Design and Operation of the Transformed National Healthy Start Evaluation.

Purpose Improving pregnancy outcomes for women and children is one of the nation's top priorities. The Healthy Start (HS) program was created to address factors that contribute to high infant mortality rates (IMRs) and persistent disparities in IMRs. The program began in 1991 and was transformed in 2014 to apply lessons from emerging research, past evaluation findings, and expert recommendations. To understand the implementation and impact of the transformed program, there is a need for a robust and comprehensive evaluation. Description The national HS evaluation will include an implementation evaluation, which will describe program components that affect outcomes; a utilization evaluation, which will examine the characteristics of women and infants who did and did not utilize the program; and an outcome evaluation, which will assess the program's effectiveness with regard to producing expected outcomes among the target population. Data sources include the National HS Program Survey, a HS participant survey, and individual-level program data linked to vital records and the Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Assessment Descriptive analyses will be used to examine differences in risk profiles between participants and non-participants, as well as to calculate penetration rates for high-risk women in respective service areas. Multivariable analyses will be used to determine the impact of the program on key outcomes and will explore variation by dose, type of services received, and grantee characteristics. Conclusion Evaluation findings are expected to inform program decisions and direction, including identification of effective program components that can be spread and scaled.

Putting the "M" back in the Maternal and Child Health Bureau: reducing maternal mortality and morbidity.

Maternal mortality and severe morbidity are on the rise in the United States. A significant proportion of these events are preventable. The Maternal Health Initiative (MHI), coordinated by the Maternal and Child Health Bureau at the Health Resources and Services Administration, is intensifying efforts to reduce maternal mortality and severe morbidity in the U.S. Through a public-private partnership, MHI is taking a comprehensive approach to improving maternal health focusing on five priority areas: improving women's health before, during and beyond pregnancy; improving the quality and safety of maternity care; improving systems of maternity care including both clinical and public health systems; improving public awareness and education; and improving surveillance and research.

Clustering patterns of comorbidities associated with in-hospital death in hospitalizations of US adults with venous thromboembolism.

BACKGROUND: Venous thromboembolism (VTE) is a significant source of mortality, morbidity, disability, and impaired health-related quality of life in the world. OBJECTIVE: We aimed to evaluate the clustering patterns and associations of 29 comorbidities with in-hospital death among adult hospitalizations with a diagnosis of VTE in the United States by analyzing data from the 2009 Nationwide Inpatient Sample. METHODS: This cross-sectional study included 153,124 adult hospitalizations with a diagnosis of VTE. Adjusted rate ratios and 95% confidence intervals (CI) for in-hospital death were generated by using multivariable log-linear regression models to measure independent associations between comorbidities and in-hospital death. RESULTS: We estimated that 44,200 in-hospital deaths occurred in 2009 among 773,273 US adult hospitalizations with a diagnosis of VTE. Subgroups of hospitalizations with comorbidities of "congestive heart failure," "chronic pulmonary disease," "coagulopathy," "liver disease," "lymphoma," "fluid and electrolyte disorders," "metastatic cancer," "peripheral vascular disorders," "pulmonary circulation disorders," "renal failure," "solid tumor without metastasis," or "weight loss" were positively and independently associated with 1.07 (95% CI: 1.02-1.12 ) to 2.06 (95% CI: 1.97-2.16) times increased likelihoods of in-hospital death, when compared to those without the corresponding comorbidities. The clustering patterns of these comorbidities by 4 disease categories (i.e., "cancer," "cardiovascular/respiratory/blood," "gastrointestinal/urologic," and "nutritional/bodyweight") were associated with 2.74 to 10.28 times increased likelihoods of in-hospital death, as compared to hospitalizations without any of these comorbidities. The overall increase in the cumulative number of comorbidities corresponded to significantly elevated risks (P-trend<0.01) for in-hospital death among hospitalizations with a diagnosis of VTE. CONCLUSION: The presence of multiple comorbidities is ubiquitous among hospitalizations of adults with VTE and among in-hospital deaths with VTE in the United States. The findings of our study further suggest that, among hospitalizations of adults with VTE, the presence of certain comorbidities or clustering of these comorbidities significantly elevates the risk of in-hospital death.

Prevalence of polycystic ovary syndrome among the privately insured, United States, 2003-2008.

OBJECTIVE: The purpose of this study was to estimate the prevalence of polycystic ovary syndrome (PCOS) and its phenotypes as defined by the National Institutes of Health, Rotterdam criteria, and Androgen Society. STUDY DESIGN: Thomson Reuters MarketScan Commercial databases (Thomson Reuters Healthcare Inc, New York, NY) for 2003-2008 were used to calculate the prevalence of PCOS and to assess differences in demographic characteristics and comorbid conditions among women who were 18-45 years old with and without PCOS. RESULTS: The prevalence of PCOS was 1585.1 per 100,000; women with phenotype A or classic PCOS were most prevalent at 1031.5 per 100,000. Women with PCOS were more likely than those without PCOS to be 25-34 years old, be from the South, be infertile, have metabolic syndrome, have been seen by an endocrinologist, and have taken oral contraceptives. CONCLUSION: This is the first study to use all available criteria to estimate the prevalence of PCOS. Providers should evaluate women with menstrual dysfunction for the presence of PCOS.

Evaluation of bleeding disorders in women with menorrhagia: a survey of obstetrician-gynecologists.

OBJECTIVE: To better understand the current evaluation of unexplained menorrhagia by obstetrician-gynecologists and the extent to which a bleeding disorder diagnosis is being considered in this population. STUDY DESIGN: A total of 1200 Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists were invited to participate in a survey on blood disorders. Respondents completed a questionnaire regarding their patient population and their evaluation of patients with unexplained menorrhagia. RESULTS: The overall response rate was 42.4%. Eighty-two percent of respondents reported having seen patients with menorrhagia caused by a bleeding disorder. Seventy-seven percent of physicians reported they would be likely or very likely to consider a bleeding disorder as causing menorrhagia in adolescent patients; however, only 38.8% would consider bleeding disorders in reproductive age women. CONCLUSION: The current data demonstrate that obstetrician-gynecologists seem to have a relatively high awareness of bleeding disorders as a potential underlying cause of menorrhagia.

Is polycystic ovary syndrome another risk factor for venous thromboembolism? United States, 2003-2008.

OBJECTIVE: We sought to determine prevalence and likelihood of venous thromboembolism (VTE) among women with and without polycystic ovary syndrome (PCOS). STUDY DESIGN: We performed a cross-sectional analysis using Thomson Reuters MarketScan Commercial databases for the years 2003 through 2008. The association between VTE and PCOS among women aged 18-45 years was assessed using age-stratified multivariable logistic regression models. RESULTS: Prevalence of VTE per 100,000 was 374.2 for PCOS women and 193.8 for women without PCOS. Compared with women without PCOS, those with PCOS were more likely to have VTE (adjusted odds ratio [aOR] 18-24 years, 3.26; 95% confidence interval [CI], 2.61-4.08; aOR 25-34 years, 2.39; 95% CI, 2.12-2.70; aOR 35-45 years, 2.05; 95% CI, 1.84-2.38). A protective association (odds ratio, 0.8; 95% CI, 0.73-0.98) with oral contraceptive use was noted for PCOS women. CONCLUSION: PCOS might be a predisposing condition for VTE, particularly among women aged 18-24 years. Oral contraceptive use might be protective.

Impact of pre-conception health care: evaluation of a social determinants focused intervention.

The purpose of this study was to evaluate the outcomes of the social determinants component of a multiple determinants model of pre- and inter-conception care. Health department vital statistics and infectious disease data on birth and factors influencing birth outcomes were analyzed for participants in a program designed to mitigate the effects of social class and stress in contrast to a matched comparison group and other relevant populations. The program showed promising results related to reducing infant mortality and reducing other high-risk factors for poor birth outcomes, including low birth weight and sexually transmitted disease. Social determinant interventions, designed to mitigate the impact of social class and stress, should be considered with efforts to reduce infant mortality, particularly the disparities associated with infant mortality. Additional research should be conducted to refine replicable social determinant focused interventions and confirm and generalize these results.

Overcoming social and health inequalities among U.S. women of reproductive age - challenges to the nation's health in the 21st century.

OBJECTIVE: To frame the discussion of the nation's health within the context of maternal and child health. METHODS: We used national data or estimates to assess the burden of 46 determinants. RESULTS: During 2002-2004, U.S. women of reproductive age experienced significant challenges from macrosocial determinants, to health care access, and to their individual health preservation. Two-thirds of women do not consume recommended levels of fruits and vegetables. Overall, 29% experienced income poverty, 16.3% were uninsured. About one in four women of reproductive age lived with poor social capital. Compared with white women of reproductive age, non-white women reported higher levels of dissatisfaction with the health care system and race-related discrimination. Among all U.S. women, chronic diseases contributed to the top nine leading causes of disability adjusted life years. About one-third of women had no prophylactic dental visits in the past year, or consumed alcohol at harmful levels and smoked tobacco. One in three women who had a child born recently did not breast feed their babies. Demographics of women who are at increased risk for the above indicators predominate among the socioeconomically disadvantaged. CONCLUSIONS: At least three-fourths of the U.S. women of reproductive age were at risk for poor health of their own and their offspring. Social intermediation and health policy changes are needed to increase the benefits of available health and social sector interventions to women and thereby to their offspring.

Secular trends in the rates of preeclampsia, eclampsia, and gestational hypertension, United States, 1987-2004.

BACKGROUND: Few studies have reported on population-level incidence of or trends in the hypertensive disorders of pregnancy, and none report on data through 2004. We describe population trends in the incidence rates of preeclampsia, eclampsia, and gestational hypertension in the United States for 1987-2004. METHODS: We analyzed public-use data from the National Hospital Discharge Survey (NHDS), which has been conducted by the Centers for Disease Control and Prevention, National Center for Health Statistics since 1965. We calculated crude and age-adjusted incidence rates and estimated the risk associated with available demographic variables using Cox regression modeling. RESULTS: Rates of preeclampsia and gestational hypertension increased significantly (by 25 and 184%, respectively) over the study period; in contrast, the rate of eclampsia decreased by 22% (nonsignificant). Women under the age of 20 were at significantly greater risk for all three outcomes. Women in the south of the country were at significantly greater risk for preeclampsia and gestational hypertension when compared to those in the Northeast. CONCLUSIONS: The increase in gestational hypertension may be exaggerated because of the revised clinical guidelines published in the 1990s; these same revisions would likely have reduced diagnoses of preeclampsia. Therefore, our observation of a small but consistent increase in preeclampsia is a conservative indication of a true population-level change.

The clinical content of preconception care: an overview and preparation of this supplement.

In June 2005, the Select Panel on Preconception Care established implementation workgroups in 5 areas (clinical, public health, consumer, policy and finance, and research and surveillance) to develop strategies for the implementation of the Centers for Disease Control and Prevention recommendations on preconception health and healthcare. In June 2006, members of the clinical workgroup asked the following questions: what are the clinical components of preconception care? What is the evidence for inclusion of each component in clinical activities? What health promotion package should be delivered as part of preconception care? Over the next 2 years, the 29 members of the clinical workgroup and > 30 expert consultants reviewed in depth > 80 topics that make up the content of the articles that are contained in this supplement. Topics were selected on the basis of the effect of preconception care on the health of the mother and/or infant, prevalence, and detectability. For each topic, the workgroup assigned a score for the strength of the evidence that supported its inclusion in preconception care and assigned a strength of the recommendation. This article summarizes the methods that were used to select and review each topic and provides a summary table of the recommendations.

The clinical content of preconception care: alcohol, tobacco, and illicit drug exposures.

Substance abuse poses significant health risks to childbearing-aged women in the United States and, for those who become pregnant, to their children. Alcohol is the most prevalent substance consumed by childbearing-aged women, followed by tobacco, and a variety of illicit drugs. Substance use in the preconception period predicts substance use during the prenatal period. Evidence-based methods for screening and intervening on harmful consumption patterns of these substances have been developed and are recommended for use in primary care settings for women who are pregnant, planning a pregnancy, or at risk for becoming pregnant. This report describes the scope of substance abuse in the target population and provides recommendations from the Clinical Working Group of the Select Panel on Preconception Care, Centers for Disease Control and Prevention, for addressing alcohol, tobacco, and illicit drug use among childbearing-aged women.

Where is the "W"oman in MCH?

Scientific evidence indicates that improving a woman's health before pregnancy will improve pregnancy outcomes. However, for many years, our efforts have focused primarily on prenatal care and on caring for infants after birth. The concept of preconception care has been identified repeatedly as a priority for improving maternal and infant health. Preconception care is not something new that is being added to the already overburdened healthcare provider, but it is a part of routine primary care for women of reproductive age. Many opportunities exist for preconception intervention, and much of preconception care involves merely the provider reframing his or her thinking, counseling, and decisions in light of the reproductive plans and sexual and contraceptive practices of the patient. With existing scientific evidence that improving the health of "W"omen will improve the health of mothers and children, we must focus on improving the health of "W"omen before pregnancy and put the "W" in Maternal and Child Health.

Preconception care: a 2008 update.

PURPOSE OF REVIEW: This study reviews what we know about preconception care, its definition, goals, and content; the science behind the recommended interventions; opportunities for implementing preconception care; and the challenges facing its implementation. RECENT FINDINGS: There is solid scientific evidence that many interventions will improve pregnancy outcomes if delivered before pregnancy or early in pregnancy. Experts continue to explore the most effective means for implementing preconception care, taking into consideration issues related to policy, finance, public health practice, research/surveillance, and consumer and provider education. SUMMARY: Over the past 4 years, there has been renewed interest and a great emphasis on preconception health and healthcare as alternative and additional approaches to counter the persistent increasing incidence in adverse pregnancy outcomes in the United States. Following the publication of the 'Recommendations to Improve Preconception Health and Healthcare' in 2006, many state and local health departments initiated programs to implement the recommendations. Several countries such as Canada, Belgium, and the Netherlands have also started to implement preconception care programs. There are many opportunities for promoting preconception health and providing preconception care; however, making preconception care a standard practice continues to face many barriers.

Policy and finance for preconception care opportunities for today and the future.

This special supplement of Women's Health Issues offers 2 types of articles related to the policy and finance context for improving preconception health and health care. These articles discuss the impact of finance and policy on preconception health and health care, as well as the strategies that are being used to overcome the challenge of implementing preconception care with limited resources and inadequate health coverage for women. Invited papers from authors with expertise in health policy and finance issues describe how women's health and preconception care fit into the larger debates on health reform and how the paradigm for women's health must change. Other invited papers discuss opportunities and challenges for using programs such as Medicaid, Title X Family Planning, Title V Maternal and Child Health Services Block Grant, Healthy Start, and Community Health Centers in improving preconception health and health care. Contributed articles on health services research in this supplement characterize the types of change occurring across the country. This paper also presents a framework for understanding the role of policy and finance in the larger Centers for Disease Control and Prevention Preconception Health and Health Care Initiative.

The future of preconception care: a clinical perspective.

The concepts of preconception care (PCC) have been discussed for over 20 years and the standards for PCC have been recently promulgated by the clinical committee of the Centers for Disease Control and Prevention's Select Panel of Preconception Care. For PCC to be fully realized, however, changes must be made in clinical practice, public health supports, and health coverage. This article discusses 1) the clinical content and delivery of PCC, 2) barriers to why this care does not fit easily into the current clinical paradigm for providing medical care, and 3) how new information technologies within the concept of the medical home might be a promising new way to assist in the diffusion of these concepts.

Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.

This report provides recommendations to improve both preconception health and care. The goal of these recommendations is to improve the health of women and couples, before conception of a first or subsequent pregnancy. Since the early 1990s, guidelines have recommended preconception care, and reviews of previous studies have assessed the evidence for interventions and documented the evidence for specific interventions. CDC has developed these recommendations based on a review of published research and the opinions of specialists from the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. The 10 recommendations in this report are based on preconception health care for the U.S. population and are aimed at achieving four goals to 1) improve the knowledge and attitudes and behaviors of men and women related to preconception health; 2) assure that all women of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health; 3) reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children; and 4) reduce the disparities in adverse pregnancy outcomes. The recommendations focus on changes in consumer knowledge, clinical practice, public health programs, health-care financing, and data and research activities. Each recommendation is accompanied by a series of specific action steps and, when implemented, can yield results within 2-5 years. Based on implementation of the recommendations, improvements in access to care, continuity of care, risk screening, appropriate delivery of interventions, and changes in health behaviors of men and women of childbearing age are expected to occur. The implementation of these recommendations will help achieve Healthy People 2010 objectives. The recommendations and action steps are a strategic plan that can be used by persons, communities, public health and clinical providers, and governments to improve the health of women, their children, and their families. Improving preconception health among the approximately 62 million women of childbearing age will require multistrategic, action-oriented initiatives.

Recommendations to improve preconception health and health care: strategies for implementation.

Promoting preconception health and health care is widely accepted as a useful prevention strategy to lessen adverse maternal and infant health outcomes. There remains, however, a lack of national standards of practice or a comprehensive agenda to ensure that all women of childbearing age receive appropriate services that will enable them to achieve optimal health before any pregnancy. To address this need, the Centers for Disease Control and Prevention (CDC) launched the Preconception Health and Health Care Initiative, which aims to improve the health of women before pregnancy. In 2005, the CDC sponsored the first National Summit on Preconception Care, bringing together over 400 participants to share their expertise and information about various activities currently underway. In conjunction with the National Summit, a Select Panel on Preconception Care, a group of experts and representatives of 35 national organizations and 22 CDC programs, was convened. Based on the literature, presentations made at the National Summit, and deliberations during the Select Panel meeting, the recommendations to improve Preconception Health and Health Care--United States were developed. In order to move the recommendations from paper to practice, the Select Panel was convened to develop strategies to implement the recommendations across three areas: clinical practice, consumer roles, and public health practice. Future plans include developing a research agenda, supporting existing and new research activities, and developing policy and financing initiatives that will advance the practice of preconception health and health care. In addition, a Second National Summit is being planned. This paper describes current and future activities to implement the recommendations.

Globalization of behavioral risks needs faster diffusion of interventions.

International trade, population migration, changes in living conditions (i.e., consumption transition, nutritional transition), and changes in production, marketing, and availability of consumer goods (i.e., production transition) have brought about continuous and rapid changes in the human environment. Such changes have improved the health and economic status of many people in developing countries. At the same time, a parallel phenomenon is occurring: the rapid emergence and expansion of modifiable risk behaviors. These behaviors adversely affect the national health of developing countries and that of future generations because of their impact on maternal, child, and adolescent health. Furthermore, these behaviors are increasing at a faster rate than interventions to curb their growth are being implemented. We discuss the current status of five modifiable risk behaviors--alcohol consumption, tobacco use, overweight and obesity, low fruit and vegetable consumption, and physical inactivity--to emphasize the need for global advocacy and local action to enhance policy formulation and diffusion of interventions necessary to moderate the spread of these behaviors.