Working Together to Improve
Birth Outcomes in North
Carolina
Region IV and Region VI Infant Mortality Summit
January 12-13, 2012
New Orleans
Belinda Pettiford, MPH
NC Division of Public Health, Women’s Health
Branch
Sarah Verbiest, DrPH, MSW, MPH
University of NC at Chapel Hill, Center for
Maternal and Infant Health
Thanks to our amazing partners!
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Women, men, and families!
NC Child Fatality Task Force
Division of Medical Assistance (Medicaid)
UNC Center for Maternal and Infant Health
NC Community Health Center Association
NC Healthy Start Foundation
Community Care of North Carolina
Perinatal Quality Collaborative of NC
NC Chapter of March of Dimes
Division of Mental Health, Dev. Disabilities, and Substance Abuse Svs.
NC Medical, Pediatric, and NC OB/GYN Societies
NC Academy of Family Practice
Local health departments, local CCNC networks, and other providers
Numerous universities, colleges, faith entities, and CBOs
And the Division of Public Health (home of Title V and OMHHD) and
many more!
Every day, two babies die in North Carolina
 A society's infant mortality
rate is considered an
important indicator of its
health, because infant
mortality is associated with
socioeconomic status,
access to health care, and
the health status of women
of childbearing age.
(Congressional Budget Office,
1992)
Leading Causes of Infant Mortality
 Low Birth weight
 Prematurity
 Perinatal Conditions Related to Maternal Health
 Birth Defects
 Sudden Infant Death Syndrome (SIDS)
About Two-Thirds of NC Child Deaths are Infants
Infants
1 to 4
5 to 9
10 to 14
15 to 17
Deaths due to perinatal related conditions and birth defects are a major cause of
death for children ages 1 to 9 years.
2008 child fatality data from State Center for Health Statistics
Racial Distribution of
North Carolina Live Births, 2010
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There were 122,302 births in NC; 3.5% decrease from 2009.
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Approximately 24% of live births in North Carolina were to
African Americans, 71% to Whites, and 5% to other races.
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While nearly 16% of NC live births are to women who report an
Hispanic ethnicity, most of these Hispanic births are counted in
the White racial category, according to NCHS vital statistics
coding rules.
Infant Mortality Rate
North Carolina, 1988-2010
25
20
15
10
5
0
1988
1991
1994
1997
2000
Af. Am.
2003
White
2006
2009
Data Review
o In 1988, NC’s overall IM rate was 12.5 per 1000 live births; the
2nd highest in the country.
o The downward trend in the NC infant mortality rates has slowed
since the mid-1990s, then fluctuated between 8.1 and 8.8
between 2000 and 2008. NC’s IM rate was at an all time low in
2010 (7.0 per 1000 live births); 44% reduction since 1988.
o The largest decrease in 2010 was among non-Hispanic African
American (19.6% reduction); NH White IMR declined 3.6%.
o Racial disparities in IMR remain, with African American NH
continuing to have an IMR more than two times (2.3) higher
than White NH.
Data Review
 The neonatal mortality rate (deaths occurring during the first
28 days of life) decreased 7.5% overall in 2010; there were
substantial differences between whites and minorities. The
White NH rate increased slightly (2.9%) while the African
American NH rate decreased 14.0% (after showing a 13.8%
increase the previous year). The Hispanic rate decreased
13.6% after showing a 4.8 percent increase the previous year.
 The post-neonatal mortality rate (28 days to one year)
declined 19.2% overall in 2010, with White NH showing a
decline of 10.5%, African American NH a decline of 30.8%,
and Hispanics a decline of 15.4%.
Birth Weight Data
 The percentage of infants delivered very low birthweight
(less than 1500 grams) remained about the same in 2010
(1.7% in 2010 compared to 1.8% in 2009).
 However, NH African American women experience
markedly higher rates of low and very low birthweight
births (14.1%) than did NH White (7.8%) and Hispanics
(6.3%).
 The percentage of babies that were delivered by Cesarean
section decreased slightly to 31.4% -- down from 31.7% in
2009.
Birth Weight Trends
 In 2010, more than one in ten (12.6 percent) of all resident
births were premature (less than 37 weeks gestation). This is
down slightly from 13.2% of all births in 2009.
 While the percentage of live births that are low birth weight has
remained somewhat steady, the mortality rates in each birth
weight category have decreased dramatically until recently.
 The greatest increase in low birthweight has been for babies
born under 500 grams; steady for 2010 for a rate of 0.2%.
Clinical / Quality Improvement
Reducing Recurring PTB – 17P Initiative
 Increase appropriate
utilization of 17P through
a) education of public
health leaders, clinicians,
and women, b) addressing
systems and access issues.
 Funded by DPH (via
General Assembly) since
2006. Strong partnership
with Medicaid and CCNC.
 www.mombaby.org –
click 17P
NC Community Health Centers
 NC has 27 federally qualified health centers
 13 of 27 provide OB services
 Report to HRSA %LBW babies delivered and the
trimester entered into prenatal care
 Majority pregnant women served are Hispanic
women
 Recently received a special grant from HRSA to focus
on tobacco cessation counseling
NC Federally Qualified Health Centers
Babies born (2005 – 2009)
 7% born low birthweight
 63% enter care in the first trimester
 High percent uninsured
 In 2010, the % of LBW babies born to Hispanic/Latina women
was lower than the percent of LBW babies born to nonHispanic/Latina women (7% vs. 11%, respectively).
Tobacco Cessation
 You Quit Two Quit Project – funded by former
Health & Wellness Trust Fund (2008-2012)
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QI projects in 4 counties based in health departments
Statewide educational and outreach efforts including NICUs
 New Project for Low SES Women of CBA funded by
Fed Office of Women’s Health (2011-2013)
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Focused QI on 8 practices in one CCNC network
Training and TA will be provided to all Chronic Disease and
Pregnancy Care Managers within the CCLCF network
Training opportunities will be made available to all practices
within the network
Hope to expand to a larger statewide QI program in the future
www.YouQuitTwoQuit.com
Patient Education Materials
18
www.MinuteToAsk.com
Perinatal Quality Collaborative of NC (PQCNC)
Mission:
• Promote high value perinatal care
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Spread best evidenced practice and reduce variation
Partner with families and patients
Optimize resources
Make North Carolina the best place to be born
PQCNC Initiatives
Hospital Based Initiatives:
 Eliminating elective deliveries under 39 Weeks
gestation
 Reduce Catheter Associated Blood Stream Infections
(CABSI) by 75% in participating centers
 Increase Exclusive Human Milk Mother - Baby
 Increase Exclusive Human Milk NICU
 Support for Intended Vaginal Birth (SIVB)
Reducing Elective Deliveries <39 Weeks
Decrease of
43%
PQCNC Reduce CABSI
Pregnancy Medical Home
 Improve birth outcomes in the North Carolina
Medicaid population
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Provide evidence-based, high-quality maternity care to
Medicaid patients
Focus care management resources on those women at highest
risk for poor birth outcome
 Improve stewardship of limited perinatal health
resources
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In this program, quality improvement goals are aligned with
cost savings goals – keeping more babies out of the NICU and
avoiding associated expenses
Methods
 Quality Improvement focus for Pregnancy Medical
Home practices
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Identify outliers, work with them to improve performance
 Specific, required performance measures
 Support, training and resources
 Pregnancy Case Management is the key intervention
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Identify the population most at risk of poor birth outcome
and focus resources on these women
Pregnancy Medical Home Responsibilities
 Provide comprehensive, coordinated maternity care to
pregnant Medicaid patients and allow chart audits for
evaluation purposes for QI measures
 Postpartum visit must include: depression screening
using a validated screening tool; addressing the patient’s
reproductive life plan; and connecting the patient to
ongoing care if it will not be provided in the PMH
practice
 Provide information on how to obtain MPW, WIC,
Family Planning Waiver
 Collaborate with public health OBCM to ensure high-risk
patients receive care management
Pregnancy Medical Home Responsibilities
 Eliminate elective deliveries (induction of labor and
scheduled cesareans) before 39 weeks
 Maintain primary c-section rate at or below
threshold level
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Primary C/S rate of 20% or lower
Risk-adjusted (term, singleton,vertex) primary C/S rate of 16%
or lower
 Offer and provide 17p to eligible patients
 Conduct standardized risk screening on all Medicaid
patients
 Clinical integration with care management teams
Priority Risk Factors
focus on preterm birth prevention
 History of preterm birth
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(<37 weeks)
History of low birth weight
(<2500g)
Chronic disease that might
complicate the pregnancy
Multifetal gestation
Fetal complications
(anomaly, IUGR)
 Tobacco use
 Substance abuse
 Unsafe living environment
(housing, violence, abuse)
 Unanticipated hospital
utilization (ED, L&D triage,
hospital admission)
 Late entry to prenatal
care/missing 2 or more
prenatal appointments
without rescheduling
 Provider request for care
management assessment
Benefits of being a Pregnancy Medical Home
 Support from CCNC network
 Data-driven approach to improving care and outcomes
 Incentives:
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Increased rate of reimbursement for global fee for vaginal deliveries
to equal that of c-section global fee (similar increase for providers
who do not bill global fee)
$50 incentive payment for risk screening
$150 incentive payment for postpartum visit
No prior authorization required for OB ultrasounds
What is CCNC?
• Improves Health Outcomes & Reduces Care Costs:
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Manages care via population management
strategies
Supports the primary care medical home
Care Management Services
Community-based, provider-led
Focuses on quality improvement
Data driven
CCNC Networks
Programs & Campaigns
Working with Communities to
Reduce Disparities
 Healthy Beginnings
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12 NC communities
 Primarily paraprofessionals provide outreach, care
coordination and education with specific focus on
breastfeeding promotion, folic acid, safe sleep,
environmental tobacco reduction/elimination,
healthy weight and reproductive life planning.
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provided to 900 women in 2010; with no
infant deaths.
Working with Communities to
Reduce Disparities
 NC Healthy Start Programs
 Healthy Start Corps & Baby Love Plus
 15 communities in our state
 Focus primarily within African American and American Indian
communities.
Include outreach, health education, case management, depression
screening, interconception care, and community engagement.
 Most (80%) of the communities showed an improvement in birth
outcomes among minority families in 2010.
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 Community Health Ambassador (OMHHD)
NC Maternal, Infant, and Early Childhood Home
Visiting Program
 Goal: Coordinate an effective statewide planning and
implementation system through a strong alliance with key
partners in support of a continuum of home visiting services
for families.
 North Carolina receives $3.2 million annually through the formula
grant created by the Patient Protection and Affordable Care Act of 2010
(P.L. 111-148) to support evidence-based home visiting.
 North Carolina implementation:
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Supports four home visiting models:
 Nurse-Family Partnership
 Healthy Families America
 Parents as Teachers
 Early Head Start/Home Based Option
Home Visiting cont.
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Seven sites at Local Health Departments & Community Based
Organizations
Partnership with the National Implementation Research
Network and The Finance Project to support implementation
and sustainability planning
 Current status:
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Implementation began on December 1, 2011
Oversight from the Governor’s Early Childhood Advisory
Division of Public Health staff support sites in achieving
fidelity to the model, learning continuous quality improvement
and implementation science through training and technical
assistance.
Breastfeeding
Promotion
Breastfeeding Promotion
 NC Maternity Center Breastfeeding-Friendly Designation
 Expansion of Regional Training Center Infrastructure (6
centers that provide training and TA)
 Expansion of the Breastfeeding Peer Counselor Program (70
funded programs covering 86 Counties as of July 2011)
 Office of State Personnel Lactation Policy that covers all SPA
employees with paid break time and space (the ACA only
covers hourly workers)
 Child Care Regulation providing onsite space to mothers to
pump or feed their infant (s)
Trends in the percentage of infants ever breastfed and
breastfed at least 6weeks, 6 & 12 months,
NC WIC Program 1993-2010
Breastfeeding Challenges
 Poverty-in rural areas due to our unfortunate and
uncomfortable history of slavery, breastfeeding is
seen as a “poor” act and a reminder of the past since
many slaves were wet nurses.
 PRAMS data shows that going back to work and
school is a major barrier to continuation of
breastfeeding.
 Race-there are assumptions by some providers that
African American and American Indian women will
not breastfeed so they may not “push” the issue.
NC Infant Safe Sleep Campaign
(formerly Back to Sleep)
 Established in 1994
 Partnership with Division of Public Health (Title V)
 Adheres to American Academy of Pediatrics (AAP)
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Standards
Administered by NC Healthy Start Foundation
Uses evidence-based research, epidemiology,
principles of public health
Incorporates social marketing strategies
Nationally recognized for outreach and social
marketing
Child care, communities, media, etc. (providers and
public)
Safe Sleep History in NC
1994
NC’s Back to
Sleep
Campaign
started
2005
2003
NC SIDS Law
for Childcare:
ITS-SIDS
BESST begins
to strengthen
community
outreach
2006-2007
2011
HOPES begins
with Advisory
Group & 5
hospitals
New AAP
SIDS/SleepRelated Infant
Death Policy
www.nchealthystart.org
• www.mamasana.org
North Carolina leads the way…
Largest and most comprehensive Shaken Baby Syndrome
Prevention program in the United States.
3 basic components:
 Hospital education of parents of newborns
 Community reinforcements
 Media campaign
www.PURPLEcryingnc.info
What is PURPLE?
Hospital Implementation
86 Hospitals (over 5,000 staff) across the
state are participating in implementation
Primary Care Provider Participation (as of April 2010)
373 offices participating; 96 out of 100 counties
Collaboration with Center for Child & Family Health, UNC Injury
Prevention Research Ctr, and National Ctr for Shaken Baby Syndrome
Preconception Health Coalition
 Initiated in Jan 2007 ‐
leadership team formed
 Initial focus areas:
pregnancy intendedness
and healthy weight.
 NC Preconception Health
Strategic Plan released in
November 2008.
 From June 2008 –July
2011: 4 workgroups
meeting regularly to move
from strategies to action.
Preconception Health Coalition
 Over 150 people.
 Representatives from DPI, DHHS, local health
departments, public and private universities,
community based organizations, non-profit agencies
and consumers.
 Restructuring coalition so that instead of
workgroups, the larger coalition will meets more
frequently; will use webinar and videoconference to
engage new participants.
 Minutes from meetings and other pertinent info
available at www.everywomannc.org
Women’s Wellness Materials
Reproductive Life
Planning
Postpartum Visit Project
NC Preconception Health Campaign
 March of Dimes is home of Campaign
 Funded by state and federal contracts
 Works closely with State’s NC Preconception Health
Coalition and state leadership
 Focuses on educating public and health care providers
about the importance of being healthy prior to pregnancy
 Grew out of state’s successful folic acid campaign
NC Preconception Health Campaign
Current Campaign Topics
 Folic acid
 Reproductive life planning
 Healthy weight
 Tobacco cessation
Healthy weight trainings
 Empowering providers in public and private clinics across
the state to use BMI as tool to start discussions about
weight with their patients
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Link between overweight/obesity and maternal and infant health
outcomes
Common barriers for providers & patients
Evidence-based Eat Smart Move More strategies
 Offering new Healthy Habits for Life booklet in English &
Spanish for providers to use with their patients,
BMI/gestation wheels, posters, etc.
Successes
 10-year NTD reduction of 39%; 72% reduction in
western NC
 More than 550 health care practices and thousands
of providers trained over 5-year period
 Consumer education using peer education – 100-150
lay health educators trained each year who in turn
reach 5,000-10,000 women each year
Preconception Peer Education
 Reach college-age population with targeted health messages
emphasizing preconception health and healthcare.
 Train college students as peer educators.
 Arm peer educators with materials, activities and exercises to
train their peers in college and in the community at large.
NC Participating Universities
 A & T State University
 Duke University
 East Carolina University
 Fayetteville State University
 Johnson C Smith University
 NC Central University
 NC State University
 Shaw University
 UNC-Chapel Hill
 UNC-Greensboro
 Winston Salem State
University
Adolescent Pregnancy Prevention
 NC’s 2010 teen pregnancy rate was lowest in state
history – 49.7 per 1000 live births (15-19 years)
 Currently supports 29 sites in the state
 10 additional PREP (Prepare for Success) sites
 Healthy Youth Act – NC law requires all NC public
schools to offer abstinence-based, comprehensive sex
education to 7th through 9th graders.
Innovations
 Life Course Perspective
 Motivational Interviewing
 Community Transformation Grant (NEW)
 Tobacco free living
 Active living and healthy eating
 High impact evidence-based clinical and other preventive
services
Policy & Collaborations
Family Planning Waiver
North Carolina’s Be Smart Family Planning Waiver program
is designed to reduce unintended pregnancies and improve
the wellbeing of children and families in N.C. by extending
eligibility for family planning services to eligible women
ages 19 through 55 and men ages 19 through 60 who meet
the eligibility requirements for participation.
N.C. Medicaid Family Planning Waiver (FPW)
Program Update
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Based on the 2010 federal health care reform legislation,
States now have the option to provide family planning
services through a Medicaid State Plan amendment without
the formal process of routinely needing to seek Federal
approval for a waiver
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The Division of Medical Assistance submitted a State Plan
amendment (SPA) to Centers for Medicare and Medicaid
services (CMS) on 8/18/11.
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CMS approved North Carolina’s request to extend the
current FPW through 1/31/12 while processing North
Carolina’s SPA application for Family Planning Services
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FPW recipients who are at or below the 185% of the federal
poverty level will continue to receive services under the new
option.
N.C. Medicaid FPW Program Update (cont.)
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In addition to providing services currently covered under
the waiver, the State is proposing screening and treatment
for STIs, which will be covered for any or all of the six
periodic visits allowed under the new SPA program.
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The State is proposing screening only for HIV, which will
be covered for any or all of the six periodic visits allowed
under the new SPA program.
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Under the SPA, there will no longer be restrictions for
eligibility based age to receive family planning services.
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The SPA will provide an opportunity for North Carolina to
further reduce the rate of unintended pregnancies and
improve the well-being of children and families by
continuing the services previously covered under the FPW.
Advocate for Environmental and Policy Changes that Support
Preconception Health
 Maternity Leave Checklist and Benefits List created for state
employees - covers benefit and health tips for women prior to
pregnancy, during each trimester and postpartum.
Advocate for Environmental and Policy Changes that Support
Preconception Health
 Healthy Babies Healthy Business, a free intranet- based tool
from March of Dimes now posted on the state health plan
website
 Promote BMI assessment and healthy weight guidance in the
family planning and maternity clinics
 Promoting appropriate gestational weight gain through
trainings and/or web materials for public and private
providers
Tobacco Cessation Policies
 Smoke-Free Hospitals and Campuses
 House Bill 2 – Smoke-Free Restaurants and Bars
 Quitline – Free NRT
 5As Counseling requirement for MH clinics; strongly
encouraged in Title X clinics
 Alliance for Health and Other Groups trying to protect
tobacco use prevention dollars
Child Fatality Task Force
 Charged with making and implementing recommendations for changes
to laws, rules and policies to support the safe and healthy development
of our children and to prevent child abuse, neglect and death.
 Purpose is to develop a communitywide approach to understand the
causes of childhood deaths, and identify any gaps or deficiencies that
may exist in the delivery of services to children and their families.
 Comprised of Appointed Members (including legislators) to the Task
Force and wider Membership on its Three Committees:
 Unintended Death
 Intended Death
 Perinatal Health
http://www.ncleg.net/DocumentSites/Committees/NCCFTF/Homepage/
Perinatal Health Committee
 Comprised of over 125 members from across the state.
 Studied many different issues over the years – some
brought forward by the public, partners and legislators
 Introduces fiscal items as well as policy items.
 Currently focusing on two new areas:
 Health Inequities in Birth Outcomes
 Synchronizing / Systematizing core public health
messages for pregnant and new parents and families
PHC: Focus on Disparities in Birth Outcomes
 Increase collective knowledge and understanding of health
inequities in birth outcomes and any evidence and best
practices available to address those inequities across North
Carolina.
 Increase connections among members of the PHC and
others who have an interest in working together on this
issue.
 Develop a response to this issue which could include study,
policy, research, program or legislative items. ONGOING
Birth Equity Council
 Follow up to PHC Series – Initial Funding via NIH U13
 25+ member leadership team representing a variety of
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sectors including Commerce
60+ member Council
Purpose: develop an actionable strategic plan to address
disparities in birth outcomes…then fund and implement
Council in process of deciding on focus and framework for
this work. Strong interest in addressing underlying social
determinants of health
Will launch over 15 stakeholder forums across NC as part of
this process
Timeline for completion and funding – Fall 2013
Contribution to Regional
Efforts
Women’s Integrated Systems for Health (WISH)
 A systems-based, integrated approach to the design
and delivery of women’s health services, policies and
programs to include mental health and wellness
 Distance Education Resources (Free)
 Orientation webinar series – archived
 Foundation - 6 online, self-paced modules
 Academy – intensive online, instructor led
 New MCH library knowledge pathway
• Go to www.EveryWomanSoutheast.org – Training
Funded by U.S. Health Resources &Services Administration’s Maternal &Child Health Bureau
What is Every Woman Southeast?
 A coalition of leaders in Alabama, Florida, Georgia,
Kentucky, Mississippi, North Carolina, South Carolina and
Tennessee to build multi-state, multi-layered partnerships
to improve the health of women and infants in the
Southeast.
Objectives
 Operationalize the life course model.
 Promote health equity.
 Train leaders to facilitate connectivity between sectors, to
think about populations, and to address social determinants
of health.
 Leverage policy and advocacy opportunities.
 Build on social media and social capital.
 Re-engage business and faith communities.
 Focus on the “grass tips” approach.
Accomplishments to date
 Conducted an online survey
 Recruited Regional and State Teams
 Held planning meeting on March 2, 2010.
 Produced a compendium of activities
 Launched blog, website and Facebook page
 Launched webinar series
 National Preconception Summit Partner
 Team conversations, idea generating, study
 Logic model and grant submissions – In Progress
www.EveryWomanSoutheast.org
Questions?
Belinda Pettiford – 919-707-5699 or
b e l i n d a . p e t t i fo r d @dh h s . n c . g o v
http://whb.ncpublichealth.com/
Sarah Verbiest – 919.843.7865 or
s a r a h v @ m e d . u n c . e du