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DR. RUTH ANN SHEPHERD: This was the multiple determinants of health model that was used
nationally at the time we developed Healthy Babies are Worth the Wait, and although there
are new versions, what we know is that the context and environment where people live
is as important as the medical care in influencing health outcomes.
So we need to implement not just the evidence-based medical interventions for preventing prematurity
but also to better define and implement the evidence base for addressing the social, environmental
and political determinants of health. That being said, there are still a number of medical
interventions, both medical and public health that we know right now can reduce preterm
birth. The approach of the Healthy Babies are Worth the Wait initiative was the vision
of Dr. Karla Damus, who was then a Senior Scientist at the March of Dimes.
And she asked, what would happen if we took what we know now about preventing preterm
birth and tried to implement all of it in a real world setting; could we make a difference?
She posed this question to the March of Dimes and Johnson & Johnson Pediatric Institute
who had a long standing corporate partnership to address prematurity and they decided to
fund a demonstration project to test that question.
The design of the initiative rather than working from the traditional cause and effect paradigm
was that community partners would work together to implement bundled interventions known to
be effective using both medical and public health interventions in real world settings
with the primary target of preventable preterm birth. This multi-level ecological approach
was to build systems of care and support that would mediate the psychosocial and contextual
factors, as well as promoting the evidence-based medical practices for preterm birth prevention.
Fortunately, national discussions are now going around similar models that focus on
building these comprehensive coordinated systems of care that link clinical and public health
practices. Hopefully communities will be able to address prematurity through these models
and funding will soon follow. The process where Kentucky was selected and chosen to
be the third partner and the location for this initiative included elements that many
of you would consider in a readiness assessment. A key factor was the data that would drive
the focus and direction of the project.
In Kentucky we had a preterm birth rate that was rising more than twice as fast as the
national rise. But, Kentucky had also analyzed that data and determined that the driving
force of our rising rate was actually the bigger preterm infants as you see in the slide,
those 33 to 34 weeks and 35 to 36 weeks both in vaginal births and c-section births. These
infants were later categorized in the literature as late preterm infants. But this data fit
with the initiative design and the focus on preventable preterm birth as there were indications
that many of these babies were being delivered electively, both nationally and in Kentucky.
Kentucky also had a high rate of potentially modifiable risk factors, especially smoking,
and another key factor, of course, was leadership. Kentucky had a committed leadership at the
state Department for Public Health and an active perinatal association to offer leadership
and expertise in support of the initiative. According to the power analysis done by March
of Dimes, we needed 12,000 births over the three years, and that would be 6,000 in the
intervention sites and 6,000 in comparison sites.
In the intervention sites we would do everything feasible in the real world setting to reduce
preterm birth and in the comparison sites do nothing but monitor their trends. Baseline
and follow up data including consumer surveys, provider surveys, policy and environmental
scans were done at both intervention and comparison sites. Three implementation sites were chosen
for strong leadership at both the local hospital and the local health department as we considered
them the two health leaders in the community.
The geographic diversity was also intentional. We had two rural settings and one urban setting.
We chose three very different practice settings for the intervention. One was a private practice
site, one university-based, and one a hospital-based clinic who had started centering. The comparison
sites were matched on geographic similarity and similar birth populations. The intent
of this model was to have enough flexibility to address issues according to each community’s
needs and capacity so that when we addressed the issues whether it was oral health or substance
abuse or smoking cessation or early elected delivery, it looked different in each of the
three sites but it fit their local situation.
The initiative was scheduled for a three year demonstration project and the primary target
was to reduce single preterm birth rates by 15 percent in the intervention sites. We also
helped to raise awareness of the issue of prematurity among all members of the community
and to enhance the ongoing local and national dialogue about preventable preterm birth.
As we began to develop this model for possible replication, we identified five core components
of Healthy Babies are Worth the Wait that you see here; partnership and collaboration,
provider initiatives, patient support, public engagement and progress measures.
Perhaps the most important part of any community-based project is developing strong partnerships.
In this project, we are fortunate to have national partners with March of Dimes and
Johnson & Johnson who worked side by side with our state and local experts in developing
and guiding this project. At each site partnerships were built through local implementation teams
which consisted of staff from local hospitals and health departments and included nurses,
physicians, administrators, public relations staff, risk managers, health educators, dental
hygienists and many others.
For many of these people, even though they were working in the same communities with
the same population of patients, they really didn’t know each other prior to Healthy
Babies are Worth the Wait, and as they established and strengthened their relationships, the
benefits accrued to the patients as the services and referral processes were strengthened and
improved. We regularly brought representatives from each site together for face to face meetings,
conference calls and other venues, and we made a concerted effort to get as many people
as possible from the sites to stay in national meetings on prematurity prevention.
This both increased the collaboration among the sites and kept their knowledge base current
with the current state of the art. In the other four areas, again, we do not try to
work on individual interventions, but on bundling of interventions that would work in their
location. Some of these were hospital-based interventions, others were public health interventions
and they were bundled according to local needs and local capacity. Through quarterly Grand
Rounds presentations and resource centers with current literature, we kept sites up
to date on best practices, both in the medical and public health arenas.
And after a Grand Rounds presentation, for example, we would convene the local implementation
teams to sit down and discuss how their local practices measured up to the best practices
they had just heard and what they could do to improve their processes. These teams were
enthusiastic and always anxious to do better, learn from what worked and what didn’t and
continually built better systems of care for their communities. Our signature education
piece was the Brain Card which came out of the focus groups we did at the beginning of
a project where we tested messages.
The mothers in those groups told us they needed something concrete to understand why the last
few weeks of pregnancy were important. When they saw the picture of the brain at 35 weeks
compared to term, they immediately recognized the significant differences and that became
a strong and persuasive talking point. Providers requested laminated copies of this to put
in every exam room so they could explain to patients who requested early delivery why
that was not a good idea.
This Brain Card spoke to all audiences and it’s been used widely now with providers,
patients and community partners. March of Dimes now has a simplified version available.