Pregnant Women, Infants and Family Systems: Tools and Techniques to Assess Risks

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A. Nienhuis presentation given at the 2012 South Carolina Home Visiting Summit

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  • The Annie E. Casey Foundation has released its annual Kids Count Data Book for 2010. The Data Book presents ten indicators of child wellbeing with standardized, comparable data for the latest available years (2007 and 2008). South Carolina once again ranks among the bottom ten states in terms of child wellbeing. The 2010 report ranks SC 45th, ahead of only 5 states (Mississippi, Louisiana, Arkansas, Alabama, and New Mexico). Over the past two decades of the Kids Count Data Book, South Carolina has never ranked better than 42nd. Typically, SC ranks 45th or 46th. Fluctuations in low incidence indicators such as child and teen deaths tend to move states up or down within the bottom 10 states, but these fluctuations have little statistical meaning. The bottom line for SC is that we are very near the bottom, reliably ahead of only Mississippi and Louisiana.
  • First tool-PRAMS SC PRAMS is an ongoing, population-based survey that collects information on SC mothers who have recently given birth to a live-born infant. Monitors and describes maternal characteristics, attitudes, and behaviors during pregnancy and in early infancy and describes relationships between known risk factors occurring before or during pregnancy and selected adverse pregnancy outcomes It is important to remember that information in this module is representative of all South Carolina mothers delivering live infants in South Carolina. Thus, generalizations can be made to this group only. Also, keep in mind that all survey information is based on self-reports from the women I. Background In 2006, South Carolina’s infant mortality rate was 8.4 deaths per 1,000 live births. From 1989 to 2006, the overall infant mortality rate declined from 12.8 to 8.4. The race specific infant mortality rate for white babies was 5.7 deaths per 1,000 live births in 2006, while for black infants the rate was 13.2 deaths per 1,000 births in 2006. As compared to infants of white mothers, infants of minority mothers are more than twice as likely to die before they reach one year of age (2). Birthweight is a major determinant of infant death. Infants with a birthweight of less than 2,500 grams (LBW) are at increased risk of death and future chronic disabilities. A comprehensive report on the prevention of low birthweight calls for a better understanding of the behavioral, social, and health service utilization factors that may contribute to the health disparities among minority women and women of lower socioeconomic status (3). II.
  • Based on selected PRAMS survey topics—some risk factors show us that when working with families there are a few issues we need to make sure we assess—
  • Smoking Fact Sheet From 1993-2008: The percentage of women smoking during the last trimester of pregnancy fell from 15.9% in 1993 to a low of 11.4% in 2003, but has since returned to 15.9% in 2008. The percentage of women who quit smoking during pregnancy decreased from 54.0% in 1999 to 39.8% in 2008. The percentage of women who quit smoking during pregnancy and remained nonsmokers after delivery has fallen from a high of 29.2% in 2006 to 16.2% in 2008. From 2006-2008, the percentage of women who smoked during the last trimester has increased from 12.1% to 15.9%. This includes increases among mothers who were 18-34 years of age, mothers that had a high school education or less and mothers that were on Medicaid. In 2008, women who reported smoking during the last trimester of pregnancy were more likely to: be non-Hispanic white be unmarried and have less than a high school education. We have not yet reached the Healthy People 2010 goal to increase abstinence from tobacco by pregnant women to 99%. In 2008, just over 84% of mothers abstained from smoking during pregnancy.
  • regnant women should take note that smoking during pregnancy as well as exposure to secondhand smoke is extremely detrimental to the cognitive development of the newborn baby. New research suggests that active and passive smoking are dangerous for the baby's mental growth. Read more at http://www.medicaldaily.com/articles/12138/20120915/smoking-during-pregnancy-impairs-mental-development-newborn.htm#XpM5iS8TbEtL0cZu.99
  • Why do we care about their drinking before the pregnancy? Because 50% of all pregnancies are unintended and therefore women may be consuming alcohol before they even know the are pregnant Remember this data is all self reported too
  • he new program, called the Screening, Brief Intervention and Referral to Treatment (SBIRT) program, will provide doctors tools and reimbursement to perform standardized screening and referrals to more than 30,000 pregnant women each year through receiving Medicaid benefits. Pregnant women will be asked a series of standardized questions by their doctor and/or plan care coordinator. The one-page questionnaire is specifically designed for ease of use and effectiveness in eliciting responses and – as with all medical records – remains strictly confidential. If a woman indicates she is using harmful substances, she will be referred for drug and alcohol treatment or to free smoking cessation counseling.   Those with depression and victims of domestic violence will receive counseling and/or a referral to local women’s shelters. The SBIRT program includes SCDHHS, the SC Department of Alcohol and Other Drug Abuse Services (DAODAS) the SC Department of Health and Environmental Control, SC Department of Mental Health (DMH), as well as many other private non-profit organizations, such as the SC March of Dimes and the SC Coalition Against Domestic Violence and Sexual Assault. “ Problems caused by alcohol, tobacco and other drugs are the only completely preventable type of birth defects,” said DAODAS Director Bob Toomey. “It is crucial that we identify pregnant women using these harmful substances as early as possible and provide the help they need to stop.  The health of their babies depends on it.” Both DAODAS and DMH have been actively engaged in the planning of SBIRT and will help ensure expectant mothers find placement in appropriate treatment programs available throughout the state. Primary care doctors enrolled in Medicaid coordinated care plans are receiving special training on the SBIRT questionnaire and referral tool and will receive an enhanced payment for the screening. To gauge the program’s effectiveness, researchers at the University of South Carolina will track the health outcomes of each baby born to mothers who received screenings and treatment. SBIRT will be made available to all pregnant Medicaid enrollees in the state in March following regional training.
  • On PRAMS survey we ask two questions related to depression—these are the results of the women who responded “yes” to feelings of depression-this is a profile of those women +PPD symptoms are seen more in non hispanic black women and those numbers are on the rise Usually between 18-24 Less than a high school education Not married
  • 2 nd Screening Tool-Edinburgh, could also include another depression screening tool if desired This screening tool can be used with every woman postpartum You can find online free of charge with instructions on how to score This is a screening tool—not an diagnosis so if a woman scores high you need to refer them for treatment and further consultation When should you use the scale—some say to use 6-8 weeks postpartum BUT some hospitals are using right after delivery prior to d/c—controversy over that but at least the hospital is able to refer the woman back to OB-GYN sooner rather than later PROBLEM: Not all Ob-Gyns are willing to start a woman on an anti-depressant because you have to f/u with the patient etc. So please continue to follow this woman until she is into care with a MD.
  • South Carolina ranks 7 th in the Nation for women being killed at the hands of a partner This is serious business for everyone
  • We know women are more vulnerable during pregnancy to violence Remembering these numbers are SELF reported Much more violence against women goes Unreported
  • Behaviorally specific inquiries (for example, “ Does your partner ever hit, slap, kick, choke, or punch you?”) are critical to capturing intimate partner violence in clinical settings. Because the chart prompt embedded in our health history form was simply a line item stating “Physical/Sexual/Emotional Abuse,” health care providers may have underidentified victims of past or current abuse. Of note, before the implementation of the new annual health history forms in 2004, all health care providers were oriented to the form components and a brief update on intimate partner violence screening was provided. Since 2007, didactic sessions on intimate partner violence have been added to the residents’ core curriculum, new postgraduate year 1’s are now introduced during orientation to the hospital’s standard- 1164 Kang et al Interpersonal Violence and Screening OBSTETRICS & GYNECOLOGY ized intimate partner violence screening and interventional protocol, the Women’s Primary Care Center nurse practitioners now participate in a didactic session on intimate partner violence, and monthly audits of intimate partner violence screening in the Women’s Primary Care Center have begun as part of a hospitalwide initiative to improve preventive care. Finally, evidence-based screening questions have been directly incorporated into the annual examination forms, replacing the more general prompt of “ Physical/Sexual/Emotional Abuse
  • Pregnant Women, Infants and Family Systems: Tools and Techniques to Assess Risks

    1. 1. Tools and Techniques To AssessRisk in Home VisitationAmy Nienhuis, LISW-CP, MSWDirector of ProgramsChildren’s Trust of South Carolina
    2. 2. OBJECTIVES Participants will be able to name 5 risk factors for infant morbidity and mortality. Participants will identify 3 screening tools to use when assessing pregnant women, infants, and family systems.
    3. 3. Risk Factors:How Do I Know What IsImportant? Proof is in the data  Why is data important to me as a home visitor?
    4. 4.  2012 KIDS COUNT Data Book: State Trends in Child Well-Being
    5. 5. Risk Factors to Assess Smoking Alcohol use Psychosocial stress Depression Intimate Partner Violence Sleep Positioning in Infants
    6. 6. Smoking:During Pregnancy andPostpartumo Smoking during pregnancy has been linked to 10 percent of all infant deaths and can impair fetal brain and nervous system development.o Babies who are born to women who smoke are three times more likely to die from Sudden Infant Death Syndrome (SIDS) and are typically born underweight.o Smoking during pregnancy is also associated with low birth weight in infants
    7. 7. 2 As + RSC Quitline http://tcrc.rapidlearner.com/ContentRegi stration.aspx?DocumentID=a50dd4e2- d416-4b48-951d- fbbefdcbd2ae&Cust=34622&ReturnUrl=/ p/3462221282
    8. 8. Alcohol Use Before Pregnancy inSC SC PRAMS DATA BOOK, 2008
    9. 9. Alcohol Use During Pregnancy inSC SC PRAMS DATA BOOK, 2008
    10. 10. SBIRT: Screening, Brief Intervention,Referral to Treatment• SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders.• Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur.• Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.• Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.• Referral to treatment provides those identified as needing more extensive treatment with access to specialty care.
    11. 11. SBIRT Use in SC DHHS: The program is specific to pregnant women to include 12 months postpartum. SBIRT is important in increasing the health outcomes of the mother and infant. Medicaid will currently pay $24.00 for the screening And $48.00 for the brief intervention
    12. 12. SBIRT:ALCOHOL SCREENING TOOLCurrent barriers:Educating physiciansaboutThe use and availabilityMandatory reportingLaws
    13. 13. Postpartum depression
    14. 14. Postpartum depression:Edinburgh Assessment Tool
    15. 15. Intimate Partner Violence SC PRAMS DATA BOOK, 2008
    16. 16. SC PRAMS DATA BOOK, 2008
    17. 17. Intimate Partner Violence:ACOG recommended questions3 simple questions ACOG recommends:1. Within the past year -- or since you have been pregnant -- have you been hit, slapped, kicked or otherwise physically hurt by someone?2. Are you in a relationship with a person who threatens or physically hurts you?3. Has anyone forced you to have sexual activities that made you feel uncomfortable?
    18. 18. Infant Mortality in SC
    19. 19. Leading Causes of Infant Deathin SC2010 IMR Highlights, PHSIS, SCDHEC
    20. 20. Infant deaths due to Accidental Suffocation,Strangulation in Bed, and Threats to Breathing2010 IMR Highlights, PHSIS, SCDHEC
    21. 21. SC PRAMS Data Book, 2008
    22. 22. Assessing and Educating onSafe Sleep Environments As a home visitor you have a unique opportunity to actually assess the living situation Educate family on safe sleep environment Cribs for Kids in your area Safe Kids
    23. 23. AAP Guidelines for Safe Sleeping• Always place your baby on his or her back for every sleep time.• Always use a firm sleep surface. Car seats and other sitting devices are not recommended for routine sleep.• The baby should sleep in the same room as the parents, but not in the same bed (room- sharing without bed-sharing).• Keep soft objects or loose bedding out of the crib. This includes pillows, blankets, and bumper pads.• Wedges and positioners should not be used.• Pregnant woman should receive regular prenatal care.• Don’t smoke during pregnancy or after birth.• Breastfeeding is recommended.• Offer a pacifier at nap time and bedtime.• Avoid covering the infant’s head or overheating.• Do not use home monitors or commercial devices marketed to reduce the risk of SIDS.• Infants should receive all recommended vaccinations.• Supervised, awake tummy time is recommended daily to facilitate development and minimize the occurrence of positional plagiocephaly (flat heads).Published 10/18/2011 12:00 AM
    24. 24. QUESTIONS?Amy Nienhuis, LISW-CP, MSW803-744-4035anienhuis@scchildren.org

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