Emerging Issues in MCH

Debra Bara MAPPOR

Incorporating Preconception Health into

MCH Services

Perinatal Periods of Risk Practice Collaborative

Sponsored by CityMatCH, UNMC

Partners included National Offices of

March of DimesCenters for Disease

Control and Prevention

Practice Collaborative Members

Teams from 16 cities that included:Policy RepresentativeData RepresentativeCommunity Representative

Met to “refine the practice” of PPOR and adapt for use in urban cities in industrialized country.

OVERVIEW

Perinatal Periods of Risk

Both a DATA ANALYSIS TOOL and an APPROACH to identify critical gaps in the maternal and child health system that lead to infant mortality.

OVERVIEW

PPOR Differs from conventional analysis

In addition to AGE AT DEATH, PPOR takes into account the BIRTH WEIGHT, an equally important predictor of survivability.

OVERVIEW

PPOR differs from conventional analysis:Utilizes LINKED birth and death records,

which allows investigators to sort and study variables on the birth certificates, which is generally more complete that death certificate records alone.

OVERVIEW

PPOR differs from conventional analysisCombines fetal and infant deaths in a

“feto-infant” death rate. Includes fetal deaths as over 24 weeks, live

births greater than 500 grams, (excluding spontaneous and induced abortions)

Ensures comparability of data (reference group)

OVERVIEWFeto-infant mortality rates are

“mapped” according to the time of death and weight

Maternal Health

MaternalCare

NewbornCare

Infant Health

Age at death

Birth Weight

Fetal 24+ wks. Neonatal Postneonatal

DATA LEADS TO ACTION !

Maternal Health/ Maternal Health/ PrematurityPrematurity

Maternal CareMaternal Care

Newborn CareNewborn Care

Infant HealthInfant Health

Preconception Health

Health Behaviors

Perinatal Care

Prenatal Care

High Risk OB Referrals

Insurance Coverage

Perinatal Management

Neonatal Care

Pediatric Surgery

Sleep Position

Breast Feeding

Injury Prevention

Maternal HealthRisk Factors

InfectionStress and WorkGeneral state of health prior to pregnancyInjuries and abuseFamily planningNutrition Tobacco/alcohol/drug usePrevious pregnancy outcomes

Maternal CareRisk Factors

Nutrition during pregnancy

Late/inadequate PNC

Treatment of infection

Poor weight gain

Tobacco/alcohol/drug use during pregnancy

Lack of recognition of problems needing care

Recognition/management of early labor

Obesity

Newborn CareRisk Factors

Availability of neonatal intensive care

Prevention of infection

Recognition of emergency situation

Obstetric expertise

Pediatric expertise

Regular newborn care including feeding/well baby care.

Infant HealthRisk Factors

Prevention & treatment of infection

Recognition of birth defects/developmental anomalies

Prevention/treatment of injuries

Recognition of signs & symptoms of illness

Failure to obtain well-child care or follow-up for illness

SIDS prevention

Opportunity gapsUses a “comparison group” model to

quantify the specific opportunity to improve

United States “reference group” is white women, 13+ years of education, over 20 years of age, married.

What it tells us

Common Finding across Cities

Maternal Health was greatest opportunity for improvement

Infant Health was most frequent second opportunity

Often documented racial disparity issues as occurring in Maternal Health Cell

National PPOR Rates by Race/Ethnicity,by Period of Risk Components, for Resident

Mothers 20+ years age, 13+ years of education in US, 1998-2000 (Table 6.3)

2.2

6.4

2.8

1.5

2.5

1.81.1

1.4

11

2

1

0

2

4

6

8

10

12

14

White non-

Hispanic

Black non-

Hispanic

Hispanic

Rat

es p

er 1

,000

Infant Health

Newborn Care

Maternal Care

Maternal Heath/Prematurity

Implications

Changes in Practice Program & Policy

PRACTICE

EXAMPLES-Integrating pre and interconceptional care into existing services Family Planning ClinicsHome Visitation servicesDeveloping risk screening process for non-

pregnant population of women

Program- EXAMPLEHealthy Start Home Visitation

Services

Risk assessment Women’s Health

questionnaire-25 questions Access to Health Care,

Maternal Infections, Baby Spacing

Nutrition & Physical Activity

Chronic Health Issues Stress & Mental Health Environmental Health

Interventions Home Visitation Staff

linking non-pregnant patients to:

Smoking cessation services

Domestic violence prevention, MH services, including drug treatment

Health Care

Policy

Answer questions “who do we serve & how?”What programs need to be organizationally connected for optimum service to women throughout the life span?Funding ImplicationsResearch Implications