Maternal and Infant Mortality Health Disparities Research: Striving and Thriving

1. Maternal and Infant Mortality Health Disparities Research: Striving and Thriving Phyllis W. Sharps, PhD, RN, CNE, FAAN Associate Dean, Community and Global Programs Professor Community Public Health Nursing Johns Hopkins University School of Nursing February 1, 2013

2. Perinatal Nurse Home Visitation Home Visitation Enhanced with mHealth (DOVE 2) NIH/NINR - R01NR009093-01A2 /NINR

3. The Journal Begins With A Vision:Excellence in Nursing

4. MARY SEACOLE 1805 - 1881 Mary Seacole's reputation after the Crimean War (1853-1856)rivaled Florence Nightingale's. Unlike Nightingale, Seacole also had the challenge to have her skills put to proper use in spite of her being black. A born healer and a woman of driving energy, she overcame official indifference and prejudice. She got herself out to the war by her own efforts and at her own expense; risked her life to bring comfort to the wounded and dying soldiers; and became the first black woman to make her mark on British public life. But while Florence Nightingale has gone down in history and become a legend, Mary Seacole was relegated to obscurity until recently.

5. Hatching DOVE • Active duty – military perinatal nurse • Maternal and Infant Clinical Nurse Specialist • Home Visiting – Reaching Mothers and Infants • Parents and Children Together – HOME (doctoral student) • Adolescent Postpartum Depression and Mother and Infant Interaction (dissertation research) • Pride in Parenting (lay home visitors; DC Cooperative Perinatal Studies to Reduce IMR) • Passport to Health (nurse home visit intervention to reduce violence related health disparities)

6. Hatching DOVE Other Constant Research and Practice Interests: • Reducing Infant Mortality Rate among African American women • Depressive symptoms in pregnant and parenting low income women • IPV and perinatal health outcomes

7. Hatching DOVE • Other Experiences • Research assistant • Member of interdisciplinary research team • Mentored research with a senior research (K Award) • Working and listening to community - shelter • Immersing in research activities/environment (NNVAWI/Research Consortium) • All contributed to my keen desire to do health disparities research – before it was even called health disparities

8. Background for DOVE • IPV violence during pregnancy linked with adverse outcomes for: • Mothers • Infants • More than 3 million children witness IPV of mother each year • More than 50% of these children are under 6 years old

9. Background for DOVE • 8-22% of pregnant women (vs. 7% pre-eclampsia or hypertension during pregnancy) • Most significant risk factor - abuse before pregnancy.

10. Background for DOVE (Ballard et. al., ’98) Protective period • Women beaten before and after – (30%) Risk period • May start during pregnancy (24%) – especially first pregnancy - “Business as usual” • IPV neither increases or decreases (75%) - (Martin ’01; Saltzman ‘03)

11. Background for DOVE Patterns of IPV During Pregnancy • Type of Abuse Changes • Physical abuse may lessen or stop but emotional abuse, controlling behaviors stay same or increase (Castro ’03) • Teens at Greater Risk • Higher prevalence of abuse during pregnancy among adolescents than adult women (Parker, McFarlane ’93)

12. Background for DOVE Ethnic group comparison significantly lower in Hispanic couples (Mexican American) -14% vs. 16% in African American and Anglo (McFarlane & Parker ‘92)

13. Abuse During Pregnancy By Ethnic Group And Assessment (N=1000) *Torres, Campbell, et.al. ‘99 Birth weight & Abuse During Pregnancy (NINR) N=187 N=198 N=89 N=141 N=192 N=196

14. Background for DOVE Associated with poor outcomes • Late entry into prenatal care • Increased low birth weight birth • Poor weight gain • Increased preterm delivery • Poor adherence to medications

15. Background for DOVE IPV Correlates • Depression • Substance abuse • Low social support IPV Correlates • Spontaneous abortion • Smoking • Risk of homicide (Gielen et al ‘94; Campbell et al ‘92)

16. Background for DOVE Infant Health Correlates • LBW • Low income/poor women (Bullock & McFarlane ‘89) • Connections w/ smoking • Poor maternal low weight gain • substance abuse (Curry et al ‘99) • Child Abuse • Most severe abuse – non-biological father

17. Background for DOVE(Campbell et al ‘99;Torres et al ’01) Poor Infant Outcomes • LBW in term infants • Physical abuse - risk factor (OR = 3.29) • Physical abuse not a risk factor for preterm-infants (bivariate analysis) • Evidence of mediation in multivariate LR • Low weight gain (OR = 3.4) • And/or inadequate prenatal care (OR = 1.8) • And/or poor obstetric Hx (OR = 3.6)

18. Infant Mortality Rates (CDC 2012)

19. Infant Mortality Miami-Dade County • Infant mortality rates most profound indicator of health disparities • Blacks have the highest rate 2.5 times higher than Whites and 3 times higher than Hispanics

20. Background for DOVE IPV AND Maternal Mortality • Maternal Mortality • Death from all causes during pregnancy, and year after delivery or pregnancy termination • Homicide • Leading cause of maternal mortality in US cities where measured (NYC, Chicago, DC) (Dannenberg, ’95; Krulewitch ‘01) • Leading cause of maternal mortality in entire state of MD - – 20% of deaths (Horon & Cheng, 2001)

21. Background for DOVE • Little evidence of appropriate interventions to reduce IPV among mothers and exposure for neonates and infants • DOVE proposes to address this gap

22. Domestic Violence Enhanced Home Visitation Program (DOVE) NIH/NINR - R01 NR009093

23. Purpose of DOVE • Rigorous test of structured IPV intervention – DOmesticViolence Enhanced Home Visitation Program • Mothers and infants • 2 Sites and Settings • Urban – Baltimore City HD • Urban –Missouri HD • Rural –Missouri HD

24. Design • 3 different designs in 3 different settings • RCT • Mixed methods – quantitative & qualitative • BCHD(women and infants) • Eligible women = R→DOVE vs. UC • MOHD (women and infants) • 12 HDs = R→ 6 HD DOVEvs. 6 UC • NFP(Olds HV model; mothers and infants) DOVEvs. Olds database

25. Schema for DOVE Project Kansas City, Missouri URBAN (Baltimore City Health Dept.) RURAL (Missouri Health Dept.) ò ò ò Selected from NFP National Data 1 NFP (N=40) 12 HD’s (N=160) Referrals ò ò ò RANDOMIZE REFERRAL BCHD  ÷ ø ò DOVE-NFP RANDOMIZE Usual Care (6 HD’s) DOVE (6 HD’s) ÷ ø Usual Care (M&I) DOVE (M&I & DOVE) Data Collection/Follow Up Assessments -

26. Methods • Recruit women – up to 31 weeks gestation • Intervention • DOVE =Structured IPV pamphlet • Nurse home visit intervention+ DOVE • DOVE – 3 prenatal sessions • DOVE – 3 postpartum sessions (up to 12 weeks) • Data Collections • Baseline (recruitment) • Delivery • Postpartum – 3, 6,12,18, 24 months

27. Methods Quantitative Study: Measures • IPV • Maternal Mental Health ( stress, depression, PTSD) • Parenting(stress, stimulation) • Infant Growth & Development • Use of Community Resources

28. Methods Qualitative Study • Patterns of IPV • Urban/Rural influences on patterns of IPV

29. DOVE Has Wings • Funded – Feb 1, 2006 – Nov 30, 2011 • Human Subjects Approvals • 2 Universities and 2 Health Departments • Certificate of Confidentiality • Final IRB Approvals • Data Collection • Began – Dec, 2006 • Ended – October 2011

30. DOVE Project Team Investigators • Phyllis Sharps, PhD, RN, PI - JHUSON • Linda Bullock, PhD, RN, Co-PI – Univ. of Missouri • Jackie Campbell, PhD, RN, Co-PI - JHUSON • Linda Rose, PhD, RN , Investigator - JHUSON • Michelle Cooley, PhD, Investigator - JHBSPH (child psychologist) Consultants • David Olds, PhD – Univ. of Colo. (NFP) • Barbara Parker, PhD, RN, UVA (Structured Intervention) • Linda Pugh, PhD, RN – York College (intervention fidelity monitoring) • Karen Soeken, PhD – Professor Emeritus (biostatistician) • Sharon Ghazarian, PhD (biostatistician) ) PROJECT STAFF Project Coordinator • Kim Hill, MPH DOVE Intervention Nurse • BCHD –Keauna Williams, BSN DOVE Research Nurses • Etasha Crowder, BSN • Kristina Marcantonio, MSN Post Doctoral Fellow • Sandra Giangrande, PhD, RN Doctoral Students • Jeanne Alhusen, PhD, RN • Marguerite Baty, PhD, RN • Rachel Walker, UG Honors Research – now PhD candidate

31. Are We Making A Difference Preliminary Findings

32. Baseline Demographics

33. Preliminary Data:IPV and Health Outcomes Mean Scores

34. Other Preliminary Findings • Nurse HV for abuse women feasible • DOVE can be integrated into HD HV programs • Good retention • DOVE reduced self reported IPV • UC reduced IPV too • More analysis • Multiple partners • Did DOVE work better for some women • SGA babies and IPV

35. Other “ANNA” Stories • Data analyses from the Qualitative Phase of the DOVE study are showing that women, whose violence was addressed early during the home visiting program, are telling us about many positive choices they are making in improving their lives and their children’s lives by 24 months post-delivery. • Talking about the violence to the home visitor has been powerful! • Women will talk about IPV

36. Lessons Learned Developing Partnerships

37. Academic-Community Partnership Johns Hopkins School of Nursing (JHUSON) • Location:Baltimore, Maryland, USA • Mission:To provide leadership to improve health care and advance the profession through education, research, practice, and service. Baltimore City Health Department (BCHD) • Location: Baltimore, Maryland, USA • Mission: Maternal and Infant (M&I)Nursing Program provides home visiting and case management services to pregnant women and infants in Baltimore City in order to improve maternal health, birth and infant outcomes.

38. Partnership Benefits • Established Infrastructures • JHUSON Academic Resources • BCHD-M&I Program Community Resources • Sharing of Resources • DOVE Intervention Nurse=Liaison • Between JHUSON & BCHD-M&I • Implementation of DOVE intervention into existing BCHD-M&I program • Application of evidenced based research into real practice setting – a test of efficacy • Potential Positive Impact on MCH Outcomes

39. Preparing to Launch DOVE • Developing The Town (Home Visitors) and Gown (Research team) Partnership • Both Health Departments: • The Missouri Department of Health and Senior Services (MoDHSS) • Baltimore City Health Department Maternal and Infant Home Visit programs • Extremely supportive of identifying IPV and working with both research teams

40. Developing the Town/Gown Partnership • Examples of activities to develop partnership • Research team members made frequent visits to the DOVE sites and reviews the research protocol with trained HV and new staff • Monthly meeting with BCHD to discuss DOVE protocols • DOVE Nest newsletter sent monthly to all health departments • Conducted professional in service training for health departments • We have conducted 10 different workshops regarding screening for IPV with the home visitors over a four -year period at both sites

41. Issues for the Partnership • Challenges of partnering with urban and rural health departments • Home Visitors lack of educational preparation regarding research protocols • Lack of understanding of the importance of screening for IPV • Discomfort with screening for IPV • Rural Settings - distance that has to be traveled by the research team to maintain relationships with the staff • Urban Settings – bureaucratic procedures that hinder recruitment process • Urban Settings – large case loads limit time available for intervening

42. Threat To The Study’s Integrity • After 3 ½ years of recruitment – referrals made at both sites (Baltimore and MO) have not met targeted goals • PIs at both sites hypothesized that: • There may be an issue with women disclosing: • Because of the rural setting of the MO site • Because of the urban setting of Baltimore site • The HVs are not comfortable screening women for IPV • Barriers Study

43. Partnership Limitations • Control • Interdependence of each entity for project results • Communication • Ensuring all team members are up-to-date • Motivation • Team members professional investment in project

44. Clinical Significance • DOVE combines evidenced based protocols • DOVE an be integrated into existing culturally based approaches • DOVE intervention is low cost • DOVE intervention requires training and “buy-in” • Women had many positive comments about DOVE

45. Striving and Thriving • Find your passion • Being part of a team or partnership • Nurturingis the norm • Committed to success of all members • Mutual benefits • Expected, spelled out, agreed upon • Establishment of trust • Clear expectations – but some give and take • Meeting deadlines – mutual respect not obligations

46. Striving and Thriving • Community Connections • Be a part of a community – a real commitment • Community is also a part – a real commitment • Meaningful and important roles and involvement for community members • Do no harm • Share what you learn with the community • Enhance the community – include on teams

47. Striving and Thriving Planned Small Steps • Projects • Small projects • Each project builds on the next • Carve out a part of a larger project – that builds on where you want to go • Funding • Foundations • Professional groups • Community Groups/Faith partners • NIH ( Mentored awards, small R’s →→ RO1)

48. Striving and Thriving Have Fun Along the Way !! • Celebrate the achievements of all (publications, presentations, recruitment goals, enrolling in courses) • Celebrate the milestones • Support each other over the rejections and disappointments (no funding, rejections, slow recruitment, grants, abstracts, manuscripts, slow recruitment)

49. NATIONAL DOMESTIC VIOLENCE HOTLINE 1-800-799-SAFE NURSING NETWORK ON VIOLENCE AGAINST WOMEN INTERNATIONAL (NNVAWI) 1-888-909-9993 NNVAWI.ORG NATIONAL DOMESTIC VIOLENCE HEALTH RESOURCE CENTER (FVPF) 1-800-537-2238 ENDABUSE.ORG

50. DOVE WEBSITE • http://www.son.jhmi.edu/research/dove psharps@son.jhmi.edu • 410-614-5312 Thank You !!!