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Disparities in Birth Outcomes: A continuing challenge in Wisconsin
Kelli J. Jones, RN,MSNMurray L. Katcher, MD, PhDPatrice M. Onheiber, MPA
Department of Health and Family ServicesDivision of Public Health
February 24, 2006
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In an Average Week in Wisconsin:
• 1,349 babies are born
• 148 babies are born preterm
• 94 babies are born low birthweight
• 8 babies die before reaching their first birthday
2004 Data
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Objectives
• Define racial/ethnic disparities in birth outcomes in Wisconsin
• Review evidence-based practices for prevention
• Describe Healthy Birth Outcomes Action Plan
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Key Indicators of Perinatal Health
• Infant mortality rate (the number of infants who die before the first birthday/1,000 live births)
• Percent of babies born preterm (<37 weeks)• Percent of babies born with low birth
weight (<2,500 g; <5.5 lb)• Percent of pregnant women who receive
prenatal care that begins in the first trimester (<13 weeks)
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Infant Mortality Rates, by Country, 2004Rank Country IMR Rate Rank Country IMR Rate
1 Singapore 2.28 60 Sri Lanka 14.78
2 Sweden 2.77 61 United Arab Emirates 15.06
3 Hong Kong S.A.R. 2.97 62 Mauritius 15.57
4 Japan 3.28 63 Argentina 15.66
5 Iceland 3.31 64 Russia 16.01
6 Finland 3.59 65 Jamaica 16.63
7 Norway 3.73 66 Panama 17.14
8 Malta 3.94 67 Bahrain 17.91
9 Czech Republic 3.97 68 Jordan 18.11
10 Germany 4.2 69 Malaysia 18.35
11 France 4.31 Wisconsin Black 19.212 Macau S.A.R. 4.39 70 Qatar 19.32
13 Switzerland 4.43 71 Georgia 19.34
14 Spain 4.48 72 West Bank 20.16
15 Slovenia 4.5 73 Oman 20.26
Wisconsin White 4.5 74 Thailand 20.83
16 Denmark 4.63 75 Bulgaria 21.31
17 Austria 4.68 76 Mexico 21.69
18 Australia 4.76 77 Colombia 21.72
19 Belgium 4.76 78 Solomon Islands 22.09
20 Canada 4.82 79 Albania 22.31U.S. Census International Data Base, for countries with populations greater than 250,000
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Infant Mortality Rates: Total, White, and African American, Wisconsin, 1989-2004
2 . 0
7 . 0
1 2 . 0
1 7 . 0
1989
1991
1993
1995
1997
1999
2001
2003Infa
nt M
orta
lity
Rat
e
B/W Ratio = 2.4 B/W Ratio = 4.3
19.2African American
Total
White
Year
WISH (Wisconsin Interactive Statistics on Health), Infant Mortality Module, accessed 8/9/05.
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Infant Mortality Rates: Wisconsin’s Rank (of reporting states)
Race 1979-1981 1999-2001 2001-2002
White #10 (51) #22 (51) #19 (50)Black #3 (34) #32 (34) #40 (40)
Kvale, et al. Wis. Med J. 2004;103(5):42-47US DHSS, CDC, NCHS, Health United States, 2004
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African American infant mortality rates, among reporting states, 2000-2002
US 13.6
Rank State Black Rate Rank State Black Rate Rank State Black Rate
1 Washington 9.5 14 Florida 13.0 26 Mississippi 14.7
2 Oregon 10.4 15 Georgia 13.4 29 Delaware 14.9
3 Massachusetts 10.5 16 New Jersey 13.6 30 South Carolina 14.9
4 Kentucky 10.8 16 Virginia 13.6 31 Nebraska 15.0
4 Minnesota 10.8 18 Colorado 13.7 32 North Carolina 15.1
6 Texas 11.1 18 Louisiana 13.7 33 District of Columbia 15.3
7 New York 11.2 18 Nevada 13.7 33 Ohio 15.3
8 California 11.4 21 Indiana 13.9 35 Missouri 15.6
8 Iowa 11.4 22 Connecticut 14.3 36 Illinois 15.8
10 West Virginia 11.7 22 Arizona 14.4 36 New Mexico 15.8
11 Rhode Island 12.6 23 Pennsylvania 14.4 38 Michigan 16.9
12 Maryland 12.7 25 Oklahoma 14.5 39 Tennessee 17.0
13 Arkansas 12.8 26 Alabama 14.7 40 Wisconsin 17.9
26 Kansas 14.7
US DHSS, CDC, NCHS, Health United States, 2004
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Map of Milwaukee Infant Deaths
2000-2001(N = 253)
Zip Code 53206 had the greatestnumber of infant deaths = 35
Rate = 23.3
Zip Code 53233 had the highestInfant mortality rate = 36.9
N = 13 infant deaths
Milwaukee Home Visitation ProgramIs in 53204, 33, 05, 06, 08, & 12
2001-2002 FIMR Status Report, Milwaukee
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Infant Mortality Rate/1,000 Live Births1999-2003
3.026.5816.795.56All Wisconsin
2.988.1216.595.90MKE County
2.788.7515.435.55Rest ofCity of MKE
2.298.5317.517.62City of MKEZip Code Group
B/W RatioHispanicBlackWhiteCity/County
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Using Geography
to target with limited resources:
Zip codes
11
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More effective targeting with smaller geographical area:
Census Tract
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Targeting at the neighborhood level:Census Blocks
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Infant Mortality Rates, 2000-2004
City/County White Black HispanicBW
RatioDane 4.15 12.18 4.38 2.9
Madison 3.49 13.41 4.87 3.8
Kenosha 4.79 14.04 5.20 2.9
Racine 6.73 26.51 7.02 3.9
Rock 5.55 20.41 4.89 3.7
Beloit 6.83 24.53 7.98 3.6
Wisconsin 5.32 17.67 6.07 3.3
WISH (Wisconsin Interactive Statistics on Health), Infant Mortality Module, accessed 11/22/05.
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SIDS in Wisconsin, 2000-2004
0
0 .5
1
1 .5
2
2 .5
3
W h i t e B l a c k A m . I n d i a n H i s p a n i c L a o / H m o n g
Race/Ethnicity
SID
S ra
te p
er 1
,000
live
birt
hs
WISH (Wisconsin Interactive Statistics on Health), Infant Mortality Module, accessed 11/22/05.
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Racial & Ethnic DisparitiesInfant Mortality, Hispanic
0
1
2
3
4
5
6
7
8
9
Mexican PuertoRican
Cuban Central/SA Other
Per 1,000 Live Births
7.2
8.3
4.7 4.7
NCHS 2002
5.5
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Percent of LBW Infants by Race/Ethnicity
0
5
1 0
1 5
2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4N o n - H i s p a n i c W h i t e N o n - H i s p a n i c B l a c k A m e r i c a n I n d i a nH i s p a n i c L a o t i a n / H m o n g T o t a l
WISH (Wisconsin Interactive Statistics on Health), Infant Mortality Module, accessed 11/22/05.
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Preterm Births in Wisconsin• In 2004, there were 7,703 preterm births in Wisconsin,
representing 11.0% of live births.
Higher percentages of premature infants were born to:
- African American women 17.1%- Teen moms less than 18 years 16.0%- Women who were unmarried 13.4%- Women who smoked during pregnancy 13.0%- Women with less than a high school education 12.6%
Wisconsin Department of Health and Family Services, Division of Public Health, Bureau of Health Information and Policy, Wisconsin Births and Infant Deaths, 2004 (PPH 53464-04). August 2005
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05
1 01 52 0
2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4N o n - H is p a n ic W h it e N o n - H is p a n ic B la c k A m e r ic a n In d ia nH is p a n ic L a o t ia n / H m o n g T o t a l
Percent of Live Births that are Preterm, by Race and Ethnicity,
Wisconsin
WISH (Wisconsin Interactive Statistics on Health), Infant Mortality Module, accessed 11/22/05.
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Birth Weight and Infant Hospitalization Charges During the First Year of Life
2001 Medicaid Births in Selected Counties(Dane, Kenosha, Milwaukee, Racine, and Rock Counties)
$107,776
$35,684
$13,659$4,326
$251,788
$223,565
$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
NormalWeight
2,000-2,499
Grams
1,500-1,999
Grams
1,000-1,499
Grams
750-999Grams
< 750Grams
Total: $123,038,281
Linked Birth Events File, Bureau of Health Information
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Percent of Mothers Who Received 1st Trimester Prenatal Care, Wisconsin
01 02 03 04 05 06 07 08 09 0
1 0 0
2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4
N o n - H i s p a n i c W h i te N o n - H i s p a n i c B la c k A m e r i c a n In d i a nH i s p a n i c L a o t i a n /H m o n g T o ta l
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Birth Rate per 1,000 Females Age 15-19 years by Race/Ethnicity,
Wisconsin, 2004
Wisconsin Department of Health and Family Services, Division of Public Health, Bureau of Health Information and Policy, Births to Teens in Wisconsin, 2004 (PPH 5365-04). August 2005.
6 0 . 5
1 9
9 4 . 3 9 7 . 2
0
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
9 0
1 0 0
W h i t e B l a c k / A f r i c a nA m e r i c a n
A m e r i c a nI n d i a n
H i s p a n i c / L a t i n o
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Infant Mortality Rates: Total, White, and African American by Maternal Age, Wisconsin, 2000-2004
Age Total White African American
< 20 years 11.62 8.81 19.84
20-29 years
6.61 5.44 16.79
30-39 years
5.28 4.64 16.11
> 40 years 7.16 5.29 --
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Life Course Perspective
• Perhaps the best way to understand the racial and ethnic disparities in birth outcomes is from a “life course perspective.”
• The life course perspective takes a more holistic, longitudinal approach to the problem of poor birth outcomes, which spans generations.
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Stress and Preterm BirthCulture
LBW
Biological Risk Factors
Behavioral Risk Factors
Psychosocial StressPhysical &Social Environ
Stressors
ProtectiveCultural Factors
James (1993)
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Life Factors that Affect Infant MortalityPOVERTY
– In Wisconsin, percent poverty for
kids <5 years old:» White 7%
» Black 44%
» American Indian 32%
» Hispanic 26%
» Asian 17%
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Pathways to Preterm Birth
Preterm Birth
Stress
LowBirth
Weight
InfantMortality
IntrauterineGrowth
Restriction
Environment
Host
Microbe
Infection
Racism
Safety
Money
Work
Relations
Health
Abuse
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Life Course Perspective
Poor NutritionStressAbuseTobacco, Alcohol, DrugsPovertyLack of Access to Health CareExposure to Toxins
Poor Birth Outcome
Good Birth OutcomeWhite
AfricanAmerican
Puberty Pregnancy0 5Age
Lu, 2003
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Life Course Perspective
White
AfricanAmerican
Reproductive Potential
PregnancyAgeLu, 2003
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Life Course Perspective
White
AfricanAmerican
Reproductive Potential
PregnancyAgeLu, 2003
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Racial and Ethnic DisparitiesIntergenerational Factors
• Perinatal mortality and LBW– related to social class of father & maternal
grandfather– lowest among women born into the highest
class & married within the highest class– highest among women born into the lowest
class & married within the lowest class– upwardly mobile women (born low but marry
high) had birth outcomes that were in-between
Illsley 1963
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Low birth weight & preterm birth is lower among foreign-born African Americans
0
5
10
15
20
25
30
Low Birth Weight Preterm Birth
African Americans Residing in Harlem, NY
Perc
ent o
f All
Bir
ths
Foreign Born New York City Born
Valanis 1979
3.8%
24.3%
11.4%
18.4%
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Life Course Perspective
Prenatal Care
Poor Birth Outcome
0 5 PregnancyPuberty
Internatal Care
Primary Care for Women
Early Intervention
Prenatal Care
Primary Care for Children
WhiteGood Birth Outcome
AfricanAmerican
Age
Lu, 2003
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Wisconsin’s Leading Causes of Infant Mortality, 2000-2004
Cause of death Total White BlackCongenital Malformations/Birth Defects
19.8% 22.2% 12.1%
Perinatal: Disorders related to Preterm Birth & LBW
20.0% 16.4% 28.2%SIDS (Sudden Infant Death Syndrome)
11.6% 9.9% 16.5%
Perinatal: Maternal Complications of Pregnancy
4.6% 4.4% 5.1%
Perinatal: Newborn Complications of Placenta/Cord/Membranes
3.6% 3.8% 3.3%
Respiratory Distress Syndrome (RDS)
3.3% 3.4% 3.0%WISH (Wisconsin Interactive Statistics on Health), Infant Mortality Module, accessed 11/22/05.
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Interventions
Must be:• family-centered• community-based• culturally-competent• coordinated and collaborative
Must also be evidence-basedor a best practice
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Evidence-Based orBest-Practice Interventions
• Psychosocial Support and Decreased Isolation
• Maternal-Infant Bonding
• Infant Mental Health
• Depression Screening and Treatment
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Evidence-Based orBest-Practice Interventions
Behavioral-Risk Reduction:
Tobacco Use – low birth weight
Alcohol Use – fetal alcohol spectrum disorders
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Evidence-Based orBest-Practice Interventions
Behavioral-Risk Reduction:
• Prescription Medication
• Over-the-Counter Drugs
• “Recreational” Drugs
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Evidence-Based orBest-Practice Interventions
• Nutritional support• Breast Feeding• Prevention of birth defects with
folic acid and other vitamins/minerals
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Evidence-Based orBest-Practice Interventions
Medical Conditions:
• Diabetes and Gestational Diabetes(diabetes of pregnancy)
• Hypertension
• Infections
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Evidence-Based orBest-Practice Interventions
Diagnosis and Treatmentof Infections:
• Periodontal Disease
• Sexually-Transmitted Disease (STDs)and HIV/AIDS
• Urinary Tract Infections
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Risk Factors forSudden Infant Death Syndrome
• maternal smoking during pregnancy• late or no prenatal care• young maternal age• preterm birth and/or low birth weight• male gender• higher rates are found in black and
American Indian/Alaska Native
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Risk Factors forSudden Infant Death Syndrome
Unsafe Sleep Environment:• prone (face down) sleep position• sleeping on a soft surface• sleeping with soft objects or
loose bedding• overheating• smoking in household• probably “co-bedding”
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SIDS by Month of Age
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Teen Births, by Race, Wisconsin
0
20
40
60
80
100
120
140
1995
-199
7
1996
-199
8
1997
-199
9
1998
-200
0
1999
-200
1
2000
-200
2
Rat
e pe
r 1,0
00
WhiteAfrican AmericanHispanicAmerican Indian
Figure 1. Wisconsin birth rates per 1,000 females age 15-19 years by race/ethnicity, 3-year moving averages, 1995-1997 to 2000-2002.
Ashby SL, Remington PL, Katcher ML. Wis Med J 2005;104(6): 37-40
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46
Teen Births, Wisconsin and US
67.3
86.377.2
31.7
81.8
97.5
114.3
23.1
USWisconsin
White African American Hispanic American Indian
Figure 2. Birth rates per 1,000 females age 15-19 years by race/ethnicity, US and Wisconsin, 1998-2002.
Ashby SL, Remington PL, Katcher ML. Wis Med J 2005;104(6): 37-40
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47
Teen Births, Hispanic
7075
808590
95100
105110
1995
-1997
1996
-1998
1997
-1999
1998
-2000
1999
-2001
2000
-2002
Rat
e pe
r 1,
000
USWisconsin
Figure 4. Birth rates per 1,000 Hispanic females age 15-19 years, 3-year moving averages, US and Wisconsin, 1995-1997 to 2000-2002.
Ashby SL, Remington PL, Katcher ML. Wis Med J 2005;104(6): 37-40
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Unintended Pregnancy
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SIDS and Sleep Position by Race
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Evidence-Based orBest-Practice Interventions
Safe Sleep:• “Back to Sleep”• Firm surface• No soft objects or loose bedding• No overheating• NO smoking in environment
of sleeping baby• Probably no co-bedding
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Elimination of Racial and Ethnic Disparities in
Birth Outcomes A 5-Year Action Plan for
Wisconsin
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Draft February 2006 52
Goals
Communication & Outreach
Quality Improvement
Community & Evidence-Based Practices
Data
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Draft February 2006 53
Communication & Outreach
• Develop a 5-year plan
– Engage key stakeholders
– Periodic evaluations and revisions
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Draft February 2006 54
Communication & Outreach
• Community
– Consumer participation
– Culturally-appropriate education campaign
– Messages that lead to desired and endorsed behavior change
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Draft February 2006 55
Communication & Outreach
• Key Partner Relationships
– Foster and facilitate effective collaboration
– With partners, seek additional public and private funding
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Draft February 2006 56
Quality Improvement
• Enhanced Coordination
– Department-wide workgroup– Smoking and alcohol cessation– Oral health – Teen pregnancy
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Draft February 2006 57
Quality Improvement
• Assessment, Assurance, and Policy Development
– Services for mothers, children, and families– WIC, Nutrition Education, and FoodShare– STDs– HIV testing during pregnancy
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Draft February 2006 58
Quality Improvement• Access
– Medicaid eligibility and coverage– New web-based tool– Acceptance and education for temp cards– Access to new BadgerCare prenatal benefit
for incarcerated pregnant women – Develop pay-for-performance for healthy birth
outcomes
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Draft February 2006 59
Community and Evidence-Based Practices
• Consumer Involvement
– Work with community members and opinion leaders to foster trust and remove barriers
– Leverage minority health grant dollars for innovative, local prevention programming
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Draft February 2006 60
Community and Evidence-Based Practices
• Trusted Gateways– Dedicated personnel from Wisconsin’s
Minority Health and Maternal and Child Health Programs
– Expand First Breath and integrate with My Baby and Me
– Fetal and Infant Mortality Review– Milwaukee Comprehensive Home Visiting
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Draft February 2006 61
Community and Evidence-Based Practices
• Policy/System Changes
– Educate policy makers at high levels to promote shared agenda
– Work with DWD on education, employment and fatherhood for Milwaukee Home Visiting Project
– Provider education on evidence-based practices to reduce low birthweight and prematurity
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Draft February 2006 62
Data
• DHFS Data Workgroup
– Assess needs, conduct monitoring, coordinate with partners
– Fact sheets
– Leverage vital records, hospital discharge, Medicaid, and other key databases
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Draft February 2006 63
Data• Collaborative Partner Data Workgroup
– Identify data and research needs
– Data Sharing Agreements
– Prioritize research and evaluation projects
– Identify and implement strategies and secure funding
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Draft Februrary 2006 64
Data
• Key Program Evaluation
– Prenatal Care Coordination (PNCC) benefit
– Milwaukee Comprehensive Home Visiting Project
– Identify other key DHFS programs
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Draft February 2006 65
Data• Dissemination of Information
– Internet site: http://dhfs.wisconsin.gov/healthybirths/
– Presentations at national, state, and local forums
– Assure knowledge is used for purpose of community health improvement
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Summary
Elimination of Racial and EthnicDisparities in Birth Outcomes
• Data should lead to awareness and action.
• Action should be evidence-based or best practices.
• The Action Plan, through partnerships, will lead to the elimination of disparities in birth outcomes.