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The Interpregnancy Care Program The Feasibility and Impact of Delivering Interpregnancy Care to Mothers of Very-low-birthweight Infants at Grady Memorial Hospital. February 16, 2006. Background . Georgia ranks among the 10 states with the highest infant mortality (IM) rates;

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slide1

The Interpregnancy Care Program

The Feasibility and Impact of Delivering

Interpregnancy Care to Mothers

of Very-low-birthweight Infants

at Grady Memorial Hospital

February 16, 2006

background
Background
  • Georgia ranks among the 10 states with the highest infant mortality (IM) rates;
  • The largest contributor to Georgia’s high IM rate is the delivery of low birth weight (LBW; < 2500 gm) and very low birth weight (VLBW; < 1500 gm) infants, accounting for 70% and 50% of IR, respectively;
  • African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasians, resulting in twice the rate of IM.
background1
Background
  • The best predictor of a woman who will have a preterm/LBW delivery is a history of a preterm/LBW delivery; rates of recurrence increase as the duration of the first pregnancy decreases and for African-American and teen mothers;
  • The reasons for recurrence of preterm/LBW deliveries are likely that aspects of the woman’s pre-existing health status; untreated medical problems; and unaddressed nutritional, social, and behavioral risk factors that may have contributed to delivery of the first preterm/LBW delivery persist after delivery and in subsequent pregnancies.
background2
Background

In particular, a growing body of evidence links VLBW delivery to the following:

  • short interpregnancy intervals (especially < 9 months),

and;

  • aspects of a woman's health status, including:
      • unrecognized and poorly-controlled medical problems;
      • reproductive tract infections;
      • substance abuse;
      • periodontal disease;
      • psychosocial problems.
goal of ipc program
Goal of IPC Program

To evaluate the effectiveness of interpregnancy care (IPC; primary health care received from delivery of one child until conception of the next) toward improving subsequent reproductive outcomes for African-American women who have delivered a VLBW infant by:

  • improving the woman's interpregnancy health through reduction and management of her identified medical, dental, and social risks;
  • assisting the woman in developing and achieving her reproductive goals, which may include a planned pregnancy with an interpregnancy interval of at least 9 months, and preferably 18 months.
implementation of ipc
Implementation of IPC
  • The IPC Program enrolls African-American women who deliver VLBW infants at Grady Memorial Hospital (GMH) and provides them with the following package:
    • Definition of an individualized IPC plan based on assessments of medical and social risks for poor pregnancy outcomes;
    • Provision of primary health care and dental services in accordance with the individualized IPC plan for 24 months;
    • Assistance in achieving intendedness and spacing (at least 9 months and ideally 18 months) of subsequent pregnancies;
    • Community outreach via a trained Resource Mother and nurse case manager.
  • During the ‘Feasibility Phase,’ 29 participants were enrolled.
    • 24 months of follow-up will be complete for all in March, 2006.
results participation in ipc
Results: Participation in IPC
  • During Initial 12 months of IPC Program:
    • 21/29 (72.4%) actively participating;
    • 8/29 (27.6%) not actively participating:
      • 2 moved out of state;
      • 3 electively disenrolled (2 prior to 1st IPC visit; 1 after a single visit);
      • 3 become lost to follow-up (2 prior to 1st iPC visit; 1 after a single visit).
  • During Second 12 months of IPC Program:
    • 16/29 (55.2%) completed (or nearly completed) follow-up;
    • 13/29 (44.8%) not actively participating:
      • In addition to 8 described above,
      • 1 disenrolled (working with health insurance benefits);
      • 4 lost to follow-up.
results health impact
Results: Health Impact
  • Chronic health conditions:
    • 7/21 (33.3%) active participants with previously unrecognized or poorly managed chronic diseases that were identified and managed;
    • Conditions included hypertension, diabetes, asthma, lupus, sickle cell disease, valvular heart disease, hepatitis C, generalized anxiety disorder, and a pituitary tumor.
  • Acute health conditions:
    • 15/21 (71.4%) diagnosed and treated for reproductive tract infections;
    • 5/21 (23.8%) diagnosed and treated for iron-deficiency anemia;
    • 8/21 (38.1%) screened positive for postpartum depression and were linked to psychiatric evaluation and psychologic support services;
    • 7/15 (46.7%) fully evaluated and treated for oral infections and periodontal disease.
results health impact1
Results: Health Impact
  • Substance Abuse Disorders:
    • 12/29 (41.4%) those enrolled with substance abuse disorder;
    • 9/21 (42.8%) active participants with substance abuse disorder:
      • Tobacco alone – 3 (1 has quit);
      • Tobacco, alcohol – 1 (reduced alcohol; uses tobacco);
      • Street drugs, tobacco, alcohol – 5 (3 completed outpatient rehab, 2 completed residential rehab).
results social impact
Results: Social Impact
  • Educational Attainment:
    • 18/21 (85.7%) without h.s diploma or GED at study entry;
    • 13/18 (72.2%) were assisted in earning diploma or GED during the study:
      • 8/18 earned h.s. diploma or GED;
      • 5/18 enrolled in G.E.D. training program, but did not complete the program.
  • Employment Attainment:
    • 20/21 (95.2%) without employment at study entry;
    • 12/20 (60%) assisted in achieving full- or part-time work during the study.
results birth planning impact
Results: Birth Planning Impact
  • Reproductive plans development and follow-through:
    • 21/21 actively participating women developed a reproductive plan with care providers during the study;
    • 21/21 actively participating women were provided with a contraceptive method of their choosing.
results birth spacing impact
Results: Birth Spacing Impact
  • For comparison purposes, we constructed a Grady Historical Cohort of women with consecutive VLBW deliveries at GMH during an 18-month period preceding initiation of the IPC program (06/2001 through 12/2002);
  • Matched to IPC intervention group on two variables:
    • African-American ethnicity;
    • Census tract.
results birth spacing impact1
Results: Birth Spacing Impact
  • Attainment of at least 9-month interpregnancy interval:

Grady IPC CohortGrady Historical Cohortp-value*

29/29 (100%) 40/58 (69%) 0.0002

  • Attainment of at least 18-month interpregnancy interval:

Grady IPC CohortGrady Historical Cohortp-value**

24/29 (82.8%) 18/58 (31%) 0.0026

**p-value for Fisher’s exact test; intention-to-treat analysis.

results birth outcomes
Results: Birth Outcomes
  • Subsequent birth outcome ascertainment incomplete for IPC cohort as pregnancies currently in gestation;
  • Subsequent birth outcomes for Grady Historical Cohort (the comparison group) reveals a high rate of adverse outcomes* for the 36 pregnancies conceived within 18-months of the index VLBW delivery:
    • 21/36 (58.3%) resulted in an adverse outcome;
    • 6/36 (16.7%) resulted in an elective abortion;
    • 8/36 (22.2%) resulted in a liveborn, normal birth weight infant;
    • 1/36 (2.7%) had an unknown outcome (delivery outside Grady).

* A composite outcome comprising spontaneous abortions, stillbirths, and liveborn deliveries with birth weight < 2500 grams.

lessons learned content of interpregnancy period
Lessons Learned:Content of Interpregnancy Period

For women who have had a VLBW delivery:

  • There is a relatively high prevalence of unrecognized and/or poorly managed chronic diseases;
  • Reproductive tract infections, iron-deficiency anemia, and substance abuse are common following a VLBW delivery;
  • Substance abusers who do not enroll in treatment programs are difficult to track and have poor insight regarding the role of substance abuse in poor reproductive outcomes;
  • The receipt of health care services for themselves is less of a priority than is securing income/employment, and this influences their health care seeking behaviors;
  • Community outreach via the Resource Mother is valued by participants and is instrumental in helping women follow-through with their individualized IPC plan (medical and social).
lessons learned impact of interpregnancy care
Lessons Learned:Impact of Interpregnancy Care

For women who have had a VLBW delivery, the provision of IPC contributes to improvement of women’s health during their reproductive years by facilitating:

  • the availability of primary care for the identification and management of chronic and acute conditions epidemiologically-linked to LBW and preterm delivery;
  • the development of a personal reproductive plan by participating women;
  • the achievement of a 9-month interpregnancy interval.
slide17
Georgia Perinatal Task Force Report, 1998.

Adams, M. M., K. M. Delaney, P. W. Stupp, B. J. McCarthy and J. S. Rawlings. "The relationship of interpregnancy interval to infant birthweight and length of gestation among low-risk women, Georgia." Paediatric and Perinatal Epidemiology 1997, 11(Suppl 1): 48-62.

Klerman, L. V.; S.P. Cliver; R.L. Goldenberg. The impact of short interpregnancy intervals on pregnancy outcomes in a low-income population. American Journal of Public Health 1998, 88, 1182-1185.

Rawlings, J. S., V. B. Rawlings and J. A. Read. "Prevalence of low birth weight and preterm delivery in relation to the interval between pregnancies among white and black women." NEJM 1995, 332: 69-74.

Goldenberg, R. L. and D. J. Rouse. "Prevention of premature birth." New England Journal of Medicine 1998, 339(5): 313-20.

Adams, M. M., L. D. Elam-Evans, H. G. Wilson and D. A. Gilbertz. "Rates of and factors associated with recurrence of preterm delivery." JAMA 2000, 283(12): 1591-6.

References: