The Magnolia Project

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The Magnolia Project

• A Preconception Strategy for Improving Birth
  Outcomes
• Carol Brady, MA, Executive Director
• Northeast Florida Healthy Start Coalition
• Fort Worth, Texas ? February 27, 2009

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A little history. . .

• Duval was one of three counties in 1995-97 that
  had an infant mortality rate significantly higher
  than the state
• Two factors contribute to higher infant mortality
  rates in Duval
• Proportion of nonwhites in the population
• Poor outcomes among nonwhites

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Infant Mortality Rates, Duval County, 1992-2001
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Why focus on well-women?

• PPOR!
• Greatest racial disparities occurred in
  Maternal Health and Maternity Care
• Disparities disappeared in the other categories
• Kitagawa too many black babies born too soon and
  too small
• FIMR!

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Black White Fetal-Infant Death Rates By Period
of Risk, Duval County 1995-97
Fetal (24 Wks Gestation)
Neonatal
Postneonatal
Maternal Health/Prematurity Black 6.9 White
2.3 R 3.01 (2.14, 4.25 95 C.I.)
500- 1499g 1500g
Maternal Care Black 3.4 White 2.0 R1.70 (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 R1.96 (1.59, 2.41 95 C.I.)
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What do all the numbers mean?

• Almost two-thirds of the mortality difference
  between black women and the internal reference
  group is due to birth weight distribution
• The focus of efforts should be on Maternal Health
  and Prematurity as they account for 95 of the
  excess deaths.

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Fetal Infant Mortality Review (FIMR)

• Information abstracted from birth, death,
  medical, hospital and autopsy records
• Family interviews
• ACOG process
• Case review team determines medical, social,
  financial and other issues that may have impacted
  on poor outcome

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FIMR Process

• 142 fetal and infant cases reviewed by CRT since
  1995
• 83 white
• 53 black
• 6 other
• Systematic, not random, sample based on specific
  criteria

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Linking FIMR to PPOR

• Most Frequent FIMR Factors
• Infections and STDs
• No Healthy Start screening
• Late/inadequate prenatal care
• Previous poor outcome
• Family planning problems
• General state of mothers health
• Poor nutrition

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From data to action

• Used PPOR FIMR findings to respond to federal
  Healthy Start RFP in 1999 to address racial
  disparities in birth outcomes
• Funded for proposed a Pre- and Interconceptional
  Model
• Initiated the Magnolia Project

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The Magnolia Project

• Area accounts for more than half of the Black
  infant mortality in the city
• About 25,000 women age 15-44 years old live in
  the project area

• 85 African-American

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The Magnolia Project

• Storefront site
• Collaborative effort
• Local Health Department
• HS Coalition
• Community agencies

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The Magnolia Project

• Interventions (1999)
• Enhanced clinical care
• Case management risk reduction
• Outreach
• Community development
• Additions (2001)
• Depression screening
• Health education

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The Magnolia Project
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Who Did We Serve?

• Average age
• 80 single
• 90 black
• 40 less than HS education
• 90 uninsured (but would be insured if pregnant!)

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The Magnolia Project

• Case management
• 15-44 and living in target area
• Not pregnant, but sexually active
• 3 or more risk factors previous loss, repeated
  STDs, no family planning, substance abuse,
  pregnancy
  protective services, no source of care

• Clinic services
• Age 15-44
• Resident of target area
• Pregnant or able to get pregnant
• Health exam 1 year

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Care coordination risk reduction

• Referral (internal external)
• Engagement enrollment (WIS)
• Assessment
• Womens Health Questionnaire
• Problem Checklist
• Goal setting and risk reduction
• Health education, anticipatory guidance
  integrated into care coordination

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Care coordination

• Primarily face-to-face (home, community sites,
  clinic)
• Team
• Paraprofessionals
• Nurse consultant
• Social worker
• Health educator

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Care Coordination

• Levels I, II, III
• Entry at highest level (frequency of contact)
• Average enrollment period

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Care Coordination

• Periodic re-assessment of risk status using
  assessment checklist
• Limited caseloads (20-25)
• Under revision transition to life course,
  strength-based approach

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Community Component

• Community Council
• Staff outreach
• Project location

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Community Component

• Centering Pregnancy
• Birthing Project
• Community Voice
• Qualitative evaluation (focus groups, surveys)

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Measuring Success

• Evaluating Impact
• HRSA Performance Outcome indicators (focus
  pregnancy)
• Local Outcome indicators
• Consistent use of birth control method
• No repeat STDs

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Measuring Success

• Priority risks at closure (2004-06)
• 58 of participants with family planning issues
  were consistently using a method at closure
• 72 of participants with repeated STDs had no
  recurrent STDs at closure

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Measuring Success

• Longitudinal evaluation
• Funded by CDC
• Examination of outcome of future pregnancies
  among women who participated in care coordination

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Evaluation Design

• Intermediate Outcomes
• Pre/Post Scales
• Risky behaviors, perceived stress, self
  efficacy, social support and goals for the
  future
• Distal (Retrospective) Outcomes
• Infant mortality, low birth weight, birth
  spacing and repeat STDs
• Magnolia Project care coordination participants
  vs. comparison group

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Preliminary Findings

• Magnolia Project successfully reaches
  exceptionally high-risk women
• Statistically significant reductions in low
  birthweights STDs among participants
• No significant difference in IM, birth
  intervals.

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Preliminary Findings
Comparison of Birthweights Magnolia Case
Management Participants vs. Control, 1995-2005
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Preliminary Findings
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Preliminary Findings

• Magnolia Project successfully provided culturally
  sensitive care that enhanced utilization and
  client-focused decision making.

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Resident Infant Mortality RatesCounty, Target
Area, Black Race, 2001-2007
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Next Step Integrating a Life Course Perspective

• Opportunities for integration
• Organization and delivery of services
• Content of care
• Tracking monitoring
• Operationalizing the life course
• Group care
• Social determinants
• Self-scaling (GAS, other models)

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Take Home Message

• Data need to move before and beyond prenatal
  care
• Integrate womens health assessment, primary care
  and risk reduction into current activities
• Healthy Start postpartum case management
• FP waiver integration
• Family planning (birth control vs. health care)
• STD clinic
• Pediatric care
• Opportunities to integrate life course
  perspective

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Thank you!

• www.nefhealthystart.org
• www.magnoliaproject.org