PROMOTING PRECONCEPTION HEALTH: THE INTEGRATION OF THE OMH PPE PROGRAM INTO PROFESSIONAL HEALTH PRACTICE CURRICULA Karla Damus, PhD MSPH MN RN FAAN Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, MA Isabel M. Estrada-Portales, PhD MS Director of Communications, Office of Minority Health Resource Center, Rockville, MD

Infant, Neonatal, and Postneonatal Annual Mortality Rates* US, Per 1,000 live births for each group: infant ( <1 year), neonatal ( 0-27 days), and postneonatal (28 days to <1 year). From 1940 to 2005 infant, nenonatal, and postneonatal annual mortality rates in the US declined substantially. The infant mortality rate decreased 85%, from 47 in 1940 to 6.9 in 2005; the neonatal rate decreased 84%, from 28.8 to 4.54; the postneonatal rate decreased 87%, from 18.3 to SOURCE: Kung HC, Hoyert DL, Xu J, Murphy SL. Deaths: final data for Natl Vital Stat Rep 2008;56(10). After decades of decline there was no change in the IMR between 2000 and 2005

Infant Mortality Rates by Maternal Race/Ethnicity, US 2000 and 2005

BPHC (2010). Health of Boston 2010 Boston resident live births and deaths, MA Dept of Public Health Infant Mortality Rates by Race/Ethnicity Boston,

Infant Mortality Rates by Race/Ethnicity Boston and MA, 2006 US B:W Ratio 13.5/5.7= 2.4 Boston B:W Ratio 10.8/2.5= 4.3

Strategies to Reduce Infant Mortality  Tertiary PreventionNICUs, surgery  Secondary Prevention Early detection treatment progesterone, antenatal steroids, surfactant  Primary PreventionRisk factor identification/ reduction 

Critical Periods of Development Weeks gestation from LMP Central Nervous System Heart Arms Eyes Legs Teeth Palate External genitalia Ear Missed Period Mean Entry into Prenatal Care Most susceptible time for major malformation We currently intervene-- Too Late!!

. Social Determinants of Health and Racial/Ethnic Disparities Stress Social Supports Social Determinants Fetal Response Maternal Response Normal Birth Outcomes Neonatal Mortality Morbidity Long-Term or Adult-Onset Morbidities Gestational Age 

Healthy People Goals on Disparities 2000, 2010, and 2020  2000 Goal  Reduce disparities in health status among different populations  2010 Goal  Eliminate health disparities  2020 Goal  Achieve health equity, eliminate disparities, and improve the health of all groups

Why Focus on Health Disparities  After 30 years of research and demonstration projects, substantial disparities in birth outcomes remain in the US  Interventions have primarily focused on care during pregnancy --- often too late to impact preterm delivery, low birth weight, and infant mortality risk  African American women are 30% more likely to deliver preterm than white women and infant mortality rates are 2-5 times higher

Five Leading Causes of Infant Mortality Boston and MA, 2006

Percent of Infant Deaths from Preterm-related Causes by Race/Ethnicity, US, 2000 and 2005

Preterm Birth Rates by Gestational Age Categories United States, 1990, 2000, * 11.6 *preliminary Source: National Vital Statistics Reports Vol 58, Number 16 April 2010

Risk Factors for Preterm Labor/Delivery  The best predictors for having a preterm birth are: current multifetal pregnancy a history of preterm labor/delivery or prior low birthweight mid trimester bleeding (repeat) some uterine, cervical and placental abnormalities

Risk Factors for Preterm Labor/Delivery  Other Risk Factors: –unintended pregnancy –maternal age ( 35 yrs) –black race –low SES –unmarried –previous fetal or neonatal death –3+ spontaneous terminations –uterine abnormalities –incompetent cervix –cervical procedures (LEEP, cone bx) –genetic predisposition –low pre-pregnant weight –obesity –infections –anemia –major/chronic stress –lack of social supports –tobacco use –illicit drug use –alcohol abuse –elective inductions/cesareans –folic acid deficiency

Folic Acid Deficiency  Predisposes to: NTDs (spina bifida, anencephaly) Other birth defects (cleft lip/palate, cardiac, limb reduction, urinary tract, omphalocele, trisomies) Early and recurrent pregnancy loss Low birth weight and prematurity Bukowski R, et al. SMFM % reduction of early spon PTB independent of hx of PTB Gestational hypertension, preeclampsia in Black women Atherosclerotic vascular disease (stroke, CAD) Age-related macular degeneration (decrease of about 30%) Colorectal and cervical cancer Acute Lymphocytic Leukemia Alzheimer’s Disease? Autism?

Knowledge that Folic Acid Should be Taken Before Pregnancy Nationally representative telephone surveys conducted by Gallup, targeting approximately 2000 English-speaking women ages each year. Margin of error is +/- 3%.

Life Course Perspective Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life- course perspective.Matern Child Health J. 2003;7: Poor Nutrition Stress Abuse Tobacco, Alcohol, Drugs Poverty Lack of Access to Health Care Exposure to Toxins

Background  The life course perspective approach supports pre/interconception assessment, promoting evidence based interventions, health throughout the life span, and ultimately reducing disparities  Yet the yield from efforts to engage, educate and motivate health care providers to do so has been disappointing

Research Questions  How can we target health care professionals to improve their personal pre/interceoncepiton health and promote pre/interconception care as they care for women and families?  Can the PPE training content be integrated into the Northeastern SON curricula?

Objectives  The main objective is to integrate the OMH PPE training program into the curricula of the Northeastern School of Nursing (SON)  Assess the impact on the knowledge, attitudes, and behaviors (KAB) and satisfaction of participating students and faculty  Document and evaluate follow-up activities led by these students in the community  Assess intention to use preconception continuing education and other preconception-related resources

Methods  Conduct a OMH PPE training at Northeastern covering the following topics:  health disparities, racial/ethnic disparities in birth outcomes  the social determinants of health  causes of infant mortality  the Life Course Perspective--preconception health and care for men and women, research and recommendations, racism and associated stress  men, health and fatherhood

Evidence-Based Preconception Interventions that Work Giving Protection:  Folic Acid Supplements  Rubella Immunization  Testing for HIV/AIDS  Hepatitis B Vaccination Manage Conditions:  Diabetes  Hypothyroidism  Maternal PKU  Obesity  STIs  Oral Health Avoid Teratogens:  Alcohol use  Anti-epileptic drugs  Acutance use  Oral anticoagulants  Smoking

Prevent the Preventable  Ø Unintended pregnancies  Ø Short inter-pregnancy intervals  Ø Folic acid and other micronutrient deficiencies (vit D, iron, vit C)  Ø Alcohol  Ø Cigarette smoking and second hand smoke  Ø Illicit drugs  Ø Infections (UTIs, STIs, periodontal disease)  Ø Extremes of weight  Ø Some medications (Rx, OTC, home remedies)  Ø Environmental toxins  Ø Known genetic/familial risks  Ø Unnecessary interventions resulting in preterm birth  Insure timely interventions needed for optimal outcomes  Deliver all services with dignity and respect at least..... DO NO HARM

Closing the Black-White Gap in Birth Outcomes: 12 Point Plan 1. Provide interconception care to women with prior adverse pregnancy outcomes 2. Increase access to preconception care for African American women 3. Improve the quality of prenatal care 4. Expand healthcare access over the life course 5. Strengthen father involvement in African American families 6. Enhance service coordination and systems integration 7. Create reproductive social capital in African American communities 8. Invest in community building and urban renewal 9. Close the education gap 10. Reduce poverty among Black families 11. Support working mothers and families 12. Undo racism Lu MC, Kotelchuck M, Hogan V, et al. Closing the black-white gap in birth outcomes: A life-course approach. Ethnicity and Disease

OMH PPE Training at Northeastern University February 11-12, 2011  121 students from Bouvé College  91 achieved PPE certification  Follow-up activities were planned and implemented during National Public Health Week (4/4-10/11)  Other activities are planned and will be implemented in including additional PPE trainings  Activities are being documented and evaluated

Methods  Integrate the training into an undergrad (Public Health- NRSG 4604) and a PhD graduate course (Urban Practice Oriented Research- NRSG 7756)  Link students with professional continuing education resources to promote preconception health (OMH, CDC, NICHD, MOD,  Use results from the SON pilot to work with other health sciences schools/departments at Northeastern University (eg PA, PT, pharmacy)  eventually provide developed materials to other SONs and health professional programs in Boston and other regions of the nation

Integrating the Gabby System into the PPE Training and Follow Up Activities in Selected Sites Gabby ECA System to Improve Health of Young Women Goal – to address disparities in IMR and PTD/LBW Assess >100 Reproductive Risks in 12 Health Domains Assess Readiness for change in each risk area Provides information Provides “story” appropriate for readiness level (personal change narratives) Opportunity to leave your story behind Social networking function encourages “referral” to friends Gabby Developed by Dr. T. Bickmore, College of Computer Sciences, Northeastern University and Dr. B. Jack, Vice Chair Dept FM, BUSOM; Collaborator Dr. K. Damus, SON NU

Next Steps  The evaluation process is underway  Students and faculty have reported a high level of satisfaction with the PPE materials and the student nurses experiences that are important to the preparation of nurses to serve in urban, high risk communities.  Although most nursing education curricula includes some content on disparities and HP, the curricula needs significant expansion to include a greater focus on the life course perspective, pre/interconception health promotion, perinatal outcomes and social determinants to insure that all nurses (and eventually all other health professional students) understand what their role is in helping to make progress toward the national HP2020 goal of eliminating disparities.

Implications  Prior to the integration of the OMH PPE materials, the Northeastern SON curricula did not include a focus on the life course perspective nor a strong focus on preconception health.  The PPE initiative at the Northeastern SON can serve as a pilot for other health sciences schools nationwide to integrate the OMH PPE training into their curricula and create a sustainable system to promote ongoing education of future practitioners about these key topics.  It is expected that this will translate into healthier future practitioners who are more likely to embrace the life course perspective, provide preconception risk assessment and care, and to personally engage in more health promoting behaviors, all of which should increase progress to ameliorating the persistent health disparities in the nation.