Delaware Journal of Public Health - Maternal and Child Health

Delaware Journal of

Volume 4 | Issue 3

May 2018

Public Health A publication of the Delaware Academy of Medicine / Delaware Public Health Association

www.delamed.org | www.delawarepha.org

Delaware Academy of Medicine Board of Directors: OFFICERS Daniel J. Meara, M.D., D.M.D. President Omar A. Khan, M.D., M.H.S. President-Elect Victor L. Gregory, D.M.D.

Delaware Journal of

May 2018

Public Health Volume 4 | Issue 3

Vice President & Secretary S. John Swanson, M.D.

A publication of the Delaware Academy of Medicine / Delaware Public Health Association

Treasurer Arun V. Malhotra M.D.

www.delamed.org | www.delawarepha.org

Immediate Past President Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio DIRECTORS

4 | In this Issue Omar A. Khan, M.D., M.H.S. Timothy E. Gibbs, M.P.H.

David M. Bercaw, M.D. Ehtasham A. Qureshi, M.D. Eric T. Johnson, M.D. Joseph F. Kestner, Jr, M.D. Brian W. Little, MD, Ph.D. Sandra P. Medinilla, M.D., M.P.H. Joseph A. Napoli, M.D., D.D.S. John P. Piper, M.D. Albert A. Rizzo, M.D. EMERITUS

5 | Guest Editor David A. Paul, M.D.

6 | Improving Access to Contraception in Delaware Mark Edwards, co-founder of Upstream USA and Liz O’Neill, Delaware CAN Director of Upstream USA

Robert B. Flinn, M.D. Barry S. Kayne, D.D.S. Leslie W. Whitney, M.D.

Delaware Public Health Association

Advisory Council: Omar Khan, M.D., M.H.S. President

12 | Breastfeeding Support Group for Puerto Rican Moms Yukiko Washio, Ph.D. Lauren Wills, B.S. Elisa Colchado, M.Ed. Mara Humphreys, M.Ed. Carla P. Aponte, M.S. Delsy M. Morales, B.S. Linda M. Kilby, Ph.D, R.D., L.D.N.

Timothy E. Gibbs, M.P.H. Executive Director Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S. Richard E. Killingsworth, M.P.H. Erin K. Knight, Ph.D., M.P.H. Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D.

18 | Changing Preterm Birth in Delaware

32 | Delaware Birth Spacing Campaign

58 | Maternal Health Disparities Among Puerto Ricans

Leah Woodall, M.P.A. Jennifer Reid, M.S., C.H.E.S., EP-C

Yukiko Washio, Ph.D. Omar Khan, M.D. Ralph Rivera-Gutiérrez, Ph.D., M.S.W.

38 | Implementation of Group Prenatal Care for Pregnant Women on Opioid-agonist Therapy at a Community-based Substance Use Treatment Clinic

Sean Dooley, Community Relations Officer, Division of Public Health

Elizabeth Zadzielski, M.D., M.B.A,  F.A.C.O.G. Michelle Drew, C.N.M. Stephanie Rogers, R.N. Yukiko Washio, Ph.D.

64 | Maternal and Child Health Lexicon of Terms

44 | Newborn Screening for Cystic Fibrosis in Delaware

70 | From the history and archives collection

Ambika Shenoy1, M.D. Kathi Peeke, A.P.N. Kathryn Tullis, Ph.D. Michael Cellucci, M.D. Aaron Chidekel, M.D.

Matthew K. Hoffman M.D., M.P.H.

52 | The Pregnancy Recovery Support Program

24 | Delaware Infant Mortality

Elizabeth Zadzielski, M.D., M.B.A,  F.A.C.O.G. Terry L. Horton, M.D.

David A. Paul, M.D. Neal D. Goldstein, Ph.D., M.B.I. Robert Locke, D.O., M.P.H.

60 | Dispose of prescription drugs properly by visiting a collection site

68 | Maternal and Child Health Resource Guide

Kate Lenart, M.A.

Karyl T. Rattay, M.D., M.S. Margot L. Savoy, M.D., M.P.H. William J. Swiatek, M.A., A.I.C.P.

COVER Delaware Journal of Public Health Timothy E. Gibbs, M.P.H. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief David A. Paul, M.D. Guest Editors Liz Healy, M.P.H. Deputy Editor Suzanne Fields Image Director

Maternal and child HEALTH is important to APHA and its Delaware affiliate DPHA, because we have the opportunity to end preventable deaths among all women, children, and adolescents; and greatly improve their health and well-being. Far too many women, infants, and children worldwide still have little or no access to essential, quality health services and education, clean air and water, or adequate sanitation and nutrition.

The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA). Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Write ehealy@ delamed.org or call Liz Healy at 302-733-3989. Advertising: Please write to ehealy@delamed.org or call 302-733-3989 for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products. Copyright © 2018 by the Delaware Academy of Medicine / Delaware Public Health Association. Opinions expressed by authors of articles summarized, quoted, or published in full in this journal represent only the opinions of the authors and do not necessarily reflect the official policy of the Delaware Public Health Association or the institution

with which the author(s) is (are) affiliated, unless so specified. Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages may not be photocopied, except in limited quantities, or posted online, without permission of the Academy/DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to ehealy@delamed.org.

2018 Delaware APA Regional Conference

in partnership with the DE Academy of Medicine / DE Public Health Association Atlantic Sands Hotel, Rehoboth Beach, Delaware | October 23-24, 2018

Overview

This two-day conference will feature exemplary planning efforts in Delaware, the surrounding region, and beyond. The theme for 2018’s conference is: Planning 360: Economy, Environment and Public Health. Sponsored by the Delaware Chapter of the American Planning Association, in partnership with the Delaware Academy of Medicine / Delaware Public Health Association, this conference is one of the best learning experiences for APA/AICP members and public health practitioners in the region. New for this year, its focus will expand to embrace public health and healthcare practitioners. The conference features two days of high quality, hands-on and interactive sessions, mobile workshops, planning law and planning ethics presentations, member networking, vendor contacts, plus a few surprises! The conference will run several parallel tracks with 90-minute sessions. There will be no published conference proceedings, but presentation graphics will be posted on our web site. The audience will consist primarily of professionals from the public and private sectors working in planning (city, county, and state), public health, and healthcare related jobs. Whether you are an APA member, an AICP member, an Academy/DPHA member, a student, or a person with an interest in the practice of Planning, this conference always delivers something for everyone!

Call for Presentations

The Conference is now accepting proposals for presentations. Eligible submissions can cover a broad range of topics related to technological advances and their impacts on infrastructure planning, design, operations, and management related to the conference theme. Subjects may include those related to Economic Development, Environmental Quality, Public Health, or Planning-related Communications. We are accepting proposals for full 90-minute sessions, for individual presentations within a session, and for Mobile Workshops. Research-based sessions highlighting promising emerging and innovative research ideas, best practices, or case studies are encouraged. The submission deadline has been extended to July 31, 2018. CLICK HERE for Information, or here to submit an abstract

Sponsorship Opportunities

To host a conference of this magnitude, we rely on a variety of sponsorships and contributions. These sponsorships not only benefit our organizations but also the sponsors whose message will be before planning professionals (including land use planners, landscape architects, engineers, architects, GIS professionals, etc.), other local and state government decision makers, interested residents, and, this year, given our topic, health care and public health professionals. More information on the conference in general, on the Call for Presentations, and on sponsorship opportunities is available on the Chapter’s website: http://delawareapa.org. 3

I N THIS I SSUE The process of childbirth has become safer as science and medicine have evolved, but it remains one of the most dangerous things a woman can do. Access to prenatal care, to surgical delivery when necessary, to antibiotics, tocolytics, uterine stimulants and vaccines, have all helped keep both mother and baby as healthy as possible for as long as possible. Despite all this, thousands of women around the world die every year from preventable pregnancy related causes.

Omar A. Khan, M.D., M.H.S. President Elect

Infant and maternal health is connected, and a healthy mother will usually give birth to a healthy baby. Unfortunately, racial and ethnic health disparities, chronic disease, social factors, and access can all affect a mother’s health. Newborns are additionally susceptible to any number of diseases and health conditions. Statistically, we track the result of all of these impacts with the infant mortality rate (IMR). In the United States – one of the largest countries of the developed world – the IMR is 5.9 infant deaths per 1,000 live births. In Delaware, that number is higher. Just as no two mothers will have the same birth experiences, the suite of services and preventive health packages necessary for safe childbirth is likely unique to individual mothers. This issue focuses on some of the many efforts researchers are taking to support pregnant women in the State of Delaware, and how our public health programs, health care providers, and medical facilities can keep our mothers and babies as safe and as healthy as possible during pregnancy, birth, and all that happens after.

Timothy E. Gibbs, M.P.H. Executive Director

We are delighted to have David A. Paul, M.D., chair of the Department of Pediatrics at Christiana Care Health System and clinical leader of the Women and Children’s Service Line as guest editor for this edition on Maternal and Child Health. Dr. Paul has led initiatives to decrease infant mortality and premature birth for over 10 years. During those years, he has acted as chair of the Delaware Healthy Mother and Infant Consortium, has authored many publications, and has presented on countless occasions to professional and lay groups. We hope that you enjoy this edition of the Journal, learn new information, and make new connections. As always, we welcome your feedback and engagement as we work together to improve the health and well-being of all Delawareans. It is particularly appropriate that this issue is released around Mother’s Day 2018. We take this opportunity to thank our mothers, and all those who support maternal & child health in the First State.

4 Delaware Journal of Public Health – May 2018

S

ince the time I came to Delaware in 1994 as Junior Faculty in the Department of Pediatrics, at the then Medical Center of Delaware, poor Maternal-Child Health Outcomes have been a recurrent state theme. Periodically I have felt like Sisyphus, experiencing many highs and lows while working on these issues with many caring and skilled stakeholders. High infant mortality and preterm birth rates, large number of unintended pregnancies and other adverse public health statistics have all made local headlines and been the subject of many scholarly articles in recent decades. Delaware’s maternal child health outcomes are worse than expected given the ready access to high level health care and the population demographics including income and education. I am often asked why Delaware? What makes our state so unique and why are some of our outcomes worse than expected? Although the answers to these questions are not known with certainty, this issue of the Delaware Journal of Public Health provides important insights into the health of woman and children in Delaware. In this issue we explore in detail some of the most important public health topics facing Delaware and dig deep into the epidemiology and root causes of these adverse outcomes. Many of the causes of poor maternal child health have deep roots in the social determinants of health. This issue of the Delaware Journal of Public Health highlights the problem of infant mortality and premature birth, both metrics improving over time, but remaining stubbornly high in Delaware. Despite years of effort Delaware still has unacceptable racial disparities in both of these important bellwether health metrics. The articles in this addition of the journal point to both the hope for medical advances, as well as the need to spread a wider net into the community to stem these problems. While there are many stakeholder in Delaware intent on improving health through community level interventions, there remains a need to produce a greater collective impact of efforts between hospitals, community leaders, public health and our elected officials if we are going to see continued reduction in preterm births and improvement in our infant mortality rates. While much attention has been paid to preterm birth and infant mortality in Delaware there are many other important public health issues affecting the woman and children of our State. Like many other states in the country, the opioid epidemic has left a big imprint on Delaware. The number of mothers and babies needing care for substance exposure continues to increase. While medical care for woman and babies exposed to opioids continues to improve and be refined their remains great concern over the cost and long term impacts on infant development, safety and family stability. Important advances in treating mothers and babies exposed to opioids have been implemented in Delaware but there is an urgent need to stem the increasing population of patients seeking treatment. Despite the many challenges in improving health in Delaware, there are areas of tremendous recent success. In 2014 the CDC ranked Delaware second for breast feeding support indicators. Thanks to the support of former Governor Jack Markell, and many others, Delaware has gone from the infamous leader in unintended pregnancies to national trailblazer in providing long acting reversible contraceptives (LARCS). The understanding of inherited diseases such as cystic fibrosis continues to improve. Through early detection, and the better understanding of the relationship between genotype and disease outcomes the care and outcomes for infants born with this condition continue to get better. The subject matter that is presented in this issue of the Delaware Journal of Public Health outlines the successes and challenges in improving maternal child health in Delaware. As we look into the future, there will surely be new health issues to tackle and hopefully many older problems that are put to bed. The size of Delaware and the collaborative nature of the relationship between many stakeholders in the State provide a unique incubator to improve health. Certainly improving health starts with a strong understanding of epidemiology and a continued focus on research and knowledge. It is only with this foundation that we will continue to see an improvement in the health of the community and subsequent progress in better outcomes for woman and children. David A. Paul, M.D., Chair, Department of Pediatrics, Christiana Care Health System Service Line Leader, Woman and Children’s Service Line, Christiana Care Health System Professor of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University

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Mark Edwards, co-founder of Upstream USA and Liz O’Neill, Delaware CAN Director of Upstream USA

The Problem: Unplanned Pregnancy Over a half century after the United States Food and Drug Administration first approved the birth control pill for contraceptive use, nearly half of all pregnancies in the United States are unplanned, resulting in 1.5 million unplanned births per year (Guttmacher, 2016). The children who result from these unplanned pregnancies frequently have poorer health and economic outcomes. Unplanned babies suffer from higher rates of deferred prenatal care and are frequently born at lower gestational ages and birth weights, conditions which have lifelong 6 Delaware Journal of Public Health – May 2018

negative consequences (Shah et al., 2009; Claridge et al., 2015). However, unplanned pregnancy is more than a health issue. Young parenthood (which is often unintended) contributes to more than 25 percent of all high school dropouts—and more than one-third of all female dropouts (Bridgeland et al.,2006). Put simply, in the United States today, unplanned pregnancy can contribute to intergenerational poverty and health and economic inequality. The burden of unplanned pregnancy is distributed unevenly across the economic spectrum. Low-income

women are five times more likely than women with incomes above 200 percent of the federal poverty level to experience unplanned pregnancy (Finer and Zolna, 2011). Of the 38 million women in need of contraceptive care in the United States in 2010, 20 million were in need of publicly funded contraceptive services. These women account for 75 percent of all unplanned pregnancies in the United States (Frost et al., 2016). In 2010, Delaware’s unplanned pregnancy rate was the highest in the nation with 62 unplanned pregnancies for every 1,000 women aged 15–44. That same year, 57 percent of Delaware’s 19,300 pregnancies were unplanned, and 40 percent of the 11,400 resulting births were unplanned (Guttmacher, 2014). The total, annual healthcare related public cost of unplanned pregnancies in the state was approximately $94 million, of which state funds paid $36 million (Guttmacher, 2014). Research shows that unplanned pregnancies are expensive and cost women, families, government, and society significant resources (Sawhill and Venator, 2014). The Opportunity: Long-Acting Reversible Contraception There are many reasons for the uneven distribution of unplanned pregnancy in the United States, but a major one is access to some of the most effective forms of contraception: long-acting reversible contraception (LARC) such as an intrauterine device (IUD) or implants. In the United States, many women cannot easily access LARCs because health centers either do not offer LARC methods or impose barriers that make it very difficult to obtain them. This state of affairs persists despite the fact that LARCs are endorsed by The American College of Obstetricians and Gynecologists, American Academy of Pediatrics, and Centers for Disease Control as a safe and effective “first-line” choice (Committee on Gynecologic Practice, 2015; American Academy of Pediatrics, 2014; Centers for Disease Control, 2016). Moreover, IUDs and the implant are available free or without co-pay to the vast majority of low-income women in the United States, thanks to state-by-state contraceptive coverage laws and public

family planning funding provided through the Title X program and Medicaid (Guttmacher, 2017; Walls et al., 2016). Despite the many benefits of LARCs and their relative affordability, a recent study found that one-third of clinics providing publicly funded family planning services—primarily to clients under 250 percent of the federal poverty level—offer no LARC methods, and 70 percent of primary care clinics do not offer the implant (Guttmacher, 2012). Many health centers and the clinical providers and staff who work in them do not have the systems, expertise, or knowledge to offer their patients the full range of contraceptive methods, including LARC. Often, providers do not have the training to provide IUDs and the implant. Misinformation and poor patient counseling mean that many women who are eligible for LARCs are not informed of the option. Even when patients can receive LARCs, many health centers require that their patients make multiple visits to get them, adding barriers to care and longer waits. Billing and coding problems make it difficult for health centers to stock the expensive devices. Cost fears also prohibit many patients from seeking LARCs. The potential benefits of greater LARC access are even more apparent when you consider that more than 40 percent of unplanned pregnancies occur among women who were using contraception. However, these women are not using the form of contraception that works well for them (Guttmacher, 2016). Poor compliance is particularly an issue with the hormonal birth control pill. On average, a woman’s chance of getting pregnant over ten years while on the pill is 61 percent, mostly due to poor compliance (Aish and Marsh, 2014). There is 7

strong evidence that when financial barriers to LARC access are removed and women are counseled well about their contraceptive options, many more will choose— and be more satisfied with—a long-acting reversible form of contraception (Secura et al., 2010).

Upstream’s Solution Upstream USA is a national, fast-growing nonprofit that is working to expand economic opportunity and mobility by reducing unplanned pregnancy in the United States. Upstream’s approach takes three critical steps to help reduce unplanned pregnancies: 1) enable health centers to ask all women of reproductive age as a routine part of primary care if they want to get pregnant in the next year; 2) enable health centers to provide women with single-visit access to the full range of contraceptive methods, including LARC, so women can freely choose the best method for them; and 3) create consumer demand for contraception by developing public awareness campaigns to educate women about their options. Recent, rigorous evaluations of comparable statewide and national initiatives demonstrate the effectiveness of this approach in reducing unplanned pregnancies (Secura, 2010; Colorado Department of Public Health and Environment, 2017). Upstream partners with states, including Delaware, to deliver training, technical assistance, and quality improvement to health centers so that they can offer their patients the full range of contraceptive methods the same day they are requested. Upstream’s model is a comprehensive, customized, whole health center approach to creating system-level, clinic-level, and provider-level changes. Upstream’s intervention includes an initial diagnostic visit to assess each health center’s needs and barriers regarding contraceptive access, oneto-two days of in-person training that incorporates adult learning techniques, and approximately twelve months of intensive technical assistance and quality improvement. Technical assistance is tailored to help each health center overcome the specific barriers that prevent them from providing women with same-day access to the full range of contraception, including provider knowledge, clinic work flow, stocking, billing, coding, and consumer awareness. By training and equipping health centers to embed these practices in their workflow and to access existing public and private 8 Delaware Journal of Public Health – May 2018

funding streams for contraception, Upstream’s model ensures these changes will be sustained long after its training is complete and will benefit increasing numbers of women and families for years to come. Delaware CAN In 2015, Upstream launched Delaware Contraceptive Access Now (Delaware CAN), a public private partnership with the Delaware Division of Public Health with the support of then-Governor Jack Markell. The goal of Delaware CAN is to reduce the rate of unplanned pregnancy in Delaware. The project plans to demonstrate that dramatic improvements in contraceptive access, counseling, and care can significantly reduce unplanned pregnancies and improve birth outcomes. In addition, Upstream projects that a reduction in unplanned pregnancies will save the state millions of dollars in pregnancy-related health care and other public costs. Upstream is creating a healthcare infrastructure that empowers all women in Delaware, regardless of insurance status, with convenient, sameday access to the full range of contraceptive methods, including the most effective, IUDs and the implant.

Upstream provides comprehensive training and technical support to the vast majority of public and private healthcare providers and a broad set of social service agencies in the state. Providers receive training on the insertion and removal of LARC; staff receive training on workflow support and assistance with contraceptive billing and stocking; and the entire team learns how to counsel patients effectively about all forms of

contraception. As of December 31, 2017, Upstream has provided 99 trainings to 547 clinicians and 1589 support staff at 164 sites across the state of Delaware, including 85 public and private healthcare providers and a broad set of 79 social service providers. These sites represent 41 agencies which annually serve nearly 125,000 of Delaware’s approximately 190,000 women of reproductive age, and this number continues to grow as sites take on new patients and clients over time (Kearney, 2018). Additionally, offering contraceptive care in the hospital postpartum setting is a vital opportunity to help women prevent unplanned pregnancies and provide women support for their goals of healthy birth spacing. Upstream has collaborated with Delaware Medicaid and Medical Assistance and health centers to ensure that policies and practices are conducive to providing women the full range of contraception the same day as requested including Immediate Postpartum (IPP) LARC. This collaboration resulted in rule changes establishing a separate reimbursement fee for IPP LARC devices in the hospital setting and in the outpatient setting at federally qualified health centers, removing a financial barrier that had kept many public providers from offering LARCs. Currently, four out of five birthing hospital systems in Delaware, which account for 86 percent of births in the state, now provide IPP LARC. In addition to improving access through training and technical support, Upstream is committed to ensuring that all women in Delaware are aware of the accessibility

of effective contraception and know where to go to receive best-in-class contraceptive care. In May 2017, Upstream launched a consumer campaign, Be Your Own Baby, after over a year of development with direct input from Delaware women. The campaign helps Delaware women overcome barriers to contraception and drives demand to Upstream-trained health centers. It supports Upstream’s model by helping patients understand they have access to free and convenient contraception and facilitating their ability to schedule an appointment and get to the health center. Response to the campaign among Delaware women has been overwhelmingly positive, and early evidence suggests the campaign is inspiring women to schedule appointments at Upstreamtrained health centers. Early Evidence of Outcomes The early evidence of Upstream’s outcomes among Delaware healthcare providers is very promising. Provision of all methods of contraception, including LARC, has begun to increase. Delaware Title X clinics, which include all federally qualified health centers, state-run clinics and Planned Parenthood of Delaware, provide family planning services to low-income individuals and treat a high proportion of women at highest risk of unplanned pregnancy. At Delaware Title X sites, the percentage of women ages 15-44 (excluding those pregnant or seeking pregnancy) who left with any method of contraception rose from 52 percent in 2014 to 65 percent in 2016, and the percentage who received a Title X service and left with a LARC method rose from 6 percent in 2014 to 15 percent in 2016 (Berman et al., 2018). Delaware Title X Sites: LARC use at end of visit 15%

12%

5%

2012

5%

2013

6%

2014

2015

2016

% of female patients ages 15-44 receiving a Title X service who left with an IUD or implant (excluding those pregnant or seeking pregnancy)

These positive results have been coupled with strong evidence that Delaware women visiting Upstreamtrained health centers are making their own decisions about which birth control method is right for them. 9

Last year, Upstream fielded a patient survey at a representative sample of sites to assess whether Delaware women visiting Upstream-trained health centers are receiving care that effectively empowers them to choose the contraceptive method that is best for them. According to preliminary results, 99 percent of women reported that they chose or made a shared decision with their healthcare provider about their preferred method of contraception, and 98 percent of women reported that they did not feel pressured by someone to use a particular method of birth control at their visit (Delaware Division of Public Health, 2017). To assess Delaware CAN’s long-term impact, the University of Maryland, in partnership with the University of Delaware, is conducting an independent evaluation of the intervention. The evaluation includes both a process and impact study and focuses on assessing the initiative’s key outcomes of interest, including contraceptive use, LARC use, Medicaid costs, and unplanned pregnancies resulting in unplanned births. Though it will be several years before there are any long-term results from Delaware CAN, feedback on Delaware CAN has been resoundingly positive throughout the state. Conclusion Given Upstream’s early progress in Delaware and significant demand from healthcare leadership across the United States, Upstream is poised to scale its

intervention nationwide and to empower millions of women to plan if and when they want to become pregnant. Upstream has already begun working with stakeholders and funders to launch additional statewide projects and by 2023, Upstream’s goal is to reach health centers that serve 1.6 million women of reproductive age in three states beyond Delaware. References

Aish, G. and Marsh, B. (September 2014). How Likely Is It That Birth Control Could Let You Down? The New York Times. American Academy of Pediatrics (September 2014). AAP Updates Recommendations on Teen Pregnancy Prevention. Bridgeland, J.M., et al. (2006). The Silent Epidemic: Perspectives of High School Dropouts. Civic Enterprises, Peter D Hart Research Associates and The Bill & Melinda Gates Foundation. Centers for Disease Control (2016). US Selected Practice Recommendations (US SPR) for Contraceptive Use, 2016. Claridge, A.M. et al. (2015). Pregnancy Intention and Positive Parenting Behaviors Among FirstTime Mothers: The Importance of Mothers’ Contexts. Journal of Family Issues. Colorado Department of Public Health and Environment (Juanary 2017). Taking the Unintended Out of Pregnancy: Colorado’s Success with Long-Action Reversible Contraception. Committee on Gynecologic Practice, Long-Acting Reversible Contraception Working Group (October 2015). Committee Opinion: Increasing Access to Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. Delaware Division of Public Health (2017) Annual Statewide Title X Data, 2014, 2015, 2016: unpublished. Guttmacher Institute (May 2012). Variation in Service Delivery Practices Among Clinics Providing Publicly Funded Family Planning Services in 2010. Retrieved from: https://www.guttmacher.org/ sites/default/files/report_pdf/clinic-survey-2010.pdf Guttmacher Institute (2014). State Facts About Unintended Pregnancy. Retrieved from: https://www.guttmacher.org/statecenter/unintended-pregnancy/DE.html Guttmacher Institute (March 2016). Unintended Pregnancy in the United States. Guttmacher Institute (June 2017). Insurance Coverage of Contraceptives. Finer, L.B. and Zolna, M.R. (2011). Unintended Pregnancy in the United States. Contraception, 84(5): 478-85. Frost, J.J., Frohwirth, L. and Zolna, M.R. (2016), Contraceptive Needs and Services, 2014 Update. New York: Guttmacher Institute. Retrieved from: h�p://www.gu�macher.org/pubs/ win/contracep�ve-needs-2014.pdf. Kearney, J. (2018) Master Training List Numbers. Upstream Internal Dashboard: unpublished. Sawhill, I. V. and Venator, J. (2014). Reducing Unintended Pregnancies for Low-Income Women. The Hamilton Project. Retrieved from: https://www.brookings.edu/research/reducingunintended-pregnancies-for-low-income-women/ Secura, G. M., et al. (2010). The Contraceptive CHOICE Project: Reducing Barriers to LongActing Reversible Contraception. American Journal of Obstetric Gynecology, 203(2): 115.e1-115e7.

Mark Edwards is the co-founder of Upstream USA, a national nonprofit that expands access to all forms of contraception to reduce unplanned pregnancy and improve economic opportunity. He is a frequent speaker and commentator on the intersection of upward mobility and reproductive health care. Mark is a graduate of Harvard College, a Draper Richards Kaplan Foundation Entrepreneur and an Ashoka Fellow, and has served on more than a dozen nonprofit boards and advisory committees.

Pull bio pics from word doc

10 Delaware Journal of Public Health – May 2018

Liz O’Neill is the Delaware CAN Director of Upstream USA, leading the statewide effort to increase access to all forms of contraception through partnerships, education, training and technical assistance. Before joining Upstream, Liz was the project director of Christiana Care Health System’s Community Center of Excellence in Women’s Health. She previously had served as the director of program services for the Delaware chapter of the March of Dimes and as a family support specialist for the Delaware birth to three program.

The DPH Bulletin

From the Delaware Division of Public Health

April 2018 DPH launches Lyme disease campaign Delaware is among the top 10 states with the highest incidence rates of Lyme disease, a bacterial infection spread through the bite of the black-legged tick or deer tick. According to the Centers for Disease Control and Prevention, Lyme disease is the most commonly reported vectorborne illness in the United States.

Discussing acute overdose care management are, clockwise from top left: Rochelle Little, family crisis therapist, Department of Services for Children, Youth, and Their Families; Dr. Karyl Rattay, director, Division of Public Health; Fran Phillips, acting health officer, Anne Arundel County Department of Health; John Powell, chair of the Department of Emergency Medicine, Christiana Care Health System (CCHS); and Kate Groner, MD, attending physician, Department of Emergency Medicine, CCHS. Photos by Donna Sharp.

DPH convenes forum on acute overdose system of care The Division of Public Health (DPH) convened a forum last month to get feedback from Delaware emergency medical services, law enforcement, and emergency department partners on plans to develop an Overdose System of Care. Delaware is the first state to take on a statewide system of care approach for overdoses, modeled after its other successful systems of care. For more information, contact Kate Brookins, Public Health Treatment Program Administrator, at 302-223-1741.

DPH will run Lyme disease ads and social media messages this spring, summer, and fall. Educational materials are being distributed to students in grades K-12. Five key messages are: bathe within two hours after coming indoors; look for ticks on your body and remove them; apply repellent; spray your yard; and treat your pet. One symptom of Lyme disease is a red bull’s-eye rash that can occur anywhere on the body, and vary in size and shape. Not everyone develops the rash. Other early symptoms are fever and/or chills, fatigue, muscle and joint aches, and headaches. Seek early treatment from a health care provider to prevent debilitating symptoms such as severe joint pain and swelling; heart palpitations; dizziness; neck stiffness; severe headaches; and short-term memory and concentration problems. For more information about Lyme disease, including fact sheets, visit http://de.gov/lyme.

What are vaping teens inhaling?

Nearly one in three U.S. 12th grade students use vaping devices, yet do not know what they are inhaling, according to the National Institutes of Health’s (NIH) 2017 Monitoring the Future survey. Nearly 52 percent of 12th graders said, “just flavoring,” 32.8 percent said “nicotine,” and 11.1 percent said “marijuana” or “hash oil.” Labeling can be inconsistent or inaccurate. Read the results at: https://www.drugabuse.gov/news-events/newsreleases/2017/12/vaping-popular-among-teensopioid-misuse-historic-lows.

The New Castle County Vo-Tech School District opened the St. George’s Vocational Technical High School Wellness Center in February. DPH Director Dr. Karyl Rattay (pictured in the center of the back row) spoke with other attendees. In 2017, of all students seen in Delaware’s wellness centers, 40 percent were seen for mental health reasons. The other 60 percent were seen for medical reasons such as sports physicals, nutrition counseling, and diagnoses and treatment for sexually transmitted infections. Photo by Jen Brestel.

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Breastfeeding Support Group for Puerto Rican Moms Yukiko Washio, Ph.D., Christiana Care Health System/University of Delaware Lauren Wills, B.S., Elisa Colchado, M.Ed., Mara Humphreys, M.Ed., Temple University Carla P. Aponte, M.S., Delsy M. Morales, B.S., Christiana Care Health System Linda M. Kilby, Ph.D, R.D., L.D.N. - N.O.R.T.H., Inc., Philadelphia WIC program

12 Delaware Journal of Public Health – May 2018

Ethnic Disparities in Breastfeeding Lack of breastfeeding increases the risk for pediatric overweight and a variety of infectious diseases, including otitis media, gastroenteritis, and respiratory infections (NICHD, 2017). Over $3.6 billion in annual healthcare costs would be saved if breastfeeding increased to the rates endorsed by Healthy People 2020, and $13 billion would be saved annually if 90% of mothers in the U.S. exclusively breastfed their children (U.S. Department of Health and Human Services, 2011).

Children’s Fund (UNICEF; WHO/UNICEF, 1989), in which the only strategy to maintain breastfeeding is the last step of postpartum referrals to peer-support groups. We have recently conducted weekly peer support groups for breastfeeding at an urban WIC setting in order to support continued breastfeeding among WIC-enrolled Puerto Rican mothers. A bilingual breastfeeding counselor of Puerto Rican heritage with WIC program experiences was hired to introduce the program and to facilitate the weekly 1-hour meetings from July 2014 to January 2015.

While low-income Hispanic women have high breastfeeding initiation rates overall (80%) and 6and 12-month duration rates (45%; 25%) similar to non-Hispanic White women (Sparks, 2011), there is considerable disparity in breastfeeding duration by national origin within the Hispanic community, with low-income Puerto Rican women having a median breastfeeding duration of only two weeks (Chapman & Pérez-Escamilla, 2012).

The weekly support group meetings were intended to provide information related to breastfeeding, provide social support to reinforce continued breastfeeding, and problem-solve on issues that caused difficulties in continuing breastfeeding. The Puerto Rican breastfeeding consultant addressed the general technique related to breastfeeding, the importance and benefits of breastfeeding, cultural misconceptions about early weaning and formula supplementation before 6 months postpartum, and the risks of smoking and secondThe Special Supplemental Nutrition Program for hand smoke exposure to children. The breastfeeding Women, Infants, and Children (WIC) serves to consultant encouraged mothers to talk about their safeguard the health of socioeconomically disadvantaged experiences and provided social support to reinforce pregnant, postpartum, and their efforts to continue breastfeeding. The breastfeeding breastfeeding women, infants, and consultant provided advice and problem-solved on issues children up to age 5 who are at that caused difficulties in breastfeeding. These difficulties nutritional risk by providing nutritious generally included latching techniques, milk production foods to supplement diets, information issues, sore nipples, and time management issues. The on healthy eating including breastfeeding consultant facilitated discussions among breastfeeding promotion and support, mothers on how to continue breastfeeding while and referrals to health care. WIC is administered by working, have babies latch better, take care of sore the Food and Nutrition Service (FNS), a Federal agency nipples, and deal with negative views of family and of the U.S. Department of Agriculture. National WIC others. Association proposed “Six Steps to Achieve Breastfeeding Goals for WIC Clinics” in 2011 including accessible Of 44 meeting opportunities offered, a total of 16 individual lactation support (National WIC Association, meetings (36%) were conducted, and at other meeting 2011). However, the average breastfeeding duration in opportunities, no mother showed up. A total of 18 this region remains relatively short (<10 weeks). WIC mothers participated in group peer support meetings remains one of the largest distributors of free infant at least once. No more than two mothers attended in formula in the U.S., greatly undermining the practice to any of the meetings conducted. Specifically, for 14 out promote breastfeeding and establish breastfeeding as the of 16 meetings conducted (87.5%), only one mother social norm (Pérez-Escamilla, 2012). attended. For 2 out of 16 meetings conducted (12.5%), two mothers attended. Breastfeeding Support Group for Puerto Rican Eight of the 18 mothers that signed up to attend Mothers the meetings (44%) ever attended a support group The Baby-Friendly Hospital Initiative to promote meeting at a WIC office. Only 4 of the 8 mothers breastfeeding initiation and maintenance has the Ten (50%) participated in more than one support group Steps to Successful Breastfeeding developed by the meetings at WIC in the range of 2 to 5 times. Those World Health Organization and the United Nations who attended a meeting(s) reported benefits of the 13

meetings being “information about formula”, “latching technique”, “stress coping skills”, and “socialization.” Barriers to attend meetings included childcare issues (n = 6), weather issues (n = 3), working full-time (n = 3), transportation issues (n = 1), and scheduling issues (n = 1). Preferred format for support group included individual breastfeeding support, relative to group support only. Preferred type of individuals to provide breastfeeding support was health professionals (n = 7), family or relatives (n = 4), friends (n = 2), and Spanishspeaking peer (n = 1). Individualized Strategy to Maintain Breastfeeding The attendance rate among Puerto Rican mothers for the breastfeeding support group meetings at an urban WIC setting was poor. WIC-enrolled Puerto Rican mothers had many logistic barriers that prevented them from attending weekly support group meetings. Moreover, they preferred individual professional support over group peer support. A review by Chapman and Perez-Escamilla (Chapman & Pérez-Escamilla, 2012) of individualized peer counseling interventions targeting low-income racial/ ethnic-minority women (African American and Puerto Rican mothers) demonstrated significant improvements in breastfeeding initiation, but non-significant effects on breastfeeding continuation at 1- and 3-month. Providing financial incentives contingent on verified breastfeeding among WIC-enrolled Puerto Rican mothers in an urban setting significantly increased the rate of breastfeeding at 6-month postpartum (Washio et al., 2017). In this study, all participants were introduced to a bilingual Puerto Rican breastfeeding peer counselor, and half of the randomized participants also received an escalating magnitude of financial incentives contingent on verified breastfeeding. Individualized breastfeeding support with additional incentives (Washio et al., 2017) or additional services to address logistic barriers (e.g., home visitations, flexible time schedules, convenient meeting locations) might be more appropriate and motivating for WIC-enrolled Puerto Rican mothers to utilize the breastfeeding service and maintain breastfeeding. The anecdotal observation in the Delaware state has been consistent with the presented empirical findings in this commentary. The Health Ambassador program funded by the Department of Public Health in Delaware provides education and community referrals for promoting breastfeeding after hospital discharge. 14 Delaware Journal of Public Health – May 2018

The program hosted a community baby shower even for Hispanic mothers, and three out of 60 families were Puerto Rican, predominantly with Mexican and Central American families. The Delaware community has a clinic focused on Hispanic populations which provides bilingual lactation consultation and conducts breastfeeding peer support meetings; however, predominant Hispanic ethnicities who utilize the services were Mexican and Central Americans. Informal interviews with Puerto Rican mothers indicated that the Puerto Rican culture prefer individualized professional help rather than group-based peer support. In summary, the current commentary brought attention to ethnic disparities in the rate of continued breastfeeding, especially among low-income Puerto Rican mothers. While the global initiative to promote breastfeeding recommends a strategy of group peer support referral to maintain initiated breastfeeding as the last step, such a strategy may not be always acceptable among mothers of a certain racial/ethnic group. A patient-centered approach such as comprehensive, individualized breastfeeding support should be explored to support continuation of breastfeeding especially for racial/ethnic groups with low rates of continued breastfeeding. Such an endeavor should follow a public health model such as socio-ecological model in order to effectively address individual needs while advocating and improving the norm around breastfeeding within the community and Puerto Rican ethnic group. We recommend a future, national and global breastfeeding support initiative to explore and include several options as strategies to maintain breastfeeding so they are more feasible and acceptable to various racial/ethnic groups of mothers. References Chapman, D. J., & Pérez-Escamilla, R. (2012). Breastfeeding among minority women: moving from risk factors to interventions. Advances in Nutrition (Bethesda, Md.), 3(1), 95–104. http://doi.org/10.3945/an.111.001016 National WIC Association. (2011). Six Steps to Achieve Breastfeeding Goals for WIC Clinics. Retrieved from http://www.dhhs.nh.gov/dphs/nhp/wic/documents/six-steps.pdf NICHD. (2017). What are the benefits of breastfeeding? Retrieved April 6, 2017, from https:// www.nichd.nih.gov/health/topics/breastfeeding/conditioninfo/Pages/benefits.aspx Pérez-Escamilla, R. (2012). Breastfeeding social marketing: lessons learned from USDA’s "Loving Support" campaign. Breastfeeding Medicine : The Official Journal of the Academy of Breastfeeding Medicine, 7(5), 358–63. http://doi.org/10.1089/bfm.2012.0063 Sparks, P. J. (2011). Racial/ethnic differences in breastfeeding duration among WIC-eligible families. Women’s Health Issues : Official Publication of the Jacobs Institute of Women’s Health, 21(5), 374–82. http://doi.org/10.1016/j.whi.2011.03.002 U.S. Department of Health and Human Services. (2011). The Surgeon General’s Call to Action to Support Breastfeeding. Washington DC. Retrieved from http://www.surgeongeneral. gov/library/calls/breastfeeding/executivesummary.pdf Washio, Y., Humphreys, M., Colchado, E., Ortiz, M., Kilby, L.M., Zhang, Z., Collins, B., Chapman, D., Higgins, S.T., & Kirby, K. C. (2017). Incentive-based intervention to increase breastfeeding duration among Puerto Rican mothers. Pediatrics. WHO/UNICEF. (1989). Protecting, promoting and supporting breastfeeding: The special role of maternity services.

Yukiko Washio, Ph.D., Christiana Care Health System, University of Delaware

Lauren Wills, B.S., Temple University

Elisa Colchado, M.Ed., Temple University

Mara Humphrey, M.Ed., Temple University

Carla Aponte, M.S., Christiana Care Health System

Linda Kilby, Ph.D., R.D., L.D.N., Executive Director N.O.R.T.H., Inc., Philadelphia WIC program

Delsey Morales, B.S., Christiana Care Health System *not shown

15

From the President The increasing prevalence of gun violence is a complex and daunting crisis, but it is one that we can see abate in our lifetime. I authored three editorials recently on this topic -- two with NAM member Dr. Alan Leshner, CEO emeritus of the American Association for the Advancement of Science and Committee Chair of Priorities for Research to Reduce the Threat of Firearm-Related Violence (Science and Annals of Internal Medicine), and one with NAM Member Dr. Mark Rosenberg, founding director of the National Center for Injury Prevention and Control at the CDC (The Washington Post). All three editorials highlighted the critical need for research to investigate the causes of gun violence, as well as allocated funding to support that research. Evidence-based policies will lead to safer schools, safer communities, and less unnecessary deaths, and do not have to infringe on the rights of law-abiding citizens. These policies are long overdue. -- Victor J. Dzau, MD President, National Academy of Medicine NAM Perspectives Perspectives are expert commentaries and discussion papers by leading voices in health and health care. Read the latest releases and updates below and subscribe to receive new Perspectives as soon as they’re published. Investing in Children to Promote America’s Prosperity Accelerating Precision Health by Applying the Lessons Learned from Direct-to-Consumer Genomics to Digital Health Technologies The Health Care Career Pipeline: A Program Director’s Reflection on Extending the Resources of the University to the Minority Student Community Pediatricians Play Important Role in Decreasing Sugary Drink Intake in Young Children NAM Action Collaborative on Clinician Well-Being and Resilience The Clinician Well-Being Knowledge Hub Our health care system leaves many health professionals exhausted and overwhelmed, which can directly affect patient health. It’s time to take care of those who take care of us. Introducing the Clinician Well-Being Knowledge Hub -- a first-ofits-kind comprehensive repository that provides resources to ensure and enhance clinician well-being. The Knowledge Hub contains a wide variety of resources that health system leaders and clinicians can utilize to build a better system that supports clinicians and enables them to thrive, including peer-reviewed research, blog posts, presentations, toolkits, and testimonials. Explore the knowledge hub at nam.edu/ClinicianWellBeing and share it with your colleagues, supervisors, or anyone else who you think might benefit from these resources. Click here for a resource toolkit including logos, advertisements, email templates, graphics, and newsletter language that you can use to share the Knowledge Hub. Perspective from Action Collaborative Co-Chairs Action Collaborative co-chairs Darrell G. Kirch and Thomas J. Nasca, with Victor J. Dzau, authored a perspective published in the New England Journal of Medicine on the clinician burnout crisis and what the Action Collaborative is doing to combat the crisis and promote clinician well-being. Read the perspective>> NAM Culture of Health Program Communities Driving Health Equity - A Spotlight Video Series The National Academy of Medicine is proud to present a documentary video series that spotlights local organizations across the United States who are advancing health equity for their communities by addressing the environmental, social, economic, and structural challenges that may impact the health of members of their communities. These diverse communities face complex, pervasive challenges but are all making progress in advancing health equity -- meaning everyone has the same shot at living a healthy life. Watch the videos>>

16 Delaware Journal of Public Health – May 2018

88 th Annual Meeting &Awards Ceremony Chase Center on the Riverfront, Christina Ball Room Wilmington, Delaware

FRIDAY, MAY 11, 2018 5:30—9:30 p.m. Keynote Speaker

DARSHAK SANGHAVI, M.D.

Chief Medical Officer and Senior Vice President of Translation

OPTUMLABS

President’s Award Honoree NICHOLAS J. PETRELLI, M.D. and the Helen F. Graham Cancer Center and Research Institute

Helen F. Graham Cancer Center & Research Institute

Public Health Recognition

Register online at www.delamed.org/2018

17

Changing Preterm Birth in Delaware Matthew K. Hoffman1, M.D., M.P.H., Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, DE

Introduction & Epidemiology:

Preterm delivery (delivery prior to 37 weeks 0/7 days gestation) remains the dominant cause of neonatal morbidity and mortality throughout the world1–3 . In the state of Delaware the rate of preterm birth was noted to be 10.1% in 2016, a slight increase from 20154. Fortunately, the majority (70%) of preterm births occur in the late preterm birth period, between 34 0/7 weeks and 36 6/7 weeks, where the outcomes are generally more favorable5. Though preterm births prior to 34 weeks are less common, the most neonatal deaths result from children born before 34 weeks. Likewise significant differences exist between different ethnic groups with African American women having an 11.8% rate of preterm birth compared to Hispanics (7.9%) and Caucasians (9.0%)4. In addition to the individual burdens of preterm birth, significant financial burdens results from prematurity. Recent estimates of direct inpatients costs attributable to prematurity are largely unavailable; however, in 2005 the direct medical costs for preterm infants born in the United States were noted to exceed 26.2$ billion dollars6. Children born at earlier gestational ages are noted to have proportionally higher health care costs than those born later in pregnancy. This estimate of cost does not reflect the longitudinal medical costs beyond the birth hospitalization which are known to be significantly higher than children born at term . Children born prematurely are also at an increased risk for long term medical complications such as respiratory, gastrointestinal, cardiovascular, and metabolic disorders7,8. Premature children born are also known to have a variety of learning delays including lower IQ’s, difficulty with language acquisition and are more likely to have neurobehavioral challenges9–11. Overall, approximately 50% of pediatric neurodevelopmental disorders are attributed to prematurity12. Biology of Prematurity:

Increasingly preterm birth has become recognized as an outcome of a series of antecedent causes with a common final pathway13. It should be remembered that 18 Delaware Journal of Public Health – May 2018

approximately 40% of prematurity is due to iatrogenic preterm birth, which is mostly the result of preeclampsia and fetal growth restriction. The remaining 60% of prematurity is the result of spontaneous preterm birth. Most researchers are increasingly viewing spontaneous preterm birth as being the result of the following causes: decidual hemorrhage, inflammation/infection, uterine distention, maternal stress, cervical insufficiency, preterm premature rupture of the membranes, maternal comorbidities, familial factors and premature activation of the fetal hypothalamic-pituitary-adrenal (HPA) axis14. Spontaneous preterm births prior to 28 weeks (the largest cause of mortality) are largely driven by three predominant causes: infection/inflammation, decidual hemorrhage and cervical insufficiency. Due to this complexity, effective prevention and treatment of preterm birth may require pathway specific treatments and that a solitary treatment approach may not exist. Iatrogenic Prematurity:

As 40% of preterm births are iatrogenic, assuring that providers are evidenced based in their approach to elective preterm delivery may be a great opportunity. In an examination of iatrogenic late preterm births (34 to 37 weeks), Gyamfi et al. found that 56.7% of iatrogenic late preterm births were not supported by nationally published guidelines though all cases of iatrogenic preterm birth had a reason for delivery15. Both the publication of national guidelines on the timing of iatrogenic delivery to specific obstetrical conditions16 and public reporting of elective deliveries prior to 39 weeks have resulted in a significant decline in iatrogenic prematurity17. Nonetheless, iatrogenic preterm delivery are mostly due to preeclampsia and fetal growth restriction and strategies to mitigate these causes are increasingly being employed. Recognizing that these diseases are vascularly mediated and begin early in pregnancy, several professional organizations have recommended the use of low dose aspirin for the prevention of preeclampsia in at-risk women early in pregnancy (13 weeks )18,19.

Meta-analyses of low dose aspirin have suggested a 20% reduction in the risk of preeclampsia and similarly a lowering of the risk of fetal growth restriction20,21. Pravastatin which has long been used to treat adult vascular disease may play an important role22 to prevent preeclampsia to women who are deemed at risk for this condition. Trials in women at high risk for recurrent preeclampsia are currently being planned. Prediction of preterm birth:

Accurate prediction of preterm birth would allow providers to identify treat women at risk in a much more systematic way. Historical or clinical risk factors have long been utilized to identify women at risk for preterm birth. Socio-economic status, ethnicity (particularly African-American race), geographic location, and maternal stress have been established as risk factors for preterm birth; though their ability to identify women who will deliver prematurely are extremely limited23,24. The most predictive factor for subsequent preterm birth in a singleton gestation is having had a prior preterm birth, which carries an approximate risk of 30% in a subsequent pregnancy. For African-American women, those with earlier preterm births and those with multiple prior preterm births, a history of a prior preterm birth is an even stronger risk factor25. Researchers have begun to look for other markers for preterm birth. Transvaginal cervical ultrasound measurement of the cervical length has been a frequent subject of investigation26. Two authors have suggested that universal transvaginal cervical length screening when coupled with treatment with vaginal progesterone is a cost effective strategy27,28. Nonetheless, full implementation of such a strategy would only result in a small decrease in the overall rate of preterm birth. Moreover, a recent prospective study of nulliparous women demonstrated that only a minority (AUC= 0.58) of women who deliver prematurely will be detected through cervical length screening; limiting its usefulness as a strategy29. Another marker that has garnered research interest is fetal fibronectin, an anchor protein from the maternal decidua to the fetal chorion30. Though fetal fibronectin has been accepted as a useful test (high negative predictive value) in women who present with symptoms of preterm labor from 24 to 34 weeks, the utility of this test to identify asymptomatic women who will deliver prematurely remains in question. The results of several investigations have been mixed and a recent large prospective trial has suggested that the predictive ability of fibronectin is poor30.

Recognizing that proteomic expression in the placenta may portend preterm birth, researchers have become interested in the role of proteomics and preterm birth. Saade and colleagues recently examined both proteins associated with pregnancy and novel discovery of random proteins to determine their predictive ability to identify women at risk for preterm birth amongst 5501 women31. The group identified and subsequently developed an FDA approved blood test obtained at 19 to 21 weeks that accurately identifies women who will deliver prematurely. This test has demonstrated moderate sensitivity and specificity for preterm birth <37 weeks (AUC=0.75) but had high sensitivity at predicting preterm delivery <35weeks (AUC=0.92). Though promising, studies coupling the use of this test with treatment will be required to demonstrate the utility of such a test. Similarly, the University of California San Francisco has announced the development of a test that utilizes a mixture of clinical information and blood analytes that claims to prospectively identify 80% of preterm births12. Treatment:

Equally important to identifying women at risk for preterm birth, is the development of effective treatment strategies. Three studies of giving exogenous progesterone to women with risk factors for preterm birth have suggested beneit. The Maternal Fetal Medicine Units randomized 434 women with a prior history of preterm birth begun between 16 to 20 weeks to either 250mg of 17 alpha-hydroxyprogesterone caproate (17-0HPC) on a weekly basis or an identical placebo32. Women who received 17 OHPC were approximately a third less likely to deliver prior to 34 and 37 weeks compared to women who received a placebo. Hassan and colleagues randomized women with a cervical length between 10-20mm33 and Da Fonseca randomized women with a cervical length <15mm to vaginal progesterone or an identical placebo and both showed a decrease in preterm birth prior to 34 weeks34. Though promising, multiple other trials using different formulations or risk factors to preterm birth35,36 have failed to demonstrate any benefit to antenatal progesterone. Another medical approach is the use of low dose aspirin. Studies of LDA to prevent preeclampsia have enrolled greater than 43,000 women for the indication of preventing preeclampsia37. These studies have suggested a moderate reduction in the risk of preterm birth (AOR 0.8). This effect may be amplified by beginning 19

LDA before 16 weeks and using higher doses (100mg to 150mg)38. Other analyses of primary studies have suggested a trend towards lower rates of prematurity in women taking early low-dose aspirin. These studies have lacked significant power to firmly establish the potential role of LDA in the prevention of preterm birth39. Currently a trial of nearly 12,000 first time mothers in low/middle Income countries has been undertaken and recruitment will be completed in June of 201840. Interest in pessaries to support the cervix was recently piqued by the Spanish Pesario Cervical para Evitar Prematuridad (PECEP) trial41. In this trial, 385 women with a singleton pregnancy with a short cervix by ultrasound were randomized to an Arabin pessary or usual care. Those who received a pessary (N=192) were less likely to deliver before 34 weeks (OR 0·18, 95% CI 0·08-0·37; p<0·0001). Similar outcomes were seen in an Italian trial of 300 women42. In contrast, an international trial of 942 women who had a short cervix and were randomized to either a pessary or placebo and found no difference in the rate of women delivering before 34 weeks43. This trial differed from the (PECEP) trial in that women received progesterone for a cervical length under 15mm and 24.5% of women had removal of the pessary. Social Determinants:

Finally it should be remembered that beyond the medical issues of preterm birth, the social determinants of health have long been chronicled to have profound impacts on health outcomes and preterm birth. Being of African-American race has long been documented to be a risk factor for preterm birth44 and outcomes are worse amongst women living in poverty. Compounding the issue is that living in poverty may further compound the social and developmental growth of children born prematurely45. Likewise, women of reproductive age are increasingly ethnically diverse and are at risk of living in poverty within the current demographic shifts that occurring within the US44. To address this issue, ACOG and other professional organizations have recommended that routine screening be performed to address inequities in reproductive health46. Likewise, ACOG notes that opportunities to improve patient center outcomes can be done through medical-legal partnerships, liaisons with community based social needs programs, interpreter services and coalitions that can address transportation and logistical challenges. Further research demonstrating improved outcomes from strategies addressing these concerns are wanting; however, it must be acknowledged that the social determinants of health are integral if we are to engage in the issue of prematurity. 20 Delaware Journal of Public Health – May 2018

Conclusion:

Despite years of stagnation and a failure to improve the rates of preterm birth within Delaware, a deeper scientific understanding of the underlying biology provides a potential road map for novel diagnostic studies and therapeutic options. Current studies are underway, potentially offering new hope to the families and children. References: 1. March of Dimes Save the Children, WHO. P. Born Too Soon: The Global Action Report on Preterm Birth. . (CP Howson JE Lawn. MVK, ed.). Geneva: World Health Organization; 2012. 2. Mathews TJ, Menacker F, MacDorman MF. Infant mortality statistics from the 2002 period: linked birth/infant death data set. Natl Vital Stat Rep. 2004;53(10):1-29. http://www.ncbi.nlm. nih.gov/pubmed/15622996. Accessed November 22, 2013. 3. Anderson RN, Smith BL. Deaths: leading causes for 2001. Natl Vital Stat Rep. 2003;52(9):185. http://www.ncbi.nlm.nih.gov/pubmed/14626726. Accessed November 22, 2013. 4. Dimes M of. March of Dimes Peristats-Delaware. https://www.marchofdimes.org/peristats/ tools/reportcard.aspx?reg=10. Accessed February 10, 2018. 5. Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary Data for 2009. Natl Viatl Stat Rep. 20011;57(12):1-36. 6. Russell RB, Green NS, Steiner CA, et al. Cost of hospitalization for preterm and low birth weight infants in the United States. Pediatrics. 2007;120(1):e1-9. doi:10.1542/peds.20062386. 7. McCormick MC, Richardson DK. Premature infants grow up. N Engl J Med. 2002;346(3):197-198. doi:10.1056/NEJM200201173460310. 8. Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet. 2008;371(9608):261-269. doi:10.1016/S0140-6736(08)60136-1. 9. Yang S, Platt RW, Kramer MS. Variation in child cognitive ability by week of gestation among healthy term births. Am J Epidemiol. 2010;171(4):399-406. doi:10.1093/aje/kwp413; 10.1093/aje/kwp413. 10. Rose O, Blanco E, Martinez SM, et al. Developmental scores at 1 year with increasing gestational age, 37-41 weeks. Pediatrics. 2013;131(5):e1475-81. doi:10.1542/peds.20123215; 10.1542/peds.2012-3215. 11. Phua DY, Rifkin-Graboi A, Saw SM, Meaney MJ, Qiu A. Executive functions of six-yearold boys with normal birth weight and gestational age. PLoS One. 2012;7(4):e36502. doi:10.1371/journal.pone.0036502; 10.1371/journal.pone.0036502. 12. Goldenberg RL, Rouse D. Prevention of preterm birth, Review Article. N Engl J Med. 1998;339(5):313-320. 13. Lockwood CJ, Kuczynski E. Risk stratification and pathological mechanisms in preterm delivery. Paediatr Perinat Epidemiol. 2001;15 Suppl 2:78-89. 14. Bukowski R, Sadovsky Y, Goodarzi H, et al. Onset of human preterm and term birth is related to unique inflammatory transcriptome profiles at the maternal fetal interface. PeerJ. 2017;2017(9). doi:10.7717/peerj.3685. 15. Gyamfi-Bannerman C, Fuchs KM, Young OM, Hoffman MK. Nonspontaneous late preterm birth: Etiology and outcomes. Am J Obstet Gynecol. 2011;205(5). doi:10.1016/j. ajog.2011.08.007. 16. Spong CY, Mercer BM, D’alton M, Kilpatrick S, Blackwell S, Saade G. Timing of indicated late-preterm and early-term birth. Obstet Gynecol. 2011;118(2 Pt 1):323-333. doi:10.1097/ AOG.0b013e3182255999; 10.1097/AOG.0b013e3182255999. 17. Gyamfi-Bannerman C, Ananth C V. Trends in spontaneous and indicated preterm delivery among singleton gestations in the United States, 2005-2012. Obstet Gynecol. 2014;124(6):1069-1074. doi:10.1097/AOG.0000000000000546. 18. WHO Recommendations for Prevention and Treatment of Pre-Eclampsia and Eclampsia. Geneva: WHO Press; 2011. http://apps.who.int/iris/bitstream/10665/44703/1/9789241548335_eng. pdf. 19. LeFevre ML. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(11):819-826. doi:10.7326/M14-1884. 20. Knight M, Duley L, Henderson-Smart DJ, King JF. Antiplatelet agents for preventing and treating pre-eclampsia. Cochrane database Syst Rev. 2000;(2):CD000492. doi:10.1002/14651858.CD000492. 21. Bujold E, Roberge S, Lacasse Y, et al. Prevention of Preeclampsia and Intrauterine Growth Restriction With Aspirin Started in Early Pregnancy. Obstet Gynecol. 2010;116(2, Part 1):402-414. doi:10.1097/AOG.0b013e3181e9322a. 22. Costantine MM, Cleary K, Hebert MF, et al. Safety and pharmacokinetics of pravastatin used for the prevention of preeclampsia in high-risk pregnant women: a pilot randomized controlled trial. Am J Obstet Gynecol. 2016;214(6):720.e1-720.e17. doi:10.1016/j. ajog.2015.12.038. 23. ACOG. ACOG practice bulletin no. 127: Management of preterm labor. Obstet Gynecol. 2012;119(6):1308-1317. doi:10.1097/AOG.0b013e31825af2f0. 24. Goldenberg RL, Iams JD, Mercer BM, et al. The preterm prediction study: the value of new vs standard risk factors in predicting early and all spontaneous preterm births. NICHD MFMU Network. Am J Public Health. 1998;88(2):233-238. http://www.pubmedcentral. nih.gov/articlerender.fcgi?artid=1508185&tool=pmcentrez&rendertype=abstract. Accessed December 29, 2015. 25. Mercer BM, Goldenberg RL, Moawad AH, et al. The preterm prediction study: effect of gestational age and cause of preterm birth on subsequent obstetric outcome. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units

Network. Am J Obstet Gynecol. 1999;181(5 Pt 1):1216-1221. http://www.ncbi.nlm.nih.gov/ pubmed/10561648. Accessed February 3, 2018. 26. Iams JD, Goldenberg RL, Meis PJ, et al. The length of the cervix and the risk of spontaneous premature delivery. National Institute of Child Health and Human Development Maternal Fetal Medicine Unit Network. N Engl J Med. 1996;334(9):567-572. 27. Cahill AG, Odibo AO, Caughey AB, et al. Universal cervical length screening and treatment with vaginal progesterone to prevent preterm birth: a decision and economic analysis. Am J Obstet Gynecol. 2010;202(6):548.e1-548.e8. doi:10.1016/j.ajog.2009.12.005. 28. Werner EF, Han CS, Pettker CM, et al. Universal cervical-length screening to prevent preterm birth: a cost-effectiveness analysis. Ultrasound Obstet Gynecol. 2011;38(1):32-37. doi:10.1002/ uog.8911; 10.1002/uog.8911. 29. Sean Esplin M, Elovitz MA, Iams JD, et al. Predictive accuracy of serial transvaginal cervical lengths and quantitative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous women. Obstet Gynecol Surv. 2017;72(7). 30. Esplin MS. The Use of Cervical Length and quantitative fetal fibronectin to identify nulliparous women at risk of subsequent spontaneous preterm birth. AmJObstetGynecol. 2016;214(1):s6. 31. Boggess K, Saade G, Sullivan S, et al. 193: Verification of a proteomic serum-based classifier to predict spontaneous preterm birth in asymptomatic patients. Am J Obstet Gynecol. 2016;214(1):S119. doi:10.1016/j.ajog.2015.10.230. 32. Meis PJ, Klebanoff M, Thom E, et al. Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone caproate. N Engl J Med. 2003;348(24):2379-2385. doi:10.1056/ NEJMoa035140. 33. Hassan SS, Romero R, Vidyadhari D, et al. Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol. 2011;38(1):18-31. doi:10.1002/ uog.9017. 34. Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH, Group FMFSTS. Progesterone and the risk of preterm birth among women with a short cervix. N Engl J Med. 2007;357(5):462469. doi:10.1056/NEJMoa067815. 35. Grobman WA, Thom EA, Spong CY, et al. 17 alpha-hydroxyprogesterone caproate to prevent prematurity in nulliparas with cervical length less than 30 mm. Am J Obstet Gynecol. 2012;207(5):390.e1-8. doi:10.1016/j.ajog.2012.09.013.

36. Norman JE, Marlow N, Messow C-M, et al. Vaginal progesterone prophylaxis for preterm birth (the OPPTIMUM study): a multicentre, randomised, double-blind trial. Lancet. 2016;387(10033):2106-2116. doi:10.1016/S0140-6736(16)00350-0. 37. Duley L, Henderson-Smart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane database Syst Rev. 2007;(2):CD004659. doi:10.1002/14651858.CD004659.pub2. 38. Roberge S, Demers S, Bujold E. Initiation of aspirin in early gestation for the prevention of pre-eclampsia. BJOG. 2013;120(6):773-774. doi:10.1111/1471-0528.12170. 39. Silver RM, Ahrens K, Wong LF, et al. Low-dose aspirin and preterm birth: a randomized controlled trial. Obstet Gynecol. 2015;125(4):876-884. doi:10.1097/ AOG.0000000000000736. 40. Gonzalez-Quintero VH, Istwan NB, Rhea DJ, Smarkusky L, Hoffman MC, Stanziano GJ. Gestational age at initiation of 17-hydroxyprogesterone caproate (17P) and recurrent preterm delivery. J Matern Fetal Neonatal Med. 2007;20(3):249-252. doi:10.1080/14767050601152845. 41. Goya M, Pratcorona L, Merced C, et al. Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial. Lancet. April 2012. doi:10.1016/ S0140-6736(12)60030-0. 42. Saccone G, Maruotti GM, Giudicepietro A, Martinelli P, Italian Preterm Birth Prevention (IPP) Working Group. Effect of Cervical Pessary on Spontaneous Preterm Birth in Women With Singleton Pregnancies and Short Cervical Length. JAMA. 2017;318(23):2317. doi:10.1001/jama.2017.18956. 43. Nicolaides KH, Syngelaki A, Poon LC, et al. A Randomized Trial of a Cervical Pessary to Prevent Preterm Singleton Birth. N Engl J Med. 2016;374(11):1044-1052. doi:10.1056/ NEJMoa1511014. 44. Hamilton BE, Martin JA, Osterman MJK, Curtain SC. Births: Preliminary Data for 2014. Natl Vital Stat Rep. 2015;64(6):1-19. http://www.ncbi.nlm.nih.gov/pubmed/26114874. Accessed January 1, 2016. 45. Brumberg HL, Shah SI. Born early and born poor: An eco-bio-developmental model for poverty and preterm birth. J Neonatal Perinatal Med. 2015;8(3):179-187. doi:10.3233/NPM15814098. 46. ACOG Committee Opinion No. 729 Summary. Obstet Gynecol. 2018;131(1):198-199. doi:10.1097/AOG.0000000000002453.

Dr. Hoffman is the Marie E. Pinizzotto, M.D., Endowed Chair of Obstetrics & Gynecology at Christiana Care Health System.He is an active researcher both nationally and internationaly in perinatal medicine with a focus on the prevention of preterm birth.

DELAWARE MILITARY & VETERANS SUBCOMMITTEE

(DELAWARE SUICIDE PREVENTION COALITION)

SAVE THE DATE

2018 Military & Veterans Mental Health Summit Tuesday, September 11, 2018 Registration information coming soon!

Dover Downs 1131 N. DuPont Highway, Dover, DE 19901 FREE FOR ALL ACTIVE MILITARY MEMBERS AND VETERANS! 21

TOBACCO INDUSTRY-SPONSORED YOUTH PREVENTION PROGRAMS IN SCHOOLS CDC OFFICE ON SMOKING AND HEALTH APRIL 2018 Tobacco industry-sponsored school-based tobacco prevention programs are ineffective and may promote tobacco use among youth. Despite this evidence, the tobacco industry, including e-cigarette product makers, continue to engage in school-based youth tobacco prevention initiatives. Because the presence of the tobacco industry in school settings may increase the likelihood of youth tobacco product initiation, it is critical that public health and school-based efforts to prevent youth tobacco product use remain independent of tobacco industry influences.

The 2012 Surgeon General’s Report documents the ineffectiveness of tobacco industry-sponsored youth prevention programs. The 2012 Surgeon General’s report, Preventing Tobacco Use Among Youth and Young Adults (2012 SGR), reviewed tobacco-industry sponsored youth prevention initiatives in depth, including school-based programs. It found that “the tobacco industry’s youth smoking prevention activities and programs have not provided evidence that they are effective at reducing youth smoking. Indeed, unpublished internal industry documents available to the public because of litigation, and published academic studies, indicate that they are ineffective or serve to promote smoking among youth.”1

Industry-sponsored youth prevention programs are intended to promote positive attitudes toward the industry. According to the 2012 Surgeon General’s Report: 





“The industry uses [youth prevention] efforts to convey to the public, policymakers, judges, and members of juries that it is doing something substantial about the issue of youth’s tobacco use. In this way, the programs serve to promote positive attitudes about the tobacco industry. Such positive attitudes could help to limit the industry’s legal liability and make it easier for its views to be heard on legislative issues.”1 Products “provided to students by the tobacco industry, as well as other industry-sponsored efforts with the stated purpose of preventing youth tobacco use, could create favorable impressions of the sponsoring tobacco companies among young people, their parents, or others in the community.”1 In contrast, “a substantial body of research has demonstrated that anti-tobacco industry attitudes reduce the likelihood of future initiation of smoking among youth and young adults.”1

School-based prevention programs are most effective when part of a comprehensive approach to reduce and prevent tobacco use.   



The 2012 Surgeon General’s Report concluded: “The evidence is sufficient to conclude that school-based programs with evidence of effectiveness, containing specific components, can produce at least short-term effects and reduce the prevalence of tobacco use among school-aged youth.”1 Because there is limited evidence of the long-term effectiveness of school-based programs to prevent smoking, school programs may not be fully effective as a stand-alone strategy to reduce and prevent tobacco use.2 However, school-based prevention initiatives free of tobacco industry influence, including enforcement of tobacco-free school grounds policies, can be undertaken in combination with proven, community-based youth tobacco prevention strategies.1-3 These can include: o High-impact media campaigns that warn young people about the dangers of tobacco use. o Strategies to raise the price of tobacco products, which reduces youth initiation and use. o Comprehensive smoke-free air laws that prohibit smoking and e-cigarette use in public indoor areas. Additional promising youth prevention strategies that could be part of a comprehensive strategy include, but are not limited to, raising the age of tobacco sales to 21, restrictions on flavored tobacco product sales, and requirements that ecigarette products kept behind the store counter or in a locked box.

22 Delaware Journal of Public Health – May 2018

Cigarette companies and e-cigarette companies continue to engage in school-based prevention initiatives. Despite evidence of ineffectiveness of industry-sponsored school-based programs, tobacco companies continue to promote these programs. For example:  R.J. Reynolds’ Right Decisions Right Now, according to the company, is a “free educational tobacco prevention program for students in grades 5-9” that “emphasizes prevention of tobacco in any form, including e-cigarettes and smokeless tobacco.” (http://www.rightdecisionsrightnow.com/)  JUUL Labs, maker of JUUL e-cigarettes, is engaging school principals and youth prevention coordinators in multiple states to share a pilot youth prevention/education program and offering money to schools to test that program. The focus of the pilot program (the “JUUL Program”) is to educate, prevent, and/or discourage students from using e-cigarettes and marijuana. The company also says it is developing technological solutions that prevent students from using JUUL products on school grounds.5,6

CDC does not partner with or accept donations from the tobacco industry or industry-sponsored foundations.  

 

The activities of the tobacco industry are incompatible with CDC’s public health objectives to prevent and reduce tobacco use across the lifespan and protect the public from secondhand smoke exposure. The 2014 Surgeon General’s Report concluded that “the tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which deliberately misled the public on the risks of smoking cigarettes.”3 Additionally, a Federal court found, among other violations, that tobacco companies “intentionally marketed to young people under the age of twenty-one in order to recruit ‘replacement smokers’ to ensure the economic future of the industry.”7 CDC observes article 5.3 of the World Health Organization (WHO) Framework Convention on Tobacco Control (2005), of which the U.S. is a signatory but has not ratified, which contains specific recommendations on the protection of public health policies from the vested interests of the tobacco industry.8 Additionally, CDC’s gift policy explicitly prohibits the agency from accepting donations from tobacco corporations or foundations related to tobacco corporations.9

REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.

USDHHS. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: HHS, U.S. Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs — 2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. USDHHS. The Health Consequences of Smoking—Fifty Years of Progress. Atlanta, GA: HHS, U.S. Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Campaign for Tobacco-Free Kids. Big surprise: tobacco company prevention campaigns don’t work; maybe it’s because they are not supposed to. Available at: https://www.tobaccofreekids.org/assets/factsheets/0302.pdf. Lind, T. A new twist on vaping: Juuls are small, discreet, and have health and school officials concerned. The Spokesman-Review. March 14, 2018. Available at: http://www.spokesman.com/stories/2018/mar/12/a-new-twist-on-vaping-juuls-are-small-discreet-and/#/0. JUUL Prevention, Intervention, & Replacement Initiatives: Plans & Progress. Handout distributed by JUUL representatives to California schools December 15, 2017. U.S. V. Philip Morris USA, Inc., et al., No. 99-CV-02496GK (U.S. Dist. Ct., D.C.), Final Opinion, August 17, 2006. Available at: http://www.tobaccofreekids.org/content/what_we_do/industry_watch/doj/FinalOpinion.pdf. World Health Organization. Framework Convention on Tobacco Control. Available at: http://apps.who.int/iris/bitstream/10665/42811/1/9241591013.pdf?ua=1. Centers for Disease Control and Prevention. Administration of Gifts to CDC. Policy updated December 21, 2016. Available at: https://www.cdc.gov/maso/Policy/ADMINISTRATION-OF-GIFTS_Policy_20170329_Version-for-CDC-gov_508.pdf

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23

Delaware Infant Mortality

David A. Paul, M.D., Neal D. Goldstein, Ph.D., M.B.I., Robert Locke, D.O., M.P.H.

Delaware’s infant mortality rate remains above Healthy People 2020 targeted goal of 6.0 per 1000 births (Figure 1).1,2 The structural issues that underline the Delaware’s elevated rate require a forward-thinking public health approach. This commentary and review will describe the underlying factors contributing to Delaware’s infant mortality rate (IMR), and the Delaware State Governmental, State Health Systems and public health entities current approaches and challenges to improve outcomes.

Figure 1: US and Delaware Infant Mortality Rate and US Healthy 2020 Target Goals (Best fit lines) 24 Delaware Journal of Public Health – May 2018

Infant mortality is divided into early (0-28 days or neonatal mortality) and late (29 – 364 days or postneonatal mortality). National and local major factors contributing to neonatal mortality include preterm birth, birth defects, health disparities and underlying maternal health complications causing preterm delivery or birth related compromise (Table 1).3–9 These factors are interrelated. Health disparities, especially those delineated across racial/ethnic divisions, are associated with differential rates of prematurity. Infants with congenital malformations are more likely to be delivered prematurely. Poor glucose control is major teratogen.10 Women with diabetes, weight-related and/or hypertensive disorders are more likely to deliver preterm or an infant with complications.7 Health disparities, socio-economic and race-ethnicity, exacerbates these maternal health issues.3,9,11 Racial differences in prematurity rates, especially elevated Black rates of premature birth, is a major factor for the underlying racial differences in infant mortality and utilization of high cost services such as the NICU (Figure 2).2,3 Post-neonatal infant mortality is most commonly associated with improper sleep related position, sudden unexpected infant death or sudden infant death syndrome (SIDS), injury and infant infection.12,13 Similar to neonatal mortality, all of these leading causes have a multifactorial health disparity component that includes individual and contextual aspects.

Figure 2: Racial-Ethnic differences in gestational age among infants admitted to the Christiana Care Health System NICU over time.

These interactions are not unique to Delaware. A proportion of Delaware’s infant mortality rate compared to other states reflects demographic differences with a higher population of groups in Delaware associated with preterm delivery. However, demographic variables do not account for all of the differences in Delaware infant mortality. Correcting for maternal Black/White/ Hispanic race-ethnicity, tobacco use, and cesarean section rates, there remains excess mortality and prematurity in the state.5,14–16 Based upon information from the Delaware’s Birth Defect Registry, this does not appear to arise from excess congenital malformations.17 More likely, the primary driving cause is from the other contributing factors, including higher rates of preterm births compared to similar population states (Figure 3; Table 2).

A primary driver of infant mortality within Delaware is the elevated rate of prematurity.2,18 The risk of infant death is inversely related to gestational age. Even small changes in gestational age can have a significant impact. Nationally there has been a successful effort to reduce elective deliveries prior to 39 weeks. Although 37 weeks may be perceived to be “term” by conventional and older classification systems, 37-38 weeks deliveries have a high relative risk of physiologic compromise and poor outcomes compared to 39-40 weeks gestation.19 Eliminating elective deliveries prior to 39 weeks have had a meaningful impact. The March of Dimes, physician groups, governmental entities and local maternity centers deserve significant credit in converting this evidence-based goal into every day practice reality. The greatest risk of death is in the smallest infants. Although the number of infants born <1000 grams (2.2 pounds) is less than 1%, this group of infants accounts for over 50% of the Delaware’s IMR (Figure 4).2,16 There are limited medical interventions that can reduce the rate of prematurity.20 Tocolytic medications to stop preterm labor have limited efficacy. Purposefully limiting the number of multiple gestation pregnancies, especially beyond twins in cases of infertility and following nationally recognized guidelines is one effective intervention but of limited scope. At a population level, prevention of a subsequent preterm birth delivery can be slightly altered by 17-OH progesterone. Access to prenatal care remains high in Delaware.2 An additional important factor is spacing of pregnancies. An interpregnancy interval <18 months is a risk for a preterm delivery.21–23 Interpregnancy interval is partially under the domain of an individual, but the opportunity to have access to affordable and effective contraceptives is primarily determined by federal and state policies.

Figure 3: Percent preterm births in DE and US 1999-2015. (Note: Beginning in 2014 NCHS changed the standard for gestational period from the Last Menstrual Period based gestation period to the Obstetric/Clinical Gestation Estimate based gestation period)

Teenage births across Delaware have markedly declined in the past 10 years through a combination of national trends and local efforts.24 A reduction in elective multiple births, especially multiples beyond twins, have also diminished.10,16,18 The occurrence of preterm triplets and quadruplets because of infertility interventions is now an uncommon event in Delaware. Regionalization of care through coordination of transport and perinatal services can reduce infant mortality.25 25

Figure 4A: Percentage of Delaware Infant deaths by birthweight (bars) compared to percentage of births by weight (line).

Within Delaware there is verbally agreed upon nonbinding agreement to follow best practice national guidelines that the highest risk infants and infants with congenital malformations deliver at Delaware’s regional perinatal center. With rare exceptions, these national best practices are generally followed. There is an opportunity to further coordinate maternal and infant transports and levels of care as designated by the AAP and ACOG.

opportunities for improvement. Once an infant is born prematurely, especially for those <1500 grams, survival rates in Delaware are equivalent to or exceed expected rates compared to European or other US states.26,27 Christiana Care Health System (CCHS) , the largest and only Level III NICU in the state at a delivery hospital, is the primary provider for infants <1500 grams birthweight. CCHS NICU, meets or exceeds all risk-adjusted outcomes measures for infants < 1500 grams birthweight among comparative databases, including the largest international benchmarking quality database, the Vermont-Oxford Network, with over 1000 US and international neonatal intensive care units.26 These outcomes reflect a high-volume, high-capacity system of maternal and infant care providers and a health system that has made this component of care a priority. Delaware’s children’s hospital, Nemours/A.I. duPont Hospital for Children, participates in selective benchmarking. Nemours cardiothoracic program has equivalent outcomes to the best program in Pittsburgh and Philadelphia.28 Various subspecialty surgical programs meet or exceed comparative outcomes.29 Nemours Extracorporal Membrane Oxygenation (ECMO) team are leaders among the benchmarking ELSO registry.30 The Nemours NICU does not participate in the Vermont Oxford or other large medical outcome comparative networks for premature infants at their Delaware site. All of the Delaware maternal delivery centers are Baby Friendly USA certified, a rigorous program to promote breastfeeding, except for St. Francis and Nanticoke Hospitals.31 Christiana Care Health System Neonatology, Christiana Maternal Fetal Medicine teams and members of Nemours are in leadership positions in national quality improvement efforts and national organizations that set standards of care.

If the within-hospital risk-adjusted care in Delaware meets or exceeds national and international benchmarks, why is DE’s infant mortality elevated? All research indicates that the Figure 4B: Delaware IMR by birthweight (bars) compared to percentage of greater than expected mortality rate comes from births by weight (lines). a disproportionate rate of high risk infants being born to high risk mothers.5,7,14–16,32 Previously Although many of the drivers for preterm delivery our group demonstrated that the degree of physiologic occur outside the hospital, benchmarking health compromise of infants being born continues to rise.14,15 system and health provider outcomes are essential Though recently improving, the rate of premature steps in understanding provider and hospital system infants in Delaware has been nearly twice that of similar 26 Delaware Journal of Public Health – May 2018

whose mother has a college degree compared to non-Hispanic Whites without a high school diploma.2 Nationally, Blacks have double the IMR of Hispanics despite a similar socio-economic status.2 Nationally there is an increased rate of black premature infant death. At Christiana Care Health System there is not an elevated risk of death prior to hospital discharge compared to other racial/ethnicities. The hospital birth survival rate at Christiana Care Health System for ≤ 30 week premature Black infants is better than Whites (Table 3).16 There is no difference between non-Hispanic White or Hispanics in <30 week prematurity hospital survival, suggesting that there is no adverse healthcare bias or survival based on race/ethnicity.16 Figure 5: Percent of infants admitted to the Christiana Hospital NICU whose mothers had pre-existing or gestational diabetes or a hypertensive disorder during pregnancy.

population states.2 On the positive side, Delaware’s teen pregnancy rate has been declining.2,17 In contrast, maternal preconception, intra- and inter-conception health, especially with respect to hypertensive and weight-related disorders, continues to have an untoward impact on adverse neonatal outcomes (Figure 5).16 Of crucial importance, there remain significant health disparities in outcomes. Our group has demonstrated that there are complex interactions between race/ ethnicity, maternal obesity, hypertensive disorders, placental factors, and adverse neonatal outcomes in including death and/or chronic lung injury among survivors.7,8,15,32 These have been detailed in our other previous publications. From a public health perspective, addressing health disparities and underlying maternal intra- and preconception health are potentially modifiable factors that the state of Delaware, citizens, health systems, faithbased groups and non-profits can make a significant impact. There is a wide infant mortality gap between non-Hispanic Black and non-Hispanic White infants. The DE non-Hispanic White IMR is statistically similar to the US national IMR, while the DE non-Hispanic Black IMR is frequently twice as high (Figure 6).2 The difference is not based upon modifiable behaviors, such as tobacco use, education or socio-economic status. Non-Hispanic Blacks use tobacco less frequently than non-Hispanic Whites while pregnant, yet the IMR for Black non-smokers is higher than White smokers during pregnancy.33 Nor is this education or economic based. The IMR is higher among non-Hispanic Blacks

Figure 6: Comparative infant mortality rates between US and Delaware based on Race/Ethnicity

In European countries, racial differences in outcomes are less apparent. Non-Hispanic Blacks born in Europe have the same IMR as non-Hispanic Whites. Recent African-American immigrants to the United States have the same birthweight and infant outcomes as US Whites.34,35 Within two generations the Black-White gap appears. Epigenetics may play an important role.36–38 The US Black vs White IMR difference is present only in Black Americans who have been here for more than one generation. This evidence suggests that there are important non-genetic, social factors influencing the Black population in the US compared to other countries, consistent with the “Weathering Hypothesis” that has an untoward risk for a poor pregnancy outcome.39,40 27

Blacks experiencing racism are 2.7 times as likely to deliver an infant <1500 grams.34 Chronic stress and cumulative life experiences are risks for delivering preterm and a low birthweight infant.39,41 These known physiologic responses during pregnancy are mimicked in animal models and present in large epidemiologic observations. These experiences lead to prenatal programming in which the experiences of women, starting in utero and early childhood, can alter the risk for an adverse pregnancy outcome, cross generations and may take generations to repair. These prenatal programming effects are beyond chronic altered stress, a pathway contributing to preterm labor, but increase the risk of hypertensive disorders, metabolic syndromes and other complicating health factors.36,37,39 A fetus developing from a simple cellular organism to complex human within that environment, the prenatal status can contribute to organ developmental associated with hypertensive, metabolic, hypertensive and epigenetic changes, even among infants delivering at term. Preterm infants in general have high rates as adults of diabetes/ glucose intolerance and metabolic syndrome than predicted based upon family-genetic history. Breaking this cycle, make take more than one generation, and has a moral imperative above this critical health factor. The health of all women prior to and during pregnancy is important. Among Whites and Hispanics, overweight and obesity are associated with adverse risks of pregnancy outcomes and higher rates of all cause NICU admission.7,8 Socioeconomic and underlying health factors and behavioral aspects (e.g. tobacco) are important and modifiable.13,33,42 In all groups, breastfeeding and human milk are important positive factors reducing the risk of mortality if premature, reducing the risk of SIDS in all gestational ages infants, and reducing the risk of serious infant infection.43,44 A single early prenatal care visit may not alter the average healthy pregnancy. For other high-risk women, including women who do not realize their pregnancy is at high risk, comprehensive pregnancy, nutritional, emotional and global health support may be critical.5,22,23 The best medical evidence to date from combination of large epidemiologic studies, targeted interventions, and controlled mammalian models, indicate that optimally maximizing the health of mothers in the preconception period, ideally going back to when a mother was inutero herself, can not only reduce IMR, but reduce the risks of premature birth and long-term health consequences in survivors and subsequent generations.41 The precise reason for all cause higher rates of preterm birth in Delaware is not completely clear, but the DE 28 Delaware Journal of Public Health – May 2018

Division of Public Health (DPH), Delaware Healthy Mother Infant Consortium (DHMIC), Christiana Care Health System (CCHS), Healthy Mothers Healthy Babies (HMHB), and a multitude of non-profit stakeholders have engaged in activities to tackle the more modifiable underlying causes. Delaware’s participation in Pregnancy Risk Association Monitoring System (PRAMS), a detailed CDC monitoring program, the Birth Defect Registry (BDR) and Fetal Infant Mortality Review (FIMR) permits a more detailed understanding of local process and influences that can help guide future interventions. These programs focusing on improved maternal and infant-childhood health may have a strong local impact. Prior to the creation of the DHMIC in 2005 by the Governor and Legislature, Delaware’s IMR was rising while the US was experiencing a decline. Since 2005, with active investiture in the DHMIC and related programs, there has been a local Delaware reversal with a decreasing IMR trend (Figure 7).

Figure 7: DE IMR before and after the start of DHMIC in 2005

Two-thirds of DE’s IMR occurs during the neonatal period (0-28 days of life). One-third of infant mortality occurs later during the first year of life.2 Delaware’s postneonatal infant mortality rate has been declining in recent years and now similar to neighboring states (Figure 6). A portion of those infant’s mortality is attributed to consequences of prematurity, congenital anomalies and aspects surrounding birth. Other high causes in Delaware are preventable conditions such sleep position-related and infections.2 The childhood vaccine rate in Delaware is suboptimal, especially for conditions of early childhood including pertussis. Accidents and

trauma during infancy remain leading and preventable causes of infant mortality at a national and local level. A highly modifiable factor to reduce late infant mortality (29-364 days) is adherence to the AAP infant sleep guidelines.45,46 The Delaware State Public Department, health providers, health entities and non-profit groups have helped advocate for safe sleep practices in accordance to AAP guidelines. In addition to safe sleep practice, other modifiable factors are important in reducing SIDS and sleep-related infant deaths. Tobacco increases the risk of SIDS four-fold.45 Breastfeeding reduces the risk of SIDS by an equivalent amount.44,45 Breastfeeding also significantly reduces other infant mortality risks, especially infant infections. Breastfeeding supportive policies in the workplace that permit a mother to breastfeed or safely pump and store her milk are essential to maximize the health of infants and have been proven to be highly cost effective at an employer, employee and public health level.47,48 Investiture in maternal-infant healthcare entities is crucial to achieve targeted low infant mortality rates, but this strategy cannot work in isolation. Interventional strategies that globally address healthier communities including: a living wage, constructive paternal involvement and expanded healthcare access, especially to affordable preconception care, are essential to continually lower infant mortality rates. The average preterm infant costs $66,742 (2017 dollars).49 Extrapolating between 2007 and 2015, the cost of preterm infants in Delaware was $869 million dollars. About half of premature infants are on Medicaid, yielding an estimated direct cost of $435 million to the state. Doing nothing has direct costs to the state budget. In contrast, investing in these aspects has multiplier benefits beyond infant mortality. The emotional impact on families and communities is beyond calculation. Delaware has an excellent healthcare structure, an involved and response state government, and activist community groups. Opportunities exist to meet and exceed targeted goals. References

1. Healthy People 2020 Maternal Infant and Child Health. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Accessed 12/10/17. https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-andchild-health/objectives. 2. United States Department of Health and Human Services (US DHHS), Centers of Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) D of VS (DVS). Linked Birth / Infant Death Records 2007-2015, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program, on CDC WONDER On-line Database. http://wonder.cdc.gov/lbd-current.html on Jan 9, 2018 2:53:08 PM. 3. Macdorman MF, Mathews TJ. Understanding Racial and Ethnic Disparities in U.S. Infant Mortality Rates Key findings. 4. Macdorman MF, Hoyert DL, Mathews TJ. Recent Declines in Infant Mortality in the United States, 2005–2011. 2005. 5. Paul DA, Mackley A, Locke RG, Stefano JL, Kroelinger C. State infant mortality: An ecologic study to determine modifiable risks and adjusted infant mortality rates. Matern Child Health

J. 2009;13(3):343-348. doi:10.1007/s10995-008-0358-9. 6. MacDorman MF, Hoyert DL, Mathews TJ. Recent Declines in Infant Mortality in the United States, 2005–2011. NCHS Data Brief No 120. 2013. 7. De Jongh BE, Paul DA, Hoffman M, Locke R. Effects of pre-pregnancy obesity, race/ethnicity and prematurity. Matern Child Health J. 2014. doi:10.1007/s10995-013-1296-8. 8. de Jongh BE, Locke R, Paul DA, Hoffman M. The differential effects of maternal age, race/ ethnicity and insurance on neonatal intensive care unit admission rates. BMC Pregnancy Childbirth. 2012. doi:10.1186/1471-2393-12-97. 9. Willis E, McManus P, Magallanes N, Johnson S, Majnik A. Conquering racial disparities in perinatal outcomes. Clin Perinatol. 2014. doi:10.1016/j.clp.2014.08.008. 10. Mills JL. Malformations in Infants of Diabetic Mothers. doi:10.1002/bdra.20757. 11. Spong CY, Iams J, Goldenberg R, Hauck FR, Willinger M. Disparities in perinatal medicine: Preterm birth, stillbirth, and infant mortality. Obstet Gynecol. 2011. doi:10.1097/ AOG.0b013e318211726f. 12. Mathews TJ, Macdorman MF, Thoma ME. Infant Mortality Statistics From the 2013 Period Linked Birth/Infant Death Data Set. Natl Vital Stat Reports. 2013;64(9). 13. MacDorman MF. Race and Ethnic Disparities in Fetal Mortality, Preterm Birth, and Infant Mortality in the United States: An Overview. Semin Perinatol. 2011. doi:10.1053/j. semperi.2011.02.017. 14. Schempf A, Kroelinger C, Guyer B. Rising infant mortality in Delaware: An examination of racial differences in secular trends. Matern Child Health J. 2007;11(5):475-483. doi:10.1007/s10995-007-0198-z. 15. Paul DA, Locke RG, Walrath J, Esterly K, Stefano JL. Is infant mortality in Delaware truly increasing? Evidence for increasing illness severity and shift to fetal deaths and previable births. Del Med J. 2004;76(11):399-404. 16. Paul D, Goldstein N, Locke R. CCHS NICU Database. 17. March of Dimes. Peristats. https://www.marchofdimes.org/peristats/Peristats.aspx. 18. Mathews TJ, MacDorman MF, Thoma ME. Infant Mortality Statistics From the 2013 Period Linked Birth/Infant Death Data Set. Natl Vital Stat Reports. 2013;64(9). 19. Hoffmire CA, Chess PR, Saad T Ben, Glantz JC. Elective delivery before 39 weeks: The risk of infant admission to the neonatal intensive care unit. Matern Child Health J. 2012. doi:10.1007/s10995-011-0830-9. 20. Obert R, Oldenberg LG, Wight D, Ouse JR. P REVENTION OF P REMATURE B IRTH. 339(5). 21. Brown W, Ahmed S, Roche N, Sonneveldt E, Darmstadt GL. Impact of family planning programs in reducing high-risk births due to younger and older maternal age, short birth intervals, and high parity. Semin Perinatol. 2015. doi:10.1053/j.semperi.2015.06.006. 22. Kozuki N, Lee AC, Silveira MF, et al. The associations of birth intervals with small-forgestational-age, preterm, and neonatal and infant mortality: A meta-analysis. BMC Public Health. 2013. doi:10.1186/1471-2458-13-S3-S3. 23. Hollowell J, Oakley L, Kurinczuk JJ, Brocklehurst P, Gray R. The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review. doi:10.1186/1471-239311-13. 24. Office of Adolescent Health; Department of Health and Human Resources. Delaware Adolescent Reproductive Health Facts. https://www.hhs.gov/ash/oah/facts-and-stats/ national-and-state-data-sheets/adolescent-reproductive-health/delaware/index.html. Accessed November 1, 2018. 25. Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants a meta-analysis. JAMA - J Am Med Assoc. 2010. doi:10.1001/jama.2010.1226. 26. Paul DA, Locke R, Goldstein ND. Vermont Oxford Neonatal Network - Personal Communication. https://public.vtoxford.org. 27. Mohangoo AD, Buitendijk SE, Szamotulska K, et al. Gestational age patterns of fetal and neonatal mortality in Europe: Results from the Euro-Peristat project. PLoS One. 2011. doi:10.1371/journal.pone.0024727. 28. Pennsylvania Health Cost Containment Council. Pediatric and Congenital Heart Surgery. 2015;(February). http://cardiac_pediatric2012report.pdf. 29. Piatt JH. Thirty-day outcomes of cerebrospinal fluid shunt surgery: data from the National Surgical Quality Improvement Program-Pediatrics. J Neurosurg Pediatr. 2014;14(2):179-183. doi:10.3171/2014.5.PEDS1421. 30. ELSO. Extracorporal Life Support Organization. https://www.elso.org/AboutUs/Overview. aspx. 31. Baby Friendly USA. Baby Friendly USA. https://www.babyfriendlyusa.org/find-facilities/ designated-facilities--by-state. Accessed August 1, 2018. 32. Strouss L, Goldstein ND, Locke R, Paul DA. Vascular placental pathology and the relationship between hypertensive disorders of pregnancy and neonatal outcomes in very low birth weight infants. J Perinatol. 2018. doi:10.1038/s41372-017-0032-4. 33. Curtin SC MT. National Vital Statistics Reports Smoking Prevalence and Cessation Before and During Pregnancy : Data From the Birth. Natl Vital Stat Reports. 2016;65(1). 34. Collins JW, Rankin KM, David RJ. Low birth weight across generations: The effect of economic environment. Matern Child Health J. 2011. doi:10.1007/s10995-010-0603-x. 35. Collins JW, Soskolne GR, Rankin KM, Bennett AC. Differing first year mortality rates of term births to white, African-American, and Mexican-American US-born and foreign-born mothers. Matern Child Health J. 2013. doi:10.1007/s10995-012-1197-2. 36. Wallack L, Thornburg K. Developmental Origins, Epigenetics, and Equity: Moving Upstream. Matern Child Health J. 2016. doi:10.1007/s10995-016-1970-8. 37. Lane RH. Fetal programming, epigenetics, and adult onset disease. Clin Perinatol. 2014. doi:10.1016/j.clp.2014.08.006. 38. Burris HH, Collins JW. Race and Preterm Birth - The Case for Epigenetic Inquiry. 39. Geronimus AT, Hicken M, Keene D, Bound J. “Weathering” and age patterns of allostatic load scores among blacks and whites in the United States. Am J Public Health. 2006. doi:10.2105/AJPH.2004.060749. 40. Holzman C, Eyster J, Kleyn M, et al. Maternal weathering and risk of preterm delivery. Am J Public Health. 2009. doi:10.2105/AJPH.2008.151589. 41. Lu MC, Kotelchuck M, Hogan V, Jones L, Wright K, Halfon N. Closing the Black-

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White gap in birth outcomes: A life-course approach. Ethn Dis. 2010. doi:10.1300/ J010v20n01_05. 42. Dietz PM, England LJ, Shapiro-Mendoza CK, Tong VT, Farr SL, Callaghan WM. Infant Morbidity and Mortality Attributable to Prenatal Smoking in the U.S. Am J Prev Med. 2010. doi:10.1016/j.amepre.2010.03.009. 43. Hauck FR, Thompson JMD, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis. Pediatrics. 2011. doi:10.1542/peds.2010-3000. 44. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries: Evidence Report/Technology Assessment, No. 153. 2007. 45. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. doi:10.1542/peds.2011-2284.

46. Bombard JM, Kortsmit K, Warner L, Shapiro-mendoza CK, Cox S. Vital Signs : Trends and Disparities in Infant Safe Sleep Practices — United States , 2009 – 2015. 2018;67(1):20092015. 47. Office of Women’s Health D. Business Case for Breastfeeding Support. https://www. womenshealth.gov/breastfeeding/employer-solutions/business-case.html. Accessed November 1, 2018. 48. Dinour LM, Szaro JM. Employer-Based Programs to Support Breastfeeding Among Working Mothers: A Systematic Review. Breastfeed Med. 2017;12(3):131-141. doi:10.1089/ bfm.2016.0182. 49. Institute of Medicine. Preterm Birth: Causes, Consequences, and Prevention. 2007. https:// doi.org/10.17226/11622.

Infant Mortality Neonatal < 28 days 67% of Infants Deaths Leading Causes: • Prematurity • Birth Defects • Maternal health condi�ons • Lack of Access to Risk-Appropriate Care • Intrapartum birth/delivery complica�ons

Post-neonatal 28-364 days 33% of Infant Deaths Leading Causes: • Inappropriate Sleep Posi�on; Sudden Unexpected infant death (SUID); Sudden infant death syndrome (SIDS); • Congenital Malforma�ons • Injury • Infec�on

Table 1: Leading causes of Infant Mortality

State Delaware Alaska Montana Rhode Island South Dakota

Percent Preterm Births < 1500 grams Preterm Births < 1500 gms Total Births 208 1.87 % 11,116 105 0.93% 11,282 104 0.83% 12,583 155 1.41% 10,933 127 1.03% 12,336

Table 2: Preterm births < 1500 grams and total births in year 2015 among similar birth population states

Pre-Hospital Discharge Mortality Birth Gestational Age ≤ 30 weeks

P

Hispanic .141 Race/Ethnicity Non-Hispanic Black .001 Non-Hispanic White . a. Controlling for Year of Birth and Birth Gesta�onal Age

OR .720 .691 1

95% Confidence Interval Lower Upper .465 1.115 .552 .863 . .

Table 3: Christiana Care Health System pre-hospital discharge mortality differences based upon race/ethnicity controlling for birth gestational age and birth year.

30 Delaware Journal of Public Health – May 2018

David A. Paul, M.D. is the Clinical Leader of the Women and Children’s Service Line and Chair of Pediatrics at Christiana Care Health System. Dr. Paul is a Professor of Pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA and has served as the Governor Appointed Chair of the Delaware Healthy Mother and Infant Consortium since 2005.

Neal D. Goldstein, Ph.D., M.B.I. is an infectious disease epidemiologist at Christiana Care Health System (Newark, DE), and holds an appointment as assistant research professor in the Department of Epidemiology & Biostatistics at Drexel University Dornsife School of Public Health (Philadelphia, PA). His research spans several disciplines including vaccine-preventable diseases, sexual minority health, pediatric infectious diseases, and women’s health surrounding pregnancy. He also possesses a background in biomedical informatics with detailed knowledge of hardware and software in the healthcare domain. Most recently, he has focused on translational epidemiology, or moving from knowledge generation to application and advocacy. He writes a science blog, which is available at www.goldsteinepi.com/blog. Robert Locke, D.O., M.P.H., is an attending critical care neonatologist at Christiana Care Health System and Professor of Pediatrics at Sidney Kimmel School of Medicine at Thomas Jefferson University with an affiliation at Bayhealth Medical Center. He has experience in maternal-child epidemiology and translational research. He has served on the editorial boards of medical journals and on board of directors and various committees for various non-profit health entities.

D E TA I L S 2018 C O L L E G E O F H E A LT H S C I E N C E S

GALA

If you’ve been on the lookout for our 2018 CHS Gala invitation, don’t worry—you haven’t missed it! With the opening of The Tower at STAR slated for September, we’ll be holding the Gala on Friday, November 9. This will give everyone the opportunity to explore this exciting new space with us. Visit udel.edu/star-tower to see the plans for The Tower at STAR and to learn more about our expanding research and clinical activities. In the meantime, please know how much we appreciate your continued support and look forward to seeing you in the fall!

S AV E T H E D AT E 11.9.18 chs.udel.edu 31

Delaware Birth Spacing Campaign: An Effort to Improve Maternal and Child Health Outcomes Leah Woodall, M.P.A., Division of Public Health, Delaware Health and Social Services Jennifer Reid, M.S., C.H.E.S., EP-C, Worldways Social Marketing

Introduction Infant mortality rate (IMR) is defined as the number of infant deaths under one year of age per 1,000 live births (Infant Mortality Task Force, 2005). In the 1990s, Delaware’s IMR was increasing even though nationally the IMR was decreasing. Between 2000 and 2004, Delaware’s infant mortality rate was 9.3 infant deaths per 1,000 live births, compared to the U.S. rate of 6.9 deaths per 1,000 live births (Delaware Vital Statistics Annual Report, 2005). This troubling trend provoked then Governor Ruth Ann Minner to assemble an Infant Mortality Task Force in June of 2004 (DE Thrives, 2013, DHMIC, About, History section, para. 1). The Task Force compiled a final report proposing a three-year plan with 20 recommendations to reduce the IMR in Delaware. The plan called for the formation of the Delaware Healthy Mother & Infant Consortium (DHMIC) to enforce the Task Force recommendations (Infant Mortality Task Force, 2005). In spite of the very significant progress we have made, too many babies in Delaware do not live to see their first birthday. At 7.7 infant deaths per 1,000 live births in 2011-2015, Delaware’s infant mortality rate is still significantly higher than the national average of 32 Delaware Journal of Public Health – May 2018

5.9 (Delaware Vital Statistics Annual Report, 2015). The Delaware rate masks a significant racial disparity: in 2011-2015, the black infant mortality rate of 12.3 infant deaths per 1,000 live births is more than twice as high as the white rate of 5.3 infant deaths (Delaware Vital Statistics Annual Report, 2015). We can do better and are committed to do so. DHMIC’s mission is to “provide statewide leadership and coordination of efforts to prevent infant mortality and to improve the health of women of childbearing age and infants throughout Delaware” (DE Thrives, 2013, DHMIC section, para. 1). The consortium consists of two members each of the Delaware House of Representatives and State Senate; one representative of the Governor’s office; the Secretary of the Department of Services for Children, Youth, and Their Families or a designee; the Secretary of the Department of Health and Social Services or a designee; and 15 Governorappointed members representing the medical, social service, professional, and consumer communities (DE Thrives, 2013, DHMIC, About, Membership section). The goal of the DHMIC is to reduce the infant mortality rate through several statewide initiatives in partnership with the Division of Public Health (DPH)

and the Delaware Perinatal Cooperative. The Delaware Perinatal Cooperative was established in February 2011 as an action arm of the DHMIC. It enhances community-based collaboration, promotes evidencebased best practice and standardized care among providers, and improves perinatal outcomes in Delaware. Members of the Cooperative, representing birth hospitals, collect and report on data points chosen by the Cooperative’s clinical priorities. A Perinatal Education Coordinator (established through partnership with the March of Dimes’ Delaware Chapter and DPH) and a Medical Director both provide oversight, education, and technical assistance on quality improvement initiatives for the Cooperative (DE Thrives, 2013, DHMIC, Perinatal Cooperative section, para. 1). DPH and the Cooperative collect and analyze data to support quality improvement projects at the hospital/facility level. As a part of continuous quality improvement (CQI), the data is shared with members of the Cooperative (DE Thrives, 2013, DHMIC, Perinatal Cooperative section, para. 2), who review it in collaboration with the DHMIC and implement CQI intervention initiatives to increase adherence to best practices (DE Thrives, 2013, DHMIC, Perinatal Cooperative section, para. 3).

Maternal Infant Health, Infant Mortality, Causes of Infant Mortality section). Furthermore, Healthy People 2020 calls for a 10% reduction in pregnancies that occur within 18 months of a previous birth. A woman’s body needs at least 18 months to heal and recover from the physical and emotional stress of pregnancy, but about one third of all pregnancies in the United States occur within 18 months of a previous birth (Gemmill & Lindberg, 2013). This is frequently the result of unintended pregnancy. Therefore, DHMIC, DPH, and the Perinatal Cooperative determined that an appropriate strategy to improve health outcomes for Delaware women and babies is to help women plan and space their pregnancies. The Campaign Through the statewide efforts of these three groups, a birth spacing campaign was developed and implemented near the end of 2017 to educate, encourage, and empower women of child bearing age to wait at least 18 months between giving birth and getting pregnant again. Women are educated about the benefits of practicing optimal IPI for mom, baby, and family. These benefits include more time for parent/child bonding, more interacting and play time, and more time for parents to have with each other, as well as more time for mom my life. my plan: women

Why wait at least 18 months? This gives every baby, mom, and family the best start by:

Birth Spacing Birth spacing is the interpregnancy interval between the delivery date of the baby and the conception date of the subsequent pregnancy. The Delaware Perinatal Cooperative and the DHMIC made optimal birth spacing a priority CQI focus area for 2017-2018. Recommendations by the American College of Obstetricians and Gynecologists (ACOG, 2016), the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the Fetal and Infant Mortality Review (FIMR) Process support that the optimal interpregnancy interval (IPI) is greater than 18 months and less than five years. National data shows that for every month IPI is less than 18 months, preterm birth increases 1.9%, low birth weight increases 3.3%, and small-for-gestational-age increases 1.5% (CondeAgudelo et al., 2006). All three of these outcomes increase the risk of infant mortality (Centers for Disease Control and Prevention, 2018, Reproductive Health,

Increasing chances for a healthy baby

Increasing interaction and play

Increasing bonding time

Decreasing Increasing financial time with your stress partner

Family

Baby

Increasing family time

Regaining physical health

Restoring emotional wellness

Mom Restoring vitamins and nutrients

Decreasing stress and anxiety

to heal, restore essential nutrients such as folic acid, and regain energy. Additional benefits are the increased chance of the next baby being born at the right time and at a healthy weight, and allows for more time to 33

breastfeed. Many of the predictors of school readiness relate to conditions prior to, and following, the birth of the child, and with optimal birth spacing, children are better prepared to begin kindergarten and perform better in school. It is recommended that OB/GYNs provide women with birth spacing materials at four different intervention points (i.e. first prenatal visit, third trimester appointment, hospital discharge, and the post-partum visit) and it is suggested that providers document what was discussed and what materials were provided. To support optimal birth spacing, it is recommended that during the first prenatal visit, women are given a reproductive life plan. In Delaware, over 50% of pregnancies are unplanned (Delaware Health and Social Services [DHSS], DPH, 2012-2015). The reproductive life plan is intended to help women determine pregnancy intention by asking, “Do you want to become pregnant again in the next year?” If the answer is no, it is a good opportunity to discuss contraception options. It is also recommended that women are given a brochure/poster on optimal birth spacing during the third trimester of pregnancy, a worksheet on the benefits of birth spacing at hospital discharge, and a checklist on the benefits of birth spacing at the postpartum visit. DELAWARE HEALTH AND SOCIAL SERVICES

Birth Spacing

Division of Public Health Center for Family Health Research and Epidemiology

BENEFITS FOR MOM Restore key vitamins and nutrients Return to healthy weight with exercise and healthy eating Heal, recover, and regain energy Adjust to stress and new demands of parenting

Having a baby can be a huge change physically and emotionally. Birth spacing can provide time for these benefits:

BENEFITS FOR BABY

Increase the chances of baby being born at the right time and a healthy weight Increase bonding time

More time to breastfeed if mom chooses

Increase interactions and play time Birth spacing can help to give your baby the best start in life with these benefits:

Children are better prepared to begin kindergarten and perform better in school

BENEFITS FOR FAMILY

Parents and other family members will have a chance to bond with the new baby Older children will have time to adjust

Parents will have time with each other

Decrease financial stress Having a baby can be a huge change within your family and home. Birth spacing may provide these added benefits:

Increase family time

18 MONTHS is how long you should wait between giving birth and getting pregnant again!

Addressing a woman’s known risks for morbidities and mortality must be a priority, regardless of whether or not they ever become pregnant again (The National Preconception Curriculum & Resources Guide for Clinicians, 2016). Therefore, as recommended by ACOG (2016), a large part of this campaign is an effort 34 Delaware Journal of Public Health – May 2018

to reframe the postpartum visit into a well-woman visit and to ensure that women receive this visit in a timely manner, from two to six weeks postpartum. Providers should view this visit as the start of the next stage of the woman’s health care needs and not as the end of her prenatal care. The challenge is to increase the number of women who attend a postpartum visit. The postpartum visit is a platform for birth spacing discussion as well as an opportunity to help women achieve their health goals. Providers may initiate discussions about Reproductive life planning, Emotional wellness, Alcohol /tobacco/substance use, Chronic conditions, and Healthy weight (REACH): While reproductive life planning took place at the first prenatal visit, the postpartum/wellwoman visit is a chance to re-evaluate pregnancy intention, contraception, and other life goals. The emotional wellness discussion should include a postpartum depression screening and referral if needed. Stress level, demands of parenting, and the parents’ social support system should also be discussed. Alcohol, tobacco and substance use can be a sensitive topic. The provider may start by asking open ended and non-judgmental questions. For example, “Is it okay if I ask you some questions about drugs and alcohol?” Popular, proven, and easy-to-use screening tools that address drugs and alcohol are the CAGE and CAGE-AID Questions. It is important to educate women on the dangers of alcohol, tobacco, and substance use generally and specifically during pregnancy and postpartum (i.e. breastfeeding). Providers can access more information at www. helpisherede.com and http://dethrives.com/ordermaterials/browse for resources. Risk for chronic conditions may be assessed and discussed. Education on how to manage chronic health conditions to address short and long term health outcomes are important to assess the risks and their impact on future pregnancies. Likewise, women may be counseled on how future pregnancies will impact any chronic conditions. Medication adherence and management can also be part of the discussion as well as appropriate referrals if needed. The majority of postpartum women want to know strategies for losing weight (Ohlendorf et. al., 2012.) Many providers are looking for ways on best practices for counseling and educating their patients on this topic. Providers can encourage women

to set realistic goals, decrease caloric intake, and increase exercise. The focus should not be solely on body mass index (BMI). Leaving the door open for future discussions is important. It may take some longer than others to return to a healthy weight. Materials DHMIC partnered with Worldways Social Marketing to create a Birth Spacing Implementation Toolkit for providers. The toolkit includes a provider letter, implementation letter, reproductive life plan, brochure/ poster, worksheet, and checklist flyer (in English and Spanish). Signed by the DPH director, the DHMIC chair, and the Perinatal Cooperative’s medical director, the provider letter explains the research behind the birth spacing initiative and implores the provider community to champion the statewide campaign. The DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health

Evaluation

Dear Provider: About one-third of pregnancies in the United States occur within 18 months of a previous birth. Shortened inter-pregnancy intervals are frequently the result of unintended pregnancy. Helping women plan and space their pregnancies is an acknowledged strategy to support healthy outcomes for mothers and babies. Provision of information regarding the benefits of birth spacing must include the potential consequences of shortened inter-pregnancy interval as well as provide counseling on reproductive life planning and effective contraception. Addressing optimal birth spacing in reproductive life planning during preconception/inter-conception, prenatal, and postpartum periods offers an opportunity to provide education, support and resources to help patients and their families achieve the goal of optimal birth spacing. The American College of Obstetricians and Gynecologists (ACOG) has suggested reframing the postpartum visit as preparation for the next stage in a woman’s life. Doing so will better prepare our patients for their future health needs. The postpartum visit can serve as an opportunity to address optimal birth spacing as well as engage in a discussion regarding important health issues such as emotional wellness, chronic illness, healthy weight and substance misuse, whether or not a woman intends to become pregnant again. Optimal birth spacing is recommended by the World Health Organization, the Centers for Disease Control and ACOG. 1The Delaware Healthy Mother and Infant Consortium (DHMIC) and the Division of Public Health (DPH) ask that all providers champion our state-wide awareness campaign to: 1. Increase the number of women who receive education on waiting at least 18 months after delivering a baby to conceiving another pregnancy. 2. Increase the number of women who receive a timely postpartum visit (from 2 to 6 weeks). Information concerning this campaign is included with this letter. If you are interested in having planned education for you and/or your staff on birth spacing, please contact Heather Baker, Perinatal Nurse Educator, at (302) 225-1020 or Hbaker@marchofdimes .org. If you would like more information concerning the work of the DHMIC and DPH, please visit DEThrives.com. We look forward to hearing from you. Sincerely,

Karyl T. Rattay, MD, MS Director

David A. Paul, MD, FAAP Chair, Delaware Healthy Mother Infant Consortium

groups working with women of reproductive age. On-site education started with the Healthy Women Healthy Babies provider locations statewide. Obstetricians, birthing hospitals, home visitors, substance use partners, and various community groups were also identified for on-site education. Upon completion, a webinar of the presentation will be developed and available on www.dethrives.com for provider training.

Garret H.C. Colmorgen, MD Medical Director, Delaware Perinatal Cooperative

1 This has also been recommended annually since 2013 by the Delaware Fetal-Infant Mortality Review (FIMR) at https://courts .delaware .gov/childdeath/reports.aspx.

implementation letter explains how to use the remaining materials with patients to spread the birth spacing message. All toolkit items can be found by visiting http:// dethrives.com/order-materials/browse. The reproductive life plan booklet and birth spacing worksheet are available for order and download under the website’s “My Life, My Plan: Woman” section. The remaining items are available for order and download under the “Birth Spacing Materials” section. The Perinatal Education Coordinator is supporting implementation by providing on-site education. The research, reasoning, and roll-out instructions are presented via PowerPoint presentation to select provider

DHMIC, DPH, and the Perinatal Cooperative are looking for opportunities for feedback and lessons learned from the provider community. To that end, there will be a process for data collection, and providers will be surveyed to determine campaign effectiveness. Given the uniqueness of this campaign and the statewide efforts, it will take time to determine the efficacy of this approach. Promoting optimal birth spacing is a key strategy of the DHMIC, DPH, and the Perinatal Cooperative for improving the health of women and babies. The birth spacing conversation between providers and women relies heavily on women attending a timely postpartum visit. As we aim to reduce rates of preterm birth and other adverse birth outcomes, it is important to creatively encourage women to understand the value of the postpartum/well woman visit and to focus on health before and in between pregnancies. DHMIC, DPH, and the Perinatal Cooperative promote the care of women across the lifespan and in this dialogue, challenge our partners to join this campaign to emphasize the importance of well woman care between pregnancies. Resources The American College of Obstetricians and Gynecologists (ACOG) (2016). Optimizing postpartum care. Committee Opinion No. 666. Obstetrics & Gynecology, 127, e187-92. Centers for Disease Control and Prevention (2018). Retrieved from https://www.cdc.gov/ Conde-Agudelo et al. (2006). Birth spacing and risk of adverse perinatal outcomes: a metaanalysis. The Journal of the American Medical Association, 295(15), 1809-23. Delaware Fetal-Infant Mortality Review (FIMR) (2013). https://courts.delaware.gov/childdeath/ reports.aspx Delaware Health and Social Services (DHSS), Division of Public Health (DPH) (2012-2015). Pregnancy Risk Assessment Monitoring System (PRAMS) data.

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DE Thrives (2013). Retrieved from http://dethrives.com/ Gemmill & Lindberg (2013). Short interpregnancy intervals in the U.S. Obstetrics & Gynecology, 122(1), 64-71. Infant Mortality Task Force (2005). Reducing Infant Mortality in Delaware: The Task Force Report. Retrieved from http://dethrives.com/wp-content/uploads/2013/06/DHMIC-2006-TaskForce-Report.pdf The National Preconception Curriculum & Resources Guide for Clinicians (2016). In Between Time: Interconception Health Care Starting with the Postpartum Visit; Part 1: Routine postpartum care for every woman. Retrieved from https://beforeandbeyond.org/modules/module4-in-between-time-interconception-health-care-starting-with-the-postpartum-visit/ Ohlendorf J, et al. (2012). Weight-management information needs of postpartum women. The American Journal of Maternal/Child Nursing (MCN), 17(1). “Screening Tests,” (2004-2005). Alcohol Research and Health, 28(1), 28-29.

Leah Jones Woodall, M.P.A. is the Section Chief of Family Health Systems with the Delaware Department of Health and Social Services’ Division of Public Health, which houses most maternal and child health programs. In this capacity, Leah is responsible for the following programs: Infant Mortality, Pregnancy Risk Assessment Monitoring System, Title V Maternal and Child Health, Maternal, Infant and Early Childhood Home Visiting, Children with Special Health Care Needs, Early Childhood, Newborn Screening Program, State Systems Development, Adolescent and Reproductive Health, School Based Health Centers and Adolescent Pregnancy Prevention.She serves as a senior manager and as a member of the Division of Public Health’s leadership team. Jennifer Reid, MS, CHES, EP-C is a vital Worldway’s team member in both Delaware and Louisiana. Her work focuses on sexual, reproductive, and family health. Prior to Worldways, she managed Delaware’s Healthy Women, Healthy Babies Program forging relationships with many women’s health providers throughout the state.

Westside Family Healthcare’s

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30th Anniversary Gala

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November 3, 2018

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An Evening of Celebration at The Queen Wilmington, Delaware www.westsidehealth.org/gala/

36 Delaware Journal of Public Health – May 2018

HIGHLIGHTS FROM

The

NATION’S HEALTH A P U B L I C AT I O N O F T H E A M E R I C A N P U B L I C H E A LT H A S S O C I AT I O N

May 2018 Highlights from The Nation’s Health Online-only news from The Nation’s Health newspaper •Accreditation a boon for US public health departments In just a few years, 220 health agencies have gotten accredited. •ACA essential health benefits come under threat Federal policy proposals would water down health c overage, experts say. •Q&A with HHS’ Don Wright: Public health can promote better health for aging population An upcoming summit on healthy aging will focus on challenges and solutions. •Many parents not getting advice on when to start dental visits for their kids A late start can harm oral health. •Few young adults use nutrition labels This population is missing out on important dietary information. •Gay, bisexual high school boys receive less HIV education Sex education focuses largely on pregnancy prevention, rather than infection prevention. •Newsmakers Check out who’s who in public health. •Resources New tools and publications in public health.

•Healthy You: How to make your weekly meal prep easy Your time and money are valuable. So why not try to save a little of both and eat healthier too? Learn more this month in Healthy You. Read Healthy You online, or download as a PDF in English or Spanish. Take this week’s public health news quiz and test your public health news knowledge! So long, Storify. Missed any of our Storify posts? Check them out now; Storify shuts down this month. Here are some of our favorites to revisit: •Public health at risk if prevention funding is eliminated •Signs of the times: 30 ideas for your public health protests •Get to know social determinants of health •What ‘Parks and Recreation’ taught us about public health Visit our website to read more news, share articles on social media and download our free app. Need to contact us? Send an email. Does your library or organization receive The Nation’s Health? Keep your colleagues and students informed about what’s happening in public health by subscribing to APHA’s newspaper.

37

Implementation of Group Prenatal Care for Pregnant Women on Opioid-agonist Therapy at a Community-based Substance Use Treatment Clinic Elizabeth Zadzielski, M.D., M.B.A, F.A.C.O.G. 1, Michelle Drew, C.N.M.1, Stephanie Rogers, R.N.1, and Yukiko Washio, Ph.D.2

Introduction The epidemic of opioid use among women of childbearing age in the U.S. has contributed to increase of opioid use among pregnant women.1 Opioid prescription claims have been significantly higher among Medicaid-eligible women, compared to privately insured women, in which over 21% of pregnant women were prescribed for an opioid, and 2.5% were receiving chronic opioid prescriptions for more than a month.2 The proportion of pregnant women on medicationassisted opioid therapy has significantly increased from 8.1% to 14.2% between 1992-2012 according to the Treatment Episode Data Set – Admissions.3 Many patients on prescription opioids switched to heroin because it is inexpensive, better availability, and easier to use intravenously.4 This is also reflected among pregnant women with over 66% on medication-assisted treatment who report a history of heroin use.5 Increase in prenatal opioid use has led to an increase in adverse neonatal outcomes including neonatal abstinence syndrome (NAS).6 NAS is a set of withdrawal symptoms that opioid-exposed neonates may experience shortly after birth.6 The number of NAS diagnoses has increased nearly fivefold between 2000 and 2012.7,8 Neonates diagnosed with NAS were more likely to have low birth weight, have respiratory complications, and be covered by Medicaid.8 The cost for treating neonates with NAS has increased from $39,400 in 2000 to $53,400 in 2009,8 although rooming-in practice to promote family-centered care for neonates with NAS resulted in significant decreases in the cost of NAS care as well as the proportion of neonates with NAS treated with morphine.9 Over 35% of pregnant women on opioid-agonist therapy screen positive for other illicit drugs including marijuana, cocaine, and benzodiazepines,10 and cigarette smoking rates can be as high as 95%.11,12 Psychiatric co-morbidities including depression, anxiety, bipolar 38 Delaware Journal of Public Health – May 2018

affective disorder, personality disorders, and PTSDs are prevalent among pregnant women on opioid agonist therapy.13–15 Intimate partners often play a major role in women’s substance use, and intimate partner violence can be prevalent among women who misuse substances.16,17 Group-based peer support among pregnant women with health risks has been acceptable and effective in improving pregnancy outcomes such as decreased risks for small for induced labor, gestational age, low birth weight, NICU admission, short intervals between pregnancies, lack of condom use, and unprotected sex18,19 and improvements in breastfeeding initiation and maintenance and adherence to postpartum checkup.19 Social support including individual peer support has been helpful for individuals with substance use disorders.20–22 Thus, group-based peer support among pregnant women who misuse substances may help to provide a protected environment to receive prenatal care while addressing prenatal substance use. The current report describes implementation of group prenatal care for pregnant women on opioid-agonist therapy at a community-based substance use treatment clinic.

Process Setting A community-based clinic that provides methadone substitution therapy and comprehensive psychosocial support provided dedicated space for bi-weekly sessions of group prenatal care, in which pregnant women on opioid-agonist therapy were encouraged to attend as many sessions as possible for receiving prenatal care, attending educational sessions regarding prenatal and postnatal maternal and infant care, and learning and providing support around prenatal substance, alcohol, and tobacco use. A midwife, midwife assistant, and nurse have attended each session to provide prenatal care and guide the group support and discussion. Christiana Care currently implements CenteringPregnancy for all

pregnant patients. The general format of group prenatal care for pregnant women on opioid-agonist therapy was adapted from the ongoing service; however, the session content focused on providing prenatal care by midwife and group sessions tailored to the target population (see below). Christiana Care Institutional Review Board has approved the protocol. Session content A patient attending a 2-hour session received prenatal care on the first come first serve basis. Prenatal care included taking vital signs, measuring weight, answering pregnancy-related questions, and listening to infants’ heartbeat. If she was due for an ultrasound visit, a provider made an appointment at a nearby affiliated community hospital. Light refreshments were provided. After the initial half an hour, the lead midwife started a group session in which she covered 10 major topics that are specifically tailored for pregnant populations on opioid-agonist therapy. The topics were: (1) nutrition; (2) common discomfort/oral health; (3) stress/relaxation technique; (4) breastfeeding; (5) contraception; (6) what to expect with NAS infants; (7) prenatal substance and tobacco use; (8) process in labor; (9) postpartum depression; (10) infant care and safety. The session was made interactive, and the midwife made sure to ask and answer all questions the attendees had. The midwife also facilitated conversations among attending patients so they can provide peer support to each other. The midwife used national holidays and celebration days to make sure that a session was enjoyable. A patient who passed 37 gestational weeks received a baby-shower by the provider team. The provider team also had brief meetings with the community clinic providers so the team is aware of patients’ substance use and other psychosocial conditions. Data collection and analysis Pregnancy and birth outcomes were collected as part of the electronic medical record. Outcome data were extracted from the electronic medical record at Christiana Care and compared to those who did not participate in group prenatal care but were on opioidagonist therapy during pregnancy. Continuous and categorical variables were reported as mean ± standard deviation or percentages, and analyzed by Pearson Chi-square test for categorical variables and the Wilcoxon rank-sum tests for continuous variables. Fisher’s exact test was used when a cell count was below five. All analyses were performed using R version 3.2.1 (R Foundation for Statistical Computing Platform).

Outcomes Since the beginning of 2016 to date, a total of 36 methadone-maintained pregnant patients gave birth at a large-scale community hospital in a Mid-Atlantic region. Twenty-three of them attended group prenatal care at least once at the community-based substance use treatment clinic. Table 1 shows basic demographic characteristics between the group prenatal care attendees (n = 23) and historic counterparts (n = 13). A majority of participants were White, single, and on Medicaid, and older than 30 years old on average. No significant differences were detected. Table 2 shows comparisons between the two groups. Reasons of not attending group prenatal care included logistic availability issues or receiving substance use treatment at other clinics. All participants delivered at the large-scale community hospital, where the provider team had access to prenatal and birth records. Birth outcomes included the average gestational age at birth and birth weight as well as the rates of Cesarean birth, NICU admission, breastfeeding, and long-acting reversible contraceptives (LARC). No statistically significant differences were identified for any of the outcomes; however, decreases in the rates of Cesarean birth and NICU admission in the group prenatal care group (GPC) were observed compared to the historic control. On the other hand, birth weight was heavier, and gestational age at birth was longer in the historic control compared to the GPC group. Use of LARC was also higher with patients in the historic control compared to the GPC group.

Discussion The current report described the implementation effort to improve the quality of care for pregnant women on opioid-agonist therapy by providing group prenatal care. The implementation is ongoing, and promising pregnancy and birth outcomes have been observed compared to historic control. The large-scale community hospital has already been emphasizing room-in care, skin-to-skin contact, and breastfeeding for infants with neonatal abstinence syndrome and LARC implantation at birth or immediately postpartum. The content of group prenatal care sessions can be improved by emphasizing the importance of LARC and promoting healthy lifestyle during pregnancy among group prenatal care patients. The major barrier of bi-weekly group prenatal care at the substance use treatment clinic in the community was that patients already had a set daily schedule of when 39

to pick up a methadone dosage, which was not always References 1. Krans EE, Patrick SW. Opioid Use Disorder in Pregnancy: Health Policy and Practice compatible with the group prenatal care schedule. Not in the Midst of an Epidemic. Obstet Gynecol. 2016;128(1):4-10. doi:10.1097/ all pregnant patients had reliable transportation, many AOG.0000000000001446. EC, Dawson AL, Lind JN, et al. Opioid prescription claims among women had multiple children, and work and other appointments 2. Ailes of reproductive age--United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2015;64(2):37-41. made it not feasible for them to come back to the 3. SAMHSA. Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to clinic for group prenatal care sessions. The large-scale 2012 (ICPSR 25221). 4. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United community hospital that the provider team is affiliated States: a retrospective analysis of the past 50 years. JAMA psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366. with has been in the process of certifying all providers 5. Krans EE, Zickmund SL, Rustgi VK, Park SY, Dunn SL, Schwarz EB. Screening and so as to be able to administer buprenorphine to patients evaluation of hepatitis C virus infection in pregnant women on opioid maintenance therapy: A retrospective cohort study. Subst Abus. 2016;37(1):88-95. doi:10.1080/08897077.2015.1 on opioid-agonist therapy who come into emergency 118720. 6. Finnegan LP, Connaughton JF, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment rooms for opioid withdrawal. The community outreach and management. Addict Dis. 1975;2(1-2):141-158. efforts, including phone-based support by nurses and 7. Patrick SW, Davis MM, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. community-based peer support for pregnant patients on 2015;35(8):667. doi:10.1038/jp.2015.63. 8. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. opioid-agonist therapy, have been in development. Future development of implementing group prenatal care for patients on opioid-agonist therapy is to increase the number of venues and opportunities to provide group prenatal care sessions both at a substance use treatment clinic and community hospital as well as provide more comprehensive services including childcare and ultrasound examinations, in coordination with other ongoing outreach efforts to increase access to care for this population. The current report to improve the quality of care for pregnant women on opioid-agonist therapy has a few limitations. The number of participants is relatively small, warranting further implementation and monitoring of outcomes with this initiative for pregnant women on opioid-agonist therapy. We did not have access to biochemical results of substance use during the reported period, although Christiana Care recently implemented biochemical screenings of substance use at labor admission for all pregnant patients. The current report contributes to the existing body of literature by the implementation effort of group prenatal care to improve the quality of care for pregnant women on opioid-agonist therapy. The implementation effort is innovative in that group prenatal care was tailored to pregnant women on opioid-agonist therapy and was implemented in a community-based substance use treatment clinic.

40 Delaware Journal of Public Health – May 2018

Neonatal abstinence syndrome and associated health care expenditures: United States, 20002009. JAMA. 2012;307(18):1934-1940. doi:10.1001/jama.2012.3951. 9. Holmes AV, Atwood EC, Whalen B, et al. Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost. Pediatrics. 2016;137(6). doi:10.1542/peds.2015-2929. 10. Keegan J, Parva M, Finnegan M, Gerson A, Belden M. Addiction in pregnancy. J Addict Dis. 2010;29(2):175-191. doi:10.1080/10550881003684723. 11. Jones HE, Heil SH, O’Grady KE, et al. Smoking in pregnant women screened for an opioid agonist medication study compared to related pregnant and non-pregnant patient samples. Am J Drug Alcohol Abuse. 2009;35(5):375-380. doi:10.1080/00952990903125235. 12. Jones HE, Heil SH, Tuten M, et al. Cigarette smoking in opioid-dependent pregnant women: neonatal and maternal outcomes. Drug Alcohol Depend. 2013;131(3):271-277. doi:10.1016/j.drugalcdep.2012.11.019. 13. Chisolm MS, Tuten M, Brigham EC, Strain EC, Jones HE. Relationship between cigarette use and mood/anxiety disorders among pregnant methadone-maintained patients. Am J Addict. 2009;18(5):422-429. doi:10.3109/10550490903077721. 14. Feske U, Tarter RE, Kirisci L, Pilkonis PA. Borderline Personality and Substance Use in Women. Am J Addict. 2006;15(2):131-137. doi:10.1080/10550490500528357. 15. Tuten M, Heil SH, O’Grady KE, Fitzsimons H, Chisolm MS, Jones HE. The impact of mood disorders on the delivery and neonatal outcomes of methadonemaintained pregnant patients. Am J Drug Alcohol Abuse. 2009;35(5):358-363. doi:10.1080/00952990903108231. 16. Krans EE, Cochran G, Bogen DL. Caring for Opioid-dependent Pregnant Women: Prenatal and Postpartum Care Considerations. Clin Obstet Gynecol. 2015;58(2):370-379. doi:10.1097/GRF.0000000000000098. 17. Meyer JP, Springer SA, Altice FL. Substance abuse, violence, and HIV in women: a literature review of the syndemic. J Womens Health (Larchmt). 2011;20(7):991-1006. doi:10.1089/ jwh.2010.2328. 18. Ickovics JR, Earnshaw V, Lewis JB, et al. Cluster Randomized Controlled Trial of Group Prenatal Care: Perinatal Outcomes Among Adolescents in New York City Health Centers. Am J Public Health. 2016;106(2):359-365. doi:10.2105/AJPH.2015.302960. 19. Schellinger MM, Abernathy MP, Amerman B, et al. Improved Outcomes for Hispanic Women with Gestational Diabetes Using the Centering Pregnancy(©) Group Prenatal Care Model. Matern Child Health J. July 2016. doi:10.1007/s10995-016-2114-x. 20. Bassuk EL, Hanson J, Greene RN, Richard M LA. Peer-Delivered Recovery Support Services for Addictions in the United States: A Systematic Review. J Subst Abus Treat. 2016;63:1-9. 21. HelpGuide.org. Self-Help Groups for Drug Addiction. 22. Hershberger A, Zapolski T AM. Social support as a buffer between discrimination and cigarette use in juvenile offenders. Addict Behav. 2016;59:7-11.

Table 1. Participant demographic characteristics Maternal age (M/SD) Race White Black Medicaid insurance Marital status a

Historic control (n = 13) 30.77(5.53)

Group prenatal care (n = 23) 31.13(4.94)

84.6% 15.4% 92.3% 0.0%

69.6% 30.4% 81.0% 13.0%

P value .86 .44 a

.63 a .29 a

Fisher exact test for a cell count of <5

Table 2. Birth outcomes by status of group prenatal care participation Historic control (n = 13) 38.5%

Cesarean birth Gesta�onal age at birth (M/SD) Birth weight (M/SD) NICU admission Breas�eeding LARC a

37.91(1.77) 3005(468.65) 41.7% 46.2% 69.2%

Group prenatal care (n = 23) P value 13.0% .11a 36.81(3.3) 2592.39(692.04) 13.0% 43.5% 43.5%

.51 .09 .09a .88 .14

Fisher exact test for a cell count of <5

Elizabeth Zadzielski, M.D., M.B.A., F.A.C.O.G. received her Medical Degree from Rutgers Medical School and a Master’s of Business Administration from the Fox School of Business, Temple University. She has practiced general OB/GYN for over thirty years and has developed an interest in the challenges of addiction in pregnancy. Dr. Zadzielski is a member of the Education Faculty in the Department of OB/GYN at Christiana Care Health System.

Michelle Drew, C.N.M. is a midwife and Advanced Practice Nurse Practitioner at Christiana Care, as well as an adjunct professor at the Graduate School of Nursing at Texas Woman’s University.

Stephanie Rogers, M.S.N., R.N. is a research nurse who has managed the Delaware Healthy Mothers Healthy Babies program at Christiana Care and the WIC Breastfeeding Peer Counselors. She has also served as the Nurse Manager of Parent Education, Lactation, and Outpatient programs at Christiana Care.

Yukiko Washio, Ph.D. Dr.Washio is a maternal and infant health researcher, jointly hired by Christiana Care OBGYN and University of Delaware College of Health Sciences. She is trained in behavioral science focused on maternal and infant health disparity issues

41

DIABETES DIABETES CARE CARE ARTICLES ARTICLES EXAMINES EXAMINES THE THE SKYROCKETING SKYROCKETING COSTS COSTS OFOF DIABETES DIABETES

Periodic Periodic economic economic analyses analyses performed performed by the by American the American Diabetes Diabetes Association Association (ADA) (ADA) havehave shown shown an increase an increase in the in total the total direct direct costscosts of diabetes of diabetes in the in United the United States States - from - from $116$116 billion billion in 2007 in 2007 to to $237$237 billion billion in 2017, in 2017, and and annual annual indirect indirect costscosts related related to lost to lost productivity productivity nownow totaltotal $90$90 billion. billion. These These staggering staggering costscosts make make diabetes diabetes the most the most expensive expensive chronic chronic condition condition in the in United the United States, States, where where one one in four in four health health carecare dollars dollars spent spent is incurred is incurred by someone by someone withwith diabetes, diabetes, and and carecare for afor person a person withwith diabetes diabetes nownow costscosts an average an average of $16,752 of $16,752 per year. per year. Diabetes Diabetes CareCare Editor-in-Chief Editor-in-Chief Matthew Matthew C. Riddle, C. Riddle, of Oregon of Oregon Health Health & Science & Science University, University, and and William William H. Herman, H. Herman, of the of University the University of Michigan of Michigan Schools of Medicine and and Public Health, call these costscosts “an elephant in the impossible to miss but frequently ignored.” TheirTheir commentary Schools of Medicine Public Health, call these “an elephant in room, the room, impossible to miss but frequently ignored.” commentary in the MayMay issueissue introduces a special collection of articles focused on this crucial issue. in journal’s the journal’s introduces a special collection of articles focused on this crucial issue.

CDC CDC GUIDE GUIDE OUTLINES OUTLINES BEST BEST PRACTICES PRACTICES FOR FOR CARDIOVASCULAR CARDIOVASCULAR DISEASE DISEASE PREVENTION PREVENTION PROGRAMS PROGRAMS GUIDE GUIDE

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The The BestBest Practices Practices Guide Guide for Cardiovascular for Cardiovascular Disease Disease Prevention Prevention Programs Programs describes describes and and summarizes summarizes scientific scientific evidence evidence behind behind eighteight effective effective strategies strategies for lowering for lowering highhigh blood blood pressure pressure and and cholesterol cholesterol levels levels thatthat can can be implemented be implemented in health in health carecare systems systems and and thatthat involve involve community-clinical community-clinical links.links. Studies Studies havehave shown shown thatthat you you maymay be be ableable to lower to lower youryour highhigh blood blood pressure pressure by changing by changing youryour lifestyle. lifestyle. Check Check out the out evidence the evidence for meditafor meditation,tion, yoga, yoga, and and relaxation relaxation techniques. techniques. ClickClick herehere to read to read more. more.

The The Guide Guide highlights highlights strategies strategies thatthat havehave beenbeen found found to beto be effective effective for widespread for widespread control control of hypertension of hypertension and and hyperlipidhyperlipidemia, emia, but which but which are not are yet notbeing yet being usedused widely widely as standard as standard practice. practice. ThisThis guide guide was was developed developed to serve to serve as a as resource a resource for state for state and and locallocal health health departments, departments, decision decision makers, makers, public public health health professionals, professionals, and and otherother stakeholders stakeholders interested interested in using in using proven proven strategies strategies to to improve improve cardiovascular cardiovascular health. health. ClickClick herehere to download to download the Guide. the Guide.

42 Delaware Journal of Public Health – May 2018

WEBCASTS FROM THE AMERICAN DIABETES ASSOCIATION'S 65TH ADVANCED POSTGRADUATE COURSE ARE NOW AVAILABLE ONLINE! The American Diabetes Association’s (ADA) Advanced Postgraduate Course is designed for physicians, physician assistants, nurses, nurse pracitioners, dietitians, pharmacists, psychologists, certified diabetes educators, and other health care professionals who care for patients with diabetes, or who manage the complications related to this disease. Learn more about our 65th Advanced Postgraduate Course, and view the webcasts today! Some of the ADA course webcasts now available online include: • New Drugs and Devices: What’s in the Pipeline for Type 1 and Type 2 Diabetes? - 0.75 credit • Nutrition Counseling for the Non-RD - 1.5 credit • Cardiovascular Outcome Trials of Diabetes Medications: Translating Results into Practice - 1 credit • The Use of Language in Diabetes Care and Education - 0.75 credit • Prediabetes: Real World Implementation of the National Diabetes Prevention Program - 0.75 credit If you have any questions, please contact professionaleducation@diabetes.org.

DELAWARE PHARMACISTS SOCIETY NOW OFFERING NO-COST MEDICATION ADHERENCE PROGRAM FOR HEALTHCARE PROVIDERS The Delaware Pharmacists Society (DPS) is now offering a no-cost medication adherence program to educate healthcare providers across the state. Quality Insights has partnered with DPS to identify practices interested in having a pharmacist provide a 30 to 45 minute presentation on medication adherence to all clinical staff that would address medication adherence with patients. Presentation topics include:

• The benefits of medication adherence

• Proven strategies to ensure patients take their medication as prescribed

• Provider question and answer session

The presentation will be shared with practice leadership and can be customized to meet your practice needs. Light refreshments will be served. Download this flyer to learn more.

PATIENT VIDEO DEMONSTRATES PROPER TECHNIQUES FOR HOME BLOOK PRESSURE MONITORING Monitoring blood pressure at home can play a key role in keeping hypertension in check.

Share this video, How to Check My Own Blood Pressure, with your patients to teach them the proper techniques for taking a blood pressure measurement at home. The video, developed by the Home Health Quality Improvement National Campaign, also talks about the cost of home blood pressure monitors, where they can be purchased, features to look for in a monitor, and much more.

CONTACT INFORMATION

For more details about the Improving Hypertension and Diabetes Care & Prevention project, please contact Ashley Biscardi, Sarah Toborowski, Ryan Williamson, or Danielle Nugent Funding provided by the Pennsylvania Department of Health through the State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health federal grant from the Centers for Disease Control and Prevention. Publication number: DEDPH-HD-050418 43

Newborn Screening for Cystic Fibrosis in Delaware Ambika Shenoy1, M.D.; Kathi Peeke, A.P.N.1; Kathryn Tullis, Ph.D.2, Michael Cellucci, M.D.2, Aaron Chidekel, M.D.1 Division of Pediatric Pulmonology, Nemours/Alfred I. duPont Hospital for Children Delaware State Newborn Screening Program

1 2

Overview A four-month-old female was admitted to the hospital with severe failure to thrive and diffuse macular rash. Additional symptoms included abdominal distension and colicky pain along with frequent emesis. Respiratory symptoms were absent. Screening bloodwork to evaluate failure to thrive was unrevealing and medical management for gastroesophageal reflux was unsuccessful. Upon admission to the hospital, height and weight were below the 5th percentiles for age. Sweat chloride testing was obtained on hospital day 3, confirming the diagnosis of Cystic Fibrosis (CF). Comprehensive management resulted in improved nutritional status and resolution of the rash, which was attributed to nutritional zinc deficiency. Her hospital stay lasted 15-days. An eighteen-month-old male was admitted to the hospital for evaluation of recurrent bronchiolitis and worsening noisy breathing. Chronic cough had been present for several months and attributed to recurrent 44 Delaware Journal of Public Health – May 2018

viral respiratory tract infections. A trial of bronchodilator therapy was unsuccessful. No prior history of pneumonia was reported and chest radiography on admission was negative for infiltrate. Growth and developmental parameters were normal. Pulmonology and Otolaryngology consultations were requested on hospital day 4. Due to ongoing noisy breathing, a combined airway evaluation with flexible and rigid bronchoscopy was scheduled. Upon entering the airway, copious purulent secretions were noted to be filling the tracheal and bronchial lumens. After the procedure, the patient required intensive care unit admission due

to respiratory distress. Broad-spectrum antibiotics were started and bacterial cultures were positive for Pseudomonas aeruginosa. Once stable enough to undergo sweat chloride analysis, this test confirmed the diagnosis of CF. Comprehensive management was initiated with clinical improvement. His hospital stay lasted 18-days.

in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. CF is an autosomal recessive disease that results from mutations in a single CFgene located on chromosome 7. Despite this overt simplicity, the actual genetics of CF are extremely complex and multidimensional, and a full discussion of this complexity is beyond the scope of this review. A three-week-old male infant was evaluated in Cystic For example, over 1800 mutations have been described Fibrosis Clinic due to a newborn screen for CF in the CFTR gene, but only approximately 10-15% of consistent with this diagnosis. An initial Immunoreactive these mutations have been shown to cause CF disease. Trypsinogen (IRT) was abnormal at 89ng/mL and the Furthermore, the clinical significance of many CFTR repeat IRT value was further increased at 166ng/mL. In gene mutations or variants is incompletely understood, addition, CF-gene mutation analysis revealed two copies and this occasionally results in diagnostic uncertainty. of the most common CF-causing mutation: F508del. It has also necessitated the development of newborn The infant was asymptomatic, but had not yet regained screening strategies that are more involved than simply his birthweight. Confirmatory sweat chloride testing testing for CF-gene mutations.2 and genotype analysis were performed. Comprehensive CF care and multidisciplinary family support was Table 1: Common clinical manifestations of Cystic Fibrosis upon initial presentation in children implemented with prompt acceleration of weight gain and the infant has remained healthy over the Respiratory: • Recurrent respiratory infec�ons • Obstruc�ve lung disease ensuing months. Newborn screening (NBS) for CF has revolutionized the diagnosis and early management of this common, inherited disease. The goal of NBS for CF is to allow for the initiation of comprehensive, CF-specific medical and psychosocial therapies in pre-symptomatic infants with this disease. This is in stark contrast to the situation prior to the availability and implementation of NBS, when patients with CF would present symptomatically, most often with persistent respiratory symptoms, failure to thrive or both. These symptomatic presentations could be severe or even devastating in nature or subtle and puzzling, resulting in prolonged periods of evaluation and testing before a diagnosis of CF was confirmed. Termed “diagnostic odysseys” these difficult journeys have largely been eliminated by newborn screening. NBS for CF and its impact on the early diagnosis, management and outcomes for children and families affected by this disease is nothing short of a public health triumph.1.

• Chronic mucopurulent cough • Nasal polyposis (especially in young children) • Chronic sinusi�s

Gastrointestinal/Nutrition

• Growth disturbances/Failure to thrive • Malnutri�on due to exocrine pancrea�c insufficiency • Fat soluble vitamin (A, D, E, K) deficiencies • Pancrea��s • Meconium ileus • Bowel obstruc�on

Metabolic

• Electrolyte imbalances/Increased insensible salt loss • Salt deple�on (par�cularly in infants) • Metabolic Alkalosis

The CF gene encodes the CFTR protein, a chloride channel found on the apical membrane of epithelial cells; most notably in the respiratory tract, gastrointestinal tract and the sweat gland. Due to the absence of chloride secretion and subsequent hyperabsorption of sodium, mucus and/or secretions in the CF respiratory or gastrointestinal epithelia are

Cystic Fibrosis: An Introduction to the Disease and its Common Features CF is one of the most common life-shortening genetic conditions, seen in approximately 1 out of every 3500 live births per year in the United States. While CF occurs with greater frequency in the Caucasian population, it is described in people of all ethnic, genetic and cultural backgrounds. Table 1 lists common clinical symptoms described in patients with CF. These clinical characteristics occur as the result of mutations 45

dehydrated. In the CF airway, tenacious, inspissated mucus is difficult to clear, prone to infection and causes cyclical airway obstruction, ongoing inflammation and ultimately gradual decline in lung function. Premature death, most commonly due to respiratory failure, is the result of this vicious cycle. In the gastrointestinal tract, inspissated mucus in the pancreatic ducts (even before birth) results in exocrine pancreatic insufficiency accounting for the original description of patients with this disease: “Cystic fibrosis of the pancreas” by Dorothy Anderson in 1938.3 Inability of the pancreas to secrete digestive enzymes results in steatorrhea (loose, greasy or fatty, malodorous, bulky stools) with poor weight gain and lack of linear Mucous Plug Stomach

Pancreas

Pancreatic Duct Small Intestine Digestive enzymes from the pancreas are blocked and do not make it into the small intestine.

growth. Inspissated mucus in the intestinal tract combined with exocrine pancreatic insufficiency with partially digested gastrointestinal contents may cause meconium ileus (at birth) or intestinal obstruction following the perinatal period. CFTR protein in the sweat glands is important for reabsorption of chloride secreted by integumentary epithelia for temperature regulation. CF patients experience increased insensible salt losses, increased sweat chloride concentration and are at higher risk for dehydration and electrolyte disturbances, particularly in infants.4 The diagnosis of CF is based on the presence of clinical symptoms in combination with diagnostic testing. Historically, clinical symptoms would bring an individual to medical attention for this testing, as seen in the first two clinical cases described earlier. In the era of newborn screening for CF however, it is most often a positive NBS for CF that brings a minimally or even asymptomatic infant to medical attention 46 Delaware Journal of Public Health – May 2018

for further testing and confirmation of the presence or absence of CF. The diagnosis of CF requires both clinical manifestations as well as direct evidence of CFTR absence or dysfunction. Evidence for the former (clinical manifestations) is provided by an abnormal NBS; an elevated IRT, which may indicate CF-related pancreatic dysfunction. Evidence of CFTR dysfunction is confirmed by performing a sweat chloride test to demonstrate an elevated sweat chloride concentration that confirms an absence of functional CFTR in the sweat gland. The Cystic Fibrosis Foundation requires sweat testing on all infants with CF as a criterion for inclusion in the national CF Patient Registry. The evaluation for presence of two CF gene mutations that are known to cause CF is additional testing that is performed in patients.5 With the implementation of widely available, statesponsored NBS programs, approximately 64% of infants with CF are diagnosed within the first month of life and prior to the development of clinical symptoms of CF (apart from meconium ileus).2 Early diagnosis helps decrease development of clinical symptoms such as frequent, severe respiratory infections, growth failure and malnutrition, or electrolyte disturbances. Early diagnosis also allows for the timely initiation of CF therapies including airway clearance, pancreatic enzyme replacement therapy, salt supplementation and more aggressive antimicrobial therapies in the setting of infections. Early intervention with these therapies provides the opportunity to potentially improve quality of life, stabilize decline in lung function, improve growth and electrolyte imbalances and have improved life expectancy from the teens in the 1970s to >40 years as of 2017.2

CF Newborn Screening: Testing Nationwide newborn screening for CF commenced in 2010 following strong endorsements by US Centers for Disease Control in conjunction with the Cystic Fibrosis Foundation.2 Many states were including CF in their NBS programs prior to this time. NBS for CF in Delaware began in 2007. The CF NBS screening strategy utilized by each state depends on varying factors including NBS programs already in place (i.e. 1 or 2 bloodspot), cost of testing, local CF expertise and recommendations, and concern for identifying asymptomatic CFTR mutation carriers. NBS for CF meets all of the requirements of an efficacious screening test in terms of its sensitivity, specificity and positive (or negative) predictive value, although these will vary slightly depending upon the precise newborn screening

protocol employed.6 False negative tests, while reported, are quite rare.7 All screening tests in the United States primarily utilize measurements of IRT as the first tier or indicator of positive screening. The IRT is a protein marker of pancreatic inflammation/disease. This is typically elevated in most patients with CF. Determining if IRT is elevated varies by state program and may include top percentage of IRT values on the day of testing versus an absolute cut-off for elevation which is based on the normal distribution of IRT values occurring within the individual state.8 Regardless of strategy used to measure IRT, elevation of initial IRT typically triggers a second tier of testing. Some states, may retest IRT levels (known as IRT/IRT). Typically these states, utilize two-tier NBS already and therefore, the second IRT level is drawn from blood with the second NBS around 14 days of life. The strategy is to determine if IRT is persistently elevated as is typical in patients with CF. The benefits of this methodology may include lower cost and lower carrier rate detection. However, challenges include: ensuring early notification that initial IRT is elevated, appropriate ordering and completion of the second IRT testing, in addition to the frequent need for confirmatory sweat testing. The IRT/IRT screening strategy is declining due to risk of missed diagnoses from false negatives or concerns about lack of follow-up. There are very few states that currently employ this screening strategy. To further improve the sensitivity and specificity of CF NBS, and to decrease the need for confirmatory sweat testing, most states adopted a testing strategy combining IRT measurements with testing for common CF-causing mutations. These IRT-DNA or IRT/IRT-DNA strategies are similar in principle and all require additional testing after an initially elevated IRT result on the first screen. Some states will repeat the IRT screen and if still elevated, proceed to additional DNA testing (known as IRT/IRT/DNA). More commonly, many states forgo second-round IRT testing and proceed directly to DNA testing when the initial IRT is elevated (known as IRT/ DNA). An important exception is the infant with an “ultrahigh IRT� level on the initial blood spot. This result is considered significant enough to warrant referral for sweat testing. Similar to the variability in IRT testing strategies, states may also use various CF DNA mutation panels. The DNA testing panel (run upon initial blood spot) may screen only for a single CFTR mutationF508del (formerly called DeltaF508)- 1 copy is found in ~80% of patients with CF, or employ a combination

panel including between ~ 23-43 mutations/variants in the CFTR gene.9 Even less commonly, some states will perform CFTR full gene analysis. Delaware uses a combination of these modalities. If the initial IRT is elevated, a CFTR mutation panel of approximately 40 mutations/variants is screened on the first bloodspot and a second IRT level is drawn with the second blood spot while DNA is being processed. Utilization of DNA testing improves sensitivity and specificity of diagnosing patients with abnormal NBS with CF. However, it also increases the rate of identifying 47

CF mutation carrier state if a CF-causing mutation is identified on NBS. Genetic counseling or visit with CF specialist should be offered to patients with abnormal CF NBS in combination with the need for diagnostic testing. At present, our CF NBS strategy is being reevaluated with input from the Nemours-Alfred I. duPont for Children CF Center in combination with State of Delaware NBS program. Newborn screening for CF can be challenging and it should be noted that it only represents a screen. Infants identified as demonstrating a positive NBS for CF, require a diagnostic evaluation with sweat chloride testing at a Cystic Fibrosis Foundation and CLABSI-accredited laboratory. Infants delivered in setting of perinatal stress, hypoglycemia, low Apgar scores, congenital anomalies in addition to certain ethnic backgrounds may demonstrate elevated IRT in the absence of CF. These infants may still require sweat chloride testing to determine if the screen was falsely positive (in the absence of other clinical signs or symptoms of CF). Additionally, infants with CF manifesting with meconium ileus, may demonstrate low IRT levels and may not demonstrate positive CF NBS. Infants with meconium ileus, regardless of NBS results should undergo confirmatory CF-testing with sweat chloride and/or CFTR genotype analysis to provide a diagnosis and avoid a falsely negative screen given that clinical symptoms of CF are already present.8 NBS does not replace clinical judgment by care providers; diagnostic testing should be pursued in patients with symptoms concerning for CF regardless of NBS results. Other challenges of CF NBS may include parental anxiety about the possibility of a genetic disease in their healthy appearing neonate or misunderstanding about test results. Candid discussion about test results, rationale for additional testing, and genetic counseling by CF knowledgeable caregivers is helpful in these situations.

Evaluation of an Infant with Positive Newborn Screen: Most infants identified with a positive NBS for CF do not have the disease, but rather have a false positive NBS. Some additional infants are identified as CF carriers, as stated previously. All infants with a positive NBS for CF require confirmatory testing with sweat chloride analysis. This situation is associated with family stress and medical complexity. The Cystic Fibrosis Center at the Nemours/Alfred I. duPont Hospital for Children is committed to evaluating infants with positive CF NBS results accurately, efficiently and 48 Delaware Journal of Public Health – May 2018

supportively so that the status of each affected infant can be defined, and their families counseled appropriately. The involvement of the CF Center begins when Center staff, most often the Advanced Practice Nurse (APN) Coordinator, is contacted by the Delaware NBS Program about an infant with a positive screen. Four general groups of infants are evaluated in our program depending upon the State of birth and testing strategy employed: Infants with ultrahigh IRT, infants with persistently elevated IRT, infants with elevated IRT and one identified CF-gene mutation and infants with elevated IRT and two identified CF-gene mutations. The NBS Program contacts the CF Center within 1-2 days of abnormal results. Once a member of the CF team is contacted, a telephone call is made to the infant’s primary care provider (PCP) to determine if they have received the results and have spoken with the family. After discussion with the PCP confirming the discussion of an abnormal NBS result requiring a sweat chloride testing, the CF APN Coordinator will contact the family. The discussion with the family includes: sweat chloride testing instructions, scheduling of the sweat chloride test and an appointment with a physician member of the CF team the same day as the sweat test. Table 2 lists strategies for optimizing yield of the sweat test. Additional topics of discussion include providing information about CF, assessing parental CF-gene carrier status, the presence of other siblings in the family, and an assessment of the status of the infant with the positive NBS. Salt supplementation may be started in select infants. The family is also provided the Cystic Fibrosis Foundation (www.cff.org) website if they request more information regarding CF, but it is also stressed that most infant sweat test results (~90%) are negative. Table 2: Optimizing Yield of Sweat Chloride Testing: • Ensure pa�ent is afebrile and well-hydrated • Ensure minimum infant weight of ~2.5-3.5 kg is met • Avoid creams/lo�ons or other skin care products to the forearms for at least 24-72 hours prior to tes�ng • Avoid tes�ng when cutaneous rash is present on forearms • Avoid tes�ng during cri�cal or severe illness • Avoid tes�ng in se�ng of electrolyte disturbance

Sweat chloride testing must be performed at an accredited Cystic Fibrosis Care Center. Despite this, sweat chloride testing in infants can be challenging and it is critical that the strategies in Table 2 be shared with the family to maximize the chances of obtaining an adequate test. The sweat test is scheduled Monday through Thursday at the outpatient lab of the Nemours/

Alfred I. duPont Hospital for Children and the appointment with the CF physician occurs later the same day. At the appointment with the CF physician, the results of the sweat test are reviewed and questions about the Newborn Screening process and results answered in person and in detail. Most often, this simply involves reporting a negative sweat test result and reassuring the family. Parents of infants who have been identified as CF carriers are counselled about this clinical finding. In cases where the sweat test is insufficient or the results are indeterminate, additional clinical assessment of the infant, counselling and follow up testing is scheduled. Finally, if the infant has a positive sweat chloride indicating that the infant indeed has CF, comprehensive and multidisciplinary care and family support can be provided.10 During the past year (2017), 36 infants from Delaware and surrounding states have been evaluated through this clinical process. Four infants were confirmed to have CF, two infants have had indeterminate testing and are being monitored clinically and the remainder of the infants had false positive newborn screen results. Of these 30 infants, with false positive NBS results, 19 were identified as carrying one copy of an abnormal CF-gene. Therefore, in this small population of infants with positive CF NBS, the false positive rate was 83% (30/36), the true positive rate was 11% (4/36) and in 6% (2/36) of infants CF has not yet been able to have CF confirmed or ruled out. This last group of infants are a recognized group who require additional testing and follow up to define their clinical status, and a certain percentage of these infants will go on to be confirmed to have CF over time.11

Diagnostic Testing: Sweat Chloride Measurements Sweat chloride testing or “pilocarpine iontophoresis� is the gold standard test for diagnosing CF.12 This process directly measures CFTR function in the sweat

duct. Fortunately, it does not require any needles or bloodwork. The test takes approximately sixty minutes. During the test, pilocarpine, a cholinergic agonist, is applied to the forearms and low current electrodes are attached to stimulate sweat production. The sweat volume is collected in discs and chloride concentration calculated by trained technicians. As previously mentioned, it is imperative that sweat chloride testing be completed in CFF and CLABSI-accredited laboratories. The Nemours- Alfred I. duPont Hospital for Children is the only such laboratory in the state of Delaware. Depending on the methodology, adequate sweat volume (of at least 15 ÂľL) is required in order to report reliable test results. Regardless of age, sweat chloride values greater than or equal to 60 mmol/L are consistent with CF and require repetition on a second day for confirmation.13 In infants less than 6 months of age, sweat chloride values less than 30 mmol/L make possibility of CF unlikely. There are very rare cases of patients in whom CF is diagnosed with sweat chloride levels less than 30mmol/L. In patients less than 6 months of age, sweat chloride values between 31-59 mmol/L are indeterminate and require repetition. If values on follow-up testing are still in the indeterminate range, additional testing with CFTR gene mutational analysis is indicated by 2 months of age with follow-up sweat chloride testing suggested again around 6 months of age.2

Outcomes: NBS diagnosis for CF allows for earlier therapeutic intervention. Infants identified early by NBS with CF and pancreatic insufficiency who initiated high calorie diet and pancreatic enzyme replacement therapy demonstrated improved growth compared with CF infants with delayed diagnosis upon onset of clinical symptoms. In a randomized clinical trial, growth parameters (height, weight, head circumference) were significantly greater for CF infants with early diagnosis (NBS) when compared with a control group of later diagnosis upon onset of clinical symptoms.14 Furthermore, these anthropometric differences between early and late-diagnosis CF infants remained apparent into early childhood and adolescence despite both groups being maintained on similar higher calorie diet and pancreatic enzyme replacement therapy. This suggests that earlier diagnosis and initiation of diseasespecific therapy impacts later childhood growth. It also 49

supports the idea that “catch-up” growth is difficult following severe malnutrition observed in symptomatic CF infants. This study also suggested that non-NBS CF infants demonstrated Vitamin E deficiency compared with CF NBS identified infants. Vitamin E deficiency was thought to negatively impact cognitive development. The Baby Observational and Nutrition Study (BONUS) demonstrated that CF infants identified by NBS also achieved normal predicted weight in the first year of life compared with age-matched infants without CF.15 Achievement of weight for length greater than or equal to the 50%ile for age at 2 years, is associated with improved baseline lung function in childhood compared with CF patients with weight for length less than the 50%ile.16 Therefore, establishing normal growth and stable nutritional status in early childhood also impacts later lung function for patients with CF. Spirometric values obtained in school-aged children diagnosed by NBS suggest lung function preservation and significantly better lung function compared with CF patients diagnosed later upon onset of symptoms.17 In an Australian cohort, patients with CF diagnosed by NBS demonstrate increased lung function compared with non-NBS counterparts even into adolescence18 while other studies have not identified persistent spirometric improvements.19 The current US data published in the 2016 Cystic Fibrosis Foundation Annual Patient Registry Report20 supports overall normal lung function in school-aged and pre-teen patients with CF. CF infants diagnosed by NBS exhibited decreased rates of hospitalization compared with those diagnosed upon onset of symptoms. CF patients with later diagnosis typically required hospitalization for respiratoryrelated symptoms earlier and for greater length of stay.21 There did not appear to be differences in rates of hospitalization for gastrointestinal manifestations.

Summary: In conclusion, the diagnosis of CF earlier through NBS detection helps to identify and treat infants early and prior to severe manifestations of disease and improves overall outcomes. Patients diagnosed with CF following NBS, demonstrate reduced rate and duration of respiratory hospitalizations. They also demonstrate better nutritional status and overall more stable, improved lung function. Furthermore, early identification offers benefits for family members including education about the disease, earlier initiation of therapy and also genetic counseling. Lastly, patients may also benefit from initiation of disease, genetic mutation-specific therapies 50 Delaware Journal of Public Health – May 2018

which have become available in the last 4-5 years which may also impact the trajectory of CF-manifestations. Collaboration between the state NBS program and local CF team is also important to ensure that all infants with CF are appropriately identified and given the best possible opportunity for a healthy start. References:

1. Rosenfeld, M., M.K. Sontag, and C.L. Ren, Cystic Fibrosis Diagnosis and Newborn Screening. Pediatr Clin North Am, 2016. 63(4): p. 599-615. 2. Farrell, P.M., et al., Diagnosis of Cystic Fibrosis in Screened Populations. J Pediatr, 2017. 181S: p. S33-S44 e2. 3. Andersen, D., Cystic fibrosis of the pancreas and its relationship to celiac disease. Am J Dis Child, 1938. 56: p. 344-399. 4. Beckerman RC, T.L., Hypoelectrolytemia and metabolic alkalosis in infants with cystic fibrosis. Pediatrics, 1979. 63(4): p. 580-583. 5. Farrell, P.M., et al., Diagnosis of Cystic Fibrosis: Consensus Guidelines from the Cystic Fibrosis Foundation. J Pediatr, 2017. 181S: p. S4-S15 e1. 6. Rock, M.J., et al., Newborn screening for cystic fibrosis in Wisconsin: nine-year experience with routine trypsinogen/DNA testing. J Pediatr, 2005. 147(3 Suppl): p. S73-7. 7. Dunn, C.T., et al., The need for vigilance: the case of a false-negative newborn screen for cystic fibrosis. Pediatrics, 2011. 128(2): p. e446-9. 8. Comeau, A.M., et al., Guidelines for implementation of cystic fibrosis newborn screening programs: Cystic Fibrosis Foundation workshop report. Pediatrics, 2007. 119(2): p. e495-518. 9. Baker, M.W., et al., Optimal DNA tier for the IRT/DNA algorithm determined by CFTR mutation results over 14 years of newborn screening. J Cyst Fibros, 2011. 10(4): p. 278-81. 10. Borowitz, D., et al., Cystic Fibrosis Foundation evidence-based guidelines for management of infants with cystic fibrosis. J Pediatr, 2009. 155(6 Suppl): p. S73-93. 11. Ren, C.L., et al., Outcomes of infants with indeterminate diagnosis detected by cystic fibrosis newborn screening. Pediatrics, 2015. 135(6): p. e1386-92. 12. Gibson, L.E. and R.E. Cooke, A test for concentration of electrolytes in sweat in cystic fibrosis of the pancreas utilizing pilocarpine by iontophoresis. Pediatrics, 1959. 23(3): p. 545-9. 13. Farrell, P.M., et al., Guidelines for diagnosis of cystic fibrosis in newborns through older adults: Cystic Fibrosis Foundation consensus report. J Pediatr, 2008. 153(2): p. S4-S14. 14. Farrell, P.M., et al., Early diagnosis of cystic fibrosis through neonatal screening prevents severe malnutrition and improves long-term growth. Wisconsin Cystic Fibrosis Neonatal Screening Study Group. Pediatrics, 2001. 107(1): p. 1-13. 15. Leung, D.H., et al., Effects of Diagnosis by Newborn Screening for Cystic Fibrosis on Weight and Length in the First Year of Life. JAMA Pediatr, 2017. 171(6): p. 546-554. 16. Stallings, V.A., et al., Evidence-based practice recommendations for nutrition-related management of children and adults with cystic fibrosis and pancreatic insufficiency: results of a systematic review. J Am Diet Assoc, 2008. 108(5): p. 832-9. 17. Waters, D.L., et al., Clinical outcomes of newborn screening for cystic fibrosis. Arch Dis Child Fetal Neonatal Ed, 1999. 80(1): p. F1-7. 18. McKay, K.O., D.L. Waters, and K.J. Gaskin, The influence of newborn screening for cystic fibrosis on pulmonary outcomes in new South Wales. J Pediatr, 2005. 147(3 Suppl): p. S47-50. 19. Farrell, P.M., et al., Bronchopulmonary disease in children with cystic fibrosis after early or delayed diagnosis. Am J Respir Crit Care Med, 2003. 168(9): p. 1100-8. 20. 2016 Annual Data Report, in Cystic Fibrosis Founation Patient Registry. 2016, Cystic Fibrosis Foundation: Bethesda, MD. 21. Coffey, M.J., et al., Differences in Outcomes between Early and Late Diagnosis of Cystic Fibrosis in the Newborn Screening Era. J Pediatr, 2017. 181: p. 137-145 e1.

Aaron Chidekel, M.D. is a pediatric pulmonologist and Director of the Cystic Fibrosis Center at the Nemours/ duPont Hospital for Children.

Ambika Shenoy, M.D. is a pediatric pulmonologist and Associate Director of the Cystic Fibrosis Center at the Nemours/duPont Hospital for Children.

Kathleen Peeke, A.P.N. is an advanced practice nurse and is the Nurse Coordinator of the Cystic Fibrosis Center at the Nemours/duPont Hospital for Children.

Kathryn Tullis, Ph.D. is the Program Administrator of the Newborn Screening Program of the State of Delaware.

Michael Cellucci, M.D. is a pediatrician in the Division of Diagnostic Pediatrics at the Nemours/duPont Hospital for Children

49th Annual

Robert O.Y. Warren, MD Memorial Seminar November 14, 2018 Nemours/Alfred I. duPont Hospital for Children Wilmington, Delaware Co-Sponsored by The Delaware Chapter of the American Academy of Pediatrics, The Delaware Academy of Medicine & Nemours/Alfred I. duPont Hospital for Children. Regisration and accreditation information available at www.Pedsuniversity.org

Š 2018. The Nemours Foundation. Nemours is a registered trademark of the Nemours Foundation.

51

Comprehensive Services for Pregnant Women with Substance Use Disorder

Elizabeth Zadzielski, M.D., M.B.A, F.A.C.O.G. and Terry L. Horton, M.D.

The opioid epidemic has adversely impacted Delaware and its citizens as described in the August issue of this Journal. An especially challenging aspect of the epidemic is in the care and management of women with a substance use disorder who are pregnant. They are at significantly greater risk for sexually transmitted diseases and domestic partner violence because of high risk behaviors. The intense societal stigma of untreated addiction and pregnancy often prevents these women from seeking prenatal care. Adverse outcomes associated with addiction include preterm birth, fetal demise, intrauterine growth restriction, placental abruption and Neonatal Abstinence Syndrome (NAS)1. 52 Delaware Journal of Public Health – May 2018

The American College of Obstetricians and Gynecologists (ACOG), in a recent Committee Opinion published jointly with the American Society of Addiction Medicine (ASAM), noted a fivefold increase in antepartum maternal opioid use from 2000 to 2009. The Committee Opinion also reported an increased incidence of Neonatal Abstinence Syndrome (NAS) from 1.5 cases per 1,000 hospital births in 1999 to 6.0 per 1,000 hospital births in 2013, resulting in a staggering $1.5billion increase in related annual hospital charges1. Similarly, as illustrated in Graph 1, the rate of NAS reported by hospitals in Delaware has progressively increased. There is a direct association with opioid prescribing rates among health care providers and the incidence of NAS. States with the highest rates of opioid prescribing have the highest rates of NAS1. The Centers for Disease Control and Prevention reported on prescribing patterns in eight states in the October 16, 2015 edition of the Morbidity and Mortality Weekly Report. Delaware and Maine ranked highest in both mean daily opioid dosage and in the percentage of opioid prescriptions written for >100 morphine milligram equivalents (MMEs) per day. The top 1% of prescribers wrote one in four prescriptions in Delaware, compared with one in eight in Maine2. While this data is reflective of practice patterns in 2013, the resultant impact on NAS rates is cause for concern. Data specific to Christiana Care Health System, the region’s Perinatal Referral Center, demonstrates a continued increase in patient days related to NAS (Graph 2).

Current evidence does not demonstrate an association between medical supervised withdrawal and fetal death or preterm delivery. ACOG does not recommend that women undergo medical supervised withdrawal from opioids during pregnancy because relapse rates ranging from 59% to more than 90% have been reported among this cohort of patients. Risks associated with

relapse include communicable disease transmission, accidental overdose because of loss of tolerance, obstetric complications and lack of prenatal care1.

The most frequently abused opioids are prescription medications such as oxycodone followed closely by heroin. The vast majority of patients who are in Medically Assisted Treatment are currently treated with methadone. There is a growing body of evidence that supports the use of buprenorphine for pregnant women. Treatment with buprenorphine allows for outpatient management without the need for daily visits to an opioid treatment center. In addition there are reports of less severe incidence of NAS in infants whose mothers were treated with buprenorphin3. The resultant shorter newborn length of stay is an important parameter given overall trends in NAS patient days and the resultant costs. The need for an integrated approach to care for pregnant patients with a substance use disorder at Christiana Care was identified in 2015. Consultation and a site visit with the team at Magee Women’s Hospital at the University of Pittsburgh Medical Center provided members of the steer with the operational details of an established program. A team consisting of physician and nursing representatives from Obstetrics and Gynecology, Behavioral Health, Neonatology as well as peer counselors (Project Engage) and social services was assembled to determine the appropriate course of action. The most immediate challenge identified by the group was in the management of pregnant patients presenting to Christiana Care in active withdrawal to the OB Triage Unit or any of the Health System’s Emergency Rooms. Several obstetric providers obtained certification in 53

buprenorphine prescribing through the Substance Abuse and Mental Health Services Administration in order to facilitate patient care. The team developed the algorithm below as a guide for management. Education for the medical staff consisted of Grand Rounds presentations as well as special lectures for the residents. Focused in-service presentations were conducted for nursing personnel.

Participants were able to choose their provider for prenatal care and were not obligated to deliver at Christiana Care Health System. Initial data from the pilot demonstrated earlier entry into prenatal care among participants as well as greater acceptance of long acting reversible contraception when compared with nonparticipants. Of note, participants would also include the baby’s father in group prenatal sessions. The successes realized with the pilot, as well as an increase in prenatal patients treated with buprenorphine by Christiana Care’s Behavioral Health team, resulted in the formation of the Pregnancy Recovery Support Program. Initiated in September, 2017 the program is based at the Wilmington campus of Christiana Care Health System and meets on a weekly basis. The team consists of a midwife, addictions counselor, addiction psychiatrist and case management for prenatal as well as social service needs. Additional support is provided by a program coordinator and women’s health medical assistant.

The challenge of providing appropriate prenatal care for patients was also recognized. Disordered and chaotic home environments pose challenges for regularly scheduled appointments. As stated earlier, the stigma of addiction and pregnancy serves as a significant barrier to prenatal care for these patients. Traditional care in a physician’s office does not provide the behavioral health, social services and peer support needed for these patients to succeed in their recovery journey. Group visits have long been a mainstain of therapy in behavioral health. The Centering Model of Prenatal Care is group prenatal care that has been implemented in the United States and abroad since 1995. It provides an integrated approach to prenatal care in a group setting, incorporating family members, peer support and education4. A subgroup consisting of midwives, women’s health nurse practitioner and nursing case manager was formed to adapt the proscriptive Centering model to the needs of pregnant patients with a substance use disorder. Content for ten educational sessions was developed and tailored for this patient population. A pilot program in collaboration with Brandywine Counseling was launched in January, 2016. Sessions were conducted on the first and third Tuesdays of the month and lasted for two hours. Enrollment was open to any pregnant patient receiving treatment at Brandywine Counseling. 54 Delaware Journal of Public Health – May 2018

There has been a steady increase in participation in the program to date. Future expansion for the program will be the addition of group care for the post partum period in an effort to continue support at a time when the likelihood of relapse to addiction increases significantly. Outcomes that will be analyzed are gestational age at entry to care, gestational age and birthweight at delivery, acceptance of contraception post partum and breast feeding rates. A recent metaanalysis that compared group prenatal care with traditional prenatal care indicated reduced preterm delivery rates among African American women who participated in a group prenatal care model. An explanation offered by the study is the provision of social support, coping strategies and stress reduction through group prenatal care5. While of varied ethnic background, pregnant women with substance abuse disorder are a vulnerable cohort at high risk for a number of adverse pregnancy outcomes. The goal of the Pregnancy Recovery Support Program is to provide group prenatal care as well as comprehensive support services in a welcoming environment. Expansion of this vital work and reporting to the medical community at large of our outcomes will be an essential component of our continued efforts to combat the challenges posed by the opioid epidemic.

References

1. Opioid Use and Opioid Use Disorder in Pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017; 130:e81-94. 2. CDC. Controlled Substance Prescribing Patterns-Prescription Behavior Surveillance System, Eight States, 2013. MMWR. Morbid Mortal Wkly Rep 2015; 64:9. 3. Jones, HE, Kaltenbach K, Heil SH, Stine SM, Coyle MG, Arria AM, et al. Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure. N Engl J Med 2010; 2320-31. 4. Ickovics JR, Kershaw TS, Westdahl C, Magriples U, Massey Z, Reynolds H, Rising SS. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol 2007; 110:330-9. 5. Carter EB, Temming LA, Akin J, Fowler S, Macones GA, Colditz GA, et al. Group prenatal care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet Gynecol 2016;128:551-61.

Terry Horton, M.D., is the chief of Christiana Care’s Division of Addiction Medicine and a recognized authority on substance abuse. He is also Medical Director for Project Engage, the Associate Physician lead for the Behavioral Health Service Line and a scholar in Christiana Care’s Value Institute. Dr. Horton joined Christiana Care in 2007 as director of the Consult Service at Wilmington Hospital. The next year, he helped launch Project Engage at Wilmington Hospital. This program embeds a peer engagement specialist at the hospital to reach substance-addicted patients when they most need help and provide a clear pathway to treatment. Project Engage has drawn national attention for its innovative approach and success in reducing health care costs and utilization by reducing emergency room visits and hospital stays. Dr. Horton has also help institute a number of innovations at Christiana Care Health System including methodologies to screen and treat alcohol and opioid withdrawal. He has published and presented both nationally and internationally on addiction-related topics.

Elizabeth Zadzielski, M.D., M.B.A., F.A.C.O.G. received her Medical Degree from Rutgers Medical School and a Master’s of Business Administration from the Fox School of Business, Temple University. She has practiced general OB/GYN for over thirty years and has developed an interest in the challenges of addiction in pregnancy. Dr. Zadzielski is a member of the Education Faculty in the Department of OB/GYN at Christiana Care Health System.

55

Christiana Care Golf Classic M AY 2 4 , 2 0 1 8



DUPONT COUNTRY CLUB

Join us for an exciting day of golf on the magnificent natural surroundings of the DuPont Country Club as we celebrate the 27th anniversary of the Christiana Care Golf Classic. The Golf Classic supports the The Fund for Christiana Care, helping us respond quickly to our community’s health needs and ensure our patients are offered the latest in technology and advanced medical care. Register online at giving.christianacare.org/Classic Sponsorships are available call 302-327-3364 for more information. 18DEV16

Libations and Donations: Guest Bartending Event Thursday, May 17, 2018 BBC Tavern & Grill, Greenville, Delaware Westside is hosting a guest bartending event on Thursday, May 17, 2018 at BBC Tavern and Grill featuring local celebrities pouring libations for a great cause. All beverage gratuities generated in the bar area will be donated to Westside Family Healthcare. There will be two guest bartending events this year; the second event will be held in the fall. LIBATIONS AND DONATIONS SPONSORSHIP OPPORTUNITIES INCLUDES BOTH EVENTS 56 Delaware Journal of Public Health – May 2018

57

Maternal health disparities among Puerto Ricans Yukiko Washio, Ph.D., Christiana Care Health System/University of Delaware Omar Khan, M.D., Christiana Care Health System Ralph Rivera-Gutiérrez, Ph.D., M.S.W., University of Puerto Rico

The primary causes of death in females – i.e., causes of over 1 million deaths- are cardiovascular diseases, infectious and parasitic diseases, cancer, respiratory diseases and infections, unintended injuries, and perinatal conditions.1 Given the significant role of women in families, loss of women can result in further poverty, higher mortality among children, food insecurity, and children being withdrawn from school.1 WHO identified four main risk factors contributing to these causes of death: tobacco use, harmful use of alcohol, malnutrition, and limited physical activity.1 If pregnant or immediately postpartum women are exposed to these risk factors, there are significant health effects on maternal and pediatric outcomes.2–7 The economic consequence of exposure to these risk factors is not trivial.8–10 Puerto Ricans are the second largest Hispanic subgroup in the U.S., following those of Mexican origin.11 The number of Puerto Ricans living in the U.S. (4.6 million) surpassed that living in Puerto Rico (3.7 million) in 2010.12 Moreover, given the economic reality facing the island, over the next few years, more Puerto Ricans may migrate to the United States mainland in search of better economic opportunities.13 Moreover, newer Puerto Rican migrants tend to be poorer than their earlier counterparts, and face a higher probability of living in poverty.14 The state of Pennsylvania has a population of 366,082 Puerto Ricans (2.9% of the entire state population15), and the state of Delaware is within the top 10 states with the most Puerto Rican residents by proportion (2.5%).15 Puerto Ricans living in the U.S. have worse health outcomes relative to other Hispanics, including chronic liver disease, heart disease, diabetes, cancer, and homicide.16 Some of these non-communicable diseases are attributable to unhealthy behaviors, including the highest smoking rates among Hispanics and a sedentary lifestyle.16 Puerto Rican pregnant women living in the U.S. once had the second highest prenatal smoking rate (12.2%) in the U.S., following American Indian/Alaska 58 Delaware Journal of Public Health – May 2018

Native populations.17 Recent evidence showed that the self-reported prenatal smoking rate among Puerto Rican women was 21% in one region of the U.S.18 This may have significantly impacted breastfeeding rates among Puerto Rican mothers, due to inverse correlations between prenatal smoking and breastfeeding rates.19,20 Low-income mothers in Puerto Rico maintain a median breastfeeding duration of five months;21 however, a considerable disparity in breastfeeding duration has been observed among low-income Puerto Rican women in the U.S., with a median duration of only two weeks.22 The disparity in breastfeeding is also observed between Puerto Rican mothers and other Hispanic subgroups within the U.S., in which 45% of low-income, overall Hispanic women breastfeed for six months, similar to non-Hispanic White women.23 In terms of healthy lifestyle during pregnancy, only about 13% of Puerto Rican pregnant women in a U.S. region met physical activity guidelines and 19% met fruit/vegetable guidelines.18 The overall prevalence of meeting the guidelines of healthy nutrition and physical activity is low; however, Spanish-language preference (an indicator of less acculturation), and college education were significantly associated with meeting the healthy guidelines.18 Given the economic and long-term health consequences from adverse pregnancy and postpartum outcomes, as well as a growing number of Puerto Ricans migrating to the mainland, attention should be paid to their maternal and infant health indicators. Psychosocial and behavioral interventions to address maternal smoking range from brief counseling to comprehensive psychosocial support,24–26 and psychosocial interventions such as incentive use and counseling show significant effects on prenatal smoking cessation rates.24 Physical exercise interventions and nutritional and exercise counseling for overweight and obese pregnant women7,27 have had a significant reduction in the incidence of gestational diabetes, albeit with no consistent impact on preventing

adverse birth outcomes.27 Peer support has been the most promising component to increase continued breastfeeding rates22,28 as shown by recent evidence in significantly increasing continued breastfeeding rates by combining that with incentive use.29 The Delaware Department of Public Health funds a community outreach program (Health Ambassadors) to educate and make community referrals for managing maternal and infant health in the state. This type of program can suggest the value of racial and ethnic diversity in the approach to communities, and also demonstrate the efficacy and cost-effectiveness of evidence-based, multi-component interventions to address prenatal smoking, prenatal healthy eating and physical activity, and breastfeeding. We propose that any effective intervention should be culturally tailored to the intended audience. This has obvious benefits in terms of initial acceptance and continued sustainability. We further propose that in these efforts, Puerto Rican women remain a high priority given their high level of vulnerability. References 1. World Health Organization: The NCD Alliance. NON- COMMUNICABLE DISEASES: A PRIORITY FOR WOMEN’S HEALTH AND DEVELOPMENT International Diabetes Federation. 2011. http://www.who.int/pmnch/topics/maternal/2011_women_ncd_report.pdf. pdf. Accessed May 3, 2017. 2. Aliyu MH, Wilson RE, Zoorob R, et al. Alcohol consumption during pregnancy and the risk of early stillbirth among singletons. Alcohol. 2008;42(5):369-374. doi:10.1016/j. alcohol.2008.04.003. 3. Bailey BA, McCook JG, Hodge A, McGrady L. Infant birth outcomes among substance using women: why quitting smoking during pregnancy is just as important as quitting illicit drug use. Matern Child Health J. 2012;16(2):414-422. doi:10.1007/s10995-011-0776-y. 4. Bartick M. Mothers’ costs of suboptimal breastfeeding: implications of the maternal disease cost analysis. Breastfeed Med. 2013;8(5):448-449. doi:10.1089/bfm.2013.0070. 5. Catalano PM, Shankar K. Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child. BMJ. 2017;356:j1. http://www.ncbi.nlm.nih.gov/ pubmed/28179267. Accessed May 4, 2017. 6. Dupraz J, Graff V, Barasche J, Etter JF, Boulvain M. Tobacco and alcohol during pregnancy: prevalence and determinants in Geneva in 2008. Swiss Med Wkly. 2013;143:w13795. doi:10.4414/smw.2013.13795. 7. Yeo S, Walker JS, Caughey MC, Ferraro AM, Asafu-Adjei JK. What characteristics of nutrition and physical activity interventions are key to effectively reducing weight gain in obese or overweight pregnant women? A systematic review and meta-analysis. Obes Rev. 2017;18(4):385-399. doi:10.1111/obr.12511. 8. Bartick M. Breastfeeding and the U.S. Economy. Breastfeed Med. 2011;6(5):313-318. doi:10.1089/bfm.2011.0057. 9. Florence CS, Adams EK, Ayadi MF. Pediatric health care costs attributable to exposure to second-hand smoke: an exploratory analysis. J Health Care Finance. 2007;34(1):36-43. http:// www.ncbi.nlm.nih.gov/pubmed/18972984. Accessed May 22, 2017. 10. Popova S, Lange S, Burd L, Rehm J. Canadian Children and Youth in Care: The Cost of Fetal Alcohol Spectrum Disorder. Child Youth Care Forum. 2014;43:83-96. doi:10.1007/s10566013-9226-x. 11. Pew Research Center. The 10 Largest Hispanic Origin Groups: Characteristics, Rankings, Top Counties | Pew Research Center. http://www.pewhispanic.org/2012/06/27/the-10-largesthispanic-origin-groups-characteristics-rankings-top-counties/. Published 2012. Accessed August 16, 2017. 12. Pew Research Center. A Demographic Portrait of Puerto Ricans | Pew Research Center. http://www.pewhispanic.org/2011/06/13/a-demographic-portrait-of-puerto-ricans/. Published 2011. Accessed August 16, 2017. 13. Historic population losses continue across Puerto Rico. http://www.pewresearch.org/facttank/2016/03/24/historic-population-losses-continue-across-puerto-rico/. Published 2016. Accessed March 24, 2016. 14. Puerto Rican Population Declines on Island, Grows on U.S. Mainland. http://www. pewhispanic.org/2014/08/11/puerto-rican-population-declines-on-island-grows-on-u-smainland/. Published 2014. 15. Rodriguez FVM. Puerto Ricans in the United States: Past, Present and Future. http://www. csg-erc.org/wp-content/uploads/2013annualmeeting/documents/Matos.pdf. Published 2010. 16. CDC: Puerto Ricans in the U.S. Have the Worst Health : Science/Health : Headlines & Global News. http://www.hngn.com/articles/90053/20150505/cdc-report-puerto-ricans-u-sworst-health.htm.

17. National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD; 2012. 18. Gollenberg A, Pekow P, Markenson G, Tucker KL, Chasan-Taber L. Dietary behaviors, physical activity, and cigarette smoking among pregnant Puerto Rican women. Am J Clin Nutr. 2008;87(6):1844-1851. http://www.ncbi.nlm.nih.gov/pubmed/18541576. Accessed August 16, 2017. 19. Collins BN, DiSantis KI, Nair US. Longer previous smoking abstinence relates to successful breastfeeding initiation among underserved smokers. Breastfeed Med. 2011;6(6):385-391. doi:10.1089/bfm.2010.0076. 20. Higgins TM, Higgins ST, Heil SH, et al. Effects of cigarette smoking cessation on breastfeeding duration. Nicotine Tob Res. 2010;12(5):483-488. doi:10.1093/ntr/ntq031. 21. Sinigaglia OE, Ríos EM, Campos M, Díaz B, Palacios C. Breastfeeding practices, timing of introduction of complementary beverages and foods and weight status in infants and toddlers participants of a WIC clinic in Puerto Rico. Springerplus. 2016;5(1):1437. doi:10.1186/ s40064-016-3154-9. 22. Chapman DJ, Pérez-Escamilla R. Breastfeeding among minority women: moving from risk factors to interventions. Adv Nutr. 2012;3(1):95-104. doi:10.3945/an.111.001016. 23. Sparks PJ. Racial/ethnic differences in breastfeeding duration among WIC-eligible families. Womens Health Issues. 2011;21(5):374-382. doi:10.1016/j.whi.2011.03.002. 24. Chamberlain C, O’Mara-Eves A, Oliver S, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane database Syst Rev. 2013;10:CD001055. doi:10.1002/14651858.CD001055.pub4. 25. Logan CA, Rothenbacher D, Genuneit J. Postpartum Smoking Relapse and Breast Feeding: Defining the Window of Opportunity for Intervention. Nicotine Tob Res. 2016;19(3):ntw224. doi:10.1093/ntr/ntw224. 26. Risica PM, Gavarkovs A, Parker DR, Jennings E, Phipps M. A tailored video intervention to reduce smoking and environmental tobacco exposure during and after pregnancy: Rationale, design and methods of Baby’s Breath. Contemp Clin Trials. 2017;52:1-9. doi:10.1016/j. cct.2016.10.010. 27. Magro-Malosso ER, Saccone G, Di Mascio D, Di Tommaso M, Berghella V. Exercise during pregnancy and risk of preterm birth in overweight and obese women: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand. 2017;96(3):263273. doi:10.1111/aogs.13087. 28. Howell E Bodnar-Deren S Balbierz A Parides M Bickell N. An intervention to extend breastfeeding among black and Latina mothers after delivery. Am J Obstet Gynecol. 2014;210(3):239.e1-5. 29. Washio, Y., Humphreys, M., Colchado, E., Ortiz, M., Kilby, L.M., Zhang, Z., Collins, B., Chapman, D., Higgins, S.T., & Kirby KC. Incentive-based intervention to increase breastfeeding duration among Puerto Rican mothers. Pediatrics. 2017.

Yukiko Washio, Ph.D. Dr.Washio is a maternal and infant health researcher, jointly hired by Christiana Care OBGYN and University of Delaware College of Health Sciences. She is trained in behavioral science focused on maternal and infant health disparity issues

Omar Khan, M.D., M.H.S., F.A.A.F.P., is the Editor-in-Chief of the Delaware Journal of Public Health, as well as the President of the Delaware Public Health Association, and the President-Elect of the Delaware Academy of Medicine. He is also the CEO of the Delaware Health Sciences Alliance and is the physician leader for Partnerships and Academic Programs at Christiana Care. He is also the Co-Director for the Community Engagement & Outreach component of the multi-site NIH funded DE Clinical & Translational Research program (ACCEL).

Ralph Riviera-Gutierrez, Ph.D., M.S.W., is the former Dean, and a current professor, at the Graduate School of Public Health at the University of Puerto Rico. Dr. Rivera-Gutierrez has extensive experience with Latino community health issues in the United States and Puerto Rico, and has also been the Principal Investigator and Director of the UPR Center for Public Health Preparedness for the past 12 years. He has also served on the boards of numerous Massachusetts latino community-based organizations and groups. 59

Dispose of prescription drugs properly by visiting a collection site Sean Dooley, Community Relations Officer, Division of Public Health

Hundreds of Delawareans lose their lives each year to prescription drug abuse. Significantly more suffer behavioral and cognitive impairments and other effects as a result of being under the influence of substances. Those in the vice grip of substance use disorders also risk losing their families, jobs, friendships, and dignity. It is more important than ever to properly dispose of prescribed and over-the-counter drugs that are expired or no longer needed. Improperly using prescription drugs can lead to addiction and overdose. According to the Drug Enforcement Administration (DEA), more than 70 percent of people abusing prescription pain relievers obtain them through friends or relatives, or by raiding medicine cabinets.1 Some people may also raid trash cans. Youth are particularly vulnerable. One in five high school students have abused prescription drugs2 and twice as many Americans regularly abused prescription drugs than the number who regularly used cocaine, 60 Delaware Journal of Public Health – May 2018

hallucinogens, heroin, and inhalants combined, the DEA reported in 2015.3 Prescription opioids are also a known gateway to abusing illegal substances, particularly heroin.4 According to DEA statistics, eight out of 10 new heroin users began by abusing prescription painkillers and when they could no longer obtain or afford them, started using heroin. Youth are especially at risk for developing substance abuse disorders. Nearly 70 percent of those who try an illicit drug before the age of 13 develop a substance use disorder in the next seven years, according to the 2015 National Survey on Drug Use and Health.5 Although some will connect to treatment services, others may succumb to addiction. The Division of Public Health (DPH) reported to the Centers for Disease Control and Prevention that 293 people died in Delaware from drug overdoses (accidental, intentional and unknown intent) in 2016, compared to 214 in 2015 and 201 in 2014, according to the DPH Health Statistics Center.6

Additionally, when expired and unused medications remain in the home, they can lead to accidental poisonings of children, pets, and adults. In 2015, 60 percent of unintentional poisonings were drug-induced, according to the Delaware Vital Statistics Annual Report, 2015. National Prescription Drug Take-Back Day is a twice-annual event that provides safe, convenient, and responsible sites for the anonymous disposal of used, expired, or unwanted prescription drugs. The State of Delaware, medical centers, police departments, pharmacies, and hospitals participate. Since 2010, Delawareans donated 76,474 pounds of unwanted prescription medications through these successful events.7 Under the Controlled Substances Act, household members can dispose of their own household’s pharmaceutical controlled substances. Disposing of medications from other households is not permitted as the Act defines ultimate users as “a person who has lawfully obtained, and who possesses, a controlled substance for his own use or for the use of a member of his household or for an animal owned by him or a member of his household.”8 While Drug Take Back Day events are successful opportunities for persons to rid themselves of unwanted medications, it was believed that there needed to be a similar solution year-round. The Prescription Drug Action Committee (now reconstituted as the Addiction Action Committee) recommended to the establishment of permanent drug disposal sites, and 21 collection sites now exist at various police stations and Walgreens pharmacies: six in New Castle County, seven in Kent County,9 and eight in Sussex County. For the full list of Delaware collection sites, visit http:// delawarehealthyhomes.org.

Drug Disposal Instructions When disposing drugs at permanent collection sites or Drug Take-Back Day events, leave liquid medications in their original containers. Other drugs should be in pill bottles, boxes, blister packs, or zip-top or sealable plastic

bags with prescription labels and personal identifying information marked out with a felt-tip marker. Needles, aerosols, biohazard materials, medical equipment, batteries, and syringes are prohibited from these disposal sites. Businesses such as medical clinics or pharmacies must not use these drop boxes but instead must follow Federal Regulation 21CFR1307.21 for disposal of unwanted stock.10 Needles, lancets, and other sharps should be placed in strong plastic containers with lids sealed with duct tape. Delawareans should dispose of sharps containers in the regular trash, or they can take them to the Delaware Solid Waste Authority’s (DSWA) household hazardous waste collection events.11 For more information, call the Citizen’s Response Line at 1-800-404-7080 or visit the DSWA’s website at http://dswa.com. Delawareans who are unable to bring their unused or expired medicines to a proper disposal site can disposed of them in their household trash following these procedures.12 First, mix the medicines (do not crush tablets or capsules) with an unpalatable substance such as dirt, kitty litter, or used coffee grounds. Place the mixture in a container such as a zip-top or sealable plastic bag, and discard the sealed container in the household trash. Remember to use a felt-tip marker to make personal information on prescription labels unreadable.

Substance Use Disorder Treatment Those struggling with substance use disorders, or who are trying to connect others to treatment resources, can call 24/7 Services at 1-800-652-2929 in New Castle County, or 1-800-345-6785 in Kent and Sussex counties. For a list of Delaware treatment providers as well as for information on identifying the signs of addiction, talking about the subject with loved ones, resources for recovery, and how to administer the overdoes-reversing drug naloxone, visit Delaware’s one stop online resource Help Is Here at http://www. helpisherede.com/. To learn how to identify controlled substances by photo and their side effects, read Drugs of Abuse: A DEA Resource Guide, 2017 edition, published by the U.S. Department of Justice, DEA, at: https://www. dea.gov/pr/multimedia-library/publications/drug_of_ abuse.pdf.13 References 2013 Drug Enforcement Administration article: Public Response to DEA’s National Prescription Drug Take-Back Days Keeps Growing, https://www.dea.gov/divisions/hq/2013/ hq050213.shtml. 2 2012 Partnership Attitude Tracking Study Sponsored by MetLife Foundation, Partnership Attitude Tracking Study (PATS), 2013. 1

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2015 National Survey on Drug Use and Health: Detailed Tables, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. 2016 Drug Enforcement Administration article: DEA Collects Record-Setting Amount of Meds at Latest National Rx Take-Back Day, https://www.dea.gov/divisions/hq/2016/hq050616.shtml. 5 2015 National Survey on Drug Use and Health: Detailed Tables; U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration 6 Delaware Vital Statistics Annual Report, 2015, Delaware Division of Public Health Office of Vital Statistics, http://www.dhss.delaware.gov/dhss/dph/hp/files/ar2015_net.pdf. 7 2017 Division of Public Health press release http://www.dhss.delaware.gov/dhss/ pressreleases/2017/takeback_11162017.html 8 Drug Enforcement Administration Pharmacist’s Manual – Appendix A-N; https://www. deadiversion.usdoj.gov/pubs/manuals/pharm2/appendix/appdx_b.htm 9 Delaware Healthy Homes, http://www.dhss.delaware.gov/dhss/dph/hsp/files/hhdrugtbloc.pdf 10 Delaware Healthy Homes, http://dhss.delaware.gov/dph/hsp/hhdrugtakeback.html 11 Delaware Department of Natural Resources and Environmental Control, http://www.dnrec. delaware.gov/dwhs/SHWMB/Pages/WasteManagementFAQs.aspx 12 Drug Enforcement Administration, “How to Properly Dispose of Your Unused Medicines,” https://www.getsmartaboutdrugs.gov/sites/getsmartaboutdrugs.com/files/publications/DEAUnused-Medicine-Disposal-2017-ONLINE.pdf 3

4

References

2015 National Survey on Drug Use and Health: Detailed Tables, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration DEA Collects Record-Setting Amount of Meds at Latest National Rx Take-Back Day, Drug Enforcement Administration, 2016, https://www.dea.gov/divisions/hq/2016/hq050616.shtml Delaware Department of Health and Social Services, Division of Public Health press release, 2017, http://www.dhss.delaware.gov/dhss/pressreleases/2017/takeback_11162017.html

Delaware Healthy Homes, http://www.dhss.delaware.gov/dhss/dph/hsp/files/hhdrugtbloc.pdf and http://dhss.delaware.gov/dph/hsp/hhdrugtakeback.html Delaware Prescription Drug Action Committee Recommendations, October 21, 2013, http:// www.dhss.delaware.gov/dhss/dph/files/pdacfinalreport2013.pdf Delaware Solid Waste Authority, http://dswa.com Delaware Vital Statistics Annual Report, 2015, Delaware Division of Public Health Office of Vital Statistics, http://www.dhss.delaware.gov/dhss/dph/hp/files/ar2015_net.pdf. Drug Enforcement Administration Pharmacist’s Manual – Appendix A-N; https://www. deadiversion.usdoj.gov/pubs/manuals/pharm2/appendix/appdx_b.htm Drug Enforcement Administration, Title 21 United States Code (USC) Controlled Substances Act, https://www.deadiversion.usdoj.gov/21cfr/21usc/ Drugs of Abuse: A DEA Resource Guide, 2017 edition, U.S. Department of Justice, Drug Enforcement Administration, https://www.dea.gov/pr/multimedia-library/publications/drug_of_ abuse.pdf How to Properly Dispose of Your Unused Medicines, Drug Enforcement Administration, 2017, https://www.getsmartaboutdrugs.gov/sites/getsmartaboutdrugs.com/files/publications/DEAUnused-Medicine-Disposal-2017-ONLINE.pdf Partnership Attitude Tracking Study (PATS) Sponsored by MetLife Foundation, 2013, http:// www.drugfree.org/newsroom/full-report-and-key-findings-the-2012-partnership-attitudetracking-study-sponsored-by-metlife-foundation/ Public Response to DEA’s National Prescription Drug Take-Back Days Keeps Growing, Drug Enforcement Administration, 2013, https://www.dea.gov/divisions/hq/2013/hq050213.shtml, 2013.V

Delaware Department of Natural Resources and Environmental Control, http://www.dnrec. delaware.gov/dwhs/SHWMB/Pages/WasteManagementFAQs.aspx

Sean Dooley is a community relations officer for the Delaware Division of Public Health within the Department of Health and Social Services. He is a graduate of Lock Haven University, where he received a Bachelor of Arts degree in journalism and mass communications. Previously, he was employed as a graphic designer for GateHouse Media.

The Delaware Journal of Public Health is posting an open call for submissions. The DJPH publishes scientific articles, case reports, opinion pieces, editorials, and other articles relating to the public health sector. Authors should refer to the Submission Information page: http://delamed.org/wpcontent/uploads/2017/08/DJPH-Submission-Information.pdf Submissions should be sent to ehealy@delamed.org 62 Delaware Journal of Public Health – May 2018

JUNE 9, 2018 TROLLEY SQ., WILMINGTON 7:30 AM REGISTRATION & 8:30 AM RACE START

REGISTER FOR THE RUN OR WALK

www.thewestsideway.org All race proceeds benefit Westside Family Healthcare, a nonprofit community health center providing care to families, regardless of ability to pay. Learn more about Westside and the 30th Anniversary activities by visiting: www.westsidehealth.org/30years

63

MATERNAL AND CHILD HEALTH LEXICON OF TERMS

A

D

Abortion – The number of times a woman has lost pregnancies for any reason, including induced abortions or miscarriages. Does not include stillbirths. Often coupled or grouped with gravity and parity to indicate more details of a woman’s obstetric history. (G1, P2, A0 indicates a woman has been pregnant once, carried two fetuses to term (i.e.: had twins), and has had no miscarriages or abortions.)

Disparity – Discrepancy; imbalance

E Emesis – Vomiting

Epigenetics – The study of changes in organisms caused by modification of gene expression, rather than alteration of the genetic code itself; the study of Abortus – Immature placental or fetal tissue prematurely biological mechanisms that will switch genes on and off passed or curetted Exogenous – Not grown within the body Antecedent – A thing or event that existed before or logically precedes another

F

Antenatal – Before birth; during or relating to pregnancy; prenatal Asymptomatic – Showing no symptoms of a disease Autosomal recessive – Two copies of an abnormal gene must be present in a non-sex chromosome for a disease to be present

Failure to Thrive – A state of poor or inadequate growth in a child. This condition may be from undernutrition due to inadequate caloric intake, inadequate caloric absorption, or excessive caloric expenditure; weight for age that falls below the 5th percentile on multiple occasions; weight deceleration that crosses two major percentile lines on a growth chart (

C

Fetal Growth Restriction – See: Intrauterine Growth Restriction

Cervical Insufficiency – A medical condition of pregnancy in which the cervix begins to dilate (widen) and efface (thin) before the pregnancy has reached full term (37 weeks or more)

G

Cesarean Section – A surgical operation for delivering a child by cutting through the wall of the mother’s abdomen; C-section. Often necessary when a vaginal delivery would put the baby or the mother at risk Congenital – Present from birth Contraception – The deliberate use of artificial methods or other techniques to prevent pregnancy. The major forms are: barrier methods (condoms), hormonal methods (the pill, the shot), intrauterine devices (IUDs), and sterilization Cystic Fibrosis – A hereditary disorder causing the production of abnormally thick mucus, leading to the blockage of the pancreatic ducts, intestines, and lungs, and often results in respiratory infection 64 Delaware Journal of Public Health – May 2018

Gastroenteritis – Inflammation of the stomach and intestines, typically resulting from bacteria or viral infection, usually causing vomiting and/or diarrhea Gestation – The process of carrying or being carried in the womb between conception and birth Gestational age – Common term used during pregnancy to describe how far along the pregnancy is. It is measured in weeks, from the first day of the woman’s last menstrual cycle to the current date. A normal pregnancy can range from 38 to 42 weeks. Gestational Diabetes – Any degree of glucose intolerance with onset or first recognition during pregnancy. This applies whether insulin or diet modification is used for treatment and whether or not the condition persists after pregnancy

Gravity/Gravida – The number of times a female is or has been pregnant. Often coupled or grouped with parity and abortus to indicate more details of a woman’s obstetric history. (G1, P2, A0 indicates a woman has been pregnant once, carried two fetuses to term (i.e.: had twins), and has had no miscarriages or abortions.) Gynecologist – A physician or surgeon qualified to practice gynecology Gyneocology – The branch of physiology and medicine that deals with the functions and diseases specific to women and girls, especially those affecting the reproductive system

M Macular Rash – Small, flat, discolored spots on the surface of the skin Meconium – The dark green substance forming the first feces of a newborn Meconium Ileus – A bowel obstruction that occurs when the meconium in a child’s intestine is thicker and stickier than normal, and creates a blockage in the ileum of the small intestine

H Hemorrhage – An escape of blood from a ruptured blood vessel, especially when profuse Hyperglycemia – High blood sugar Hypertension – High blood pressure Hypoglycemia – Low blood sugar

I Inspissate – Thick Intrauterine Growth Restriction – IUGR a fetal weight that is below the 10th percentile for gestational age, as determined through an ultrasound. Symmetric/Primary IUGR – all internal organs are reduced in size (20 – 25% of all IUGR cases). Asymmetric/Secondary IUGR – head and brain are normal size, abdomen is smaller. Typically not evident until the third trimester. Iatrogenic – Relating to illness caused by medical examination or treatment Infant – A baby from two months to one year of age

L Lactation – The secretion of milk by the mammary glands; the suckling of young

Metabolic Syndrome – A cluster of biochemical and physiological abnormalities associated with the development of cardiovascular disease and type 2 diabetes (e.g.: insulin resistance, obesity, high blood pressure, high cholesterol) Miscarriage – Also known as: spontaneous abortion. The natural death of an embryo or fetus before it is able to survive independently. Some physicians use the cutoff of 20 weeks gestation, after which fetal death is known as a stillbirth. Morbidity – The condition of being diseased Mortality – Death, the state of being subject to death Mucopurulent – Containing both mucus and pus Multigravida – A woman who has been pregnant more than one time

Live Birth – When a fetus, regardless of gestational age, exits the mother’s body and subsequently shows any sign of life, such as voluntary movement, heartbeat, or pulsation of the umbilical cord, for however brief a time, and regardless of whether the umbilical cord or placenta are intact. 65

N Nasal polyposis – Nasal polyps; soft, painless, noncancerous growths on the lining of nasal passages or sinuses Neonatal – Relating to newborn children Neonate – A newborn child less than four weeks (28 days) old NICU – Neonatal Intensive Care Unit; an intensive care unit in the hospital specializing in the care of ill or premature newborn infants Non-Communicable Disease – A disease or medical condition not caused by infectious agents and is not contagious (i.e. chronic diseases: diabetes, heart disease, cancer) Nulligravida – A woman who has never been pregnant

O Obstetrician – A physician or surgeon qualified to practice in obstetrics Obstetrics – The branch of medicine and surgery concerned with childbirth and the care of women giving birth Otitis – Inflammation of the ear, usually distinguished as otitis externa (of the passage of the outer ear), media (of the middle ear), and interna (of the inner ear; labyrinthitis)

P Parity – The number of pregnancies carried to a viable gestational age (greater than 20 weeks), including live births and stillbirths. Often coupled or grouped with gravity and abortus to indicate more details of a woman’s obstetric history. (G1, P2, A0 indicates a woman has been pregnant once, carried two fetuses to term (i.e.: had twins), and has had no miscarriages or abortions.) Pediatric – Relating to the branch of medicine dealing with children and their diseases Pediatrician – A medical practitioner specializing in children and their diseases Perinatal – Relating to the time, usually a number of weeks, immediately before and after birth 66 Delaware Journal of Public Health – May 2018

Pessary – A small, soluble block that is inserted into the vagina to treat infection, or as a contraceptive; an elastic or rigid device that is inserted into the vagina to support the uterus Postpartum – After childbirth Preeclampsia – A condition in pregnancy characterized by high blood pressure and protein being spilled in the urine. Symptoms include fluid retention Preterm – A baby born alive before 37 weeks gestation, also: premature Primigravida – A woman who is pregnant for the first time, or has been pregnant one time Progesterone – A hormone that stimulates the uterus to prepare for pregnancy Proteomics – A branch of biotechnology concerned with applying the techniques of molecular biology, biochemistry, and genetics to analyzing the structure, function, and interactions of the proteins produced by the genes of a particular cell, tissue, or organism.

R Risk Factor – Any attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease or injury.

S Sensitivity – Statistical measure of the “true positives:” the proportion of positives that are correctly identified as positive by a particular statistical test (e.g. the proportion of sick people who are correctly identified as having the condition) Singleton – A pregnancy with one fetus (as opposed to twins/multiples) Sinusitis – Inflammation of the sinuses Social Determinants of Health – “Life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care, whose distribution across populations effectively determines length and quality of life.” (CDC) Socio-Ecologic Model – Considers the complex interplay between individual, relationship, community, and societal factors, and how these factors affect people making health-based decisions.

TEACHERS AND PARENTS: That USB Stick Might Be an E-cigarette

E-cigarettes are the most commonly used tobacco product among U.S. middle and high school students.

Specificity – Statistical measure of the “true negatives:” the proportion of negatives that are correctly identified as negative by a particular statistical test (e.g. the percentage of healthy people who are correctly identified as not having the condition) Stillbirth – Fetal death. It results in a baby born without signs of life.

Some e-cigarettes don’t look like tobacco products, so some kids use them unnoticed in schools, including in classrooms and bathrooms.

T Teratogen – An agent or factor that can disturb the development of an embryo or fetus (i.e. radiation, maternal infections, chemicals, drugs) Tocolytic agent – Medications that can inhibit labor, slow down or halt the contractions of the uterus (i.e. magnesium sulfate)

An increasingly popular e-cigarette, called JUUL, is shaped like a USB flash drive.

JUUL delivers a high dose of nicotine. Nicotine is highly addictive and can harm adolescent brain development.

Toddler – A baby aged one to four years of age

U Ultrasound – A test using high frequency sound waves to create images of internal structures. These tests help identify abnormalities and help doctors diagnose conditions. Ultrasounds can be external (using a wand on a patient’s stomach) or internal (also called a transvaginal ultrasound, a technician inserts a probe two to three inches into the vagina)

V Vascular – Of, relating to, affecting, or consisting of blood vessels

TOBACCO PRODUCT USE IN ANY FORM, INCLUDING E-CIGARETTES, IS UNSAFE FOR YOUTH.

LEARN MORE about the risks of e-cigarettes for youth and access tips for talking to youth at: https://e-cigarettes.surgeongeneral.gov/resources.html

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MATERNAL AND CHILD HEALTH RESOURCES

Other

Support Groups

Delaware Resources Name

Audience

Breastfeeding Support Group

Moms helping other moms with the guidance of a lactation consultant (Christiana Hospital). Mondays, 2-3pm, room 1932 Wednesday, 6-7 pm, room 1927

Centering Pregnancy

Pregnant pa�ents currently being cared for by a Chris�ana Care obstetrician

Chris�nana – 302-733-3510 Wilmington – 302-320-4414

Embracing Motherhood

New moms support group, Lewes

Kelly - 302-401-4734

Moms Heal

Pregnant women and new moms coping with perinatal mood difficulties, anxiety, and stress (Christiana Hospital). Thursdays, 6-7pm

cwew@chris�anacare.org 302-733-6662

Mother/Baby Development

First time moms with babies up to 12 weeks old. Open discussions about an array of topics including breastfeeding, adjusting to motherhood, and ways to calm your baby (Christiana Hospital). Mondays, 10-11:30 am, room 1932

New Mothers Postpartum Support Group

Postpartum women

Rebecca – 302-294-2365

Parent Education & Support

To guide patients and their families through early pregnancy, labor, birth and beyond, Christiana Care Parent Education Department offers a wide variety of classes in Labor & Delivery, Relaxation & Breathing, Newborn & Breastfeeding Classes, Grandparenting Class, CPR for Family & Friends. https://christianacare.org/services/baby/parented/

302-733-3360

Be Your Own Baby

h�ps://www.beyourownbaby.org/

Delaware Center for Maternal & Fetal Medicine of Christiana Care

Perinatologists with advanced training and experience to care for high risk pregnancies https://christianacare.org/services/baby/maternalfetalmedicine/

Delaware Thrives

Resources, programs, and social networks for reproductive life planning, healthy pregnancy, raising healthy babies, and more. http://dethrives.com/

Health Ambassadors

The health ambassadors work in targeted high risk zip codes to connect pregnant women and young families to health care, social services, home visiting and educational programs. The health ambassadors work with community partners including Henrietta Johnson Medical Center, St. Francis Healthcare, Westside Family Healthcare and the Wilmington Hospital Health Center.

Maternal & Child Health Program

The MCH Bureau is housed within the Family Health Systems Section of the Division of Public Health, and includes Title V Maternal and Child Health Program, Early Childhood Comprehensive Systems Program, Children and Youth With Special Health Care Needs Program, and the Newborn Screening Program. http://dhss.delaware.gov/dph/chca/dphmchhome.html

Planned Parenthood of Delaware

https://www.plannedparenthood.org/planned-parenthood-delaware

Postpartum Support International

h�p://www.postpartum.net/loca�ons/delaware/

Title X

The Title X program is the only Federal program devoted solely to the provision of family planning and reproductive health care. The program is designed to provide access to contraceptive supplies and information to all who want and need them with priority given to low-income persons. http://dhss.delaware.gov/dph/chca/dphfpservices1b.html

68 Delaware Journal of Public Health – May 2018

Contact

302-320-6582

Dr. Ruth Nduati

Dr. Magaly Blas

University of Nairobi

With initial support as a Fogarty Scholar, Dr. Magaly has givenresearch us Africans Blas was able toFogarty conduct training a year of mentored on HIV/AIDS. After earning master’s and Ph.D., she the skills weher need to conduct research, was able to conduct independent research as a Fogarty document illness and look at possible Fellow. Like her, 80 percent of all program participants interventions that work in Africa…Fogarty continue in global health.

Initial Experience

“

Fogarty Scholars

has changed the face of HIV medicine. ”

Dr. Peter Singer University of Toronto

“Fogarty’s Seniorunique, Scientist

sustained focus on Trainee becomes supporting people in their own countries to trainer, research solve their own problems leader has been a critical piece of the architecture and development global Dr. PatriciaofGarcia health.” After earning her master’s and Ph.D. with Fogarty support, Dr. Patty Garcia became a principal investigator and mentor, building a research and training grant portfolio that encompasses more than 40 NIH awards at her institution in Peru. Recently, she served as her country’s Minister of Health.

The John Edward

Fogarty at

5

Early Career

Fogarty Fellows

Advancing science for global health since 1968 Over the decades, Fogarty’s programs have made significant contributions by filling the pipeline of global health leaders, extending the frontiers of science and accelerating discovery. Above all, Fogarty invests in people—the most important resource in global health research—who serve on the front lines of the fight against diseases that threaten populations in the U.S. and around the world. Fogarty serves as a bridge between NIH and the greater global health community by facilitating exchanges among investigators, providing training opportunities and supporting promising research initiatives in developing countries. Over the last five decades, Fogarty programs have provided significant research training for about 6,000 scientists worldwide.

The Fogarty International Center supports research training at all career stages.

Find the right program for your application today: Health research in the 21st century is increasingly a team effort.

Dr. Bill Pape Dr. Bhakti Hansoti

fic.nih.gov/programs

“Hansoti I can say for us in canthat receive

Interdisciplinary research groups have been prime movers in the development of low-cost diagnostics and cost-efficient ways to prevent and treat disease. Research groups are best suited to address global health issues when the teams are multinational and sensitive to local culture and context. Building such teams in institutions around the world has been an important Fogarty strategy for decades.

connect with us

Fogarty at

Dr. Amy E. Sims Baylor College of Medicine

“My Fogarty Fellowship reassured me Mid-Career that what I want to do with my life could be Support possible, to be involved to bridge in global health clinical the gap care and research.”

5

fic.nih.gov/subscribe

@fogarty_nih

fogarty.nih

bit.ly/FogartyLinkedin

@Fogar ty_NIH

www.fic.nih.gov

NATIONAL INSTITUTES OF HEALTH • DEPARTMENT OF HEALTH AND HUMAN SERVICES

GHESKIO

Post-docs like Dr. Bhakti

support for a year Haiti, Fogarty has or been two to continue field the cornerstone of the research and generate entire program. Fogarty findings necessary to support has allowed secure future funding,us tointrain the to leaders in our addition helping train who foreign scientists. field, themselves Participants interhave trainedform thousands national research of others. ” partnerships they often maintain throughout their careers.

Dr. Marcos Espinal Dr. Thomas Gaziano PAHO

support is available to enable mid“Bridging My Fogarty training was a defining

career scientists, such as Dr. Thomas Gaziano, to

experience in my career… It opened up my advance to the next stage. He received a Fogarty world completely, gave me another view Independent Research Scientist Development and I fell in love with public health and Award, which provided a stepping stone to research. competing”successfully for an R01 research grant. 69

From the history and archives collection Kate Lenart, M.A.

Biography of Dr. Margaret Irving Handy Dr. Margaret Irving Handy was the first native-born Delawarean woman to become a physician, and the state’s first practicing pediatrician. While chief of pediatrics at the Delaware Hospital, Dr. Handy worked to improve care for premature babies and helped establish the Mother’s Milk Bank, which fed local children for forty years. She received numerous accolades during a fifty-two-year career devoted to improving children’s health, and is remembered as one of Delaware’s most respected and beloved physicians. Margaret Irving Handy was born in Smyrna, Delaware, in 1889, the daughter of a former U.S. Representative and Mrs. Irving L. Handy. She attended public schools in Newark, Delaware, and the Girls’ Latin School in Baltimore. After graduating from Goucher College in 1911, she considered becoming either a teacher or a doctor. While her father encouraged her to study medicine, her mother strongly disapproved of her entering the male-dominated field, insisting that she become a “genteel lady.” Undecided, Margaret temporarily postponed her studies. After a decidedly unfulfilling year teaching Sunday school and playing whist (a card game), it became clear to everyone that Margaret Handy would never be happy without a career. “Mother was happier than I was when I entered the Johns Hopkins University as a medical student,” she later recalled. After earning her doctor of medicine degree from the Johns Hopkins University School of Medicine in 1916, Handy interned at Philadelphia’s Woman’s Hospital and completed a residency at the Harriet Lane Hospital in Baltimore. She then settled in Wilmington, becoming the first native-born Delawarean woman doctor, and the state’s first pediatrician. She soon found more business than she could have anticipated. When the influenza epidemic ravaged the community in 1918, she was enlisted by Dr. Robert E. Ellegood, a family friend, to assist him in caring for patients suffering from the flu. She also helped establish a children’s ward, where she acted as doctor, nurse, janitor, and “lullaby singer.” Later that year, she successfully organized a pediatric clinic at the Delaware Hospital, despite conflict with some of her male colleagues. From 1921 until 1946, Dr. Handy served as chief of pediatrics at Delaware Hospital, where she became the leading crusader for improved care and facilities for premature babies. She frequently went out into the community to collect women’s surplus breast milk for the young babies of mothers who were unable to breastfeed. After meeting one of the hospital’s junior board members who had lost a child because she was unable to nurse him, the two joined forces to establish the Mother’s Milk Bank, which subsequently helped nourish local children for the next forty years. Dr. Handy was regularly honored for her tireless dedication to improving children’s health. The University of Delaware and Goucher College both conferred upon her the honorary degree of doctor of science, and she received the Elizabeth Blackwell Citation from the New York Infirmary and a certificate of merit from the Medical Society of Delaware. Wesley College in Dover, Delaware, presented her with the Annie Jump Cannon medal, and she was made a diplomate of the American Board of Pediatricians. In 1953, the Delaware State Chamber of Commerce awarded her the Josiah Marvel Cup, recognizing her as Delaware’s most distinguished citizen of the year. 70 Delaware Journal of Public Health – May 2018

Images of baby feeders donated to the Delaware Academy of Medicine By Dr. Margaret Handy.

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Index of Advertisers Call For Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Delaware Academy of Medicine The DPH Bulletin March 2018. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Division of Public Health, Department of Health and Social Services National Academy of Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Save The Date: 88th Annual Meeting and Awards Ceremony . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Delaware Academy of Medicine Delaware Military and Veterans Subcommittee - Save the Date . . . . . . . . . . . . . . . . . . . . . . . . . . 21 A partnership of the Delaware Suicide Prevention Coalition (Delaware Military and Veterans Subcommittee), the Mental Health Association of Delaware, and the Delaware Academy of Medicine Tobacco Industry-Sponsored Youth Prevention Programs in Schools . . . . . . . . . . . . . . . . . . . . . . 22 National Center for Chronic Disease Prevention and Health Collage of Health Scienses Gala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 University of Delaware Save The Date - An Evening of Celebration at the Queen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Westside Family Healthcare The Nation's Health - May 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 American Public Health Association Improving Hypertension & Diabetes Contol and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Quality Insights 49th Annual Robert O. Y. Warren Memorial Seminar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Nemours Children's Health System Christiana Care Golf Classic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Christiana Care Health System Westside Family Healthcare: Guest Bartending Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Westside Family Healthcare Winter-Spring 2018 Jefferson College of Population Health Forums . . . . . . . . . . . . . . . . . . . . . 57 Philadelphia University and Thomas Jefferson University Defend Health with Westside's Superheros . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Westside Family Healthcare The USB Stick Might Be an E-cigarette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Center for Disease Control and Prevention Fogarty at 50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 The Fogarty International Center Millennial Summit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Young Professionals Conference 72 Delaware Journal of Public Health – May 2018

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