Title: Health Services Research, Education, and Community Service in Reproductive Health and Perinatal Care
1World Health Organization
Collaborating Center in Reproductive Health
Emory University Woodruff Health Sciences Center
The National Centers for Disease Control and
Prevention (CDC) Georgia Department of Human Re
sources Division of Public Health
Alfred W. Brann, Jr., MD, Director
Woodruff Health Sciences Center
Emory University
Brian McCarthy, MD, Principal Investigator
The National Centers for Disease Control
and Prevention
2Collaborating Center in Reproductive Health
Vision
Every woman should have the opportunity, if she
desires, to experience a wanted pregnancy that
results in a full-term normal baby, and following
childbirth that she is alive and healthy and her
infant is healthy and safe in the context of
family and community.
3Womens Health
- Education
- Gender Issues
- Religion
- Culture/Society/Family
4Womens Health
- Political Stability
- Economy/Financial Security
- Health Care System
- Government Structure
5NEED
- More than 50 of the infant deaths annually occur
during the first week after birth.
- This is largely a consequence of a poorly
functioning health care delivery system that
results in the poor health of women, and poorly
managed pregnancies and births.
6NEED
- Knowledge and skills exist today that can reduce
by some 50 the excessive rates of both maternal
and infant mortality.
- This is possible if there are appropriate
attitudes and if there is a functioning modern
maternal and perinatal health care delivery
system.
7Collaborating Center in Reproductive Health
Mission
to serve the people who serve the people...
by enabling health professionals in ministries of
health, departments of health, or universities to
build a foundation of sustainable knowledge and
skills in health services research through
education using a state or country-specific
health project at the level of the Health
District.
8The Balashikha Project
- MISSION
- To dramatically improve U.S.-Russia relations
through a public/private initiative addressing
the most acute problem facing Russia its
declining population - (V. Putin, 2001).
9The Balashikha Project
- WHY
- Russias new births are not at replacement
levels. Outmigration, decreasing adult lifespan
(less than 59 years) and high infant mortality
all contribute to its declining population.
10The Balashikha Project
- WHAT
- Create a sustainable reduction in population
decline by decreasing infant mortality by 50 in
a significant sized health region in Russia.
11The Balashikha Project
- WHERE
- City of Balashikha and the Moscow Oblast, Russia
12The Balashikha Project
- HOW
- Establish a maternal and perinatal health care
delivery system (using an internationally
integrated set of health strategies) in the
Moscow Oblast to significantly reduce infant
mortality, and serve as a model for the Russian
Federation.
13Levels of the Health Care Delivery System (HCDS)
Informal
Skill Knowledge Attitude Resources Management
Manpower Materials Money
Formal
Inter- sectoral
14The Balashikha Project
- Components of a Maternal and Perinatal Health
Care Delivery System
- The Moscow Region Perinatal Center
- Evidence-based Perinatal Guidelines
- Modern Perinatal Surveillance System
15The Balashikha Project
- Components of a Maternal and Perinatal Health
Care Delivery System
- Continuous Quality Improvement Program
- International Public Health Practice
- Postgraduate Education-Distance Learning
- Public Policy and Legal Assistance
16The Balashikha Project
- Microsoft Health Care
- Application Software Vertical Health Initiatives
- such as Word, Excel, etc. such as HIV/AIDS,
Polio, etc.
-
- Operating Systems Health Care Delivery
System
- on which all Application on which all
Vertical Health
- Software is placed Initiatives are placed.
17The Balashikha Project
- WHO
- The following partners have brought about the
Balashikha Project.
18The Balashikha Project
- WHO
- Future of Russia Foundation (2,000,000 in seed
capital)
- Rotary Club of Atlanta (20,000)
- Rotary Club of Stowe, VT (20,000)
- Elfin Society of General Electric Company
(estimated 2,000,000 in Russia)
19The Balashikha Project
- Moscow Oblast Ministry of Health (Governor
Gromov committed 3,000,000)
- USAID (500,000 Global Development Alliance)
- World Health Organization Collaborating Center in
Reproductive Health (intellectual capital)
20The Balashikha Project
- WHY SHOULD AMERICANS HELP RUSSIA?
- Good health is a bedrock issue for building a
democratic society and is essential for economic
development.
- Russia, with an educated and aspiring domestic
workforce, can become one of our most important
trading partners.
- Russia is a strong ally of the U.S. in the war on
terrorism.
- Our support creates another level of mutual trust
and respect.
21The Balashikha Project
- I think nothing our generation
- could do is more important
- than getting Russia into
- the fold of successful countries,
- and nothing worse could happen
- than to lose it.
- Dr. Howard Mette, Rotarian and CCI/PEP Volunteer,
Youngstown, Ohio, 2000
22(No Transcript)
23NEED
- The status of the health of the infant
- is dependent on
- the status of health of the woman and the
pregnant woman.
24NEED
- The vast majority of men and women wish to have
children.
- All societies depend on their next generation for
their survival, well being, success and social
security.
25NEED
- Pregnancy and childbirth are the only normal
physiologic processes associated with a risk of
death.
- Women (unlike men) are exposed to this risk of
death during pregnancy and childbirth.
26NEED
- Finally, the health care system supporting
pregnancy and childbirth is the one through
which we must all pass, whether it is a good or
bad system.
27NEED
- Problems in reproductive health affect many lives
and families.
- The morbidity and disability in both mother and
child who receive suboptimal health care have
devastating and permanent consequences.
- These individual consequences further adversely
impact society and its ability to not just
survive but thrive.
28Collaborating Center in Reproductive Health Focus
The CCRH addresses one of the four top health
problems facing the state of Georgia and the
World - the complex health problems of
reproductive-age women, pregnant women, and
infants during the perinatal period of life.
29Health Services Research- The systematic study of
whether current medical and other relevant
knowledge is effectively used to improve the
health of a community under an existing set of
conditions.
30DATA...
INFORMATION...
INTERVENTION
31Interventions for Reducing Mortality
- Womens and Maternal Health
- Maternal and Fetal Care
- Neonatal Care
- Infant Care
32The Opportunity Gap- The potential for
reduction in excessive mortality based on a
comparison between rates already achieved by one
sub-population in a defined geographical area
with those experienced by the remaining
population.
33NEED
- The problems leading to high rates of mortality
and morbidity are not randomly distributed
women who are economically and intellectually
disadvantaged have, along with their infants, the
highest mortality rates, regardless of whether
they live in a third-world country or in
third-world conditions in a developed country.
34NEED
- Any further significant reduction in infant
mortality will need to focus on improving the
health of the woman.
- This will involve (1) changing the frequency of
premature infant births, and (2) decreasing
neonatal deaths, with a particular focus on the
early neonatal period (1st week).
35Georgias Six Perinatal Regions
Hospital Perinatal Center
36Management - a process for planning,
implementing, and evaluating an organized
response to a defined problem.
37Management Process
Performance Assessment
Problem Definition
Monitoring Evaluation
Intervention
Are we doing the right thing? Are we doing things
right?
38The Management Cycle in Maternal and Child Health
Care
PROBLEM DEFINITION
A Standard
- High Risk vs. Lower Risk
- Problem Description
- Identification of Risk Factors
- Identification of High Risk Groups
39The Management Cycle in Maternal and Child Health
Care
Performance Evaluation
Guidelines
- Four Essential Questions to Be Asked
- What is supposed to happen?
- What do people think is happening?
- What do people say is happening?
- What is really happening?
40The Management Cycle in Maternal and Child Health
Care
INTERVENTION
- What are they doing? vs What should they do?
- Coverage
- Referral Pattern
- Matching Skill
- Altering Risk Factors
- Training/Education
- Planning/Policy
- The five Rs
- The right person
- At the right place
- At the right time
- Doing the right thing
- Doing it right
41The Management Cycle in Maternal and Child Health
Care
MONITORING EVALUATION
A Standard
- Evaluation Measurement Comparison
- Outcome
- Process
- Community Education
- Training
- Use of Appropriate Technology
42Surveillance- a dynamic process
which collects, analyzes, and responds to data on
the occurrence and distribution of events in a
defined population within a geographical area.
43Data Surveillance System
System of Data Analysis
System of Data Collection
A - Adaptable R - Responsive C - Cost Effective
S - Simple
System of Response
44You can not manage...
What you do not measure.
45We are data rich
But information poor.
46DATA...
INFORMATION...
INTERVENTION
47Total Cohort Accountability
- Every pregnancy counts
- so account for every pregnancy.
- Every newborn has weight
- so weigh every newborn.
48Perinatal Health Care Surveillance System
Integrated Management
Performance Assessment
Problem Definition
System of Data Analysis
System of Data Collection
A - Adaptable R - Responsive C - Cost Effective
S - Simple
System of Response
Intervention
Monitoring Evaluation
Are we doing the right things? Are we doing
things right?
49Conceptual Framework for Action
Trigger Symbols
- Model for the HCDS
- Perinatal Surveillance Principles
- Management Process
50NEED
- The World Bank (in a 1993 publication ?Investing
in Health) described
- GOOD HEALTH as essential for economic
development throughout the world and made two
major recommendations.
51NEED
- THESE ARE
- To pursue policies to reduce poverty and expand
education, especially for girls
- To invest in the most cost-effective public
health initiatives and essential clinical
services. These are in the field of womens
health during the reproductive years and in child
health.
52- Spontaneous Experiences in Social Change
- COSTA RICA
- A senior general decided that a standing army was
not needed and government funds were put into
education and health.
53- Spontaneous Experiences in Social Change
- CUBA
- A revolution occurred with government funds and
programs going to improve services and access to
education, health care and social services.
54- Spontaneous Experiences in Social Change
- Karela, INDIA
- The state in India with the lowest infant
mortality that has matriarchal passage of wealth
and an intermittent elected communist government
that has strongly facilitated literacy,
accomplished land reform, and tolerated religious
diversity.
55- Spontaneous Experiences in Social Change
- ROMANEO
- An Eastern Block Country that mandated that each
woman have five children in order to have workers
for economic development.
56Reproductive HealthComparative Issues Around
the World
- A.W. Brann, Jr., M.D.
- World Health Organization Collaborating Center
- in Reproductive Health
- Atlanta, Georgia
- Vanderbilt University
- World Health Week 2005
57NEED
- Therefore, the health care system dealing with
childbirth might naturally be viewed as a very
important need a need of the highest priority.
- Yet the following facts state otherwise
58NEED
- Women are the poorest, least educated, and least
healthy segment (approximately one half) of the
worlds population.
- Women earn significantly less than men while
working approximately 25 hours longer.
-
59NEED
- The literacy rate for women in developing
countries is approximately 75 of the male rate.
- Maternal mortality rates are unconscionably high
over half a million (585,000) women die in
childbirth each year.
60Number of Feto-Infant Deaths Data Rich, Informati
on Poor
Total Deaths 3936
61Perinatal Surveillance System
- Foundation Birthweight by Age at Death
- Action Interventions for Reducing Mortality
- Opportunity Gap Excessive Mortality Rates
62Number of Feto-Infant Deaths Data Rich, Informati
on Poor
Age at Death
Total Deaths 3936
Birth Weight
63Birthweight and Age at Death
Late Fetal Death (28 wks)
Early Neontal Death (
Late Neonatal Death (7-27days)
Post Neonatal Death (28 days)
1
2
3
4
VVLBW (0-999gms)
5
6
7
8
VLBW (999-1499 gms)
9
10
12
11
IBW (1499-2499 gms)
13
14
15
16
NBW (2500 gms)
64Perinatal Surveillance System
- Foundation Birthweight by Age at Death
- Action Interventions for Reducing Mortality
- Opportunity Gap Excessive Mortality Rates
65Interventions for Reducing Mortality
- Womens and Maternal Health
- Maternal and Fetal Care
- Neonatal Care
- Infant Care
66Birthweight and Age at Death
Late Fetal Death (28 wks)
Early Neontal Death (
Late Neonatal Death (7-27days)
Post Neonatal Death (28 days)
W M Health 1
W M Health 2
W M Health 3
W M Health 4
VVLBW (0-999gms)
W M Health 5
W M Health 6
W M Health 7
W M Health 8
VLBW (999-1499 gms)
M F Care 9
Newborn Care 10
Infant Care 12
Newborn Care 11
IBW (1499-2499 gms)
M F Care 13
Newborn Care 14
Infant Care 15
Infant Care 16
NBW (2500 gms)
67Summary of Perinatal Health Care Interventions
- Family Planning
- Nutrition
- Micronutrients
- STDs
- Substance Abuse
- Anticipatory Guidance
- Preconception Care
- Pregnancy Identification
Womens Maternal Health Interventions
Infant Care Interventions
- Pregnancy Identification
- Prenatal Surveillance Care
- Anticipatory Guidance
- Intrapartum Monitoring
- ART for complications
- Surgical Services
- High Risk Maternal
- Followup
Maternal Fetal Care Interventions
Newborn Care Interventions
- Parenting Skill Education
- Child Health Supervision
- Breastfeeding/nutrition
- Immunization
- Growth/Development Monitoring
- Anticipatory Guidance
- A.R.I.
- D.D.
- Injury Control
- ART for the At-Risk-Infant
- Community Services
- Clean Delivery
- Resuscitation
- Thermal Control
- Breast Feeding
- ART for the At-Risk-Infant
- Baby Friendly Concept
- Parenting Skill Education
68Perinatal Surveillance System
- Foundation Birthweight by Age at Death
- Action Interventions for Reducing Mortality
- Opportunity Gap Excessive Mortality Rates
69The Opportunity Gap- The potential for
reduction in excessive mortality based on a
comparison between rates already achieved by one
sub-population in a defined geographical area
with those experienced by the remaining
population.
70Planning for Change
1. Measure and Compare 2. Standard against which
to compare
71Analysis of Sociodemographic Risks
Deaths per 1,000 live births
Death Rate
Excess Rate
Education
Sub-group
Age
White Group 1 20 13 years
5.7 .7 White Group 2
20 4.1 White Group 3 19 ears 13.3 8.3
Black Group 1 20 13 years
14.0 9.0 Black Group 2
20 14.0 Black Group 3 19 rs 19.6 14.6
72Calculating The Opportunity Gap Excess Morta
lity
Excess Mortality BWPR
- BWPR
TARGET POPULATION
STANDARD
Birthweight Proportionate Rate (BWPR)
Number of deaths in a given weight group
Total Number of births in all weight groups
BWPR
x 1000
OR
Maternal Health of Deaths
( in cells)
x 1000
( in entire table)
73Total Feto-Infant Deaths 3936
Excessive Feto-Infant Deaths 2314
74Feto-Infant Mortality Rate White Group I, Atlanta
Region
2.1
0.8
0.9
1.2
Total 5.0
75What do Current Data Show?
- Gaps in fetal and infant mortality exist
between
- groups of women as defined by race age, level
of
- education and residence.
- One in seven women (standard woman) 14
5/1000
- White, 20 yrs., 13 yrs. Education
- Atlanta Perinatal Region (APR)
- Six in seven women
86 14.7/1000
- Black (including college educated)
- White(even the standard group living outside
APR)
76What do Current Data Show?
- Excess fetal and infant death rates occur in all
six perinatal regions, with the highest death
rate in the Macon region followed by
Albany, Savannah, Augusta, Columbus and
Atlanta. - The standard woman has excess fetal and infant
mortality when compared to the same woman who
lives in Connecticut.
77Areas of Concentration
Area
Potential for Improvement
LOW HIGH
WOMENS MATERNAL HEALTH
60 Maternal Fetal Care
10 Neonatal Intensive
Care 9
POSTNATAL CARE
21
- All four areas contribute independently to
affect infant mortality.
- High-risk neonatal and maternal/fetal care has
reduced infant deaths.
- Low birth weight and preterm births are directly
related to womens
- health and account for 60 of preventable
deaths.
- Term infants who die after discharge account for
21 of preventable deaths.
- Womens maternal health and postnatal care are
community issues.
78Central Nervous System Morbidity
- There has been an increase in the number of
cases of cerebral palsy in children who were high
risk neonates.
- Infants less than 1000 gm. (from the Neonatal
Research Network- NICHD) survive with significant
handicapping conditions, including
- Cerebral Palsy 17
- Mental Retardation 50
- Blindness / Hearing Loss 10
- Learning Disabilities 50
- The average cost of the INITIAL HOSPITALIZATION
of a VLBW is 49,000.
- The average cost for supporting an infant who
survives with CEREBRAL PALSY is 500,000 over
their lifetime.
1
2
3
4
79VLBW Infants
- 50 of Georgias infant mortality is from only
2 of the births- 1500 gm.
- We cannot identify the woman with a pregnancy
that will end in her first
- preterm birth.
- The frequency of recurrence of a VLBW infant to
a woman whose first
- pregnancy ended with a VLBW infant is
- - 8 for white women
- - 13 for black women
- - 2x for teenage girls
- Of 2500 women who deliver VLBW infants
(500-1500gm) each year
- - 1700 are live births
- - 800 are still births
80Interconception Care
- Child Spacing 18-24 months
- Bonding with Infant
- Treatment of Chronic Medical Conditions
- Nutritional Assessment
- Modify Adverse Lifestyle Practices
- Treatment of STD
- Intendedness of Pregnancy
81Where in the World is Carmen Sandiego?
Birthweight Proportionate Mortality Rates
White Atlanta
Black Atlanta
Jiaxing
2.1
12.5
1.9
0.8
1.8
8.2
0.9
3.6
9.2
1.2
4.1
3.4
5.0
22.0
22.7
Cali
West Bank
Malawi
10.6
2.5
12.3
26.4
9.5
8.9
12.6
16.2
12.3
80.2
30.8
7.3e
43.8
55.4
131.2
82Where in the World is Carmen Sandiego?
Birthweight Proportionate Mortality Rates
2.1
12.5
1.9
0.8
1.8
8.2
0.9
3.6
9.2
1.2
4.1
3.4
5.0
22.0
22.7
10.6
2.5
12.3
26.4
9.5
8.9
12.6
16.2
12.3
80.2
30.8
7.3e
43.8
55.4
131.2
83Georgia Resident Births 1994-1998
Birth Weight 1500gm. or less
84Number of Live Births less than 1500 gm.
by Census Tract 1994-1998 Georgia and Public Heal
th Districts
85Number of Live Births less than 1500 gm.
by Census Tract Neighborhood view in Fulton Count
y