Meena Abraham, DrPH, MPH Director of Epidemiology Services Baltimore City Health Department

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1 Meena Abraham, DrPH, MPH Director of Epidemiology Services Baltimore City Health Department

2 271 Neighborhood Statistical Areas 55 Community Statistical Areas 26 Zip Codes

3 Characteristic Baltimore City Maryland Total Population 620,961 (10.8%) 5,773,552 White 29.6% 58.2% Black 63.7% 29.4% Other 6.7% 12.4% Below Poverty Level 21.3% 8.6% Women Ages Years 146,212 1,193,402 Births 8,945 73,783 3

4 Baltimore City = 73.3 yrs CSA Range = 20 yrs Maryland = 78.7 yrs 4

5 10 Priority Areas Promote access to quality health care for all Be tobacco free Redesign communities to prevent obesity Promote heart health Stop the spread of HIV and other sexually transmitted infections Recognize and treat mental health care needs Reduce drug use and alcohol abuse Encourage early detection of cancer Promote healthy children and adolescents Create health promoting neighborhoods 5

6 Healthy Communities Healthy Families Healthy Women 6

7 7

8 8

9 per 1,000 live births All Black White 9

10 Established in 1993 Tri-Partnership Baltimore City Health Department Baltimore City Healthy Start Maryland State Medical Society Developed process for conducting FIMR Engaged health and human service providers and community stakeholders in improving perinatal systems of care 10

11 Women have multiple risk factors for poor pregnancy outcome. Women are not always aware of their risks or ways to reduce them. Providers and the women they care for are often not aware of support services and community resources. Opportunities exist to improve services and increase awareness of ways to reduce risks. 11

12 Follow up care for women with poor pregnancy outcome to reduce repeat poor outcomes Perinatal infections screening and rescreening for early diagnosis and treatment Family planning and preconception/ interconception care for adequate pregnancy interval and improved maternal health status Adequate utilization of prenatal care for early and continuous care 12

13 Perinatal Outcomes I. Congenital Syphilis II. Fetal Alcohol Spectrum Disorder III. Perinatal HIV Transmission 13

14 14

15 15

16 Alarming increases in congenital syphilis rates STD Program Manager convened meeting of stakeholders for recommendations Decision made to adapt FIMR to look comprehensively at perinatal and infectious disease systems of care not just from the traditional disease intervention approach 16

17 3 rd trimester repeat syphilis screening effective Syphilis testing at delivery essential for women With no prenatal care Not tested at 3 rd trimester visit Infected after 3 rd trimester screening Re-infected after 3 rd trimester screening Opportunity for improved coordination between providers, and between providers and health dept Need to educate providers regarding health department resources 17

18 Case review meetings are held annually by Baltimore City FIMR Case management is coordinated between maternal and infant nursing and STD staff Women with syphilis are followed through delivery, not just completion of treatment Congenital syphilis cases are reviewed by all FIMR programs in Maryland 18

19 Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effects in the fetus. IOM Report to Congress,

20 Fetal and Infant Deaths Alcohol Use 10% Cigarette Use/Smoking 28% Drug Use 25% One or more substance use 39% Maryland PRAMS % not asked about alcohol use during PNC 50% used alcohol in 3 months before pregnancy 20

21 I. Identify opportunities for prevention within existing service systems Analyzed Baltimore City Healthy Start client enrollment data and conducted focus groups II. Identify contributors to alcohol use during pregnancy Conducted case reviews of women with alcohol use during pregnancy in partnership with Sinai Hospital

22 27% pregnant Healthy Start enrollees used alcohol around conception or while pregnant Alcohol use co-occurs with other substance use Women not routinely screened for alcohol use in pregnancy emphasis on illegal drug use Providers and pregnant women lack awareness of range of effects from alcohol exposure Poor relationship with baby s father as stressor Alcohol use instead of drugs because of Child Protective Services reporting

23 Identified opportunities for prevention in Healthy Start intake and case management Educated Healthy Start staff about FASD Formed Coalition for FASD Prevention Established Maryland Coalition for FASD Prevention Medical Society and Regional Perinatal Advisory Group producing a substance abuse in pregnancy provider toolkit Medical Society holding provider training 23

24 24

25 Baltimore-Towson MSA ranked third nationally for rates of adults living with HIV disease (2009) Majority (67%) of HIV-exposed births occur in Baltimore City 17% of post-partum women participating in the Maryland PRAMS survey reported that no healthcare provider had talked with them about HIV during pregnancy ( ) 25

26 Indicator HIV-infected women of reproductive age Reported Perinatal HIV Exposures Confirmed Perinatal HIV Transmissions Perinatal HIV Transmission Rate 6,784 7,144 7,368 7,351 7, % 4.0% 2.9% 1.8% 1.6% Source: Enhanced Perinatal Surveillance, Maryland DHMH 26

27 National partners: CDC, ACOG, & CityMatCH Local partners: Maryland State Medical Society and Sinai Hospital of Baltimore, with participation of Baltimore City FIMR In 2010, nine cases of perinatal HIV exposure reviewed to examine opportunities for HIV testing and linkage to care for births occurring to HIV positive women in Baltimore City 27

28 Inconsistent documentation of patient education Inconsistent family planning counseling Poor utilization of partner services Lack of support systems due to HIV/AIDS stigma Need for intensive case management and support services for engagement in care and treatment adherence Domestic violence and substance abuse issues Housing and transportation needs 28

29 Baltimore FIMR-HIV Team established IRB approvals at several hospitals Included in CDC HIV Prevention FOA Developing plan to coordinate resources and tasks between city and state for case reporting and to conduct reviews 29

30 30

31 Sentinel event reportable health outcome Adapt FIMR process and materials to review the specific sentinel event Engage key partners hospitals, programs, service providers, etc. in project Ensure appropriate expertise available to review case summaries and participate in case review team deliberations Provide training on FIMR process Provide training on standards of care for the sentinel event under review 31

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