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Alabama Perinatal Conference Translating Recommendations into Action September 14. 2012

Alabama Perinatal Conference Translating Recommendations into Action September 14. 2012 Lessons Learned from the Community-Based Prematurity Prevention Pilot in Kentucky:. Preterm Births, Low Birthweight and Infant Mortality United States, 1981 - 2004. Percent. Rate per 1,000 live births.

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Alabama Perinatal Conference Translating Recommendations into Action September 14. 2012

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  1. Alabama Perinatal Conference Translating Recommendations into ActionSeptember 14. 2012 Lessons Learned from the Community-Based Prematurity Prevention Pilot in Kentucky:

  2. Preterm Births, Low Birthweight and Infant MortalityUnited States, 1981 - 2004 Percent Rate per 1,000 live births Source: National Center for Health Statistics, final natality and mortality data Prepared by March of Dimes Perinatal Data Center, 2007

  3. Infant mortality rates excluding births at <22 weeks of gestation, US and selected European countries, 2004 MacDorman, NCHS, 2011

  4. Three Leading Causes of Infant MortalityUnited States, 1990and 2007* Rate per 100,000 live births Source: National Center for Health Statistics Adapted from a slide Prepared by March of Dimes Perinatal Data Center, 2007

  5. The Life Course Perspective of Health Development Critical Periods Cumulative Effects Interaction with Environment Health Equity TIMING TIMELINE ENVIRONMENT EQUITY Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.Maternal Child Health J. 2003;7:13-30. 5

  6. Life Course Health Development Poor Nutrition Stress Abuse Tobacco, Alcohol, Drugs Poverty Lack of Access to Health Care Exposure to Toxins Poor Birth Outcome Age 0 5 Puberty Pregnancy

  7. Birth Weight and Insulin Resistance Syndrome Barker Hypothesis Odds ratio adjusted for BMI Birthweight (lbs) Barker 1993

  8. Birth Weight and Coronary Heart DiseaseBarker Hypothesis Age Adjusted Relative Risk Birthweight (lbs) Rich-Edwards 1997

  9. Fetal Origins of DiseaseNew York Times, Oct. 2, 2010 • “Perhaps the most striking finding is that a stressful intrauterine environment may be a mechanism that allows poverty to replicate itself generation to generation. Pregnant women in low income areas tend to be more exposed to anxiety, depression, chemicals and toxins, more likely to smoke or drink… the result is children who start life at a disadvantage…” Review of ORIGINS: How the Nine Months Before Birth Shape the Rest of Our Lives. Annie Murphy Paul, 2010

  10. Fetal Origins of DiseaseAltered Gene Expression • Jirtle & Waterland, Duke University • Agouti mice • Normally fat bodies, yellow fur, predisposed to diabetes and cancer • Appearance and physiology due to a specific gene • Group of pregnant mice • Half got regular diet, have got diet high in methyl groups (can turn genes off or on) • Pups from moms on regular diet looked just like their parents • Pups from hi-methyl moms were SLENDER, BROWN FUR, NOT PREDISPOSED TO DIABETES OR CANCER Review of ORIGINS: How the Nine Months Before Birth Shape the Rest of Our Lives. Annie Murphy Paul, 2010

  11. A Community-Based Initiative to Prevent Preterm Birth CAN WE DO BETTER WITH WHAT WE KNOW NOW? • A ‘real world’, ecological design using bundling of evidence-based interventions in different health care settings (academic, private, clinic-based) • An innovative, multi-dimensional intervention program designed to prevent “preventable” preterm birth in subgroups of the population where interventions have a likelihood of success in a reasonable period of time Dr. Karla Damus

  12. July 2005- June 2006 July 2006- June 2007 July 2007-December 2009 Baseline Planning - Implementation Training • CONCEPTS/DESIGN: • Ecological “real world” design • “Bundled” medical and public health interventions • Based on improving community systems of care and support • Targeting “preventable” preterm birth • GOAL: 15% reduction in PTB in intervention sites 18

  13. Keys to Community-Based Prematurity Prevention • DATA ACTION • We know enough now to do better • RESEARCH “REAL WORLD” • Implement Best Available Evidence • SILOS SYSTEMS • Comprehensive, coordinated clinical and public health services • MEDICAL MODEL ECOLOGICAL MODEL • Multiple determinants of health,Prematurity as a public health problem • RELATIONSHIPS RESULTS • We can do better now

  14. Data ActionWe know enough now to do better

  15. Data Action • Data determines the focus Late preterm was driving the increase PTB rates • Develop the Data Consumer & provider surveys, focus groups, ACOG survey, policy and environment surveys • Data quality mattersData Definitions, consistent collection • Local Data drives improvementDon’t wait for vital statistics file Use or adapt existing data sources

  16. Percent of Live Births that were Preterm*; Kentucky and U.S. *Preterm birth is defined as any live birth occurring <37 completed weeks gestation Data Source: March of Dimes Peristats & National Center for Health Statistics

  17. Singleton Preterm Birth RatesUS and Kentucky, 1994-2004 Late Preterm Births (34-36 wks) Singleton Preterm Births (<37wk)

  18. Preterm Births by Week of GestationUnited StatesKentucky Late Preterm 73% Late preterm 71% Source: National Center for Health Statistics, 2004 final natality data Prepared by March of Dimes Perinatal Data Center, 2007 6

  19. Preterm Births • Term: • about 40 weeks • Preterm birth: • <37 completed weeks • Late preterm (near-term): • 34 -36 weeks • Very preterm: • <32 weeks

  20. Research Real World Implement best available evidence

  21. Research Real World • State of the Science: Grand Rounds (quarterly), Resource centers: Epidemology, latest research, Brain Growth, morbidity in LPTB • ACOG Guidelines (induction, elective C/S, progesterone, cervical length, antenatal steroids, etc.) • Aggressive Treatment of Infections, STI, BV • Patient Safety (Steve Clark, Kathleen Simpson) • Quality Improvement, provider feedback • Centering Pregnancy/ Group prenatal care • Smoking Cessation (5A’s) • Psychosocial screening & referral • Oral Health Screening & referral • Breastfeeding • Evidence-based home visiting

  22. Reasons for singleton Preterm births in the U.S. 1989-2000 Anath CV et al, Obstet Gyecol 2005; 105:1084-91 Intervention SPTL PROM

  23. NICHD Consensus Conference July 2005 Morbidities Associatied with Late Preterm births: Trying to separate causes and effects • Increased immediate morbidities: • Respiratory distress • Jaundice • Feeding difficulties • Hypoglycemia • Temperature instability • Sepsis • Increased NICU use (and re-admissions) • Increased cost • Long term outcome - ???

  24. The Late Preterm Morbidity:HYPOGLYCEMIA Hypoglycemia is 3X more common in late preterm infants “Unlike term infants, late preterm infants are incapable of mounting an adequate mature counter-regulatory response to hypoglycemia” Gluconeogenesis, ketogenic responses to mobilize alternate fuels is inadequate Glycogen reserves, adipose stores build up only in late gestation Astrocytes in the glia are still immature Garg M, Devaskar SU. ClinPerinatol 33:853-70, 2006.

  25. Lung Transition to Life Outside the Womb Onset of labor triggers Decrease of Fetal lung Fluid secretion Mechanical Forces “Vaginal Squeeze” ? ? Transition from Fluid-filled to Air filled Lung ENaC activation Specificity, number Surfactant to coat alveoli Steroids before birth enhance maturation Slide from L. Jain, Emory University, modified

  26. Development of the Human Brain through Gestation • The Brain is the last major organ system to develop • Lower functions mature first, cortex last • Brain at 35 wks weighs only 2/3 what it will weigh at term Cowan WM. Sci Am 241:113, 1979

  27. HBWW Consumer Surveys Provided up-to-date, locally relevant KAB information from pregnant women, the target of the HBWW Initiative Based on findings, able to tailor educational materials and communication efforts of Initiative to community needs Results will be important for evaluation of the Initiative (baseline vs. 3 year follow-up) Materials for Professionals

  28. Concerns about Late Preterm Brain Development And Potential Impact “Because one out of 11 births in this country is a late preterm birth, and since the brain of the late preterm infant is less mature than that of the term infant, even a minor increase in the rate of neurologic disability and scholastic failure in this group can have a huge impact on the health care and educational systems.” Raju TNK. Epidemiology of Late Preterm Births. Clin Perinatol 33 (2006) 751-763

  29. Mortality in the Late Preterm Late preterm infants were 3 times more likely than term infants to die in the first year of life Even excluding congenital anomalies, infant mortality rates for late preterm infants were 2.6 times higher than in term infants • Early Neonatal (<7 days) 6X more likely to die • Late Neonatal 3 X more likely • Post Neonatal: 2X more likely Late preterm infants are 8.5 times more likely to die with a diagnosis of respiratory distress in the early neonatal period Late preterm infants are twice as likely as term infants to die of SIDS Tomashek, KM, Shapiro-Mendose CK, Davidoff MJ, Petrini JR. Differences in Mortality between Late-Preterm and Term Singleton Infants in the United States, 1995-2002. J Pediatr 2007:151:450-6

  30. Late Preterm Infant Morbidity in the Neonatal Period Late Preterms were 7X more likely to have newborn morbidity than term infants. Newborn morbidity rate doubled for each gestational week earlier than 38 weeks The independent effect of late preterm birth on morbidity was 7X stronger than any of the selected maternal conditions The proportion of morbidity among late preterm infants was relatively high across the board, ranging from 18.1% to 27.8% Shapiro-Mendosa CK et al. Pediatrics 2008, 121:e223-e232

  31. Late Preterm Outcomes Compared to term infants, infants born in the late preterm period have: 6X incr risk of dying in the first week of life 3X incr risk of dying in the first year of life Increased risk of ADHD by 70% Clinically significant behavior problems in 20% Incr risk for special ed, cognitive and learning problems 2-4X increased risk for Cerebral Palsy 2-3X increased risk for IQ < 85 Increased risk for mental disorders/schizophrenia as adults 40% increased risk for medical disability that limits working capacity as adults Increased risk of long term neurodevelopmental handicap as young adults

  32. ACOG Committee Opinion # 22 ACOG has cautioned against inductions before 39 weeks in the absence of a medical indication Since 1979

  33. ACOG Committee Opinion # 404Late Preterm Infants,April 2008 • Late preterm infants often are mistakenly believed to be as physiologically and metabolically mature as term infants. However, compared with term infants, late–preterm infants are at higher risk than term infants of developing medical complications, resulting in higher rates of infant mortality, higher rates of morbidity before initial hospital discharge, and higher rates of hospital readmission in the first months of life. • Preterm delivery should occur only when an accepted maternal or fetal indication for delivery exists. Statement developed jointly with AAP Committee on Fetus & Newborn

  34. Reinforced no elective induction or C/S should be done prior to 39 weeks gestation Specific criteria for establishing gestational age should be followed A mature fetal lung test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery. (see Bates, 2009) ACOG Practice Bulletin, Number 107 August 2009 Induction of labor

  35. Elective cesarean delivery before 39 weeks is common (35.8%) and is associated with respiratory and other adverse neonatal outcomes, increased risk 2-4X: At 38 wks OR 1.2-2.1 At 37 wks OR 1.8-4.2

  36. Complications of Non-medically Indicated (Elective) Deliveries Between 37 and 39 Weeks • Increased NICU admissions • Increased transient tachypnea of the newborn (TTN) • Increased respiratory distress syndrome (RDS) • Increased ventilator support • Increased suspected or proven sepsis • Increased newborn feeding problems and other transition issues See Toolkit for more data and full list of citations Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997

  37. NICU Admissions By Weeks Gestation Deliveries Without Complications, 2000-2003 NICU Admissions Oshiro et al. Obstet Gynecol 2009;113:804-811.

  38. Preterm Births Term: about 40 weeks (39-41): • Early Term • 37-38 weeks Preterm birth: <37 completed weeks • Late preterm (near-term): • 34 -36 weeks • Very preterm: • <32 weeks

  39. Terminology Term The “New” Term Late Preterm Early Term First day of LMP 0 20 0/7 340/7 37 0/7 39 0/7 416/7 Week # Preterm Post term Modified from Drawing courtesy of William Engle, MD, Indiana University Raju TNK. Pediatrics , 2006;118 1207. Oshiro BT Obstet Gynecol 2009;113:804

  40. Rate of Scheduled Births at 360 - 386 Weeks’ Without Documented Indication Available at: http://opqc.net/presentations % Observe X 2 Months Project begun 9-1-08 11-30-09

  41. Clark SL, et al. AJOG, 2008;199:105.e1-105.e7. Improved outcomes, lower C/S rates. Decr malpractice claims by half, cost of claims by 5-fold

  42. HCA Trial of 3 Approaches for Reduction of Elective Deliveries <39 weeks Hard Stop Soft Stop/Peer Rev EducationOnly Consistent reduction in every hospital Clark SL. et al. Am J Obstet Gynecol 2010;203:449.e1-6

  43. Silos Systems“Comprehensive, coordinated, integration of clinical and public health systems of care”

  44. Silos Systems • Convene the Partners • Hospitals and Health depts as community health leaders • Don’t really know what services the other provides • Describe best practices • Don’t let perfect be the enemy of good • Determine the gaps • Prenatal classes, oral health, MNT, Substance abuse • What can we do better now? • Fax referral form, exchanging staff, co-locating services, consistent information; referrals to health dept services

  45. Healthy Babies are Worth the Wait • Oral Health • ISW - Dental hygenist regular presenter in Centering • Dental Chair in Women’s Center at hospital • When moved to Health Dept a block away, patients did not go • ISC - Improved coordination with dental school clinics • increased emphasis with residents and nurses on oral screening and care for patients • ISE - No dentists in area would treat pregnant women • Hosted regional meeting with area dentists and OB’s, nationally known dentist as speaker • Several local dentists then agreed to see pregnant women referred by their obstetrician

  46. Healthy Babies are Worth the Wait • Substance abuse prevention and management. • ISW - Improved local access to substance-abuse treatment for pregnant women • began universal screening for substance abuse as part of prenatal care; non-stigmatizing, non-punative • ISC - Improved coordination with in-house detox unit for managing substance abuse in pregnancy • Implemented universal psychosocial screening • ISE - Grand rounds on use of subutex by addiction specialist for substance abuse in pregnancy • Hospital social worker went to OB offices to see and do brief intervention with substance-abusing patients

  47. Evidence-Based Home Visiting and Preterm Birth Health Access Nurturing Development Services Voluntary, intensive weekly home visitation Overburdened, first time momsor first time dads Regardless of income Prenatal to two years of age Strengths-based, build resilience in families Designed to improve both health & social outcomes Mix of professionals and paraprofessionals 48

  48. OUTCOMES • 31% less Prematurity • 33% less LBW • 55% less VLBW • 70% less Infant Mortality • 50% less ER Usage • 29-40% less Child Abuse and Neglect • 26% improved/increased Education • Less developmental delays Outside Evaluator

  49. Social Determinants of Health Kaplan, et al. (2000). A Multilevel Framework for Health in :Promoting Health. Washington, DC: National Academy Press The basis for psychosocial screening

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