PROMOTING PRECONCEPTION HEALTH:
THE INTEGRATION OF THE OMH PPE PROGRAM
INTO PROFESSIONAL HEALTH PRACTICE CURRICULA
Karla Damus, PhD MSPH MN RN FAAN
Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, MA
Isabel M. Estrada-Portales, PhD MS
Director of Communications, Office of Minority Health Resource Center, Rockville, MD
Infant, Neonatal, and Postneonatal
Annual Mortality Rates* US, 1940-2005
After decades of decline
there was no change in
the IMR between 2000
and 2005
Per 1,000 live births for each group: infant ( <1 year), neonatal ( 0-27 days), and postneonatal (28 days to <1 year).
From 1940 to 2005 infant, nenonatal, and postneonatal annual mortality rates in the US declined substantially.
The infant mortality rate decreased 85%, from 47 in 1940 to 6.9 in 2005; the neonatal rate decreased 84%, from 28.8 to 4.54; the
postneonatal rate decreased 87%, from 18.3 to 2.34.
SOURCE: Kung HC, Hoyert DL, Xu J, Murphy SL. Deaths: final data for 2005. Natl Vital Stat Rep 2008;56(10).
Infant Mortality Rates by Maternal Race/Ethnicity,
US 2000 and 2005
Infant Mortality Rates by Race/Ethnicity
Boston, 1996-2008
BPHC (2010). Health of Boston 2010
Boston resident live births and deaths, MA Dept of Public Health
Infant Mortality Rates by Race/Ethnicity
Boston and MA, 2006
US B:W Ratio
13.5/5.7= 2.4
Boston B:W Ratio
10.8/2.5= 4.3
www.marchofdimes.com/peristats
Strategies to Reduce Infant Mortality
Tertiary Prevention NICUs, surgery
 Secondary Prevention

Early detection treatment
progesterone, antenatal
steroids, surfactant


Primary Prevention Risk factor identification/
reduction
Critical Periods of Development
Weeks gestation
from LMP
Most susceptible
time for major
malformation
4
5
6
7
8
9
10
11
12
Central
Central Nervous
Nervous System
System
Heart
Heart
Arms
Arms
Eyes
Eyes
We currently
intervene-Too Late!!
Legs
Legs
Teeth
Teeth
Palate
Palate
External
External genitalia
genitalia
Ear
Ear
Missed Period
Mean Entry into
Prenatal Care
Social Determinants of Health and
Racial/Ethnic Disparities
Social
Determinants
Social
Supports
Stress
Fetal
Response
Maternal Response
Gestational Age 
Normal Birth
Outcomes
Neonatal
Mortality
Morbidity
Long-Term or
Adult-Onset
Morbidities
.
Healthy People Goals on Disparities
2000, 2010, and 2020

2000 Goal


2010 Goal


Reduce disparities in health status among different populations
Eliminate health disparities
2020 Goal

Achieve health equity, eliminate disparities, and improve the
health of all groups
www.healthypeople.gov
Why Focus on Health Disparities



After 30 years of research and demonstration projects,
substantial disparities in birth outcomes remain in the US
Interventions have primarily focused on care during
pregnancy --- often too late to impact preterm delivery, low
birth weight, and infant mortality risk
African American women are 30% more likely to deliver
preterm than white women and infant mortality rates are
2-5 times higher
Five Leading Causes of Infant Mortality
Boston and MA, 2006
Percent of Infant Deaths from Preterm-related
Causes by Race/Ethnicity, US, 2000 and 2005
Preterm Birth Rates by Gestational Age Categories
United States, 1990, 2000, 2005-2009*
14
12
10.6
12.7
12.8
12.7
12.3
9.09
9.14
9.03
8.77
12.2
11.6
10
8
6
7.3
8.22
LPTB (34-36 wks)
32-33 wks
VPTB (<32 wks)
4
2
0
1.4
1.49
1.6
1.62
1.59
1.57
1.92
1.93
2.03
2.04
2.04
1.99
1990
2000
2005
2006
2007
2008
*preliminary
Source: National Vital Statistics Reports Vol 58, Number 16 April 2010
2009
Risk Factors for Preterm Labor/Delivery

The best predictors for having a preterm birth are:
 current multifetal pregnancy
 a history of preterm labor/delivery or prior low
birthweight
 mid trimester bleeding (repeat)
 some uterine, cervical and placental abnormalities
Risk Factors for Preterm Labor/Delivery

Other Risk Factors:
–
–
–
–
–
–
–
–
–
–
–
unintended pregnancy
maternal age (<17 and >35 yrs)
black race
low SES
unmarried
previous fetal or neonatal death
3+ spontaneous terminations
uterine abnormalities
incompetent cervix
cervical procedures (LEEP, cone bx)
genetic predisposition
–
–
–
–
–
–
–
–
–
–
–
low pre-pregnant weight
obesity
infections
anemia
major/chronic stress
lack of social supports
tobacco use
illicit drug use
alcohol abuse
elective inductions/cesareans
folic acid deficiency
Folic Acid Deficiency

Predisposes to:
• NTDs (spina bifida, anencephaly)
• Other birth defects (cleft lip/palate, cardiac, limb reduction,

urinary tract, omphalocele, trisomies)
• Early and recurrent pregnancy loss
• Low birth weight and prematurity
 Bukowski R, et al. SMFM 2008-50-70% reduction of early
 spon PTB independent of hx of PTB
• Gestational hypertension, preeclampsia in Black women
• Atherosclerotic vascular disease (stroke, CAD)
• Age-related macular degeneration (decrease of about 30%)
• Colorectal and cervical cancer
• Acute Lymphocytic Leukemia
• Alzheimer’s Disease?
• Autism?
Knowledge that Folic Acid Should be
Taken Before Pregnancy
www.marchofdimes.com/peristats
Nationally representative telephone surveys conducted by Gallup, targeting approximately 2000
English-speaking women ages 18-45 each year. Margin of error is +/- 3%.
Life Course Perspective
Poor Nutrition
Stress
Abuse
Tobacco, Alcohol, Drugs
Poverty
Lack of Access to Health Care
Exposure to Toxins
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a lifecourse perspective.Matern Child Health J. 2003;7:13-30.
http://minorityhealth.hhs.gov
Background


The life course perspective approach supports
pre/interconception assessment, promoting evidence
based interventions, health throughout the life span,
and ultimately reducing disparities
Yet the yield from efforts to engage, educate and
motivate health care providers to do so has been
disappointing
www.mombaby.org/beforeandbeyond
Research Questions

How can we target health care professionals to
improve their personal pre/interceoncepiton
health and promote pre/interconception care
as they care for women and families?
 Can
the PPE training content be integrated into the
Northeastern SON curricula?
Objectives

The main objective is to integrate the OMH PPE
training program into the curricula of the
Northeastern School of Nursing (SON)
 Assess
the impact on the knowledge, attitudes, and
behaviors (KAB) and satisfaction of participating
students and faculty
 Document and evaluate follow-up activities led by these
students in the community
 Assess intention to use preconception continuing
education and other preconception-related resources
Methods

Conduct a OMH PPE training at Northeastern
covering the following topics:
 health
disparities, racial/ethnic disparities in birth
outcomes
 the social determinants of health
 causes of infant mortality
 the Life Course Perspective--preconception health and
care for men and women, research and
recommendations, racism and associated stress
 men, health and fatherhood
Evidence-Based Preconception Interventions
that Work
Giving Protection:
 Folic Acid Supplements
 Rubella Immunization
 Testing for HIV/AIDS
 Hepatitis B Vaccination
Manage Conditions:
 Diabetes
 Hypothyroidism
 Maternal PKU
 Obesity
 STIs
 Oral Health
Avoid Teratogens:
 Alcohol use
 Anti-epileptic drugs
 Acutance use
 Oral anticoagulants
 Smoking
Prevent the Preventable














Ø Unintended pregnancies
Ø Short inter-pregnancy intervals
Ø Folic acid and other micronutrient deficiencies (vit D, iron, vit C)
Ø Alcohol
Ø Cigarette smoking and second hand smoke
Ø Illicit drugs
Ø Infections (UTIs, STIs, periodontal disease)
Ø Extremes of weight
Ø Some medications (Rx, OTC, home remedies)
Ø Environmental toxins
Ø Known genetic/familial risks
Ø Unnecessary interventions resulting in preterm birth
Insure timely interventions needed for optimal outcomes
Deliver all services with dignity and respect
at least. . . . . DO NO HARM
Closing the Black-White Gap in Birth Outcomes:
12 Point Plan
1.
Provide interconception care to women with prior adverse
pregnancy outcomes
2.
Increase access to preconception care for African American women
3.
Improve the quality of prenatal care
4.
Expand healthcare access over the life course
5.
Strengthen father involvement in African American families
6.
Enhance service coordination and systems integration
7.
Create reproductive social capital in African American communities
8.
Invest in community building and urban renewal
9.
Close the education gap
10.
Reduce poverty among Black families
11.
Support working mothers and families
12.
Undo racism
Lu MC, Kotelchuck M, Hogan V, et al. Closing the black-white gap in birth
outcomes: A life-course approach. Ethnicity and Disease. 2009.
OMH PPE Training at Northeastern University
February 11-12, 2011





121 students from Bouvé College
91 achieved PPE certification
Follow-up activities were planned and implemented during
National Public Health Week (4/4-10/11)
Other activities are planned and will be implemented in 201112 including additional PPE trainings
Activities are being documented and evaluated
Methods

Integrate the training into an undergrad (Public
Health- NRSG 4604) and a PhD graduate course
(Urban Practice Oriented Research- NRSG 7756)
 Link
students with professional continuing education
resources to promote preconception health (OMH, CDC,
NICHD, MOD, www.mombaby.org/beforeandbeyond)

Use results from the SON pilot to work with other
health sciences schools/departments at
Northeastern University (eg PA, PT, pharmacy)
 eventually
provide developed materials to other SONs
and health professional programs in Boston and other
regions of the nation
Integrating the Gabby System into the PPE Training
and Follow Up Activities in Selected Sites
Gabby ECA System to Improve Health of
Young Women
Goal – to address disparities in IMR and
PTD/LBW
• Assess >100 Reproductive Risks in 12 Health
Domains
• Assess Readiness for change in each risk area
• Provides information
• Provides “story” appropriate for readiness level
(personal change narratives)
• Opportunity to leave your story behind
• Social networking function encourages
“referral” to friends
Developed by Dr. T. Bickmore, College of Computer Sciences, Northeastern University
and Dr. B. Jack, Vice Chair Dept FM, BUSOM; Collaborator Dr. K. Damus, SON NU
Gabby
Next Steps

The evaluation process is underway


Students and faculty have reported a high level of satisfaction
with the PPE materials and the student nurses experiences that
are important to the preparation of nurses to serve in urban, high
risk communities.
Although most nursing education curricula includes some
content on disparities and HP, the curricula needs significant
expansion to include a greater focus on the life course
perspective, pre/interconception health promotion, perinatal
outcomes and social determinants to insure that all nurses
(and eventually all other health professional students)
understand what their role is in helping to make progress
toward the national HP2020 goal of eliminating disparities.
Implications



Prior to the integration of the OMH PPE materials, the
Northeastern SON curricula did not include a focus on the
life course perspective nor a strong focus on preconception
health.
The PPE initiative at the Northeastern SON can serve as a
pilot for other health sciences schools nationwide to
integrate the OMH PPE training into their curricula and
create a sustainable system to promote ongoing education
of future practitioners about these key topics.
It is expected that this will translate into healthier future
practitioners who are more likely to embrace the life course
perspective, provide preconception risk assessment and
care, and to personally engage in more health promoting
behaviors, all of which should increase progress to
ameliorating the persistent health disparities in the nation.