The Interpregnancy Care Program The Feasibility and Impact of Delivering Interpregnancy Care to Mothers of Very-low-b

1. The Interpregnancy Care Program The Feasibility and Impact of Delivering Interpregnancy Care to Mothers of Very-low-birthweight Infants at Grady Memorial Hospital Good Afternoon. My name is Anne Dunlop and I am part of the Interpregnancy Care Program of Grady Memorial Hospital, here in Atlanta. We have performed a study of the feasibility and impact of delivering interpregnancy care to mothers of VLBW infants at GMH. Good Afternoon. My name is Anne Dunlop and I am part of the Interpregnancy Care Program of Grady Memorial Hospital, here in Atlanta. We have performed a study of the feasibility and impact of delivering interpregnancy care to mothers of VLBW infants at GMH.

2. 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. In the field of MCH, specific observations provide justification for our study purpose and design. First, despite an observed 50% decline in infant mortality in the state of Georgia from 1975 – 1996, Georgia still ranks among the “top ten” states for infant mortality. Second, the largest contributor to infant mortality in Georgia is the birth of LBW, and particularly VLBW, infants who account for 70% and 50% of all infant deaths, respectively, yet only 11% and 2% of births. Third, African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality. In the field of MCH, specific observations provide justification for our study purpose and design. First, despite an observed 50% decline in infant mortality in the state of Georgia from 1975 – 1996, Georgia still ranks among the “top ten” states for infant mortality. Second, the largest contributor to infant mortality in Georgia is the birth of LBW, and particularly VLBW, infants who account for 70% and 50% of all infant deaths, respectively, yet only 11% and 2% of births. Third, African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality.

3. 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. In the field of MCH, specific observations provide justification for our study purpose and design. First, despite an observed 50% decline in infant mortality in the state of Georgia from 1975 – 1996, Georgia still ranks among the “top ten” states for infant mortality. Second, the largest contributor to infant mortality in Georgia is the birth of LBW, and particularly VLBW, infants who account for 70% and 50% of all infant deaths, respectively, yet only 11% and 2% of births. Third, African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality. In the field of MCH, specific observations provide justification for our study purpose and design. First, despite an observed 50% decline in infant mortality in the state of Georgia from 1975 – 1996, Georgia still ranks among the “top ten” states for infant mortality. Second, the largest contributor to infant mortality in Georgia is the birth of LBW, and particularly VLBW, infants who account for 70% and 50% of all infant deaths, respectively, yet only 11% and 2% of births. Third, African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality.

4. 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. In the field of MCH, specific observations provide justification for our study purpose and design. First, despite an observed 50% decline in infant mortality in the state of Georgia from 1975 – 1996, Georgia still ranks among the “top ten” states for infant mortality. Second, the largest contributor to infant mortality in Georgia is the birth of LBW, and particularly VLBW, infants who account for 70% and 50% of all infant deaths, respectively, yet only 11% and 2% of births. Third, African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality. In the field of MCH, specific observations provide justification for our study purpose and design. First, despite an observed 50% decline in infant mortality in the state of Georgia from 1975 – 1996, Georgia still ranks among the “top ten” states for infant mortality. Second, the largest contributor to infant mortality in Georgia is the birth of LBW, and particularly VLBW, infants who account for 70% and 50% of all infant deaths, respectively, yet only 11% and 2% of births. Third, African-American women in Georgia have twice the rate of LBW and 3-4 times the rate of VLBW delivery compared to Caucasian women, resulting in twice the rate of infant mortality.

5. 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. Considering this background information, we developed a program with the purpose of evaluating the effect of IPC toward improving subsequent reproductive outcomes for women who have demonstrated their high-risk status by virtue of having delivered a VLBW infant by improving the health of participating women through identification and management of her identified medical, dental, and social risks and by assisting her to develop and achieve her reproductive goals. Considering this background information, we developed a program with the purpose of evaluating the effect of IPC toward improving subsequent reproductive outcomes for women who have demonstrated their high-risk status by virtue of having delivered a VLBW infant by improving the health of participating women through identification and management of her identified medical, dental, and social risks and by assisting her to develop and achieve her reproductive goals.

6. 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. Implementation of the IPC program at Grady has involved the enrollment of women who deliver VLBW infants at GMH during their delivery hospitalization and providing them with 24 months of …. To date, we have completed the feasibility phase of the IPC program and have enrolled 30 and followed 30 participants since November, 2003.Implementation of the IPC program at Grady has involved the enrollment of women who deliver VLBW infants at GMH during their delivery hospitalization and providing them with 24 months of …. To date, we have completed the feasibility phase of the IPC program and have enrolled 30 and followed 30 participants since November, 2003.

7. 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.

8. 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.

9. 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).

10. 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.

11. 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.

12. 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.

13. Results: Birth Spacing Impact Attainment of at least 9-month interpregnancy interval: Grady IPC Cohort Grady Historical Cohort p-value* 29/29 (100%) 40/58 (69%) 0.0002 Attainment of at least 18-month interpregnancy interval: Grady IPC Cohort Grady Historical Cohort p-value** 24/29 (82.8%) 18/58 (31%) 0.0026 **p-value for Fisher’s exact test; intention-to-treat analysis.

14. 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).

15. 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). We have learned at least 4 important lessons about the content of IPC for high-risk women and those are the following. One, that there is a relatively high prevalence…. Two, that reproductive tract infections, ….We have learned at least 4 important lessons about the content of IPC for high-risk women and those are the following. One, that there is a relatively high prevalence…. Two, that reproductive tract infections, ….

16. 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. To date, we are able to conclude that the major impacts of IPC for high-risk women seem to be the following: First, IPC has assisted women in developing and achieving a stated reproductive plan. Second, IPC has improved participating women’s achievement of desirable interpregnancy intervals. Third, IPC has decreased occurrence of adverse birth outcomes.To date, we are able to conclude that the major impacts of IPC for high-risk women seem to be the following: First, IPC has assisted women in developing and achieving a stated reproductive plan. Second, IPC has improved participating women’s achievement of desirable interpregnancy intervals. Third, IPC has decreased occurrence of adverse birth outcomes.

17. 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.