When she was the state's maternal child health epidemiologist about a decade ago, Pamela Xaverius recalls being disturbed by the poor birth outcomes in parts of the state and feeling helpless because she could do nothing to improve the numbers. "As a researcher, all you could do was write it up and put it in a journal where other researchers read it," she says.
These days, she's more optimistic, saying that community change and community action to improve maternal and child health are now a real possibility. The big difference between then and now, she says, is the sea change in the way St. Louis and St. Louis County intend to approach care for at-risk women. Prenatal care will still be emphasized, but a focus will also be on providing more care to women before they become pregnant because the additional health services can help them give birth to healthier babies, she says.
The concept is known as preconception care, endorsed a few years ago in a report by the Centers for Disease Control and Prevention. "This is a complete shift from how we have traditionally approached infant mortality, prematurity and low birth weight," says Kendra Copanas, executive director of the Maternal, Child and Family Health Coalition.
"Research has tried to find the cause of these outcomes during pregnancy, and we have focused all of our care and interventions for women after they become pregnant."
But lost in that old approach, she says, is the fact that "vital organs are all developing within the first eight weeks before a woman's first prenatal visit." Because this intervention comes too late for some budding health problems, she says, "We have to emphasize the importance of all women being healthy throughout their lives."
Although the local preconception movement has several partners and participants, the three key players are Copanas; Xaverius, a community medicine researcher at St. Louis University's School of Public Health; and Deborah Kiel of the College of Nursing at the University of Missouri at St. Louis.
The local project grew out of an unprecedented Regional Health Commission program to allow community groups to partner with university researchers on health-care problems selected by the community. Washington University, St. Louis University and BJC HealthCare pooled $1.5 million and awarded research grants of $100,000 each to seven community-university partnerships, with the possibility of renewing some after the first year. The preconception project was among those that got awards during both funding cycles.
The RHC funding has since been supplemented with a CDC grant of $220,000 a year for 2 years. Among other things, the extra money has allowed the group to add staff, survey more women of childbearing age and increase the size of focus groups in the Partnership for Preconception Health initiative. In addition, Copanas says the money has allowed the project to look at additional policies, such as the impact of a lack of continuous health insurance coverage on women of childbearing age. Funding during the first year included money for a study to determine what women and clinicians knew about preconception care and how many of them embraced it.
Most women, the research found, knew little about the concept or its importance. The research also found that most clinicians did not routinely perform preconception risk assessments when women were seen for checkups or other conditions unrelated to reproductive health issues. The risk assessments might include a review of a woman's reproductive history; her exposure to environmental hazards and toxins; weight management, tobacco and alcohol use; and chronic diseases, such as diabetes and hypertension.
"Interestingly, women told us that they would listen to a health-care provider about planning a pregnancy, but health-care providers told us that they didn't regard preconception care as standard care," Xaverius says. "This (care) is a shift in the way that we are suggesting that providers care for women."
NAGGING DISPARITIES IN HEALTH
In any case, the data show a need to do more to address issues that could affect birth outcomes, Xaverius says. The preconception study showed that the infant mortality rate in 2009 for black babies in Missouri was 13.8 for every 1,000 live births, compared to a rate of 6.1 for every 1,000 live births for white women. Birth data show that 12.5 percent of all births in Missouri were preterm, or less than 37 weeks gestation. The rate was 20.4 percent for black women in the city and 19 percent of black women in St. Louis County. The rate was just over 11 percent each for white women in both the city and the county.
Copanas says the second phase of the group's work, which starts this month, will involve education and training. Key targets will be clinicians and community health providers. The goal is to show those who work with women of childbearing age how health influences pregnancy and birth and how those factors in turn should inform the way health providers serve women.
In addition, Copanas says efforts will be made to educate people in general about the value of improving the health and well-being of women before they become pregnant. "With about 50 percent of pregnancies unplanned, it is important to treat every woman as if she is planning to become pregnant," Copanas said.
That task may not turn out to be easy, but Xaverius thinks it will be a rewarding step toward changing outcomes. She says it helps that what's being proposed is based on focus groups and other research showing what at-risk residents think should be a health priority. The education phase will include using social media, such as Facebook and Twitter, and other outreach efforts to educate women, men and teens about preconception health.
The hope is that the project will mean healthier moms, fewer infant deaths and a reduction in the black-white gap in those deaths.
"This is really about community change and community action," Xaverius says. "When I worked at the Department of Health, I was appalled by the disparity in birth outcomes. What's exciting to me about this project is working with people in the community to figure out where we can take action and effect some change."