Jodi F. Abbott, MD MHCMjabbott@bu.edu

Beth Monahan, CNM, MPH3.24.16

Decreasing health disparities in perinatal outcomes by engaging our patients

in Prenatal Screening

Jodi F. Abbott, MD MHCMjabbott@bu.edu

Beth Monahan, CNM, MPH3.24.16

“You don’t go telling White people nothing”

African American women's perspectives on the influence of violence and race on depression and depression care. 2010 American journal of public health, 100(8)

• We have no disclosures

Learning Objectives: This talk will help you to-

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ACOG Prenatal Care Components 5

ACOG Prenatal Care Components 6

• Maternal genetic diseases/risk

• Fetal risk of aneuploidy

• Anemia • Hypertension• Diabetes • Obesity• Depression• History of

surgery

• Gonorrhea/Chlamydia

• Syphilis• Hepatitis

B/C • Rubella• Varicella• Zika

• Tobacco• Narcotics• Cocaine• Amphetamines

/Adderall

• Bleeding in Pregnancy

• History of preterm delivery

• Twins• Fetal Position

Prenatal Care Components with Health Disparities related to Social determinants of health 7

ACOG Committee Opinion December 2015 Racial and Ethnic Differences in Obstetrics and Gynecology

WHO Prenatal Care Current components

• Screening for health and socioeconomic conditions

• Providing therapeutic interventions

• Educating for safe birth and intrapartum emergencies

WHO Programme to map best perinatal practices 2011

WHO Prenatal Care Current components

• Screening for health and socioeconomic conditions

• Providing therapeutic interventions

• Educating for safe birth and intrapartum emergencies

WHO Programme to map best perinatal practices 2011

Racial Disparities in Pregnancy Outcomes 10

Racial and Ethnic Disparities in Obstetric Outcomes and Care: Prevalence and Determinants. A. Bryant et al.

Stress and Preterm LaborMultifactorial

Adapted from Lu AJOG 2005

Money

Stress

Preterm Delivery

Poor Fetal

Growth

LowBirth Weight

Infant Mortality

Work

Family

Abuse

Safety

Racism

HealthSocial Isolati

on

March of Dimes Prematurity Report Card 2015: 9.6% 12

Rates of Unintended Pregnancy in the US

Guttmacher Institute 2014

BLACK PRETERM BIRTHSAs a percent of all births

Kaiser Family Foundation 2014

Depression, Health Disparities and Preterm Birth• August 2015 USPHSTF Recommends Universal

Depression Screening for Pregnancy

• Kaiser Permanente prospective cohort study demonstrates an adjusted hazard ratio of preterm birth in women with depression

• aHR = 2.2 (CI 1.1–4.7)

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Li, D., Liu, L., & Odouli, R. (2009). Presence of depressive symptoms during early pregnancy and the risk of preterm delivery: a prospective cohort study.Human Reproduction, 24(1), 146-153.

Nicolaidis, C., Timmons, V., Thomas, M. J., Waters, A. S., Wahab, S., Mejia, A., & Mitchell, S. R. (2010). “You don't go tell white people nothing”: African American women's perspectives on the influence of violence and race on depression and depression care. American journal of public health, 100(8), 1470-1476.

“You don’t go telling White People Nothing”

CenteringPregnancy Comprehensive Curriculum

Nutrition and weight gain goalsCommon discomfortsRelaxation and stress reductionBirth optionsEarly parentingContraception optionsBreastfeedingThe hospital experienceThe “blues” and depressionPersonal goals

Academic Site:

Base: (N=) Ethnic Disparities:

Preterm (% reduction):

LBW (% reduction):

Yale/Emory 1047 80% (Black) 9.8 (33%) 7.7 % (33%**)

Vanderbilt 355 40% (Black) 9.7(26%) 8.58% (36%)

U-South Carolina

316 34% (Black) 7.9(47%) 8.9 (22%*)

BMC 220 75% (Black) 5.7(43%) 7.26% (26%)

Improved Health Disparities Outcomes by Academic Medical Center

** LBW reduction associated with 5 or more CP group visits

*LBW reduction not statistically significant

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CenteringPregnancy cost savings by preterm delivery prevented

The estimated societal economic impact of Preterm Birth is at least $26.2 billion annually.

Barrier Analysis Rapid assessment tool used to identify behavioral determinants associated with a particular behavior so that more effective behavior change messages and support activities can be developed

Process of Barrier AnalysisIDENTIFY DO-ER’s and NON DO-ER’s

IDENTIFY DETERMINANTSWhy people do or not do the

behavior

Counseling and Documentation at Index SPTD

SPTD pts on MFM pp service

Education campaign for faculty & residents

Stickers & EmailsPosting protocol

Lessons Learned: Unsuccessful Interventions

• Grand rounds/Resident lectures• Jodi sings a preterm labor song• Processes excluding patients• Failing to prioritize preterm birth

as an obstetric RISK event• Trying to communicate priorities

without data

Lessons Learned: Successful Interventions • Counseling at delivery of index pregnancy• Experiential counseling of patients by

residents• Focused identification of patients• Streamlined processes• Assigning 17OHp Resource RN • EMPOWERED Patients are ready for 17Ohp• Audit and feedback of providers• Partnership with local DPH & CHC’s

Thera Wilson RN

17OHP Prior Auth

Queen

BMC Initiative to Prevent Recurrent Preterm Birth

Identify Women with a History of Spontaneous

Preterm Birth < 37 weeks

MFM ConsultCervical US until

30wks17 OH Progesterone

16-36wks

Cervix <2.5cm <24wks

Cervix <2.5cm >24wks

Cervical Cerclage Betamethasone

Consult can be done in ATUMakena (17)OHP needs a prior auth

“Spontaneous” delivery NOT due to preeclampsia

or IUGRCall 414-2000

to book ATU appts

Protocol as per SMFM, ACOG and Boston Public Health Commission guidelines

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Most slides courtesy of Samih Nassif BUSM 3

ZIKA

Zika Virus• Flavivirus transmitted by an infected Aedes mosquito. • Clinical manifestations: low-grade fever with

maculopapular rash, arthralgia, non-purulent conjunctivitis.

• Incubation: between 2-14 days, illness is usually mild.• Associated with Guillain-Barré syndrome, fetal loss, and

congenital microcephaly.

Images from: http://laboratoryinfo.com/wp-content/uploads/2016/01/zika-virus.jpg

Diagnosis of Zika Virus infection

• Maternal: – Serum reverse-transcription polymerase chain reaction

(RT-PCR) testing or antibody (IgM, IgG) serology 7 days after symptom onset.

• Intrauterine infection (positive or inconclusive Zika laboratory test results) – diagnostic amniocentesis– serial ultrasonography

• Newborn – Cord Blood Serum screening/Placental pathology

ACOG. (2016). Practice Advisory: Updated Interim Guidance for Care of Obstetric Patients And Women Of Reproductive Age During a Zika Virus Outbreak.

Association Between Zika Virus Infection and Microcephaly: The Data

Schuler-Faccini L, R. E., Feitosa IM et al. (2016). Possible Association Between Zika Virus Infection and Microcephaly — Brazil, 2015. MMWR Morb Mortal Wkly Rep, 65, 59–62. doi: http://dx.doi.org/10.15585/mmwr.mm6503e2

• Retrospective review of 37 cases of confirmed congenital microcephaly after birth.

• Exposure to Zika virus: presence of maternal rash, residence in or travel during pregnancy to areas of Zika exposure

• All were negative for syphilis, toxoplasmosis, rubella, cytomegalovirus, and herpes simplex virus infections.

• Weaknesses: – Media coverage lead to increased

surveillance and measurement of HC, thus increased number of cases reported.

– Zika virus was not serologically confirmed on infants or mothers, and thus presence of a rash can lead to recall bias.

Current Recommendations for Zika virus evaluation in Pregnancy• SMFM:

– If fetal HC is >2 SD below the mean, careful intracranial US for anatomy.

– Diagnosis of microcephaly is > 3SD below mean– If the intracranial anatomy is normal, recommend follow

up ultrasound in 3-4 weeks• ACOG:

– Avoiding travel to areas of Zika exposure during pregnancy.– If travel cannot be avoided, use EPA-approved bug spray with

DEET, covering exposed skin, staying in air-conditioned or screened-in areas, and treating clothing with permethrin

– If partner has traveled to ZEA use condoms remainder pregnancySMFM. (2016). SMFM Statement: Ultrasound Screening for Fetal Microcephaly Following Zika Virus Exposure. American Journal of Obstetrics and Gynecology. doi: http://dx.doi.org/10.1016/j.ajog.2016.02.043ACOG. (2016). Practice Advisory: Updated Interim Guidance for Care of Obstetric Patients And Women Of Reproductive Age During a Zika Virus Outbreak.

Prenatal Zika Screening at BMC: Protocol • Universal Screening:

– at Intake/F/up Ob visit – ATU Fetal survey

• Have you or your partner been outside the US during your pregnancy? • YES -ZIKA ENDEMIC AREA• Entered into EPIC: Potential Zika Exposure

• Did you have mosquito bites, illness with fever, or red eyes? – YES or returned W/IN 12 weeks

• Offer serum screening and recommend • Serial US for fetal growth

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Prenatal Zika Screening at BMC: Current stats• 65 women screened positive since 2/7/16• 30 women accepted serum screening• 30 pending serum screens• 2 near term patients with fetal growth delay

without criteria for microcephaly• 1 delivery (last week) of IUGR baby to screen

positive Mother– False negative Head Circumference in utero– Postnatal diagnosis of Microcephaly

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BMC Protocol:High Risk + Zika Screen Mothers• Any Mother positive blood test• Any Mother blood test without result and ANY

clinical finding• Any screen positive Mother with ultrasound

findings of: – IUGR– CNS structural abnormality– Microcephaly diagnosis

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Ideal Workflow for High risk + Zika Screen: Per MFM Yarrington/Pedi ID Barnett team

• Spreadsheet of all screen high risk Mothers and EDD’s to Pedi ID team

• Mother/Baby identified at admission to L&D and Pedi team notified

• Cord blood collected/held and placenta sent to path

• Pedi team notified of High risk screen positive baby at nursery arrival

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Thanks

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jabbott@bu.edu