Perinatal Health in Oregon: Data and Program Development

1
Perinatal Health in Oregon Data and Program
Development

• Ken Rosenberg, MD, MPH
• MCH Epidemiologist
• Office of Family Health
• November 28, 2007

2
Perinatal Data Book

• Topics include
• Infant mortality preterm birth
• Periconceptional folic acid
• Prepregnancy obesity
• Prenatal care
• Tobacco use
• Alcohol use
• Pregnancy intendedness
• Postpartum depression
• Breastfeeding
• Infant sleep position

3
Strength of Evidence

• My own personal summary of the strength of the
  evidence
• Very strong
• Strong
• Moderate
• Weak
• Very Weak

4
Infant Mortality / Preterm Birth (pages 10-19)

• Infant Mortality Rate (IMR) Preterm Birth (PTB)
  are lower in Oregon than the U.S.
• IMR has decreased past 100 years
• PTB has increased slightly past 10 years
• Increased assisted reproduction
• Increased cesarean deliveries
• Increased elective induction of labor
• Strength of evidence that it is important to
  decrease IMR/PTB very strong
• Strength of evidence that we have any
  interventions to decrease IMR/PTB very weak
  despite many attempts

5
Periconceptional Folic Acid (pages 22-23)

• 400 micrograms per day
• Multivitamin or fortified cereal
• Racial/ethnic disparities in Oregon
• 24.6 of American Indian mothers
• 30.3 of African American mothers
• 32.1 of Hispanic mothers
• 38.6 of White mothers
• Strength of evidence that folic acid can prevent
  birth defects very strong
• Strength of evidence that we can increase women
  taking folic acid moderate (hard to get more
  than 50 of any population of fertile women to
  take folic acid)

6
Perinatal Data Book Exercise Text and Appendix

• Two versions pages 23 81
• Women who took a multivitamin 4 or more days a
  week in the month before they got pregnant
• 0 times a week 53.2
• 1-3 times a week 9.4
• 4-6 times a week 6.4
• Every day of the week 31.0

7
Exercise Perinatal Data Book Appendix

• Page 81
• Women who took a multivitamin 4 or more days a
  week in the month before they got pregnant
• White 38.6
• African American 30.3
• American Indian 24.6
• Asian/Pacific Islander 31.0
• Hispanic 32.1

8
Prepregnancy Obesity (pages 24-25)

• Obese women have increased risk of
• Gestational diabetes and diabetes
• Infants with birth defects
• 22 of Oregon women who gave birth were obese
  before getting pregnant
• Strength of evidence that obesity increases the
  risk of bad pregnancy outcomes moderate (strong
  association in cross sectional studies no way to
  do randomized trials)
• Strength of evidence that we have interventions
  to decrease obesity weak (intensive diet and
  exercise has modest impact)

9
Prenatal Care (pages 26-31)

• First trimester initiation
• Oregon (80) worse than U.S. (84)
• Adequacy of prenatal care
• Oregon (70) worse than U.S. (75)
• Insurance for prenatal care
• Varies by maternal race/ethnicity graph page 31
• 8 had no insurance (68 of those without
  insurance were Hispanic) pie chart page 31
• Strength of evidence that adequate prenatal care
  leads to less infant mortality and less preterm
  birth weak (e.g., many studies on prenatal care
  and low birthweight)
• Strength of evidence that adequate prenatal care
  leads to better long-term outcomes for mother and
  child weak (few studies expensive and hard to
  do)

10
Maternal smoking during 3rd trimester of
pregnancy (pages 32-35)

• Pregnant Oregon women smoke at about U.S.
  average 13
• Most likely to smoke American Indian and White
• Among smokers 46 quit, 61 of the quitters
  stayed quit (at average of 14 weeks)
• Smoke Free Mothers and Babies increased prenatal
  providers using The 5 As
• Strength of evidence that quitting smoking is
  important, especially to decrease low birthweight
  and SIDS risk very strong
• Strength of evidence that The 5 As can decrease
  smoking strong

11
Maternal alcohol use during 3rd trimester of
pregnancy (pages 36-39)

• Alcohol use during pregnancy Oregon women (8)
  more than U.S. (6)
• Alcohol use during pregnancy leads to low
  birthweight, birth defects (including FAS) and
  child neurological problems
• Strength of evidence that stopping drinking will
  lead to healthier children moderate (underlying
  studies of drinking and child outcomes were never
  done)
• Strength of evidence that there are interventions
  that will decrease drinking among fertile women
  weak (alcohol rehab and intensive motivational
  interviewing yield modest results nothing else
  is effective)

12
Unintended Childbearing (pages 40-41)

• Oregon (37) is lower than U.S. (43)
• Young women are more likely to have unintended
  births
• Women with unintended births are less ready to be
  a parent. They are more likely to smoke and drink
  during pregnancy and less likely to have taken
  folic acid.
• Strength of evidence that increasing pregnancy
  intendedness will improve long-term birth
  outcomes weak (few studies to date)
• Strength of evidence that increasing independent
  decision-making skills of young women can prevent
  unintended pregnancies moderate (few studies to
  date)

13
Postpartum Depression (pages 44-45)

• 9 of Oregon women said that they had been
  always/often depressed since their baby was born.
  
• Postpartum depression affects mothers, infants,
  children and families
• This topic is ripe for pilot interventions such
  as educating obstetricians and pediatricians to
  screen new mothers.
• Recent popular literature is starting to reach
  new mothers.
• Strength of evidence that it is important to
  decrease postpartum depression moderate (need
  more long-term follow-up)
• Strength of evidence that we can decrease
  postpartum depression weak (proposed
  interventions are just being formulated not yet
  tested)

14
Breastfeeding (pages 46-49)

• Breastfeeding women exclusively breastfeed for
  at least 6 months in Oregon (22) more than U.S.
  (14) WERE NUMBER ONE!
• Breastfeeding leads to less infant infection,
  better maternal-infant bonding and less childhood
  obesity
• Strength of evidence that increased breastfeeding
  leads to better infant health outcomes very
  strong (observational but consistent for many
  outcomes)
• Strength of evidence that changes in birthing
  hospital can increase BF strong (especially
  rooming-in, breastfeeding on demand, education
  and new protocols)

15
Infant Sleep Position (pages 50-51)

• Infant back sleeping Oregon (75) is better than
  U.S. (65)
• Infant back sleeping reduces infants risk of
  SIDS by 50
• Back to Sleep has done a good job of educating
  people about infant sleep position.
• But 10 of Oregon mothers still put their babies
  to sleep on their stomach.
• Strength of evidence that it is important to
  decrease stomach sleeping very strong (many
  nations, many studies)
• Strength of evidence that education decreases
  stomach sleeping strong (Back to Sleep decreased
  SIDS)

16
Other topics Preconception care

• New awareness that long-term pregnancy outcomes
  need to be addressed before conception
  http//www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1
  .htm
• Preconception care (like prenatal care) is a
  collection of many separate interventions each
  of which will need to be evaluated independently
• Narrowly include preconception (or
  interconception) provider visits for tobacco,
  alcohol, folic acid, obesity
• More broadly improved preadolescent nutrition,
  adolescent smoking and improved overall health

17
Other topics Gestational diabetes
18
Other topics Gestational diabetes

• 4.3 of Oregon women have gestational diabetes
  during their pregnancy
• Women with gestational diabetes have increased
  risk of developing diabetes later
• Strength of evidence that gestational diabetes is
  harmful for mothers and their children strong
• Strength of evidence that case management for
  gestational diabetics can delay onset of type 2
  diabetes not yet tested

19
Other topics Oral health

• Good maternal oral health may improve childs
  oral health
• Prenatal care oral health screening questions
  should be part of prenatal care
• Have you seen a dentist in the past year?
• Any pain in your mouth?
• Do you brush regularly with a fluoride
  toothpaste?
• All women (including pregnant women) need to have
  a dental home
• Strength of evidence interventions have not been
  evaluated

20
Other topics Domestic violence

• Physical abuse (pregnant non-pregnant women) in
  the past 12 months
• Age 18-24 25
• Age 25-34 19
• Before pregnancy (4) during pregnancy (3)
• Assess adequacy of existing programs?
• Strength of evidence that women are negatively
  affected by domestic violence very strong
• Strength of evidence that public health
  interventions can decrease domestic violence
  weak (has not been adequately studied)

21
Contact Information

• Kenneth D. Rosenberg, MD, MPH
• Maternal Child Health Epidemiologist
• Oregon Public Health Division
• Office of Family Health
• 800 NE Oregon Street, Suite 850
• Portland, OR 97232
• Telephone [phone]
• e-mail ken.d.rosenberg_at_state.or.us