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WHAT YOU DO TO PREVENT PRETERM BIRTHIN CLEVELAND AND CUYAHOGA COUNTY

Carol Gilbert, MS

Health Data Analyst, CityMatCH

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Your Programs

• MomsFirst, • Help Me Grow, • Lead Safe, • Creating Healthy

Communities, • Produce Perks, • Breast for Success, • Place Matters, • Baby Basics, and • CFHS

Your Expertise

• Nursing• Perinatal health• Counseling• Health Systems• Education Systems• Housing Systems• Law enforcement• Justice system• Knowledge of your

clients

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….AND YOU KNOW CLEVELAND AND CUYAHOGA COUNTY

Neighborhoods

History

Values

Traditions

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Services you provide

Health education• Health literacy• Prenatal care• Breastfeeding• Family planning• Interconception

care• Parenting• Smoking Cessation• Child Health and

Development

Case management• Obtaining medical

insurance• Obtaining

transportation to medical appointments

• Screening and referral for perinatal depression

• Connect parents to social supports, medical home

Health promotion• Assess and

improve environmental, systems and policies to promote health

• Lead abatement grants

• Extra value for food stamp cards when used at farmers markets

• Breastfeeding support

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Black birth outcomes (2010-2012 birth records)

• Teen pregnancy 17%• Short birth spacing 36% (similar to reference group)• Late or no prenatal care 14% (none in the reference

group)• Very preterm birth 5% (vs 1% for reference group)• Infant mortality rate

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In Cuyahoga County, the Black infant mortality rate is 2.5 times the White rate (2006-2010)

Ohio Cuyahoga County

5.93.7

14.0

9.2

1-WHITE_NH 2-BLACK_NH

Infant mortality is complex

• Health care system• Built Environment

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Important time periods• Preconception health• Prenatal• Neonatal• Post-neonatal

Goes beyond obstetrics• Chronic disease• Mental Health• Social determinants

• Life course• Inter-generational

…and is an important indicator of population health

What is the Perinatal Periods of Risk approach, or PPOR?An approach for helping cities and large communities to use their own data to investigate the reasons for their high infant mortality rates and disparities

Uses Vital Records Data (birth and death records)Everyone is includedAvailable at local level 8

What’s different about the PPOR analytic approach?

1. Four periods of risk

2. Uses fetal death data

3. Uses a reference group

4. Tailored to every community

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The PPOR “map” of fetal and infant mortality. Perinatal Periods of Risk are named to suggest the preventive areas

500-1499 g

1500+ g

Fetal Deaths

(>=24 wks)

9 10 11 12

13 14 15 16

Maternal Health / Prematurity

Maternal Care

Newborn Care

Infant Health

Neonatal Deaths

(Birth – 27 days)

Postneonatal Deaths

(28 – 364 days)

age

weight

4.1

1.8 1.2 2.0

PPOR “maps” for Cuyahoga County*

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All 2006-2010

* PPOR Fetal and infant deaths per 1000 live births and fetal deaths

7.3

2.7 1.3 2.9

NH Black 2006-2010

9.1 14.3

But . . . What rates can we expect to see in each Period of Risk?”

PPOR answers this question using a reference group, a real population of mothers that experience best outcomes:

low fetal and infant mortality rates

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Ohio State Reference GroupPPOR MAP, 2006-2010

1.8

1.2 1.0 0.7

Reference Group Characteristics:

• 20+ years of age• 16+ years of education• Non-Hispanic White• Resident of Ohio at the

time of baby’s birth 13

Ohio State Reference Group Overall Rate = 4.7

* per 1000 live births and fetal deaths

By using the reference group, PPOR helps measure “Inequity”Remember: Inequity is a disparity that is unnecessary and unfair

Unnecessary deaths are those that could be prevented

In PPOR, preventability is estimated on a population basis by comparing the community’s outcomes to the outcomes of a real “reference group” 14

7.3

2.7 1.3 2.9

PPOR for Cuyahoga County

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Black 2006-2010

* per 1000 live births and fetal deaths

1.8

1.2 1.0 0.7

Ref2 2006-2010

5.5

1.6 0.4 2.2

Excess Mortality

14.3 4.7 9.6

169

48 11 67

PPOR for Cuyahoga CountyEstimated excess deaths

2006-2010

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Black NH

* per 1000 live births and fetal deaths

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5 6 36

All others

295 59

Cuyahoga County (2006-2010)

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Black VLBW48%

Other VLBW3%

Black MC14%

Other MC1%

Black NC3%

Other NC2%

Black IH19%

Other IH10%

Excess (preventable) Fetal and Infant Deaths By Race and Period of Risk

From Kitagawa, 92% of the blue pie slice is due to too many babies born too small; County-wide, 44% of excess mortality is due to Black prematurity

Impact on Target Populati

on

Appropriate

Interventions

Capacity

Infant Mortality

PPOR says:

Prematurity Prevention

Clear Focus

Identifying Priorities

Next Step: Determine which risk factors are most important for Cuyahoga County Black births

End of today

Some of you saw this part of PPOR analysis before

Risk Factors for Prematurity

PREMATURITY

<37 weeks_________

32-36 weeks

________

<32 weeks

Previous spontaneous preterm

Smoking

Preconception Health

Stress

During pregnancy

Over the life course

Chronic Disease

Obesity**

Hypertension

Diabetes

Short inter-pregnancy interval

Congenital Anomalies Environmental exposure

Maternal age and diet

Twins, triplets etc.Heredity

Assisted Reproductive Technology

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Potential impact of addressing …Maternal stress during pregnancy—pooled RR=1.50—prematurity defined as less than 37 weeks (Ding)

 

Short cervix—RR=6.19 (lengths at or below the 10th percentile—prematurity defined as less than 35 weeks (Iams , 1996)

 

Previous preterm birth—RR=1.5-2.0—prematurity defined as less than 32 weeks (Iams)

 

Diabetes (GDM)—RR=1.47—prematurity defined as less than 3.7 weeks (Hedderson)

 

Inter-pregnancy interval—pooled adjusted RR=1.07-1.40 (<6 to 12-17mo)—preterm defined as less than 37 weeks (Conde-Agudelo)

Prematurity is dangerous! Ohio (2006-2010) It causes death…

19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 420.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

White Black

Gestational age at delivery

Per

cen

t o

f b

abie

s w

ho

die

…prematurity also causes perinatal morbidity, and adverse childhood outcomes

Source: Mercer BM. Preterm premature rupture of the membranes. Obstet Gynecol 2003;101:178-93. Reproduced with permission from Lippincott Williams & Wilkins.

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Risk factors for prematurity that we can’t measure from birth certificate data• Maternal stress during pregnancy and over the life course

• Alcohol, prescription drugs, other drugs (even smoking is under-reported)

• Many congenital anomalies are not detected at birth

• Environmental and occupational exposures (even strenuous work)

• Periodontal disease

• Generational effects (the grandparents’ health, the mother’s health at her own birth etc.)

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Risk factors on birth certificate

Not married at time of baby’s birth (SES, social support)Teen mom age<20High school or less education (indicator for SES)Medicaid paid for delivery (indicator for SES)Received WIC during pregnancyTwins, triplets etc.Previous preterm birthBirth spacing shorter than 18 monthsHypertension before or during pregnancy (includes eclampsia)Overweight or obese prior to pregnancyDiabetes before or during pregnancySmoking before or during pregnancyLate or no prenatal care (13 weeks or later)STD (Syphilis, Chlamydia, or Gonorrhea)

Determining importance of risk factors (PPOR Phase 2 analysis, continued):

1. Is the risk factor more prevalent (more common) among Black mothers compared with the reference population?

2. Among Black mothers, does the factor have a high relative risk, i.e. is a woman more likely to have very preterm birth if she had the risk factor, compared to if she doesn’t?

3. If we could ELIMINATE the risk factor from this population, how much would the very preterm birth rate be reduced? Population Attributable Risk Percent is a simple descriptive measure of potential impact. It takes into account both “strength” (relative risk) and prevalence of the risk factor. Interaction or overlap among factors is not addressed.

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Rare among Black Cuyahoga County Births

Not married at time of baby’s birth (SES, social support)Teen mom age<20High school or less education (indicator for SES)Medicaid paid for delivery (indicator for SES)Received WIC during pregnancy (protective)Twins, triplets etc.Previous preterm birthBirth spacing shorter than 18 monthsHypertension before or during pregnancy (includes eclampsia)Overweight or obese prior to pregnancyDiabetes before or during pregnancySmoking before or during pregnancyLate or no prenatal care (13 weeks or later)STD (Syphilis, Chlamydia, or Gonorrhea)

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Low RR for VPTB among Black CC

Not married at time of baby’s birth (SES, social support)Teen mom age<20High school or less education (indicator for SES)Medicaid paid for delivery (indicator for SES)Received WIC during pregnancy (protective)Twins, triplets etc.Previous preterm birthBirth spacing shorter than 18 monthsHypertension before or during pregnancy (includes eclampsia)Overweight or obese prior to pregnancyDiabetes before or during pregnancySmoking before or during pregnancyLate or no prenatal care (13 weeks or later) [but underreporting]STD (Syphilis, Chlamydia, or Gonorrhea)

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Little impact on Black prematurity in CC

Not married at time of baby’s birth (SES, social support)Teen mom age<20High school or less education (indicator for SES)Medicaid paid for delivery (indicator for SES)Received WIC during pregnancy (protective)Twins, triplets etc.Previous preterm birthBirth spacing shorter than 18 monthsHypertension before or during pregnancy (includes eclampsia)Overweight or obese prior to pregnancyDiabetes before or during pregnancySmoking before or during pregnancyLate or no prenatal care (13 weeks or later)STD (Syphilis, Chlamydia, or Gonorrhea)

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And the winners are:

Not married at time of baby’s birth (SES, social support)Teen mom age<20High school or less education (indicator for SES)Medicaid paid for delivery (indicator for SES)Received WIC during pregnancy (protective)Twins, triplets etc.Previous preterm birthBirth spacing shorter than 18 monthsHypertension before or during pregnancy (includes eclampsia)Overweight or obese prior to pregnancyDiabetes before or during pregnancySmoking before or during pregnancyLate or no prenatal care (13 weeks or later)STD (Syphilis, Chlamydia, or Gonorrhea)

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Most important contributors to prematurity among Cuyahoga County Black mothers

Black % with factor

Ref % with factor

RR for VPTB among Black

PAR for VPTB among Black

Not married at time of baby’s birth (SES, social support)

89 6 1.4 25%

Birth spacing shorter than 18 months 36 34 1.4 13%

High school or less education (SES) 58 N.A. 1.3 13%

Previous Preterm Birth* 8 2 3.0 13%

*not preventable, but predictive

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What you can do to prevent prematurity

Strongest opportunities (based on birth certificate) :

• SES – mitigating the effects of low SES,

– reducing prevalence of low SES• Social support, strengthening families• Increasing birth spacing

WIC 43%

Poverty is prevalent among Ohio mothers!

High school or less education 44%

Medicaid for Delivery 39%

ALL THREE indicators– 20% of births

AT LEAST ONE of the three indicators of poverty apply to 61% of births

Ohio births 2006-2010

WIC 43%

Poverty is MORE prevalent among BLACK Ohio mothers!

High school or less education 58%

Medicaid for Delivery 64%

ALL THREE – 34%

AT LEAST ONE– 88%

Ohio births 2006-2010

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Approximate distribution of conditions leading to preterm birth

Spontaneous preterm labor

50%Spontaneous PROM25%

Indicated (needed to

happen)25%

March of Dimes, J Iams, Yonekura

Screening to identify women at risk of spontaneous preterm labor:• Previous preterm• Short Cervix

10% muti-fetal pregnancy (twins, triplets)contribute to all three parts

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One more potential direction

• Having a previous preterm birthBlack % with factor

Ref % with factor

RR for VPTB among Black

PAR for VPTB among Black

Previous Preterm Birth 8% 2% 3.0 13%

This is an easily identified high-risk population that could potentially be treated with progesterone or 17p during pregnancy. In a population with history of spontaneous preterm birth, weekly injections of 17p reduced preterm birth by 33% (Petrini 2005) Depending on current 17p use, we could expect up to 4% decrease in prematurity if all these women received appropriate treatment. If other high risk women could be identified, progesterone/17p could have more impact.

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Black% Ref% diff RR PARNot Married-Yes 83.80% 5.57% 78.23% 1.4 25%Teen Mom-Yes 17.40% 1.0 0%High School or Less-Yes 58.35% 1.3 13%Medicaid-Yes 68.98% 4.15% 64.83% 1.2 12%WIC-Yes 72.34% 5.35% 66.99% 0.7 -28%Plurality-Yes 3.63% 5.07% -1.44% 5.3 14%PPB-Yes 7.82% 2.47% 5.35% 3.0 13%Birth spacing <18 months 36.46% 34.34% 2.13% 1.4 13%Hypertension-Yes 13.93% 6.11% 7.82% 1.6 7%Overwt/Obese-Yes 63.59% 42.60% 20.99% 1.1 7%Diabetes-Yes 5.66% 5.46% 0.20% 1.4 2%Smoke any-Yes 16.44% 4.66% 11.78% 1.3 4%No/late Prenatal Care-Yes 14.27% 3.27% 11.00% 1.1 2%STD-Yes 11.92% 0.26% 11.66% 1.0 1%

GROUP PRENATAL CARE AND CENTERING EVIDENCE

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Centering Healthcare™: The Evidence

• Yale University randomized control trial • 1,047 women in public clinics • Randomized to traditional or group care• 33% reduction in preterm birth for women in Centering groups• Other outcomes

• Increased satisfaction with care • Increased breast-feeding rates, and • Improved knowledge and readiness for birth and parenting

• University of Kentucky Centering Pregnancy Smiles program• Reduction in preterm births from 13.7% to 6.6%• Saved ~$2.1 million in 2 years

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Centering delivers results:• Less likely to delivery prematurely: to deliver

prematurely (9.8 vs. 13.8 percent). • More likely to receive adequate prenatal care:

CenteringPregnancy participants were less likely than those enrolled in usual care to receive inadequate prenatal care (26.6 percent of program participants received inadequate care, compared with 33 percent of those getting usual care)

• Higher satisfaction with prenatal care

Centering delivers results• Increased use of postpartum family planning• Hale N, Picklesimer AH, Billings DL, et al. The impact of

Centering Pregnancy Group Prenatal Care on postpartum family planning. Am J Obstet Gynecol 2014;210:50.e1-7.

• Utilization of postpartum family-planning services was higher among women participating in GPNC than among women receiving IPNC (29% vs 20% at 12 months postpartum, p<.05)

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Home Visitation: The Evidence

• Program dependent• http://homvee.acf.hhs.gov/programs.aspx• http://

homvee.acf.hhs.gov/EvidenceOverview.aspx

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Home visiting delivers resultsEvery Child Succeeds (ECS), an established, regional home visiting program in southwest Ohio from 2007 to 2010

Healthy Families America model of home visiting; program goals are to

(1) improve pregnancy outcomes through nutrition education and substance use reduction,

(2) support parents in providing children with a safe, nurturing,

and stimulating home environment,

(3) optimize child health and development,

(4) link families to health care and other services, and

(5) promote economic self-sufficiency. for at-risk, first-time mothers.

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Home visiting delivers results

Pediatrics. 2013 Dosage effect of prenatal home visiting on pregnancy outcomes in at-risk, first-time mothers.

Goyal NK1 et. al

Evaluated the effect of home visiting dosage on preterm birth … in women in southwest Ohio. Home visits are provided by social workers, child development specialists, nurses, or paraprofessionals

Results: ≥8 completed visits by 26 weeks reduced odds of preterm birth by about 2/3 (compared with <3 visits)

Cuyahoga County (2006-2010)

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Black VLBW48%

Other VLBW3%

Black MC14%

Other MC1%

Black NC3%

Other NC2%

Black IH19%

Other IH10%

Excess (preventable) Fetal and Infant Deaths

By Race and Period of Risk

From Underlying Cause of Death, 62% of the green pie slice is due to sleep related deaths; (Black Cleveland 2008-2010)

SUID rate was 2.2, should be <.5

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Causes of Sleep-related deathSUID is:SIDS

Ill-DefinedAccidental Suffocation

Sleep Position Side or Prone (OR 2.3-13.1)Bed-sharing

(OR 2.88)Smoker Parent (OR 2.3-17.7)

Infant <3 months (OR 4.7-10.4)

Soft surfaces like couch, armchair (OR 5.1-66.9)

Multiple bedsharers (OR 5.4)Parent consumed alcohol, drugs, or is

overtired (OR 1.66)Prenatal drug and alcohol use

(OR varies, > 3.0)Use of soft bedding

(OR 5.0)Prone with soft bedding (OR 21.0)Smoke Exposure: prenatalPost-natal

Nicotine Metabolism

Source: Rachel Moon’s CDC Grand Rounds Presentation October 2012

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• Back to sleep for every sleep • Use a firm sleep surface • Room-sharing without bed-sharing is recommended • Keep soft objects and loose bedding out of the crib • Pregnant women should receive regular prenatal care • Avoid smoke exposure during pregnancy and after birth • Avoid alcohol and illicit drug use during pregnancy and

after birth • Breastfeeding is recommended• Pacifier for sleep• Avoid overheating

Source: Rachel Moon’s CDC Grand Rounds Presentation October 2012

Based on good and consistent scientific evidence

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Relevant national initiatives

• Cribs for Kids• >300 partners nationally• Provide low-cost portable cribs to organizations, who then provide

them free or at cost to parents who cannot afford a crib

• ABCs• Alone, on your Back, in a Crib• Baltimore City Health Department and others

• Safe to Sleep• NICHD-led public awareness campaign• Expands focus from back sleeping only to ALL of the components

of a safe sleep environment (position, bedding, bedsharing, sleep surface, etc.)