Han Hani K. i K. Atra Atrash sh MD, MD, MP MPH Direct - - PowerPoint PPT Presentation

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Improv Improving Pre ing Pregn gnan ancy cy Outco Outcomes mes Upda Update fr te from MCH

• m MCHB

Han Hani K. i K. Atra Atrash sh MD, MD, MP MPH Direct Director

• r

Division of Healthy Start and Perinatal Services (DHSPS) Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB) Grantmakers In Health Meeting on Improving the Health of Parents, Children, and Families through Public-Private Collaboration Washington, DC, December 10, 2014

Th The e Goo

• od

d News ews

• Inf

nfan ant Mo Mortali tality ty Rat ate e de decre reas ased ed by by 12 12.2% 2% from

• m 20

2000 00 to 20

• 2011

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• Bet

etwee een n 20 2006 06 an and 2 d 201 012: 2:

• Pret

eterm erm deliv livery ery rate e decrea reased d by 9.8%

• Low birth

th weight ght rate e dec ecreased ased by 3.3%

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Th The Continuing tinuing Challeng allenges es

• Persistent health disparities
• Other countries have achieved

better outcomes

• Worsening maternal outcomes

contribute to poor pregnancy

• utcomes

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Black-White ite dispari aritie ties s in perina natal tal outcome

• mes

s - United ed States tes 1980 to 2010

Year

2.4 1.9 1.6

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Ot Othe her r Co Countries untries Ha Have ve Do Done ne it! t!

Compared to the United States:

• 27 countries have lower IMRs
• 35 countries have lower PTB Rates, and
• >50 countries have lower MMRs

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Contributors to Pregnancy Outcomes

• Socioeco

econo nomic mic stat atus: s: household income,

• ccupational status, or parental educational

attainment

• Ri

Risky behaviors: iors: maternal cigarette smoking, delayed and inadequate utilization of prenatal care, alcohol and drug use

• Mater

ternal al conditi tions:

• ns: psychological stress, stressful

life events or perceived stress or anxiety during pregnancy, chronic conditions, perinatal infection

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Source: CDC/NCHS, Mortality Data. 2011 data are preliminary. Prepared by MacDorman for SACIM, November 2012.

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U. U.S. Ma Materna nal l Mo Mortalit lity

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5 10 15 20 25 30 35 40 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 Maternal Deaths per 100,000 Live Births

Total White Black

8.2 16.1 13.3

Source: Singh GK. Maternal Mortality in the United States. A 75th Anniversary Title V Publication. HRSA 2010

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Severe vere Matern ternal al Morbidity bidity

• Thrombotic embolism

(72%)

• Respiratory distress

syndrome (75%)

• Cardiac surgery (75%)
• Acute renal failure (97%)
• Shock (101%)
• Blood transfusion (183%)
• Aneurysms (195%)

Callaghan et al: Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 120:1029-36, 2012

• Severe maternal morbidity increased by 75% and

114% for delivery and postpartum hospitalizations respectively from 1998-99 to 2008-09

• Rates increased during delivery hospitalizations for:

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Risk sk factors ctors for r adver verse se pre regn gnanc ancy y outcom tcomes es amo mong ng wom

• men

en who ho recen cently tly del eliver vered ed a live ve-bo born rn bab aby y – PRAMS AMS 200 004 4 – Prec econ

• nception

ception hea ealt lth h con

• nditions

ditions and nd beh ehavi viors rs

Behavior /Condition % Behavior /Condition % Overweight or obese 35 Previous preterm delivery 11.9 Diabetes 1.8 Asthma 6.9 Tobacco (3 months bef preg) 23.2 Hypertension 2.2 Alcohol (3 months bef preg) 50.1 Heart problems 1.2 Multivitamins (>=4/week) 35.1 Anemia 10.2 No contraception / not planning 53.1 Previous Low Birth weight 11.6 Pre-pregnancy counseling 30.3

Centers for Disease Control and Prevention: Preconception and Interconception Health Status of Women Who Recently Gave Birth to a Live-Born Infant --- Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 Reporting Areas, 2004. MMWR 2007:56(SS10);1-35

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We Currently Intervene Too Late

Critical Periods of Development

4 5 6 7 8 9 10 11 12

Weeks gestation from LMP

Central Nervous System Central Nervous System

Heart Heart Arms Arms Eyes Eyes Legs Legs Teeth Teeth Palate Palate

External genitalia External genitalia

Ear Ear Missed Period Mean Entry into Prenatal Care Most susceptible time for major malformation

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Early prenatal care is not enough, and in many cases it is too late!

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• Implement what we know works
• Work beyond the 9 months of

pregnancy:

• Comprehensive women’s health
• Preconception / interconception
• Across the life span - “Life-course

approach”

• How we do it:
• Consider multiple contributing factors
• COINs
• Collective impact

Working smarter

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Lifecourse Perspective to Improve Pregnancy Outcomes

The lifecourse approach proposes that disparities in birth outcomes are the consequences of differential developmental trajectories set forth by early life experiences and cumulative allostatic load over the life course.

Source: Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30.

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Lifecourse Perspective to Improve Pregnancy Outcomes

Scientifi ntific c evidence ce fro rom m two wo leading longitud tudinal inal models: s:

 Th The early ly progr gramm mmin ing g model -

exposures in early life could influence future reproductive potential

 Th The cumula lativ ive e pathw hway ays s model - decline

in reproductive health results from cumulative wear and tear to the body’s allostatic systems  These two models are not mutually exclusive

Source: Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30.

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Li Life fe Co Course urse Pers erspective pective

Source: Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30.

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Source: Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30.

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Key H HRSA SA Im Improving roving Pregnancy egnancy Ou Outcom tcome e P Programs

• grams
• SA

SACI CIM

• Women’s Health Preventive Services

Clinic ical al Care Guide delin lines es

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The Natio iona nal l Mater erna nal l Health lth Initia tiative tive

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The Infan fant t Morta tality lity COIIN, IN, and

• He

Healthy thy St Start

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• 1. Improve the health of women.
• 2. Ensure access to a continuum of safe and high quality,

patient-centered care.

• 3. Redeploy key evidence-based, highly effective preventive

interventions to a new generation.

• 4. Increase health equity and reduce disparities by targeting

social determinants of health through investments in high- risk communities and initiatives to address poverty.

• 5. Invest in adequate data, monitoring, and surveillance systems

to measure access, quality, and outcomes.

• 6. Maximize the potential of interagency, public-private, and

multi-disciplinary collaboration.

Recommendations for HHS Action and Framework for a National Strategy to Reduce Infant Mortality SACIM Strategic Directions: 6 Big Ideas (1/2013)

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Women’s and Maternal Health - HR HRSA SA I Initia itiativ tives es

Women’s Health Preventive Services Clinical Visit Guidelines

• Support the development of clinical preventive

health guidelines for well woman visit

• Compile the guidelines into a succinct resource
• Disseminate these guidelines and promote their

adoption into standard clinical practice among women’s health care providers

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Women’s and Maternal Health - HR HRSA SA I Initia itiativ tives es Nation

• nal

al Matern rnal al Health th Initi itiati ative ve

• Promote coordination and collaboration within HRSA,

across HHS agencies and with professional and private organizations.

• Five priorities:
• Improve women’s health before, during, and after

pregnancy

• Improve systems of maternity care including clinical and

public health systems

• Improve public awareness and education
• Improve research and surveillance
• Improve the quality and safety of maternity care

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Women’s and Maternal Health - HRSA I Initi itiat ativ ives es Improv

• vin

ing g Mater erna nal l Health th and Sa Safet ety

• Purpose: reduce the number of maternal deaths and/or

preventable severe morbidities

• Goal: engaging health care providers, State leaders,

hospitals, payers, and consumers

• Strategies:
• Promote knowledge of and access to preconception and

interconception care through a provider education campaign

• Engage stakeholders in efforts to reduce primary cesarean delivery
• Facilitate the adoption of the maternal safety bundle through

development of a CoIIN of early adopter states

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• Established in 1991 as a presidential initiative
• Provides funding and supports communities with

high infant mortality rates and other adverse perinatal outcomes

• Focused on community innovation and creativity

and encouraged communities to do what was best for them

• Today, HRSA supports healthy start projects in

196 communities THE NATIONAL HEALTHY START PROGRAM History

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• Improve Women’s Health
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Promote te Quality ity Se Servic ices es

• St

Streng ngthe then n Fa Family y Resili ilience nce

• Ac

Achiev eve e Co Collec ective ive Impac act

• Incr

crea ease se Ac Accoun untab tabili ility ty throu

• ugh

gh Quality ity Improv

• vem

ement ent, Pe Perform

• rmanc

ance e Monitor toring ing, , and Ev Evaluati ation

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Main Changes to Healthy Start Healthy Start Approaches

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• Two new programs are being

launched:

• Supporting Healthy Start Performance

Project

• Healthy Start Information System

Implementing Healthy Start 3.0

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• SHSPP will promote the uniform

implementation of Healthy Start by:

• Ensuring skilled, well qualified workers at all levels of the

program

• Identifying and better defining effective services and

interventions

• Offering mentoring, education, and training to staff

delivering these interventions and services

• Providing shared resources

Supporting Healthy Start Performance Project

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• Data Dashboard for real-time monitoring
• f progress of activities
• Individual client data, program data, and

community outcome data for:

• Continuous quality improvement
• Provision of targeted technical assistance, and
• Ongoing local and national evaluations

Healthy Start Information System

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Healthy Start CAN Drive Collective Impact

Healthy Start programs are uniquely situated to:

• Champion the infant mortality cause in their communities
• Serve as backbone organizations to ensure collective

impact

• Implement its six main functions of a backbone
• rganization:
• Provide overall strategic direction
• Facilitate dialogue between partners
• Manage data collection and analysis
• Handle communications
• Coordinate community outreach, and
• Mobilize funding

Source: Turner S, Merchant K, Kania J, Martin E. Understanding the Value of Backbone Organizations in Collective Impact: Part 3. Stanford Social Innovation Review. Jul. 19, 2012 http://www.ssireview.org/blog/entry/understanding_the_value_of_backbone_organizations_in_ collective_impact_3 accessed March 2014

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Th The Infan fant t Morta tality lity CoIIN IN

The Collabo borati rative ve Improve roveme ment nt & Innovatio vation Network

• rk to Reduce

ce Infan ant t Mortali tality ty

• Designed to help States innovate and improve

their approaches to improving birth outcomes

• Initiated March 2012 as a mechanism to support

the adoption of collaborative learning and quality improvement principles and practices to reduce infant mortality and improve birth

• utcomes.

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COIN: Strategies & Structure

5 Strategy Teams

1. Reducing early elective deliveries <39 weeks (ED); 2. Enhancing interconception care in Medicaid (ICC); 3. Reducing SIDS/SUID (SS); 4. Increasing smoking cessation among pregnant women (SC); 5. Enhancing perinatal regionalization (RS).

Teams

• 2-3 Leads (Content Experts);
• Data and/or Method Experts
• Staff support (MCHB & partner
• rganizations)
• State representatives
• Shared Workspace
• Data Dashboard

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Non

• n-Med

Medically ically In Indi dica cated ted Ear arly ly Ter erm m Del eliv iveries eries Am Amon

• ng

g Si Sing ngle leto ton, n, Te Term m Del eliv iveries eries*

* Includes provisional birth certificate data Excludes 1 Region IV State that did not submit 2014 data

29% total decline translating to ~85,000 early elective deliveries averted since 2011 Q1 5 states met aim of 33% reduction 11 states had declines of 20%+

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Sm Smok

• king

ng Du During ng Pr Preg egna nancy ncy*

* Includes provisional birth certificate data reflecting smoking in any trimester; Excludes 1 Region IV State that did not submit 2014 data

12% total decline translating to ~17,000 fewer women smoking in pregnancy since 2011 Q1 6 states met aim of 3% reduction

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Fo For r More

• re In

Information formation

Ha Hani At Atrash sh, MD, D, MPH PH 5600 Fi Fishers ers Lane Rockv kvill ille, e, MD 20852 Offic fice: e: 301-443 443-0543 0543 Direct: ct: 301-443 443-7678 7678 Em Email: : hatra rash sh@h @hrsa.g rsa.gov

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