The Blending of Medicine & Public Health:
A Powerful Tool for Improving Maternal
and Child Health Policy
William M. Sappenfield, MD, MPH
D i r e c t o r, M C H P r a c t i c e a n d A n a l y s i s U n i t
Division of Family Health Services
Florida Department of Health
Public Health and Medicine Series
Investigator Roles
Outbreaks/Epidemics
6 Late Fetal Deaths by Geographic Location of
Maternal Residence in Bay County, 2008
3
Bay County Fetal
Deaths Delivery
February (6)
Data Source: Medical Records
6 Late Fetal Deaths by Delivery Date
Bay County February 2008
4
Number of Deaths
2
1
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Date of Delivery in February 2008
Data Source: Fetal Death Certificates
Fetal Death Counts and Probabilities for 28 day Periods
Bay County Residents Florida, 1995 to 2007
5
Bay County
Fetal Deaths per
28 day period
Number of 28 Day
Periods
Fetal
Deaths
Probability
0
51
0
1.0000
1
76
76
0.6491
2
29
58
0.2816
3
9
27
0.0892
4
4
16
0.0220
5
0
0
0.0044
6
0
0
0.0008
7
0
0
0.0001
Total
169
177
Data Source: Fetal Death Certificates
6 Late Fetal Deaths
6
Characteristics
Mean or No.
Range
28
21–36
Gestational age (wks)
37.5
35.6–39.6
Prepregnancy body mass index (kg/m2)
33.1
20.5–48.9
29
9–47
Maternal age (yrs)
Gestational weight gain (lbs)
Maternal race
2 Blacks
Maternal ethnicity
1 Hispanic
Birth weight (grams)
Total prenatal care visits
3,367
2,630–4,432
12
9–15
Data Source: Fetal Death Certificates and Medical records
6 Late Fetal Deaths
7
Characteristics
Married
# of Cases
5
Maternal education ≥ High School
6
Smoking during pregnancy
Placenta examined
Autopsy performed
1
6
2
Data Source: Fetal Death Certificates and Medical records
6 Late Fetal Deaths by Birthweight & Gestation
Compared to U.S. National Reference for Fetal Growth
8
95%
90%
50%
10%
5%
Data Source: Medical Records
Reference: Alexander 1996 Obstet & Gynecol 87(2): 163-168
Florida Births and Fetal Deaths 1/06–3/08, Adjusted
Odds Ratios for Fetal Death ≥ 2,500g by Risk Factor
9
Fetal Death
Risk Factor
≥ 2,500 grams
95% Confidence interval
Adjusted Odds Ratio
Lower
Upper
Maternal BMI < 18.5 kg/m2
0.51
0.29
0.88
Maternal BMI > 35 kg/m2
1.70
1.34
2.15
Maternal race Black
1.41
1.16
1.70
Maternal smoking
1.75
1.35
2.28
Maternal education < High School
1.16
0.94
1.43
No prenatal care
2.40
1.55
3.71
Maternal age > 35 years
1.11
0.86
1.43
Maternal age < 18 years
0.59
0.32
1.09
Chronic diabetes
9.45
6.90
12.93
Chronic hypertension
2.44
1.65
3.61
Prior terminations
1.16
0.96
1.40
Odds Ratios for Fetal Death ≥ 2,500 Grams
Bay County, 2006–2008
10
Bay County in
February 2008
Adjusted
Odds Ratios
Lower
95% C.I.
Upper
95% C.I.
29.9
12.9
69.5
Unadjusted
26.9
11.9
60.9
Data Source: Fetal Death Certificates
Clinical Information and Risk Factors
for 6 Late Fetal Deaths
11
Causes
Infarcts (2 fetal deaths)
Conditions
Oligohydramnios
Risk Factors
Obese (3 fetal deaths)
Unusual Coiled Cord (2) Lupus Anticoag Antigen
Chronic hypertension (2)
Dark Clot
Diabetes (2)
A1298C Mutation
Epidermal Separation
Black race (2)
Fibrosis Plaque
Previous preterm birth
Hemorrhagic Cyst
Infertility problem
Loose Nuchal Cord
Advanced maternal age
2 Vessel Cord
Asthma
Smoking during
pregnancy
Data Source: Medical Records
Maternal Mortality Definitions
12
Maternal Mortality: Death of a woman while pregnant
or within 42 days of termination of pregnancy, irrespective of
the duration and the site of pregnancy, from any cause related
to or aggravated by the pregnancy or its management, but not
from accidental or incidental causes. (ICD-10: A34, O00-O95, O98O99)
SOURCE: World Health Organization and National Center for Health Statistics
Pregnancy-Related Mortality: Death occurred during
pregnancy or within 1 year of pregnancy termination and
resulted from:
1) Complications of the pregnancy,
2) A chain of events initiated by the pregnancy, or
3) The aggravation of an unrelated condition by the physiologic
effects of the pregnancy or its management.
SOURCE: CDC and American Congress of Obstetricians and Gynecologists
Pregnancy-Related Mortality Ratio (PRMR) and
Maternal Mortality Rate (MMR), Florida 1999-2009
Rate and Ratio per
100,000 live births
0
5
10
15
20
25
30
13
1999
2000
2001
2002
2003
2004
Year
PRMR
2005
2006
MMR
2007
2008
Prov.
2009
Maternal Mortality Definitions
14
Pregnancy-Associated Mortality: Death
occurred during pregnancy or within 1 year of pregnancy
irrespective of cause.
SOURCE: CDC and The American Congress of Obstetricians and Gynecologists
0 10 20 30 40 50 60 70 80 90 100
Pregnancy-Related and -Associated Mortality Ratio
(PRMR & PAMR), Maternal Mortality Rate (MMR)
Florida, 1999-2009
15
1999
Rate and Ratio per
100,000 live births
2000
2001
2002
PRMR
2003
2004
Year
2005
MMR
2006
2007
PAMR
2008
2009
Pregnancy-Related Mortality Ratio (PRMR) and
Maternal Mortality Rate (MMR), Florida 1999-2009
Rate and Ratio per
100,000 live births
0
5
10
15
20
25
30
16
1999
2000
2001
2002
2003
2004
Year
PRMR
2005
2006
MMR
2007
2008
Prov.
2009
Underlying Cause of Pregnancy-Related Deaths
Florida 1999-2008 and 2009*
Hypertensive Disorders
Hemorrhage
Cardiomyopathy
Infection
Thrombotic Embolism
Amniotic Fluid Embolism
Other cardiovascular problems
Intracerebral Hemorrhage *
Others
1999-2008
Unknown
0
*Provisional
5
10
15
20
2009
25
30
Number of Ectopic Pregnancy-Related Deaths
Florida, 1999 to 2010
Provisional
18
Number of Ectopic Pregnancy Deaths & Patient
Encounter Rates, Florida, 1999 to 2010
19
8
1000
7
800
6
700
5
600
4
4
3
3
2
2
2
1
1
0
2
2
1
500
400
300
200
100
0
0
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Years
Number of Ectopic Pregnancy Deaths
Hospital Discharge Rate
Ambulatory & Outpatient Surgery Rate
Emergency Room Visit Rate
0
Patient Encounter Rate
900
Provisional
Number of Deaths
7
Influenza Vaccination
20
Percentage of All Women, Aged 18-44, Who Received an
Influenza Vaccination Within the Past Year, Florida and
U.S., 2008
30%
25.3%
25%
20%
16.3%
15%
10%
5%
0%
Florida
Source: Behavioral Risk Factor Surveillance Survey (BRFSS)
U.S.
Percent of All Women, Aged 18-44, Who Received an Influenza
Vaccination Within the Past Year, Florida & U.S., 2001-08
21
40%
30%
20%
25.3%
26.1%
17.1%
18.8%
13.8%
16.3%
10%
Florida
U.S.
0%
2001
2002
2003
2004
2005
Year
Source: Behavioral Risk Factor Surveillance Survey (BRFSS)
2006
2007
2008
Investigator Roles
Health Issues
Elimination of Non-medically Indicated (Elective)
Deliveries Before 39 Weeks
23
Terminology
Late Preterm
Early Term
First day of
LMP
Week #
0
20 0/7
340/7
37 0/7 39 0/7
Preterm
Term
Modified from Drawing courtesy of William Engle, MD, Indiana University
Raju TNK. Pediatrics, 2006;118 1207.
416/7
Post term
U.S. Cesarean Section & Labor Induction Rates Among
Singleton Live Births by Week of Gestation, 1992-2002
25
Early Term
2002 C-S
1992 C-S
2002 Induction
1992 Induction
Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April 2006.
Why are Non-medically Indicated
(Elective/Planned) Deliveries
Increasing in Frequency?
Elective Induction:
Sounds like a good idea…
27
Advanced planning
Mother lives far away; history of quick labors
Delivered by her doctor
Maternal intolerance to late pregnancy
• Excess edema, backache, indigestion, insomnia
• Prior bad pregnancy
• And, it’s okay right?
•
•
•
•
Clin Obstet Gynecol 2006;49:698-704
The Gestational Age that Women Considered
it Safe to Deliver
28
Weeks of Gestation
Obstet Gynecol 2009;114:1254
Adverse Neonatal Outcomes According to Completed
Week of Gestation at Delivery: Absolute Risk
Adapted from Tita AT, et al. NEJM 2009;360:111
Timing of Fetal Brain Development
30
• Cortex volume increases by 50% between 34 and 40
weeks gestation. (Adams Chapman, 2008)
• Brain volume increases at rate of 15 mL/week between 29
and 41 weeks gestation.
• A 5-fold increase in myelinated
white matter occurs between
35-41 wks gestation.
• Frontal lobes are the last to
develop, therefore the most
vulnerable.
(Huttenloher, 1984; Yakavlev,
Lecours, 1967; Schade, 1961; Volpe, 2001).
FPQC
Florida Perinatal
Quality Collaborative
Promoting better outcomes for our mothers and babies
Proposed Organizational Structure
FPQC Advisory
Committee
Maternal Health
Committee
•Obstetrical Leadership
•Q.I. Staff Support
Q.I.
Initiatives
FPQC Leadership Team
•Obstetrical Leadership
•Neonatal Leadership
•Project Leadership
QI Consultant
Infant Health
Committee
•Neonatal Leadership
•Q.I. Staff Support
Q.I.
Initiatives
Percent of Elective Singleton Deliveries for All
Early Term Live Births, by File Type, 2004-10
32
80%
70%
Percent
60%
50%
40%
30%
44.7%
46.5%
42.1%
43.5%
32.9%
34.0%
38.7%
20%
Birth Certificate
Linked File (BC)
10%
Linked File
0%
2004
2005
2006
2007
Year
2008
2009
2010
Percent of Elective Singleton Deliveries for All
Early Term Live Births, by Hospital, 2004-10
33
Adjusted Relative Risk for a Non-Medically
Indicated Delivery <39 Weeks, Florida 2007
34
Risk Factors
Age
<20
20-34
35+
Educ <12
12
12+
NH White
NH Black
Hispanic
Other
Induction
Ref
0.89*
0.86*
Ref
1.08*
1.09*
1.27*
Ref
0.93
0.88
Primary
Cesarean
Ref
1.47*
2.58*
Ref
1.05
1.09
1.24*
Ref
1.12
0.95
Data Source: Linked Live Birth and Hospital Discharge Records
Repeat
Cesarean
Ref
1.03
1.01
Ref
1.05
1.07*
1.02
Ref
0.98
0.95
Adjusted Relative Risk for a Non-Medically
Indicated Delivery <39 Weeks, Florida 2007
35
Risk Factors
Parity
0
1-2
3+
Medicaid
Private Ins.
Self-Pay
Other
BMI 18.5
18.5-24.9
25.0-29.9
30.0+
Induction
Ref
2.16*
2.56*
1.35*
1.57*
Ref
2.16*
1.16*
Ref
1.07*
1.27*
Primary
Cesarean
Ref
2.29*
1.43*
1.13
1.31*
Ref
1.16
1.01
Ref
1.11*
1.38*
Data Source: Linked Live Birth and Hospital Discharge Records
Repeat
Cesarean
Ref
1.02
1.02
1.09*
1.13*
Ref
1.16*
1.03
Ref
1.00
1.02
Adjusted Relative Risk for a Non-Medically
Indicated Delivery <39 Weeks, Florida 2007
36
Risk Factors
Other
Level 2
Level 3
Level 3 OB
Residency
Midwife Del
<20%
20-29%
30+%
Induction
Primary
Cesarean
Repeat
Cesarean
1.44
1.43
1.61
Ref
1.24
1.52
1.68
Ref
1.03
1.14
1.28
Ref
1.78
1.75
Ref
1.78*
1.32
Ref
1.12
0.97
Ref
Data Source: Linked Live Birth and Hospital Discharge Records
Mortality Rate of Women Ages 15 to 44
Years Due to Drugs, Florida 2003-09
37
Data Source: Medical Examiner Data Base
Infants Hospitalized with Drug
Withdrawal, Florida 1995-2009
38
Data Source: Hospital Discharge Records
Investigator Roles
Policy / Program
Evaluation
Background
Florida Healthy Start provides care
coordination and support services to high
risk pregnant women and infants to improve
pregnancy outcomes
Past evaluations have focused on infant
mortality, LBW, preterm delivery, and
Medicaid costs
Evaluation efforts have now shifted to
intermediate outcomes: health behaviors
and experiences
40
Past Healthy Start
Evaluations
Healthy
Start
Screen
LBW &
Infant
Mortality
Healthy
Start
Services
Medicaid
Healthy Start
Mother’s EligibilityUF
Prenatal ScreenUF
Prenatal ServicesUF
Live Birth
Certificate
WIC
Prenatal
Past Healthy Start
Evaluations
Healthy
Start
Screen
Healthy
Start
Services
Health Ed.
Quit Smoking
Sleep Position
Breast Feeding
Contraception
LBW &
Infant
Mortality
Medicaid
Healthy Start
Mother’s EligibilityUF
Prenatal ScreenUF
Prenatal ServicesUF
Live Birth
Certificate
WIC
PRAMS
Prenatal
Maternal Survey
Study Question
What is the association of Florida Healthy Start (HS)
prenatal services and the maternal and infant health
behaviors and experiences?
Prenatal / Perinatal
Post Partum
Adequate prenatal visits
Postpartum contraception
Prenatal counseling
Health provider in first week
Prenatal WIC participation Breastfeeding
Gestational weight gain
Sleep position & location
NICU admissions
Passive smoking
43
Methods—
Methods
—Healthy Start Intervention
Groups
HS Care Coordination: Women who
Said ‘yes’ to the screen consent and
Received an initial assessment and/or a care
coordination service
Other HS Services: Women who
Said ‘yes’ to the screen consent and
Received only a HS initial contact and/or HS
supplemental services
44
Methods—
Methods
—Healthy Start Comparison
Groups
Women screened no services: Women who
said ‘yes’ to the screen consent, and
did not receive services
Women not screened: Women who
said ‘no’ or not offered the screen, and
did not receive services
45
Methods—
Methods
—Potential Risk Factors
Birth
Certificates
Age
Race/Ethnicity
Education Marital
Father’s name
Foreign Born
Parity Previous
loss BMI
Prenatal entry
Event year
PRAMS
Healthy
Start
Stress Intendedness HS Services
Smoking/Alcohol
Risk Score
Birth Control Vitamin
Use Medicaid
Counseling
Breastfeeding Well
Visits
WIC
Prenatal WIC
46
Results— Adjusted Risk Ratios (ARR)
Results—
Healthy Start Care Coordination
Positive Prenatal and Perinatal Findings
Screened
ARR (95% CI)
No Screen
ARR (95% CI)
Adequate Number of Prenatal
1.06 (1.01-1.11)
Visits
1.05 (1.00-1.10)
Comprehensive Prenatal
Counseling
1.19 (1.04-1.36)
1.19 (1.04-1.37)
Prenatal WIC Participation
1.17 (1.10-1.25)
1.39 (1.29-1.50)
47
Results— Adjusted Risk Ratios (ARR)
Results—
Healthy Start Care Coordination
Neutral Prenatal and Perinatal Findings
Screened
ARR (95% CI)
No Screen
ARR (95% CI)
No Inadequate Weight Gain
1.06 (0.96
(0.96--1.17)
1.13 (1.02
(1.02--1.26)
No Excessive Weight Gain
1.03 (0.91
(0.91--1.17)
No Neonatal Intensive Care
Admission
0.97 (0.94(0.94-1.01)
1.10 (0.96
(0.96--1.26)
1.01 (0.97
(0.97--1.05)
48
Results— Adjusted Risk Ratios (ARR)
Results—
Healthy Start Care Coordination
Positive Postpartum and Infant Findings
Screened
ARR (95% CI)
No Screen
ARR (95% CI)
Breastfeeding Initiation
1.07 (1.01(1.01-1.14)
1.10 (1.03
(1.03--1.17)
Breastfeeding Duration of 1
Month
1.13 (1.03(1.03-1.24)
1.19 (1.09
(1.09--1.30)
49
Results— Adjusted Risk Ratios (ARR)
Results—
Healthy Start Care Coordination
Neutral Postpartum and Infant Findings
Screened
ARR (95% CI)
No Screen
ARR (95% CI)
Effective Postpartum
Contraception
1.00 (0.93(0.93-1.08)
0.98 (0.92
(0.92--1.05)
Health Provider Visit in First
Week
1.03 (0.98(0.98-1.08)
1.01 (0.97
(0.97--1.06)
Back Sleep
1.08 (0.97(0.97-1.19)
1.06 (0.96
(0.96--1.18)
Not Bed Sharing
1.03 (0.89(0.89-1.20)
1.12 (0.97
(0.97--1.29)
No Passive Smoking
1.01 (0.98(0.98-1.05)
1.02 (0.99
(0.99--1.05)
50
Summary—
Summary
—Evaluation Findings
Prenatal / Perinatal
Post Partum
Positive
Positive
• Adequate prenatal visits
• Breastfeeding initiation
• Breastfeeding duration
• Prenatal counseling
• Prenatal WIC participation
Neutral
Neutral
• Postpartum contraception
• No inadequate weight gain • Health provider in first week
• No excessive weight gain • Back sleep
• No NICU admissions
• No bed sharing
51
• No passive smoking