AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
BETSY WOOD: Good morning. I want to tell you a little bit about a story that I think we’re all very, very familiar with. When you see indicators that pile on and pile on and you recognize that there are new, a new initiative or a new twist that you need to implement, you go to the legislature and you get turned down and there’s no money. The indicators and the evidence continues to pile on and pile on and so what do you do to begin to work within existing resources to develop interconceptional services, which is what I want to talk about.
First I want to set the stage and talk to you a little bit about Florida’s data. Our first trimester entry into prenatal care decreased. It was actually increasing and in 2003 we were at 85.5 and we were really thinking that we would be able to reach the Healthy People 2010 goal of 90 percent. However, we began to decrease a little bit. We went down to 81 percent into entry into prenatal care. The hurricanes may have had something to do with that.
Our Healthy Start Prenatal Screening right, we have a universal prenatal screen to identify women at risk for poor birth outcomes. And for the last couple of years we’ve really put a lot of effort into increasing the percentage of women that are being screened for Healthy Start and we’re happy to say that it has been increasing. It’s up now to 66.5 percent of women. Our infant mortality rate had been going down in the ‘90’s, then in 2000 it began to inch back upwards. It inched, it was going up for about four years. And I’m happy to say in 2004 it went back down to the lowest amount ever which is 7.0 per thousand live births, but that’s 2004. We’ll see how it goes next year.
We have a pregnancy associated mortality review, which is Florida’s maternal mortality review. It began in 1996 and it’s based on the national femur model, which analyzes gaps in maternal health systems and talks about what may contribute to maternal mortality.
Our Pammer findings were interesting. It showed that two thirds of our women had a history of chronic illness or disease or condition and many had multiple chronic illnesses including asthma, diabetes, and epilepsy but obesity and hypertension were the most prevalent. We showed higher mortality rates for women, three point, for black women, 3.3 times greater risk of maternal death for women over 35 than those at age 19. And we showed that overweight and obese women carried between a two and five times greater risk than women of normal age, I mean normal weight. And this shows the risk by obesity categories with obese three, which is the highest BMI at greater than 40. They carried over five times the risk of normal weight women. I also want to point out that the underweight women, those with a BMI or less than 18.4 were 2.5 times more likely to die than women of normal weight.
I’m not a statistician so I’m going to read that. You’re very familiar with the perinatal periods of risk, but just as an overview. That is a method of analysis that looks at fetal and infant mortality cases where the fetus is over 34 weeks gestation and weighs more than 500 grams at delivery. And it categorizes the causes according to the age at death and the weight at delivery. From the group, we create a reference group of all fetuses that are delivered to mothers who are white, above the age of 20, and have at least a 12th grade education. And then we compare that reference group to the remaining cases and we analyze the gaps. Well, sure enough, as with many, many other places, Florida’s PPOR data showed the largest opportunity for intervention lies in the area of maternal health.
Our fetal and infant mortality review, which is located in 12 areas around the state, also supported these findings. It showed that as a trend, family planning, nutrition, access to care, and the prevention and treatment of maternal infections were major issues that Florida needed to address. So, we want to talk about recommendation number eight in the draft, which is infusing and integrating components or preconception health into existing local Public Health.
We have a wonderful Healthy Start program. It’s a state Healthy Start program where we have 32 coalitions that actually do needs assessment and actually develop the local systems of Maternal and Child Health. Coalitions are very strong maternal and child health advocates and they’re very dynamic. And we had, a couple of years ago we had two or three coalition executive directors come to the State Health office and say, “Look at PPOR. Look at our FEMA. Look at our data. We really need to focus on interconception care.” So together we developed a chapter in our Healthy Start Standards and Guidelines. This is the framework under which our Healthy Start program works. It allows local initiative and local freedom to develop programs within this, the framework that we develop. So we addressed interconception care in a new chapter 21.
What we did is develop guideline that included 10 topic areas to focus on, providing the client with information and resources to correct or mitigate existing risk factors. We developed a training to describe each of these areas and it can be found on that website that’s noted at the bottom. And again, because of our Healthy Start, the concept of the way we hold our programs, we developed these 10 topic areas but the coalitions then went and developed actual training and education courses. There are at least five different courses in the state that are all excellent and all have these core basic elements.
Some of the key components in our training that we developed. Because Florida embraces many nationalities and many cultures, we emphasize assuring that the education is presented in a culturally and educationally competent manner. As often as possible we try to provide the education in the client’s native language or through a qualified interpreter. We are very careful about the education literacy level that’s, that the education is provided. We encourage providers to be creative in how they provide the services. Education can be done on a one on one setting, at a home visit, in support groups, in a formal education setting, or it may be provided through community locations such as clinics, churches, libraries, schools, or in the other community settings.
Our target audience for these interconceptional chapter was women with a previous poor outcome and women with a behavioral or environmental issues that continue to contribute to poor outcomes unless they’re resolved.
We have a system of coding. One of the things that our coalition said was, “You’ve got to give us credit for providing these services.” And so we developed new coding schemes and coding mechanisms so that the coalitions and the Healthy Start program could indeed take credit for these services. We also thought about changing the statute because our Healthy Start program is in Florida statute and we thought about opening it and changing it and changing the definition so that we could provide interconceptional services but that was not, we decided not to do that. So instead we changed our rule to define periconceptional as pregnancy through two years postpartum so we can provide those services to women and their families up to two years after delivery.
We provide interconceptional education in a variety of venues as are listed here. Some of them are venues that we are exploring. Most of them are venues that we’re already doing right now. We also have looked at preconceptional. We targeted interconceptional first because we had, we had identified those women at risk for poor birth outcomes and poor subsequent birth outcomes. It was a little bit harder to target women because we in the Public Health System may not have touched them initially.
So this is a wider audience, our preconceptional education initiative, but the topics are the same. And it was like serendipity. It was really neat, because the March of Dimes came to the Department of Health about two years ago and they had gotten, they were awarded a vita grant, a multi vitamin settlement for two million dollars over three years to distribute multi vitamins with folic acid. And they asked if they could use the Public Health System and put a person in the Department of Health to oversee that project. And we said, “What a great idea, but let’s talk about broadening the topics that this person deals with.” So now we got a person to spearhead our interconception and preconception initiative through this March of Dimes vita grant program. In addition we have a goal of supplying 450 thousand batches of multi vitamins with folic acid to non-pregnant women of childbearing age. To date we have 182 different sites including family planning clinics, WIC clinics, Healthy Start programs, local HIV programs, Healthy Families, Early Head Start and Head Start, community health centers, faith based organizations and other for profit and non-for profit providers that are serving the target population.
So along with the vitamins, we developed a brochure for non-pregnant women talking about the need for a multi vitamin with folic acid but also talking about other health habits. And the brochure was developed and a corresponding training, which included information on access to healthcare and chronic health conditions and mental concerns, environmental health issues, exercise, baby spacing, infections, and immunizations. So our staff that the vita grant funds, which are five part time staff that are gathered, that are scattered around the state provide this brochure, the vitamins, as well as the information.
We also used a media campaign and developed it including the statewide distribution of what’s called Next magazine, which went into 750,000 high school students and 1200 school administrators, and that’s the ad for, that we distributed last fall.
Within our Health Departments, our county Health Departments, we developed what we call technical assistance guidelines. And again, it is the, it includes the components of educational topics that need to be included in any setting in which a woman comes and gets care, a woman of childbearing age comes and gets care in the Health Departments.
We also have opportunities at our primary care clinics and our school health programs and our STD and HIV clinics as well as other areas. And these technical assistance guidelines are for use for all the Department of Health staff. Some of our next steps, and again think infuse, infuse, infuse.
Our children’s medical services, is our Children with Special Healthcare Needs Program in the state of Florida and they provide care coordination and ongoing services to many NICU graduates and their families. So we’re providing preconceptional brochures, resource lists, and information sheets to this Children’s Medical Services and our Early Steps, which is our early intervention program for distribution at their statewide meeting. We’ll be providing an hour and a half in service on interconceptional topics to CMS providers including physicians, therapists, nurses, mental health providers, and others. And we use the slides that are posted on the website that I gave you earlier. And once a quarter we do a two-hour, I guess you call it a webinar. We call it a web-enhanced conference call. And we’ve specifically invited our Early Steps and our Children’s Medical Services colleagues to sit in on that training in March.
In school health we’ve provided preconceptional brochures and we’re going to be providing a 30-minute in service on the school health meet me call. Again no funds, we’re trying to reach out to where our sister and brother programs are and provide the same training kind of across the board to whomever we can reach out to and will accept this service. Our doulas, we’re going to be providing a training for a local doula program for both birth and postpartum doulas and again, the focus is to be able to reinforce the interconceptional issues and messages and be able to identify what they are as they interact with their clients.
WIC and breastfeeding support professionals. We’re going to provide training for these groups as well and include them, invite them to our interconceptional education and counseling webinar. And these next two initiatives are beginning. We’ve contacted community colleges and university health centers to distribute the preconceptional brochures and we want to start a stick campaign, which would be placing a sticker reminding women to take folic acid on all of the birth control packs that they distribute in the participating community colleges and universities.
Again, the common thread, infusing and integrating components of pre and interconception education into existing programs using uniform training so we’re giving the same message and all within existing resources. Thank you.