Planned Community Change Prenatal Care in the First Trimester By Kristyn Beaver, Catherine Giles, Lai Harper, Suzette

1. Planned Community ChangePrenatal Care in the First TrimesterBy Kristyn Beaver, Catherine Giles, Lai Harper, Suzette Ploughman

2. Lack of Prenatal Care in First Trimester Lack of prenatal care in the first trimester of pregnancy for African-American women of Kent County as demonstrated by an average of 61.3% as measured by the 2010 Michigan Department of Community Health Division for Vital Records and Health Statistics as compared to the Healthy People 2020 goal of 77.9%. The lack of prenatal care in the first trimester places African-American women at an increased risk of higher infant mortality and morbidity related to racial disparity, lower socioeconomic status, lack of insurance, and lack of education. U.S. Department of Health and Human Services (2012, March 1). Healthy People 2020. Pregnancy health and behaviors. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26

3. Michigan Statistics Kent County Prenatal Care First Trimester Note: Percentages are calculated by using live births to mothers in the specific age and race group as the denominator. Records with race not stated are included only in the "All Races" column. Records with age of mother not stated are included only in the "total" row. Source: 2010 Michigan Resident Birth File, Division for Vital Records & Health Statistics, Michigan Department of Community Health http://www.mdch.state.mi.us/pha/osr/CHI/Births/frame.html

4. Risk of Infant Mortality and Morbidity “Kent County exceeds the statewide rates in infant mortality, teen pregnancy and mothers receiving less than adequate prenatal care" (Borders, Rotondaro, and Bosscher, 2007, p. 10) Based on the Borders et al.’s research study (using Geographic Information System or GIS) in 32 Grand Rapids neighborhoods, inadequate prenatal care was associated with the following risk factors or socioeconomic/demographic variables: • Maternal smoking • Maternal alcohol use • Medicaid as primary insurance • Teen pregnancy • Less than high school education • Non-Hispanic Black women

5. Racial Disparity in Low Birth weight Live Births for African Americans by Prenatal Care Index in Kent County and in Michigan (comparison of local and state benchmark)Source: Michigan Department of Community Health (2010). Michigan Resident Birth File, Division for Vital Records & Health Statistics, Retrieved from and http://www.mdch.state.mi.us/pha/osr/CHI/Births/frame.html http://www.mdch.state.mi.us/pha/osr/chi/births/bxpnc/LWPNC.asp?DxId=1&CoCode=41&CoName=Kent

6. Racial Disparity in Infant Mortality (IM) Ratesfor African Americans (comparison of city and county benchmark) Source: Healthy Kent (2010). Fetal Infant Mortality Review 2010. Retrieved from http://www.healthykent.org/infanthealth/fimr/FIMR%20Annual%20Report.pdf Data from Michigan Department of Community Health. Michigan Death Files and Michigan Resident Birth Files, Vital Records and Health Data Development Section. Grand Rapids City: IM Rates (per 1,000 live births) by Race and Three-year Averages Kent County: IM Rates (per 1,000 live births) by Race and Three-year Averages

7. The Ecological Model Ecological model stems from the original work of Bronfenbrenner. This model is based on the belief that all processes occurring within individual people and their environment should be viewed as interdependent. It suggests that behavior change in people needs to be considered in broader social context, including developmental history, psychological characteristics, interpersonal relationships, physical environment and culture (Harkness & DeMarco, 2011 p. 79).

8. The Ecological Health Model

9. Ecological Model for Prenatal Care The ecological model is based on “intrapersonal attributes, interpersonal dynamics, person/environment interactions, cultural beliefs, and attitudes” (Harkness and DeMarco, 2012, pp. 65, 79-83).

10. Barriers to the Use of Prenatal CareSystem related • Inadequate or no maternity care providers for Medicaid-enrolled, uninsured, and other low-income women (long wait to get appointment) • Complicated, time-consuming process to enroll in Medicaid • Poorly advertised availability of Medicaid • Inadequate transportation services, long travel time to service sites, or both • Difficulty obtaining child care • Weak links between prenatal services and pregnancy testing • Inadequate coordination among such services as WIC and prenatal care • Inconvenient clinic hours, especially for working women • Long wait to see physician • Language and cultural incompatibility between providers and clients • Poor communication between clients and providers, exacerbated by short interactions with providers • Negative attributes of clinics, including rude personnel, uncomfortable surroundings, and complicated registration procedures • Limited information on exactly where to get care (phone numbers and addresses)

11. Barriers to the Use of Prenatal CareSocioeconomic barriers • Poverty • Inner city or rural residence • Minority status • High Parity (many children at home) • Non-English speaking • Unmarried • Less than High School education

12. Barriers to the Use of Prenatal Care Attitudinal • Pregnancy unplanned, viewed negatively, or both • Ambivalence • Signs of pregnancy not known or recognized • Prenatal care not valued or understood • Fear of doctors, hospitals, procedures • Fear of parental discovery • Fear of deportation or problems with the Immigration and Naturalization Service • Fear that certain health habits will be discovered and criticized (smoking, eating disorders, drug or alcohol abuse) • Attitudes related to selected lifestyles (drug abuse, homelessness) • Attitudes related to inadequate social supports and personal resources • Excessive stress • Denial or apathy • Concealment Reference: on pages 110-111 (Source: Institute of Medicine) Centers for Disease Control and Prevention (2009, June 18). Prenatal care. From data to action. CDC’s Public health surveillance for women, infants, and children. Reproductive Health of Women. Retrieved from http://www.cdc.gov/reproductivehealth/ProductsPubs/DatatoAction/pdf/rhow8.pdf

13. Possible Barriers to Prenatal Care in African American Women Barriers To Health Care In Grand Rapids/Kentwood In Kent County, Michigan Cost (with insurance) and lack of insurance: most likely related to the delay in medical care (delay more likely for Hispanic populations); delay in prescription medications (twice as likely for African Americans) Perceptions of unfair medical treatment based on patients’ characteristics • African Americans and Hispanic populations are more likely to perceive “unfair” medical treatment related to “racial/ethnic backgrounds, physical disability, education, gender, how people are dressed or groomed, how much money they have and their sexual orientation” Negative perceptions about the healthcare system. African Americans and Hispanic populations have more negative perceptions: “race or ethnic background is a factor in the quality of health care services provided” (p. 9) • Providing care to those without transportation • Providing information of health care service availability to all residents • Ensuring “high quality” health care available to all residents regardless of race/ethnicity • Offering adequate health care services to the “working poor” The community survey was funded by St. Mary’s Health Care and the Kent Health Plan in 2006. In Grand Rapids and Kentwood, a total of 524 residents (222 African Americans and 190 Hispanic populations) were randomly selected in The Community Survey. Demographics characteristics, reasons for delayed medical care, and perceptions of health care services were analyzed among ethnic/racial populations (Grand Rapids African American Health Institute, 2006, pp. 1-54). Reference Grand Rapids African American Health Institute (2006, May 23). Community survey. Executive summary and demographics analysis. Retrieved from http://www.graahi.org/Portals/0/GRAAHI%20Community%20Survey.pdf

14. Kent County Strengths and Resources

15. Kent County Strengths and Resources continued

16. Interventions to Increase Prenatal Care in the First Trimester • Primary Intervention • Expanding education to the high school students regarding preconception and early prenatal care • Secondary Interventions • Prenatal intervention check lists for women to be given at first prenatal visit. • Perinatal check list for Community healthcare providers • Flyer campaign with community resources for the pregnant woman .

17. School-Based Intervention Resource Center Classes A hands on class for new pregnant teen moms during school that is taught by nursing students in their OB rotation. • Promotes Early prenatal care • Targets schools with a high non-Hispanic black population • Shown to decrease infant mortality (A.B. Broussard & Broussard, 2010)

18. School-Based Intervention Continued • 1 hour a day/2 times a week for 6 weeks to be repeated each semester. • Several learning stations • Resources for early prenatal care • Resources for financial assistance • Nutrition games and quizzes • What smoking can do to my Baby • What drugs and alcohol can do to my Baby • What Domestic Violence can do to me and my baby (A.B. Broussard & Broussard, 2010)

19. School-Based Interventions Resources • Collaborate with Kent County School systems • Work With Nursing Programs and Nursing Students • Apply for qualified grants • Volunteers • Getting the word out to the students • Fliers (Appendix A) • Posters

20. Perinatal check list for Community healthcare providers On admission assessment: • Domestic Violence screen • Assessment with thorough history • Drug/Alcohol assessment and screening • Labs: OB panel, Blood type, Serology (to be done at about 25-28 weeks) Teaching: • First Trimester: • What the labs are for. • Domestic violence screening (it is shown that the patient won’t admit to violence until after the third time screening) • Substance or alcohol use • Second Trimester: • Signs and symptoms of preterm labor • Things to report to doctor: like sudden weight gain, sudden swelling, • Fetal kick counts • Substance or alcohol use • Vitamins • Patient concerns • Any additional labs or ultrasound

21. Perinatal check list for Community healthcare providers Continued • Third Trimester: • Labs: Group B beta-strep test; possibly repeat CBC for Hgb (might need more iron supplement) • Evaluate Nutritional and hydration status: remind of adequate fluid intake and calories, verify that the patient has enough to eat. (Possible WIC referral), screen for Pica • Appointments go from every 2 weeks to weekly now. • Evaluate for domestic violence, drug and alcohol use. • Oral health; ask if they’ve seen the dentist again since last trimester. • Evaluate smoking and cessation; offer nicotine replacement • Inquire about taking Labor and/or Breast Feeding classes. • Offer reading material regarding classes or what to expect with labor and delivery. Reference: Leveno, K. J., Cunningham, F. G. , Gant, N. F., Alexander, J. M., Bloom, S. L., Dashe, J. S., Sheffield, J. S., & Yost, N. P. (2003). Williams Manual of Obstetrics. (21th ed.). New York, NY: McGraw-Hill Publishing.

22. Prenatal Intervention Check List for Women to be Given at First Prenatal Visit Was this a planned pregnancy? Yes No How do you feel about this pregnancy now? happy unhappy not sure Are there any barriers that keep you from meeting your health care needs? If so, check all that apply. Transportation Child care Lack of health insurance Language barrier Finances – lack money to meet basic needs Understanding health care information Cultural barriers Work hours Clinic or office hours Other None How long has it been since you had a dental cleaning and checkup? less than a year more than a year Did you breastfeed any of your other children? yes no does not apply Do you plan to breastfeed this baby? Yes No not sure How do you rate your current stress level? low medium high During the last two weeks have you felt unhappy, sad, or hopeless? Yes No During the last two weeks have you had little interest or pleasure in doing things you used to enjoy? Yes No Do you or anyone in your family have a history of nerves, depression or other mental health issues? Yes no don’t know Is there someone you can count on to help you during your pregnancy and with your new baby? Yes No Not sure How many times have you moved in the past 12 months? 0-2 3 or more Do you currently have any housing concerns? Yes No Do you have enough food for your family? always sometimes never Are you in a relationship with anyone who threatens you, yells at you, or tries to control you? yes No Within the last year, have you been hit, kicked, slapped, or otherwise physically hurt by someone? yes No Within the last year has anyone forced you to engage in sexual activities that made you feel uncomfortable? Yes No Have you ever been emotionally, physically or sexually abused? Yes No In the month before you knew you were pregnant how many cigarettes did you smoke each day? I didn’t smoke then less than half a pack half to one pack more than one pack Do you smoke now? Yes No   Does anyone smoke in your home or workplace? Yes No In the month before you knew you were pregnant how much beer/liquor/wine did you drink? did not drink then less than 7 drinks per week more than 7 drinks per week Do you drink now? Yes No Does your partner use alcohol? Yes No In the month before you knew you were pregnant, did you use any street drugs or drugs not prescribed by your doctor? Yes No Does your partner use street drugs? Yes No Is there anything else you would like to tell us? The Health of You and Your Baby is Important to Us Reference: Prenatal screening tool (Healthy Kent, 2010, p. 46) Healthy Kent (2010). Fetal Infant Mortality Review 2010. Retrieved from http://www.healthykent.org/infanthealth/fimr/FIMR%20Annual%20Report.pdf The Health of You and Your Baby is Important to Us Please call if any questions

23. EvaluationInterim Evaluation Kent County Community Public Health To measure the effectiveness of interventions instituted to increase prenatal care in the first trimester for the non-Hispanic Black population, biannual statistical reports will be written from the Kent County Community Public health database (with permission from Kent County Community Public Health). • Statistical reports will pull all non-Hispanic Black women seen for pregnancy grouped by the trimester prenatal care received. • Reports will be analyzed to evaluate if the goal of 77% non-Hispanic Black women seen by the Kent County Community Public health system had received prenatal care in the first trimester by 2015. • If the goal is not met the plan will be re-evaluated and new interventions instituted.

24. EvaluationInterim Evaluation School-Based Education Post Test at end of each class semester to include the following questions. Goal set for 80% of students completing exam to answers questions correctly as noted below: • To ensure the health of your baby it is important to seek prenatal care in the first trimester. True or False • Correct Answer: True • Prenatal health care can be obtained at Kent County Community Public Health. True or False • Correct Answer: True

25. EvaluationLong Term Kent County Low Birth Weight and Infant Mortality Racial disparity in low birth weight for live Births and infant mortality rates for African Americans in Kent County and in Michigan to be measured in 2012 and 2014. Percentage of low birth weight for live births should decrease below 15.3%. Percentage of infant mortality should decrease below 14.5%

26. References Agency for Healthcare Research and Quality (2011, June 2). School-based prenatal care coordination program enhances access to culturally sensitive care, improves birth outcomes for immigrant and minority teens. Retrieved from http://www.innovations.ahrq.gov/content.aspx?id=2765 Bloch, J. R., Dawley, K., & Spulee, P.D. (2009). Application of the Kessner and Kotelchuck prenatal care adequacy indices in a preterm birth population. Public Health Nursing, 26(5), 449-459. doi: 10.1111/j.1525-1446.2009.00803.x Borders, S., Rotondaro, G., & Bosscher, R. (2007). Using GIS in conjunction with binary logistic regression: Mapping the adequacy of prenatal care access in Grand Rapids, Michigan. Michigan Journal of Public Health, 1(2), 10-28. Retrieved from http://www.mipha.org/pdf/mjph/MJPH_V1_2_2007.pdf Broussard, A. B., & Broussard, B. S. (2010). Teaching pregnant teens: Lessons learned. Nursing for Women’s Health, 14(2), 104-111. doi:10.1111/j.1751-486x.2010.01523.x Centers for Disease Control and Prevention (2009, June 18). Prenatal care. From data to action. CDC’s Public health surveillance for women, infants, and children. Reproductive Health of Women. Retrieved from http://www.cdc.gov/reproductivehealth/ProductsPubs/DatatoAction/pdf/rhow8.pdf Child and Family Resource Council (2010). Healthy Kent 2010.Pregnancy Resource Guide. Retrieved from http://www.childresource.cc/pdfs/08-09_PRG.pdf Grand Rapids African American Health Institute (2006, May 23). Community survey. Executive summary and demographics analysis. Retrieved from http://www.graahi.org/Portals/0/GRAAHI%20Community%20Survey.pdf Grigorescu, V., Larrieux, C., Bouraoui, Y., Miller, K., & Paterson, D. (2004). Prenatal care in Michigan. Michigan Department of Community Health. MI PRAMS Delivery, 3(3), 1-4. Retrieved from http://www.michigan.gov/documents/July_2004_MI_PRAMS_Delivery2CL_98673_7.pdf Harkness, G. A., & DeMarco, R. F. (2012). Community and public health nursing. Evidence for practice. Philadelphia, PA: WoltersKluwer/Lippincott Williams & Wilkins. Healthy Kent (2010). Fetal Infant Mortality Review 2010. Retrieved from http://www.healthykent.org/infanthealth/fimr/FIMR%20Annual%20Report.pdf

27. References Kent County Health Department (2010). Healthy Kent 2010. Interconception Care Program.Kent County Infant Heath Initiative Annual Report. 1-22. Retrieved from http://www.accesskent.com/Health/HealthDepartment/Publications/ Kent County Health Department (2012). Pregnancy and parenting support services. Retrieved from http://www.accesskent.com/Health/HealthDepartment/Preg_Parent_Svcs/ Leveno, K. J., Cunningham, F. G. , Gant, N. F., Alexander, J. M., Bloom, S. L., Dashe, J. S., Sheffield, J. S., & Yost, N. P. (2003). Williams Manual of Obstetrics. (21th ed.). New York, NY: McGraw-Hill Publishing. Lu, M.C., Kotelchuck, M., Hogan, V.K., Johnson, K., & Reyes, C. (2010). Innovative strategies to reduce disparities in the quality of prenatal care in underresourced settings. Medical Research and Review, 67(5), 198-230. doi: 10.1177/1077558710374324 Michigan Department of Community Health (2010). Michigan Resident Birth File, Division for Vital Records & Health Statistics. Retrieved from and http://www.mdch.state.mi.us/pha/osr/CHI/Births/frame.html http://www.mdch.state.mi.us/pha/osr/chi/births/bxpnc/LWPNC.asp?DxId=1&CoCode=41&CoName=Kent Nurse-Family Partnership (2012). State profile 2012. Nurse-family partnership in Michigan. Retrieved from http://www.nursefamilypartnership.org/assets/PDF/Communities/State-profiles/MI_State_Profile Protas, B., Korzeniewski, G., & Grigorescu, V. (2008). Racial disparities in prenatal care. Michigan Department of Community Health. MI PRAMS Delivery, 7(2), 1-4. Retrieved from http://www.michigan.gov/documents/mdch/PNCRacial_Approv_252150_7.pdf U.S. Department of Health and Human Services (2012, March 1). Healthy People 2020. Pregnancy health and behaviors. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26 Walker, L.O., & Chesnut, L.W. (2010). Identifying health disparities and social inequities affecting childbearing women and infants. JOGNN:Journal of Obstetric, Gynecologic & Neonatal Nursing, 39(3), 328-338. doi:10.1111/j.1552-6909.2010.01144.x

28. Appendix A: