1
WHAT YOU DO
TO PREVENT PRETERM BIRTH
IN CLEVELAND
AND CUYAHOGA COUNTY
Carol Gilbert, MS
Health Data Analyst, CityMatCH
2
Your Programs
Your Expertise
• MomsFirst,
• Nursing
• Help Me Grow,
• Perinatal health
• Lead Safe,
• Counseling
• Creating Healthy
• Health Systems
•
•
•
•
•
Communities,
Produce Perks,
Breast for Success,
Place Matters,
Baby Basics, and
CFHS
• Education Systems
• Housing Systems
• Law enforcement
• Justice system
• Knowledge of your
clients
3
….AND YOU KNOW
CLEVELAND AND
CUYAHOGA COUNTY
Neighborhoods
History
Values
Traditions
4
Services you provide
Health education
• Health literacy
Case management
• Prenatal care
• Obtaining medical
• Breastfeeding
insurance
• Family planning
• Obtaining
transportation to
• Interconception
medical
care
appointments
• Parenting
• Screening and
• Smoking Cessation
referral for perinatal
• Child Health and
depression
Development
• 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
5
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
6
In Cuyahoga County, the Black infant mortality rate is
2.5 times the White rate (2006-2010)
1-WHITE_NH
14.0
2-BLACK_NH
9.2
5.9
3.7
Ohio
Cuyahoga County
7
Infant mortality is complex
Important time periods
• Preconception health
• Prenatal
• Neonatal
• Post-neonatal
• Life course
• Inter-generational
Goes beyond obstetrics
• Chronic disease
• Mental Health
• Social determinants
• Health care system
• Built Environment
…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 included
 Available 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
9
The PPOR “map” of fetal and infant mortality.
Perinatal Periods of Risk are named to suggest the
preventive areas
age
Fetal Deaths
(>=24 wks)
500-1499 g
weight
1500+ g
Neonatal
Deaths
Postneonatal
Deaths
(Birth – 27
days)
(28 – 364
days)
Maternal Health / Prematurity
9
10
11
12
Maternal
13
14 Newborn
15
16 Infant
Care
Care
Health
PPOR “maps” for Cuyahoga County*
All 2006-2010
NH Black 2006-2010
4.1
7.3
1.8 1.2 2.0
2.7 1.3 2.9
9.1
14.3
11
* PPOR Fetal and infant deaths per 1000 live births and fetal deaths
12
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
Ohio State Reference Group
PPOR MAP, 2006-2010
Ohio State Reference Group
Overall Rate = 4.7
Reference Group
Characteristics:
•
•
•
•
20+ years of age
16+ years of education
Non-Hispanic White
Resident of Ohio at the
time of baby’s birth
* per 1000 live births and fetal deaths
1.8
1.2 1.0 0.7
13
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
14
a real “reference group”
PPOR for Cuyahoga County
Black 2006-2010
Ref2 2006-2010
Excess Mortality
7.3
1.8
5.5
2.7 1.3 2.9 1.2 1.0 0.7 1.6 0.4 2.2
14.3
4.7
9.6
15
* per 1000 live births and fetal deaths
PPOR for Cuyahoga County
Estimated excess deaths
2006-2010
Black NH
All others
169
11
48 11 67
295
* per 1000 live births and fetal deaths
5
6
59
36
16
Cuyahoga County (2006-2010)
Excess (preventable) Fetal and Infant Deaths
By Race and Period of Risk
Other IH
10%
Black IH
19%
Other NC
2%
Black NC
3%
Other MC
1%
Black VLBW
48%
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
Black MC
14%
17
Other VLBW
3%
Infant Mortality
PPOR says:
Some of you saw
this part of PPOR
analysis before
Prematurity Prevention
Impact on
Target
Population
Appropriate
Interventions
Capacity
End of
today
Clear
Focus
Identifying
Priorities
Next Step:
Determine which
risk factors are most
important for
Cuyahoga County
Black births
Risk Factors for Prematurity
Previous spontaneous
preterm
PREMATURITY
<37 weeks
_________
32-36 weeks
________
<32 weeks
During
pregnancy
Stress
Over the life
course
Chronic
Disease
Obesity**
Preconception Health
Short inter-pregnancy
interval
Congenital Anomalies
Hypertension
Diabetes
Environmental exposure
Maternal age and diet
Twins, triplets etc.
Smoking
Heredity
Assisted Reproductive
Technology
20
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 (CondeAgudelo)
Prematurity is dangerous! Ohio (2006-2010)
It causes death…
Percent of babies who die
100.0%
90.0%
80.0%
70.0%
White
Black
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
Gestational age at delivery
…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.
23
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.)
24
Risk factors on birth certificate
Not married at time of baby’s birth (SES, social support)
Teen mom age<20
High school or less education (indicator for SES)
Medicaid paid for delivery (indicator for SES)
Received WIC during pregnancy
Twins, triplets etc.
Previous preterm birth
Birth spacing shorter than 18 months
Hypertension before or during pregnancy (includes eclampsia)
Overweight or obese prior to pregnancy
Diabetes before or during pregnancy
Smoking before or during pregnancy
Late 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.
26
Rare among Black Cuyahoga County Births
Not married at time of baby’s birth (SES, social support)
Teen mom age<20
High school or less education (indicator for SES)
Medicaid paid for delivery (indicator for SES)
Received WIC during pregnancy (protective)
Twins, triplets etc.
Previous preterm birth
Birth spacing shorter than 18 months
Hypertension before or during pregnancy (includes eclampsia)
Overweight or obese prior to pregnancy
Diabetes before or during pregnancy
Smoking before or during pregnancy
Late or no prenatal care (13 weeks or later)
STD (Syphilis, Chlamydia, or Gonorrhea)
27
Low RR for VPTB among Black CC
Not married at time of baby’s birth (SES, social support)
Teen mom age<20
High school or less education (indicator for SES)
Medicaid paid for delivery (indicator for SES)
Received WIC during pregnancy (protective)
Twins, triplets etc.
Previous preterm birth
Birth spacing shorter than 18 months
Hypertension before or during pregnancy (includes eclampsia)
Overweight or obese prior to pregnancy
Diabetes before or during pregnancy
Smoking before or during pregnancy
Late or no prenatal care (13 weeks or later) [but underreporting]
STD (Syphilis, Chlamydia, or Gonorrhea)
28
Little impact on Black prematurity in CC
Not married at time of baby’s birth (SES, social support)
Teen mom age<20
High school or less education (indicator for SES)
Medicaid paid for delivery (indicator for SES)
Received WIC during pregnancy (protective)
Twins, triplets etc.
Previous preterm birth
Birth spacing shorter than 18 months
Hypertension before or during pregnancy (includes eclampsia)
Overweight or obese prior to pregnancy
Diabetes before or during pregnancy
Smoking before or during pregnancy
Late or no prenatal care (13 weeks or later)
STD (Syphilis, Chlamydia, or Gonorrhea)
29
And the winners are:
Not married at time of baby’s birth (SES, social support)
Teen mom age<20
High school or less education (indicator for SES)
Medicaid paid for delivery (indicator for SES)
Received WIC during pregnancy (protective)
Twins, triplets etc.
Previous preterm birth
Birth spacing shorter than 18 months
Hypertension before or during pregnancy (includes eclampsia)
Overweight or obese prior to pregnancy
Diabetes before or during pregnancy
Smoking before or during pregnancy
Late or no prenatal care (13 weeks or later)
STD (Syphilis, Chlamydia, or Gonorrhea)
30
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
31
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
Poverty is prevalent among Ohio mothers!
AT LEAST ONE of the three indicators of poverty apply to 61% of
births
WIC 43%
Medicaid
for
Delivery
39%
High school or less
education 44%
Ohio births 2006-2010
ALL THREE
indicators– 20% of
births
Poverty is MORE prevalent among
BLACK Ohio mothers!
AT LEAST ONE– 88%
WIC 43%
Ohio births 2006-2010
High school or less
education 58%
Medicaid
for
Delivery
64%
ALL THREE – 34%
34
Approximate distribution of conditions
leading to preterm birth
10% muti-fetal
pregnancy
(twins, triplets)
contribute to all
three parts
Indicated
(needed to
happen)
25%
Spontaneous
PROM
25%
Spontaneous
preterm labor
50%
Screening to identify
women at risk of
spontaneous preterm
labor:
• Previous preterm
• Short Cervix
March of Dimes, J Iams, Yonekura
35
One more potential direction
• Having a previous preterm
Previous Preterm Birth
Black
% with
birth
factor
8%
Ref %
with
factor
RR for
VPTB
among
Black
PAR
for
VPTB
among
Black
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.
36
Black%
Ref%
diff
RR
Not Married-Yes
83.80%
5.57% 78.23%
Teen Mom-Yes
17.40%
High School or Less-Yes
58.35%
Medicaid-Yes
68.98%
4.15% 64.83%
WIC-Yes
72.34%
5.35% 66.99%
Plurality-Yes
3.63%
5.07%
-1.44%
PPB-Yes
7.82%
2.47%
5.35%
Birth spacing <18
months
36.46% 34.34%
2.13%
Hypertension-Yes
13.93%
6.11%
7.82%
Overwt/Obese-Yes
63.59% 42.60% 20.99%
Diabetes-Yes
5.66%
5.46%
0.20%
Smoke any-Yes
16.44%
4.66%
11.78%
No/late Prenatal CareYes
14.27%
3.27%
11.00%
STD-Yes
11.92%
0.26%
11.66%
PAR
1.4
1.0
1.3
1.2
0.7
5.3
3.0
25%
0%
13%
12%
-28%
14%
13%
1.4
1.6
1.1
1.4
1.3
13%
7%
7%
2%
4%
1.1
1.0
2%
1%
GROUP PRENATAL
CARE AND CENTERING
EVIDENCE
38
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
39
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)
41
Home Visitation:
The Evidence
• Program dependent
• http://homvee.acf.hhs.gov/programs.aspx
• http://homvee.acf.hhs.gov/EvidenceOverview.
aspx
42
Home visiting delivers results
Every 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.
43
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)
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 20082010)
SUID rate was 2.2,
should be <.5
Other NC
2%
Black NC
3%
Other MC
1%
Other IH
10%
Black IH
19%
Black VLBW
48%
Black MC
14%
Other VLBW
3%
44
45
Causes of Sleep-related death
SUID is:
SIDS
Ill-Defined
Accidental
Suffocation
Sleep Position
Side or Prone
(OR 2.3-13.1)
Smoker Parent (OR 2.3-17.7)
Bed-sharing
(OR 2.88)
Soft surfaces like couch,
armchair (OR 5.1-66.9)
Prenatal drug and
alcohol use
(OR varies, > 3.0)
Multiple bedsharers (OR 5.4)
Smoke Exposure:
prenatal
Post-natal
Nicotine Metabolism
Use of soft bedding
(OR 5.0)
Infant <3 months (OR 4.710.4)
Parent consumed alcohol,
drugs, or is overtired
(OR 1.66)
Prone with soft bedding
(OR 21.0)
Source: Rachel Moon’s CDC Grand Rounds Presentation October 2012
46
Based on good and consistent
scientific evidence
• 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
47
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.)