Reducing Subsequent Poor Pregnancy Outcomes among Women in Michigan

1. Reducing Subsequent Poor Pregnancy Outcomes among Women in Michigan Division of Genomics, Perinatal Health and Chronic Disease Epidemiology Division of Family & Community Health CityMatCH PPOR Learning Network July 22, 2008

2. State-level action and interaction for improving preconception care in Michigan Violanda Grigorescu, MD, MSPH State MCH Epidemiologist, Director Division of Genomics, Perinatal Health and Chronic Disease Epidemiology

3. Michigan Population Demographics 2006 • Total population: 10,095,643 - White: 82% - Black: 14.8% - Native Americans: 0.7% - Asian Pacific Islander: 2.5% • Female: 50.8% - 18-44 yrs. old: 35.9% • Live births (#): 127,537 • Birth rate (live births per 1,000 population): 12.6 • Fertility Rate (live births per 1,000 women 15-44): 61.8

4. 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

5. Perinatal Periods of Risk:New Approach to Infant Mortality 6 KEY STEPS FOR PPOR • Engage community partners • Map feto-infant mortality • Focus on overall rate • Examine potential opportunity gaps • Target further efforts • Mobilize for sustainable systems change Age at Death Post neonatal Fetal Neonatal Birthweight 500- 1499g Maternal Health/ Prematurity Maternal Care Newborn Care Infant Health 1500g

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

7. Prenatal care Race Maternal age Parity Multiple Pregnancy STD/Bacterial Vaginosis Previous preterm births Unintended pregnancy Smoking/Alcohol/drug use Maternal health conditions Gestational age Referral system Mother transfer Infant transfer Perinatal care Neonatal conditions Pay source Maternal complications Maternal Health/Prematurity Birth weight Distribution (VLBW Births) Birth weight- Specific Mortality Rates CDC / CityMatCH: PPOR - PC

8. Unintended vs. Intended PregnanciesCurrent Definitions • Intended pregnancies: reported to have happened at the "right time" or later than desired (because of infertility or difficulties in conceiving). • Unintended (unplanned) pregnancies: reported to have been either unwanted (i.e., they occurred when no children, or no more children, were desired) or mistimed (i.e., they occurred earlier than desired). Important: All of these definitions assume that pregnancy is a conscious decision.

9. Trend of Unintended Pregnancies in Michigan, 1990-2003, PRAMS

10. Prevalence of Intended and Unintended Pregnancies, 2003, PRAMS

11. Profile of Women having an Unintended Pregnancy in Michigan • The overall prevalence of unintended pregnancies in Michigan in 2003 was 40.5% • In 2003, the prevalence was highest in: • Black women • Females less than 18 years of age • Women with less than a HS diploma/GED • Women who are not married • Women with no insurance • Women on Medicaid, and • Women with an annual household income of $10,000 or less 2003 Michigan PRAMS

12. Data – Driven Interventions:From Identifying to Understanding & Doing • Identify critical information in key areas • Assure participating communities understand the data/information • Assess current intervention strategies and compare to evidence-based strategies • Revise or develop new plan based on community assessment, intervention strategy assessment or other information

13. Preconception Care and Pregnancy Planning: Voices of African American women Renée B. Canady, PhD Deputy Health Officer, Ingham County Health Department Adjunct Assistant Professor, MSU College of Nursing

14. Data – Driven Interventions:From Identifying to Understanding & Doing Not everything that can be counted counts, and not everything that counts can be counted. Albert Einstein

15. Background • In order to improve the knowledge, attitudes, and behaviors of women related to preconception health, more must be understood about the idea of planningas related to pregnancy and conception. • For the clinical or public health professional, “planned pregnancy” is a term commonly used with clients, yet it is unclear if women's perceptions and understanding of family planning coincide with those of professionals. • Since African American women are nearly twice as likely to experience a poor pregnancy outcome as white women, the project was intended to build the understanding of pregnancy experiences of African American women in order to make needed changes in the health care system to support better outcomes.

16. Objectives This study endeavors to further elaborate information that is vital to our understanding of preconception issues in two ways: 1) by generally evaluating women's understanding of the concept of planned pregnancies, and by 2) interpreting those findings through the experiences of African American women who are especially at risk for poor pregnancy outcomes.

17. Methods In the summer of 2005 the Michigan Department of Community Health conducted 19 focus groups with 168 African American women across 10 counties identified as having the highest African American infant mortality rates in the state of Michigan.

18. Focus Group Emphases • To elicit feedback within the context of three key stages of the pregnancy experience: • Preconceptional • Prenatal • Post-partum • Because of our specific interest in the experiences of Black women, we also sought to extract information on the role of race and economics as factors in the pregnancy experience

19. Focus Group Protocol • The idea of having a “planned pregnancy” is often discussed as part of studies of women’s health and pregnancy outcomes. Please tell us how you would define the term “planned pregnancy • Would you describe your last pregnancy as a planned pregnancy? • What steps did you take to prepare for your pregnancy? • Please describe a time when you think your race or ethnicity / financial situation affected your ability to get the health care information or services you needed before becoming pregnant?

20. Participant Demographics

21. Results/Findings: Sixinteracting themes • Theme 1: Preconception care: An unfamiliar concept • Theme 2: Planning for pregnancy: A continuum of responses. • Theme 3: Psychology of conception-Attitudes, beliefs, and behaviors. • Theme 4: The shared nature of planning: It takes two to plan a pregnancy. • Theme 5: Birth control: The means to an end. • Theme 6: The context of preconception care: The big picture

22. Theme 1: Seeing a health care provider BEFORE a pregnancy occurs is foreign concept to many women • This theme raises a direct contradiction to the current preconception goals of health care providers and agencies. • Women associated seeing a provider with “health problems” and since they “didn’t have any health problems at the time” they did not perceive the need for care before conception.

23. Theme 1: Seeing a health care provider BEFORE a pregnancy occurs is foreign concept to many women • “What’s the question again?” • “It’s time to hang up the party dress and get to work” • Pregnancy readiness vs. pregnancy planning

24. Theme 2: Planning as a continuum • Definitions of “Planning” represented a continuum versus a unilateral definition. 1) Deliberate and informed “Everything is secured. You’re secure in your home, financial wise; ain’t that what a planned pregnancy is?”

25. Theme 2: Planning as a continuum 2) Conscious but not deliberate “Me and my husband (sic), we planned to get married, we planned to have children, but we didn’t sit down and decide ‘OK, we’re going to have a baby”

26. Theme 2: Planning as a continuum 3) Absence of Planning “It was stupid. I knew I was going to get pregnant. I just didn’t prepare NOT to get pregnant” “It wasn’t planned but since I didn’t use protection, I guess that would be planned, huh?”

27. Theme 3: The Psychology of Planning; Attitudes, Beliefs, and Behaviors • Many women expressed a level of fatalism or resignation about their ability to influence pregnancy planning. “Sometimes it’s a whole lot of maybe’s. Maybe I won’t get pregnant this time”

28. Theme 3: The Psychology of Planning; Attitudes, Beliefs, and Behaviors • “I just thought I couldn’t get pregnant, because I had one tube, but I guess I got fooled.” • “When I was 28 I had a miscarriage. From then on, I never got pregnant. I was planning my 40th birthday party and found out I was pregnant.”

29. Theme 4: The Shared Nature of Planning • It takes two to plan a pregnancy. • Often preconception care is focused solely on women. • “You mean the girl planned or the guy planned or they both planned, or what?” • “But he was there for me. He, you know, stayed by me. So it was a planned pregnancy, and yet, it wasn’t…so…”

30. Theme 5: The Means to an End • Women continue to face challenges in selecting and using appropriate birth control • This remains a barrier to managing preconception care and negotiating planning

31. Theme 5: The Means to an End • Many women believed their birth control “just didn’t work.” “…I don’t think I would have had the last baby if I could have found a birth control without side effects.”

32. Theme 6: The context of preconception care – The Big Picture • Contextual issues affecting preconception care. Preconception care is more than physical, it has social, psychological and spiritual components • Fertility norms and behaviors are culturally and socially defined (Geronimus, 2003) • Inquiry re: role of race and economics yielded less about discrimination and more about the context of women’s lives

33. Theme 6: The context of preconception care – The Big Picture • “I know a lot of white people do (plan pregnancy). By the time I hit 30, get my career or whatever, then plan (a pregnancy).” • Another woman said: “Some people that have a career, they like to start it first or, you know, like a career mother, she like to start a job first before she plan.”

34. Theme 6: The context of preconception care – The Big Picture • “I never, even in a middle class way of thinking, you know, that---because that is a middle-class way of thinking, you know. So those of us that have not obtained that status, doesn’t---it isn’t that. It’sjust that, okay, you got pregnant and, you know, baby ain’t going to starve, you know;” or “I just thought once you get married, you’re supposed to start a family.”

35. Programmatic/Clinical Implications • Preconception interventions should be developed with the input of women. Women have a consciousness about their readiness for pregnancy which should inform preconception planning. • Knowledge dissemination is only one aspect of preconception care or intervention; it is necessary to incorporate affective and behavioral needs of women, recognizing the importance of culture. • Include men as well as women in preconception interventions. Reinforce the idea that planning a pregnancy is in the control of both the woman and the man. • Selection of birth control methods should be tailored to individuals with an appreciation of their personality, life style, and potential side effects. • Preconception care for vulnerable populations requires the strengthening of cultural commitment and social justice activities of nurses and healthcare professionals through partnerships, advocacy, and dissemination of information.

36. State-local partnership: Steps to program development Cheryl Lauber, RN, MSN, DPA Consultant – Infant Mortality Initiative

37. 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

38. Key Objectives by Period of Risk • Maternal Health/Prematurity • Support healthy lifestyles for women of childbearing age • Target women with poor outcomes for interconception care • Assure access to primary care for women • Reduce unintended pregnancy • Maternal Care • Assure early entry to prenatal care with assessment of risk • Provide in-home/in-community supports to at risk women • Newborn Care • Assure high risk pregnancy delivery at NICU hospital • Provide early identification of problems and link to services • Infant Health • Assure access to primary care for infants • Reduce SIDS & other infant death • Improve resources for risk conditions & develop delay

39. Steps to Program Development • Analysis of data • Maternal Health & Prematurity • Infant Health • Racial disparity • Identified 11 communities with highest black IMR • Secured funding through Healthy Michigan Fund

40. Steps to Program Development • Local coalition development (2004-2005) • Contracts with local health departments • Hired independent consultants to provide technical assistance • Communication • Coalition Coordinators Network meets monthly • Written and oral communication with health officers • 3 deliverables due in 2005

41. 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

42. Steps to Program Development • MCH program review • MIHP redesign • Unintended pregnancy • Family Planning • WIC • Cultural Competency • Voices of the Women • Literature review • Preconception Care

43. Michigan Interconception Care Program • Identify at least 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 • Promote 18 month interpregnancy interval • Perinatal high risk case management for up to 24 months

44. Performance Against Goals • Goal: to field test an Interconception Care strategy for African- American women who experienced: • Preterm birth • 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

45. 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.

46. Project Management • Project Direction Team met monthly • Project Manager; Program Consultants; Division Managers; Epidemiologist • Good idea sharing. Necessary for keeping locals focused. Planned for each Network meeting. • Communication by email, letter, Network meetings • Not consistent people initially caused some communication problems. Network meetings face-to-face were costly. Relied on emails to local contacts. • Database tracked community achievements • Unable to keep database current. Used verbal reports at meetings.

47. Quality Assurance & Support • Product quality measured by conformity to annual expectations. Model reports provided. • Provided minimum of information initially but adequate to understand performance • Products compared to goals; • Coalitions, health education and focus groups met expectations. • Implementation of ICP intervention was new experience and slow in accomplishment. • Quality issues addressed through information/teaching and consultation. • Support/resources for ICP intervention has grown and programs all enrolling clients. Local site visits, phone consultation and quarterly meetings.

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

49. 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

50. 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