4/23/14. Healthy Start: Description of a Safety Net for Perinatal Support during Disaster Recovery*

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1 Healthy : Description of a Safety Net for Perinatal Support during Disaster Recovery* Gloria Giarratano APRN, CNS, PhD Professor, School of Nursing LSU Health Sciences Center School of Nursing, New Orleans, LA Study Team Emily Harville, PhD, Perinatal Epidemiologist Veronica Barcelona de Mendoza, MSN, MPH Doctoral Student Tulane University, School of Public Health New Orleans, LA Jane Savage RN, LCCE, FACCE, PhD Loyola University, School of Nursing, New Orleans, LA TrezMarie T. Zotkiewicz, RN-NIC, MN, APRN LSU Health Sciences Center Consultant: Dr. Cynthia Logsdon Funding: National Institute of Nursing Research 5R03NR * Models of Prenatal Care and Perinatal Health Indicators in Disaster Recovery 5R03NR Costliest disaster in US history Flooded 80% of New Orleans via Levee Failure 300,000 homes destroyed Displaced about a million people At least one-third of New Orleans remain displaced Long-term effects on all aspects of life on the Gulf Coast, especially New Orleans Extreme widespread property damage Ongoing financial problems Disaster caused by human intent: Levee Failures? High trauma impact, injuries, threat to life, loss of life Norris (2002) Psychiatry, 65, Process of restoring, rebuilding, and reshaping the physical, social, economic, and natural environment through pre-event and post-event actions. People, groups, institutions are affected differently Recovery is not linear; occurs at different rates for different entities High level of uncertainty Smith & Wenger, 2006 Handbook of Disaster Research Degree and type of exposure High secondary stress; Less social resources Lacking belief in one s ability to cope and control outcomes ---- self efficacy, optimism, coping style Personal Factors: Female, parent, low income, psychiatric history, ethnic minority Galea, et al. (2007), Arch Gen Psychiarty, 64, Norris, et al. (2002,) Psychiatry, 65,

2 Women at increased risk for PTSD, depression More sensitive to loss of resources, i.e. home, displacement Women s Health Issues - Interrupted family planning -Increased Domestic Violence - Increased use of alcohol, smoking, drugs - Lack of child care - Parenting issues Badakhsh, et al. (2010). JOGNN,39, Savage, et al. (2010) J. Holistic Nursing, 28, Fothergill, A. (2004) Heads above water. State U NY Press Birth outcomes (WTC, other disasters) - Fetal Growth - PTB/SGA Harville, et al. (2011) Obstetrical & Gynecological Survey, 65, Mental health remains the primary risk -Depression/Anxiety - Stress - Unhealthy Lifestyles - Child Development Impaired Specific Aims Lack of Social Support, Extended Family Housing Issues Limited Public Transportation Unsafe Neighborhood Lack of Medical Care Providers/OB, PSY Limited Hospital Services Lack of Day Care/Schools Lack of Retail Stores Everyone stressed and rebuilding! Higher risk for domestic abuse, unplanned pregnancy in future Badakhsh, et al. (2010). JOGNN,39, Savage, et al. (2010) J. Holistic Nursing, 28, To examine the relationship between different models of prenatal care and psychosocial and physical outcomes, including depression, pregnancy-specific anxiety, perceived stress, and lifestyle health practices. Federal Healthy Program Funded by Congress in 1991, now serves 105 communities with high infant mortality rates Reduce disparities in access and utilization of health services Core Services of direct community outreach, case management, health education, interconceptional care, and screening for depression Psychosocial and safety net care that complements routine prenatal care The purpose of this study was to compare differences in hurricane experience, recovery, mental health, and birth outcomes in pregnant women who added participation in the New Orleans Healthy program from those who only used the traditional prenatal care (PNC) system during a two year period of the long-term recovery ( ) from Hurricane Katrina. 2

3 Cross-sectional Inclusion: weeks gestation Enrolled in PNC (3 visits) Currently living in Greater N.O. area English/Spanish language Study Sites Two Med School Clinics One Community Clinic One Private OB/GYN Two Hospital-based Prenatal Classes Healthy Classes Personal Attributes Health Behaviors Socio-Demographic Survey (PRAMS, phase 5, CDC) brief COPE (Carver, 1997) Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet, 1988) Complementary and Alternative Medicine Usage Survey (NHIS Health Survey 2002) Instruments Environmental Type of PNC Add on Healthy? Hurricane Experience: Threat, loss, damage (Norris, 1996) Crime and Safety Recovery Expectations and City Problems Oil Spill Recovery Experience Daily Stress Inventory (DSI) (Brantley, 1987) Health Outcomes Edinburgh Postnatal Depression Index (EDSI) (Cox, 1987) Pregnancy-Related Anxiety (Pregnancy-distress) (Lobel, 2008) Perceived Stress Scale (Cohen, 1983; 1994) Posttraumatic Stress Disorder Checklist Scale (PCLS) (Weathers, 1994) Physical Health Indicators -- Smoking, alcohol use -- Birth Weights, Gestational Age at birth Differences in Demographics for those using Healthy PNC Healthy vs. PNC Only Relationship status N % N % <0.01 Healthy 120 total PNC 282 total Married Living with partner Single N % N % p Age <0.01 < Race <0.01 African-American > Other Currently employed <0.01 Yes Income <0.01 <$15K $15-29K $30K Education <0.01 Less than High School High School Greater than High School No

4 Differences in Hurricane Experiences for those using Healthy vs. PNC Only Health Indicators Healthy n=120 Prenatal Care ONLY n=282 Likely depression (EDSI>12) 48 (40%) 75 (26%) Likely PTSD (PCL>50) 18 (15%) 17 (6.1%) s Prenatal Care First Trimester 85 (72%) 238 (85.6) p<0.01 Difference in Prenatal Care and Mental Health Outcomes Difference in Mental Health Care Healthy PNC difference adjusted beta* mean std mean std Depression PTSD < Pregnancyrelated Anxiety Perceived stress Healthy PNC N % N % OR (95% CI) Took prescription medicine for depression ( ) (0.63, 2.14) 0.65 Counseling for depression ( ) < (1.27, 6.30) 0.01 aor (95% CI) Difference in Birth Outcomes adjusted beta p beta* p birthweight gestational age birth length head circumference *adjusted for age, partnership, race, smoking, income, body mass index, and current employment Difference in Birth Outcomes Healthy start vs. OR (95% CI) aor (95% CI)* Low birthweight 1.80 (0.70, 4.64) 1.25 (0.44, 3.60) Preterm birth 2.23 (0.87, 5.69) 2.90 (0.97, 8.65) Neonatal intensive care admission 1.69 (0.63, 4.60) 1.58 (0.51, 4.88) Gestational diabetes 1.03 (0.38, 2.78) 2.00 (0.62, 6.43) Pregnancy-induced hypertension 1.09 (0.56, 1.27) 0.93 (0.44, 1.97) anemia 0.56 (0.25, 1.27) 0.29 (0.12, 0.70) c-section 0.84 (0.50, 1.43) 0.92 (0.51, 1.66) *adjusted for age, partnership, race, smoking, income, body mass index, and current employment 4

5 Taught Prenatal Education by Prenatal Care Provider + Healthy Prenatal Care Not to smoke 77.5% 59.9% Breastfeed your baby 80.8% 67.4 % Not to use Alcohol 78.3% 60.6% Use seat belt 63.9% 36.9% Birth Control 63.3% 43.4% Not to use illegal drugs 81.7% 55.6% Report abuse 60.5% 39.4 % p<0.01 Services Offered + Healthy Case Worker 90.8% Referral to another agency 46.7% Earning Points for Products 76.7% Support Group 63.9% Counseling 14.2% p<0.01 Pregnant women using Healthy New Orleans represented a population more vulnerable to the stress of disaster and long term disaster recovery. High disaster exposure, decreased resources, and high social risks (poor, no partner, African American) are associated with mental health problems during pregnancy. As a safety net organization Healthy New Orleans was achieving its mission to target women at risk for problems. Women remain at risk for years after disaster. Community, state, and federal agencies that exist as routine or safety-net providers of care for vulnerable populations need an action plan to respond to the needs of the target population in the immediate and long term post-disaster recovery period. Professional social services and mental health care needs to be available to support families still disrupted. Private PNC providers need to partner with community safety net organizations such as Healthy to help address the psychosocial needs of socially high risk pregnant women. Prenatal care for women with a history of disaster exposure needs to include assessment for mental health (depression and PTSD) and low social support for years after the event. 5

6 Cross-Sectional Design Mental Health instruments indicate risks for depression, PTSD, etc but do not diagnosis conditions Other situational factors may contribute to mental health status other than hurricane recovery. 6