emerging approaches to improving pregnancy outcomes -- dr. hani atrash, hrsa

Emerging Approaches to Improving Pregnancy Outcomes

Hani K. Atrash MD, MPH

Director

Division of Healthy Start and Perinatal Services (DHSPS) Department of Health and Human Services (HHS)Health Resources and Services Administration (HRSA)Maternal and Child Health Bureau (MCHB)

Throughout the Reproductive Life Course: \Opportunities and Challenges for Empowering Girls and WomenWashington, DC April 2-3, 2014

Why Change our ways?Despite significant improvements in pregnancy outcomes, some challenges continueWe need to work smarter not just harderNew promising evidence based approaches:What to doHow to do it*

Improvements in Infant Birth OutcomesInfant Mortality Rate decreased by 12.2% from 2000 to 2011

Preterm delivery rate decreased by 9.8% from 2006 to 2012

Low birth weight rate decreased by 3.3% from 2006 to 2012 *

We made significant progressButWe can do more!

Continuing challenges:Worse maternal outcomesPersistent health disparitiesOther countries have achieved better outcomes*

Black-White disparities in perinatal outcomes - United States 1980 to 2010Year

Chart1

2.042.192.23

2.072.172.25

2.372.112.33

2.41.822.11

2.471.632

2.421.541.9

2.241.61.9

Infant Mortality Rate

Preterm births

Low birthweight

Sheet1

YearInfant Mortality RatePreterm birthsLow birthweight

19802.042.192.23

19852.072.172.25

19902.372.112.33

19952.41.822.11

20002.471.632

20052.421.541.9

20102.241.61.9

U.S. Maternal Mortality*8.216.113.3Source: Singh GK. Maternal Mortality in the United States. A 75th Anniversary Title V Publication. HRSA 2010

Chart2

7.95.818.2

85.918.3

7.85.419.7

7.85.220.4

7.24.918.8

6.65.114.2

8.45.919.5

7.95.618.4

8.25.422.4

7.95.818.3

7.8520.8

7.54.820.5

8.36.218.5

7.14.222.1

7.65.120.3

8.45.820.8

7.15.117.1

9.96.825.4

9.87.522

9.97.224.7

8.9624.9

12.18.730.5

13.19.334.7

15.111.136.5

13.39.532.7

12.71026.5

15.9812.6733.61

16.1312.436.97

Total

White

Black

Maternal Deaths per 100,000 Live Births

A

Maternal mortality rates per 100,000 live births by race: United States, 1935-2009NOTE: Maternal deaths are classified by race of decedent. From 1935-1988, live births were classified by race of child, and from 1989 onwards, live births are classified by race of mother.

The Black/white Inequality in Maternal Mortality increased conistently from a ratio of 1.80 in 1935 through 4.42 in 1957. Since then, the black/white ratio has hovered around 3 -4.in the last 6 decades, black women had a three- to four-fold higher maternal mortality risk than white women.

White/Figure 1:Maternal Mortality by Race, United States, 1982-2009

YearAllWhiteBlackBlack

RacesRatio

1935582.1530.6954.81.80

568.0511.6980.91.92

488.8436.1862.21.98

435.2377.2861.02.28

403.9352.8771.32.19

376.0319.8781.72.44

316.5266.0690.22.59

258.7221.8549.12.48

245.2210.5512.82.44

227.9189.4513.92.71

207.2172.1456.72.65

156.7130.7363.62.78

134.5108.6336.23.10

116.689.4303.63.40

90.368.1237.63.49

195083.361.1223.03.65

75.054.9204.23.72

67.848.9189.23.87

61.144.1168.33.82

52.437.2145.93.92

47.032.8134.34.09

40.928.7114.33.98

41.027.5121.64.42

37.626.3104.53.97

37.425.8105.04.07

196037.126.0103.63.98

36.924.9105.44.23

35.223.899.44.18

35.824.0101.14.21

33.322.393.84.21

31.621.088.34.20

29.120.274.23.67

28.019.572.63.72

24.516.665.93.97

22.215.559.53.84

197021.514.459.84.15

18.813.048.33.72

18.814.340.72.85

15.210.738.43.59

14.610.038.33.83

12.89.131.33.44

12.39.029.53.28

11.27.729.23.79

9.66.425.03.91

9.66.425.13.92

19809.26.721.53.21

19818.56.320.43.24

19827.95.818.23.14

19838.05.918.33.10

19847.85.419.73.65

19857.85.220.43.92

19867.24.918.83.84

19876.65.114.22.78

19888.45.919.53.31

19897.95.618.43.29

19908.25.422.44.15

19917.95.818.33.16

19927.85.020.84.16

19937.54.820.54.27

19948.36.218.52.98

19957.14.222.15.26

19967.65.120.33.98

19978.45.820.83.59

19987.15.117.13.35

19999.96.825.43.74

20009.87.522.02.93

20019.97.224.73.43

20028.96.024.94.15

200312.18.730.53.51

200413.19.334.73.73

200515.111.136.53.29

200613.39.532.73.44

200712.710.026.52.65

200815.9812.6733.612.65

200916.1312.4036.972.98

2010

White/

YearAllWhiteBlackBlack

RacesRatio

A

11111

Ist Quintile (Low SES)

2nd Quintile

3rd Quintile

4th Quintile

5th Quintile (High SES)

Age-Adjusted Death Rate per 100,000 Population1970 US Population Used as Standard

U.S. Cancer Mortality by Area Socioeconomic Status, 1969-1998

11111


2nd Quintile

3rd Quintile

4th Quintile



Cancer Mortality Among US Men by Area Socioeconomic Status, 1950-2000

11111


2nd Quintile

3rd Quintile

4th Quintile



Cancer Mortality Among US Women by Area Socioeconomic Status, 1950-2000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

000

Total

White

Black

Maternal Deaths per 100,000 Live Births

11111


2nd Quintile

3rd Quintile

4th Quintile



Cancer Mortality Among US White Men by Area Socioeconomic Status, 1950-1998

11111


2nd Quintile

3rd Quintile

4th Quintile



Cancer Mortality Among US Men Aged 25-64 Years by Area Socioeconomic Status, 1950-1998

11111


2nd Quintile

3rd Quintile

4th Quintile



Cancer Mortality Among US Men Aged 65+ Years by Area Socioeconomic Status, 1950-1998

11111


2nd Quintile

3rd Quintile

4th Quintile



Cancer Mortality Among US Men Aged 65+ Years by Area Socioeconomic Status, 1950-1998

11111


2nd Quintile

3rd Quintile

4th Quintile



Cancer Mortality Among US Women Aged 25-64 Years by Area Socioeconomic Status, 1950-1998

11111


2nd Quintile

3rd Quintile

4th Quintile



Cancer Mortality Among US Women Aged 65+ Years by Area Socioeconomic Status, 1950-1998

11111


2nd Quintile

3rd Quintile

4th Quintile



Cancer Mortality for the US Non-White Population by Area Socioeconomic Status, 1950-1998

11111


2nd Quintile

3rd Quintile

4th Quintile



Cancer Mortality for the US White Population by Area Socioeconomic Status, 1950-1998

1111

All Races

White

Black

Black/White Ratio

Infant Deaths per 1,000 Live Births

Rate Ratio

U.S. Infant Mortality Rates by Race, 1980-2007

Severe Maternal MorbidityThrombotic embolism (72%)Respiratory distress syndrome (75%)Cardiac surgery (75%)Acute renal failure (97%)Shock (101%)Blood transfusion (183%)Aneurysms (195%)Callaghan et al: Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 120:1029-36, 2012Severe maternal morbidity increased by 75% and 114% for delivery and postpartum hospitalizations respectively from 1998-99 to 2008-09

Rates increased during delivery hospitalizations for:

Better surveillance and improved detectionDemographics of childbearing are changing Assisted reproductive technology Advances in medicineWomen are entering pregnancy with more chronic conditionsMaternal Morbidity and Mortality on the Increase

Risk factors for adverse pregnancy outcomes among women who recently delivered a live-born baby PRAMS 2004 Preconception health conditions and behaviors

Behavior /Condition%Behavior /Condition%Underweight (BMI < 19.8)13.2Previous Low Birthweight11.6Overweight (BMI 26 to 29)13.1Previous preterm delivery11.9Obese (BMI > 29)21.9Diabetes1.8Tobacco (3 months bef preg)23.2Asthma6.9Alcohol (3 months bef preg)50.1Hypertension2.2Multivitamins (>=4/week)35.1Heart problems1.2No contraception/not planning53.1Anemia10.2Pre-preg counseling30.3

We Currently Intervene Too Late

Critical Periods of Development 4 5 6 7 8 9 10 11 12Weeks gestation from LMPCentral Nervous SystemCentral Nervous SystemHeartHeartArmsArmsEyesEyesLegsLegsTeethTeethPalatePalateExternal genitaliaExternal genitaliaEarEarMissed PeriodMean Entry into Prenatal CareMost susceptible time for major malformation

Early prenatal careis not enough,and in many casesit is too late!

Work smarter not just harder

Change what we do and how we do it

Adopt / adapt emerging and re-emerging evidence-based models of practice How do we proceed from here?*

What we do - Work beyond the 9 months of pregnancy:Comprehensive womens healthPreconception / interconceptionAcross the life span - Life-course approachHow we do it:Circles of influenceCOINsCollective impactWorking smarter*

Circles of Influence*** Courtesy of Dr. Magda Peck, CityMatCH

Two Key HRSA Infant Mortality Reduction ProgramsThe Collaborative Innovation and Improvement Network to reduce infant mortality, and

Healthy StartGloor PA. Swarm Creativity: Competitive Advantage through Collaborative Innovation Networks. New York: Oxford University Press, 2006.*

Collaborative Innovation NetworksA CoIN, or Collaborative Innovation Network, is a team of self-motivated people with a collective vision, enabled by the Web to collaborate in achieving a common goal by sharing ideas, information, and work. Gloor PA. Swarm Creativity: Competitive Advantage through Collaborative Innovation Networks. New York: Oxford University Press, 2006.*

Key Elements of a CoIN

Being a cyber-team (i.e. most CoIN work will be distance-based)

Innovation comes through rapid and on-going communication across all levels

Work in patterns characterized by meritocracy, transparency, and openness to contributions from everyone

*Source: Gloor PA. Swarm Creativity: Competitive Advantage through Collaborative Innovation Networks. New York: Oxford University Press, 2006.

The Infant Mortality CoIINThe Collaborative Improvement & Innovation Network to Reduce Infant Mortality

Designed to help States:Innovate and improve their approaches to improving birth outcomes Uses the science of quality improvement and collaborative learning

Team driven Phase 1: Regions IV and VI (13 states)Phase 2: Region V (6 states)Phase 3: National (31 states)

Part of a portfolio of efforts to improve birth outcomes and works in partnership with these initiatives*

COIN: Strategies & Structure5 Strategy Teams

Reducing early elective deliveries

Non-Medically Indicated Early Term Deliveries Among Singleton, Term Deliveries** Based on provisional birth certificate data; excludes women with pre-existing conditions25% total decline translating to ~50,000 early, elective deliveries averted since 2011 Q1*

Smoking During Pregnancy** Based on provisional birth certificate data reflecting smoking in any trimester; 3 States using unrevised birth certificate; 1 State excluded that did not report 2013 data8% total decline translating to ~8,000 fewer women smoking in pregnancy since 2011 Q1*

Other COIIN AccomplishmentsInterconception Care: 7 out of 8 states introduced polices to improve interconception care access or content

Perinatal Regionalization: several states are working together to address levels of care designations

Safe Sleep: monthly collaborative learning sessions to share best practices and innovations*

Established in 1991 as a presidential initiatives Started as a 5-year demonstration projectTargets communities with high infant mortality rates and other adverse perinatal outcomesInitially focused on community innovation and creativityToday, HRSA supports 105 grants in 196 counties, in 39 States, DC, Puerto RicoTHE NATIONAL HEALTHY START PROGRAMHistory *

Perinatal outcomes significantly improved:IMR = 4.78 compared with 6.15 nationally, 11.63 for African Americans Low birth-weight rate =10% compared with 8.1% nationally, and 13.53% for African Americans

Very low birth-weight rate 1.7% compared with 1.45% nationally, and 2.98%for African Americans

A profile of Healthy Start: Findings from the Evaluation of the Federal Healthy Start Program 2012

THE NATIONAL HEALTHY START PROGRAMProgress - Outcomes

Improve Womens HealthPromote Quality ServicesStrengthen Family ResilienceAchieve Collective ImpactIncrease Accountability through Quality Improvement, Performance Monitoring, and EvaluationMain Changes to Healthy StartHealthy Start Approaches

Healthy Start can drive collective impactHealthy Start programs are uniquely situated to:

Champion the infant mortality cause in their communities

Serve as backbone organizations to ensure collective impact

Implement its six main functions of a backbone organization:Provide overall strategic direction Facilitate dialogue between partners Manage data collection and analysis Handle communicationsCoordinate community outreach, and Mobilize funding

Source: Turner S, Merchant K, Kania J, Martin E. Understanding the Value of Backbone Organizations in Collective Impact: Part 3. Stanford Social Innovation Review. Jul. 19, 2012 http://www.ssireview.org/blog/entry/understanding_the_value_of_backbone_organizations_in_collective_impact_3 accessed March 2014

For More InformationHani Atrash, MD, MPH5600 Fishers LaneRockville, MD 20852Office: 301-443-0543Direct: 301-443-7678Email: [email protected]

*

************COIN strategies and structure******

emerging approaches to improving pregnancy outcomes -- dr. hani atrash, hrsa

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