MATERNAL AND CHILD HEALTH FELLOWS · MATERNAL AND CHILD HEALTH FELLOWS WELCOME BACK!...
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1 DAY THREE MATERNAL AND CHILD HEALTH FELLOWS WELCOME BACK! #NCSLMCHFELLOWS
Transcript of MATERNAL AND CHILD HEALTH FELLOWS · MATERNAL AND CHILD HEALTH FELLOWS WELCOME BACK!...
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DAY THREE
MATERNAL AND CHILD HEALTH FELLOWS
WELCOME BACK! #NCSLMCHFELLOWS
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NCSL Legislative Summit
GETTING READY TO REDISTRICT: NCSL SEMINARS FOR LEGISLATORS, LEGISLATIVE STAFF AND OTHERS
These seminars are intended for legislators and legislative staff to help prepare them for this once-in-a-decade task. Everyone is welcome though!
❖ June 20-23, 2019 | Providence, R.I.❖Oct. 24-27, 2019 | Columbus, Ohio❖May 6-10, 2020 | Las Vegas, Nev.❖Sept. 24-27, 2020 | Portland, Ore.❖January 2021 | Washington, D.C.
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AGENDA FOR TODAY
Infant Mortality and Maternal Mortality
Break
Action Planning and Reflection
Post Test
Evaluation
Reminders
Wrap up by 11:30 a.m.
MATERNAL AND CHILD HEALTH FELLOWS PROGRAM
INFANT MORTALITY AND MATERNAL MORTALITY
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SESSION OVERVIEW
Purpose
Introductions
State Response: Louisiana’s Efforts to Reduce Infant Mortality
Maternal Mortality in the US
Question & Answer Opportunity
NATIONAL EXPERTS
Dr. Lynne Coslett-Charlton
Pennsylvania District Legislative Chair, The American College of Obstetricians and Gynecologists
Jane Herwehe, MPH
Data Action Team Lead, Bureau of Family Planning, Office of Public Health, Louisiana Department of Public Health
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Perinatal Health and
Infant Mortality in
Louisiana
Jane Herwehe, MPH
Office of Public Health
Bureau of Family Heath
Total Population
Poverty and Children
• 40% (946,144) of our 2.4 million resident women are age 15 to 44 years
Louisiana’s Population (2016)
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59%
32%
5%
4%
non-Hispanic white
non-Hispanic black
Hispanic
non-Hispanic other race
• 4,681,666 residents– 51% female, 49% male
– 16% female headed families with no husband present
Women of Reproductive Age
6.3 7.9
38.0
49.3
0
10
20
30
40
50
Marriedno children
Marriedwith children
Single, femaleno children
Single, femalewith children
Race - Ethnicity
Perc
ent
(%)
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Measures Community Well-Being• Uses five census variables to rank census tracts
within the state (75th percentile)• Percent of households with children < 18 years old
located in areas of highly concentrated disadvantage
• Linked to low social capital– Communities with highly concentrated disadvantage
have less ability to improve neighborhood conditions, limit neighborhood violence, and intervene in the community for the common good
• Highly concentrated disadvantage areas are linked to poorer outcomes, including overall health, mental health, teen pregnancy and adolescent delinquency, and long-term early individual mortality
Concentrated Disadvantage
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<5%5 - <10%10 - <20%20 - <40%40+ %
American Community Survey 2011-2015 data
Birth Outcomes
Live Births, Fetal Deaths, Infant Characteristics, Mortality
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• Opportunities exist
• Offering full range of contraceptive methods with counseling on moderately to most effective methods
0
10
20
30
40
50
60
70
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Per
cen
t (%
)
Not Trying Not Using Contraception
Pregnancy Intention
• Unintended pregnancy is declining in Louisiana
– 45% (2012) to 37% (2016)
– Intended: range 41% to 51%
– Unsure ~15% annually
• Decline observed for both mistimed and unwanted pregnancies
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0
10
20
30
40
50
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Perc
ent
(%)
MISTIMED
UNWANTED
Potential opportunity(~20,000 women)
Data source: Louisiana PRAMS; note that these data reflect women who have given birth in 2016, not all reproductive age
Live Births
• ~63,000 annually (2016=63,242)
– ~99% of births occurring in Louisiana are resident women
– 65.5% Medicaid eligible in 2016
• Little fluctuation annually
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Fetal Deaths
• 350-400 reported per year, on average
• Relatively little change over time, overall
• No clear pattern by gestational age group– So few reported at 39+ weeks, hard to evaluate
• No clear pattern by geographic region– Regions 3 and 5 often on the higher side
– Regions 7 and 8 often on the lower side
• Persistent black-white disparity (about double, potentially widening)
– Lower fetal mortality under 28 weeks gestation among black women
– Greatest disparity at 37-38 weeks gestation and at 39+ weeks for past 2 years
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0.0
2.0
4.0
6.0
8.0
10.0
12.0
2013 2014 2015 2016 2017
Feta
l mo
rtal
ity
rate
Total NH white NH black Hispanic
Preterm Birth
• 7,707 preterm births in 2017
• Pronounced geographic and racial disparities persist
• Louisiana 2016 rank = 49
• Required Reduction: ~2,400*
* To achieve ranking in the top 25% of US states
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0
2
4
6
8
10
12
14
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Per
cen
t (%
) p
rete
rm
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Repeat Preterm Birth
• Among women who have delivered preterm, about
(1 in 3) deliver preterm again in a subsequent birth
• “39 week variables” indicate about 1/2 were premature rupture of the membrane (PROM) or spontaneous active labor
Among women who have previously delivered preterm
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0
5
10
15
20
25
30
35
40
45
200
7
200
8
200
9
201
0
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Per
cen
t (%
) re
pea
t p
rete
rm
Birth Weight
10.7
1.9
7.8
1.1
15.6
3.2
0
2
4
6
8
10
12
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Low birth weight Very low birth weight
Perc
ent
(%)
Overall
non-Hispanic white
non-Hispanic black
• Louisiana typically ranks among the worst of US states low birth weight
• About half of very low birth weight (VLBW) births result in infant deaths
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Infant Mortality Over Time
• Important racial and geographic disparities persist
• Distribution of timing of 2017infant deaths
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• Decreased for much of 1990s
• Brief period of increase
• Continued decrease since about 2004
Post-neonatal3.5, N=213 (48%)
Neonatal3.8, N=231 (52%)
1990-98 APC -2.5 (p<0.05)1998-04 APC 1.72004-16 APC -2.5 (p<0.05)
APC = Annual percent change0.0
2.0
4.0
6.0
8.0
10.0
12.0
199
0
199
1
199
2
199
3
199
4
199
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200
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200
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200
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201
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201
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IMR
(p
er
1,0
00
bir
ths)
7.3
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Prematurity Related Infant MortalitySudden Unexpected Infant Death (SUID) Related Infant Mortality
Cause-Specific Infant Mortality
151.0 145.2163.4
150.5162.5
0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
2013 2014 2015 2016 2017
316.3
292.0
266.6 269.3
216.6
0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
2013 2014 2015 2016 2017
Infa
nt
dea
ths
per
10
0,0
00
live
bir
ths
Louisiana rate was ~50% higher than the US rate of 87.2 in 2014
SUID has accounted for ~20% of infant deaths in Louisiana each year
Louisiana rate was ~33% higher than the US rate of 211.4 in 2014
Prematurity accounted for 33% of infant deaths in Louisiana in 2016, down from 38% in 2014
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Infant Mortality and Race
• Louisiana exceeds the US rate for infant mortality for both major race groups, however the rate for black women in Louisiana has been more similar to the US rate during several of these years
• The disparity ratio in Louisiana was 2.6 in 2017– ranged from 1.9 (2004, 2008, 2009, 2014) to
2.6 (2017) over time
– US disparity ranged from 2.2 to 2.5
• From 2001-2015, the average annual percent decrease was– 1.9% - LA white
– 1.3% - US white
– 2.1% - LA black
– 2.0% - US black
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0.0
2.0
4.0
6.0
8.0
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LA White US White LA Black US Black
Infant Mortality, Geography and Race, 2014-16
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9.49.5
6.1
6.2
10.8 7.66.6
7.6 6.5
5.86.3
4.9
4.2
5.3 6.04.4
5.3 4.5
2.162.20
1.90
2.52
2.91 2.202.87
2.29 2.02
12.613.8
9.3
10.5
15.4 13.112.6
12.2 9.1
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Focused Interventions to Reduce Infant Mortality
• Medicaid policy changes for contraception access
• Integration of reproductive health services into primary care
• Contraception (intention and spacing)
– Education and access to a range of contraceptive methods for women interested in contraception
– Patient-centered counseling on most to moderately effective methods
– Same day access to Long Acting Reversible Contraceptives (LARC)
• Smoking cessation esp. for residents of reproductive age
• Prevention, early identification and Treatment of sexually transmitted infections (STI)
– Screening and treatment for all women of reproductive age
– Multiple time points during pregnancy
• Nutritional counseling through WIC
• Prevention of Preterm birth:
– Improve preconception health - well visits
– Working to make sure 17P is available for eligible women
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Focused Interventions…
• Early elective delivery / C-section
– Eliminate early non-medically indicated deliveries
– Reduce Nulliparous, Term, Singleton, Vertex (NTSV) C-sections
• Risk appropriate care for VLBW infants
• Decreasing adverse maternal outcomes– Maternal Mortality Review (PAMR)
– LaPQC -Hospital quality initiatives through use of standardized protocols and unit drills for early identification and reduction of obstetric hemorrhage and severe hypertension / preeclampsia
• Robust family support and coaching- Nurse Family Partnership and Parents as Teachers
• Infant sleep environment
– Campaigns
– Family-centered risk reduction approach addressing modifiable behaviors and practices to reduce infant mortality
– Inclusion of fathers
• Elevating importance of social determinants and factors (poverty, stress, depression, housing status, discrimination, economic stability, etc)
• Fetal Infant Mortality Review (FIMR)
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Takeaways for Policy Makers
• Get to know your Title V program and support its priorities and programs
• Utilize the principles of ethical practice of public health- Public Health Leadership Society www.phls.org
• Conduct a health impact assessment-For more information - the Healthy Community Design Team at [email protected]
• View all policy decisions through an equity lens and weigh how local decisions can impact infant mortality (think social determinants of health!)
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https://partnersforfamilyhealth.org/
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Thanks!
Jane Herwehe, MPH
Office of Public Health -Bureau of Family Heath
Main: 504-568-3504
Website: Partners for Family Healthy https://partnersforfamilyhealth.org/
Requests for data may be submitted on the Partners for Family Health, Data Center website or emailed to [email protected]
The Maternal Mortality
Crisis in the US
How state legislatures can impact improving maternal health
outcomes.
Lynne Coslett-Charlton, MD FACOG
American College of Obstetrics and Gynecology District III Legislative Chair
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Maternal Mortality in the United States
1. US has a higher rate of maternal mortality than any other developed country
2. As many as 60% of maternal deaths in the US are estimated to be preventable
3. Non-hispanic black women are 3 to 4 times more likely to lose their lives while
pregnant or post partum compared to non-hispanic white women
4. For every maternal death in the US, there are 100 women who experience
severe maternal morbitidy “near misses”
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Possible explanations for the rising US rate
Older new mothers with more complex medical histories
50% of pregnancies are unplanned….and many complex health issues are not
addressed prior to conception
Increased cesarean section rates, leading to higher comorbidities with current
and future pregnancies
Fragmented health care delivery systems, system failures, and access issues
Why are are mothers dying in the US?
Hemorrhage
Cardiovascular and coronary conditions
Cardiomyopathy
Infection
Opioid abuse - overdose and suicide
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Maternal Mortality Review Committees (MMRC)
Multidisciplinary groups of local experts in maternal and public health, as well as
patient and community advocates, that closely examine maternal death cases
and identify locally-relevant ways to prevent future deaths.
Traditional public health surveillance using vital statistics can tell us about trends
and disparities but MMRCs are intended to comprehensively evaluate each
death and identify OPPORTUNITIES FOR PREVENTION.
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Maternal Mortality Review Committees
33 States have MMRCs.
14 states (8 including PA in 2018) passed laws establishing MMRCs since 2016.
Laws provide authority to access records and keep data and proceedings
confidential.
Most state laws require annual reports to the Legislature including prevention
recommendations.
MMRC
For each death:
1. Not pregnant at time of death
2. Pregnant at time of death
3. Not pregnant at time of death but delivered within 42 days
4. Not pregnant at time of death but delivered within 43 days to 1 year
5. Unknown if pregnant
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MMRC
Review all maternal deaths and ask 6 key questions;
1. Was the death pregnancy-related?
2. What was the underlying cause of death?
3. Was the death preventable?
4. What factors contributed to the death?
5. What are the recommendations and actions that address the contributing
factors?
6. What is the anticipated impact of these actions if implemented?
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CDC report on MMRC data from 9 states
Colorado, Delaware, Georgia, Hawaii, Illinois, North Carolina, South Carolina,
Ohio, and Utah
680 maternal deaths were reported
237 deaths were found to be pregnancy related
38% while pregnant
45% within 42 days
18% within 43 days - 1 year
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WHY ARE PREVENTABLE MATERNAL DEATHS OCCURRING?
1. Patient lack of
knowledge of warning
signs of trouble
2. Misdiagnosis or
insufficient treatment
3. System failures
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Racial disparities
Social determinants of health must be considered when evaluating maternal mortality
Studies have shown that socioeconomic status and geography or location may be
related to maternal death (access issues, resource availability)
Racial disparities in maternal death rates are evident and health equity will be
incorporated in MMRC discussions
AIM (Alliance for Innovation in Maternal Health) patient safety bundle addresses racial
disparities, focusing on provider education on implicit bias and addressing patient’s
language and cultural needs
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California Maternal Quality Care Collaborative
Possible preventative deaths : Hemorrhage 70%, Preeclampsia 60%
Developed toolkits for hospitals which once implemented resulted in a 21%
reduction in maternal deaths
By 2013 maternal deaths fell to 7/100,000 women, mirroring results in other
industrialized nations such as France and Canada
Alliance for Innovation in Maternal Health (AIM)
ACOG (American College of Obstetrics and Gynecology) led initiative to form a
national alliance of clinicians, hospital administrators, patient safety
organizations, and patient advocates.
AIM creates condition-specific “bundles” which are evidence-based toolkits to
improve maternal outcomes.
Examples of bundles include severe hypertension, maternal mental health,
obstetric care of women with opioid use disorder, obstetric hemorrhage, and
racial disparities in maternity care.
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TO PARTICIPATE IN AIM STATES MUST
HAVE AN ACTIVE MMRC
Building U.S. Capacity to Prevent Maternal Deaths initiative
Partnership between:
CDC’s National Center for Chronic Disease Prevention and Health
Promotion
CDC Foundation
Association for Maternal and Child Health Programs
Merck for Mothers ($500 million initiative to improve maternal health)
Provides technical assistance to states to establish MMRCs and ensure they are
employing evidence based practices in reviewing data
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Maternal Mortality Review Information Application (MMRIA)
Application which provides complete, detailed, and organized medical and social data
for MMRC use
Provides a standardized database which documents MMRC decisions and analyzes
data for action
Allows grouping of regional and national data for greater impact
POTENTIAL FOR POSITIVE IMPACT
1. Adaptation of maternal levels of care for hospitals and birthing centers
2. Improve policies for prevention initiatives
3. Enforce policies and procedures for maternal hemorrhage
4. Improving policies related to patient management
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Importance of the “Fourth Trimester”
18% of pregnancy related deaths occur after the traditional 6 week post partum office
visit
Medicaid which accounts for almost 50% of US deliveries does not cover maternal care
beyond 6 - 8 weeks postpartum, most insurers only cover one visit
40% of patients skip their post partum visit (even greater in low income populations)
ACOG Committee Opinion : “Optimizing Postpartum Care” attempts to address this
issue, encouraging a culture change to more intensive postpartum management
HB 1318 The Preventing Maternal Deaths Act
Assists states in creating or expanding maternal mortality review committees
Authorizes federal funding for MMRC ($58 M for each fiscal year 2019-2023)
Signed into law December 2018
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Questions?
Lynne Coslett-Charlton, MD FACOG
American College of Obstetrics and Gynecology District III Legislative Chair
Erik Skinner, MPH
303-856-1461
Jane Herwehe, MPH
Dr. Lynne Coslett-Charlton
CONTACT INFORMATION
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THANK YOU!
BREAK
Self care
Network with each other
Reflect on content and think about your action plan
Share your ideas with your followers
#NCSLmchfellows
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Write down last thoughts
Finalize action plan
Stickies:
Topics for future webinar/meeting
ACTION PLANNING
CONTENT FOR JUNE MEETING & WEBINARS
Medicaid In schools Waivers
Childhood Obesity & Nutrition Immunizations/Vaccinations Neonatal Abstinence Syndrome (NAS) Newborn screening Possibly:
Infertility and In Vitro Fertilization Reducing Teen Pregnancy Reducing Suicide Home Visiting
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THINK, PAIR, SHARE
Reflect on your action plan
Pick one thing you want to do when you get home
Pair up with someone at your table and share
POST-ASSESSMENT
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ANSWERS TO POST TEST
Periodic e-Newsletter
News, resources, Fellows’ activity
Check-in email/call
NCSL resources and publications
Research and informational memos
Providing testimony or helping identify and invite experts
Supporting a hearing or informational session in your state
Convening stakeholders in your state to hear from experts and discuss an issue
Connecting you with national experts, other legislators, state officials, etc.
NCSL SUPPORT AND TECHNICAL ASSISTANCE
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SEE YOU SOON!
Webinar #1: Friday, March 1, 2 p.m. ET
Webinar #2: Friday, April 12, 2 p.m. ET
Second Meeting: June 23-25 or June 17-19 in Denver, Colo.
Optional meeting for HHS Chairs: June 25-27 or June 19-21
