Preconception _ Early Prenatal Care Evidence Based Practice by pengtt


									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
 Explore challenges
 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
    Care (IPNC)
    ◦ 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,
IPNC Percentage to People (2007)
 Kansas overall rate
  was ~ 6,351 pregnant
 Jefferson & Shawnee
  counties ~360
 Lower 8 counties in
  Southeast KS ~ 230
 Wyandotte county
  748 women
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?
    ◦ CNMs
    ◦ WHNPs
    ◦ FNPs
 Physician Assistants
 Professional (lay)
 Indigenous midwives
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
        health conditions

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
    available research
    evidence with clinical
    expertise and patient

    (Sackett DL, Strauss SE,
    Richardson WS, et al. Evidence-
    based medicine: how to practice
    and teach EBM. London:
    Churchill-Livingstone, 2000)
An example in KS
   Hunter Health Clinic,
    ◦ Comanzando Bien
      prenatal care program
      with focus on Spanish
      speaking pregnant
      women diagnosed with
      Gestational Diabetes
    ◦ Funded by the KS
      Chapter MOD and
      other agencies
   Other EBP examples
    in Kansas?
Five Step Model of Evidence-
Based Practice
 ◦ 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-
      existing conditions.
    ◦ Consider how gender, age, race, payer status,
      religion, SES or other variables influence the
      desired outcome.
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
    ◦ Relieve…
    ◦ Reduce…
    ◦ Improve…
So a question might be…
   “In pregnant patients
    with no insurance, is
    access to care through
    coordinated, regionalized
    services among LPHDs
    effective in reducing the
    rate of late entry into
    prenatal care?”
   See worksheet FSU
    College of Medicine
   Question building…
What are AMCHP Best Practice
Models? (2004)
 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
  health issue.
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
    important decision.
   Large search engines will give you access to
    the primary literature.
   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
  tutorial at
 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
  search engine
EBP Tools: Hierarchy of rigor
Guideline Recommendation and
Evidence Grading (GREG)
   Evidence grade:
    ◦ 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
      and quantified
   Recommendation grade:
    ◦ 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.
and Definitions
   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, (2006) Obstetrics & Gynecology, 107 (3), 625-31.
Exemplary Models of PNC
   What are the
    characteristics of
    PNC believed to be
    of value for providers
    and consumers?

   Discussion…
LA, California
   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)
                  Indiana Access:
                  A Community Based
                  Research & Training
                  Project designed to
                  improve access to
                  services for low-
                  income pregnant
                  women and children.
IPN Background
 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
  prenatal care.
 Based on the Disney Model for Customer Service
Indiana Access Key Findings:
   Handout from Indiana Perinatal Network
    Consumer Survey

   How does that impact what we do and
    might need to change in Kansas?

   Discussion…
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:
    health departments.
                                 CHWs
   LCHDs provide activities
    including pregnancy          Baby Arizona, a
    testing, community            public/private
    education, clinical           partnership
    services, information and
                                 Public awareness
   County develops goals
    depending on needs           Focus on early and
    identified by community       consistent PNC
    members, service
    providers, and medical
    community                      bg.htm
Additional models of exemplary MCH
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
     creating change
   What are some
    provider and service-
    related issues,
    barriers, and
    variables related to
    EARLY access to
    prenatal care?
What about maternal
   Marital Status
    ◦ For each maternal age group, unmarried status increase risk for LBW
    ◦ Father acknowledging his child early in pregnancy**
   Adolescent Pregnancy**
    ◦ Increased risk for PTB, LBW, and infants die in first 12 months
   Socioeconomic Status
    ◦ Increases risk suboptimal outcome, particularly with PTB**
   Substance Abuse
    ◦ Virtually EVERY illicit recreational drug associated with adverse
      pregnancy outcomes
   Stress
   Amount of education**
   Culture and Tradition
   Pregnancy Wantedness
   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
    ◦   Services
    ◦   Billing
    ◦   Staff
    ◦   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

    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.
Creating Process/Outcome
 Seek usefulness, not
 Use small or
  repeated samples.
 Measure over
  specified time and
  over a wide range of
 Include quantitative
  and qualitative
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
    2010 program.

**No goal has been set for reducing late or
  no prenatal care.
Are outcomes just about
Entry/Access of PNC?
   Preconception and
    Family Planning
   Scope of services
   Provider collaborative
   Awareness campaign
   Educational and
    supportive services
   Community
    engagement and
    business partners
Challenges ahead
Expecting Trouble: The Myth of
Prenatal Care in America (2000)
 by Thomas Strong, MD, MFM University of
Obvious challenges
 Time
 Money
 Human and Nonhuman Resources
 Geographic Distance
 Required Partnerships
 Issue and Outcome Measures
 Provider types & services
 Population demographics
not so obvious challenges
                    Leader/Follower
                    Authority line
                    Hidden Influencers
                    Priority setting
                    Commitment
                    Consensus
                    Collegiality
                    Common end
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,
Next Steps
 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

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