Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003

Preterm Delivery Initiative

CAROL BRADY: I think this presentation is going to be a good reinforcement of some of the information that was presented in the opening plenary.  So we are going to be kind of booked and so I hope you think about that as I present this information today.  Just little bit of background on where the Magnolia Project came from.  Our beginnings were actually, and rather innocuous analysis that was done by our office of vital statistics.  And several years ago, looking at three-year rates for the 67 counties in Florida, comparing them to the overall state rates.  I mean this is a really simple analysis and actually do all county Jacksonville was sited in this study as one of the three counties in the state that had a significantly higher infant mortality rate.  As many of we may know of Florida has been fortunate for the last 10 years to have a Statewide Healthy Start Initiative that included the development of community coalitions.  And when I presented this information to our coalition, basically, their hair lit on fire. 

I mean our responsibility was to address infant mortality in our area and here we were in this publication, you know were sited as one of three counties in the state, so basically they said, okay find out what is going on and what the heck we do about it.  When we did our first preliminary analysis of that information, it was fairly clear that if we are going to impact infant mortality overall in Jacksonville, we are going to have to address racial disparities.  Most of you think of Florida as Disney World or Miami.  We are the other Florida, we are actually closer in location to Georgia and the population characteristics than we are to Orlando or Miami.  We have among the urban communities in this state, the largest proportion of our childbearing population that is African-American.  And unfortunately at that time, outcomes in our African-American population were poor than outcomes in the African-American population statewide.  So why will woman care?  Well, again as it was mentioned in the plenary session this morning, we use the perinatal periods of risk to look at the differences in outcomes between Blacks and Whites in our community. 

And what we found was the greatest racial disparities occurred in that cell having to do with the care or the health prior to pregnancy.  PPOR, I think was alluded to this morning and I am not going to present the map it is familiar I think to many of us, but essentially it looks that divide your rate between four different periods of risks prior to pregnancy, during pregnancy, at birth, and post discharge.  The interesting thing in our community is that we had two of the four cells where there were no racial disparities and that set a whole dialog about how we change our approach.  There are several phases to PPOR and when we looked at again some of the more detailed information about birth weight survival versus birth weight distribution, what we found is that again in our community, too many Black babies were being born too small and too soon.  And that was the contributing factor to our overall high infant mortality rate.  And we also have had a FIMR project and were able to link FIMR with our PPOR findings that actually looked at what was going on in our community.

This is really at the urging of our state epidemiologist, who said okay you know now what’s going on in PPOR, you take the closure look at the actual deaths in your community based on your FIMR findings that set the criteria for that maternal health.  So we had about a sort of the deaths, that we had reviewed that actually set the maternal health.  So and this is what we found, again it reinforces what PPOR told us we are going to find.  These are the most frequent contributing factors cited in out FIMR reviews.  General health of mother, preterm labor, maternal infections other than STDs, premature rupture of membranes, history of a previous fetal or infant loss.  There is a couple having to do with birth defects and infection in babies, substance abuse, and family planning’s issues.  We quickly move from data to action, and actually use the findings from PPOR and FIMR to respond to a Federal Healthy Start RFP that was issued in 1999.  It was the first RFP to try to address racial disparities in birth outcomes. 

And what we proposed, again based on the data, and what was happening in our community, was that if we are going to address racial disparities in Jacksonville, we are going to have to do something with women when they were not pregnant, prior to pregnancy.  And that is where the Magnolia Project came from.  We were funded.  Thank you very much Dr. Van Dyck, twice.  And the area that’s being addressed by the Magnolia Project is a community Jacksonville, largely African-American that at time it started accounted for more than half of the Black infant mortality in the city, and about 30% of the Black births.  We operate out of the storefront side.  We use a collaborative model, which means we have no staff ourselves as the coalition.  We actually subcontract out for people with expertise in that area to provide the services.  We actually have staff from three agencies including our local health department that are collocated at this site, as well as other community agencies.  This is the staff, I get to go around and talk about it.  They are back home doing all the work so recognize them. 

What essentially we have done in the Magnolia Project is to take four Healthy Start models that we really developed at the four of the at-risk pregnant population, and apply them to a population that is at risk, but not pregnant.  And if they were pregnant tomorrow would be eligible for Healthy Start and everything that we do to women now during their pregnancy.  We have added some editions in our recent grant application to enrich this.  We were doing enhanced clinical care essentially, Well-Women Care, the most interesting and I think innovative part is the case management piece, that is integrated with risk reduction, outreach, and of course community development, which is important part of all Healthy Start Grants.  So, who are we serving, our average age of our clients is right under 25 years predominantly, single, Black, 40% they have a less than a high school education.  These are not teenagers. 

There are women, who should have high school education.  Again, the interesting thing for us except not very surprising is that 90% of the women that we are serving are uninsured, if they became pregnant tomorrow they will be covered by Medicaid, they will be eligible for Healthy Start in these services.  I am going to show you information about what we were finding with our case management because again I think that is probably the most innovative peace that we were working with.  Most of the risk factors that we are dealing with, with case management, and we do case management on a high-risk subset of the women that we serve or who are referred to us by other agencies.  About the sort of the risk or medical risk 2/3rds are social, the duration of our current participants more than half or our participants have actually been in case management services for over a year. 

And for those of us, who are involved in programs during pregnancy, a year engagement of a nonpregnant woman is pretty impressive.  So this is obviously a model that you can keep women engaged in.  Looking at the services that we provided through case management last year, we served 100 women.  The average length of participation was 464 days, about 60% of them came to our clinic, the other 40% were referred by community agencies.  We do a risk profile on them and our case management clients at the time of entry into the program had an average of 15 recipes and these were definitely at risk women and this summarizes the type of risk we were looking at.  Family planning issues that means they were sexually active, not regularly using birth control methods at all, and had no intentions of getting pregnant.  That’s a fairly really significant issue.  But, then you look at some of the social issues, education issues, job issues, and medical issues like PV and repeated STDs.  We are in the process of tracking and designing in of a longitudinal evaluation for the women who have completed case management.  We closed 30 and a little over 30 in 2002.  About 45% were in case management for over a year.  We had a high completion rate for our referrals and again something that’s I think most enlightening is that, we were actually able to resolve almost 90% of risk that they presented with at the beginning of case management.  Obviously, our challenge is to try to demonstrate that by resolving these risks, we have positively inherited the outcome of their next pregnancy whenever that should occur, and we were in the process of designing or trying to get funding for that longitudinal evaluation now.  We have had some success in reducing our infant mortality rates both in the target areas and in Jacksonville as a whole. 

They are in 2002 at their lowest rate that they have been in five years.  We are not so foolish as to say this is all due to the Magnolia Project, but we certainly think that the project has contributed to some of the positive trends that were seeing.  And particularly with the community development piece, has brought the whole issue of infant mortality on the radar of that community.  We have really brought a lot of different programs and resources that I think cumulatively have contributed to this improvement.  My words of encouragement is that in terms of impacting, the potential for impacting women’s health before pregnancy and the potential that it holds for impacting prematurity is important that we change our thinking I think about pregnancies.  Because nearly half of all pregnancies in fact in this country are unplanned meaning that they have miss timed or unwanted.  Therefore, I mean those lot of women in this room who are pre or interconceptional.  Any women at any time should, who fits the age category of 15 to 44 or be considered pre or interconceptional.  And in terms of actually developing services around women’s health, I think one of the most important things that we can do, is to look around now at opportunities or missed opportunities that we have for addressing pre or interconceptional issues, short of starting a Magnolia Project.  There are things that we can do tomorrow within the programs that we have to actually improve interconceptional health. 

Most obvious is family planning with pediatrics.  I mean again we have an interconceptional women standing there getting her child the Well-Baby check.  Now however, we are taking the advantage of that and the potential for actually using a case management model on an at-risk population, who is not pregnant.  In conclusion, I just think that again to reinforce what we stated in the opening plenary, there maybe a value, an important value, we have to show that of expanding our focus on how we impact with outcomes beyond just the nine months of pregnancy.  And there are certainly opportunities within our current system of care to implement some of these changes assured of a whole new initiative.  Thank you.