In your opinion, where do you see the greatest opportunities in making a difference on prematurity in the U.S.?
ECCS Director, Bureau of Family, Maternal & Child Health, Michigan Department of Community Health
In Michigan we use the information that comes from reviewing the perinatal periods of risk (PPOR) which affords a more targeted approach by offering a better understanding of infant mortality. PPOR suggested that maternal health is an area that can make a significant difference and in particular preconceptional health. Michigan has several initiatives operating to address this. The complexity of preventing premature births has made us look at the initiatives like spokes in a wheel. Working to ensure that a woman is healthy before pregnancy is done through several initiatives to prevent unintended pregnancies. Offering an environment that helps women to have access to contraception is one effort. This helps to assure that each pregnancy is intentional and desired. We offer Title X Family Planning services, as well as administering the Medicaid waiver, called Plan First!, to allow income eligible women Medicaid coverage for contraception, who have no other insurance coverage. We also introduced a clinical guideline for discussing pregnancy “intendedness” with adults that was endorsed by Blue Cross Blue Shield of Michigan through the Michigan Quality Improvement Consortium, an avenue that establishes standards of care for medical providers. There is also an initiative that targets middle school parents, called Talk Early & Talk Often. This is designed to help parents develop the necessary skills to talk to their children about abstinence and sexuality.
Several years ago, Michigan implemented a project targeting the communities with the highest African American infant mortality rates to provide preconception health care to high risk women of child bearing age, including health education and service referral. Efforts are made to identify chronic illness in women and connect them with health care to assure adequate maintenance of their condition. This effort also involves community advocacy and mobilization for preconception health in order to generate community will and increase knowledge on the importance of healthy women for healthy infants. Future work includes establishing a medical home for all, which suggests potential benefits as well.
Finally, Michigan is working to identify guidelines for level of perinatal care in the state’s delivery hospitals to assure that high risk women deliver their infants at the appropriate facility with the right mix of staff, equipment and professional expertise. Michigan had a state coordinated regional perinatal system a few decades ago, that went away in the nineties. The literature and national experts indicate that states with a regionalized and coordinated perinatal system of care assure better and appropriate care to women and infants.
Kevin Ryan, MD, MPH
Chief, Women’s and Children’s Health Section, North Carolina Division of Public Health
Improving the health of women prior to conception and reducing unintended pregnancies are the greatest opportunities to prevent preterm births and related disparities. Four North Carolina (NC) publications describe the health status of NC women and the opportunities to improve their reproductive health outcomes.1,2,3,4 Healthy Start Initiative and First Time Motherhood/New Parent Initiative grant funds are providing the resources to improve the health of new mothers by linking them to health care, preventive health activities, and increasing community support. Access to family planning services has improved by increasing income eligibility for Medicaid enrollment through an 1115 Medicaid Waiver.
Administration of 17 alpha hydroxprogesterone caproate (17P) to prevent recurrent preterm birth is one of the few evidence based, clinical interventions to prevent premature births. If utilized as recommended by ACOG, 17P is very cost effective and will reduce the recurrence of preterm birth by over 33 percent among women with a singleton pregnancy and a prior spontaneous preterm birth.5 Prior to 2007, few NC low income pregnant women received 17P. New funds provided by our General Assembly and recent coverage of 17P by our Medicaid Program has enabled us to provide 17P without charge to all high risk, low income pregnant women. Physician and patient oriented guidelines/educational materials were developed with the support of a physician advisory group led by the UNC Center for Maternal and Infant Health. NC physicians and health departments can obtain clinical advice, order 17P, and obtain these materials through the Center’s website (Look under progesterone).
1. NC Institute of Medicine. Infant Mortality in North Carolina. North Carolina Medical Journal May-June 2004, 65(3). Available at http://www.ncmedicaljournal.com/may-jun-04/toc0504.shtml (Accessed October 31, 2008)
2. NC Healthy Start Foundation. Women’s Health: Attitudes and Practices in North Carolina. Focus Group Research. Raleigh, NC June 2005. Available at http://www.nchealthystart.org/index2.htm (Accessed October 31, 2008)
3. UNC Center for Maternal and Infant Health. Looking Back Moving Forward: North Carolina’s Plan for Healthier Women and Babies. Chapel Hill NC March 2007. Available at http://www.mombaby.org/index.php?c=3 (Accessed October 31, 2008)
4. NC Division of Public Health. North Carolina Preconception Health Strategic Plan. Raleigh, NC 2008. (in process).
5. Use of Progesterone to Reduce Preterm Birth. ACOG Committee Opinion No. 419. Obstetrics & Gynecology. 2008,112(4) 963.