WABASH VALLEY HEALTHY MOMS AND BABIES

INITIATIVE

Optimizing Birth Outcomes for Rural Women

Providing Great Starts for BabiesBuilding Hopeful, Healthy Neighborhoods!

The Rural Health Innovation Collaborative

A 14 member public-private not-for-profit organization dedicated to community health and wellness, interprofessional education and practice, economic vitality.

National Leadership Academy for Public Health (NLAPH)

Sponsored by:• Public Health Institute• Centers for Disease Control and Prevention

Mission:• NLAPH is an applied leadership training program that enables multi-

sector jurisdictional teams to address public health problems within their communities through team-identified community health improvement. projects.

Goals:• Educate stakeholders about evidence-based policies• Drive the adoption of evidence-based practices in communities• Better align medicine and public health• Improve health outcomes in our nation through sustainable systems

change

Team Members: Wabash Valley Healthy Moms and Babies

• Clay• Greene• Owen• Parke• Putnam• Sullivan• Vermillion• Vigo

Wabash Valley Target Counties

Key Activity 1: Learn from Communities

1. Engage community stakeholders to:• Identify their priorities in

light of state health data. 2. Promote: • Development of community-

based prevention and intervention strategies.

• Broad spectrum of community participation that leads to sustainability.

Impact to Date: Building Community Capacity for Better Birth Outcomes

• Since March 2014:– Interacted with 98

community stakeholders within the identified counties.

– Stakeholders identified priorities for community-based learning forums.

– Follow-up sessions for 4 counties planned to facilitate solution strategies.

Topics of Interest in Wabash Valley Counties

Role of Fathers

Smoking Cessation

Safe Environment

Key Activity 2: Implement Data Review Process to Produce Change

Goal: Promote regional data collection regarding causes of fetal and infant death

Action: Establish regional fetal and infant mortality review board using perinatal periods of risk model

Outcomes: • Strengthen state-regional

connections• Promote regional data collection

to implement targeted prevention and intervention strategies

Key Activity 3: Develop a Network of Community Maternal Health

Advocates

What Causes Poor Birth Outcomes in your Neighborhood?

• “I believe some of the things that contribute to poor birth outcomes are stress, poor eating habits, lack of support and knowledge, and sometimes habits that the pregnant mother can’t shake.”

• “Lack of knowledge and the fact that our culture does not emphasize asking for help”

• “I believe the lack of support, stress and a lot to do with mothers just not living a healthy lifestyle and the lack of knowledge.”

ååå

Individual

Relationship

Community

Societal

Social – Ecological Model: A Framework for Prevention

(CDC)

Why Focus on Fostering Supportive Relationships?

• Toxic: Strong, frequent, or prolonged activation of the body’s stress management system. Events that are chronic, uncontrollable, and experienced without having access to the support of caring adults.

• Tolerable: Stress that occurs for brief periods, allowing the brain to recover. Occurs in the presence of supportive adults, which creates a safe environment for learning coping skills.

• Positive: Moderate, short-lived stress response, normal part of life. Learn to manage with supportive relationships.

Linking Toxic Stress to Poor Birth Outcomes

• Allostatic Load

– Comprehensive and cumulative risk across multiple physiological regulatory systems resulting from chronic exposure to life challenges or stressors that influence health outcomes across the life span (McEwen and Stellar, 1993).

Poor Relationships

Chronic Stress

Poor Birth Outcomes

Strategies to Reduce Stress

• Identify sources of stress and strategies to

deal with them

• Sleep

• Exercise (under direction)

• Good Nutrition: 5-6 small meals/day

• Avoid smoking, alcohol and drugs

• Support network

Addressing Perinatal Mental Health in Low Income, Minority, and/or

Rural Women1. Major health concern in low

income women-poses serious risks for a woman, her family, her infant.

2. FEW studies or programs addressing minority, low income, or rural women during perinatal period.

3. Often these women do not seek help, until it is too late.

4. Easily accessible, low cost interventions work• Support Networks

Women's’ Networks are Powerful in Decision Making Processes

•Peer supporters:

– Connect health and social service providers with community

– Cost effective way to improve health outcomes

– Increase community acceptance of health services

• Peer Support Programs:

– Improve psychosocial variables associated with pregnancy outcomes in low-income women

– Improve breastfeeding rates in low-income women

– Promotes coping skills in first time mothers.

Anderson, AK, Damio, G, Young, S, Chapman, DJ, Perez-Escamilla, R (2005)Baffour, TD, Chonody, JM (2009) Canuso, R (2003) Lapierre, J, Perreault, M, Goulet, C (1995)

METHODS

Connections Tiered Approach

Community Learning Forums

Community Health

Advocacy Leaders

Peer Support

Team

Community Health Advocacy Leaders

• Received leadership training - EvaluLEAD• Provide leadership in project meetings and all elements of project• Moderated community learning forums• Form networks with national leaders in health disparities research

and outreach. • Mentor peer support teams

Gail Ross Kathy J. Trotter Thelma Sims

Pregnancy Peer Support Program

• Pregnant African American women (19-44 years of age) and peer supporters were recruited

• Peer supporters completed a 6 hour training program

• Pairs were matched based on personality assessment results

• Pairs work together through infant’s 3rd month

• All participants received monthly gift card

Pregnancy Peer Support Program Outcome Measures

• Evaluate: change in anxiety, depression, and self efficacy of BOTH the pregnant woman and peer supporter.

• Qualitative assessment of program via monthly structured interviews.

Recruitment Strategies

Peer Supporters

• Work development programs

• Local colleges/universities

• Churches

• Community events

Pregnant Women

• WIC sites

• 2 local hospital-based OB/GYN

practices

Assessments

• Quantitative• Big 5 Personality Test• Patient Health Questionnaire – 9 (PHQ-9)• State Trait Anxiety Inventory (STAI)• General Self Efficacy Scale (GSES)

• Qualitative• Monthly structured interviews analyzed

with NVivo

RESULTS

Demographic Information• Peer Supporters:

o 17 women recruited and enrolled – Mean age 32.6 yrs (range 21-60 yrs..)

15 women had ≥ 1 child; 2 had no children 14 were African American; 3 were Caucasian

• Pregnant Women:o 21 recruited and enrolled

– Mean age 23.6 yrs. (range 19-31 yrs.)– 1 in 1st trimester; 13 in 2nd trimester; 7 in 3rd trimester– Varied levels of support

40% in committed relationships; 40% “complicated” relationships; 20% unknown relationship status

– Varied living situations Living alone, with family and/or extended family, or with

significant other’s family

Quantitative Results

Peer Supporters: o 76% completed the program

(n=13)o 4 did not complete the program

o 1 left program (lost contact)

o 2 pregnant women left program

o 1 pregnant woman requested different peer supporter

Pregnant Women: o 71% completed the program (n=15)o6 women did not complete the program

o 3 left the program (lost contact)

o 1 due to infant deatho 2 completed the program,

but failed to complete exit assessments (lost contact)

• 16 total pairs, average length of relationship = 6 mos. (range 3-8 mos.)

Birth Outcomes

• 1 set of twins born at 25 weeks gestation (1 passed away at 3 months)

• 1 late preterm infant• 1 low birth weight

baby• 1 infant death at

delivery due to placental abruption

Big 5 Personality Test Results

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Peer Supporters

Pregnant Women

Personality Domain

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core

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PHQ-9 Scores

Entry Exit0

5

10

15

Peer Supporters - Depression Scores

PHQ-9

Mea

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10

5

10

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Pregnant Women - Depression Scores

EntryExit

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Entry Exit

PHQ-9 Peer Supporters

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PHQ-9 Pregnant Women

STAI Scores

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Peer Supporter - Anxiety Scores

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60Pregnant Women - Anxiety Scores

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State Anxiety Trait Anxiety

STAI Trait Scores - Peer Supporters

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reSTAI Trait Scores - Pregnant

Women

GSES Scores

Entry Exit0

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Peer Supporters - Self Efficacy Scores

GSES

Mea

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core

105

101520253035404550

Pregnant Women - Self Efficacy Scores

Entry Exit

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Entry Exit

GSES – Peer Supporters

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Entry

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GSES Scores – Pregnant Women

Qualitative Results

1. How often did you “meet?” • Weekly

2. How did you communicate with each other? • Text• Phone

3. What kinds of things did you talk about? • Baby/pregnancy• Baby’s father - in/out of the picture, how to deal with lack of

help• Relationships – with family and baby’s father• “Issues” (personal, financial, and family)

Qualitative Results4a. What kinds of stressors did you encounter this past month?

• Concern about baby’s health and growth• Disappearing and reappearing father• Work • School• None

4b. How has your peer support relationship helped?• Gave peer supporters and pregnant women someone to talk to • Helped take their mind of their own troubles and help someone else

5. What do you hope to gain from your peer support relationship during this upcoming month? Do you have any expectations?

• Continued support of each other and friendship• No expectations• Closer relationship

Qualitative Results

6. Do you have any ideas/suggestions for activities or topics to discuss during our next Connections family meeting?

•Breastfeeding•Baby preparedness•How to deal with the fathers when they are not supportive•Healthy relationships•Social gatherings

7. What can we do to help you optimize your peer support relationship?

•Nothing•Good relationship

Monthly Family Meetings

•Key ObjectivesSocialization

•Celebrating•Baby Showers

Professional Development•Breastfeeding•Financial management•Nutrition Moment •Career readiness•The role of men

What We Learned

• Peer supporters provided the 3 elements of social support (Antonucci, 1985; House & Kahn, 1985; Kahn & Antonucci, 1980)– Emotional– Instrumental– Instructional

• The importance of community leaders• Challenging work – need of a social worker to assist• The power of the social determinants of health – the

joy of fostering relationships

University of Nebraska Medical Center

Thank you!Acknowledgements: Funding: Nebraska Department of Health and Human Services, The Learning Community of Douglas and Sarpy Counties, Nebraska March of Dimes, Omaha Home for Boys, and the generous donations of private philanthropists.

Staff: Kathleen Burke, PhD, Kellee Hanigan, DPT, Dennis Molfese, PhD and lab staff, Susan Landry, PhD and lab staff, Lisa St. Clair, PhD, Jack Turman, III and Fran Higgins for photographic and videographic work.