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Service Delivery Innovation Profile

Prenatal and Postpartum Behavioral Counseling Significantly Reduces Health Risks in African-American Women


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Snapshot

Summary

A group of organizations in Washington, DC, implemented an inperson and telephone-based counseling program for pregnant African-American women at six prenatal care clinics, with the goal of reducing behavior-related risk factors during pregnancy and in the postpartum period. In addition to receiving standard prenatal care, pregnant women attend an average of four behavioral counseling sessions during pregnancy and one session after giving birth. The intervention significantly reduced health risks from baseline to 10 weeks postpartum. Early results from a study evaluating the program's impact on birth weight and infant mortality are encouraging.

Evidence Rating (What is this?)

Strong: The evidence primarily consists of a randomized control trial comparing the presence of behavioral health risk factors in an intervention and usual care group.
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Developing Organizations

Children's National Medical Center; George Washington University; Georgetown University; Howard University; National Institute of Child Health and Human Development; Research Triangle Institute
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Date First Implemented

2001
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Patient Population

Race and Ethnicity > Black or african american; Vulnerable Populations > Racial minoritiesend pp

Problem Addressed

Risky behaviors and behavioral health issues can often have a negative impact on the health of women both during pregnancy and in the postpartum period, leading to increased risk of poor birth outcomes, particularly among African-American women. Even if women reduce risky behaviors during pregnancy, they may return following delivery.
  • Strong link with poor birth outcomes: Pregnant women with behavioral health issues, including those who engage in risky health behaviors (and/or are the victim of someone else's risky behaviors) are at increased risk of poor birth outcomes. For example, research has clearly indicated that smoking during pregnancy can lead to premature birth, certain birth defects, and infant death.1 Other studies have shown an association between poor birth outcomes and domestic violence,2 secondhand smoke exposure,3 and depression and anxiety.4
  • Especially for African-American women: Addressing behavioral health issues and risky health behaviors is especially important for African-American women, as the infant mortality rate in this population is twice the national average, at approximately 14 deaths per 1,000 live births.5
  • Failure to sustain behavior change: Women who successfully manage health risks during pregnancy may not continue to do so after the birth, thus increasing risks for themselves and the newborn. For example, women may return to cigarette smoking and/or not be able to maintain a smoke-free home environment. Behavioral interventions during pregnancy may help but have limited effectiveness if they address individual risk factors in isolation6 and/or do not continue postpartum.

What They Did

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Description of the Innovative Activity

A group of organizations in Washington, DC, implemented an inperson and telephone-based counseling program for pregnant African-American women at six prenatal care clinics, with the goal of reducing risky behaviors both during pregnancy and in the postpartum period. In addition to receiving standard prenatal care, pregnant women attend an average of four behavioral counseling sessions during pregnancy and one session after giving birth. The intervention ran from July 2001 through October 2003, the period for which funding was approved. Key elements of the program included the following:
  • Target population: Trained behavioral health counselors (master's-level social workers or mental health professionals) screened pregnant women for participation using a computer-based screening tool that relies on information about demographics and risk factors. The target population was African-American women age 18 or older who spoke English, lived in the District of Columbia, and who were no later than 28 weeks pregnant. Eligible patients reported at least one of the following risk factors: cigarette smoking in the 6 months before pregnancy and since learning of the pregnancy, environmental tobacco smoke exposure (i.e., exposure to smokers at home, in the same room at work, or in a car), depression (evaluated using the Beck Depression Inventory), and/or intimate partner violence (i.e., being physically hurt or forced to have sexual intercourse in the past year, or fear of current partner).
  • Baseline interview: The counselors conducted a baseline telephone interview to elicit more detailed information on social demographics, medical history, and identified risk factors. Counselors used various screening tools, including the Smoke-Free Families Screening, the Hopkins Symptom Checklist for depression, and the Conflict Tactics Scale for intimate partner violence. If depression screening indicated risk of suicide, the counselor contacted a 24-hour mental health/psychiatry provider to arrange for immediate services.
  • Inperson and telephone counseling during and after pregnancy: Counselors provided inperson behavioral counseling based on each women's particular risk factors during sessions scheduled immediately preceding or following prenatal care visits. Multiple risk factors could be addressed at one session, and women were asked about all four risk factors at each session (even if they did not initially have them) so that newly developed issues could be addressed. Women attended between four and eight sessions (each lasting 30 to 45 minutes) during the pregnancy. In addition, women participated in one or two telephone sessions (also 30 to 45 minutes each) with the counselor after delivery. General information about how these sessions addressed each of the risk factors is provided below:
    • Active and passive smoking: Counselors discussed behavioral methods for smoking cessation and strategies to avoid exposure to environmental tobacco smoke. Counseling was based on the transtheoretical model (which specifies that interventions be tailored to an individual’s stage of readiness for change), the Smoking Cessation or Reduction in Pregnancy Treatment materials, and the Pathways to Change manual.
    • Depression: The counseling intervention, which was adapted from an intervention by Miranda and Munoz, focused on mood control strategies, with no medications being prescribed.
    • Intimate partner violence: Counseling centered on self-efficacy behaviors, safety behaviors related to intimate partner relationships, interaction with members of the woman’s support system and with the partner, and strategies to help the woman exit the relationship if desired. The counseling intervention was based on the Parker-McFarlane structured intervention and Dutton’s empowerment theory.
  • Telephone followup and assessment: Trained staff periodically called participants to assess the current status of the four risk factors, with three brief interviews being conducted—one each during the second and third trimesters, and a final interview roughly 10 weeks after birth.

Context of the Innovation

The study was conducted in six prenatal care clinics run by various health care institutions in Washington, DC. The clinics, which are geographically distributed across the city, serve many minority patients. The impetus for the program came after researchers from these institutions met to discuss why infant mortality rates and premature birth rates among the African-American population living in Washington continued to be high, despite adequate insurance coverage for prenatal care. The researchers speculated that prenatal care in its current form and content was not adequately addressing health problems that have a direct impact on pregnancy outcomes and decided to test the value of psychosocial and behavioral counseling as a component of prenatal care.

Did It Work?

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Results

A randomized control trial (RCT) at six clinics in Washington, DC, that included 1,070 women, found that the intervention significantly reduced health risks from baseline to 10 weeks postpartum, as compared with a control group of patients receiving usual prenatal care (which typically includes a limited counseling component). Early results from a study evaluating the program's impact on birth weight and infant mortality are encouraging.
  • Fewer overall risk factors: Nearly one-third (32.1 percent) of program participants reported none of the four risk factors studied, compared with just under one-fourth (24.9 percent) in the control group. In addition, only 8.6 percent of participants reported three or four of the risk factors, well below the 12.3 percent rate in the control group.
  • Greater declines in risk factors: Program participants were much more successful in reducing the targeted risk factors than were members of the control group, as outlined below:
    • Exposure to tobacco smoke: Among program participants, reported exposure to tobacco smoke fell from 82.2 percent at baseline to 51.6 percent postpartum, a decline of 30.6 percentage points. In the control group, reported exposure fell from 83.1 to 57.9 percent over the same time period, a decline of 25.2 percentage points.
    • Depression: Among program participants, incidence of depression fell by half, from 50.6 percent at baseline to 25.5 percent postpartum. In contrast, in the control group, the corresponding decline was from 50.8 percent at baseline to 29.0 percent postpartum.
    • Intimate partner violence: Among program participants, self-reported incidence of intimate partner violence fell significantly, from 37.4 percent at baseline to 8.6 percent postpartum. The corresponding decline in the control group was smaller, from 36.2 percent at baseline to 11.3 percent postpartum.
    • Smoking recidivism: Among program participants, smoking rates increased slightly, from 23.4 percent who smoked at baseline to 25.6 percent postpartum. The corresponding increase in the control group was larger, from 20 percent who smoked at baseline to 27.3 percent postpartum.
  • Possible positive impact on infant outcomes: An analysis of the program's impact on birth weight and infant mortality is currently underway; early results are encouraging. The intervention was successful in reducing very preterm births (<34 weeks gestation). In addition, separate data analyses addressing reduction of intimate partner violence and reduction of environmental tobacco smoke were both successful in improving birth outcomes.

Evidence Rating (What is this?)

Strong: The evidence primarily consists of a randomized control trial comparing the presence of behavioral health risk factors in an intervention and usual care group.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Conducting literature search: The researchers searched the literature to identify psychosocial and behavioral risks that have been proven to have an impact on pregnancy outcomes; they chose the four risk factors for which the link with pregnancy outcomes was strongest.
  • Developing counseling content: The researchers developed the counseling intervention based on screening tools and interventions discussed in the literature.
  • Gaining clinic support: Researchers described the content and logistics of the behavioral counseling sessions to clinic physicians and nurses and worked with clinic staff to incorporate the scheduling of sessions into prenatal care visits.
  • Hiring and training counselors: The researchers hired social workers and mental health professionals to serve as counselors. All counseling staff received intensive, full-time training over a 6-week period. Training focused on use of screening tools, interviewing strategies, cultural awareness and sensitivity, and research methods.

Resources Used and Skills Needed

The resources required to develop the program included the following:
  • Staffing: The program employed approximately eight counselors (many of whom were African American) who had a master's degree or higher level of education. Each counselor handled between 20 and 40 women at any given time. During the research study, counselors worked full time, although only about half their time was spent on patient interventions (with the rest being used to fulfill administrative requirements of the research study).
  • Costs: Data on the costs of the intervention are not available, although the primary expense consists of the salary and benefits for the counselors.
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Funding Sources

National Institute of Child Health and Human Development; National Center on Minority Health and Health Disparities
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Tools and Other Resources

El-Mohandes AA, Kiely M, Blake SM, et al. An intervention to reduce environmental tobacco smoke exposure improves pregnancy outcomes. Pediatrics. 2010;125(4):721-8. Epub 2010 Mar 8. [PubMed]

El-Mohandes AA, Kiely M, Joseph JG, et al. An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial. Obstet Gynecol. 2008;112(3):611-20. [PubMed]

El-Mohandes AA, Kiely M, Gantz MG, et al. Very preterm birth is reduced in women receiving an integrated behavioral intervention: a randomized controlled trial. Matern Child Health J. 2011;15(1):19-28. Epub 2010 Jan 16. [PubMed] 

Kiely M, El-Mohandes AA, El-Khorazaty MN, et al. An integrated intervention to reduce intimate partner violence in pregnancy: a randomized controlled trial. Obstet Gynecol. 2010;115(2 Pt 1):273-83. [PubMed]

Adoption Considerations

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Getting Started with This Innovation

  • Gain administrator support: Leadership support is critical to the program's success. For hospitals or health systems, leaders can be persuaded by emphasizing the potential cost savings achieved by avoiding premature births. The savings achieved by ensuring that even one baby is carried to term rather than born prematurely would likely exceed the cost of a behavioral counselor’s annual salary.
  • Educate obstetrics professionals about the value of counseling: Obstetricians can be strong advocates of these services once they understand their importance.
  • Ensure that interventions are culturally sensitive: Cultural issues should be incorporated into counselor training. Employing counselors from the same cultural background can also be beneficial.

Sustaining This Innovation

Work with payers to obtain reimbursement for counseling services: As with hospital and health system administrators, health plan leaders can likely be persuaded to support the program (by providing reimbursement for counseling services) by emphasizing the cost savings potential of the initiative.

More Information

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Contact the Innovator

Ayman El-Mohandes, MBBCh, MD, MPH
Dean
CUNY School of Public Health
2180 Third Avenue, Room 502
New York, NY 10035
(212) 396-7729
E-mail: dean@sph.cuny.edu

Innovator Disclosures

Dr. El-Mohandes has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

El-Mohandes AA, Kiely M, Joseph JG, et al. An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial. Obstet Gynecol. 2008;112(3):611-20. [PubMed]

Footnotes

1 U.S. Centers for Disease Control and Prevention. Pregnant? Don’t Smoke: Learn Why and How to Quite for Good [Web site]. Updated January 28, 2008. Available at: http://www.cdc.gov/Features/PregnantDontSmoke/.
2 Neggers Y, Goldenberg R, Cliver S, et al. Effects of domestic violence on preterm birth and low birth weight. Acta Obstet Gynecol Scand. 2004;83(5):455-60. [PubMed]
3 U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. 2006. Available at: http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).
4 Field T, Diego M, Hernandez-Reif M, et al. Pregnancy anxiety and comorbid depression and anger: effects on the fetus and neonate. Depress Anxiety. 2003;17(3):140-51. [PubMed]
5 U.S. Centers for Disease Control and Prevention—Office of Minority Health & Health Disparities. Eliminate Disparities in Infant Mortality [Web site].
6 El-Mohandes AA, Kiely M, Joseph JG, et al. An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial. Obstet Gynecol. 2008;112(3):611-20. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 24, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 06, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.