Cheryl Lauber, DPA, MSN Perinatal Consultant Michigan Department of Community Health

1. Leveraging Opportunities for Prevention across the Life-Course: Utilizing Data to Target Risk Factors Cheryl Lauber, DPA, MSN Perinatal Consultant Michigan Department of Community Health

2. Trend of Infant Mortality Rate in Michigan Basic Health Indicator: Infant Mortality Rate (IMR): number of infant deaths per 1,000 live births Infant Mortality Rate

3. PPOR Findings: Eleven Communities with High Infant Mortality (1998-2002) IMR Difference IMR difference: Black IMR compared to reference group

4. Profile of Women having an Unintended Pregnancy in Michigan • In 2004, the prevalence was highest in: • Black women • less than 18 years of age • less than a HS diploma/GED • not married • no insurance • Medicaid • annual household income of $10,000 or less 2004 Michigan PRAMS

5. Profile of Women having an Unintended Pregnancy in Michigan • Unintended Pregnancy is: • 3.9 times more likely if not receiving any prenatal care • 2.8 times more likely if experiencing one or more stressors • 2.2 times more likely if smoking during pregnancy • 1.3 times more likely if LBW infant 2003 Michigan PRAMS

6. Voices of the Women • Preconception health and concept of planningas related to pregnancy is not well understood. • An understanding of pregnancy experiences of African American women are needed to make changes in the health care system to support better outcomes.

7. Voices of the Women • Women have a consciousness about their readiness for pregnancy which should inform preconception planning. • Affective and behavioral needs of women must be incorporated in preconception care. • Reinforce that planning a pregnancy is in the control of both the woman and the man. • Strengthen cultural commitment of healthcare professionals through partnerships, advocacy, and information.

8. Primary Goals for Reducing Infant Mortality • Improve maternal preconception health • Improve access to healthcare for mothers and infants • Eliminate the racial disparity in infant mortality rates • Improve infant health and safety

9. Steps to Program Development • Goals of local coalitions • Identify access and service system barriers • Identify needed prevention, primary care and support activities and services • Develop, implement, evaluate a community-wide plan • Produce annual report on the community’s infant mortality status

10. Michigan Interconception Care Program • Identify 25 women with a poor pregnancy outcome • Hospital discharge • Other health department programs. • Nursing/medical/genetic risk assessment • Provide grief support if indicated • Contraception access • Access to a medical home • Chronic disease management • Target obesity, substance use, mental health • Promote 18 month interpregnancy interval • Case management up to 24 months

11. Performance Against Goals • Goal: to field test an Interconception Care strategy for African- American women who experienced: • Preterm birth or low birth weight birth • Fetal or neonatal death • Actual: 104 women have been recruited from communities and have reported data • 65 Preterm birth/Low birth weight birth • 24 Fetal or neonatal death • 14 Miscarriage

12. Project Planning • What was good about the plan? • Logical path from data to action • Phased approach • Evidence based intervention • What was missing from the plan? • Specific protocol for the home visiting • Staff support for more local training • Was the plan realistic? • Time to make this change was limited • Funding was not guaranteed • How did the plan evolve over time? • Began with local organization, education & assessment • Evolved to service delivery options & intervention strategies • Key areas for improvement: • Make very specific recommendations.

13. Project Management • Project Direction Team meets monthly • Project Manager; Program Consultants; Division Managers; Epidemiologist • Sharing about issues, recent data, strategic plan accomplishments • Communication • Network meetings quarterly • Conference calls as needed • Database tracks client progress • Meetings with broader perinatal program partners

14. Outcome Indicators • Preterm births • Low birth weight • Unintended pregnancy rate • Family planning access • Intergestation timeframes

15. Evaluation Elements • Index Pregnancy Info • Outcome • Delivery Date • Birth Weight • Gestational Age • NICU Admission • PNC Started • Number PNC Visits • Maternal Age • Source of Payment • Mother’s Information • DOB • Residence • Race • Education • Marital Status • Source of Primary Care • Pregnancy History

16. Evaluation Elements • Subsequent Pg Info • Outcome • Delivery Date • Birth Weight • Gestational Age • NICU Admission • PNC Started (weeks) • Number of PNC Visits • Maternal Age • Source of Payment • Index Pg Risk Factors • Prepregnancy Weight • Infection History • Alcohol Use • Tobacco Use • Street Drug Use • Domestic Violence • Mental Health Problems • Chronic Illness • Unplanned Pregnancy

17. Evaluation Elements • ICC Program Information • Eligibility • Enrollment date • Recruitment source • # Home visits made • Referrals completed • Assessment completed • Family planning • Nutrition • Mental Health • Substance Abuse • Bereavement Support • Discharge date • Type of provider

18. What Went Right • Partnership with other state programs • WIC; MIHP; FP; Healthy Start • Local coalition building • Good local awareness • Local partnerships started • Able to pilot interconception care in variety of settings

19. Developing Partnerships • Division of Chronic Disease • ECIC • Children’s Special Health Care Services • Southeast Michigan Regional Infant Mortality Task Force

20. What Went Wrong • Local willingness to develop an intervention project • LHDs are less involved in direct service • More comfortable with education campaign • Funding stability • State fiscal crisis • Little commitment from legislature • Project management • Hiring new staff was delayed • Trouble mandating qualified local staff

21. Preliminary Data • Pregnancy Outcome for women recruited N=104 • #/% fetal deaths 15 (14%) • #/% neonatal death 9 (9%) • #/% preterm birth 62 (60%) • #/% miscarriages 14 (14%) • Characteristics of women • mean age 22.7 (14 <18 yrs) • #/% African American 75 (72%) • #/% High School educ 60 (71%) • #/% married 21 (20%) • #/% Medicaid eligible 76 (84%)

22. Preliminary Data • Index Pregnancy Information • mean birth weight 1698 g • mean Gestation Age 27.5 wks • #/% NICU adm 52 (54%) • mean # PNC visits 4.9 visits • #/% PNC 1st trimester 54 (79%) • Program Information • recruitment sources: MIHP, FIMR, Healthy Start, SIDS Program, Hospital social worker, Birth certs, flyers, Early On, WIC, NFP

23. More Action Needed • Identify women and intervene in existing programs, WIC, MIHP, Family Planning. • Revise program policy to include these goals. • Target women eligible for Medicaid. • Focus FIMR data collection on fetal death, pre-term and low birth weight births. • Provide training for program staff. • Educate private ob-gyn providers on life-course perspective and inter-conception care.