HEALTHY START MANATEE

1. HEALTHY START MANATEE NANCY HARDT, MD FAMILY DATA CENTER UF COLLEGE OF MEDICINE SEPT 6, 2010

2. CONTACT hardt@ufl.edu 352-514-3991 cell

3. OUTLINE • PAMR • RISK FACTORS FOR POOR BIRTH OUTCOMES • MATERNAL DEATHS DUE TO TRAUMA • CHILD ABUSE • HEALTHY START SCREEN AS A PREDICTOR • YOUR SUGGESTIONS

4. HEALTHY START PROVIDERS • IN YOUR EXPERIENCE, WHAT RISK FACTORS PREDICT PREMATURITY?

5. RISK FACTORS FOR PREMATURITY • PREVIOUS PREMATURE • SHORT INTERVAL BETWEEN PREGNANCIES (??SEXUAL COERSION, BIRTH CONTROL SABOTAGE) • TEEN MOTHER • FREQUENT CHANGE OF ADDRESS • USE OF ALCOHOL, DRUGS • POVERTY • MORBID OBESITY OR UNDERWEIGHT • LATE ENTRY INTO PRENATAL CARE

6. ASIDE FROM PREMATURITY AND INFANT MORTALITY, WHAT ARE OTHER SUBOPTIMAL BIRTH OUTCOMES?

7. SUBOPTIMAL BIRTH OUTCOMES • PREMATURITY • INFANT MORTALITY • MATERNAL MORTALITY • CHILD ABUSE/NEGLECT

8. HEALTHY START IN FLORIDA • CREATED IN 1991 BY STATE LEGISLATURE • GOAL TO REDUCE PRE-TERM BIRTH AND INFANT MORTALITY • SCREENING INSTRUMENT OFFERED AT FIRST PRENATAL VISIT • WE REVIEWED 600,000 SCREENS WITH 144 MATERNAL TRAUMATIC DEATHS

9. FL. HEALTHY START SCREEN • MARRIED? • HIGH SCHOOL GRADUATE? • MOVED MORE THAN 3 TIMES IN LAST YEAR? • FEEL UNSAFE WHERE YOU LIVE? • ANYONE GO TO BED HUNGRY? • USE TOBACCO, DRUGS, ALCOHOL? • PREGNANCY UNWANTED OR MISTIMED?

10. FL. HEALTHY START SCREEN • HISTORY OF MISCARRIAGE, STILLBIRTH, PREMATURITY? • CHRONIC ILLNESS UNDER CARE? • CAN’T MAKE APPOINTMENTS? • PRE-PREGNANCY WEIGHT? • BLACK RACE?

11. 3 MAIN GROUPS OF PREGNANCY ASSOCIATED DEATH • PREGNANCY RELATED DEATH • NATURAL CAUSES • TRAUMATIC DEATH • ACCIDENTS • HOMICIDE • SUICIDE • OVERDOSES

13. Top 10 COD in PAMR Pregnancy-Related and Trauma Populations

14. IF RISK FACTORS FOR INFANTS ARE THE SAME AS RISK FACTORS FOR MATERNAL RISK OF TRAUMA, PERHAPS EXISTING PRENATAL RISK SCREENING INSTRUMENTS WILL WORK

16. COMPARISON OF TRAUMATIC DEATHS TO ALL 600K WOMEN SCREENED • 20% OF WOMEN SCREENED HAD SCORES OF ZERO COMPARED TO 3% OF WOMEN DYING OF TRAUMA. • 28% OF WOMEN SCREENED HAD SCORES OF 4 OR MORE, WHILE 56% OF WOMEN DYING OF TRAUMA HAD 4 OR MORE.

18. RELATIVE RISK OF TRAUMATIC DEATH BY HS SCORE • WITH EACH INCREASE IN SCORE OF 1, THE RELATIVE RISK OF DEATH INCREASES 1.5 TO 2X • A WOMAN WITH A RISK SCORE OF 6 HAS 12 TIMES THE RISK OF TRAUMATIC DEATH COMPARED TO A WOMAN WITH SCORE 0 • A WOMAN WITH A RISK SCORE OF 9 HAS 52 TIMES THE RISK OF TRAUMATIC DEATH COMPARED TO A WOMAN WITH SCORE 0

19. PREDICTED TRAUMATIC DEATH BASED ON HS SCREEN SCORE • AMONG 100,000 WOMEN WITH A SCORE OF 4, EXPECT 47.88 TRAUMATIC MATERNAL DEATHS (CI 45.59-50.28) • AMONG 100,000 WOMEN WITH A SCORE OF 9, EXPECT 215 TRAUMATIC DEATHS (CI 80.88-571.79)

20. FLORIDA Maternal Deaths Rolling 3-Year Rate Per 100,000 Population

21. STATE DATA

25. HEALTHY START SCREEN, CHILD MALTREATMENT, AND INTERPREGNANCY INTERVALS

26. Rationale • 38.5% of Florida Births • had interpregnancy intervals • less than 18 months MPH Competency Strengthened Monitoring health status to identify and solve community health problems

27. 2005-2007 ADDITIONAL USES OF HEALTHY START SCREEN • LOOK AT THE ASSOCIATION BETWEEN REPORTS OF CHILD MALTREATMENT AND INTERPREGNANCY INTERVALS IN THOSE FAMILIES • BIRTH VITAL RECORDS DATA ON INTERPREGNANCY INTERVAL, DCF DATA ON CHILD MALTREATMENT, AND HEALTHY START SCREEN ITEMS • HEALTHY START SCREEN ITEMS : • Evaluation of the timing of pregnancy, • Mother’s perceived harm during pregnancy

28. % OF BIRTHS WITH REPORT OF CHILD MALTREATMENT (NOTE, NOT ALL REPORTS ARE CONFIRMED BY INVESTIGATION)

29. MALTREATMENT BY INTERPREGNANCY INTERVAL • Interpregnancy interval • Less than 18 months: 20.8% • 18+ months: 15.8% • MALTREATMENT Unadjusted Odds Ratio: 1.50 (1.44, 1.55) • MALTREATMENT Adjusted Odds Ratio: 1.18 (1.13, 1.23)

30. PREGNANCY VARIABLES 2.43 1.18 1.18 1.19 Epi Competency Strengthened Demonstrate ability to analyze and interpret epidemiologic data

31. “RISK” FACTORS FOR CHILD MALTREATMENT • Adjusted Odds Ratios: • Mother’s Age Less than 20: 1.87 (1.76, 2.00) • Mother Not Married: 2.04 (1.95, 2.13) • Tobacco Use: 2.34 (2.22, 2.47) • Alcohol Use: 1.87 (1.44, 2.43) • Partner Unemployed: 1.43 (1.35, 1.51) • Low Birth Weight Infant: 1.23 (1.12, 1.35) • Preterm Infant: 1.16 (1.07, 1.26) Epi Competency Strengthened Demonstrate ability to analyze and interpret epidemiologic data

32. “PROTECTIVE” FACTORS FOR CHILD MALTREATMENT • Adjusted Odds Ratios: • Mother’s Age 30-39: 0.59 (0.55, 0.62) • Mother’s Age 40-49: 0.59 (0.48, 0.72) • Mother High School Graduate: 0.74 (0.71, 0.78) • Mother College Graduate: 0.38 (0.35, 0.41) • Black Non-Hispanic: 0.86 (0.82, 0.91) • Other Non-Hispanic: 0.56 (0.49, 0.63) • Hispanic: 0.38 (0.36, 0.40)

33. BIRTH INTERVAL INCREMENTAL PREDICTOR OF MALTREATMENT

34. FAMILY ANALYSIS • 17% REPORT OF CHILD MALTREATMENT • ADJUSTED ODDS RATIOS: • MOTHERS PERCEPTION OF HARM: 2.52 (2.26, 2.81) • INTERPREGNANCY INTERVAL: 1.31 (1.26, 1.37) • FELT UNSAFE: 1.20 (1.06, 1.36) • LATER TIMING OF PREGNANCY: 1.20 (1.15, 1.26) • EARLIER TIMING OF PREGNANCY: 1.17 (1.07, 1.28)

35. GENERAL FINDINGS • Report of child maltreatment is high in Florida • Short interpregnancy intervals significant predictor • Similar results found for infant maltreatment and intervals less than 15 months(Wu et al., 2004) • Mother’s perception of harm and feeling unsafe where she lives may be an indicator of social instability • Social instability previously linked as a causal factor for abuse in pregnancy (Stewart & Cecutti, 1993) • Wanting a later pregnancy may be reflective of an unplanned pregnancy • Unplanned pregnancies associated with child maltreatment (Zuravin, 1987)

36. ALL FLORIDA Drug Overdose Modified from: Centers for Disease Control and Prevention. (2011, July 8). Morbidity and Mortality Weekly Report. Atlanta, GA.

39. 2003-2009 FL Changes in Death Rates (per 100,000 pop.) • INCREASE • OXYCODONE +264% • ALPRAZOLAM +233% • DECREASE • HEROIN -62% • COCAINE -10%

41. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (December 28, 2010). The DAWN Report: Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD.

42. 2004-2009 Drug-related ED Visits • INCREASEin ED visits due to drugs • Total 81% • Prescription pharmaceuticals 98% • DECREASE • Illicit drugs 1.8% • Alcohol 2.5% • Alcohol plus drugs 0.8%

43. Public Health Implications • Estimated cost to U.S. in 2001: $8.6 billion / year • $2.6 billion in healthcare costs • $1.6 billion in criminal justice costs • $4.6 billion in workplace costs • Opioid users: • 4 times as likely to visit ER • 11 times as likely to receive mental health outpatient treatment • 12 times as likely to receive inpatient care • Opioid abuse 10 times more common in Medicaid vs. private insurance populations

44. Drug Addicted Infants • 1100 babies treated inpatient for withdrawal symptoms in Florida • 3 per day • Prevalence rising consistently ~30% • 15-20% of NICU admissions at some hospitals • prescription drugs are most common cause • Well documented in the press, less so in scientific literature

45. MATERNAL DEATH DUE TO TRAUMA AND DRUGS 1999-2005

46. Prescription drug abuse & pregnant women? Questions Study Design Link Bureau of Vital Statistics information to medical examiners’ records data from Pregnancy Associated Mortality Report (PAMR) Identify pregnancy-associated, traumatic deaths involving drugs Examine prevalence of different drug types • What role does drug abuse play in the traumatic deaths of Florida’s pregnant-women? • What drugs are being abused? • What can be done about it?

47. FREQUENCY OF DRUGS ENCOUNTERED

48. FREQUENCY OF DEPRESSANTS ENCOUNTERED

49. MANNER OF DEATH