Prematurity & Preconception Health | Infant Mortality | Injury Prevention
Prematurity & Preconception Health
Alabama
By Janice M. Smiley, MSN, RN
Director, State Perinatal Program, Bureau of Family Health Services, Alabama Department of Public Health
The Alabama Department of Public Health, State Perinatal Program (SPP) provides and initiates activities to strengthen the perinatal health care system throughout the state. Provider education is one initiative the program utilizes to enhance perinatal health. The program provides outreach education for physicians and their office staff with the support of the March of Dimes. One-hour continuing education sessions are available to family physicians, obstetricians and pediatricians and their staff on varied topics, including:
- the importance of preconception healthcare counseling to all women of childbearing age
- smoking cessation-counseling training targeting pregnant women and families of infants; importance of folic acid supplementation for all women of childbearing age; importance of optimal weight prior to pregnancy; substance abuse patient education; safe sleep for infants; and
- the importance of breastfeeding promotion.
These educational programs have proven to be beneficial to the providers and the recipients of perinatal health care in Alabama.
Minnesota
By Mary Jo Chippendale, MS, PHN
Family and Women's Health Supervisor, Division of Community and Family Health, Maternal and Child Health, Minnesota Department of Health
Minnesota has one of the nation’s lowest infant mortality rates for the overall population (4.8 deaths per 1,000 live births for 2003-2005). The rate masks racial and ethnic disparities in infant mortality for African American and American Indian families whose infant mortality rates are 8.7 and 8.6, respectively, for the same period. Eliminating disparities in birth outcomes is a state priority identified by our 2005 MCH Needs Assessment. We see promoting culturally specific pre and interconceptional care to populations of color and American Indians as an important strategy to reduce disparities.
Since 2006, Minnesota’s MCH staff has been actively promoting preconception/interconception health to improve birth outcomes and promote women’s health. Recognizing the need to work across many disciplines, the preconception planning group includes representatives from the March of Dimes, University of Minnesota, health care systems, local public health, the Medicaid program, and Healthy Start project. The challenge of integrating pre and interconception care into practice involves changing consumer knowledge and behaviors, clinical practice, public health programs and health care financing.
One strategic approach has been holding annual professional education conferences. The planning for the November 2008 conference began with a Diversity Round Table Structured Discussion with professionals representing and working with populations of color and American Indians. Their guidance regarding how different populations view preconception care, child spacing and other preventive health measures provided valuable input for the 2008 conference. The group described what culturally appropriate accessible care would look like, barriers within their communities, and suggested how to frame preconception care messages. Their ideas are included as presentations for the Second Annual Preconception Conference: Reaching Diverse Communities. We anticipate 200-300 attendees and to make important progress toward our goals of improving birth outcomes and women’s health, and reducing disparities.
Mississippi
By Juanita Graham, MSN RN
Health Services Chief Nurse, Mississippi State Department of Health
The Mississippi State Department of Health continues to rank infant mortality as the Agency’s highest priority. Mississippi has experienced little change in infant mortality over the past decade. The 2007 infant mortality rate was 10.1 per 1,000 live births. This rate is slightly lower than the two prior years but there continues to be a high proportion of infant deaths related to low birthweight and premature birth. Among 2007 infant deaths, approximately 66% were low birthweight (<2,500g) or very low birthweight (<1,500g) (Figure 1) and more than 56% were born premature (<37 weeks gestation) (Figure 2).
Having identified low birthweight and prematurity as key contributors to Mississippi infant mortality, new funding has been acquired and new programs are being implemented to address maternal and infant health. In 2006, Health Services began to assess the relationship between maternal health and birth outcomes among Mississippi women.
Modeling after a program among high risk Georgia mothers (Dunlop et al, 2007), two projects were devised to work with women at risk for delivering a very low birthweight infant in Mississippi. The Metropolitan Infant Mortality Elimination (MIME) project is being implemented in the Jackson metropolitan area and the Delta Infant Mortality Elimination (DIME) project is being implemented in 18 Mississippi Delta counties. Combined, the DIME and MIME projects give varying perspectives – urban and rural -- of implementing interpregnancy care in Mississippi. Primarily, the projects seek to increase access to medical homes thus enhancing access to women’s preventive healthcare and chronic disease management. Outreach and educational services will be provided at individual, community, and professional education levels.
Spaces of Hope in Harlem
By Julius Dasmariñas
Evaluation Director, Central Harlem Healthy Start, Northern Manhattan Perinatal Partnership
Spaces created for human use and consumption known as the built environment can have debilitating impact on the health of marginal and vulnerable populations. In low-income neighborhoods where parks and sidewalks are unsafe, groceries lack healthier food options, and housing is decrepit, residents are observed to suffer more from obesity, depression, violent behavior, and poor birth outcomes. Add racism into the mix and the consequences could be worse. Poor birth outcomes for many African Americans, for instance, have been related to maternal stress and depression caused by life-long exposure to racial prejudice and discrimination and, to a certain extent, its translation in physical, social, economic and service milieus.
In Harlem, however, significant gains have been achieved in improving the health of mothers and their infants through interventions that dually address individual needs and structural reforms in the built environment.
Through clinical and group education intervention of the Northern Manhattan Perinatal Partnership (NMPP), a not-for-profit organization, and its Central Harlem Healthy Start Program, over 9,500 women and their children have been linked and maintained in care. Since the program’s inception in 1990 when the infant mortality rate (IMR) was 27.7 infant deaths per 1,000 live births, the IMR in Central Harlem has plummeted to 5.2 infant deaths per 1,000 live births in 2004, much better than the national IMR of 6.78; from 2001 to 2007 on average, there had been less than 10 infant deaths per 1,000 live births within the community.
The agency also actively advocated for reforms in urban services that directly affect the health of its target population. NMPP embarked on a campaign to reduce the number of bus depots in the Harlem community because of the established correlation between the type of air quality and diesel engine fumes emitted by buses with low birth weight. It likewise supported the building of supermarkets that provide healthier foods to its constituents while ensuring that the bid of the New York City government to construct 165,000 affordable housing is realized. A number of its Healthy Start consumers have availed of the over 82,000 units that had been built so far and are now raising their families in a decent and secure environment.
To sustain their family’s economic and physical well-being, NMPP introduced a job readiness program that had placed over 890 women in full-time and part-time employment. At the policy level, it supported the empowerment-zone legislation initiated over a decade ago which infused Harlem with up to $300 million in block grants for community revitalization and job-creation projects. With the advent of gentrification and its social and economic cost on poor and working class residents, NMPP coalesced with like-minded groups to put pressure on local public leaders and private sector representatives to increase the growth of affordable housing and help boost the business acumen of local vendors so they could compete with larger stores that have settled on 125th street.
‘Taking care of one’s space’ is something that NMPP instills among its consumers and partners. Whether it is through group work where mothers express their personal troubles and understand the societal basis of their predicament as they learn to deploy effective strategies for managing their pregnancy, or through the agency’s advocacy of equitable urban policies that mediate the built environment, the charge of the agency is as clear as ever. NMPP remains determined and hopeful to establish a healthy community for mothers and children in Harlem one space at a time.
Infant Mortality
From 2004-2006, AMCHP partnered with the Centers for Disease Control and Prevention (CDC) and the National March of Dimes Birth Defects Foundation to form the State Infant Mortality Collaborative (SIMC). This three-year project supported five multidisciplinary state teams, as they investigated the infant mortality problem in their jurisdictions and made plans to address it as they deemed feasible and appropriate. The five teams included Delaware, Hawaii, Missouri, North Carolina and Louisiana and represented five of 13 U.S. states with unusually high, stagnant or increasing infant mortality rates in 2004, the year the project began. The overarching goal of the Collaborative was aimed at bringing the nation's experts together to work with these teams.AMCHP Staff followed up with the Delaware SIMC team to learn about their accomplishments since the Collaborative. Additional information on the SIMC can be found at http://www.amchp.org/publications/Downloads/SIMC_Report.pdf.
Delaware
In conjunction with preliminary results from the State Infant Mortality Collaborative, an Infant Mortality Task Force assembled 20 recommendations aimed at reducing infant mortality (IM) in Delaware including a Healthy Mother and Infant Consortium. The Delaware IM initiative is composed of a consortium of public health professionals including neonatalogists, maternal-fetal medicine specialists, registered nurses, internists, hospital administrators, non-profit organization directors, federally qualified health care center directors, state legislators, concerned citizens, researchers, and staff at the Delaware Division of Public Health. The IM initiative is fully endorsed and supported as a Governor’s initiative and thus receives state funds dedicated to research and intervention aimed at reducing infant mortality. The goal of the initiative is to reduce IM through collaborative research, program implementation and evaluation.
Since the initiative began in late 2005, the Delaware Division of Public Health (DPH) has implemented an evidence-based intervention during the prenatal and postpartum period for women considered high-risk (i.e., uninsured or underinsured, member of a minority, residing in a ZIP code identified as having a high proportion of infant deaths, living with a chronic disease, or experienced a previous poor birth outcome such as premature delivery, low birth weight delivery, stillbirth, fetal or infant death) providing supplemental care during pregnancy and up to two years postpartum for mothers and infants. Additionally, DPH implemented an evidence-based intervention program for women during the preconception period considered high-risk (i.e., using the same criteria as the prenatal program) providing supplemental care up to pregnancy or menopause. The high-risk criteria were developed through research using state vital records data, CDC recommendations for preconception care, and Fetal Infant Mortality Review pilot data.
As of June 2008, the prenatal and postpartum program has served over 4,000 pregnant women in Delaware, with 2,549 served in the last year. In a state that averages 11,226 births per year, the program impacted 23 percent of all live births. Of the number served, nine infant deaths occurred, much less than expected in this high risk population. Similarly, the preconception program has served 19,663 in the first 16 months of operation, 11 percent of the population of women of childbearing age in Delaware. Evaluation of the effectiveness of both programs is currently underway, with results expected by the close of 2009. For a full summary of program services and accomplishments, visit http://www.dhss.delaware.gov/dhss/dph/pubs2.html.
Injury Prevention
Child Passenger Safety Training
Connecticut has used MCH block grant funding to develop child passenger safety (CPS) training for child care providers, child care health consultants, and the Department of Public Health’s child care licensing staff. The workshops cover CPS basics, state laws, and local resources so that child care professionals can provide accurate information to the families with which they work. The MCH program also offers booster seat distribution and education at child care programs serving low-income families (such as Head Start) and has run several classes titled “Safe Travel for All Children: Transporting Children with Special Health Care Needs.” These activities are conducted in cooperation with state and local Safe Kids coalitions.
Bullying Prevention
Starting in 2006, the Virginia Department of Health (VDH) implemented the Olweus Bullying Prevention Program in 45 schools across the state, reaching almost 40,000 students in two years. The issue of bullying had been coming up repeatedly for staff in Virginia's Division of Injury and Violence Prevention, a unit of the MCH agency. It surfaced in their Title V needs assessment; in discussions with staff from other agencies, school personnel, and parents; and in the findings of investigations into incidents of school shootings. It became apparent that bullying had a widespread health impact and was related to depression, suicide, sexual violence, and other issues on which they were already working.
VDH immediately saw the benefits of addressing bullying. They had a lot of experience working on school-based programs and a staff who could easily integrate bullying prevention training into their MCH work. They also had some discretionary financial resources to use for materials and trainings.
Moreover, they realized that effective bullying prevention programs were available, and they chose Olweus, an evidence-based model program by Blueprints for Violence Prevention, the Substance Abuse and Mental Health Services Administration (SAMHSA), the Office of Juvenile Justice and Delinquency Prevention, and the United States Department of Education. Olweus is also highlighted on the Stop Bullying Now! website (http://stopbullyingnow.hrsa.gov/).
VDH began by using funds from the MCH Block Grant to support existing Olweus programs with training and start-up resources, including videos, manuals, and books. VDH also gave small grants to 18 community-based organizations, enabling them to start bullying prevention projects and activities. Building on this successful work and with CDC planning and implementation grants, VDH expanded its bullying prevention efforts to schools throughout the state.
VDH is evaluating its bullying prevention project and is collecting data on changes in bullying-related knowledge, attitudes, behaviors, and school and classroom practices. It is extending the understanding of bullying beyond disciplinary or behavior management issues to encompass the broader impact of bullying on individual and societal health. VDH informs bullying and violence prevention activities with health and mental health data, information, and research on the relationship of bullying to suicide risk, depression, and chronic disease. This information resonates with providers, who, as individuals, parents, and community members, see themselves as having more of a stake in addressing this problem.
Domestic Violence Screening
Preliminary work on the 2000 Massachusetts Title V Needs Assessment revealed that MCH service providers wanted more information on identifying and responding to domestic violence. As a result, Massachusetts’ Bureau of Family and Community Health engaged in an iterative process to confirm this need and shape a response. This process served as a catalyst for the creation of the Domestic Violence Screening, Care, Referral, and Information Project (DVSCRIP), which teaches MCH staff to identify and help clients who are victims of intimate partner violence.
Although DVSCRIP was developed by the Division of Violence and Injury Prevention, the need for this training extended across many MCH programs. The division worked with other MCH programs—including WIC, the Early Intervention Prevention Program, and the Family Planning Program—to train their staff in DVSCRIP. The collaboration with WIC proved especially successful. Alicia High, Assistant Health and Human Service Coordinator for the State WIC program, reports that although WIC is primarily a nutrition assistance program for low-income children as well as women who are pregnant, breastfeeding, or postpartum, it is also a strategic opportunity to intervene in domestic violence.
Initially, staff at all 35 WIC programs in Massachusetts received DVSCRIP training. Four of these WIC programs served as pilot sites for the routine domestic violence screening of pregnant, postpartum, and breastfeeding women. As part of the DVSCRIP training, staff from local domestic violence programs and State agencies—such as each of the Domestic Violence Units in the Departments of Social Service and Transitional Assistance—were invited to speak at these trainings. This approach helped WIC staff learn about the programs to which they can refer victims of domestic violence, and it provided an opportunity for staff to meet the individuals who would be accepting these referrals. DVSCRIP also teaches staff to care for their own emotional health, a critical skill for service providers addressing domestic violence issues. The pilot program was later expanded into a statewide effort to train all staff in every WIC program in Massachusetts to routinely screen pregnant, postpartum, and breastfeeding women for domestic violence. The success of DVSCRIP also prompted WIC to add a domestic violence section to the State’s WIC Operations Manual. This section includes policies and procedures on screening, staff roles, referrals, and self-care.
Prevention of Child Abuse and Neglect
Becoming a parent for the first time definitely is a learning experience, but the Kentucky Department for Public Health (DPH) has an innovative program proven to be an invaluable resource for new moms and dads. Known as Kentucky’s Health Access Nurturing Development Services, HANDS provides home visitation for first-time families to help meet the challenges of parenting, beginning with pregnancy and continuing through the child’s first two years of life. During the prenatal period, the health department, a doctor’s office, a place of worship, or friends and relatives may refer a new family to the state Maternal and Child Health program. After the family is screened, a DPH staff person visits the home to work with new parents on parenting skill development, provides guidance on what to expect as a baby grows, offers suggestions on making the home safe, and more. HANDS is modeled after Healthy Families and Healthy Start programs, which are used nationwide. Kentucky combined these approaches to integrate pieces of the social and medical concepts from each, creating a program that addresses such issues as low birth weight, pre-term infants, child abuse and neglect, domestic violence, underdeveloped parenting skills, teen pregnancy, financial difficulties, and substance abuse. Piloted in 1999, HANDS expanded to 15 counties in 2000 and was established in all of Kentucky’s 120 counties by the end of 2003. The program has worked with more than 40,000 families from inception to date. HANDS begins with a screening program that looks at 16 risk factors, including substance abuse, a history of psychiatric care, depression, marital status, smoking, poor prenatal care and a history of abortion. If any one of these risk factors is present, the family is eligible for HANDS home visitation services. The family will be offered a meeting with a professional who will complete a more in-depth assessment that considers such factors as mental health, parenting experience, coping skills, support system, anger management skills, expectations of the infant’s milestones and behavior, plans for discipline, perceptions of the new infant, bonding, and parental strengths. This assessment takes about an hour. If the results indicate that a family may be overburdened, home visiting services are provided to the family. Parents who are not appropriate for HANDS but could benefit from some services are provided with information and referrals to community agencies.
Birth indicators based on 2000–2003 data showed that HANDS participants have fewer premature births, fewer low- and very low-birth weight infants and fewer birth defects when compared to other first-time parents who did not participate in the program. A 2004 study of child abuse and neglect found that participating teens had no incidents of substantiated physical, sexual, or emotional abuse.