Maternal Child Health and Maternal Child Health and Maternal Child - - PowerPoint PPT Presentation

• Maternal Child Health and

Chronic Disease

The Odd Couple

• r

A Marriage Made in Heaven?

AMCHP Women and Perinatal Health Information Series July 17, 2008 Joan Ware, MSPH, RN, Consultant, Women’s Health Council, National Association of Chroni Disease Directors

Maternal Child Health and Maternal Child Health and Chronic Disease Chronic Disease

The Odd Couple The Odd Couple

• r
• r

A Marriage Made in Heaven? A Marriage Made in Heaven?

AMCHP Women and Perinatal Health Information Series July 17, 2008 July 17, 2008 Joan Ware, MSPH, RN, Consultant, Women Joan Ware, MSPH, RN, Consultant, Women’ ’s Health Council, National Association of Chroni s Health Council, National Association of Chronic Disease Directors Disease Directors

• Outline

Outline Outline

• What is NACDD?

What is NACDD?

• Why chronic disease and MCH?

Why chronic disease and MCH?

• Why gestational diabetes?

Why gestational diabetes?

• What is the Gestational Diabetes

What is the Gestational Diabetes Collaborative Project Collaborative Project

• What can MCH programs do?

What can MCH programs do?

• !!

!!

Collaborators Collaborators

• Who is NACDD?

Who is NACDD? Who is NACDD?

• The

The “ “AMCHP AMCHP” ” for Chronic Disease for Chronic Disease

• More than 800 members from every US

More than 800 members from every US state and territory state and territory

• 16 Councils and special interest groups

16 Councils and special interest groups supporting state public health activities supporting state public health activities focusing on specific chronic disease focusing on specific chronic disease and health promotion areas and health promotion areas

• Councils and Special

Interest Groups Councils and Special Councils and Special Interest Groups Interest Groups

• Asthma

Asthma

• Arthritis

Arthritis

• Cancer

Cancer

• Diabetes

Diabetes

• Heart Disease and

Heart Disease and Stroke Stroke

• School Health

School Health

• Women

Women’ ’s Health s Health

• Osteoporosis

Osteoporosis

• Obesity

Obesity

• Healthy Aging

Healthy Aging

• Health Disparities

Health Disparities

• Physical Activity

Physical Activity

• Vision and Eye

Vision and Eye Health Health

• Tobacco Use

Tobacco Use Prevention Prevention

• Depression

Depression

• Why Link MCH and Chronic

Disease/Health Promotion? Why Link MCH and Chronic Why Link MCH and Chronic Disease/Health Promotion? Disease/Health Promotion?

• Preconception care is important, especially for

Preconception care is important, especially for women with chronic diseases women with chronic diseases – – Risk factors and conditions can be identified Risk factors and conditions can be identified early and addressed early and addressed

• Pregnancy can unmask a potential for chronic

Pregnancy can unmask a potential for chronic diseases diseases

• Pregnancy is an entry point into health care and

Pregnancy is an entry point into health care and an opportunity for primary prevention of chronic an opportunity for primary prevention of chronic diseases diseases

• "
• !
• "
• !

• Why Chronic Disease?

Why Chronic Disease? Why Chronic Disease?

Among women of child bearing age: Among women of child bearing age:

• Asthma (medication risk)

Asthma (medication risk) 6.1% 6.1%

• Hypertension/CVD

Hypertension/CVD 6.4% 6.4%

• Diabetes

Diabetes 9.3% 9.3%

• Smoke during pregnancy

Smoke during pregnancy 11.4% 11.4%

• Overweight or obese

Overweight or obese 55.0% 55.0%

• 250,000 breast cancer

250,000 breast cancer survivors under age 40 survivors under age 40

• Why Chronic Disease?

Why Chronic Disease? Why Chronic Disease?

Of women who are pregnant: Of women who are pregnant:

• 3

3-

• 8% will develop gestational diabetes

8% will develop gestational diabetes

• 10

10-

• 15% will develop postpartum depression

15% will develop postpartum depression

• If overweight prior to pregnancy, her offspring is 3 times more

If overweight prior to pregnancy, her offspring is 3 times more likely to be overweight by age 7 likely to be overweight by age 7

• If preeclampsia developed in pregnancy there is an increased

If preeclampsia developed in pregnancy there is an increased lifetime risk of metabolic syndrome, ischemic heart disease and lifetime risk of metabolic syndrome, ischemic heart disease and stroke stroke

• Postpartum state confers 5

Postpartum state confers 5-

• fold risk of new

fold risk of new-

• onset rheumatoid
• nset rheumatoid

arthritis, especially after first pregnancy arthritis, especially after first pregnancy

• Why Now?

Why Now? Why Now?

• The perinatal period is too late to modify maternal

The perinatal period is too late to modify maternal behaviors, health conditions and risk factors behaviors, health conditions and risk factors

• Rising prevalence of obesity and diabetes and the

Rising prevalence of obesity and diabetes and the trend to delay child bearing until later in life mean trend to delay child bearing until later in life mean women are more likely to have chronic disease risk women are more likely to have chronic disease risk factors which complicate pregnancy factors which complicate pregnancy

• Why Now?

Why Now? Why Now?

New Target Populations for New Target Populations for Prevention of Chronic Disease Prevention of Chronic Disease

• Preconception

Preconception

• Interpregnancy

Interpregnancy

• Postpartum

Postpartum

• Interconception

Interconception

• Collaboration Issue:

Gestational Diabetes Collaboration Issue: Collaboration Issue: Gestational Diabetes Gestational Diabetes

As defined by the As defined by the Hyperglycemia and Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) Study Adverse Pregnancy Outcomes (HAPO) Study Cooperative Research Group : Cooperative Research Group :

“ “G Glucose intolerance with onset or first

lucose intolerance with onset or first recognition during pregnancy. recognition during pregnancy.

• Why Gestational Diabetes?

Why Gestational Diabetes? Why Gestational Diabetes?

• Gestational diabetes (GDM) is the

Gestational diabetes (GDM) is the most common metabolic disorder of most common metabolic disorder of pregnancy pregnancy

• GDM is a leading cause of maternal

GDM is a leading cause of maternal hospitalizations prior to delivery, and hospitalizations prior to delivery, and results in longer hospital stays results in longer hospital stays

• Method to promote healthier moms and

Method to promote healthier moms and

• ffspring, and prevent a major
• ffspring, and prevent a major

chronic disease at the same time chronic disease at the same time

• Prevalence of GDM

Prevalence of GDM Prevalence of GDM

• Prevalence ranges between 1%

Prevalence ranges between 1%-

• 14%

14% 1

1

• Complicates 4% of all pregnancies annually

Complicates 4% of all pregnancies annually 1

1

• Affects 150,000

Affects 150,000-

• 200,000 pregnancies each year

200,000 pregnancies each year in the United States in the United States 2

2

1. Diagnosis and Classification of Diabetes Mellitus. ADA. Diabetes Care. Volume 30, Supplement 1, January 2007. 2. CDC Division of Diabetes Translation, 2007 Teleconference Presentation to Connecticut Data Surveillance Work Group

• What are the Concerns?

What are the Concerns? What are the Concerns?

• 14% of risk of developing type 2 diabetes in 20 weeks

14% of risk of developing type 2 diabetes in 20 weeks after pregnancy after pregnancy

• 50

50-

• 65% risk of GDM with next pregnancy

65% risk of GDM with next pregnancy

• 20

20-

• 30% risk of type 2 in 7

30% risk of type 2 in 7-

• 10 years

10 years

• 50

50-

• 70% risk of type 2 progression in lifetime

70% risk of type 2 progression in lifetime

• Increased risk of type 2 DM in children of mothers

Increased risk of type 2 DM in children of mothers with GDM with GDM

Kim, C., Newton, K.M., and Knopp, R.H. 2002. . Gestational diabetes and the Incidence of Type 2 Diabetes. Diabetes Care. 25:1862-1868.

• The Risks of GDM

The Risks of GDM The Risks of GDM

• Miscarriages and stillbirth

Miscarriages and stillbirth

• Increased inductions and C

Increased inductions and C-

• sections

sections

• Macrosomia

Macrosomia

• Intrauterine developmental and growth abnormalities

Intrauterine developmental and growth abnormalities

• Preeclamsia

Preeclamsia

• Depression

Depression

• Birth and neonatal complications (e.g. shoulder dystocia)

Birth and neonatal complications (e.g. shoulder dystocia)

• Offspring predisposed to obesity and type 2 diabetes

Offspring predisposed to obesity and type 2 diabetes

• GDM Screening

GDM Screening GDM Screening

• Screening recommended at 24

Screening recommended at 24-

• 28 weeks gestation,

28 weeks gestation, even if no high risk factors even if no high risk factors

• Some guidelines recommend earlier screening if

Some guidelines recommend earlier screening if high risk to rule out type 2 diabetes high risk to rule out type 2 diabetes

• First screening test should be 1

First screening test should be 1-

• hr GCT

hr GCT 1

1

• If elevated level, then women undergo a 2

If elevated level, then women undergo a 2-

• hr or 3

hr or 3-

• hr

hr OGTT to confirm OGTT to confirm 1

1

• 1. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, Volume 30,

Supplement I, January 2007, pp S42-S47

• Screening Recommendations

Screening Recommendations Screening Recommendations

High Risk for GDM High Risk for GDM

– – Age > 35 years Age > 35 years – – BMI > 29 kg/m BMI > 29 kg/m2

2 before

before pregnancy pregnancy – – Personal history of GDM Personal history of GDM – – Previous macrosomic infant Previous macrosomic infant – – History of GDM related obstetric complications History of GDM related obstetric complications – – Racial/ethnic group with high prevalence of GDM Racial/ethnic group with high prevalence of GDM – – First degree relative with diabetes First degree relative with diabetes

• Goals of the Project

Goals of the Project Goals of the Project

• Compare PRAMS data to medical records

Compare PRAMS data to medical records

• Examine routinely collected data to assess quality of

Examine routinely collected data to assess quality of data data

• Summarize findings

Summarize findings

• Make recommendations for improving quality of data

Make recommendations for improving quality of data systems and applications to improve care systems and applications to improve care

• Enhance collaboration among public health programs

Enhance collaboration among public health programs

• Why Did DDT Fund

This Project? Why Did DDT Fund Why Did DDT Fund This Project? This Project?

• Establish 6

Establish 6-

• state collaboration to identify, catalogue,

state collaboration to identify, catalogue, and validate routinely collected data about GDM and validate routinely collected data about GDM

• Identify gaps in quality of GDM prevalence data

Identify gaps in quality of GDM prevalence data

• Develop recommendations for improving data

Develop recommendations for improving data quality quality

• Determine implications for care

Determine implications for care

• Five State Collaborative

Five State Collaborative Five State Collaborative

• Michigan

Michigan

• North Carolina

North Carolina

• Oklahoma

Oklahoma

• Utah

Utah

• West Virginia

West Virginia

• Background

Background Background

• Prevalence rates of gestational diabetes from Utah

Prevalence rates of gestational diabetes from Utah 2004 PRAMS and 2004 birth certificates were 2004 PRAMS and 2004 birth certificates were compared compared

• 6.1% reported high blood sugar level according to

6.1% reported high blood sugar level according to PRAMS weighted data PRAMS weighted data

• 2.4% had GDM recorded on birth certificates

2.4% had GDM recorded on birth certificates

• PRAMS 2004 Questions on

Blood Sugar PRAMS 2004 Questions on PRAMS 2004 Questions on Blood Sugar Blood Sugar

Did you have any of these problems during Did you have any of these problems during your most recent pregnancy? your most recent pregnancy?

High blood sugar (diabetes) that High blood sugar (diabetes) that started before this pregnancy started before this pregnancy Yes Yes No No High blood sugar (diabetes) that High blood sugar (diabetes) that started during this pregnancy started during this pregnancy Yes Yes No No

• Study Question

Study Question Study Question

How does gestational diabetes How does gestational diabetes identified on PRAMS and NOT on identified on PRAMS and NOT on the birth certificate compare with the birth certificate compare with medical records? medical records?

• 2004 Utah PRAMS Surveys

2004 Utah PRAMS Surveys 2004 Utah PRAMS Surveys

Elevated Blood Elevated Blood Sugar on PRAMS Sugar on PRAMS N=136 N=136 GDM on Birth GDM on Birth Certificate Certificate 46 46 (34%) (34%) GDM Not on Birth GDM Not on Birth Certificate Certificate 90 90 (66%) (66%)

• Validation Methods

Validation Methods Validation Methods

• Selected all 90 women reporting

Selected all 90 women reporting “ “high blood sugar high blood sugar levels during most recent pregnancy levels during most recent pregnancy” ” on 2004 PRAMS

• n 2004 PRAMS

survey but GDM not recorded on birth certificate survey but GDM not recorded on birth certificate

• Of these, 80 hospital medical records were available

Of these, 80 hospital medical records were available for review for review

• Conducted IRB

Conducted IRB-

• approved review of hospital records to

approved review of hospital records to validate GDM data validate GDM data

• Definition of GDM used in

Medical Record Review Definition of GDM used in Definition of GDM used in Medical Record Review Medical Record Review

• 2 abnormal values on the 3

2 abnormal values on the 3-

• hour OGTT

hour OGTT (Carpenter/Coustan diagnostic criteria) (Carpenter/Coustan diagnostic criteria)

• Physician or other health care provider wrote

Physician or other health care provider wrote “ “gestational diabetes gestational diabetes” ” diagnosis in chart diagnosis in chart

• Women who reported GDM on

PRAMS but GDM was not Indicated on the BC (n=80) Women who reported GDM on Women who reported GDM on PRAMS but GDM was not PRAMS but GDM was not Indicated on the BC (n=80) Indicated on the BC (n=80)

100.0% 100.0% Total Total 62.5% 62.5% No GDM No GDM 25.0% 25.0% GDM GDM 12.5% 12.5% No information No information

Medical Record Review Medical Record Review

• Documentation of GDM Tests

Results and Follow-up Documentation of GDM Tests Documentation of GDM Tests Results and Follow Results and Follow-

• up

up

100.0% 100.0% Total Total 27.5% 27.5% Inadequate documentation Inadequate documentation (e.g. No testing or results (e.g. No testing or results information; no follow information; no follow-

• up test

up test

• n elevated 1
• n elevated 1-
• hr GTT tests)

hr GTT tests) 72.5% 72.5% 1 hr screen and 3 1 hr screen and 3-

• hr OGTT

hr OGTT documented on chart review documented on chart review

Medical Record Review Medical Record Review

• Conclusions

Conclusions Conclusions

1. 1. The PRAMS survey question is not specific for The PRAMS survey question is not specific for GDM, and should not be used as a source for GDM, and should not be used as a source for prevalence of gestational diabetes in Utah. prevalence of gestational diabetes in Utah. 2. 2. Birth certificate data underestimated the Birth certificate data underestimated the prevalence of GDM prevalence of GDM

• Problems with GDM Surveillance

Problems with GDM Surveillance Problems with GDM Surveillance

• There are no universally accepted

There are no universally accepted “ “Gold Standard Gold Standard” ” guidelines. guidelines.

• Guideline conflicts affect the prevalence of GDM.

Guideline conflicts affect the prevalence of GDM.

• Inconsistencies in reporting and data coding

Inconsistencies in reporting and data coding

• Lack of documentation of testing and results

Lack of documentation of testing and results

• Lack of follow

Lack of follow-

• up on elevated screening levels

up on elevated screening levels

• Public Health Implications

Public Health Implications Public Health Implications

• Opportunity for MCH and chronic disease program

Opportunity for MCH and chronic disease program collaboration to: collaboration to:

• Validate existing data sources

Validate existing data sources

• Improve quality of data collection

Improve quality of data collection

• Promote appropriate GDM testing,

Promote appropriate GDM testing, diagnosis and care diagnosis and care

• Promote postpartum follow

Promote postpartum follow-

• up care

up care

• Prevent onset of type 2 diabetes

Prevent onset of type 2 diabetes

• MCH Opportunities for Collaboration

MCH Opportunities for Collaboration MCH Opportunities for Collaboration

• Include chronic disease prevention and health promotion in

Include chronic disease prevention and health promotion in your intervention strategies your intervention strategies

• Invite chronic disease and health promotion team members to

Invite chronic disease and health promotion team members to participate in planning and intervention efforts participate in planning and intervention efforts

• Invite input for analysis and application of chronic disease or

Invite input for analysis and application of chronic disease or health promotion data from PRAMS survey health promotion data from PRAMS survey

• Leverage the expertise of chronic disease and health

Leverage the expertise of chronic disease and health promotion programs to develop intervention strategies, promotion programs to develop intervention strategies, especially for healthy weight, gestational diabetes, especially for healthy weight, gestational diabetes, hypertension and tobacco related activities hypertension and tobacco related activities

• Consult the NACDD website for more ideas from other states

Consult the NACDD website for more ideas from other states

• For More Information

For More Information For More Information

Please contact: Please contact:

Joan Ware, Consultant Joan Ware, Consultant

National Association of Chronic Disease National Association of Chronic Disease Directors (NACDD) Women Directors (NACDD) Women’ ’s Health Council s Health Council Telephone: 801 Telephone: 801-

• 277

277-

• 2353l

2353l Email: ware@chronicdisease.org Email: ware@chronicdisease.org Web: Web: www.chronicdisease.org www.chronicdisease.org