Preconception & Early Prenatal Care:
Examining Evidence Based Practice
Strategies for KS MLC Project
Ginger Breedlove PhD, CNM, ARNP, FACNM
Assistant Professor, KU School of Nursing
Nurse Midwifery Education Program Director
What is this all about?
Improving lives of women &
children in Kansas
Birth rates for 15-19 year olds 2005/2006
◦ 41.4/1,000 and 42.0/1,000 respectively
Birth rate for unmarried women ages 15-44
at all time high in U.S. – 50.6%
◦ In Kansas rate is 35% (all races)
Number and percentage of preterm births in
Kansas in 2006
◦ 4,824 and11.8% respectively
NVSR, Vol 57, (7), January 7, 2009
Discuss Evidence Based Practice (EBP) &
Best Practice Models
Describe exemplary models of PNC in
Define access & outcomes issues
Enhance concept development
Adequacy of Prenatal Care (PNC)
in KS - 2007
Kansas reported 39,055 live births [met definition of PNC]
◦ 77% received adequate or better
◦ 23% received less than adequate
Of this subset 16% received Inadequate PNC
Kansas counties with highest percentage of Inadequate Prenatal
◦ Scott, Seward, Hamilton, average 38%
◦ Significant clustering of IPNC in lower southwest KS counties
Southeastern counties rate of IPNC
◦ Cherokee 31%
◦ Other surrounding counties range 9 – 28%
Jefferson & Shawnee counties rate of IPNC were 11% and 14%
Urban county with largest index of IPNC – Wyandotte, 29%
KS APNC Utilization Index, 2007, CHES/KDHE publication, http://www.kdheks.gov/ches/
IPNC Percentage to People (2007)
Kansas overall rate
was ~ 6,351 pregnant
Jefferson & Shawnee
Lower 8 counties in
Southeast KS ~ 230
U.S. Trends in PNC
PNC by Race/Origin in U.S.
Young women in their teens are by far the most
likely to receive late or no prenatal care
Providers of PNC in KS
OB/GYNs Is it just a provider
Family Medicine shortage issue?
Benefits of PNC
Early and ongoing PNC can improve
pregnancy outcomes by:
◦ Assessing health risks
◦ Providing health care advice
◦ Assisting in supportive services
◦ Managing chronic and pregnancy-related
NVSR, Vol 57, (7), January 7, 2009
What is EBM/EBP?
Evidence based medicine
is a systematic approach
to clinical problem
solving which allows the
integration of the best
evidence with clinical
expertise and patient
(Sackett DL, Strauss SE,
Richardson WS, et al. Evidence-
based medicine: how to practice
and teach EBM. London:
An example in KS
Hunter Health Clinic,
◦ Comanzando Bien
prenatal care program
with focus on Spanish
women diagnosed with
◦ Funded by the KS
Chapter MOD and
Other EBP examples
Five Step Model of Evidence-
◦ Convert information needs into answerable
◦ Track down with maximum efficiency the best
evidence with which to answer them
◦ Critically appraise that evidence for its validity
and usefulness for your desired outcome
◦ Apply the results of this appraisal to your
◦ Evaluate your performance
Create your Question
How would you describe a group of
patients you are interested in OR a
particular problem of interest?
What are the most important
characteristics of the population?
◦ This may include the primary topic, or co-
◦ Consider how gender, age, race, payer status,
religion, SES or other variables influence the
Determine an intervention,
prognostic factor or exposure
Which main intervention is most
What do you want to do for the patient?
Improve access? Improve outcomes?
Provide minimal services?
What factors may influence the outcome?
◦ Co-existing problems?
Is there an influencing exposure delaying
◦ Substance abuse, others
Comparisons of Interest
What is the main alternative to compare
with the intervention?
Are you trying to decide between two
◦ an outcome with no intervention vs. usual
◦ or two pilot interventions
◦ or between multi-site outcomes
Your clinical question does not always
need a specific comparison.
What can you hope to accomplish,
measure, improve or affect?
What are you trying to do for the
So a question might be…
“In pregnant patients
with no insurance, is
access to care through
services among LPHDs
effective in reducing the
rate of late entry into
See worksheet FSU
College of Medicine
What are AMCHP Best Practice
AMCHP defines “best practices" as a continuum
of practices, programs and policies ranging from
promising to evidence-based to science-based.
A best practice could focus on the health of
women, adolescents, young children, families, or
children with special health care needs.
It could address mental health, data and
assessment, financing, program integration,
workforce development, emergency
preparedness, family involvement, or a public
Resources for MCH Best Practices
MCH national database are materials published in
2000 or later that are program practices evaluated
to be effective, or best practices, in a variety of
topics, including community programs, women's
health, infant health, and others.
Sakala, C. & Corry, M. P. Evidence-based maternity
care: What it is and what it can achieve. New York,
NY: Milbank Memorial Fund, 2008,128 pp.
MCH Preconception and Pregnancy
Knowledge Path (April 2008)
Maternal and Child Health Library at Georgetown
It offers a selection of current, high-quality resources
that analyze perinatal health statistics, describe effective
prenatal care programs, and report on research aimed
at improving access to and quality of prenatal care and
improving perinatal health outcomes.
A separate section lists consumer health resources.
Includes section of resources on specific aspects of
preconception and pregnancy: childbirth, depression,
drug and alcohol use, environmental concerns, fertility
and infertility, nutrition, oral health, and tobacco use.
Searching the Academic Literature
There are literally millions of published
reports, journal articles, correspondence and
studies available to clinicians.
Choosing the best resource to search is an
Large search engines will give you access to
the primary literature.
◦ CINNAHL, PubMed, OVID, MEDLINE
The Cochrane Library database provides
access to systematic reviews which help
summarize the results from a number of
How to do an effective search
If you are not familiar with searching
PubMed, you may want to use the PubMed
If you are not familiar with searching
MEDLINE in OVID, you may want to use the
OVID tutorial at
You can even try GOOGLE SCHOLAR as a
EBP Tools: Hierarchy of rigor
Guideline Recommendation and
Evidence Grading (GREG)
◦ I (High): the described effect is plausible, precisely
quantified and not vulnerable to bias
◦ II (Intermediate): the described effect is plausible but is not
quantified precisely or may be vulnerable to bias
◦ III (Low): concerns about plausibility or vulnerability to
bias severely limit the value of the effect being described
◦ A (Recommendation): there is robust evidence to
recommend a pattern of care
◦ B (Provisional recommendation): on balance of evidence, a
pattern of care is recommended with caution
◦ C (Consensus opinion): evidence being inadequate, a
pattern of care is recommended by consensus
Common reporting terms
Confidence Intervals are calculated on
the results of the data to show the
strength or weakness of the evidence.
◦ A 95% CI [range] means that if you were to
repeat the same clinical trial a hundred times
you can be 95% sure that the data would fall
within the calculated range.
Odds Ratio describes the odds of an
experimental patient suffering an adverse
event relative to a control patient.
p Value refers to the probability that any
particular outcome would have arisen by chance.
◦ The smaller the p value the less likely the data was by
◦ Standard scientific practice, usually deems a p value of
less than 1 in 20 (expressed as p=.05) as "statistically
◦ The smaller the p value the higher the significance.
◦ A p value of p=.01 (less than 1 in 100) is considered
"statistically highly significant"
Relative Risk is the risk of developing a disease
in the exposed group divided by the risk of
developing the disease in the unexposed group.
Article on PNC
Early Access to Prenatal Care: Implications for
Racial Disparity in Perinatal Mortality
◦ Sub-analysis from large prospective RCT
examining first and second trimester risk of
Down’s and NTDs
◦ Conclusions: Racial disparities exist in perinatal
outcomes despite early access and entry to PNC
Healy, Malone, Sullivan, et.al. (2006) Obstetrics & Gynecology, 107 (3), 625-31.
Exemplary Models of PNC
What are the
PNC believed to be
of value for providers
Developed a Comprehensive Perinatal
Collaborative Program in LA County
Integrated a referral for perinatal services into
the 2-1-1 system and serve as a main referral
agency for entry into PNC
Promote risk appropriate perinatal care in early
pregnancy and beyond for seamless integration of
Developed Speaker’s Bureau
Preconception Care Marketing Tools
Reproductive Life Plan Toolkit
Pregnancy and Family Friendly Workplace Policies
Indiana Perinatal Network (IPN)
A Community Based
Research & Training
Project designed to
improve access to
services for low-
women and children.
In 2002, after competing with more than 70 cities
throughout the nation, Indianapolis was one of
four chosen to participate in a community-based
research project, known nationally as Friendly
Access, and locally as Indiana Access.
This community-based research project is
governed by the principle that the way in which
people are treated plays a role in whether
they access and continue to participate in
primary and preventive health services, including
Based on the Disney Model for Customer Service
Indiana Access Key Findings:
Handout from Indiana Perinatal Network
How does that impact what we do and
might need to change in Kansas?
Arizona Perinatal Health Initiative
on early PNC
A crucial step to improving prenatal care
utilization is the identification of pregnant women
early in the pregnancy (i.e. before conception or
within the first trimester).
Outreach efforts are also crucial to assure that
pregnant women receive consistent prenatal care.
Identification and outreach activities work hand-in
◦ For example, identifying high-risk pregnancies and
providing outreach activities to assure consistent
prenatal care utilization among high-risk pregnancies
will result in better birth outcomes.
Arizona activities increase early
access to PNC
Funded 15 high priority Interventions include:
LCHDs provide activities
including pregnancy Baby Arizona, a
testing, community public/private
education, clinical partnership
services, information and
County develops goals
depending on needs Focus on early and
identified by community consistent PNC
providers, and medical http://www.azdhs.gov/phs/owch/cp
Additional models of exemplary MCH
RESOURCES FROM A
Center for Health Care Inc. (CHCS)
Improving the quality and cost-effectiveness of
publicly financed health care
Nonprofit health policy resource center
dedicated to improving the quality and cost
effectiveness of health care services for low-
income populations and people with chronic
illnesses and disabilities.
CHCS works directly with states and federal
agencies, health plans, and providers to
develop innovative programs that better
serve people with complex and high-cost
health care needs.
CHCS Toward Improving Birth
Outcomes: A BCAP Toolkit
Toolkit provides a step-by-step, practical
approach for improving birth outcomes among
Medicaid and SCHIP enrollees.
It includes a simple process improvement model
to consistently follow including:
◦ strategies for identification, stratification,
outreach, and intervention, including case
studies and communications tactics for
What are some
provider and service-
variables related to
EARLY access to
What about maternal
◦ For each maternal age group, unmarried status increase risk for LBW
◦ Father acknowledging his child early in pregnancy**
◦ Increased risk for PTB, LBW, and infants die in first 12 months
◦ Increases risk suboptimal outcome, particularly with PTB**
◦ Virtually EVERY illicit recreational drug associated with adverse
Amount of education**
Culture and Tradition
Interpregnancy Interval **Highest Rate Late Entry PNC
Association of Preconception Care
and Early PNC
2006 Article by Liu and Li (China)
How might incorporation of an annual
preconception health care appointment
◦ Educational Resources
◦ Reduction of poor perinatal outcomes
◦ Earlier entry into PNC
◦ MOD Preconception Screening (See Tool)
Trust for America’s Health:
Healthy Women, Healthy Babies
An ISSUE BRIEF, June 2008
The leading document on improving outcomes
through incorporation of universal preconception
“IT’S BEEN DONE A CERTAIN WAY FOR 40 YEARS. EVERY
WOMAN IS SUPPOSE TO SEEK CARE DURING THE FIRST
3 MONTHS OF PREGNANCY. WHAT WE HAVE LEARNED
IS THAT THIS IS GOOD -- BUT IT’S NOT GOOD ENOUGH!”
Magda Peck ScD, CityMatch
Factors Influencing Outcomes!
Outcome Measures – Common
Where do you find reliable measures?
What is a comparable benchmark?
How long should it take?
What if I can’t replicate the same
It might cost more than the accessible funds
The stakeholders might not be interested.
We don’t have enough human resources to
conduct the project.
Seek usefulness, not
Use small or
specified time and
over a wide range of
PNC Determinants & Outcomes
Goals of 90 percent have been set both
for care beginning in the first trimester of
pregnancy and for early and adequate
prenatal care, as part of the Healthy People
**No goal has been set for reducing late or
no prenatal care.
Are outcomes just about
Entry/Access of PNC?
Scope of services
Expecting Trouble: The Myth of
Prenatal Care in America (2000)
by Thomas Strong, MD, MFM University of
What is ADEQUATE PNC?
Human and Nonhuman Resources
Issue and Outcome Measures
Provider types & services
not so obvious challenges
Comments from Rural KS
“I am from a small town in rural KS which has a huge
population of people without insurance. I recently
worked at a hospital where women frequently came
in to labor with no prenatal care whatsoever. This was
because they could not afford insurance. Some had no
complications, but many had complications that could
have been prevented. Many just needed medications
and could not afford them. How can this be
happening to women and babies in America? This is a
HUGE problem that needs to be addressed and
Masters student in NRSG 835 Spring, 2009 online Primary Care of Women Course,
State the problem or outcome and
construct your clinical question(s)
Determine the main interventions are you
◦ Reflect on Greatest Impact -- Percentages and
Investigate evidence based intervention,
exposure or actions addressing your defined
Implement and monitor your intervention
Evaluate your outcomes
◦ Consider comparison data
Discussion and Questions