Maternal and Infant Mortality Health Disparities Research: Striving and Thriving
Phyllis W. Sharps, PhD, RN, CNE, FAAN Associate Dean, Community and Global Programs Professor Community Public Health Nursing Johns Hopkins University School of Nursing February 1, 2013 1
Perinatal Nurse Home Visitation Home Visitation Enhanced with mHealth (DOVE 2)
NIH/NINR - R01NR009093-01A2 /NINR 2
The Journal Begins With A Vision: Excellence in Nursing
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MARY SEACOLE 1805 - 1881 Mary Seacole's reputation after the Crimean War (1853-1856)rivaled Florence Nightingale's. Unlike Nightingale, Seacole also had the challenge to have her skills put to proper use in spite of her being black. A born healer and a woman of driving energy, she overcame official indifference and prejudice. She got herself out to the war by her own efforts and at her own expense; risked her life to bring comfort to the wounded and dying soldiers; and became the first black woman to make her mark on British public life. But while Florence Nightingale has gone down in history and become a legend, Mary Seacole was relegated to obscurity until recently. 4
Hatching DOVE Active duty – military perinatal nurse
Maternal and Infant Clinical Nurse Specialist Home Visiting – Reaching Mothers and Infants Parents and Children Together – HOME (doctoral
student) Adolescent Postpartum Depression and Mother and Infant Interaction (dissertation research) Pride in Parenting (lay home visitors; DC Cooperative Perinatal Studies to Reduce IMR) Passport to Health (nurse home visit intervention to reduce violence related health disparities) 5
Hatching DOVE Other Constant Research and Practice Interests: Reducing Infant Mortality Rate among African American women Depressive symptoms in pregnant and parenting low income women IPV and perinatal health outcomes
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Hatching DOVE
Other Experiences Research assistant Member of interdisciplinary research team Mentored research with a senior research (K Award) Working and listening to community - shelter Immersing in research activities/environment
(NNVAWI/Research Consortium)
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All contributed to my keen desire to do health disparities research – before it was even called health disparities
Background for DOVE IPV violence during pregnancy linked with adverse
outcomes for:
Mothers Infants More than 3 million children witness IPV of mother each year More than 50% of these children are under 6 years old
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Background for DOVE 8-22% of pregnant women (vs. 7%
pre-eclampsia or hypertension during pregnancy)
Most significant risk factor - abuse
before pregnancy.
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Background for DOVE (Ballard et. al., ’98)
Protective period Women beaten before and after – (30%) Risk period May start during pregnancy (24%) – especially first pregnancy “Business as usual” IPV neither increases or decreases (75%) (Martin ’01; Saltzman ‘03)
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Background for DOVE Patterns of IPV During Pregnancy Type of Abuse Changes Physical abuse may lessen or stop but emotional abuse,
controlling behaviors stay same or increase (Castro ’03)
Teens at Greater Risk Higher prevalence of abuse during pregnancy among
adolescents than adult women (Parker, McFarlane ’93)
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Background for DOVE Ethnic group comparison significantly lower in Hispanic couples (Mexican American) -14% vs. 16% in African American and Anglo (McFarlane & Parker ‘92)
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Abuse During Pregnancy By Ethnic Group And Assessment (N=1000) *Torres, Campbell, et.al. ‘99 Birth weight & Abuse During Pregnancy (NINR) 9 8 7 AAS ISA-P
6 5 4 3 2
N=187
N=198
N=89
N=141
Puerto Rican
Mexican American
Cuban American
Central American
Anglo
0
African American
1
N=192
N=196
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Background for DOVE Associated with poor outcomes Late entry into prenatal care Increased low birth weight birth Poor weight gain Increased preterm delivery Poor adherence to medications
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Background for DOVE IPV Correlates Depression Substance abuse Low social support
IPV Correlates Spontaneous abortion Smoking Risk of homicide
(Gielen et al ‘94; Campbell et al ‘92) 15
Background for DOVE Infant Health Correlates
LBW Low income/poor women (Bullock & McFarlane ‘89) Connections w/ smoking Poor maternal low weight gain substance abuse (Curry et al ‘99) Child Abuse Most severe abuse – non-biological father
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Background for DOVE (Campbell et al ‘99;Torres et al ’01)
Poor Infant Outcomes
LBW in term infants
Evidence of mediation in multivariate LR
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Physical abuse - risk factor (OR = 3.29) Physical abuse not a risk factor for preterm-infants (bivariate analysis) Low weight gain (OR = 3.4) And/or inadequate prenatal care (OR = 1.8) And/or poor obstetric Hx (OR = 3.6)
Infant Mortality Rates
(CDC
2012)
14 12 10 8
Series 1 Column1 Column2
6 4
2 0 National 18
Whites
Blacks
Hispanics
Infant Mortality Miami-Dade County Infant mortality rates most profound indicator of health disparities Blacks have the highest rate 2.5 times
higher than Whites and 3 times higher than Hispanics
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Background for DOVE IPV AND Maternal Mortality Maternal Mortality Death from all causes during pregnancy, and year after delivery or pregnancy termination Homicide Leading cause of maternal mortality in US cities where measured (NYC, Chicago, DC) (Dannenberg, ’95; Krulewitch ‘01) Leading cause of maternal mortality in entire state of MD - – 20% of deaths (Horon & Cheng, 2001) 20
Background for DOVE
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Little evidence of appropriate interventions to reduce IPV among mothers and exposure for neonates and infants DOVE proposes to address this gap
Domestic Violence Enhanced Home Visitation Program (DOVE)
NIH/NINR - R01 NR009093 22
Purpose of DOVE Rigorous test of structured IPV intervention –
DOmestic Violence Enhanced Home Visitation Program
Mothers and infants 2 Sites and Settings Urban – Baltimore City HD Urban – Missouri HD Rural – Missouri HD 23
Design
3 different designs in 3 different settings RCT Mixed methods – quantitative & qualitative BCHD (women and infants) Eligible women = R→ DOVE vs. UC
MOHD (women and infants) 12 HDs = R→ 6 HD DOVE vs. 6 UC NFP (Olds HV model; mothers and infants) DOVE vs. Olds database
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Schema for DOVE Project URBAN (Baltimore City Health Dept.)
RURAL (Missouri Health Dept.)
12 HD’s (N=160)
1 NFP (N=40)
RANDOMIZE
REFERRAL
Referrals BCHD RANDOMIZE Usual Care (M&I)
Usual Care (6 HD’s)
DOVE (6 HD’s)
DOVE (M&I & DOVE)
Data Collection/Follow Up Assessments
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Kansas City, Missouri
DOVE-NFP
Selected from NFP National Data
Methods Recruit women – up to 31 weeks gestation
Intervention DOVE = Structured IPV pamphlet Nurse home visit intervention + DOVE DOVE – 3 prenatal sessions DOVE – 3 postpartum sessions (up to 12 weeks) Data Collections Baseline (recruitment) Delivery Postpartum – 3, 6,12,18, 24 months 26
Methods Quantitative Study: Measures IPV Maternal Mental Health ( stress, depression, PTSD) Parenting (stress, stimulation) Infant Growth & Development Use of Community Resources 27
Methods Qualitative Study Patterns of IPV Urban/Rural influences on patterns of IPV
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DOVE Has Wings Funded – Feb 1, 2006 – Nov 30, 2011 Human Subjects Approvals 2 Universities and 2 Health Departments Certificate of Confidentiality - Final IRB Approvals - Data Collection - Began – Dec, 2006 - Ended – October 2011
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DOVE Project Team Investigators
Phyllis Sharps, PhD, RN, PI - JHUSON Linda Bullock, PhD, RN, Co-PI – Univ. of Missouri Jackie Campbell, PhD, RN, Co-PI JHUSON Linda Rose, PhD, RN , Investigator JHUSON Michelle Cooley, PhD, Investigator JHBSPH (child psychologist)
Consultants
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David Olds, PhD – Univ. of Colo. (NFP) Barbara Parker, PhD, RN, UVA (Structured Intervention) Linda Pugh, PhD, RN – York College (intervention fidelity monitoring) Karen Soeken, PhD – Professor Emeritus (biostatistician) Sharon Ghazarian, PhD (biostatistician) )
PROJECT STAFF Project Coordinator Kim Hill, MPH DOVE Intervention Nurse BCHD –Keauna Williams, BSN DOVE Research Nurses Etasha Crowder, BSN Kristina Marcantonio, MSN Post Doctoral Fellow
Sandra Giangrande, PhD, RN
Doctoral Students
Jeanne Alhusen, PhD, RN Marguerite Baty, PhD, RN
Rachel Walker, UG Honors Research – now PhD candidate
Are We Making A Difference
Preliminary Findings
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Baseline Demographics Demographic Characteristics Mean Age Racial Background: African American White Other Education: Less Than High School HS/GED Some College/Trade Trade/Community College/College Grad Marital Status: Single Partnered/Not Married Married Divorced Other Employment Status: Employed FT Employed PT 32 Unemployed
Total Sample N= 238
DOVE Sample N= 124 (52%)
Usual Care Sample N= 114 (48%)
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24
23
47% 42% 11%
44% 45% 11%
51% 40% 9%
41% 25% 23% 11%
40% 26% 24% 9%
40% 24% 22% 14%
51% --% 25% 11% 6%
52% 24% 15% 2% 8%
49% 26% 8% 11% 6%
12% 16% 72%
12% 11% 76%
12% 21% 67%
Preliminary Data: IPV and Health Outcomes Mean Scores Health Indicator
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Black American
White American
Other
Conflict Tactics Scale (IPV)
73
71
56
Edinburgh Depression Scale (Depression)
16
13
8
Davidson Trauma Scale (PTSD)
64
33
18
Severity of Violence Against Women Scales
85
92
87
Women’s Experience With Battering
33
30
37
Other Preliminary Findings Nurse HV for abuse women feasible DOVE can be integrated into HD HV
programs Good retention DOVE reduced self reported IPV UC reduced IPV too More analysis
Multiple partners Did DOVE work better for some women SGA babies and IPV 34
Other “ANNA” Stories Data analyses from the Qualitative Phase of
the DOVE study are showing that women, whose violence was addressed early during the home visiting program, are telling us about many positive choices they are making in improving their lives and their children’s lives by 24 months post-delivery. Talking about the violence to the home visitor has been powerful! Women will talk about IPV 35
Lessons Learned
Developing Partnerships
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Academic-Community Partnership Johns Hopkins School of Nursing (JHUSON) Location: Baltimore, Maryland, USA Mission: To provide leadership to improve health
care and advance the profession through education, research, practice, and service.
Baltimore City Health Department (BCHD) Location: Baltimore, Maryland, USA Mission: Maternal and Infant (M&I) Nursing
Program provides home visiting and case management services to pregnant women and infants in Baltimore City in order to improve maternal health, birth and infant outcomes.
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Partnership Benefits Established Infrastructures
JHUSON Academic Resources BCHD-M&I Program Community Resources
Sharing of Resources DOVE Intervention Nurse=Liaison
Between JHUSON & BCHD-M&I
Implementation of DOVE intervention into existing BCHD-
M&I program
Application of evidenced based research into real practice setting – a test of efficacy
Potential Positive Impact on MCH Outcomes 38
Preparing to Launch DOVE Developing The Town (Home Visitors) and Gown
(Research team) Partnership
Both Health Departments: The Missouri Department of Health and Senior Services (MoDHSS) Baltimore City Health Department Maternal and Infant Home Visit programs
Extremely supportive of identifying IPV and working
with both research teams
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Developing the Town/Gown Partnership Examples of activities to develop partnership Research team members made frequent visits to the DOVE sites
and reviews the research protocol with trained HV and new staff
Monthly meeting with BCHD to discuss DOVE protocols DOVE Nest newsletter sent monthly to all health departments Conducted professional in service training for health departments We have conducted 10 different workshops regarding screening
for IPV with the home visitors over a four -year period at both sites
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Issues for the Partnership Challenges of partnering with urban and rural health
departments
Home Visitors lack of educational preparation regarding
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research protocols Lack of understanding of the importance of screening for IPV Discomfort with screening for IPV Rural Settings - distance that has to be traveled by the research team to maintain relationships with the staff Urban Settings – bureaucratic procedures that hinder recruitment process Urban Settings – large case loads limit time available for intervening
Threat To The Study’s Integrity After 3 ½ years of recruitment – referrals made at
both sites (Baltimore and MO) have not met targeted goals
PIs at both sites hypothesized that: There may be an issue with women disclosing: Because of the rural setting of the MO site Because of the urban setting of Baltimore site The HVs are not comfortable screening women for
IPV Barriers Study 42
Partnership Limitations Control
Interdependence of each entity for project results
Communication
Ensuring all team members are up-to-date
Motivation
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Team members professional investment in project
Clinical Significance DOVE combines
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evidenced based protocols DOVE an be integrated into existing culturally based approaches DOVE intervention is low cost DOVE intervention requires training and “buy-in” Women had many positive comments about DOVE
Striving and Thriving Find your passion Being part of a team or partnership Nurturing is the norm Committed to success of all members Mutual benefits Expected, spelled out, agreed upon Establishment of trust Clear expectations – but some give and take Meeting deadlines – mutual respect not
obligations
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Striving and Thriving Community Connections Be a part of a community – a real commitment Community is also a part – a real commitment Meaningful and important roles and involvement
for community members Do no harm Share what you learn with the community Enhance the community – include on teams
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Striving and Thriving Planned Small Steps Projects Small projects Each project builds on the next Carve out a part of a larger project – that builds on where you want to go Funding Foundations Professional groups Community Groups/Faith partners NIH ( Mentored awards, small R’s →→ RO1) 47
Striving and Thriving Have Fun Along the Way !!
Celebrate the achievements of all (publications, presentations, recruitment goals, enrolling in courses)
Celebrate the milestones
Support each other over the rejections and disappointments (no funding, rejections, slow recruitment, grants, abstracts, manuscripts, slow recruitment)
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NATIONAL DOMESTIC VIOLENCE HOTLINE
1-800-799-SAFE
NURSING NETWORK ON VIOLENCE AGAINST WOMEN INTERNATIONAL (NNVAWI) 1-888-909-9993 NNVAWI.ORG NATIONAL DOMESTIC VIOLENCE HEALTH RESOURCE CENTER (FVPF) 1-800-537-2238 ENDABUSE.ORG 49
DOVE WEBSITE
http://www.son.jhmi.edu/research/dove
[email protected] 410-614-5312
Thank You !!! 50
