1. The Magnolia Project Reducing Infant Mortality: An Interconceptional Care Strategy Carol Brady, MA, Executive Director Northeast Florida Healthy Start Coalition MCH Emerging Issues

2. A little history... zDuval was one of three counties in 1995- 97 that had an infant mortality rate significantly higher than the state zTwo factors contribute to higher infant mortality rates in Duval: yProportion of nonwhites in the population yPoor outcomes among nonwhites

3. Infant Mortality Rates, Duval County, 1992-2001

4. Why focus on well-women? zPPOR! yGreatest racial disparities occurred in Maternal Health and Maternity Care yDisparities disappeared in the other categories yKitagawa: too many black babies born too soon and too small zFIMR!

5. Black & White Fetal-Infant Death Rates By Period of Risk, Duval County 1995-97 500- 1499g 1500+g Fetal (24+ Wks Gestation) NeonatalPostneonatal Maternal Health/Prematurity Black 6.9 White 2.3 R= 3.01 (2.14, 4.25 95% C.I.) Maternal Care Black 3.4 White 2.0 R=1.70 (1.12, 2.58 95% C.I.) Newborn Care Black 1.5 White 1.2 R= 1.22 (0.67, 2.20 95% C.I.) Infant Care Black 2.8 White 1.9 R= 1.44 (.092, 2.24 95% C.I.) Total Feto-Infant Deaths/1000 (Live Births + Fetal Deaths) = Black 14.6 White 7.4 R=1.96 (1.59, 2.41 95% C.I.)

6. What do all the numbers mean? zAlmost two-thirds of the mortality difference between black women and the internal reference group is due to birth weight distribution zThe focus of efforts should be on Maternal Health and Prematurity as they account for 95% of the excess deaths.

7. Fetal & Infant Mortality Review (FIMR) zInformation abstracted from birth, death, medical, hospital and autopsy records zFamily interviews zACOG process zCase review team determines medical, social, financial and other issues that may have impacted on poor outcome

8. FIMR Process z142 fetal and infant cases reviewed by CRT since 1995 y83 white y53 black y6 other zSystematic, not random, sample based on specific criteria

9. Linking FIMR to PPOR zMost Frequent FIMR Factors: yInfections and STDs yNo Healthy Start screening yLate/inadequate prenatal care yPrevious poor outcome yFamily planning problems yGeneral state of mother’s health yPoor nutrition

10. From data to action zUsed PPOR & FIMR findings to respond to federal Healthy Start RFP in 1999 to address racial disparities in birth outcomes zFunded for proposed a Pre- and Interconceptional Model zInitiated the Magnolia Project

11. The Magnolia Project zArea accounts for more than half of the Black infant mortality in the city zAbout 25,000 women age 15-44 years old live in the project area 85% African-American

12. The Magnolia Project Storefront site Collaborative effort:  Local Health Department  HS Coalition  Community agencies

13. The Magnolia Project zInterventions (1999): yEnhanced clinical care yCase management & risk reduction yOutreach yCommunity development zAdditions (2001): yDepression screening yHealth education

14. The Magnolia Project

15. Who Did We Serve? zAverage age <25 years old z80% single z90% black z40% less than HS education z90% uninsured (but would be insured if pregnant!)

16. The Magnolia Project zClinic services yAge 15-44 yResident of target area yPregnant or able to get pregnant yHealth exam > 1 year z Case management y15-44 and living in target area yNot pregnant, but sexually active y3 or more risk factors: previous loss, repeated STDs, no family planning, substance abuse, pregnancy <15 yrs, mental health probs, protective services, no source of care

17. The Magnolia Project zProject experience (2002) y509 Women served x405 clinic x104 case management (3+ months) y18% pregnant y3,137 clinic visits y762 pregnancy tests (70% negative)

18. The Magnolia Project zClinical Patient Profile y41% sexually active but not using birth control y42% STDs y20% previous miscarriage or infant death y27% poor nutrition

19. Clinic Services zTailoring Care to the Community yEvening clinic yMagnolia for Men yWalk-in Wednesdays yRyan White III partnership yGroup prenatal care??

20. Clinic Services z Birth Outcomes for Pregnant Clients (n=73) y 77% began care in first trimester y 15% LBW y 4.1% VLBW y18% pre-term y No infant deaths

21. The Magnolia Project zRisk Factors by Type y35.1% Medical y64.9% Social zDuration of Service (current participants) y59% >12 months y14% 9-12 months Case Management

22. z100 served in 2002 zAverage length of participation = 464 days z60% referred by clinic zAverage of 14.9 risk factors/patient y65% family planning issues y58% education/training y48% job placement y39% BV y32% repeat STDs

23. Case Management z30+ clients closed to service in 2002 y45% were in case management for 1 year+ y83% completed referrals y86% of risks were resolved or managed zOutcome of next pregnancy?? MOD proposal.

24. Outreach zProject staff, partner agencies (Jp Ministries, HS/Grand Park Place, others) y8,000 contacts yStreet outreach, nightclubs, health fairs y300+ scheduled at Magnolia or linked to another provider for care

25. Health Education z1,186 one-on-one counseling sessions on FIMR risks (STDs & infections, substance use, family planning, safe sex, douching) z100+ families participated in Cooking Among Sisters z90 community residents attended Women’s Community Health Conference z30 agencies, 300+ residents participated in Street Party

26. Infant Mortality Rates, Duval County, 1997-2002 (Preliminary)

27. Impacting Women’s Health Before Pregnancy zNearly half of all pregnancies are unplanned (mistimed or unwanted) zAll women age 15 - 44 should be considered pre-/interconceptional! zID opportunities for addressing pre- /interconceptional issues (FP, pediatrics, case management).