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  • Jodi F. Abbott, MD [email protected] Monahan, CNM, MPH3.24.16

    Decreasing health disparities in perinatal outcomes by engaging our patients in Prenatal Screening

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  • Jodi F. Abbott, MD [email protected] Monahan, CNM, MPH3.24.16

    You dont 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-*

  • ACOG Prenatal Care Components*

  • ACOG Prenatal Care Components*Maternal genetic diseases/riskFetal risk of aneuploidyAnemia HypertensionDiabetes ObesityDepressionHistory of surgeryGonorrhea/ChlamydiaSyphilisHepatitis B/C RubellaVaricellaZikaTobaccoNarcoticsCocaineAmphetamines/AdderallBleeding in Pregnancy History of preterm deliveryTwinsFetal Position

  • Prenatal Care Components with Health Disparities related to Social determinants of health*ACOG Committee Opinion December 2015 Racial and Ethnic Differences in Obstetrics and Gynecology

  • WHO Prenatal Care Current components Screening for health and socioeconomic conditionsProviding therapeutic interventionsEducating for safe birth and intrapartum emergencies

    WHO Programme to map best perinatal practices 2011

  • WHO Prenatal Care Current components Screening for health and socioeconomic conditionsProviding therapeutic interventionsEducating for safe birth and intrapartum emergencies

    WHO Programme to map best perinatal practices 2011

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

    *

  • Stress and Preterm LaborMultifactorial

    Adapted from Lu AJOG 2005Money

    StressPreterm DeliveryPoor Fetal GrowthLowBirth WeightInfant MortalityWorkFamilyAbuseSafetyRacismHealthSocial Isolation

  • March of Dimes Prematurity Report Card 2015: 9.6%

    *

    *

  • 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 BirthAugust 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 1.14.7)

    *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 dont go telling White People Nothing

  • CenteringPregnancy Comprehensive CurriculumNutrition and weight gain goalsCommon discomfortsRelaxation and stress reductionBirth optionsEarly parentingContraception optionsBreastfeedingThe hospital experienceThe blues and depressionPersonal goals

    Th*

  • Improved Health Disparities Outcomes by Academic Medical Center** LBW reduction associated with 5 or more CP group visits*LBW reduction not statistically significant

    Academic Site:Base: (N=)Ethnic Disparities:Preterm (% reduction): LBW (% reduction):Yale/Emory104780% (Black)9.8 (33%)7.7 % (33%**)Vanderbilt35540% (Black) 9.7(26%)8.58% (36%)U-South Carolina31634% (Black)7.9(47%)8.9 (22%*)BMC22075% (Black)5.7(43%)7.26% (26%)

    The Big Why should we do this is in the outcomes. To discuss the impact of Centering on Health disparities I have created a slide of the 3 largest studies conducted at AMC and included the % of Black particpants in the study. *

  • * CenteringPregnancy cost savings by preterm delivery prevented The estimated societal economic impact of Preterm Birth is at least $26.2 billion annually.

    Cost data from published estimates of the cost of preterm birth and health benefits associated with breastfeeding were applied to US birth census data as follows to calculate the cost savings per Mom associated with CenteringPregnancy:Researchers calculated an average of $33,200 spent in infant medical care costs per preterm birth (above and beyond what would have been expended had these infants been born at term). Including maternal delivery costs, early intervention services, and special education services associated with a higher prevalence of four disabling conditions among premature infants, as well as lost household and labor market productivity associated with those disabilities, the total cost per preterm infant increased to $37,152 in direct medical costs and $51,600 cost total. These cost estimates are considered conservative. (Behrman and Butler, 2006. Preterm Birth: Causes, Consequences, and Prevention, July 13, 2006. Institute of Medicine). The cost of preterm birth in the US was calculated by applying these data to the number of births reported in 2010. The reduction in the odds of preterm birth associated with Centering cited by Ickovics et al, 2007 (33% reduction) was used to calculate the estimated potential cost savings from preterm births averted across the US in one year. These savings, along with just over $100 in estimated direct savings realized through improved breastfeeding rates (Bartick & Reinhold, 2010) were divided by the number of births in 2010 for a rough estimate of the savings per Mom.*

  • 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-ERs and NON DO-ERs

    IDENTIFY DETERMINANTSWhy people do or not do the behavior

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  • 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 lecturesJodi sings a preterm labor songProcesses excluding patientsFailing to prioritize preterm birth as an obstetric RISK eventTrying to communicate priorities without data

  • Lessons Learned: Successful Interventions Counseling at delivery of index pregnancyExperiential counseling of patients by residentsFocused identification of patientsStreamlined processesAssigning 17OHp Resource RN EMPOWERED Patients are ready for 17OhpAudit and feedback of providersPartnership with local DPH & CHCs

    Thera Wilson RN17OHP Prior Auth Queen

    Add images of centering pregnancy, chcs and boston DPH*

  • 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

  • *Most slides courtesy of Samih Nassif BUSM 3ZIKA

  • Zika VirusFlavivirus 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-Barr syndrome, fetal loss, and congenital microcephaly.

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

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  • Diagnosis of Zika Virus infectionMaternal: 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 amniocentesisserial ultrasonographyNewborn 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.

    (to evaluate for microcephaly or intracranial calcifications) *

  • 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, 5962. 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 exposureAll 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.

    -2 cases removed; one had congenital CMV, another had autosomal recessive microcephaly

    -The Brazilian Ministry of Health created the Zika Embryopathy Task Force. Task force members collect data concerning the pregnancy (including exposure history, symptoms, and laboratory testing), physical examination of the infant, and any additional studies using a standardized spreadsheet.

    -Infection with Zika virus is difficult to confirm retrospectively because serological immunological tests might cross-react with other flaviviruses, especially dengue virus (6). Therefore a mothers report of a rash illness during pregnancy was used as a proxy indicator of potential Zika virus infection*