Early Start: Increasing 1 st Trimester Prenatal Care in Rural Counties

1. Early Start: Increasing 1st Trimester Prenatal Care in Rural Counties Theresa Hunter, MPH, MS Title V Coordinator Maternal and Child Health Division

2. Objectives • Give an overview of the Title V Program • Discuss the MCH programs currently taking place in Indiana • Describe the components of the Early Start Program • Specifically discuss the implementation of the Early Start Program in Harrison County

3. What is the Title V Block Grant? • Enacted in 1935 as a part of the Social Security Act, the Title V Maternal and Child Health Program is the Nation’s oldest Federal-State partnership.

5. Title V Program- Indiana • Currently fund 46 grantees throughout Indiana • Focus on issues related to: • Infant mortality • Pregnant mothers • Family planning • Children’s health • Adolescent health • Oral health • CYSHCN • Indiana Family Help Line

6. Infant Mortality- Indiana • Infant Mortality is Indiana’s #1 Health Priority • In 2011 Indiana had 7.7 deaths/1000 • Indiana is 45th worst out of 51 states (includes DC) in 2011 • IN consistently one of the worst in USA • Indiana only <7.0 once in 113 yrs!! • 6.945 in 2008

7. What causes infant mortality?

8. Top 5 Causes of Infant Mortality • Born with a serious birth defect • Born too small or too early • Preterm • <39 weeks • Low Birth Weight (LBW) • Weight less than 5lbs 8 oz (2500 grams) at birth • Very Low Birth Weight (VLBW) • Less than 3lbs 5 oz (1500 grams) at birth • Sudden Infant Death Syndrome (SIDS) • Affected by maternal complications of pregnancy • Diabetes, hypertension, obesity, etc. • Victims of injuries • Suffocation deaths

9. Risk Factors for Infant Mortality • Smoking during pregnancy • Drug use during pregnancy • Drinking alcohol during pregnancy • Late prenatal care

10. Prenatal Care Coordination • The primary goal of Prenatal Care Coordination is early entrance and continued participation in prenatal and postpartum care to reduce low birth weight, preterm labor, and infant mortality.

11. Barriers to Early Prenatal Care • One of the main barriers to receiving 1st trimester prenatal care is the increasing number of unplanned pregnancies. • Transportation to prenatal care visits is a problem for many low-income pregnant women, especially those in rural areas. • Many low-income pregnant women do not receive early prenatal care because they are not aware of available resources. This is common for women who are not already enrolled on Medicaid.

12. Early Start Program- History • In the late 1990s the Indiana State Department of Health investigated the infant mortality rate in Indiana and found that 80% of mothers whose child did not reach his or her first birthday had not received 1st trimester prenatal care. • After investigating these findings, the Early Start Program was developed. • This program aimed to help low-income women receive 1st trimester prenatal care. • This program has been active in Harrison County and Kosciusko County for over a decade.

13. Goals of the Early Start Program • Increase the percent of pregnant women receiving prenatal care in the first trimester • BMI assessment and education on appropriate weight gain and nutrition • Prenatal education regarding smoking, alcohol, and drug use • Prenatal education regarding folic acid • 90% of all pregnant women found to be at high-risk at the time of the Early Start assessment will be seen by a physician within two weeks of referral

14. Early Start- Program Policies • Early Start Programs shall be affiliated with a free pregnancy testing program that provides outreach activities to find high-risk pregnant women • The Early Start Program may be coordinated by a Registered Nurse, Nurse Midwife, OB • The project must have access to a physician or certified nurse midwife providing prenatal care to the identified population • Memorandums of Understanding with WIC office and county Medicaid office

15. Early Start- First Encounter • Health and Pregnancy History • Prenatal Risk Assessment • Nutrition Assessment • Height/Weight/ BMI • Prenatal Labs • Dispense Prenatal Vitamins • First Trimester Education • Medicaid Enrollment if Eligible • WIC Referral • Social Services Referrals • Prenatal Care Coordination Referral

16. Early Start: Follow-up • Women identified as high risk medically are referred to sponsoring physician within 1-2 weeks • Women not at high risk are seen in the clinic until they get Medicaid or choose to leave to be seen by a prenatal care physician

17. Implementing Early Start Jennifer Krieger Riley, MA MCH Project Director, Harrison County Health Department

18. A Little About Us…… • Harrison County MCH was opened in 1970 in a small apartment building in Corydon, IN as a division of the Harrison County Health Department • We moved to our newly renovated facility in January 2011 • 100% of grant funding goes to patient care

19. Funding • Harrison County MCH works off of two Title V Program Grants from the State of Indiana • MCH Title V Grant • Title V – Infant Mortality Grant – new thisyear • Utilize sliding scale based on income

20. Just the Facts • Average 130 prenatal patients per year ranging in ages from 14- 40 • Harrison County MCH serves Crawford, Floyd, Harrison, Orange and Washington counties for prenatalhealthcare • Local OB/GYN donates his time one day a week to come to clinic to see MCH patients

21. Who Qualifies? • Patients who will receive Medicaid Benefits • Patients who will receive Package E – Medicaid Benefits • Uninsured/Under Insured Patients *** Once Medicaid benefits have been received, patient is discharged to Physician of their choice.

22. How it Works??? • Our goal is to enroll patients before 12 weeks gestation (1st Trimester) • Utilize the concept of Life Course Perspective • Help new mother to take care of herself so she can take care of baby once he/she arrives

23. Enrollment Visit  Assessheight, weight and determine BMI  Educate on proper nutrition  Evaluate for Sexuallytransmitted infections  Stress importance of not smoking  Evaluate patient for drug/alcohol use  Familyhistory/health issues  Assess for housing/transportation needs  Assistwith Medicaid application/Claim Aid  Educate on PrenatalVitamins/Patient given a bottle of vitamins and prenatalworkbookduringvisit

24. Educate, educate, educate!!!! • Patients are educated on a variety of topicsduringenrollment and this information isreinforcedduringeach patient visit. • A few of theseinclude: Smoking, drugs, alcohol, caffeine (ASK Form) Warning Signs Breastfeeding SafeSleep Practices SIDS/SUIDS Car Seat Safety

25. Did I sayeducate? • Weeducate and assess on smoking statusateachvisit • STI’s • Reinforcesigns of miscarriage/pretermlabor • PrenatalVitamins/FolicAcid • Nausea • Assess for areas of highrisk

26. NeedsAssessment • Transportation • Food, Clothing, Shelter • Family/Friend Support • EmotionalWell-Being • HealthHistory/Conditions • History of Abuse • Stressors

27. Barriers to Early Intervention • Denial – Patients feelthat if they ignore the issue, itwill go away • Lack of knowledge of availableresources • Familydoesn’twant patient to come to clinic • Afraid to come due to alcohol/drugs • No reliable transportation/no gas money • School/workschedules • Court Cases/Custody Issues

28. It takes a village……..Partnerships • Harrison, Crawford, Washington and Orange WIC Offices • Harrison County Hospital/HCH Dietician • Free PregnancyTesting Program • Claim Aid – A service provided by Harrison County Hospital • Local Medicaid Office • Harrison County Hospital • Harrison County HealthyFamilies • Early Head Start • Harrison County EMS – Car Seat Program • Harrison County Community Services • Local Churches/Food Pantries/Pack-n-Play Donations • State STD Program – Free Condoms • Ramsey Popcorn • Indiana State Tobacco Quitline

29. Important things to remember……. • Be patient, but consistent • Patients willLIE • In some cases MCH Staff is the only support patient will have • Patient will not always know healthhistory or Social Security # • Applying for Medicaid is not always a priority to patients • You wantthem to come to an appointmentat 8:00 a.m. What?

30. Successes • Babies have a muchbetter chance whenprenatal care beginsearly • Smoking Cessation • Encourage patients to continue care after baby arrives • Birth control, annualpapsmears, prevention, STI screenings • BirthSpacing • Consistant support system for patients

31. Challenges • Patient Compliance • Transportation • Medicaid Compliance • Patient isonlyconcernedwithultrasound • Drug Use/Smoking • No Patient Support

32. Thankyou for your time!