NATIONAL ASSOCIATION OFNATIONAL ASSOCIATION OF

CHRONIC DISEASE DIRECTORSCHRONIC DISEASE DIRECTORS

WOMENWOMEN’’S HEALTH COUNCILS HEALTH COUNCIL

Maternal Child Health and Chronic Disease

The Odd Couple

orA 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 ChronicDisease Directors

Maternal Child Health and Maternal Child Health and

Chronic DiseaseChronic DiseaseThe Odd CoupleThe Odd Couple

oror

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

AMCHP Women and Perinatal Health Information Series

July 17, 2008July 17, 2008

Joan Ware, MSPH, RN, Consultant, WomenJoan Ware, MSPH, RN, Consultant, Women’’s Health Council, National Association of Chronics Health Council, National Association of Chronic

Disease DirectorsDisease Directors

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OutlineOutlineOutline•• 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 ProjectCollaborative Project

•• What can MCH programs do?What can MCH programs do?

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CHRONIC DISEASE DIRECTORSCHRONIC DISEASE DIRECTORS

WOMENWOMEN’’S HEALTH COUNCILS HEALTH COUNCIL

NATIONAL ASSOCIATION OFNATIONAL ASSOCIATION OF

CHRONIC DISEASE DIRECTORSCHRONIC DISEASE DIRECTORS

WOMENWOMEN’’S HEALTH COUNCILS HEALTH COUNCIL

PRAMSPRAMSPregnancy Risk Assessment andPregnancy Risk Assessment and

Monitoring SystemMonitoring System

CollaboratorsCollaborators

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CHRONIC DISEASE DIRECTORSCHRONIC DISEASE DIRECTORS

WOMENWOMEN’’S HEALTH COUNCILS HEALTH COUNCIL

Who is NACDD?Who is NACDD?Who is NACDD?•• The The ““AMCHPAMCHP”” for Chronic Diseasefor 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 areasand health promotion areas

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Councils and Special Interest Groups

Councils and Special Councils and Special

Interest GroupsInterest Groups

•• AsthmaAsthma

•• ArthritisArthritis

•• CancerCancer

•• DiabetesDiabetes

•• Heart Disease and Heart Disease and

StrokeStroke

•• School HealthSchool Health

•• WomenWomen’’s Healths Health

•• OsteoporosisOsteoporosis

•• ObesityObesity

•• Healthy AgingHealthy Aging

•• Health DisparitiesHealth Disparities

•• Physical ActivityPhysical Activity

•• Vision and Eye Vision and Eye

HealthHealth

•• Tobacco Use Tobacco Use

PreventionPrevention

•• DepressionDepression

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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 diseaseswomen with chronic diseases

–– Risk factors and conditions can be identified Risk factors and conditions can be identified early and addressedearly and addressed

•• Pregnancy can unmask a potential for chronic Pregnancy can unmask a potential for chronic diseasesdiseases

•• 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 diseasesdiseases

ChronicChronicDiseaseDisease

MCMCHH

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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%

•• DiabetesDiabetes 9.3%9.3%

•• Smoke during pregnancySmoke during pregnancy 11.4%11.4%

•• Overweight or obeseOverweight or obese 55.0%55.0%

•• 250,000 breast cancer250,000 breast cancer

survivors under age 40survivors under age 40

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Why Chronic Disease?Why Chronic Disease?Why Chronic Disease?Of women who are pregnant:Of women who are pregnant:

•• 33--8% will develop gestational diabetes8% will develop gestational diabetes

•• 1010--15% will develop postpartum depression15% 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 7likely 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 5Postpartum state confers 5--fold risk of newfold risk of new--onset rheumatoid onset rheumatoid arthritis, especially after first pregnancyarthritis, especially after first pregnancy

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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 factorsbehaviors, 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 pregnancyfactors which complicate pregnancy

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Why Now?Why Now?Why Now?

New Target Populations for New Target Populations for

Prevention of Chronic DiseasePrevention of Chronic Disease

•• PreconceptionPreconception

•• InterpregnancyInterpregnancy

•• PostpartumPostpartum

•• InterconceptionInterconception

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Collaboration Issue: Gestational Diabetes

Collaboration Issue: Collaboration Issue:

Gestational DiabetesGestational 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 :

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

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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

pregnancypregnancy

•• 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 staysresults in longer hospital stays

•• Method to promote healthier moms and Method to promote healthier moms and

offspring, and prevent a major offspring, and prevent a major

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

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Prevalence of GDMPrevalence of GDMPrevalence of GDM

•• Prevalence ranges between 1%Prevalence ranges between 1%--14% 14% 11

•• Complicates 4% of all pregnancies annually Complicates 4% of all pregnancies annually 11

•• Affects 150,000Affects 150,000--200,000 pregnancies each year200,000 pregnancies each year

in the United States in the United States 22

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

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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 pregnancyafter pregnancy

•• 5050--65% risk of GDM with next pregnancy65% risk of GDM with next pregnancy

•• 2020--30% risk of type 2 in 730% risk of type 2 in 7--10 years10 years

•• 5050--70% risk of type 2 progression in lifetime70% 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 GDMwith 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.

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The Risks of GDMThe Risks of GDMThe Risks of GDM•• Miscarriages and stillbirthMiscarriages and stillbirth

•• Increased inductions and CIncreased inductions and C--sectionssections

•• MacrosomiaMacrosomia

•• Intrauterine developmental and growth abnormalitiesIntrauterine developmental and growth abnormalities

•• PreeclamsiaPreeclamsia

•• DepressionDepression

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

•• Offspring predisposed to obesity and type 2 diabetesOffspring predisposed to obesity and type 2 diabetes

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WOMENWOMEN’’S HEALTH COUNCILS HEALTH COUNCIL

GDM ScreeningGDM ScreeningGDM Screening

•• Screening recommended at 24Screening recommended at 24--28 weeks gestation, 28 weeks gestation,

even if no high risk factorseven if no high risk factors

•• Some guidelines recommend earlier screening if Some guidelines recommend earlier screening if

high risk to rule out type 2 diabeteshigh risk to rule out type 2 diabetes

•• First screening test should be 1First screening test should be 1--hr GCT hr GCT 11

•• If elevated level, then women undergo a 2If elevated level, then women undergo a 2--hr or 3hr or 3--hr hr

OGTT to confirm OGTT to confirm 11

1. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, Volume 30, Supplement I, January 2007, pp S42-S47

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Screening RecommendationsScreening RecommendationsScreening Recommendations

High Risk for GDMHigh Risk for GDM

–– Age > 35 yearsAge > 35 years

–– BMI > 29 kg/mBMI > 29 kg/m2 2 beforebefore pregnancypregnancy

–– Personal history of GDMPersonal history of GDM

–– Previous macrosomic infantPrevious macrosomic infant

–– History of GDM related obstetric complicationsHistory of GDM related obstetric complications

–– Racial/ethnic group with high prevalence of GDMRacial/ethnic group with high prevalence of GDM

–– First degree relative with diabetesFirst degree relative with diabetes

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WOMENWOMEN’’S HEALTH COUNCILS HEALTH COUNCIL

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WOMENWOMEN’’S HEALTH COUNCILS HEALTH COUNCIL

Goals of the ProjectGoals of the ProjectGoals of the Project

•• Compare PRAMS data to medical recordsCompare PRAMS data to medical records

•• Examine routinely collected data to assess quality of Examine routinely collected data to assess quality of

data data

•• Summarize findingsSummarize findings

•• Make recommendations for improving quality of data Make recommendations for improving quality of data

systems and applications to improve caresystems and applications to improve care

•• Enhance collaboration among public health programsEnhance collaboration among public health programs

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Why Did DDT Fund This Project?

Why Did DDT Fund Why Did DDT Fund

This Project?This Project?

•• Establish 6Establish 6--state collaboration to identify, catalogue, state collaboration to identify, catalogue, and validate routinely collected data about GDMand 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 qualityquality

•• Determine implications for careDetermine implications for care

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WOMENWOMEN’’S HEALTH COUNCILS HEALTH COUNCIL

Five State CollaborativeFive State CollaborativeFive State Collaborative•• MichiganMichigan

•• North CarolinaNorth Carolina

•• OklahomaOklahoma

•• UtahUtah

•• West VirginiaWest Virginia

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BackgroundBackgroundBackground

•• 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 comparedcompared

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

•• 2.4% had GDM recorded on birth certificates2.4% had GDM recorded on birth certificates

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PRAMS 2004 Questions on Blood Sugar

PRAMS 2004 Questions on PRAMS 2004 Questions on

Blood SugarBlood 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) thatHigh blood sugar (diabetes) that

started before this pregnancystarted before this pregnancy YesYes NoNo

High blood sugar (diabetes) thatHigh blood sugar (diabetes) that

started during this pregnancystarted during this pregnancy YesYes NoNo

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Study QuestionStudy QuestionStudy 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?

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2004 Utah PRAMS Surveys2004 Utah PRAMS Surveys2004 Utah PRAMS SurveysElevated BloodElevated Blood

Sugar on PRAMSSugar on PRAMS

N=136N=136

GDM on BirthGDM on Birth

CertificateCertificate

4646

(34%)(34%)

GDM Not on BirthGDM Not on Birth

CertificateCertificate

9090

(66%)(66%)

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Validation MethodsValidation MethodsValidation Methods

•• Selected all 90 women reporting Selected all 90 women reporting ““high blood sugar high blood sugar

levels during most recent pregnancylevels during most recent pregnancy”” on 2004 PRAMS on 2004 PRAMS

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

•• Of these, 80 hospital medical records were available Of these, 80 hospital medical records were available

for reviewfor review

•• Conducted IRBConducted IRB--approved review of hospital records to approved review of hospital records to

validate GDM datavalidate GDM data

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Definition of GDM used in Medical Record Review

Definition of GDM used in Definition of GDM used in

Medical Record ReviewMedical Record Review•• 2 abnormal values on the 32 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 diabetesgestational diabetes”” diagnosis in chartdiagnosis in chart

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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%TotalTotal

62.5%62.5%No GDMNo GDM

25.0%25.0%GDMGDM

12.5%12.5%No informationNo information

Medical Record ReviewMedical Record Review

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Documentation of GDM Tests Results and Follow-up

Documentation of GDM Tests Documentation of GDM Tests

Results and FollowResults and Follow--upup

100.0%100.0%TotalTotal

27.5%27.5%

Inadequate documentationInadequate documentation

(e.g. No testing or results (e.g. No testing or results

information; no followinformation; no follow--up test up test

on elevated 1on elevated 1--hr GTT tests)hr GTT tests)

72.5%72.5%1 hr screen and 31 hr screen and 3--hr OGTT hr OGTT

documented on chart reviewdocumented on chart review

Medical Record ReviewMedical Record Review

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ConclusionsConclusionsConclusions

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 GDMprevalence of GDM

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Problems with GDM SurveillanceProblems with GDM SurveillanceProblems with GDM Surveillance

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

•• Guideline conflicts affect the prevalence of GDM. Guideline conflicts affect the prevalence of GDM.

•• Inconsistencies in reporting and data codingInconsistencies in reporting and data coding

•• Lack of documentation of testing and resultsLack of documentation of testing and results

••

•• Lack of followLack of follow--up on elevated screening levels up on elevated screening levels

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Public Health ImplicationsPublic Health ImplicationsPublic Health Implications

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

--Validate existing data sourcesValidate existing data sources

--Improve quality of data collectionImprove quality of data collection

--Promote appropriate GDM testing, Promote appropriate GDM testing,

diagnosis and carediagnosis and care

--Promote postpartum followPromote postpartum follow--up care up care

--Prevent onset of type 2 diabetesPrevent onset of type 2 diabetes

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MCH Opportunities for CollaborationMCH Opportunities for CollaborationMCH Opportunities for Collaboration

•• Include chronic disease prevention and health promotion in Include chronic disease prevention and health promotion in your intervention strategiesyour 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 effortsparticipate 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 surveyhealth 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 statesConsult the NACDD website for more ideas from other states

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For More InformationFor More InformationFor More Information

Please contact:Please contact:

Joan Ware, ConsultantJoan Ware, Consultant

National Association of Chronic Disease National Association of Chronic Disease

Directors (NACDD) WomenDirectors (NACDD) Women’’s Health Councils Health Council

Telephone: 801Telephone: 801--277277--2353l2353l

Email: ware@chronicdisease.org Email: ware@chronicdisease.org

Web:Web: www.chronicdisease.orgwww.chronicdisease.org