Basics, and • CFHS
….And you know Cleveland and Cuyahoga county Neighborhoods History Values Traditions
Services you provide Health education • Health literacy • Prenatal care • Breastfeeding • Family planning • Interconception care • Parenting • Smoking Cessation • Child Health and Development Case management • Obtaining medical insurance • Obtaining transportation to medical appointments • Screening and referral for perinatal depression • Connect parents to social supports, medical home Health promotion • Assess and improve environmental, systems and policies to promote health • Lead abatement grants • Extra value for food stamp cards when used at farmers markets • Breastfeeding support
Black birth outcomes (2010-2012 birth records) • Teen pregnancy 17% • Short birth spacing 36% (similar to reference group) • Late or no prenatal care 14% (none in the reference group) • Very preterm birth 5% (vs 1% for reference group) • Infant mortality rate
In Cuyahoga County, the Black infant mortality rate is 2.5 times the White rate (2006-2010)
Infant mortality is complex • Important time periods • Preconception health • Prenatal • Neonatal • Post-neonatal • Health care system • Built Environment • Goes beyond obstetrics • Chronic disease • Mental Health • Social determinants • Life course • Inter-generational …and is an important indicator of population health
An approach for helping cities and large communities to use their own data to investigate the reasons for their high infant mortality rates and disparities • Uses Vital Records Data (birth and death records) • Everyone is included • Available at local level What is the Perinatal Periods of Risk approach, or PPOR?
Four periods of risk Uses fetal death data Uses a reference group Tailored to every community What’s different about the PPOR analytic approach?
The PPOR “map” of fetal and infant mortality. Perinatal Periods of Risk are named to suggest the preventive areas age Neonatal Deaths (Birth – 27 days) Postneonatal Deaths (28 – 364 days) Fetal Deaths (>=24 wks) weight Maternal Health / Prematurity 500-1499 g 9 10 11 12 Maternal Care Newborn Care Infant Health 13 14 15 16 1500+ g
PPOR “maps” for Cuyahoga County* All 2006-2010 NH Black 2006-2010 4.1 7.3 1.8 2.7 1.2 1.3 2.0 2.9 9.1 14.3 * PPOR Fetal and infant deaths per 1000 live births and fetal deaths
But . . . What rates can we expect to see in each Period of Risk?” PPOR answers this question using a reference group, a real population of mothers that experience best outcomes: low fetal and infant mortality rates
Ohio State Reference Group PPOR MAP, 2006-2010 Ohio State Reference Group Overall Rate = 4.7 1.8 • Reference Group Characteristics: • 20+ years of age • 16+ years of education • Non-Hispanic White • Resident of Ohio at the time of baby’s birth 1.2 1.0 0.7 * per 1000 live births and fetal deaths
Remember: • Inequity is a disparity that is unnecessary and unfair • Unnecessary deaths are those that could be prevented • In PPOR, preventability is estimated on a population basis by comparing the community’s outcomes to the outcomes of a real “reference group” By using the reference group, PPOR helps measure “Inequity”
PPOR for Cuyahoga County Black 2006-2010 Ref2 2006-2010 Excess Mortality 7.3 1.8 5.5 1.6 1.2 2.7 0.4 1.0 1.3 2.9 2.2 0.7 14.3 4.7 9.6 * per 1000 live births and fetal deaths
PPOR for Cuyahoga County Estimated excess deaths 2006-2010 Black NH All others 169 11 48 5 11 6 67 36 295 59 * per 1000 live births and fetal deaths
Cuyahoga County (2006-2010) From Kitagawa, 92% of the blue pie slice is due to too many babies born too small; County-wide, 44% of excess mortality is due to Black prematurity
Infant Mortality PPOR says: Some of you saw this part of PPOR analysis before Next Step: Determine which risk factors are most important for Cuyahoga County Black births Prematurity Prevention Clear Focus End of today Identifying Priorities
Potential impact of addressing … Maternal stress during pregnancy—pooled RR=1.50—prematurity defined as less than 37 weeks (Ding) Short cervix—RR=6.19 (lengths at or below the 10th percentile—prematurity defined as less than 35 weeks (Iams , 1996) Previous preterm birth—RR=1.5-2.0—prematurity defined as less than 32 weeks (Iams) Diabetes (GDM)—RR=1.47—prematurity defined as less than 3.7 weeks (Hedderson) Inter-pregnancy interval—pooled adjusted RR=1.07-1.40 (<6 to 12-17mo)—preterm defined as less than 37 weeks (Conde-Agudelo)
Source: Mercer BM. Preterm premature rupture of the membranes.Obstet Gynecol 2003;101:178-93. Reproduced with permission from Lippincott Williams & Wilkins. …prematurity also causes perinatal morbidity, and adverse childhood outcomes
Risk factors for prematurity that we can’t measure from birth certificate data • Maternal stress during pregnancy and over the life course • Alcohol, prescription drugs, other drugs (even smoking is under-reported) • Many congenital anomalies are not detected at birth • Environmental and occupational exposures (even strenuous work) • Periodontal disease • Generational effects (the grandparents’ health, the mother’s health at her own birth etc.)
Determining importance of risk factors (PPOR Phase 2 analysis, continued): • Is the risk factor more prevalent (more common) among Black mothers compared with the reference population? • Among Black mothers, does the factor have a high relative risk, i.e. is a woman more likely to have very preterm birth if she had the risk factor, compared to if she doesn’t? • If we could ELIMINATE the risk factor from this population, how much would the very preterm birth rate be reduced? Population Attributable Risk Percent is a simple descriptive measure of potential impact. It takes into account both “strength” (relative risk) and prevalence of the risk factor. Interaction or overlap among factors is not addressed.
Most important contributors to prematurity among Cuyahoga County Black mothers *not preventable, but predictive
What you can do to prevent prematurity Strongest opportunities (based on birth certificate) : • SES – mitigating the effects of low SES, – reducing prevalence of low SES • Social support, strengthening families • Increasing birth spacing
Poverty is prevalent among Ohio mothers! Medicaid for Delivery 39% AT LEAST ONE of the three indicators of poverty apply to 61% of births WIC 43% High school or less education 44% ALL THREE indicators– 20% of births Ohio births 2006-2010
Poverty is MORE prevalent among BLACK Ohio mothers! Medicaid for Delivery 64% AT LEAST ONE– 88% WIC 43% High school or less education 58% ALL THREE – 34% Ohio births 2006-2010
Approximate distribution of conditions leading to preterm birth 10% muti-fetal pregnancy (twins, triplets) contribute to all three parts • Screening to identify women at risk of spontaneous preterm labor: • Previous preterm • Short Cervix
One more potential direction • Having a previous preterm birth This is an easily identified high-risk population that could potentially be treated with progesterone or 17p during pregnancy. In a population with history of spontaneous preterm birth, weekly injections of 17p reduced preterm birth by 33% (Petrini 2005) Depending on current 17p use, we could expect up to 4% decrease in prematurity if all these women received appropriate treatment. If other high risk women could be identified, progesterone/17p could have more impact.
Centering Healthcare™: The Evidence • Yale University randomized control trial • 1,047 women in public clinics • Randomized to traditional or group care • 33% reduction in preterm birth for women in Centering groups • Other outcomes • Increased satisfaction with care • Increased breast-feeding rates, and • Improved knowledge and readiness for birth and parenting • University of Kentucky Centering Pregnancy Smiles program • Reduction in preterm births from 13.7% to 6.6% • Saved ~$2.1 million in 2 years
Centering delivers results: • Less likely to delivery prematurely: to deliver prematurely (9.8 vs. 13.8 percent). • More likely to receive adequate prenatal care:CenteringPregnancy participants were less likely than those enrolled in usual care to receive inadequate prenatal care (26.6 percent of program participants received inadequate care, compared with 33 percent of those getting usual care) • Higher satisfaction with prenatal care
Centering delivers results • Increased use of postpartum family planning • Hale N, Picklesimer AH, Billings DL, et al. The impact of Centering Pregnancy Group Prenatal Care on postpartum family planning. Am J ObstetGynecol 2014;210:50.e1-7. • Utilization of postpartum family-planning services was higher among women participating in GPNC than among women receiving IPNC (29% vs 20% at 12 months postpartum, p<.05)
Home Visitation: The Evidence • Program dependent • http://homvee.acf.hhs.gov/programs.aspx • http://homvee.acf.hhs.gov/EvidenceOverview.aspx
Home visiting delivers results Every Child Succeeds (ECS), an established, regional home visiting program in southwest Ohio from 2007 to 2010 Healthy Families America model of home visiting; program goals are to (1) improve pregnancy outcomes through nutrition education and substance use reduction, (2) support parents in providing children with a safe, nurturing, and stimulating home environment, (3) optimize child health and development, (4) link families to health care and other services, and (5) promote economic self-sufficiency. for at-risk, first-time mothers.
Home visiting delivers results Pediatrics.2013 Dosage effect of prenatal home visiting on pregnancy outcomes in at-risk, first-time mothers. GoyalNK1 et. al Evaluated the effect of home visiting dosage on preterm birth … in women in southwest Ohio. Home visits are provided by social workers, child development specialists, nurses, or paraprofessionals Results: ≥8 completed visits by 26 weeks reduced odds of preterm birth by about 2/3 (compared with <3 visits)
Cuyahoga County (2006-2010) From Underlying Cause of Death, 62% of the green pie slice is due to sleep related deaths; (Black Cleveland 2008-2010) SUID rate was 2.2, should be <.5
Causes of Sleep-related death Source: Rachel Moon’s CDC Grand Rounds Presentation October 2012
Based on good and consistent scientific evidence • Back to sleep for every sleep • Use a firm sleep surface • Room-sharing without bed-sharing is recommended • Keep soft objects and loose bedding out of the crib • Pregnant women should receive regular prenatal care • Avoid smoke exposure during pregnancy and after birth • Avoid alcohol and illicit drug use during pregnancy and after birth • Breastfeeding is recommended • Pacifier for sleep • Avoid overheating Source: Rachel Moon’s CDC Grand Rounds Presentation October 2012
Relevant national initiatives • Cribs for Kids • >300 partners nationally • Provide low-cost portable cribs to organizations, who then provide them free or at cost to parents who cannot afford a crib • ABCs • Alone, on your Back, in a Crib • Baltimore City Health Department and others • Safe to Sleep • NICHD-led public awareness campaign • Expands focus from back sleeping only to ALL of the components of a safe sleep environment (position, bedding, bedsharing, sleep surface, etc.)