Date of Defense:
April 20, 2018
Pre-term birth is defined as a birth that has occurred before 37 weeks’ gestation, is the leading cause of perinatal mortality and morbidity in the United States1. There are close to 500,000 babies born pre-term each year2,3. When babies are born early, they are at high risk of death, disability, breathing issues, feeding difficulties, cerebral palsy, developmental delay, vision problem and hearing impairment1. Additionally, costs of healthcare for pre-term birth related outcomes are high. Pre-term birth associated healthcare costs total to more than $26 billion per year3. Today, the average healthcare costs for families who have a pre-term birth are ~$50,000 which is approximately $45,000 more than giving birth to a healthy baby2.
It is still unknown what all the possible causes of pre-term birth are. However, there are some established risk factors with pre-term birth – including social, environmental and biological factors2. Examples of these factors include: teen births, births to women over the age of 35, African American race, low-income, tobacco use, substance abuse, and stress2. The best predictor of pre-term birth risk is a previous pre-term birth2. To combat pre-term birth, 17- alpha Hydroxyprogesterone Caproate (17p) has been investigated for patient prescription. 17p is a synthetic progesterone treatment that mimics the natural progesterone hormone that regulates conception and pregnancy4. Eligibility for 17p treatment is a previous singleton pre-term birth. Despite literature supporting the cost effectiveness and benefits of 17p, there are low rates of administration of 17p. Though there are roughly 100,000 eligible women for 17p, only a fraction of these women receives or are offered this treatment5,6.
In Minnesota, the pre-term birth rate is 8.7%. Although the rate of pre-term birth in Minnesota is lower than the national average (9.6%)4, there is still room for improvement. There are significant ethic and racial disparities in Minnesota. The pre-term birth rate among African Americans is 9.6%, while the pre-term birth rate for Native Americans is 12%, relative to the 8.4% pre-term birth rate among White Americans7.
The field experience was located at the Minnesota Department of Health (MDH), within the Maternal and Child Health (MCH) Section. MDH noted that among high rates of infant mortality, pre-term birth is the second leading cause of mortality. Among minority populations, pre-term birth was often the leading cause of infant mortality. In an attempt to reduce the incidence of both infant mortality and address the existing health equity issues, MDH decided to develop the 17p Quality Improvement Project8. The 17p project is a two-year pilot project with the goal of reducing the incidence, severity and disparity of pre-term birth in Minnesota. The pilot consisted of 3-7 clinics that serve higher rates of minority populations, with the objective of increasing access and uptake of 17p to this demographic. The outcomes of the pilot are to (1) achieve 100% screening of all prenatal patients for pre-term birth, (2) increase 17p prescription to those who are eligible, and (3) increase uptake among women who are eligible for treatment8. The learning objectives for the field experience were: (1) Assist in implementation of statewide quality improvement initiative for infant health outcomes and (2) Participate as a member of a multidisciplinary public health team. For the 17p project I conducted a literature review of national studies, policies, and programs around 17p. This also involved contacting states that have successfully increased access and uptake of 17p. I also developed a clinical flow sheet based on the literature review and the pilot program conducted by MDH. The clinical flow sheet was instrumental in identifying the major barriers to accessing 17p at the system, provider, and patient level. After identifying the major barriers, I developed a list of policy recommendations to address the barriers.
MDH is the Minnesota state department of health. MDH’s mission statement is to “protect, maintain and improve the health of all Minnesotans”9. MDH is a collaborative organization that works with partners statewide to provide services to address health issues. Within MDH, the MCH Section has its own mission statement to “provide statewide leadership and public health information essential for promoting, improving or maintaining the health and well-being of women, children and families throughout Minnesota”10. The MCH Section’s role in the health department is to identify the needs of women, children and families, and advocate for programs, services, and policies on their behalf10.
MDH is an extremely large and complex organization. Collaboration on projects from multiple internal departments and external partners is often necessary to accomplish the work needed. Most projects require coalitions and work groups to make progress. Time needed to make progress and/or complete projects at the state level is often longer than predicted. During the field experience, there was one specific missed opportunity for me to participate in a hospital-based safe-sleep campaign. The MCH Section was unable to get approval for access to databased during my time at MDH, as a result the project was pushed back and I was unable to take part in the campaign. I learned during my field experience than setbacks like this is very common obstacle for projects at the state level.
There are several improvements and additions that could be made the 17p Quality Improvement Project. The first addition would be a cost-benefit analysis. The second addition would be a state specific return on investment. These two additions would help the MCH Section to strengthen the justification for increased access to 17p. If there was more evidence suggesting that 17p could improve health, and reduce health costs associated with pre-term birth, stakeholders may show more interest in supporting the project. Additionally, if the quality improvement project continues, clinics with higher rates of pre-term birth should targeted for the intervention. One issue MDH faced with this round of the pilot study was an inability to include Federally Qualified Health Centers (FQHC) to participate. This is due to the Medicaid classification of 17p as a medical procedure instead of a pharmaceutical. This prevents FQHC’s from receiving federal funding. If these clinics participated, they would become bankrupt from the cost of 17p. If Medicaid reclassified 17p to a pharmaceutical, these clinics would be able to participate. This would be beneficial to the program since FQHC clinics typically serve minority and low-income populations. Participation of these clinics could really show the effectiveness of 17p in reducing pre-term birth and improving health equity for pre-term birth in Minnesota.
MDH is a wonderful organization that is doing important work. I feel so grateful to the MCH Section and my preceptor, Susan Castellano, for introducing me into the professional world of public health. In addition to giving my opportunity to be a part of such a variety of projects, especially the 17p Quality Improvement Project. I have a new passion for prenatal health and would love to continue doing this work after graduation.
1.Reproductive Health [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2017 [cited 2017Oct18]. Available from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm
2. 17p Fact Sheet [Internet]. ASTHOS. 2013 [cited 2017Oct18]. Available from: http://www.astho.org/Maternal-and-Child-Health/17P-Fact-Sheet/
3. Armstrong J. 17 Progesterone for preterm birth prevention: a potential $2 billion opportunity. American Journal of Obstetrics and Gynecology. 2007;196(3):194–5.
4. Hydery T, Price MK, Greenwood BC, Takeshita M, Kunte PS, Mauro RP, et al. Evaluation of Progesterone Utilization and Birth Outcomes in a State Medicaid Plan. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2017;37(10):1328–34.
5. Campbell E, Balderas M, Hollier P, Hollier L. Utilization of 17-Alpha-Hydroxyprogesterone Caproate in a Medicaid Population [16D]. Obstetrics & Gynecology. 2016;127.
6. Rudolph CM. Advancing Health Equity by Increasing Access to 17P. Journal of Public Health Management and Practice. 2017;23(4):417–9.
7. County Preterm birth rate Grade – March of Dimes [Internet]. March of Dimes. 2016 [cited 2017Oct18]. Available from: https://www.marchofdimes.org/materials/premature-birth-report-card-minnesota.pdf
8. 17P Quality Improvement Project [Internet]. Minnesota Department of Health. 2018 [cited 2018Apr6]. Available from: http://www.health.state.mn.us/divs/cfh/program/prematurity/17p.cfm
9. Minnesota Department of Health Overview [Internet]. Minnesota Department of Health. 2012 [cited 2018Apr6]. Available from: http://www.health.state.mn.us/divs/opa/MDHoverview20120401.pdf
10. Maternal & Child Health (MCH) Section [Internet]. Minnesota Department of Health. 2018 [cited 2018Apr6]. Available from: http://www.health.state.mn.us/divs/cfh/program/mch/