By Patricia McKane, Cristin Larder and Quess Derman
Michigan Department of Community Health
The Michigan Department of Community Health (MDCH) is committed to improving MCH epidemiology capacity enabling epidemiologists to leverage existing data resources to assess and monitor maternal, infant and child health. MCH epidemiologists work collaboratively with MCH programs on a number of projects, perhaps most visibly to provide analysis in support of the Michigan Infant Mortality Reduction Plan.1 Infant mortality, defined as the death of an infant before one year of age, is a globally accepted critical health indicator. As such, infant mortality is an important indicator not only of maternal and child health, but it also is a proxy for family and community-level factors that are difficult to measure and impact the health of the mother-infant dyad.
Infant mortality was selected as one of two health indicators on the Governor’s Dashboard, bringing bolstered support and broadened the expectation of a reduction in the state rate. Toward that effort, a diverse steering committee of MCH experts, stakeholders and advocates was convened to examine the causes of infant death in Michigan and developed the Michigan Infant Mortality Reduction Plan,1 consisting of eight strategies to improve birth outcomes and infant survival. One of the strategies is to support the health status of women and girls.
The connection between maternal health during pregnancy and infant health has been long established, but only recently has the connection between infant and maternal health prior to pregnancy been recognized. Preconception health refers to the health and well-being of women prior to becoming pregnant the first or subsequent times, while interconception health refers to the time period between pregnancies. Improving preconception and interconception health of women can improve maternal and infant health outcomes as well.2,3,4 In 2010, nearly 45 percent of Michigan mothers delivering live births reported that the pregnancy was unintended (Michigan Pregnancy Risk Assessment Monitoring System (PRAMS), 2010). The prevalence of unintended birth is greater than 65 percent for low-income women who often have more risks for poor pregnancy outcomes. Additionally, many women do not seek prenatal care until eight weeks of gestation or later, after a period that carries a high risk for the fetus has already passed.4 If Michigan is to improve maternal and infant health baseline knowledge, along with trends, in-depth analyses are needed to inform programs, policymakers and other stakeholders.
Using the Preconception Health Indicator 3 as a framework, epidemiologists and interns representing both MCH and chronic disease generated annual tables and revised the preconception health fact sheet series. Because obesity is the other health indicator on the Governor’s dashboard, a fact sheet to provide stakeholders the health status of Michigan women and girls related to nutrition and physical activity was selected for the inaugural issue.5
While the fact sheet provides important descriptive statistics, regression analysis of the impact of women’s health, specifically chronic disease, on birth outcomes using data from the Michigan PRAMS is being conducted.6,7 To date we have examined associations between preconception chronic conditions captured by the PRAMS survey and birth outcomes, namely low birth weight, preterm birth, and admission to the Neonatal Intensive Care Unit. Asthma, anemia and depression reported during the three months before pregnancy were all correlated with higher prevalences of at least one of the measured birth outcomes after controlling for relevant demographic confounders.8 The results of this analysis, along with descriptive statistics outlining the health status of Michigan women and girls, has been used to educate stakeholders and policymakers about the impact of women’s health on infant health and the possible impact of insurance coverage in mediating this association.
Coupled with information about the cost of premature birth and neonatal intensive care, we plan to estimate the impact of maternal chronic disease on labor and delivery costs in Michigan. To support the development of a preconception/interconception health work plan, additional analysis related to care access, pregnancy interval, and maternal risks, with an emphasis on integrating the life course indicators and social determinants of health, is underway. MCH epidemiologists and programs promote a collaborative and data driven approach to ensure that the state is moving closer to its goals for maternal and child health.
1 Michigan Department of Community Health (MDCH) State of Michigan Infant Mortality Reduction Plan. 2012 michigan.gov/documents/mdch/
2 Recommendations to improve preconception health and health care – United States. MMWR 2006; 55(RR06):1-23
3 Broussard DL, et al. Core state preconception health indicators: a voluntary, multi-state selection process. Matern. Child Health J. 2011; 15(2):158-168.
4 United States Department of Health and Human Services. "Healthy People 2020." 2013. Available online: healthypeople.gov/2020/default. aspx. Accessed May 10, 2013.
5 Vanos H, Larder C, Fussman C, McKane P, Wahl R. Michigan Department of Community Health. "Preconception Health in Michigan: Nutrition and Physical Activity." 2013. michigan.gov/documents/mdch/ Preconception_Nutrition_and_Physical_Activity_Project_final_428644_7. pdf
6 Zimmerman N, Larder C, Lyon-Callo S, Wahl, R., McKane, P., Bach J. Michigan Department of Community Health; "Preconception Chronic Disease and Birth Outcomes in Michigan, 2009-2010"
7 Jary H, Larder C, Lyon-Callo S. Michigan Department of Community Health; "Preconception Health, MI PRAMS 2009." MI PRAMS Delivery. Volume 11, Issue 2. Michigan Department of Community Health. Spring 2012. michigan.gov/documents/mdch/PRAMS_Spring_2012_Newsletter_ Preconception_Health_Final_395572_7.pdf
8 Zimmerman N, Larder C, Lyon-Callo S, Wahl R, McKane P, Bach J. Michigan Department of Community Health; "Preconception Chronic Disease and Birth Outcomes in Michigan, 2009-2010" MI PRAMS Special Report Volume 1, Issue 1: August 2013.