Preconception Early Prenatal Care: Examining Evidence Based Practice Strategies for KS MLC Project

1. Preconception & Early Prenatal Care: Examining Evidence Based Practice Strategies for KS MLC Project Ginger Breedlove PhD, CNM, ARNP, FACNM Assistant Professor, KU School of Nursing Nurse Midwifery Education Program Director

2. What is this all about?

3. Improving lives of women & children in Kansas Birth rates for 15-19 year olds 2005/2006 41.4/1,000 and 42.0/1,000 respectively Birth rate for unmarried women ages 15-44 at all time high in U.S. � 50.6% In Kansas rate is 35% (all races) Number and percentage of preterm births in Kansas in 2006 4,824 and11.8% respectively NVSR, Vol 57, (7), January 7, 2009

4. Objectives Discuss Evidence Based Practice (EBP) & Best Practice Models Describe exemplary models of PNC in U.S. Define access & outcomes issues Explore challenges Enhance concept development

5. Adequacy of Prenatal Care (PNC) in KS - 2007 Kansas reported 39,055 live births [met definition of PNC] 77% received adequate or better 23% received less than adequate Of this subset 16% received Inadequate PNC Kansas counties with highest percentage of Inadequate Prenatal Care (IPNC) Scott, Seward, Hamilton, average 38% Significant clustering of IPNC in lower southwest KS counties Southeastern counties rate of IPNC Cherokee 31% Other surrounding counties range 9 � 28% Jefferson & Shawnee counties rate of IPNC were 11% and 14% respectively Urban county with largest index of IPNC � Wyandotte, 29% KS APNC Utilization Index, 2007, CHES/KDHE publication, http://www.kdheks.gov/ches/

7. IPNC Percentage to People (2007) Kansas overall rate was ~ 6,351 pregnant women Jefferson & Shawnee counties ~360 women Lower 8 counties in Southeast KS ~ 230 women Wyandotte county 748 women

8. U.S. Trends in PNC

9. PNC by Race/Origin in U.S.

10. Young women in their teens are by far the most likely to receive late or no prenatal care

11. Providers of PNC in KS OB/GYNs Family Medicine ARNPs CNMs WHNPs FNPs Physician Assistants Professional (lay) midwives Indigenous midwives Is it just a provider shortage issue? Discussion�

12. Benefits of PNC Early and ongoing PNC can improve pregnancy outcomes by: Assessing health risks Providing health care advice Assisting in supportive services Managing chronic and pregnancy-related health conditions NVSR, Vol 57, (7), January 7, 2009

13. What is EBM/EBP? Evidence based medicine is a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values. (Sackett DL, Strauss SE, Richardson WS, et al. Evidence-based medicine: how to practice and teach EBM. London: Churchill-Livingstone, 2000)

14. An example in KS Hunter Health Clinic, Wichita Comanzando Bien prenatal care program with focus on Spanish speaking pregnant women diagnosed with Gestational Diabetes Funded by the KS Chapter MOD and other agencies Other EBP examples in Kansas?

15. Five Step Model of Evidence-Based Practice Convert information needs into answerable questions Track down with maximum efficiency the best evidence with which to answer them Critically appraise that evidence for its validity and usefulness for your desired outcome Apply the results of this appraisal to your practice/project Evaluate your performance

16. Create your Question How would you describe a group of patients you are interested in OR a particular problem of interest? What are the most important characteristics of the population? This may include the primary topic, or co-existing conditions. Consider how gender, age, race, payer status, religion, SES or other variables influence the desired outcome.

17. Determine an intervention, prognostic factor or exposure Which main intervention is most relevant? What do you want to do for the patient? Improve access? Improve outcomes? Provide minimal services? What factors may influence the outcome? Co-existing problems? Is there an influencing exposure delaying care? Substance abuse, others

18. Comparisons of Interest What is the main alternative to compare with the intervention? Are you trying to decide between two outcomes: an outcome with no intervention vs. usual care or two pilot interventions or between multi-site outcomes Your clinical question does not always need a specific comparison.

19. Outcomes What can you hope to accomplish, measure, improve or affect? What are you trying to do for the patient? Relieve� Reduce� Improve�

20. So a question might be� �In pregnant patients with no insurance, is access to care through coordinated, regionalized services among LPHDs effective in reducing the rate of late entry into prenatal care?� See worksheet FSU College of Medicine Library Question building�

21. What are AMCHP Best Practice Models? (2004) AMCHP defines �best practices" as a continuum of practices, programs and policies ranging from promising to evidence-based to science-based. A best practice could focus on the health of women, adolescents, young children, families, or children with special health care needs. It could address mental health, data and assessment, financing, program integration, workforce development, emergency preparedness, family involvement, or a public health issue.

22. Resources for MCH Best Practices MCH national database are materials published in 2000 or later that are program practices evaluated to be effective, or best practices, in a variety of topics, including community programs, women's health, infant health, and others. http://www.mchlibrary.info/action.lasso?-database=Biblio&-layout=Web&-response=/databases/BibLists/bib_effective.html&-MaxRecords=all&-DoScript=auto_search_effective&-search Sakala, C. & Corry, M. P. Evidence-based maternity care: What it is and what it can achieve. New York, NY: Milbank Memorial Fund, 2008,128 pp. http://www.milbank.org/reports/0809MaternityCare/0809MaternityCare.html

23. MCH Preconception and PregnancyKnowledge Path (April 2008) Maternal and Child Health Library at Georgetown University It offers a selection of current, high-quality resources that analyze perinatal health statistics, describe effective prenatal care programs, and report on research aimed at improving access to and quality of prenatal care and improving perinatal health outcomes. A separate section lists consumer health resources. Includes section of resources on specific aspects of preconception and pregnancy: childbirth, depression, drug and alcohol use, environmental concerns, fertility and infertility, nutrition, oral health, and tobacco use. http://www.mchlibrary.info/

24. Searching the Academic Literature There are literally millions of published reports, journal articles, correspondence and studies available to clinicians. Choosing the best resource to search is an important decision. Large search engines will give you access to the primary literature. CINNAHL, PubMed, OVID, MEDLINE The Cochrane Library database provides access to systematic reviews which help summarize the results from a number of studies.

25. How to do an effective search If you are not familiar with searching PubMed, you may want to use the PubMed tutorial at http://www.nlm.nih.gov/bsd/pubmed_tutorial/m1001.html If you are not familiar with searching MEDLINE in OVID, you may want to use the OVID tutorial at http://www.mclibrary.duke.edu/training/ovid You can even try GOOGLE SCHOLAR as a search engine

26. EBP Tools: Hierarchy of rigor

27. Guideline Recommendation and Evidence Grading (GREG) Evidence grade: I (High): the described effect is plausible, precisely quantified and not vulnerable to bias II (Intermediate): the described effect is plausible but is not quantified precisely or may be vulnerable to bias III (Low): concerns about plausibility or vulnerability to bias severely limit the value of the effect being described and quantified Recommendation grade: A (Recommendation): there is robust evidence to recommend a pattern of care B (Provisional recommendation): on balance of evidence, a pattern of care is recommended with caution C (Consensus opinion): evidence being inadequate, a pattern of care is recommended by consensus

28. Common reporting terms Confidence Intervals are calculated on the results of the data to show the strength or weakness of the evidence. A 95% CI [range] means that if you were to repeat the same clinical trial a hundred times you can be 95% sure that the data would fall within the calculated range. Odds Ratio describes the odds of an experimental patient suffering an adverse event relative to a control patient.

29. and Definitions p Value refers to the probability that any particular outcome would have arisen by chance. The smaller the p value the less likely the data was by chance. Standard scientific practice, usually deems a p value of less than 1 in 20 (expressed as p=.05) as "statistically significant" The smaller the p value the higher the significance. A p value of p=.01 (less than 1 in 100) is considered "statistically highly significant" Relative Risk is the risk of developing a disease in the exposed group divided by the risk of developing the disease in the unexposed group.

30. Article on PNC Early Access to Prenatal Care: Implications for Racial Disparity in Perinatal Mortality Sub-analysis from large prospective RCT examining first and second trimester risk of Down�s and NTDs Conclusions: Racial disparities exist in perinatal outcomes despite early access and entry to PNC Healy, Malone, Sullivan, et.al. (2006) Obstetrics & Gynecology, 107 (3), 625-31.

31. Exemplary Models of PNC What are the characteristics of PNC believed to be of value for providers and consumers? Discussion�

32. LA, California Developed a Comprehensive Perinatal Collaborative Program in LA County Integrated a referral for perinatal services into the 2-1-1 system and serve as a main referral agency for entry into PNC Promote risk appropriate perinatal care in early pregnancy and beyond for seamless integration of services Developed Speaker�s Bureau Preconception Care Marketing Tools Reproductive Life Plan Toolkit Pregnancy and Family Friendly Workplace Policies Brief

33. Indiana Perinatal Network (IPN) Indiana Access: A Community Based Research & Training Project designed to improve access to services for low-income pregnant women and children.

34. IPN Background In 2002, after competing with more than 70 cities throughout the nation, Indianapolis was one of four chosen to participate in a community-based research project, known nationally as Friendly Access, and locally as Indiana Access. This community-based research project is governed by the principle that the way in which people are treated plays a role in whether they access and continue to participate in primary and preventive health services, including prenatal care. Based on the Disney Model for Customer Service

35. Indiana Access Key Findings: Handout from Indiana Perinatal Network Consumer Survey How does that impact what we do and might need to change in Kansas? Discussion�

36. Arizona Perinatal Health Initiative on early PNC A crucial step to improving prenatal care utilization is the identification of pregnant women early in the pregnancy (i.e. before conception or within the first trimester). Outreach efforts are also crucial to assure that pregnant women receive consistent prenatal care. Identification and outreach activities work hand-in hand. For example, identifying high-risk pregnancies and providing outreach activities to assure consistent prenatal care utilization among high-risk pregnancies will result in better birth outcomes.

37. Arizona activities increase early access to PNC Funded 15 high priority health departments. LCHDs provide activities including pregnancy testing, community education, clinical services, information and referral County develops goals depending on needs identified by community members, service providers, and medical community Interventions include: CHWs Baby Arizona, a public/private partnership Public awareness campaign Focus on early and consistent PNC http://www.azdhs.gov/phs/owch/cpbg.htm

38. Resources from a non-profit, Public/private collaborative Additional models of exemplary MCH practice

39. Center for Health Care Inc. (CHCS) Strategies Improving the quality and cost-effectiveness of publicly financed health care Nonprofit health policy resource center dedicated to improving the quality and cost effectiveness of health care services for low-income populations and people with chronic illnesses and disabilities. CHCS works directly with states and federal agencies, health plans, and providers to develop innovative�programs that better serve people with complex and high-cost health care needs.

40. CHCS Toward Improving Birth Outcomes: A BCAP Toolkit Toolkit provides a step-by-step, practical approach for improving birth outcomes among Medicaid and SCHIP enrollees. It includes a simple process improvement model to consistently follow including: strategies for identification, stratification, outreach, and intervention, including case studies and communications tactics for creating change http://www.chcs.org/publications3960/publications_show.htm?doc_id=212947

42. Access What are some provider and service-related issues, barriers, and variables related to EARLY access to prenatal care?

43. What about maternal characteristics? Marital Status For each maternal age group, unmarried status increase risk for LBW babies Father acknowledging his child early in pregnancy** Adolescent Pregnancy** Increased risk for PTB, LBW, and infants die in first 12 months Socioeconomic Status Increases risk suboptimal outcome, particularly with PTB** Substance Abuse Virtually EVERY illicit recreational drug associated with adverse pregnancy outcomes Stress Amount of education** Culture and Tradition Pregnancy Wantedness Interpregnancy Interval **Highest Rate Late Entry PNC

44. Association of Preconception Care and Early PNC 2006 Article by Liu and Li (China) How might incorporation of an annual preconception health care appointment impact: Services Billing Staff Educational Resources Reduction of poor perinatal outcomes Earlier entry into PNC MOD Preconception Screening (See Tool)

45. Trust for America�s Health: Healthy Women, Healthy Babies An ISSUE BRIEF, June 2008 The leading document on improving outcomes through incorporation of universal preconception care �IT�S BEEN DONE A CERTAIN WAY FOR 40 YEARS. EVERY WOMAN IS SUPPOSE TO SEEK CARE DURING THE FIRST 3 MONTHS OF PREGNANCY. WHAT WE HAVE LEARNED IS THAT THIS IS GOOD -- BUT IT�S NOT GOOD ENOUGH!� Magda Peck ScD, CityMatch http://healthyamericans.org/reports/files/BirthOutcomesLong0608.pdf

46. Factors Influencing Outcomes!

47. Outcome Measures � Common Concerns Where do you find reliable measures? What is a comparable benchmark? How long should it take? What if I can�t replicate the same interventions? It might cost more than the accessible funds available. The stakeholders might not be interested. We don�t have enough human resources to conduct the project.

48. Creating Process/Outcome Measures Seek usefulness, not perfection. Use small or repeated samples. Measure over specified time and over a wide range of conditions. Include quantitative and qualitative measures

49. PNC Determinants & Outcomes Goals of 90 percent have been set both for care beginning in the first trimester of pregnancy and for early and adequate prenatal care, as part of the Healthy People 2010 program. **No goal has been set for reducing late or no prenatal care.

50. Are outcomes just about Entry/Access of PNC? Preconception and Family Planning Scope of services Provider collaborative Awareness campaign Educational and supportive services Community engagement and business partners

51. Challenges ahead

52. Expecting Trouble: The Myth of Prenatal Care in America (2000) by Thomas Strong, MD, MFM University of Arizona What is ADEQUATE PNC?

53. Obvious challenges Time Money Human and Nonhuman Resources Geographic Distance Required Partnerships Issue and Outcome Measures Provider types & services Population demographics

54. not so obvious challenges Leader/Follower styles Authority line Hidden Influencers Priority setting Commitment Consensus Collegiality Common end GOAL�

55. Comments from Rural KS �I am from a small town in rural KS which has a huge population of people without insurance. I recently worked at a hospital where women frequently came in to labor with no prenatal care whatsoever. This was because they could not afford insurance. Some had no complications, but many had complications that could have been prevented. Many just needed medications and could not afford them. How can this be happening to women and babies in America? This is a HUGE problem that needs to be addressed and changed.� Masters student in NRSG 835 Spring, 2009 online Primary Care of Women Course, KUMC/KUSON

56. Next Steps State the problem or outcome and construct your clinical question(s) Determine the main interventions are you considering Reflect on Greatest Impact -- Percentages and People Investigate evidence based intervention, exposure or actions addressing your defined question/outcomes Implement and monitor your intervention Evaluate your outcomes Consider comparison data

57. Discussion and Questions