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Collaborative effort to enhance birth outcomes and reduce infant mortality rates in North Carolina. Focus on key causes and trends in infant mortality data.
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Working Together to Improve Birth Outcomes in North Carolina Region IV and Region VI Infant Mortality Summit January 12-13, 2012 New Orleans Belinda Pettiford, MPH NC Division of Public Health, Women’s Health Branch Sarah Verbiest, DrPH, MSW, MPH University of NC at Chapel Hill, Center for Maternal and Infant Health
Women, men, and families! NC Child Fatality Task Force Division of Medical Assistance (Medicaid) UNC Center for Maternal and Infant Health NC Community Health Center Association NC Healthy Start Foundation Community Care of North Carolina Perinatal Quality Collaborative of NC NC Chapter of March of Dimes Division of Mental Health, Dev. Disabilities, and Substance Abuse Svs. NC Medical, Pediatric, and NC OB/GYN Societies NC Academy of Family Practice Local health departments, local CCNC networks, and other providers Numerous universities, colleges, faith entities, and CBOs And the Division of Public Health (home of Title V and OMHHD) and many more! Thanks to our amazing partners!
Every day, two babies die in North Carolina • A society's infant mortality rate is considered an important indicator of its health, because infant mortality is associated with socioeconomic status, access to health care, and the health status of women of childbearing age. (Congressional Budget Office, 1992)
Leading Causes of Infant Mortality Low Birth weight Prematurity Perinatal Conditions Related to Maternal Health Birth Defects Sudden Infant Death Syndrome (SIDS)
About Two-Thirds of NC Child Deaths are Infants Deaths due to perinatal related conditions and birth defects are a major cause of death for children ages 1 to 9 years. 2008 child fatality data from State Center for Health Statistics
Racial Distribution of North Carolina Live Births, 2010 • There were 122,302 births in NC; 3.5% decrease from 2009. • Approximately 24% of live births in North Carolina were to African Americans, 71% to Whites, and 5% to other races. • While nearly 16% of NC live births are to women who report an Hispanic ethnicity, most of these Hispanic births are counted in the White racial category, according to NCHS vital statistics coding rules.
Data Review • In 1988, NC’s overall IM rate was 12.5 per 1000 live births; the 2nd highest in the country. • The downward trend in the NC infant mortality rates has slowed since the mid-1990s, then fluctuated between 8.1 and 8.8 between 2000 and 2008. NC’s IM rate was at an all time low in 2010 (7.0 per 1000 live births); 44% reduction since 1988. • The largest decrease in 2010 was among non-Hispanic African American (19.6% reduction); NH White IMR declined 3.6%. • Racial disparities in IMR remain, with African American NH continuing to have an IMR more than two times (2.3) higher than White NH.
Data Review • The neonatal mortality rate (deaths occurring during the first 28 days of life) decreased 7.5% overall in 2010; there were substantial differences between whites and minorities. The White NH rate increased slightly (2.9%) while the African American NH rate decreased 14.0% (after showing a 13.8% increase the previous year). The Hispanic rate decreased 13.6% after showing a 4.8 percent increase the previous year. • The post-neonatal mortality rate (28 days to one year) declined 19.2% overall in 2010, with White NH showing a decline of 10.5%, African American NH a decline of 30.8%, and Hispanics a decline of 15.4%.
Birth Weight Data • The percentage of infants delivered very low birthweight (less than 1500 grams) remained about the same in 2010 (1.7% in 2010 compared to 1.8% in 2009). • However, NH African American women experience markedly higher rates of low and very low birthweight births (14.1%) than did NH White (7.8%) and Hispanics (6.3%). • The percentage of babies that were delivered by Cesarean section decreased slightly to 31.4% -- down from 31.7% in 2009.
Birth Weight Trends • In 2010, more than one in ten (12.6 percent) of all resident births were premature (less than 37 weeks gestation). This is down slightly from 13.2% of all births in 2009. • While the percentage of live births that are low birth weight has remained somewhat steady, the mortality rates in each birth weight category have decreased dramatically until recently. • The greatest increase in low birthweight has been for babies born under 500 grams; steady for 2010 for a rate of 0.2%.
Reducing Recurring PTB – 17P Initiative Increase appropriate utilization of 17P through a) education of public health leaders, clinicians, and women, b) addressing systems and access issues. Funded by DPH (via General Assembly) since 2006. Strong partnership with Medicaid and CCNC. www.mombaby.org – click 17P
NC Community Health Centers NC has 27 federally qualified health centers 13 of 27 provide OB services Report to HRSA %LBW babies delivered and the trimester entered into prenatal care Majority pregnant women served are Hispanic women Recently received a special grant from HRSA to focus on tobacco cessation counseling
NC Federally Qualified Health Centers Babies born (2005 – 2009) 7% born low birthweight 63% enter care in the first trimester High percent uninsured In 2010, the % of LBW babies born to Hispanic/Latina women was lower than the percent of LBW babies born to non-Hispanic/Latina women (7% vs. 11%, respectively).
Tobacco Cessation • You Quit Two Quit Project – funded by former Health & Wellness Trust Fund (2008-2012) • QI projects in 4 counties based in health departments • Statewide educational and outreach efforts including NICUs • New Project for Low SES Women of CBA funded by Fed Office of Women’s Health (2011-2013) • Focused QI on 8 practices in one CCNC network • Training and TA will be provided to all Chronic Disease and Pregnancy Care Managers within the CCLCF network • Training opportunities will be made available to all practices within the network • Hope to expand to a larger statewide QI program in the future
Perinatal Quality Collaborative of NC (PQCNC) Mission: Promote high value perinatal care Spread best evidenced practice and reduce variation Partner with families and patients Optimize resources Make North Carolina the best place to be born
PQCNC Initiatives Hospital Based Initiatives: • Eliminating elective deliveries under 39 Weeks gestation • Reduce Catheter Associated Blood Stream Infections (CABSI) by 75% in participating centers • Increase Exclusive Human Milk Mother - Baby • Increase Exclusive Human Milk NICU • Support for Intended Vaginal Birth (SIVB)
Reducing Elective Deliveries <39 Weeks Decrease of 43%
Pregnancy Medical Home • Improve birth outcomes in the North Carolina Medicaid population • Provide evidence-based, high-quality maternity care to Medicaid patients • Focus care management resources on those women at highest risk for poor birth outcome • Improve stewardship of limited perinatal health resources • In this program, quality improvement goals are aligned with cost savings goals – keeping more babies out of the NICU and avoiding associated expenses
Methods Quality Improvement focus for Pregnancy Medical Home practices Identify outliers, work with them to improve performance Specific, required performance measures Support, training and resources Pregnancy Case Management is the key intervention Identify the population most at risk of poor birth outcome and focus resources on these women
Pregnancy Medical Home Responsibilities Provide comprehensive, coordinated maternity care to pregnant Medicaid patients and allow chart audits for evaluation purposes for QI measures Postpartum visit must include: depression screening using a validated screening tool; addressing the patient’s reproductive life plan; and connecting the patient to ongoing care if it will not be provided in the PMH practice Provide information on how to obtain MPW, WIC, Family Planning Waiver Collaborate with public health OBCM to ensure high-risk patients receive care management
Pregnancy Medical Home Responsibilities • Eliminate elective deliveries (induction of labor and scheduled cesareans) before 39 weeks • Maintain primary c-section rate at or below threshold level • Primary C/S rate of 20% or lower • Risk-adjusted (term, singleton,vertex) primary C/S rate of 16% or lower • Offer and provide 17p to eligible patients • Conduct standardized risk screening on all Medicaid patients • Clinical integration with care management teams
Priority Risk Factors focus on preterm birth prevention History of preterm birth (<37 weeks) History of low birth weight (<2500g) Chronic disease that might complicate the pregnancy Multifetal gestation Fetal complications (anomaly, IUGR) Tobacco use Substance abuse Unsafe living environment (housing, violence, abuse) Unanticipated hospital utilization (ED, L&D triage, hospital admission) Late entry to prenatal care/missing 2 or more prenatal appointments without rescheduling Provider request for care management assessment
Benefits of being a Pregnancy Medical Home Support from CCNC network Data-driven approach to improving care and outcomes Incentives: Increased rate of reimbursement for global fee for vaginal deliveries to equal that of c-section global fee (similar increase for providers who do not bill global fee) $50 incentive payment for risk screening $150 incentive payment for postpartum visit No prior authorization required for OB ultrasounds
What is CCNC? • Improves Health Outcomes & Reduces Care Costs: • Manages care via population management strategies • Supports the primary care medical home • Care Management Services • Community-based, provider-led • Focuses on quality improvement • Data driven
Working with Communities to Reduce Disparities • Healthy Beginnings • 12 NC communities • Primarily paraprofessionals provide outreach, care coordination and education with specific focus on breastfeeding promotion, folic acid, safe sleep, environmental tobacco reduction/elimination, healthy weight and reproductive life planning. • Services provided to 900 women in 2010; with no infant deaths.
Working with Communities to Reduce Disparities • NC Healthy Start Programs • Healthy Start Corps & Baby Love Plus • 15 communities in our state • Focus primarily within African American and American Indian communities. • Include outreach, health education, case management, depression screening, interconception care, and community engagement. • Most (80%) of the communities showed an improvement in birth outcomes among minority families in 2010. • Community Health Ambassador (OMHHD)
NC Maternal, Infant, and Early Childhood Home Visiting Program • Goal: Coordinate an effective statewide planning and implementation system through a strong alliance with key partners in support of a continuum of home visiting services for families. • North Carolina receives $3.2 million annually through the formula grant created by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148) to support evidence-based home visiting. • North Carolina implementation: • Supports four home visiting models: • Nurse-Family Partnership • Healthy Families America • Parents as Teachers • Early Head Start/Home Based Option
Home Visiting cont. • Seven sites at Local Health Departments & Community Based Organizations • Partnership with the National Implementation Research Network and The Finance Project to support implementation and sustainability planning • Current status: • Implementation began on December 1, 2011 • Oversight from the Governor’s Early Childhood Advisory • Division of Public Health staff support sites in achieving fidelity to the model, learning continuous quality improvement and implementation science through training and technical assistance.
Breastfeeding Promotion • NC Maternity Center Breastfeeding-Friendly Designation • Expansion of Regional Training Center Infrastructure (6 centers that provide training and TA) • Expansion of the Breastfeeding Peer Counselor Program (70 funded programs covering 86 Counties as of July 2011) • Office of State Personnel Lactation Policy that covers all SPA employees with paid break time and space (the ACA only covers hourly workers) • Child Care Regulation providing onsite space to mothers to pump or feed their infant (s)
Trends in the percentage of infants ever breastfed and breastfed at least 6weeks, 6 & 12 months, NC WIC Program 1993-2010
Breastfeeding Challenges • Poverty-in rural areas due to our unfortunate and uncomfortable history of slavery, breastfeeding is seen as a “poor” act and a reminder of the past since many slaves were wet nurses. • PRAMS data shows that going back to work and school is a major barrier to continuation of breastfeeding. • Race-there are assumptions by some providers that African American and American Indian women will not breastfeed so they may not “push” the issue.
NC Infant Safe Sleep Campaign (formerly Back to Sleep) • Established in 1994 • Partnership with Division of Public Health (Title V) • Adheres to American Academy of Pediatrics (AAP) Standards • Administered by NC Healthy Start Foundation • Uses evidence-based research, epidemiology,principles of public health • Incorporates social marketing strategies • Nationally recognized for outreach and social marketing • Child care, communities, media, etc. (providers and public)
Safe Sleep History in NC www.nchealthystart.org • www.mamasana.org
North Carolina leads the way… Largest and most comprehensive Shaken Baby Syndrome Prevention program in the United States. 3 basic components: Hospital education of parents of newborns Community reinforcements Media campaign www.PURPLEcryingnc.info
Hospital Implementation 86 Hospitals (over 5,000 staff) across the state are participating in implementation
Primary Care Provider Participation (as of April 2010) 373 offices participating; 96 out of 100 counties Collaboration with Center for Child & Family Health, UNC Injury Prevention Research Ctr, and National Ctr for Shaken Baby Syndrome
Preconception Health Coalition • Initiated in Jan 2007 ‐ leadership team formed • Initial focus areas: pregnancy intendedness and healthy weight. • NC Preconception Health Strategic Plan released in November 2008. • From June 2008 –July 2011: 4 workgroups meeting regularly to move from strategies to action.
Preconception Health Coalition • Over 150 people. • Representatives from DPI, DHHS, local health departments, public and private universities, community based organizations, non-profit agencies and consumers. • Restructuring coalition so that instead of workgroups, the larger coalition will meets more frequently; will use webinar and videoconference to engage new participants. • Minutes from meetings and other pertinent info available at www.everywomannc.org
Women’s Wellness Materials Reproductive Life Planning Postpartum Visit Project
