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MSS Prenatal Targeted Risk Factor Matrix

MSS Risk Factor Definition Desired Outcome Rationale for Risk Factor Risk Factor Criteria  Term birth greater than or African American and Black A. Not an option for this risk factor equal to (≥) 37 weeks women have a significantly B. Not an option for this risk factor higher risk for LBW and C. American Indian, Alaska Native or  weighing greater than . In addition, non-Spanish speaking indigenous or equal to (≥) 5 pounds 8 currently known risk factors women from the Americas (see Client (woman) identifies ounces associated with LBW/preterm definition) herself as: birth do not capture all Or African American women at  African American or Black risk. African American or Black Or  American Indian, Alaska American Indians or Alaska Native, or non-Spanish Natives (as a population) Pacific Islander Race speaking indigenous have more risk factors women from the Americas associated with LBW/preterm (e.g. women whose birth than other populations primary language is in this state. Mixteco, Mam, or Kanjobal, etc.) Pacific Islanders have the lowest rates among all racial  Pacific Islander groups for seeking in the first trimester. They also have the second highest rate of preterm births behind African Americans.  Prenatal care initiated Early prenatal care provides A. Greater than or equal to (≥) 14 and before 14 weeks gestation important medical assessment less than (<) 24 weeks gestation and  Prenatal care initiated including ultrasound and no prenatal care started at time of Late Entry prenatal care - within 1 month of starting blood and urine tests. Early screening. women greater than or equal to MSS care is important to identify B. Greater than or equal to (≥) 24 weeks Prenatal Care (≥) 14 weeks gestation and no more accurate gestation before prenatal care started prenatal care is established at of the and any possible Or the time of screening problems. Late entry can also Greater than or equal to (≥)24 weeks be an indicator of other risk gestation and no prenatal care has factors associated with poor been started birth outcomes. C. Not an option for this risk factor  Accessing WIC and food Food insecurity places A. Runs out of food before the end of the resources women at high risk for poor month or cuts down on food to feed nutrition (malnutrition, others Food insecurity- Runs out of ), weight gain issues, B. Not an option for this risk factor food before the end of the chronic stress, depression, C. Not an option for this risk factor Nutrition Food insecurity month or cuts down on amount and inability to address other eaten to feed others issues in her life including medical appointments and health conditions.

Revised 12/16/2014 - MSS Prenatal Risk Matrix 2

MSS Prenatal Targeted Risk Factor Matrix

MSS Risk Factor Definition Desired Outcome Rationale for Risk Factor Risk Factor Criteria Total weight gain Underweight women are four *A. Pre-pregnancy BMI less than (<) 18.5 within Institute of Medicine times more likely to deliver a but pregnancy weight gain within (IOM) recommendation based low and/or guidelines (see desired outcome Pre-pregnancy BMI less than on Pre-pregnancy BMI: preterm infant regardless of column) (<) 18.5 pregnancy weight gain. B. Not an option for this risk factor  Singleton Birth – 28 to 40 *C. Pre-pregnancy BMI less than (<) 18.5 Pre-pregnancy Body Mass pounds total for the Women who gain less than and inadequate weight gain based on Index (BMI) classified as pregnancy. Approximately the Institute of Medicine’s guidelines (see desired outcome underweight (less than < 18.5 1+ pound a week starting in guidelines are at 6 times the column) BMI) the second trimester. risk. Research shows that women who eat a quality diet Use CDC BMI table for  Multiples - no set and gain within IOM guideline. Approximately recommendations have better 40+ pounds total. birth outcomes.

Weight gain within IOM Women with a pre-pregnancy A. Pre-pregnancy BMI 25.0 to 29.9 (See recommendation based on Pre- BMI 25.0 to 29.9 are twice as desired outcome column) Pre-pregnancy BMI 25 to 29 pregnancy BMI: likely to develop diabetes and B. Not an option for this risk factor than women C. Not an option for this risk factor Pre-pregnancy Body Mass  Singleton birth – 15 to 25 who start out in the normal Index (BMI) classified as pounds total for the BMI range pre-pregnancy. overweight (Pre-pregnancy Pre-pregnancy pregnancy. Approximately Nutrition BMI 25.0 to 29.9) BMI 1/2 pound a week starting second trimester Use CDC BMI table for adults  - 31to 50 pounds total Weight gain within IOM Women with a pre-pregnancy *A. Pre-pregnancy BMI greater than or recommendation based on Pre- BMI greater than or equal to equal to (≥) 30.0 and pregnancy pregnancy BMI: (≥) 30.0 are more than twice weight gain within guidelines (See as likely to have a poor birth desired outcome column) Singleton Birth - outcome regardless of Pre-pregnancy BMI greater *B. Pre-pregnancy BMI greater than or  11-20 pounds total for the pregnancy weight gain. That equal to (≥) 30.0 and weight gain not than or equal to( ≥) 30 risk increases with the pregnancy with women who within guidelines (see desired increase in BMI (40 BMI = 8 Pre-pregnancy Body Mass are high in BMI gaining at outcome column) times the risk). Index (BMI) classified as obese the lower end of the weight C. Not an option for this risk factor

(Pre-pregnancy BMI greater gain range Obese women are twice as than and equal to( ≥) 30.0)  Approximately 1/2 pound a likely to have a stillbirth, week starting second fetal abnormality, and Use CDC BMI table for adults trimester  4 pounds or less the first preterm birth due to trimester metabolic changes that include glucose intolerance Multiples - 25 to 42 pounds (separate from GDM) and lipid metabolism.

Revised 12/16/2014 - MSS Prenatal Risk Matrix 3

MSS Prenatal Targeted Risk Factor Matrix

MSS Risk Factor Definition Desired Outcome Rationale for Risk Factor Risk Factor Criteria  Term birth greater than or Shorten Interval between A. Current pregnancy conception less Period between end of last equal to (≥) 37 weeks does not allow than (<) 9 months from end of last pregnancy and current gestation for the woman’s body to pregnancy Inter-pregnancy Interval less pregnancy is less than (<) 9 than 9 months  Infant born weighing return to the most optimum B. Not an option for this risk factor months. (This includes greater than or equal to (≥) physiologic/nutrition status C. Not an option for this risk factor , terminations) 5 pounds 8 ounces before pregnancy.

Stable blood sugars: Type 1 or 2 diabetes places A. Not an option for this risk factor Diabetic Type 1 or 2 Fasting 60mg -100mg/dl women at risks for fetal loss, B. Not an option for this risk factor 1hr postprandial 100-140 mg/dl stillbirth, depression, C. Diabetic Type 1 or 2 Diabetes diagnosed prior to 2hr postprandial <120 mg/dl hypo/hyperglycemia, pregnancy: Before Bed 100-120mg/d increased risk of infection, c- section and preterm birth. Weight gain within Institute  Type 1 is an insulin Diabetes of Medicine (IOM) guidelines are at higher risk for dependent diabetic fetal /stillbirth, birth based on Pre-pregnancy BMI: Example for singleton defects, jaundice,  Type 2 is diet controlled <18.5 BMI: 28-40 lbs hypoglycemia, macrosomia, and possibly taking oral 18.5 to 24.9 BMI: 25-35 lbs diabetes later in life. medication 25.0 -29.9 BMI: 15-25 lbs ≥30.0 BMI: 11-20 lbs Stable blood sugars: Gestational diabetes places A. Not an option for this risk factor Fasting 60mg-100mg/dl women at risk for preterm B. History of gestational diabetes with 1hr postprandial 100-140 mg/dl birth, depression, infection, last pregnancy and diabetes in the future. C. Gestational diabetes with current Medical Gestational Diabetes: 2hr postprandial <120 mg/dl Pregnant women who did not pregnancy have diabetes prior to Before Bed 100-120mg/d Infants are at higher risk for pregnancy but have been jaundice, hypoglycemia, Gestational diagnosed by a medical Weight gain within Institute macrosomia, and later in life Diabetes provider to have high blood of Medicine (IOM) guidelines diabetes. sugar (glucose) levels during based on Pre-pregnancy pregnancy (determined by BMI: Example for singleton glucose tolerance test) <18.5 BMI: 28-40 lbs 18.5 to 24.9 BMI: 25-35 lbs 25.0 -29.9 BMI: 15-25 lbs ≥30.0 BMI: 11-20 lbs Delivery greater than or equal Multiple have the A. Not an option for this risk factor to (≥) 37 weeks gestation. highest incidence of B. Not an option for this risk factor Multiple Pregnant with more than one preterm/low birth rate and C. Current pregnancy with multiple Gestation fetus many other poor birth fetuses outcomes for both and infant.

Revised 12/16/2014 - MSS Prenatal Risk Matrix 4

MSS Prenatal Targeted Risk Factor Matrix

MSS Risk Factor Definition Desired Outcome Rationale for Risk Factor Risk Factor Criteria Chronic high blood pressure Blood pressure less than or Chronic high blood pressure A. Gestational Hypertension in past (BP): BP screening greater equal to (≤) 120/80; and PIH/GH places a woman pregnancy. than or equal to (≥) 140/90 at  Following prescribed care at high risk for preeclampsia, B. Not an option for this risk factor more than one reading which by medical provider preterm birth and adverse C. Chronic Hypertension and Pregnancy started before the woman  Following diet and exercise birth outcomes. Induced Hypertension/Gestational became pregnant or before she routine to promote blood Hypertension (see definitions) is 5 months pregnant (less than pressure within normal (<) 20 weeks gestation) limits Hypertension (HTN) Pregnancy induced Hypertension (PIH)/ Gestational Hypertension (GH): Blood pressure screening greater than and equal to (≥) 140/90 and the woman is more than 5 months pregnant  Infant born greater than or Pregnancy history of A. Not an option for this risk factor equal to ( ≥)37 weeks LBW/premature infants or B. Not an option for this risk factor. gestation fetal death puts a woman at C. Prior LBW/preterm birth, including increased risk for repeat Medical A prior pregnancy resulted in:  Infant birth weight greater fetal death  (LBW) than or equal to (≥) 5lbs. 8 LBW/preterm birth for History of Low Or oz current pregnancy. Birth Weight infant. LBW = Birth Current preterm labor: client infant (LBW) weight less than (<) 5 diagnosed with preterm labor (labor and/or pounds 8 ounces (2500 If a woman with a singleton before 37 weeks gestation) requiring premature birth gm) gestation has had at least one bed rest or hospitalization or fetal death  Premature birth less than spontaneous preterm labor (<) 37 weeks gestation or and/or rupture of the fetal death . membranes, she may qualify for 17P treatment. Refer the client to ask her OB provider about 17P.  Connected to a support Teens less than (<) 17 years A. 16 years of age of age at conception system – family, school, of age are biologically at a B. Up through 15 years of age at WIC, medical care greater risk of having a conception  Weight gain within preterm infant. C. Not an option for this risk factor Maternal age less than (<) 17 Institute of Medicine (IOM) Very young teens, less than Maternal Age at the time of conception guidelines: Ex of singleton (<) 16 years old, have a two <18.5 BMI: 28-40 lbs fold increase in risk for a 18.5 to 24.9 BMI: 25-35lbs very early preterm birth (less than (<) 33 weeks). 25.0 -29.9 BMI: 15-25 lbs

≥30.0 BMI: 11-20 lbs

Revised 12/16/2014 - MSS Prenatal Risk Matrix 5

MSS Prenatal Targeted Risk Factor Matrix

MSS Risk Factor Definition Desired Outcome Rationale for Risk Factor Risk Factor Criteria  Early screening for Risk for poor pregnancy/birth A. Greater than or equal to (≥) 35 years hypertension and diabetes outcomes increase for women of age and prior healthy pregnancy  Weight gain within greater than and equal to (≥) and no assisted reproductive Institute of Medicine (IOM) 35 years of age, i.e. HTN, technology Maternal age greater than or guidelines: Ex of singleton diabetes, birth defects. Risk B. Greater than or equal to ( ≥) 35 years equal to (≥) 35 years at the <18.5 BMI: 28-40 lbs for multiple fetuses increases of age at conception and one of the time of conception 18.5 to 24.9 BMI: 25-35 lbs if infertility treatment is used, following: Assisted Reproductive (1) First pregnancy 25.0 to 29.9 BMI: 15-25 lbs Technology (ART). (2) Assisted reproductive technology ≥ 30.0 BMI: 11-20 lbs (ART) with this pregnancy C. Not an option for this risk factor  No cigarette, other tobacco, Women who quit smoking A. Quit 3 months prior to pregnancy or or other nicotine product and using other tobacco and upon pregnancy diagnosis use during pregnancy nicotine products before or B. Continues to use tobacco/nicotine  A plan to continue early in pregnancy since pregnancy diagnosis Maternal Tobacco/ Nicotine Use of tobacco/nicotine by abstinence of tobacco/ significantly reduce the risk C. Not an option for this risk factor Use client during pregnancy nicotine use for several negative  Client is knowledgeable of pregnancy outcomes. resources to support tobacco and nicotine cessation Use or abuse during pregnancy  No alcohol, illicit substance There is no safe use of A. Not an option for this risk factor of: use and/or prescription drug alcohol use during pregnancy *B. Stopped alcohol/substance use upon  Alcohol abuse during pregnancy due to potential or real effects diagnosis of pregnancy and has not  Illicit substances – i.e. on developing fetus: i.e. used for more than or equal to (≥) 90 cocaine, alcohol related birth defects days methamphetamine, including low birth weight or Or marijuana, heroin premature birth. Actively engaged in alcohol/drug  Non-prescriptive use of treatment program and has not used prescription drugs i.e. Illicit use of addictive alcohol/substance for greater than or Oxycodone, Xanax substances can lead to equal to (≥) 90 days Maternal Alcohol and  Diagnosed with abuse or complications during *C. Stopped use of alcohol, illicit Substance Abuse or pregnancy resulting in poor substances, or non-prescriptive use of Addiction dependence to alcohol and or substances and less than birth outcomes for both prescription drugs for less than (<) 90 (<) 90 days of no use mother and infant: i.e. days and/or inconsistent preterm birth, low birth Or participation in Chemical weight, neonate abstinence Any use of alcohol, illicit substances, Dependency treatment syndrome including opiate or non-prescriptive use of prescriptive withdrawal, previa. drugs once the client knows she is pregnant

Time spent incarcerated does not count toward 90 day clean and sober.

Revised 12/16/2014 - MSS Prenatal Risk Matrix 6

According to the CDC, IPV is a  Pregnant women are not The research associated with A. IPV has occurred more than one year serious, preventable public being exposed or IPV and low birth ago health problem. Intimate experiencing IPV weight/preterm birth is B. In the last year, the woman’s intimate partner violence describes  All women screened and evolving with the strongest partner and/or FOB has committed or physical, sexual, or association at this time for threatened physical/sexual violence psychological harm by a provided health messages and referrals/developed married women. against her Intimate Partner Violence current or former partner or safety plans if indicated C. Not an option for this risk factor (IPV) spouse. There are 4 main types IPV is the leading cause of of IPV (Saltzman et al. 2002): female homicides and injury- physical violence, sexual related in pregnancy. violence, threats of physical or sexual violence, and psychological/emotional violence. Severe Mental Illness (SMI): Severe Mental Illness and Women with untreated severe *A. No history of mental health preexisting mental health Perinatal Mood Disorders: mental illness have multiple diagnosis, but screens positive for “In diagnosis resulting in  Knowledgeable of her risks associated with poor the last month, have you felt down, impairment of general individual mental health birth outcomes for both depressed or hopeless?” or showing functioning, i.e. current or symptoms and possible mother and infant, i.e. not depression symptoms, but depression previous suicidal ideation or impact on pregnancy recognizing existence of screening results mild risk attempts, previous psychiatric  Understands treatment pregnancy, not accessing (Edinburgh score less than (<) 10 or a hospitalization, and current or options prenatal care, not recognizing comparable score on another recent (6mos or less) use of  Initiates and is compliant signs of preterm labor or standardized depression screening psychotropic medication with prescribed care labor resulting in precipitous tool) birth, alcohol/substance *B. History of mental health treatment Perinatal Mood Disorders: abuse, and tobacco/nicotine for SMI and stable or Perinatal Mood mood and anxiety symptoms use. Disorders and Edinburgh score less that occur during pregnancy or than (<) 10 (or a comparable score on up to one year postpartum Women with moderate to another standardized depression Mental Health which result in impairment of severe Perinatal Mood screening tool) Severe Mental Illness general functioning disorders are at risk for Or Perinatal Mood Disorders preterm birth and other poor Current mental health diagnosis of birth outcomes. SMI and/or Perinatal Mood Disorders and is actively participating in mental health treatment *C. Mental health symptoms are evidenced by Edinburgh depression score greater than or equal to (≥) 10 (or a comparable score on another standardized tool that indicates possible depression) Or Client has a mental health diagnosis with active symptoms that are interfering with general functioning and is not actively engaged in mental health treatment

Revised 12/16/2014 - MSS Prenatal Risk Matrix 7

RCW 71A.10.020 defines Pregnant women with a Women with intellectual *A. Severe developmental disability developmental disability as a developmental disability will disability (see definition) are which may impact the woman’s disability attributable to receive health education, at greater risk of ability to care for herself or infant, but intellectual disability, cerebral support and case management preeclampsia, low birth has an adequate support system and palsy, epilepsy, autism, or services (including care weight infants. demonstrates evidence of follow another neurological or other coordination) to promote through with health care condition closely related to an healthy pregnancy and birth out appointments/advice and self-care intellectual disability or to comes through prenatal B. Not an option for this risk factor Developmental Disability require treatment similar to that medical and self care. *C. Severe developmental disability (RCW 71A.10.020(4)) required for individuals with which impacts the woman’s ability to intellectual disabilities, which care for herself infant, and has an originated before the individual inadequate support system or does attained age 18, can be not demonstrate evidence of follow expected to continue through with health care indefinitely and results in appointments/ advice and self-care substantial limitations to an individual’s intellectual and/or adaptive functioning

Revised 12/16/2014 - MSS Prenatal Risk Matrix