MCH Alert - July 24, 2009

MCH Alert

Maternal and Child Health Library

This and past issues of the MCH Alert are available at http://www.mchlibrary.info/alert/archives.html.

July 24, 2009

************************************************************

Special Notice: MCH Alert Reader Feedback Form 2009

We continue to receive responses to the 2009 MCH Alert Reader Feedback Form and thank all who have submitted responses to date. If you have not yet responded, please take a few moments to complete the questions and submit your comments. You will find the form online at https://www.surveymonkey.com/s.aspx?sm=16ZJG5kXZgVQC_2bHc_2bxFH6A_3d_3d

Thank you for your time and for helping make the MCH Alert a success!

************************************************************

1. Toolkit Helps Employers Tailor Workplace Breastfeeding Programs and Policies
2. American Academy of Pediatrics Updates Statement on the Pediatricians' Role in Youth Violence Prevention
3. Study Investigates Changes in Professional Practice Behaviors Regarding the Evaluation and Treatment of Overweight and Obesity
4. Authors Examine Psychosocial Risk Factors as Contributors to Pregnancy-Associated Death in Virginia
5. Article Evaluates Malpractice Premium Subsidy's Impact on Availability of Maternity Care in Oregon

************************************************************

1. TOOLKIT HELPS EMPLOYERS TAILOR WORKPLACE BREASTFEEDING PROGRAMS AND POLICIES

Investing in Workplace Breastfeeding Programs and Policies: An Employer's Toolkit provides resources to help employers understand the components of breastfeeding programs, get started, and measure success. The toolkit was produced by the Center for Prevention and Health Services, National Business Group on Health with support from the U.S. Department of Health and Human Services Office on Women's Health and the Health Resources and Services Administration's Maternal and Child Health Bureau. Resources include breastfeeding program options, employer case studies, and materials for employees. The toolkit is available at http://businessgrouphealth.org/healthtopics/breastfeeding/docs/BF_entire_toolkit_FINAL.pdf.

Readers: This toolkit was adapted from the 2008 Health Resources and Services Administration and Every Mother Inc. publication titled The Business Case for Breastfeeding: Steps for Creating a Breastfeeding Friendly Worksite. Available at http://www.womenshealth.gov/breastfeeding/programs/business-case.

************************************************************

2. AMERICAN ACADEMY OF PEDIATRICS UPDATES STATEMENT ON THE PEDIATRICIANS' ROLE IN YOUTH VIOLENCE PREVENTION

Policy Statement -- Role of the Pediatrician in Youth Violence Prevention outlines and defines the emerging role of the pediatrician in the prevention of youth violence, outlines possible interventions that could be woven into routine health maintenance and preventive care practice, and identifies opportunities for pediatricians to assume leadership roles in violence prevention education and advocacy in community-based and out-of-office settings. The policy statement, developed by the American Academy of Pediatrics' Committee on Injury, Violence, and Poison Prevention, updates the evolving epidemiology of intentional injury, identifies important emerging issues related to violence prevention in children, and reaffirms the basic tenets that support the recommendations made in the original statement 10 years ago. Key new areas highlighted in the revised policy statement incorporate new information and resources concerning bullying and dating violence and provide further specific counseling guidance for pediatricians. The policy statement is available at http://www.pediatrics.org/cgi/content/full/124/1/393.

************************************************************

3. STUDY INVESTIGATES CHANGES IN PROFESSIONAL PRACTICE BEHAVIORS REGARDING THE EVALUATION AND TREATMENT OF OVERWEIGHT AND OBESITY

"These preliminary study findings suggest that PNPs [pediatric nurse practitioners] may need to increase the amount of attention they place on the assessment of psychosocial/mental health concerns when caring for overweight children and teens," state the authors of an article published in the July-August 2009 issue of the Journal of Pediatric Health Care. In response to the rapid rise in excess adiposity in children, a panel of experts was convened to develop recommendations (published in 1998) to guide physicians, nurse practitioners, and nutritionists in the evaluation and treatment of overweight in children, adolescents, and their families. During the same time period, childhood overweight and obesity became a focus of media attention in an attempt to raise the awareness of health professionals and the public. Despite an increase in information available, the prevalence of overweight and obese children and adolescents continued to climb. Research studies completed after the publication of the expert recommendations suggest that practitioners' evaluations of child and adolescent overweight and obesity continue to fall short of recommended practice. The article presents findings from a study to understand the current state of health professional practice -- specifically, assessment and management practices regarding childhood overweight and obesity and the self-reported barriers and practice changes that may have occurred from 1999 to 2005.

PNPs were asked to complete an anonymous survey during the 2005 NAPNAP Annual Conference. The questionnaire was the same as that used to survey PNPs, pediatricians, and registered dieticians in 1999, one year following the publication of expert recommendations. A total of 413 PNPs participated in these two cohort surveys, combined (1999 and 2005). Following analysis of demographic, assessment, and management practice items and identified barriers to care, tests were conducted to examine differences between 1999 and 2005 survey participants for the continuous variables.

The authors found that

Although there was significant improvement in adherence to the expert recommendations from 1999 to 2005 for assessing overweight in children and adolescents, adherence was still less than 50 percent.
There were significant improvements in reported adherence for the screening for co-morbid medical conditions (45.30 percent vs. 55.36 percent), and laboratory evaluations for those conditions (45.20 percent vs. 62.52 percent).
There was an 8 percent reduction in adherence to the expert recommendations for psychological, emotional, and behavioral assessments (87.57 percent vs. 79.83 percent) during this 6-year time period.
Slight improvements were noted in the recommended and reported assessment of family history and physical activity, but these changes failed to reach statistical significance.
Perceived barriers associated with parent interactions and with the health care system limiting the care of children and adolescents who are overweight or obese increased during the 6-year time period; however, this change did not reach statistical significance.

"This study does provide some preliminary evidence that PNP practice may be changing as these health care providers begin to engage in new behavior skills in their attempt to address the overwhelming crisis of childhood/adolescent overweight/obesity," conclude the authors.

Small L, Anderson D, Sidora-Arcoleo K, et al. 2009. Pediatric nurse practitioners' assessment and management of childhood overweight/obesity: Results from 1999 and 2005 cohort surveys. Journal of Pediatric Health Care 23(4):231-241. Abstract available at http://www.journals.elsevierhealth.com/periodicals/ymph/article/S0891-5245(08)00122-3/abstract.

Readers: More information is available from the following MCH Library resource:

- Overweight and Obesity in Children and Adolescents (knowledge path) at http://www.mchlibrary.info/KnowledgePaths/kp_overweight.html

************************************************************

4. AUTHORS EXAMINE PSYCHOSOCIAL RISK FACTORS AS CONTRIBUTORS TO PREGNANCY-ASSOCIATED DEATH IN VIRGINIA

"Through this review, it became apparent that assessment and referral for specialized treatment for substance abuse, mental illness, and domestic violence should be completed for all women seeking care during pregnancy," state the authors of an article published in the July 2009 issue of the Journal of Women's Health. Healthy People 2010 established a goal of 4.3 maternal deaths per 100,000 live births for the United States. Maternal mortality reviews are conducted to understand the causes of maternal death within the context of women's lives and the circumstances surrounding injury and disease patterns. The results of these systematic reviews are used to educate colleagues and policymakers about these deaths and the need for changes in law and practice. Maternal death reviews have found that psychosocial risk factors (substance use, mental illness, intimate partner violence) are associated with deaths of women during or soon after a pregnancy, yet few descriptions of the characteristics of women at greatest risk for fatal outcomes have been reported. The Virginia Maternal Mortality Review Team (MMRT) sought to determine through fatality review the extent of substance abuse, mental illness, and domestic violence among women who died within one year of pregnancy and to describe characteristics of those women. The multidisciplinary team also made determinations as to whether similar deaths may be averted with changes in policy and practice.

Cases of pregnancy-associated death were identified by the Virginia Department of Health. Team consensus was used to determine which risk factors were relevant in each case. The team also determined by consensus decision-making whether the death was a preventable death. The MMRT reviewed 121 cases of pregnancy-associated death that occurred between 1999 and 2001 in Virginia.

The authors found that

In 49 cases (40.5 percent of all cases reviewed), one or more of the psychosocial risk factors of domestic violence, mental illness, or substance abuse contributed to death.
The MMRT determined that substance abuse contributed to death in 28.9 percent of cases (n=35, maternal mortality ratio = 12.2); mental illness contributed to death in 16.5 percent of cases (n=20, maternal mortality ratio = 6.9); and domestic violence contributed to death in 14.0 percent of cases (n=17, maternal mortality ratio = 5.9).
African-American women were found to have higher pregnancy-associated maternal death ratios than white women for all three risks.
Median household income varied widely and ranged from $12,031 to $90,119; educational attainment ranged from 8 to 18 years.
Cases in which domestic violence was found to be a contributor to death were more often considered at least probably preventable (64.7 percent) than cases with mental illnesses (50.0 percent) or substance abuse (45.7 percent) as a contributor. The percentages of deaths among the latter two types of cases that were considered at least probably preventable were similar to the percentage of preventable deaths among women with no psychosocial risk factors (44 percent).

The MMRT formulated specific recommendations to ameliorate the deleterious effects of major issues identified as contributing to these deaths. The recommendations include the following: (1) the appropriate state agency should take the lead in proposing a statewide substance abuse and mental health screening program protocol for all pregnant women, (2) licensed health professionals should be required to obtain education on domestic violence and substance abuse, and (3) both public and private third-party payers’ Maternity Management Programs should be expanded to include mental health, substance abuse, and domestic violence.

Kavanaugh VM, Fierro MF, Suttle DE, et al. 2009. Psychosocial risk factors as contributors to pregnancy-associated death in Virginia, 1999-2001. Journal of Women's Health 18(7):923-927. Abstract available at http://www.liebertonline.com/doi/abs/10.1089/jwh.2008.1037.

Readers: More information is available from the following MCH Library resources:

Depression During and After Pregnancy (knowledge path) at http://www.mchlibrary.info/KnowledgePaths/kp_postpartum.html

Domestic Violence (knowledge path) http://www.mchlibrary.info/KnowledgePaths/kp_domviolence.html

************************************************************

5. ARTICLE EVALUATES MALPRACTICE PREMIUM SUBSIDY'S IMPACT ON AVAILABILITY OF MATERNITY CARE IN OREGON

"The loss of maternity care providers in Oregon is continuing," write the authors of an article published in the August 2009 issue of HSR: Health Services Research. An important component in access to maternity care services that improves maternal and neonatal outcomes is the availability of providers willing to perform deliveries. Oregon is one of several states in which the number of maternity care providers has fallen dramatically. Of particular concern to Oregon is the finding that rural physicians are discontinuing maternity care at a significantly higher rate than urban physicians. The most important reason cited for discontinuing maternity care is the rising cost of malpractice premiums. Concern about the implications of these falling numbers led the Oregon Legislature to develop a public subsidy for qualifying rural physician malpractice premiums. The subsidy legislation was passed in 2003 and fully implemented in 2004. To study the effects of the malpractice subsidy policy on the maternity care workforce, the authors conducted a longitudinal cohort study of Oregon obstetrician/gynecologists, family physicians, general practitioners, and certified nurse midwives to determine (1) the proportion of those trained to provide maternity care who continue to provide such services, (2) the important factors relating to the decision to discontinue providing maternity care services, and (3) how the rural liability subsidy is affecting maternity care providers’ ability to provide maternity care services in rural areas.

The authors surveyed all obstetrical care providers in Oregon in 2002 and 2006. Survey data, supplemented with state administrative data, were analyzed for changes in provision of maternity care, reasons for discontinuing maternity care, and effect of the malpractice premium subsidy on practice. After exclusions, 1,069 surveys were analyzed.

The authors found that
* In 2002, 47.8 percent of Oregon trained maternity care providers delivered infants in their practices, compared with 36.6 percent in 2006.

* Among the 511 providers who performed deliveries, 157 (30.7 percent) indicated plans to discontinue delivering infants in the next 1-5 years.

* Compared with providers with no plans to discontinue delivering infants, those who planned to discontinue were significantly more likely to be male, own their own practice, pay their own liability insurance, work longer hours, and be in the oldest age group.

* Specialty and rural practice location were not associated with planning to discontinue delivering.
* The three top reasons former delivery providers cited as "very important" in their decision to discontinue were (1) liability insurance cost (50.7 percent in 2002; 58 percent in 2006), (2) lifestyle issues (42 percent in 2002; 38.2 percent in 2006), and (3) fear of lawsuits (41.1 percent in 2002; 27 percent in 2006).

* Receipt of the subsidy was not associated with continuing maternity care between 2003 and 2006 either among all physicians or among rural physicians. Subsidized physicians were as likely as nonsubsidized physicians to report plans to discontinue providing maternity care services (24.1 vs. 20.9 percent).

The authors conclude that "A state program to subsidize the liability premiums of rural maternity care providers does not appear to be effective at keeping rural providers delivering babies. Other policies to encourage maternity care providers to continue delivering babies need to be considered."

Smits AK, King VJ, Rdesinki RE, et al. 2009. Change in Oregon maternity care workforce after malpractice premium subsidy implementation. HSR: Health Services Research 44(4):1253-1270. Abstract available at http://www3.interscience.wiley.com/journal/122434572/abstract.

************************************************************

To subscribe to MCH Alert, send an e-mail message to MCHAlert-request@lists.mchgroup.org with SUBSCRIBE in the subject line. You do not need to enter any text in the body of the message.

To unsubscribe from MCH Alert, send an e-mail message to MCHAlert-request@lists.mchgroup.org with UNSUBSCRIBE in the subject line. You do not need to enter any text in the body of the message.

************************************************************

To receive notice of new issues of MCH Alert, follow the MCH Library on Twitter at http://www.twitter.com/MCH_Library.

************************************************************

MCH Alert © 1998-2009 by National Center for Education in Maternal and Child Health and Georgetown University. MCH Alert is produced by Maternal and Child Health Library at the National Center for Education in Maternal and Child Health under its cooperative agreement (U02MC00001) with the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. The Maternal and Child Health Bureau reserves a royalty-free, nonexclusive, and irrevocable right to use the work for federal purposes and to authorize others to use the work for federal purposes.

Permission is given to forward MCH Alert, in its entirety, to others. For all other uses, requests for permission to duplicate and use all or part of the information contained in this publication should be sent to mchalert@ncemch.org.

The editors welcome your submissions, suggestions, and questions. Please contact us at the address below.

MANAGING EDITOR: Jolene Bertness
CO-EDITOR: Tracy Lopez
COPYEDITOR/WRITER: Ruth Barzel
LIST ADMINISTRATOR: Beth DeFrancis Sun

MCH Alert
Maternal and Child Health Library
Georgetown University
Box 571272
Washington, DC 20057-1272
Phone: (202) 784-9770
Fax: (202) 784-9777
E-mail: mchalert@ncemch.org
Web site: http://www.mchlibrary.info/alert/
Twitter: http://twitter.com/MCH_libary

************************************************************