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Melanie Lutenbacher, PhD, MSN, APRN, FAAN Infant Mortality Best Practices Forum August 31, 2011 Tennessee Connections for Better Birth Outcomes: Working to Improve Maternal and Infant Health

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Infant Mortality complex phenomenon societal issues lifestyle choices biological factors indicator of overall maternal/child health

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The Company We Keep Infant Mortality Rates

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Why Do Our Babies Die? congenital malformations & chromosomal abnormalities short gestation and low birth weight sudden infant death (SIDS) newborn affected by maternal complications of pregnancy unintentional injuries Source: National Vital Statistics Report 2006

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Acute Morbidity by Gestational Age Among Surviving Infants Mercer BM Obstet Gynecol 2003;101:178 93. Results of a community-based evaluation of 8523 deliveries, 19971998, Shelby County, Tennessee

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Escalating Hospital Costs with Decreasing Gestational Age (Phibbs and Schmitt, 2006 Journal of Early Human Development)

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One Premature Birth Significantly Increases the Likelihood for Recurrence Adams, 2000

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Approaching the Problem

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Best Practices system of providing high quality care meets the needs of patients and, is cost effective Evidence Based Practice best available evidence, moderated by patient circumstances and preferences, applied to improve the quality of clinical judgments and, facilitate cost-effective care Translational Research transforms scientific discoveries arising from laboratory, clinical, or population studies into clinical applications to reduce morbidity and mortality

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Synergistic Relationships Science Best Practice Evidence Based Translational Research

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Preterm Birth Prevention we dont have all the answers BUT, we know some of the factors that contribute to preterm births ANDwe have some promising interventions.

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Modify Maternal Risk Factors Adequate health coverage Available resources Multiple methods of service delivery *clinic *group *texting *home visit *telephone *internet Pre-conception / inter-conception care Early prenatal care Enhanced support through pregnancy System of Care Stress Infections Domestic violence Smoking Substance abuse Nutrition Dental Health Interpregnancy intervals PTB Infant Mortality

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Tennessee Connections for Better Birth Outcomes Funded by BCBS TN Health Foundation With support from: VU Clinical Translational Science Award grant UL1 RR024975-01 from NCRR/NIH VU School of Nursing Center for Research Development and Scholarship Translated existing evidence into interventions Targeted modifiable risk factors in pregnant women With history of at least one preterm birth

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Melanie Lutenbacher, PhD, MSN, APRN, FAAN * Patricia Temple Gabbe, MD, MPH, Pediatrician *+ William F. Walsh, MD, Neonatologist Etoi Garrison, MD, High Risk Obstetrician Lavenia Carpenter, MD, High Risk Obstetrician Mary S. Dietrich, PhD, Biostatistician * Sharon Karp, PhD, MSN, CPNP * Deborah Narrigan, MSN, CNM Jennifer Murray, PhD (c) * Appointments at Vanderbilt University Schools of Nursing and Medicine *+ Appointment at Ohio State University Schools of Nursing and Medicine BBO Research Team

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Study Goals improve maternal health in women with a history of at least one prior PTB via evaluation of the feasibility and efficacy of a system of care to reduce preterm births & the associated health care costs

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Pregnant Women with Prior Preterm Birth Conventional Prenatal & Postpartum Care (Control) BBO System of Care (Intervention) Observational Group (decline main study) BBO Study Design Random Assignment

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Who could participate? Confirmed pregnancy 18 40 years of age History of preterm birth (Live birth > 20wks and

BBO Birth Outcomes Control (N=102) Intervention ( N=109) Term birth (> 37 weeks)69 (67.6%)75 (68.8%) Gestational age (weeks) Median=38 wk, 0 day (Min=25wk, 0 day) (Max=42wk, 1 day) Median=38 wk, 1 day (Min=23wk, 5 days) (Max=41wk, 5 days) Change in gestational age from index birth (weeks) Median=3 wk, 5 daysMedian=4 wk, 2 days Birth weight (grams) Median=3131 (Min=435, Max=4876) Median=3071 (Min=405, Max=4440)

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Disposition of Infant

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Maternal Length of Stay for Delivery

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Key Risk Factors Assessed # prior PTBs African American race pregravid BMI smoked reported domestic violence # medical conditions # prenatal hospitalizations Level of: depressive symptoms maternal stressors social support sense of personal mastery & control

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Women with Similar Clusters of Risk Factors exploratory method of classifying cases on multiple dimensions helpful for seeing patterns in complex data generates groups of cases with similar patterns or characteristics into a cluster separates groups with discrepant or inconsistent patterns defined groups can be used for further analyses

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BBO Gestational Age by Risk Cluster (N = 188) Cluster

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Cluster 1 (N = 30) Cluster Compared to other clusters: Lowest % smoke Healthy, normal BMI Lowest in stress & depressive symptoms Higher sense of personal control

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Cluster Compared to other clusters: Higher % African American Overweight Have more medical conditions including prenatal hospitalization Higher stress, depressive symptoms, reports of DV Cluster 2 (N = 59)

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Cluster Compared to other clusters: Healthy, normal BMI Lower stress & depressive symptoms Lower sense of personal control Cluster 3 (N = 33)

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Cluster Compared to other clusters: Higher % smoke Normal BMI; healthy > number prior preterm births High social support and sense of personal control Cluster 4 (N = 36)

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Cluster Compared to other clusters: Normal to low BMI Higher stress & depressive symptoms levels Higher social support and sense of personal control Cluster 5 (N = 30)

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Depressive Symptoms At study enrollment, 28% of women had high depressive symptoms At 48 hours postpartum, after controlling for baseline depressive symptoms: women in the intervention group had a greater reduction in depressive symptoms than those in the control group

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In Her Own Words

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Where Do We Go From Here? further examine women with specific clusters of risk factors examine these clusters in relation to amount and focus of home visits share lessons learned refine intervention, study materials, and design test

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remember - prevention of infant mortality begins long before the baby arrives educate yourself, family members, friends & co-workers about risk factors for preterm birth use evidence to guide your efforts to promote healthy behaviors support adequate health care coverage & access get involved with efforts to prevent preterm births What Can You Do?

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Tennessee Connections for Better Birth Outcomes Funded by