Community Health Project- Part One - Identifying the Project's Focus Kathleen Rogers King Walden University November 26, 2012 Community Health Project-Part One -Identifying the Project's Focus This paper will identify a significant health issue and a particular population for a health management plan. Support for the significance of this health issue, and rationale for the selection of this population will be presented. Evidence about the population will be examined and discussed in regards to one asset and one challenge of this particular population.
An approach to address the issue and the rationale for this choice will be provided with a minimum of five appropriate references. Health Issue and Population Defined as birth prior to 37 weeks gestation (ACOG, 2008), preterm birth affects about 12% of births in the United States. Preterm birth is an important public health priority costing over $26. 2 billion in 2005 according to the March of Dimes (2011) report on preterm birth. Prematurity is the second leading cause of death in children under 5 years, and the single most important cause of death in the first month of life (March of Dimes, 2011).
More than 15 million babies are born too soon, with 1 in 8 babies born premature every year worldwide; of these, over 1. 1 million preterm babies die due to complications of prematurity (CDC, 2012). The cost of the first year of birth for a preterm infant is 10 times greater than for term infants (Howson, Kinney & Lawn, 2012). Support and Rationale Women and infants are a vulnerable population. Maternal mortality and morbidity disproportionally affect vulnerable populations of women, such as those living in poverty, facing racial and ethnic discrimination, and having limited language skills (Anderson & Stone, 2013).
From a public health perspective infant mortality is considered the measuring stick for determining the health of the population, whereas maternal mortality is the divider between wealth and poverty (Anderson, 2013). Eliminating racial, ethnic, and socioeconomic disparities is critical for quality health care outcomes (Shi & Stevens, 2010). Preterm births occur more often among certain racial and ethnic groups with non-Hispanic black mothers being 1. 5 times more likely to have a preterm baby, and that baby 3. times more likely to die than a non-Hispanic white baby (CDC, 2012). Sadly, although 90% of preterm babies in high-income countries will survive, 90% of preterm babies born in low-income countries will die (Presem & McDougall, 2012). The implications of being born too soon extend beyond the neonatal period and throughout the life cycle, resulting in serious consequences such as cerebral palsy, and chronic lung disease, as well as, intellectual impairment, learning difficulties, poor health, vision and hearing loss (Institute of Medicine, 2007).
In general, the more immature the preterm infant, more life-support is needed, the risks of re-hospitalization are greater, and the burden of lifetime problems more significant (IOM, 2007). Assets and Challenges Preventing preterm birth remains a challenge (CDC, 2012). There is no test that can accurately predict a preterm birth, very little is known about the causes and mechanisms of preterm birth, or about how to prevent a preterm birth, and few effective preventative strategies are available (March of Dimes, 2012; WHO, 2009; IOM, 2007).
Once a woman is pregnant, most of the interventions to prevent preterm birth only delay onset long enough to administer steroids to the mother to help prevent respiratory distress in the infant after birth and transfer the mother and fetus to a hospital for the appropriate level of care (IOM, 2007). Studies indicate that many of the factors associated the preterm birth frequently occur together, particularly in minority women, or those who have low socioeconomic status (IOM, 2007).
Medical conditions such as chronic hypertension, diabetes, infections, and stress are associated with preterm birth, as are any history of a preterm birth in a previous pregnancy, a family history of preterm birth, infertility, and a pregnancy of twins or triplets (IOM, 2007). Any significant gains to be made in the study of preterm birth will be in the area of prevention and eliminating disparities (IOM, 2007). Feasible, sustainable, cost-effective care solutions can be made available by collaboration, cooperation and alignment of services (WHO, 2012).
Clinical research continues to identify ways to prevent preterm deliveries. For example, a progesterone medication (17-alpha hydroxyprogesterone caproate or 17P) may prevent preterm birth among women who have had a prior preterm birth (CDC, 2012). Approaches and Interventions Addressing preterm birth is now an urgent priority for reaching the WHO, Millennium Development Goal 4 (WHO, 2012). Reducing child deaths by two-thirds by 2015 requires a rapid expansion of our global commitments to implement change (WHO, 2012).
Collaborative and partnership management models have evolved for addressing action and prevention programs such as, the World Health Organization’s Every Woman, Every Child, Global Strategy for Women and Children’s Health, March of Dimes, Save the Children, Born too Soon, The Partnership for Maternal, Newborn & Child Health (PMNCH), and the United Nations Millennium Development Goals (MDG’s 4 & 5) which aim to save the lives of 16 million women and children by 2015 (Howson et al, 2012; WHO, 2009).
Nationally, the framework is complete; since 1980, the CDC’s Healthy People series has been based on core public concepts: population surveillance, population health, prevention and early intervention, identification of root causes, outcome assessment, and continuous feedback so that interventions can be adjusted appropriately (Manderscheid, 2009). To achieve the Healthy People objectives, it is essential to monitor improvement regularly to ensure the resources are directed appropriately and effectively (Shi & Stevens, 2010).
A set of ten measurable leading health indicators (LHIs) was developed, which also reflect the risks of preterm birth; these are physical activity, obesity, tobacco use, substance abuse, sexual behavior, mental health, injury and violence, environmental quality, immunization, and access to health care (Shi, 2010). Implementation and Rationale Implementing priority, evidence-based interventions for prevention include reducing unplanned adolescence pregnancies, short time gaps between births, unhealthy pre-pregnancy weight (underweight or obesity), substance abuse (e. g. tobacco use) and chronic disease (e. . diabetes, hypertension). Screening for infectious sexually transmitted disease (e. g. HIV, syphilis), and implementing early treatment can also help reduce the incidence of preterm labor (WHO, 2012). Internationally, all countries need to ensure universal access to comprehensive antenatal care, quality childbirth services and emergency obstetric care (WHO, 2012). In addition, workplace policies need to promote healthy pregnancies and reduce the risk of preterm birth including regulations to protect pregnant women from physically demanding work, and exposure to harmful pollutants (WHO, 2012).
Greater provision for life-saving medications, supplies and services, as well as the resources and policies are needed to enable women and children adequate access to health care, especially skilled care at the time of birth (WHO, 2009). Empowering, and educating girls, providing health promotion, access to care for cost-effective interventions in contraception, and encouraging preconception family planning can increase the likelihood of healthy planned pregnancies, and improve preterm birth prevention according to the WHO, Born Too Soon: Global Action Report on Preterm Birth (Presem & McDougall, 2012).
In addition, Kangaroo Mother Care (skin to skin incubation with mother) can cut preterm deaths in half saving an estimated 450,000 babies a year (Presem & McDougall, 2012). The provision of inexpensive antenatal corticosteroids and antibiotics is estimated to reduce the risk of breathing difficulties in premature babies, saving around 370,000 lives a year (WHO, 2012). Fontenot and Collins Fantasia (2012) concluded that 100mg of progesterone vaginally every night between 24 and 34 weeks gestation resulted in lower incidence of preterm labor, birth, and delivery.
Approach and Action A recent article in The Lancet (2012), claims from a panel of experts, that five proven interventions could begin lowering preterm birth rates of 5 percent across 39 high-resource countries, including the United States, by 2015, and would prevent prematurity for 58,000 babies a year and $3 billion in health and economic costs (March of Dimes, 2012): * Eliminating early cesarean section deliveries and inductions of labor unless medically indicated; * Decreasing embryo transfers during assisted reproductive technologies; * Helping women quit smoking; Providing progesterone supplementation to women with high risk pregnancies; * Cervical cerclage for high-risk women with short cervix. The majority of preterm births occur spontaneously with no known cause, recent studies show that a short cervix is the single best predictor of preterm birth. Slager and Lynne (2012) propose screening for shortened cervical length, a universal risk factor, in conjunction with a proven clinical intervention by transvaginal ultrasound.
Although not available in all areas, transvaginal ultrasound is the most reliable method to evaluate cervical length, it is found to be most effective for risk estimates under 30 weeks gestation, and predictive results were improved by combining with obstetric history (Slager, J. & Lynne, S. , 2012). The combination of positive fetal fibronectin (fFN) testing and cervical length less than 25 mm is a strong predictor of impending preterm birth (Tharpe, Farley, & Jordan, 2013).
As a MSN educator, my goal will be to educate nursing, midwifery, and medical students in the principles and methods of assessment, prevention and early intervention of preterm birth indicators. On the Perinatal Special Care Unit of my employment, a new system of prenatal education will be proposed to administration detailing the benefits of group prenatal care in reducing low birth weight in premature babies (Massey, Schindler Rising, & Ickovics, 2006). Centering Pregnancy Prenatal Care Model
Centering Pregnancy group prenatal care is an innovative model of care for addressing the complex psychosocial needs of the mother and her family. Centering Pregnancy prenatal care promotes relationship-centered care, facilitates learning, develops mutual support, and strengthens the opportunities for communication and nurturing among women. Centering Pregnancy prenatal care encourages social networking, supportive relationships with their significant other are developed, women experience less stress, fewer pregnancy complications, and fewer adverse neonatal outcomes (Massey et al, 2006).
Research indicates that prenatal social support has been associated with improved fetal growth and greater infant birth weight. Good social support can improve birth outcomes; measured in longer gestations and significantly larger babies, increase women’s confidence, satisfaction, and increase self-nurturing (Massey, 2006). Centering Pregnancy is a model for group prenatal care that results in perinatal outcomes that equal or exceed prenatal traditional care, especially for teens, and other cultures accustomed to group support (Anderson, 2013).
Centering Pregnancy exemplifies an evidence-based best practice for nurse-midwives. This model places all three components of prenatal care- risk assessment, education, and support- into the group setting. It fosters a sense of empowerment as prenatal group members are encouraged to take responsibility for their own health care and group members are encouraged to seek information about healthy behaviors and common concerns of pregnancy, which builds a partnership between patient and provider (Massey, 2006).
Translating this model of providing prenatal care for our hospitalized high-risk antepartum patients is the approach I intend to take because the evidence for improved outcomes with group care for high-risk women seems compelling, and may even be a future model of care for other countries, and women of diverse cultures (Tandon, Colon, Vega, Murphy, & Alonso, 2012). References American College of Obstetricians and Gynecologists (ACOG). (2008). Use of progesterone to prevent preterm birth. Obstetrics and Gynecology, 112, 963-965. American Psychological Association. (2010).
Publication manual of the American Psychological Association. (6th. ed. ). Washington, DC. Anderson, B. , & Stone, S. (2013). Best practices in midwifery, using the evidence to implement change. Springer Publishing. New York, NY. Centers for Disease Control and Prevention (CDC). (2012). Preterm Birth. Retrieved from http://www. cdc. gov/reproductivehealth/maternalinfanthealth/PretermBirth. htm Fontenot, H. B. , Collins Fantasia, H. (2012). Vaginal progesterone to prevent preterm birth in high-risk women. Nursing for Women’s Health. Association of Women’s Health, Obstetric and Neonatal Nurses. 37-241. ISSN: 1751-4851 Howsen, C. , Kinney, M. , Lawn, J. (2012). The global action report on preterm birth. Preterm birth matters. March of Dimes. 9-14 Lynch, E. , Dezen, T. (2012). Preterm birth can be prevented with a few proven treatments, Lancet article says: Global partners challenge 39 high-income countries. March of Dimes. http://www. marchofdimes. com/news/10898. html March of Dimes. (2011). March of Dimes 2011 premature birth report card. Retrieved from http://www. marchofdimes. com/peristats/pdflib/998/US. pdf Massey, Z. Schindler Rising, S. , Ickovics, J. (2006).
Centering pregnancy group prenatal care: Promoting relationship-centered care. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35, 286-294. doi:10. 1111/J. 1552-6909. 2006. 00040. x Manderscheid, R. (2009). Aiming for a healthier population by 2020: Moving our fields toward prevention, early intervention, and population health. Behavioral Healthcare; 29, 1; Proquest Central. pg. 51 Presem, C. , McDougall, L. (2012). Born too soon: The global action report on preterm birth. World Health Organization (WHO). Retrieved from http://www. who. int/pmnch/media/news/2012/preterm_birth_report/en/index9. tml Shi, L. , & Stevens, G. (2010). Vulnerable populations in the United States (2nd. ed. ). Jossey-Bass. San Francisco, CA. Slager, J. , & Lynne, S. (2012). Assessment of cervical length and the relationship between short cervix and preterm birth. Journal of Midwifery & Women’s Health, 57(1): S4-S11. doi:10. 1111/j. 1542-2011. 2012. 00209. x Tandon, S. D. , Colon, L. , Vega, P. , Murphy, J. , Alonso, A. (2012). Birth outcomes associated with receipt of group prenatal care among low-income Hispanic women. Journal of Midwifery and Women’s Health. 57(5). 476-481. doi: 10. 111/j. 542-2011. 2012. 00184. x Tharpe, N. , Farley, C. , Jordan, R. (2013). Clinical practice guidelines for midwifery & women’s health. (4th ed. ). Jones & Bartlett Learning. Burlington, MA. 198-201. World Health Organization (WHO). (2009). The worldwide incidence of preterm birth: A systematic review of maternal morbidity and mortality. Bulletin of the World Health Organization, 88, 31-38. doi: 10. 2471/BLT. 08. 06255 World Health Organization (WHO). (2012). Born too soon: The global action report on preterm birth. http://www. who. int/pmnch/media/news/2012/preterm_birth_report/en/index. html
