2. 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

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

4. The Company We Keep… Infant Mortality Rates

5. 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

6. 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, 1997–1998, Shelby County, Tennessee

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

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

9. Approaching the Problem

10. 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

11. Synergistic Relationships Science Best Practice Evidence Based Translational Research

12. Preterm Birth Prevention we don’t have all the answers… BUT, we know some of the factors that contribute to preterm births… AND…we have some promising interventions.

13. 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

14. 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

15. 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

16. 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

17. 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

18. Who could participate? Confirmed pregnancy 18 – 40 years of age History of preterm birth (Live birth > 20wks and <37wks) Reside in Davidson or surrounding county (up to 90 miles) < 24 wks gestation at enrollment Receive prenatal care at VUMC Willing to accept nurse home visits & be randomly assigned Speak & understand English

19. BBO Before Delivery Collaborative Prenatal Care nurse midwife conducted home visits to augment standard care intervention focused on:  establishing supportive relationship  reinforcing clinical care including 17-P therapy as appropriate  monitoring maternal condition  reducing the risk of stress, depression, smoking, poor nutrition, alcohol/substance abuse/misuse, domestic issues  defining reproductive life plan  facilitating preparation for breastfeeding

20. BBO After Delivery for 18 months first post-partum visit within 48 hours of birth, with hand-off to maternal/child nurse for 18 months of care home intervention focused on:  establishing supportive relationship  continuing to address risks identified prenatally  supporting reproductive life plan  monitoring infant conditions including continuity with medical home

21. Data Sources scheduled interviews (standardized measures) medical center charge records medical/hospital records (maternal & infant) study records (e.g., screening logs, travel records, clinical forms) follow up surveys (participants, providers)

22. Intervention Fidelity visit guidelines r/t to each risk factor nurse interventionist training 24/7 clinical and study protocol backup study specific ‘clinical’ visit forms pocket ‘cue’ cards study specific charting template in VU OB EMR case reviews direct observation of home visits review of completed documents

23. Snapshot of BBO Participants

27. 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)

28. Disposition of Infant

29. Maternal Length of Stay for Delivery

30. 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

31. 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

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

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

34. 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)

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

36. 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)

37. 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)

38. 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

39. In Her Own Words…

40. 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

41. 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?

43. Tennessee Connections for Better Birth Outcomes Funded by