Initiative Team Reduction of Infant Mortality Ensuring a Healthy Future for Women and Their Families

1 Bright Beginnings: Prince George’sCounty Initiative Team Reduction of Infant Mortality Ensuring a Healthy Future for Women and Their Families Funded by Communities IMPACT Diabetes Center Mount Sinai School of Medicine Acknowledgments Communities IMPACT Diabetes Center - Mount Sinai School of Medicine Michele Johnson Marcela Campoli, BA, MHA, PhD Candidate Maryland Center Bowie State University Health Resources Commission Maryland Community Department of Health and Mental Health, Minority Health and Disparities, Children and Material Services Judy Hoyer Center Hospital Center Prince George's County Initiative to Reduce Infant Mortality Who We Are… Data Sheet… Helpful Hints… FACTS SHEET About the Sudden Infant Death Syndrome (SIDS) … Executive Summary Healthy Pregnancy Tools to Prevent Infant Mortality -Prince George’s County Who We Are… The program to reduce infant mortality "Bright Beginnings" is an extension of the organization Institute for Access to a Comprehensive and Productive Life (Access to Wholistic and Productive Living Institute Incorporated) (ATWPLI) The Institute for Access to a Comprehensive and Productive Life, is a nonprofit organization in Prince George's County, Maryland, certified 501 (C) according to the U.S Tax Code Provides access to resources of community health services, with the goal of reducing health disparities and improve the health of populations that are disproportionately affected by social inequalities and health "Bright Beginnings" seeks to address the adverse pregnancy outcomes such as infant mortality, low birth weight and other complications during pregnancy The overall objective is to reduce the negative outcomes in pregnancies of low-income women of Prince George and the consequences for their newborns " Securing a healthy future for women and their families" Fact Sheet Stress during Pregnancy • Very high levels of stress may contribute to an increased risk of premature delivery • Low birth weight babies • Overly high stress levels can increase your heart rate • Overly high stress levels can increase your blood pressure • Produce chronic anxiety • Produce certain hormones that can perhaps cause miscarriage and that very likely can bring on preterm labor • Unpleasant feelings • Episodes of depression • Racism throughout their lifetime • Affect a woman’s behavior reacting to stress by smoking cigarettes, drinking alcohol or taking illicit drugs Helpful Tips How to Manage Stress during Pregnancy  Eat a healthy, well balanced diet The more junk food you eat the more stressed your body will be  Get plenty of sleep The less sleep you get the more stressed you are likely to be If you find you are having trouble sleeping invest in a comfortable body pillow You may find it helpful to take a relaxing bath before bed Also avoid eating up to one hour before bed to prevent heartburn, which can disrupt your sleep and increase your level of stress  Exercise regularly It will also leave you feeling more energetic and ready to tackle the day's challenges Exercise can also help ease labor and alleviate some of the anxiety associated with the upcoming labor and delivery  Try some natural stress reduction techniques including biofeedback, yoga or meditation These non conventional methods will help you focus, identify stressors and release stress in a healthy, safe and energy producing manner  Talk regularly with your partner, friend or health provider They may be able to help you work through your anxiety and help comfort you in times of high stress By communicating regularly and openly with others/partner you are bound to feel more prepared to deal with the challenges each day will bring  Reduce your workload If you find you are doing too much in a day find ways to delegate certain tasks to others Carrying a baby for nine months is a lot of work You should expect that those around you will be willing to take on more responsibility to help you out in your time of need FACT SHEET FOR SIDS -Sudden Infant Death Syndrome Tummy (prone) or side sleeping Infants who are put to sleep on their tummy or side are more likely to die from SIDS than infants who sleep on their backs Soft sleep surfacesSleeping on a waterbed, couch, sofa, or pillows, or sleeping with stuffed toys has been associated with an increased risk for SIDS Loose BeddingSleeping with pillows, loose bedding such as comforters, quilts, and blankets increases and infant's risk for SIDS OverheatingInfants who over heat because they are Overdressed, have too many blankets on, or are in a room that is too hot are at a higher risk of SIDS SmokingInfants born to mothers who smoke during pregnancy are at increased risk of SIDS Also infants exposed to smoke at home or at daycare are more likely to die from SIDS Bed sharingSharing a bed with anyone other than the parents or caregivers and with people who smoke or are under the influence of alcohol or drugs, increases an infant's risk for SIDS The safest place for an infant to sleep is in their own crib or other separate safe sleep surface next to the parent or caregiver's bed Preterm and low birth weight infantsInfants born premature or low birth weight are more likely to die from SIDS Securing a Future for Women and their Families 240 550-8607 Funded through Mt Sinai School of Nursing & the Maryland Health Resource Commission Executive Summary Maryland progress in reducing infant mortality has stalled in recent years and a comprehensive, multi-faceted plan is needed to reduce its infant mortality rate by 10% by 2012 (Maryland Department of Health and Mental Hygiene) Factors contributing to Maryland high infant mortality rate are multiple, complex and include: a high percentage of unintended pregnancies (including a recent rise in the teen birth rate), a worsening early prenatal care rate, and an unacceptable high racial disparity in birth outcomes The decline in the overall infant mortality rate (IMR) in the state of Maryland was due to a 20.6% decline in the white infant mortality rate, which fell from 5.2 per 1,000 live births in 2008 to 4.1 per 1,000 live births in 2009 Although the 2009 white infant mortality fell to its lowest recorded rate in 2009, the African American infant mortality rate increased from 123.4 in 2008 to 13.6 in 2009 The IMR was 3.2 per 1,000 live births among Asians and 3.1 per 1,000 live births among Hispanics Access to Wholistic and Productive Living Institute Inc., seeks to address these disparities through its Bright Beginnings of Prince George’s County; Infant Mortality Reduction Initiative The overall goal of the initiative is to address significant disparities in perinatal health and barriers to health care confronting minority populations residing in Prince George’s County Maryland Prior to the inception of the program, it was clear that in order to reduce infant mortality in the county all sectors of care must work together in harmony, devotion and with consistency to address the social determinants of infant mortality which contributes to infant mortality in PGC Only as a team, can we create and sustain a model program for Prince George’s County and the state of Maryland which we aim to replicate throughout Maryland Background Infant mortality is a public health challenge in Prince George’s County, Maryland and the United States (with an infant mortality rate of 6.8 deaths/1,000 live births) ranks 30 th among developed nations and Maryland (rate of 8.0/1,000) ranks 39th among states in infant mortality Although there has been a 32% reduction in Maryland’s infant mortality rate over the past 25 years, progress has stalled this decade Despite the large decline in infant deaths in 2009, infant mortality rates (IMR) have fallen only slightly in Maryland over the past decade The rate fell from an average of 7.9 per 1,000 live births in the years 2000-2004 to an average of 7.7 in the years of 2005-2009, a 3.1% decline Prince George’s County (PGC) leads the state of Maryland in numerous adverse pregnancy outcomes, including infant mortality, low birth weight, and very low birth weight Women residing in Prince George’s County are more likely to receive late or no prenatal care Women of color are disproportionately represented in these statistics 10 Causes of Infant Mortality The leading causes of infant mortality are preterm/low birth weight births, congenital abnormalities, and sudden infant death syndrome (SIDS) Preterm/low birth weight births are associated with 2/3 of all infant deaths Overall, the infant mortality rate for very low birth weight infants (those with birth weights of less than 1,500 grams or 31/2 pounds) is 240/1,000, more than 100 times the mortality rate for normal birth weight infants Risks Factors for Infant Mortality Risk factors for infant mortality are multiple and include behavioral and environmental risks, health care risks, and socio-demographic risks (MDHMH) Behavioral risks such as unintended pregnancy increase neonatal mortality more than two-fold Healthcare risks such as late prenatal care increases infant mortality more than 40% Socio-demographic risks involving age, education and income are also associated with increased infant mortality However, the complexity of infant mortality is reflected by the fact that racial disparities in infant mortality cannot be explained by socio-economic factors alone (MDHMH) For example, college educated Back women have worse pregnancy outcomes than women of other races/ethnicities (White, Hispanic, and Asian) with less than an 8th grade education Cost The economic costs of preterm low-birth-weight births leading to infant mortality are high Very low birth weight infants require neonatal intensive care unit (NICU) care with daily costs exceeding $3,500 per infant and total costs which can exceed $1 million for a prolonged stay Beyond NICU costs are the extraordinary costs of managing the medical, educational and social needs of low birth weight infants Caring for the special healthcare needs of children who may develop neurological sequelae or chronic diseases can drain a family financially, physically and emotionally 11 Governor O’Malley’s 15 Strategic Policy Goals Reduce Infant Mortality in Maryland by 10% by 2012 Governor O’Malley’s 15 Strategic Policy Goals To ensure the health and well being of Maryland’s infants, the O’Malley-Brown Administration has set a goal and is implementing a plan to reduce infant mortality in Maryland by 10% by 2012 In 2007, Maryland’s number of infant deaths was 622 and its IMR was 8.0/1,000 By the end of 2012, Maryland aims to have 60 fewer infant deaths, resulting in an IMR of 7.2/1,000, which would be Maryland’s lowest recorded IMR in Maryland’s history Progress to Date The 10% reduction in infant mortality goal was achieved in 2010 (100% goal attainment) However, the rate for the African-American population increased, reaffirming the need for the targeted strategies that DHMH and partner agencies are pursuing Strategies Before Pregnancy - Expand Access to Women’s Comprehensive Health and Wellness Services • Require admission within one business day of the request for all pregnant women that present themselves to a behavioral health or disabilities programs • Mandate use of evidence-based practices for pregnant women and women of childbearing age • Assist with the training of community obstetrician-gynecologists regarding substance abuse, mental and developmental disabilities services • Support behavioral health programs identified for implementation to combat infant mortality During Pregnancy - Earlier Entry into Prenatal Care • Process applications for pregnant women in a more quickly For example, Family Investment Aides within local Departments of Social Services (funded by ARRA) will screen all applications for services for pregnant women so they can be prioritized and processed in a timely manner In addition, the Medicaid-only application will be changed to instruct all pregnant women to submit their applications to the local health department for processing in 10 days • Monitor department performance of eligibility determinations for pregnant women to ensure 10 day requirement • Send a letter to all prenatal providers encouraging uninsured pregnant women to apply for Medicaid • Train substance abuse and mental health providers concerning Medicaid eligibility and services for pregnant women 12 After Pregnancy - More Comprehensive Follow up Care • Increase the number of Medicaid women of childbearing age receiving Family Planning services • Increase the number of Medicaid postpartum women receiving follow-up services • Increase the number of hospitals that have adopted standardized discharge protocols and plan Delivering Results • • • Launched Comprehensive Women’s Health Centers to expand the services of family planning clinics, serving over 500 women per month in Baltimore City, Prince George’s County, and Somerset County Developed protocols to ensure that pregnant women applying for Medicaid receive prenatal care as early as possible, serving over 550 women in the first three months of the new protocols Funded Perinatal Navigators to assist at-risk women in navigating through the prenatal and perinatal care systems to insure infant and maternal health Progress toward delivery is monitored by the GDU, and assessed regularly at agency and crossagency Stat meetings 13 Overview of the Bright Beginnings of Prince George’s County Infant Mortality Reduction Initiative The Bright Beginnings of Prince George’s County is an initiative implemented by Access to Wholistic and Productive Living Institute, Inc., (AWPLI) (an Access Services Community Health Resource) seeks to address adverse pregnancy outcomes, including infant mortality, low birth weight, and very low birth weight in Prince George’s County Maryland The overall goal of Bright Beginnings is to reduce poor pregnancy outcomes (low birth weight, infant mortality, maternal pregnancy complications, etc.) among low income pregnant women living in Prince George’s County The specific objectives of Bright Beginnings include: (1) By June 30, 2012 provide case management services to 300 women (100 women annually); (2) Annually, identify 30 women who did not know they were pregnant and link them to prenatal care; (3) Annually provide smoking cessation services to 20 pregnant women; (4) Annually, provide health education (e.g parenting skills, nutrition, SIDS prevention, stress management, etc.) to 100 pregnant women; and (5) Annually link 100 pregnant/post partum women to medical homes for primary care (prenatal/postpartum and well child care) Specific program services delivered by Access Institute and its partners will include linking clients to appropriate prenatal and post-partum services through referrals (e.g WIC, Medicaid, health care etc.), providing health education for risk reduction and prevention, ensuring infants receive well child checksup, and providing pregnancy registration campaigns to identify women who may not know that they are pregnant to ensure that they are linked to prenatal care early Direct health care services will be delivered by community partners such as Greater Baden Medical Systems, Dimension Healthcare Systems, Prince George’s Social Service and the Prince George’s County Health Department Project services will cover the pregnancy and early post partum phases for women and infants living in the target area These intensive outreach and case management services will produce the following improved outcomes by the end of the three year period (June 2012): • • • • • • reduce the proportion of women enrolled prenatally in case management who deliver LBW infants; reduce the proportion of women enrolled prenatally in case management who deliver LBW infants; increase the proportion of women enrolled prenatally in case management who enter prenatal care in the first trimester; increase the proportion of women enrolled prenatally in case management who are linked to a primary care provider (medical home); increase the proportion of infant whose mothers are enrolled prenatally in case management who are linked to a primary care provider (medical home) and receive appropriate well child visits; and increase the proportion of women enrolled prenatally in case management who are screened for risks and linked to appropriate wraparound services (e.g WIC, Medicaid, housing etc.) 14 Healthy Pregnancy Spot the Signs of Labor False Labor Many women, especially first-time mothers-to-be, think they are in labor when they're not This is called false labor "Practice" contractions called Braxton Hicks contractions are common in the last weeks of pregnancy or earlier The tightening of your uterus might startle you Some might even be painful or take your breath away It's no wonder that many women mistaken Braxton Hicks contractions for the real thing So don't feel embarrassed if you go to the hospital thinking you're in labor, only to be sent home So, how can you tell if your contractions are true labor? Time them Use a watch or clock to keep track of the time one contraction starts to the time the next contraction starts, as well as how long each contraction lasts With true labor, contractions become regular, stronger, and more frequent Braxton Hicks contractions are not in a Most babies' heads enter the pelvis facing to one side, and then rotate to face down regular pattern, and they taper off and go away Some women find that a change in activity, such as walking or lying down, makes Braxton Hicks contractions go away This won't happen with true labor Even with these guidelines, it can be hard to tell if labor is real If you ever are unsure if contractions are true labor, call your doctor Stages of Labor 15 Labor occurs in three stages When regular contractions begin, the baby moves down into the pelvis as the cervix both effaces (thins) and dilates (opens) How labor progresses and how long it lasts are different for every woman But each stage features some milestones that are true for every woman First Stage The first stage begins with the onset of labor and ends when the cervix is fully opened It is the longest stage of labor, usually lasting about 12 to 19 hours Many women spend the early part of this first stage at home You might want to rest, watch TV, hang out with family, or even go for a walk Most women can drink and eat during labor, which can provide needed energy later Yet some doctors advise laboring women to avoid solid food as a precaution should a cesarean delivery be needed Ask your doctor about eating during labor While at home, time your contractions and keep your doctor up to date on your progress Your doctor will tell you when to go to the hospital or birthing center At the hospital, your doctor will monitor the progress of your labor by periodically checking your cervix, as well as the baby's position and station (location in the birth canal) Most babies' heads enter the pelvis facing to one side, and then rotate to face down Sometimes, a baby will be facing up, towards the mother's abdomen Intense back labor often goes along with this position Your doctor might try to rotate the baby, or the baby might turn on its own As you near the end of the first stage of labor, contractions become longer, stronger, and closer together Many of the positioning and relaxation tips you learned in childbirth class can help now Try to find the most comfortable position during contractions and to let your muscles go limp between contractions Let your support person know how he or she can be helpful, such as by rubbing your lower back, giving you ice chips to suck, or putting a cold washcloth on your forehead Sometimes, medicines and other methods are used to help speed up labor that is progressing slowly Many doctors will rupture the membranes Although this practice is widely used, studies show that doing so during labor does not help shorten the length of labor Your doctor might want to use an electronic fetal monitor to see if blood supply to your baby is okay For most women, this involves putting two straps around the mother's abdomen One 16 strap measures the strength and frequency of your contractions The other strap records how the baby's heartbeat reacts to the contraction The most difficult phase of this first stage is the transition Contractions are very powerful, with very little time to relax in between, as the cervix stretches the last, few centimeters Many women feel shaky or nauseated The cervix is fully dilated when it reaches 10 centimeters Second Stage The second stage involves pushing and delivery of your baby It usually lasts 20 minutes to two hours You will push hard during contractions, and rest between contractions Pushing is hard work, and a support person can really help keep you focused The baby twists and turns through the birth canal A woman can give birth in many positions, such as squatting, sitting, kneeling, or lying back Giving birth in an upright position, such as squatting, appears to have some benefits, including shortening this stage of labor and helping to keep the tissue near the birth canal intact You might find pushing to be easier or more comfortable one way, and you should be allowed to choose the birth position that feels best to you When the top of your baby's head fully appears (crowning), your doctor will tell you when to push and deliver your baby Your doctor may make a small cut, called an episiotomy (uh-peezee-OT-oh-mee), to enlarge the vaginal opening Most women in childbirth not need episiotomy Sometimes, forceps (tool shaped like salad-tongs) or suction is used to help guide the baby through the birth canal This is called assisted vaginal delivery After your baby is born, the umbilical cord is cut Make sure to tell your doctor if you or your partner would like to cut the umbilical cord Third Stage The third stage involves delivery of the placenta (afterbirth) It is the shortest stage, lasting five to 17 30 minutes Contractions will begin five to 30 minutes after birth, signaling that it's time to deliver the placenta You might have chills or shakiness Labor is over once the placenta is delivered Your doctor will repair the episiotomy and any tears you might have Now, you can rest and enjoy your newborn! “Securing a Healthy Future for Women and Their Families” 240 550-8607 Funded by the Mount Sinai School of Nursing and Health Resources Commission Maryland Prince George's County Prince George’s County Infant Mortality Tool Kit American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association (APA) Recommendations for the Treatment of Women with Depression during Pregnancy According to The American Congress of Obstetricians and Gynecologists (ACOG), between 14-23% of women will struggle with some symptoms of depression during pregnancy Depression is an illness that can be treated and managed during pregnancy, but the first step, seeking out help and support, is the most important What is depression during pregnancy? Depression during pregnancy, or ante-partum depression, is a mood disorder just like clinical depression Mood disorders are biological illnesses that involve changes in brain chemistry During pregnancy, hormone changes can affect brain chemicals, which are directly related to depression and anxiety These can be exacerbated by difficult life situations, which can result in depression during pregnancy What are the signs of depression during pregnancy? 18 Women with depression usually experience some of the following symptoms for two weeks or more: • • • • • • • • Persistent sadness Difficulty concentrating Sleeping too little or too much Loss of interest in activities that you usually enjoy Recurring thoughts of death, suicide, or hopelessness Anxiety Feelings of guilt or worthlessness Change in eating habits What are possible triggers of depression during pregnancy? • • • • • • • Relationship problems Family or personal history of depression Infertility treatments Previous pregnancy loss Stressful life events Complications in pregnancy History of abuse or trauma Can depression during pregnancy cause harm to my baby? Depression that is not treated can have potential dangerous risks to the mother and baby Untreated depression can lead to poor nutrition, drinking, smoking, and suicidal behavior, which can then cause premature birth, low birth weight, and developmental problems A woman who is depressed often does not have the strength or desire to adequately care for herself or her developing baby Babies born to mothers who are depressed may also be less active, show less attention and are more irritable and agitated than babies born to moms who are not depressed This is why getting the right help is so important for both mom and baby What is the treatment for depression during pregnancy? If you feel you may be struggling with depression, the most important thing is to seek help Talk with your health care provider about your symptoms and struggles Your health care provider wants the best for you and your baby and may discuss options with you for treatment Treatment options for women who are pregnant can include: 19 • • • • Support groups Private psychotherapy Medication Light therapy Are there any safe medications to treat depression during pregnancy? There is a lot of debate over the safety and long-term effects of antidepressant medications taken during pregnancy Some research is now showing that certain medications used to treat depression may be linked to problems in newborns such as physical malformations, heart problems, pulmonary hypertension and low birth weight A woman with mild to moderate depression may be able to manage her symptoms with support groups, psychotherapy and light therapy But if a pregnant woman is dealing with severe depression, a combination of psychotherapy and medication is usually recommended Women need to know that all medications will cross the placenta and reach their babies There is not enough information about which drugs are entirely safe and which ones pose no risks But when treating major depression, the risks and benefits need to be looked at closely The medication that can offer the most help, with the smallest risk to baby should be considered carefully If medication seems like the best treatment for your depression, forming a collaborative treatment team can be the most helpful This would include your prenatal care provider and your mental health provider Ask questions of both about what will provide you with the best treatment but still protect your baby Find out if you have options of medications and research on both What long term affects they have? Is your baby likely to deal with withdrawal symptoms after birth? Is this medication linked to health problems in the newborn or developmental delays in the future? And always remember that you need to weigh out the possibilities of problems in the future versus the problems that can occur right now if your depression is not treated appropriately Are there any natural ways to treat depression during pregnancy? With the controversy regarding the use of some antidepressants during pregnancy, many women are interested in other ways to help treat depression As mentioned above, support groups, psychotherapy and light therapy are alternatives to using medication to treat mild to moderate depression In addition to these, you may want to talk with your health care providers about some of the other natural ways to help relieve the symptoms of depression • Exercise Exercise naturally increases serotonin levels and decreases cortisol levels • Get adequate rest Lack of sleep greatly affects the body and mind's ability to handle stress and day to day challenges Work on establishing a routine sleep schedule that has you going to sleep and getting up at the same time • Diet and Nutrition Many foods have been linked to mood changes, the ability to handle stress and mental clarity Diets high in caffeine, sugar, processed carbohydrates, artificial 20 • • • additives and low protein can all lead to issues regarding your mental and physical health Make a conscious decision to start fueling your body with the foods that can help you feel better Acupuncture-New studies report acupuncture to be a viable option in treating depression in pregnant women Omega-3 fatty acids For years it’s been know that omega-3 can help with a number of health issues, but the newest studies are showing that taking a daily supplement of omega-3/ fish oils can decrease symptoms of depression Pregnant women would want to make sure to take a mercury free version of fish oil and check with their care provider or nutritionist on a recommended amount Herbal remedies -There are a number of herbal and vitamin supplements known to affect moods and the hormone serotonin Talk with your health care provider and nutritionist/ herbalist about the options of using St John's Wort, SAM-e, 5-HTP, magnesium, vitamin B6 and flower remedies Many of these cannot be used in conjunction with antidepressants and should be evaluated on the dosage for pregnant women If you not feel comfortable talking with your health care provider about your feelings of depression, find someone else to talk with The most important thing is that someone knows what you are dealing with and can try to help you Never try to face depression alone Your baby needs you to seek help and get treatment 21 Securing a Future for Women and their Families 240 550-8607 Funded through Mt Sinai School of Nursing & the Maryland Health Resource Commission Prince George’s County BRIGT BEGINNI NGS BRIGHT BEGINNINGS: of Prince George’s County INFANT MORTALITY REDUCTION INITIATIVE Securing a Future for Women and their Families 22 VISION LOVE LIFE HOPE FOR MORE INFORMATION OR TO MAKE AN APPOINTMENT CONTACT: Deneen Long-White MS., CHES- Program Director 240 550-8607 Acces s to Wholistic and Productive Living Institute, Inc 23 ... infant mortality in PGC Only as a team, can we create and sustain a model program for Prince George’s County and the state of Maryland which we aim to replicate throughout Maryland Background Infant. .. developed nations and Maryland (rate of 8.0/1,000) ranks 39th among states in infant mortality Although there has been a 32% reduction in Maryland’s infant mortality rate over the past 25 years, progress... George’sCounty Initiative Team Reduction of Infant Mortality Ensuring a Healthy Future for Women and Their Families Funded by Communities IMPACT Diabetes Center Mount Sinai School of Medicine Acknowledgments