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The Interpregnancy Care Program

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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. July 20, 2006

2 Background Georgia’s infant mortality declined by 50% from 1975 to 1996, primarily due to improved survival of low birth weight (LBW; < 2500 gm) infants, but Georgia still ranks among the 10 states with the highest infant mortality rates; The largest contributor to Georgia’s infant mortality rate is the birth of LBW and VLBW (< 1500 gm) infants: % of Births % of Infant Deaths < 2500 g 11% 70% < 1500 g 2% 50% 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 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 (1). Survival of VLBW infants has significantly improved in the last 25 years, but the prevalence of cerebral palsy has not changed.

4 Background Experience and a growing body of evidence link the delivery of a VLBW infant to aspects of a woman's health status, including (1): Unrecognized and poorly-controlled medical problems; Reproductive tract infections (including BV and STI’s); Substance abuse disorders; Periodontal disease; Psychosocial factors including psychological stress and domestic violence. Short interpregnancy intervals increase the risk of preterm/LBW delivery (2), particularly among low-income, African-American women (3), with the critical interval varying by race: 9 months for African-American and 3 months for white women (4). Additionally, growing evidence links the delivery of a VLBW infant to aspects of a woman’s health status, including…and short intervals between pregnancies increases the risk of preterm and LBW delivery. This is especially true for low-income, African-American women. Interestingly, the duration of the critical interval varying according to race with a 9 month interval being important to avoid increased risk of LBW delivery among Af-Amer women while just a 3 month interval is required to avoid increased risk for White women.

5 Goals 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 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.

6 Eligibility Criteria for IPC
African-American woman; Resident of Fulton or Dekalb County; Eligible for indigent care through Grady Health System; Delivery of a VLBW infant (stillborn or liveborn) at Grady Memorial Hospital during the enrollment period. 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.

7 Number of Live Births less than 1500 gm. by Census Tract
Georgia and Public Health Districts

8 IPC Intervention Package
For all enrolled women: Definition of an individualized IPC plan focusing on management of chronic diseases as well as 6 other areas epidemiologically-linked to LBW delivery: family planning & birth-spacing, reproductive tract infections, periodontal disease, appropriate nutrition & supplementation, substance abuse, and social stressors; Provision of primary health care and dental services in accordance with the individualized IPC plan for 24 months; Assistance in achieving intendedness and spacing (ideally 18 months) of subsequent pregnancies; Community outreach via a trained Resource Mother and nurse case manager.

9 Provision of IPC Contact with a multidisciplinary team, including a nurse-midwife, family physician, periodontist, nurse case manager, social worker, and Resource Mother; Primary care visits begin within 2 months of the VLBW delivery and then every 1 -3 months (dependent upon extent of health problems): Principally in a group setting with integration of group educational experiences modeled on the Centering Pregnancy Model for delivery of prenatal care; Home visits and telephone contact by the Resource Mother monthly to address psychosocial issues.

10 Evaluation of IPC Program
Comparison of the health status of enrolled women pre- and post-participation in IPC in terms of the prevalence of conditions linked to LBW delivery; Comparison of the proportion of enrolled women who achieve desirable and optimal interpregnancy intervals to that of a historical control cohort; Comparison of the birth outcomes, birth weight distributions, and morbidity and mortality experience (prior to hospital discharge) of subsequent births to enrolled women to those of a historical control cohort; Determination of the feasibility, acceptability, and cost-benefit of delivering IPC to women at risk of repeat VLBW delivery in the setting of a county-supported, public hospital. The evaluation of the IPC program will involve …

11 IPC: Participant Selection
47 consecutive women delivered VLBW infants during the enrollment period: 9 not offered enrollment because not African-American; 38 otherwise eligible did not enroll: 4 declined to sign permission-to-contact; 2 unable to be contacted after discharge; 1 moved out of town; 2 (with stillborn infants) left hospital prior to notification of nurse case manager. 29 women ultimately recruited and enrolled into the pilot phase of the IPC intervention cohort. A higher proportion of eligible women who refused enrollment in IPC had no documented prenatal care (66%) in comparison with 20.7% of women enrolled in IPC (p-value for Fisher’s exact test = 0.016), and a higher proportion of delivered infants were stillborn (40%) in comparison with 10.8% of delivered infants in the IPC intervention group (p-value for Fisher’s exact test = 0.038). They did not differ from IPC participants on age, tobacco or substance abuse, chronic disease status, marital status, primiparity status, or birthweight.

12 Comparison Group: An Historical Cohort from GMH
A comparison group constructed from 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. In addition to these descriptive analyses, we have made some comparative analyses with a historical control group constructed …

13 Demographic Description Prior to Index VLBW Delivery
Characteristic IPC Intervention Cohort (n = 29) Historical Control Cohort (n = 58) Age: Teenagers (< 20 years) Women age 20 – 35 yrs Women age ≥ 35 yrs Gravidity Range Median Parity Primiparous Prior preterm delivery Prior term delivery Prior spontaneous ab 7/29 (24.1%) 18/29 (62.1%) 4/29 (13.8%) 1-13 pregnancies 2 pregnancies 15/29 (51.7%)* 12/29 (41.4%) 15/29 (51.7%) 12/58 (20.7%) 43/58 (74.1%)) 3/58 (5.2%) 1-8 pregnancies 14/58 (24.1%)* 19/58 (32.8%) 36/58 (62.1%) 30/58 (51.7%) * p-value for Fisher’s exact test =

14 Description of Birthed Index VLBW Infants
Characteristic IPC Intervention Cohort Historical Control Cohort Birth weight Multiple gestation Stillborn 944 g ( ) 7/29 women (24.1%)* 4/37 infants (10.8%) 3/4 (75%) macerated 1023 g ( ) 3/58 women (5.2%)* 4/61 infants (4.9%) * p-value for Fisher’s exact test =

15 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 single visit); 3 become lost to follow-up (2 prior to 1st iPC visit; 1 after single visit). During Second 12 months of IPC Program: 16/29 (55.2%) 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.

16 Impact of IPC: Chronic Health Outcomes
Health status of 7 women with chronic disease before and since enrollment: Valvular heart disease; hepatitis C  Valve replacement surgery, on-going evaluation by infectious disease; Sickle cell disease, severe anemia with non-compliance  Compliance with daily multivitamin and folic acid; Hypertension, Diabetes, Asthma with non-compliance  Improved compliance with simplified medication regimen; SLE, Hypertension, Renal insufficiency  Improved blood pressure control, re-established link with rheumatology clinic; Pituitary tumor (prolactinoma)  Planned surgical resection; Cardiac arrhythmias, panic attacks  Medical management; Generalized anxiety disorder, depression, multi-substance abuse  patient lost to follow-up. Regarding the impact of the IPC program, we have identified 7 women with previously unrecognized and/or poorly managed significant chronic diseases.

17 Impact of IPC: Other Health Outcomes
During the interpregnancy period: 15 of 21 women diagnosed and treated for reproductive tract infections; 5 of 21 women diagnosed and treated iron-deficiency anemia; 7 of 15 women fully evaluated and treated for oral infections and periodontal disease; 8 of 21 women screened positive for post-partum depression and linked to appropriate psychiatric evaluation and psychological support services.

18 Impact of IPC: Substance Abuse Outcomes
12 of 29 participants with substance abuse problems: Tobacco alone – 3 (1 has quit) Tobacco, alcohol – 1 (reduced alcohol; uses tobacco) Street drugs, tobacco, alcohol – 8 (3 lost to follow-up, 3 completed outpatient rehab, 2 completed residential rehab)

19 Impact of IPC: Birth Planning
Reproductive plans development: 21/21 women stated a reproductive plan for themselves. Reproductive plans attainment: 21/21 women provided with a contraceptive method of their choosing.

20 Impact of IPC: Conception within 9-months
Outcome IPC Intervention Cohort GMH Historical Cohort Proportion of women who conceived ≥ 1 pregnancy within 9-mo of index VLBW delivery 0/29 (0%)* 18/58 (31%)* * p-value for Fisher’s exact test =

21 Impact of IPC: Conception within 18-months
Outcome IPC Intervention Cohort GMH Historical Cohort Proportion of women who conceived ≥ 1 pregnancy within 18-mo of index VLBW delivery 5/29 (17.3%)* 29/58 (50%)* * p-value for Fisher’s exact test =

22 Impact of IPC: No. pregnancies within 18-months
No. of pregnancies IPC Intervention Cohort n = 29 GMH Historical Cohort n = 58 24 29 1 3 22 2 7 Average per woman 0.241* 0.621* * A 61.2% reduction in the average no. of pregnancies within 18-months for women in the IPC cohort; p-value (Poisson regression) = Conclusion: Women in the historical cohort had 2.57 (95% CI: 1.14 – 5.78) times as many pregnancies within 18-months of the index VLBW delivery as women in the IPC cohort, on average.

23 Impact of IPC: Subsequent pregnancy outcomes
IPC Intervention Cohort: 7 pregnancies within 18 months GMH Historical Cohort: 36 pregnancies within 18 months 3/7 (42.8%) with adverse outcome: - 1 liveborn, intermed. LBW ( g); - 2 spontaneous abortions (< 20 wks’). 3/7 (42.8%) liveborn, ≥ 2500 g; 1/7 (14.3%) electively aborted. 21/36 (58.3%) with adverse outcomes: - 7 liveborn, intermed. LBW ( g); - 3 liveborn, VLBW (< 1500 g); - 4 stillborns; - 3 ectopic pregnancies; - 3 spontaneous abortions (< 20 wks’); - 1 molar pregnancy. 8/36 (22.2%) liveborn, ≥ 2500 g; 6/36 (16.7%) electively aborted; 1/36 (2.7%) unknown outcome (delivered outside GMH).

24 Impact of IPC: No. adverse pregnancy outcomes
No. adverse outcomes IPC Intervention Cohort n = 29 GMH Historical Cohort n = 58 27 41 1 13 2 4 Average per woman 0.103* 0.362* * A 71.5% reduction in the average no. of adverse outcomes of pregnancies for women in the IPC cohort; p-value (Poisson regression) = Conclusion: Women in the historical cohort had 3.51 (95% CI: 1.04 – 11.73) times as many adverse pregnancy outcomes for pregnancies conceived within 18-months of the index VLBW delivery than did women in the IPC cohort, on average.

25 Cost of IPC: First 12 months
Outpatient charges for first 12 month of enrollment: Average: $1,801 Median: $1,802 Number of visits to GMH within first 12 months of enrollment: Average: 4.6 Median: 5 Charge per visit within first 12 months of enrollment: Average: $389 Median: $366 Figures exclude two outliers (women with lupus and valve replacement)

26 Cost of IPC: Full 24 months
Outpatient charges for the full 24 month of enrollment: Average: $ 2,397 Median: $ 2,104 Number of visits to GMH within 24 months of enrollment: Average: 7 Median: 6 Charge per visit within 24 months of enrollment: Average: $342 Median: $350 Figures exclude two outliers (women with lupus and valve replacement)

27 Costs of Hospital Care for Subsequently Birthed Infants
For historical control cohort: 10 liveborn infants < 2500 g conceived within 18 months of index VLBW delivery Mean birth weight: /- 493 g Range birth weight: 730 – 2430 g Mean days hospitalized: /- 39 Range days hospitalized: 2 – 137 Cost of initial hospitalization: Total cost: $555,763 Cost per liveborn infant < 2500 g: $55,576

28 Impact of IPC: Social Outcomes (Education)
Educational Attainment: 18/21 (85.7%) active participants without h.s diploma or GED at study entry; Of those 18 without diploma or GED, 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.

29 Impact of IPC: Social Outcomes (Employment)
Employment Acquisition: 20/21 active participants without employment at study entry; Of those 20 without employment, 12/20 assisted in achieving full- or part-time work. Resource mother assisted participants in making resumes, completing job applications, acquiring telephone skills, preparation for job interviews (including role playing and self-presentation), and transportation to job interviews.

30 Lessons Learned: Content of Interpregnancy Care
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. 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, ….

31 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 intervals; a reduction in both the average number of pregnancies conceived within 18-months, and the average number of adverse pregnancy 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.

32 IPC Program: Next Steps
We are currently preparing a grant request to support a randomized trial to test the hypothesis that IPC decreases the occurrence of adverse pregnancy outcomes among subsequently conceived pregnancies to women with an index VLBW delivery; We plan to enhance participant retention by providing health care services via the community-based Grady Neighborhood Health Centers and by securing funding for participant life skills enhancement and job training.

33 Funding for IPC Program
Support for the ‘Pilot Phase’ of the IPC Program has been provided by the following: Vasser-Woolley Foundation Grady Memorial Hospital CDC Rockdale Foundation Price Family Foundation March of Dimes Healthcare Georgia Foundation

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


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