This document provides information on decreasing health disparities in perinatal outcomes through engaging patients in prenatal screening. It discusses current components of prenatal care according to ACOG and WHO, including screening for medical and socioeconomic factors. It also reviews data on racial disparities in pregnancy outcomes like preterm birth and low birth weight. Interventions discussed include CenteringPregnancy group prenatal care models and a protocol to prevent recurrent preterm birth. The document concludes with information on Zika virus infection risks and recommendations for evaluation and screening in pregnancy.

1. Jodi F. Abbott, MD MHCM
jabbott@bu.edu
Beth Monahan, CNM, MPH
3.24.16
Decreasing health disparities in perinatal
outcomes by engaging our patients
in Prenatal Screening

2. Jodi F. Abbott, MD MHCM
jabbott@bu.edu
Beth Monahan, CNM, MPH
3.24.16
“You don’t go telling White people nothing”
African American women's
perspectives on the influence
of violence and race on
depression and depression
care. 2010 American journal of
public health, 100(8)

3. • We have no disclosures

4. Learning Objectives:
This talk will help you to-
4

5. ACOG Prenatal Care Components 5

6. ACOG Prenatal Care Components 6
• Maternal genetic
diseases/risk
• Fetal risk of aneuploidy
• Anemia
• Hypertension
• Diabetes
• Obesity
• Depression
• History of
surgery
• Gonorrhea/
Chlamydia
• Syphilis
• Hepatitis
B/C
• Rubella
• Varicella
• Zika
• Tobacco
• Narcotics
• Cocaine
• Amphetamine
s/Adderall
• Bleeding in
Pregnancy
• History of preterm
delivery
• Twins
• Fetal Position

7. Prenatal Care Components with
Health Disparities related to
Social determinants of health
7
ACOG Committee Opinion December 2015
Racial and Ethnic Differences in Obstetrics and Gynecology

8. WHO Prenatal Care
Current components
• Screening for health and
socioeconomic conditions
• Providing therapeutic
interventions
• Educating for safe birth and
intrapartum emergencies
WHO Programme to map best perinatal practices 2011

9. WHO Prenatal Care
Current components
• Screening for health and
socioeconomic conditions
• Providing therapeutic
interventions
• Educating for safe birth and
intrapartum emergencies
WHO Programme to map best perinatal practices 2011

10. Racial Disparities in Pregnancy
Outcomes 10
Racial and Ethnic Disparities in Obstetric Outcomes and Care: Prevalence and Determinants. A. Bryant et al.

11. Stress and Preterm Labor
Multifactorial
Adapted from Lu AJOG 2005
Money
Stress
Preterm
Delivery
Poor
Fetal
Growth
Low
Birth Weight
Infant
Mortality
Work
Family
Abuse
Safety
Racism
Health
Soci
al
Isola
tion

12. March of Dimes Prematurity
Report Card 2015: 9.6% 12

13. Rates of Unintended Pregnancy
in the US
Guttmacher Institute 2014

14. BLACK PRETERM BIRTHS
As a percent of all births
Kaiser Family Foundation 2014

16. Depression, Health Disparities
and Preterm Birth
• August 2015 USPHSTF Recommends Universal
Depression Screening for Pregnancy
• Kaiser Permanente prospective cohort study
demonstrates an adjusted hazard ratio of preterm
birth in women with depression
• aHR = 2.2 (CI 1.1–4.7)
16
Li, D., Liu, L., & Odouli, R. (2009). Presence of depressive symptoms
during early pregnancy and the risk of preterm delivery: a prospective
cohort study.Human Reproduction, 24(1), 146-153.

17. Nicolaidis, C., Timmons, V., Thomas, M. J., Waters, A. S., Wahab, S., Mejia, A., & Mitchell, S. R. (2010). “You don't go tell
white people nothing”: African American women's perspectives on the influence of violence and race on depression and
depression care. American journal of public health, 100(8), 1470-1476.
“You don’t go telling White
People Nothing”

18. CenteringPregnancy
Comprehensive Curriculum
Nutrition and weight gain goals
Common discomforts
Relaxation and stress reduction
Birth options
Early parenting
Contraception options
Breastfeeding
The hospital experience
The “blues” and depression
Personal goals

19. Academic
Site:
Base: (N=) Ethnic
Disparities:
Preterm
(% reduction):
LBW
(% reduction):
Yale/Emory 1047 80% (Black) 9.8 (33%) 7.7 % (33%**)
Vanderbilt 355 40% (Black) 9.7(26%) 8.58% (36%)
U-South
Carolina
316 34% (Black) 7.9(47%) 8.9 (22%*)
BMC 220 75% (Black) 5.7(43%) 7.26% (26%)
Improved Health Disparities Outcomes
by Academic Medical Center
** LBW reduction associated with 5 or more CP group visits
*LBW reduction not statistically significant

20. 20
CenteringPregnancy cost savings by
preterm delivery prevented
The estimated societal economic impact of Preterm
Birth is at least $26.2 billion annually.

22. Barrier Analysis
Rapid assessment tool
used to identify behavioral
determinants associated
with a particular behavior
so that more effective
behavior change
messages and support
activities can be developed

23. Process of Barrier Analysis
IDENTIFY DO-ER’s and NON DO-
ER’s
IDENTIFY DETERMINANTS
Why people do or not do the
behavior

25. Counseling and Documentation at
Index SPTD
SPTD pts on
MFM pp
service
Education
campaign for
faculty &
residents
Stickers & Emails
Posting protocol

26. Lessons Learned: Unsuccessful
Interventions
• Grand rounds/Resident
lectures
• Jodi sings a preterm
labor song
• Processes excluding
patients
• Failing to prioritize
preterm birth as an
obstetric RISK event
• Trying to communicate
priorities without data

27. Lessons Learned: Successful
Interventions
• Counseling at delivery of index
pregnancy
• Experiential counseling of patients
by residents
• Focused identification of patients
• Streamlined processes
• Assigning 17OHp Resource RN
• EMPOWERED Patients are ready
for 17Ohp
• Audit and feedback of providers
• Partnership with local DPH & CHC’s
Thera
Wilson RN
17OHP
Prior Auth
Queen

28. BMC Initiative to Prevent Recurrent Preterm Birth
Identify Women with a
History of Spontaneous
Preterm Birth < 37 weeks
MFM Consult
Cervical US until
30wks
17 OH Progesterone
16-36wks
Cervix <2.5cm
<24wks
Cervix <2.5cm
>24wks
Cervical Cerclage Betamethasone
Consult can be
done in ATU
Makena (17)OHP
needs a prior auth
“Spontaneous” delivery
NOT due to preeclampsia
or IUGR
Call 414-2000
to book ATU appts
Protocol as per SMFM, ACOG and Boston Public Health Commission guidelines

30. 30
Most slides courtesy of Samih Nassif BUSM 3
ZIKA

31. Zika Virus
• Flavivirus transmitted by an infected Aedes mosquito.
• Clinical manifestations: low-grade fever with
maculopapular rash, arthralgia, non-purulent
conjunctivitis.
• Incubation: between 2-14 days, illness is usually mild.
• Associated with Guillain-Barré syndrome, fetal loss, and
congenital microcephaly.
Images from: http://laboratoryinfo.com/wp-content/uploads/2016/01/zika-virus.jpg

32. Diagnosis of Zika Virus infection
• Maternal:
– Serum reverse-transcription polymerase chain reaction
(RT-PCR) testing or antibody (IgM, IgG) serology 7
days after symptom onset.
• Intrauterine infection (positive or inconclusive Zika
laboratory test results)
– diagnostic amniocentesis
– serial ultrasonography
• Newborn
– Cord Blood Serum screening/Placental pathology
ACOG. (2016). Practice Advisory: Updated Interim Guidance for Care of Obstetric
Patients And Women Of Reproductive Age During a Zika Virus Outbreak.

33. Association Between Zika Virus Infection and
Microcephaly: The Data
Schuler-Faccini L, R. E., Feitosa IM et al. (2016). Possible Association Between Zika Virus Infection and Microcephaly — Brazil, 2015. MMWR Morb Mortal Wkly
Rep, 65, 59–62. doi: http://dx.doi.org/10.15585/mmwr.mm6503e2
• Retrospective review of 37 cases of confirmed
congenital microcephaly after birth.
• Exposure to Zika virus: presence of maternal
rash, residence in or travel during pregnancy to
areas of Zika exposure
• All were negative for syphilis, toxoplasmosis,
rubella, cytomegalovirus, and herpes simplex
virus infections.
• Weaknesses:
– Media coverage lead to increased
surveillance and measurement of HC, thus
increased number of cases reported.
– Zika virus was not serologically
confirmed on infants or mothers, and
thus presence of a rash can lead to recall
bias.

34. Current Recommendations for Zika
virus evaluation in Pregnancy
• SMFM:
– If fetal HC is >2 SD below the mean, careful intracranial
US for anatomy.
– Diagnosis of microcephaly is > 3SD below mean
– If the intracranial anatomy is normal, recommend follow
up ultrasound in 3-4 weeks
• ACOG:
– Avoiding travel to areas of Zika exposure during pregnancy.
– If travel cannot be avoided, use EPA-approved bug spray with
DEET, covering exposed skin, staying in air-conditioned or
screened-in areas, and treating clothing with permethrin
– If partner has traveled to ZEA use condoms remainder pregnancy
SMFM. (2016). SMFM Statement: Ultrasound Screening for Fetal Microcephaly Following Zika Virus Exposure. American Journal of Obstetrics and Gynecology. doi:
http://dx.doi.org/10.1016/j.ajog.2016.02.043
ACOG. (2016). Practice Advisory: Updated Interim Guidance for Care of Obstetric Patients And Women Of Reproductive Age During a Zika Virus Outbreak.

35. Prenatal Zika Screening at BMC:
Protocol
• Universal Screening:
– at Intake/F/up Ob visit
– ATU Fetal survey
• Have you or your partner been outside the US during your
pregnancy?
• YES -ZIKA ENDEMIC AREA
• Entered into EPIC: Potential Zika Exposure
• Did you have mosquito bites, illness with fever, or red
eyes?
– YES or returned W/IN 12 weeks
• Offer serum screening and recommend
• Serial US for fetal growth
35

36. Prenatal Zika Screening at BMC:
Current stats
• 65 women screened positive since 2/7/16
• 30 women accepted serum screening
• 30 pending serum screens
• 2 near term patients with fetal growth delay
without criteria for microcephaly
• 1 delivery (last week) of IUGR baby to screen
positive Mother
– False negative Head Circumference in utero
– Postnatal diagnosis of Microcephaly
36

37. BMC Protocol:
High Risk + Zika Screen Mothers
• Any Mother positive blood test
• Any Mother blood test without result and ANY
clinical finding
• Any screen positive Mother with ultrasound
findings of:
– IUGR
– CNS structural abnormality
– Microcephaly diagnosis
37

38. Ideal Workflow for
High risk + Zika Screen:
Per MFM Yarrington/Pedi ID Barnett team
• Spreadsheet of all screen high risk Mothers and
EDD’s to Pedi ID team
• Mother/Baby identified at admission to L&D and
Pedi team notified
• Cord blood collected/held and placenta sent to
path
• Pedi team notified of High risk screen positive
baby at nursery arrival
38

39. Thanks
39
jabbott@bu.edu