<p> Road Map for Preventing Infant Mortality in Kansas</p><p>State-Level Logic Model...... 2 State Systems Logic Model...... 3 Safe Sleep Logic Model...... 4 Access to Health Care and Social Supports Logic Model...... 5 Glossary and Acronyms List...... 6 References...... 7</p><p>Updated February 23, 2011 OVERALL LOGIC MODEL: Preventing Infant Mortality in Kansas (Kansas Blue Ribbon Panel on Infant Mortality) Vision/Mission: Assuring healthy babies for all Kansans through collaborative action for enhanced services, community support, and policy advocacy. Context/Conditions: Risk/ Protective Factors: Recommended Intervention Components and Activities: Outcomes: - Kansas ranks 40th among Behavioral: Providing Information and Enhancing Skills: Behavioral Outcomes: states in infant mortality st - Early (1 trimester) prenatal care Patient/Mother/Family Behavior: rate - Multi-year Infant mortality public awareness campaign - Folic acid use - Promote safe sleep practices via professionals, CBOs, and statewide - Increased proportion of women - Kansas ranks worst in Black - Infant sleep position & sleep environment education & receiving prenatal care in 1st trimester IMR (BIMR is 2.7 times networks. increased awareness among parents, child care providers, and - Increased proportion of women of child higher than WIMR) - Promote healthy lifestyles among women of childbearing age health care providers bearing age consuming folic acid - Highest IMR rates in high- - Promote healthy behaviors among teens - Increase the proportion of mothers - Interconception care (including 1+ years between birth) risk places (especially in SG, Enhancing Services and Support: initiating breastfeeding for infants up to 6 - Exposure to tobacco smoke WY, GE counties) - Implement state-wide PRAMS (Prenatal Risk Assessment of the months - Alcohol, tobacco, caffeine, & other drug use - Increased proportion of infants in safe Mother) to determine trends/disparities in birth outcomes of overall Barriers: - Appropriate prenatal weight gain sleep position and environment Kansas births - Lack of urgency for - Preconception education (Life Course perspective to improve - Decreased maternal use of alcohol, - Establish and maintain the FIMR projects in Wyandotte and Sedgwick reducing IMR maternal health) tobacco, caffeine, & other drug use Counties to help identify social and medical factors that contribute to - Limited resources for Biological/History/Experience: - Increased maternal healthy eating, infant death physical activity, healthy weight assuring access to needed - Maternal birth weight (“Life Course Perspective”) health services and - Promote breastfeeding through existing coalitions and partners. - Reduced levels of teenage pregnancy - Elective delivery before 39 weeks community-based programs - KDHE & State Child Death Review Board (CDRB) partnership (and related behaviors of unprotected - Previous LBW or preterm delivery sex) - Cultural and language - State Perinatal Periods of Risk (PPOR) (every 5 years) - Previous fetal demise/infant death-Prior 1st trimester induced - Increase the interval between gestations barriers (low levels of health - Identify and implement best practice models literacy) abortion - Increase proportion of infants - Improve care coordination of high-risk pregnant women adequately immunized - Low levels of overall - History of infertility - Support perinatal collaboratives and surveillance systems Provider/Health Care System Behavior: Literacy - Nulliparity & high parity - Create neonatal-perinatal quality improvement collaborative - Increased number of health care & child - Gaps in government-to- - Placental, cervical, & uterine abnormalities & infections - Support community-based programs including home visitation for care providers who deliver culturally government relationships for - Gestational bleeding competent education about safe sleep as high-risk families services - Intrauterine Growth Restriction (IUGR) well as integrate cultural assets for - Promote smoking cessation programs for families and caregivers - Multiple gestations healthy pregnancies Resources: - Promote WIC Program for all eligible women - Birth spacing - Collaboration via MOU or other process - Existing collaborative - Seek opportunities to work with IHS and tribal health clinics in KS. - Low pre-pregnancy weight & short stature for tribes in KS partnership for preventing - Elimination of elective deliveries prior to - Preeclampsia Modifying Access, Barriers, and Opportunities: IM, including among: 39 weeks . State health department - Diabetes - Ensure early, comprehensive prenatal care for all women - Race/ ethnicity (African American, Native American, Puerto - Create a more efficient and expedited process for access to Medicaid Environmental Outcomes: (including Center for - Reduced exposure to impoverished living Rican) services Health Disparities) conditions, occupational hazards, chronic . Health organizations (e.g., - Single marital status - Improve access to genetics counseling stress, tobacco smoke, and child abuse neonatal care) - Low SES & Low education - Provide Family Planning Service Option within Medicaid and neglect . March of Dimes - Maternal age (Teens & Older Age/ 35+) - Provide culturally tailored education and information - Reduced vulnerability through increased . SIDS/Safe Sleep Coalition - Family/Domestic Violence/Child Abuse/Neglect - Build collaborative relationships with organizations that are already social support, education, occupational . Professional associations - Depression addressing disparate populations and status (e.g., Kansas Academy of - Under-immunized status of infant Changing Consequences: Population-level Health/ Equity Pediatrics) Environmental: - Adequate insurance reimbursement for group visits and centering care Outcomes: . Academic and research - Impoverished living conditions - Payment of infant autopsies to coroners contingent on properly - Reduced incidence of infant mortality partners - Feelings of helplessness conducting those autopsies on infants - Reduced incidence of low birth weight . Promising Community - Unstable social support Modifying Policies & Systems: - Reduced disparities in rates of infant Initiatives (e.g., MCH mortality among different groups - Employment-related physical activity & occupation exposures - Apply for Medicaid—Family Planning Service & obtain funding Coalition of KC; Healthy (especially African Americans; currently, Babies/SG Co.) - Environmental exposures - Implement state genetics plan 3:1 ratio) . Sovereign nations & - Chronic stress (including DV, poor living conditions, - Develop hospital/provider collaborative to eliminate elective deliveries - Reduced premature birth rate (< 37 urban Indian populations unemployment, stressful living conditions) before 39 weeks weeks) in KS - Availability, access, & quality of health care (obstetric, - Support implementation of safe sleep policies in child care settings - Reduced intentional and unintentional perinatal, & neonatal) - Support tobacco legislation to reduce use and exposure injuries during first year of life Sub-Logic Model: Strengthening State Systems Preventing Infant Mortality in Kansas Vision/Mission: Assuring healthy babies for all Kansans by enhancing state-level supports for community efforts to prevent infant mortality.</p><p>Context/Conditions: Types of System-level Activities/In Priority System Changes: Effects: Outcomes/Results - Kansas ranks 40th among terventions: - Enhance surveillance systems to assess and states in infant mortality rate - Monitor IM rates related report IMR and disparities at state, local, and By 2012 By 2015 By 2020 - Kansas ranks worst in Black risk/protective factors for tribal levels - Develop a comprehensi Behavioral Outcomes: Environmental IMR (BIMR is 2.7 times higher state/disparities groups to identify, - Promote community assessment tools, risk ve strategic plan for prev - Increased proportion of Outcomes: than WIMR) diagnose and investigate problems and monitoring tools ention of infant mortality women receiving prenatal - Reduced exposure to - Highest IMR rates in high-risk goals - Establish a website about infant mortality, it in Kansas and document i care in 1st trimester impoverished living places (especially in SG, WY, - Inform, educate and empower people s risk/protective factors, strategies & resourc ts implementation and pr - Increased time interval conditions, GE counties) about IM issues es for intervention, contacts ogress between births occupational hazards, - Mobilize and support community - Develop asset map of services and supports Barriers: - Implement and evaluat - Increased assessment and and chronic stress partnerships to prevent IM, including (MADIN toll-free line) - Lack of urgency for reducing e statewide public aware screening for depression, - Reduced vulnerability among those with IM disparities - Facilitate action planning, technical support, IMR ness campaign on infant family violence/domestic through increased - Develop policies and plans to support implementation, and evaluation of comprehe - Limited resources for mortality violence social support, individual & community health efforts nsive interventions using evidence-based stra assuring access to needed - Resources secured and - Increased proportion of education, and - Enforce laws & regulations that tegies health services and comprehensive, women who report occupational status protect health and ensure safety of - Build capacity of workforce and partnership community-based programs community-based consuming adequate amounts infants and mothers s for preventing IM in local communities programs (e.g. FIMR) of folic acid Population-level Resources: - Assure access and link people to - Enhance reimbursement mechanism for pre established and - Increased proportion of Health/ Equity - Existing collaborative needed prenatal services ventive services enhanced in high-risk zip infants in safe sleep position Outcomes: partnership for preventing IM, - Strengthen system (training) for - Address gap between existing laws and iden codes and environment - Reduced incidence of including: collecting accurate data on tified IM goals - KS Perinatal Quality - Decreased levels of maternal preterm births  State health department risk/protective factors for those - Expand health insurance coverage to assure Improvement smoking - Reduced incidence of (including Center for Health completing birth and death certificates needed services Collaborative garners - Decreased maternal use of infant mortality Disparities) - Payment of infant autopsies to - Prepare local and regional staff in public technical assistance from alcohol, tobacco, caffeine, & - Reduced disparities in  Health organizations (e.g., coroners contingent on properly health departments California and/or Ohio other drug use rates of infant neonatal care) conducting those autopsies on infants -Assess KS Perinatal Quality Improvement Coll Quality Improvement - Increased maternal healthy mortality among  March of Dimes - Assure a competent workforce in aborative Collaboratives eating, physical activity, different groups  SIDS/Safe Sleep Coalition preventing IM - Establish monitoring and evaluation systems healthy weight (especially African  Professional associations - Evaluate effectiveness, accessibility, to see progress and assure accountability By 2015 - Reduced levels of teenage Americans; currently, (e.g., Kansas Academy of and quality of personal and population- - KS Perinatal Quality Imp pregnancy (and related 3:1 ratio) Pediatrics) based health services rovement Collaborative is behaviors of unprotected sex)  Academic and research - Educating workforce around the risks functioning: funding acq - Improved preterm birth partners related to infant mortality uired, partner participati outcomes  Promising Community on, data collected, analyz -Decreased level of preterm Initiatives (e.g., MCH ed and reported births Coalition of KC; Healthy -Decreased C-section rate Babies/SG Co.)  Sovereign nations & urban Indian populations in KS</p><p>2 Sub-Logic Model: Increasing Safe Sleep to Reduce Infant Mortality in Kansas Vision/ Mission: Assuring healthy babies for all Kansans through collaborative action safe sleep</p><p>Context/Conditions: Risk Factors: Recommended Intervention Components & Activities: Outcomes: - Kansas ranks 40th among states Behavioral: Providing information/enhancing skills: Behavioral Outcomes: in infant mortality rate - Cultural norms and practices - Educate parents, grandparents and caregivers of all infants on the AAP’s safe sleep - Increased number of - Kansas ranks worst in Black - Co-sleeping and/or Bed-sharing recommendations parents, caregivers, and IMR (BIMR is 2.7 times higher - Improper sleep surface - Distribute safe sleep DVD to parents, grandparents, and caregivers of all infants child care providers than WIMR) - Use of loose bedding and soft objects in - Advocate for the use of stickers on cribs demonstrating the safe sleep position consistently adhering to the - Highest IMR rates in high-risk sleep space AAP’s safe sleep places (especially in SG, WY, GE - Improper sleep position - Train health care providers, child care providers, and home visitors to provide AAP counties) - Alcohol, tobacco, cocaine, & other drug safe sleep recommendations recommendations - Encourage pediatricians, primary care physicians, and staff to educate - Increased number of Barriers: use parents/caregivers about safe sleep practices during all well-baby checks properly conducted infant - Lack of urgency for reducing - Educate child welfare workers (e.g. SRS, family preservation, and foster care) to autopsies IMR Biological/History/Experience: - Limited understanding and - Race (African American and Native provide AAP safe sleep recommendations support/ resources for Safe American) - Promote state-wide awareness of safe sleep practices through media Environmental Sleep messages - Male infant - Participate in statewide education campaign on infant mortality Outcomes: - Living in poverty - Transient population - Create and promote infant death scene investigation training via DVD and/or - Ensure parents have full - Being between one and six months old -Lack of proper scene webinar access to safe sleep tools for investigation or autopsy of - Sibling loss to SIDS - Maternal age < 20 during first pregnancy - Promote use of CDC’s Sudden Unexplained Infant Death Investigation (SUIDI) form newborns at hospital/birth unexpected infant deaths settings -Inadequate documentation - Obstetric History, Medical Illnesses & - Emphasize the relative frequency of SIDS where positional asphyxia cannot be - Increased public during infant death scene Conditions ruled out  Premature birth awareness of the risk factors investigations Enhancing services/support:  Low birth weight contributing to infant deaths - Require the Safe Sleep DVD be watched when a child care provider has a violation Resources:  Inadequate prenatal care - Ensure parents have full of safe sleep - Existing collaborative  Low maternal weight gain access to safe sleep tools partnership for preventing IM,  Placental Abnormalities - Encourage addition of a safe sleep consultation prompt to the Parents as Teachers before leaving hospital including among:  Anemia data form(s)  State health department - Develop culturally-tailored safe sleep awareness campaigns (including Center for Health Population-level Psychosocial & Environment: - Support and encourage more frequent home health visitation for infants Disparities) Health/Equity - Environmental exposures Modifying access, opportunities, and barriers:  Health organizations (e.g., Outcomes: neonatal care) - Exposure to smoke - Supply a wearable blanket to newborns - Inconsistent safe sleep messages  March of Dimes - Supply a crib (portable or other) for newborns as needed - Decreased racial disparity - Highly transient populations  SIDS/Safe Sleep Coalition - Collaborate with lactation consultants to promote consistent safe sleep messages of infant deaths - Grandparent influence on young parents  Professional associations - Child safety agencies will - Poor access to safe sleep resources (i.e. Changing Consequences: (e.g., Kansas Academy of have an increased proper cribs, wearable blankets, etc.) and - Build an incentive program for child care providers who implement a safe sleep Pediatrics) knowledge of safe sleep education materials policy based on the AAP’s recommendations  Academic and research - At-risk Families and communities with practices and risk factors partners Modifying Policies: concentrated poverty associated with infant sleep-  Promising Community - Support implementation of a safe sleep policy based on the AAP’s - Child care providers without proper safe related deaths Initiatives (e.g., MCH recommendations for hospitals and health care centers sleep education - Decreased number of Coalition of KC; Healthy - Endorse a policy for all coroners to follow the National Association of Medical - Child care providers not adhering to safe infant deaths of babies born Babies/SG Co.) sleep protocols Examiners (NAME) and Forensic Autopsy Performance standards manual for all  Sovereign nations & urban into poverty infant autopsies Indian populations in KS - Support safe sleep training regulation for new and current childcare providers - Add a safe sleep checkbox to child care surveyor’s inspection form. 3 Sub-Logic Model: Enhancing Access to Health Care and Social Supports to Reduce Infant Mortality in Kansas. Vision/ Mission: Assuring healthy babies for all Kansans through collaborative action for enhanced services, community support, & policy advocacy Context/Conditions: Risk/ Protective Factors: Recommended Intervention Components & Activities: Outcomes: -Kansas ranks 40th among Behavioral: Providing Information and Enhancing Skills: A. No elective induced labor < 39wk B. Increased folic acid intake for states in infant mortality - Alcohol, tobacco, & other drug use - Text for Baby messages rate - Maternal Nutrition: child bearing age women (100%) - PSA’s on risk of elective preterm deliveries -Kansas ranks worst in Black  Low pre-pregnancy weight (BMI < [consider link on prenatal vitamins IMR (BIMR is 2.7 times 19.8) - Public campaign on benefits of folic acid & harm of alcohol, tobacco, cocaine, & to message on safe sleep] higher than WIMR)  High pre-pregnancy weight (BMI > other drug use C. Increased access to care & -Highest IMR rates in high- 26.0) - Public campaign on spacing pregnancies utilization before, during and after risk places (especially in SG,  Inappropriate prenatal weight gain - Multi-year statewide infant mortality public awareness campaign pregnancy within a medical home, with optimal inter-pregnancy WY, GE counties)  Lack of folic acid use - Information on improving health literacy -Leading Causes of Infant - Employment: unemployed, long work hours, spacing Mortality: prematurity, low prolonged standing, low job satisfaction Enhancing Services and Support: a) Access and utilization of birth weight, birth defects, - Exercise in pregnancy - Implement state-wide PRAMS (Pregnancy Risk Assessment Monitoring System) preconception care SIDS/sleep-related deaths - Early prenatal care to determine trends/disparities in birth outcomes of overall Kansas births b) Access and utilization of care during and after the post- Barriers: Biological/History/Experience: - Establish and maintain the FIMR projects in Wyandotte and Sedgwick counties - Race/Ethnicity (African American, Native partum period -Lack of urgency for to help identify social and medical factors that contribute to infant death American, Puerto Rican) c) Access to care during minimal reducing IMR - Increased data collection, analysis, and dissemination of information on infant - Foreign born mother 18 month inter-pregnancy -Limited resources for - Early (1st trimester) prenatal care: lack of access mortality related to disparities period assuring access to needed to quality prenatal care - State Perinatal Periods of Risk (PPOR) (every 5 years) d) Access to preventive services for health services and - Multiple gestations, assisted reproductive - Identify and implement best practice models infant and mother community-based programs e) Access to genetics counseling technology - Support perinatal collaborative and surveillance systems Resources: D. Increased Social & Health Care - Maternal age (teens & older age/35+) - Create neonatal-perinatal quality improvement collaborative -Existing collaborative - Obstetric History Supports: - Support evidence-based community programs including home visitation for partnership for preventing  Previous LBW or preterm delivery a) Care coordination and high-risk families IM, including among:  Previous fetal demise/infant death family support services available st - Promote smoking cessation programs for families and caregivers for all women in high risk zip  State health department  Prior 1 trimester induced abortion codes (including Center for  Short inter-pregnancy interval - Train health care workers on screening and referral for DV/IPV, tobacco, alcohol, b) All prenatal women are Health Disparities) (<6mo) drugs, and anxiety/depression provided with education on  Health organizations  Inadequate interconception care - Improve availability of bilingual services benefits of breastfeeding, and (e.g., neonatal care)  Reproductive tract abnormalities - Support funding for state genetics plan all post-partum women have  March of Dimes & infections Modifying Access, Barriers, and Opportunities: access to breastfeeding  SIDS/Safe Sleep Coalition  Nulliparity & high parity  Professional associations - Expedite Medicaid application for prenatal care supports  Elective deliveries <39 weeks (e.g., Kansas American - Increase Medicaid access for genetic counseling pre and postnatal c) All pregnant women are - Medical Illnesses & Conditions screened for tobacco, substance Academy of Pediatrics) - Provide culturally tailored education and information  Chronic Hypertension & abuse, mental health, and DV  Academic and research Preeclampsia - Provide interconception care and get appropriate referrals partners  Systemic Lupus Erythematosus E. Attain Healthy Pregnancy for All  Promising Community (Lupus) Changing Consequences: Kansas Women Initiatives (e.g., MCH  - Provide adequate insurance reimbursement for group visits & centering care Restrictive lung disease & Asthma a) No tobacco, alcohol, drug use Coalition of KC; Healthy  Hyperthyroidism Modifying Policies & Systems: b) Appropriate physical activity Babies/FIMR/SG Co.)  Pregestational & gestational - Promote universal provision of prenatal care for uninsured women c) Appropriate prenatal weight diabetes - Apply for Medicaid Family Planning Service Option for expanded post-partum gain  Sovereign nations &  Pregestational renal disease coverage (or Medicaid 115 waiver in 2014) F. All maternal child health providers  Maternal birth weight (“Life Course urban Indian populations - Secure full funding to assure Medicaid coverage for pregnant women to 250% are culturally competent in KS Perspective”)  Prior STD history FPL. G. Inter-pregnancy period spacing:  Previous history of genetic risk - Increase in state tobacco tax >18mo - Increased spending on tobacco prevention for childbearing age women H. Data available that characterizes Psychosocial & Environment: 4 - Stress: - Change hospital/reimbursement policy for elective induced deliveries disparities and specific state and  Anxiety - Improved linkages and coordination among public, private, and tribal entities local risk factors related to infant  Depression focused on infant mortality and associated risk/protective factors mortality  Domestic Violence Glossary and Acronyms List</p><p>AAP American Academy of Pediatrics MADIN Make a Difference Information Network</p><p>BIMR Black Infant Mortality Rate MCH Maternal and Child Health</p><p>BMI Body Mass Index MCHC Maternal and Child Health Council</p><p>BRP Blue Ribbon Panel NAME National Association of Medical Examiners</p><p>CBO Community Based Organizations Neonatal Pertaining to the period of time immediately following birth</p><p>CDC Center for Disease Control and Prevention Nulliparity A condition or state in which a woman has never given birth to a child, or has never carried a pregnancy. CDRB Child Death Review Board Perinatal Pertaining to the period immediately before and after birth. DV Domestic Violence Positional A form of asphyxia which occurs when someone's position FIMR Fetal and Infant Mortality Review asphyxia prevents them from breathing adequately</p><p>FPL Federal Poverty Level PPOR Perinatal Periods of Risk</p><p>IM Infant Mortality PRAMS Pregnancy Risk Assessment Monitoring System</p><p>IMR Infant Mortality Rate PSA Public Service Announcement</p><p>IHS Indian Health Service SES Socioeconomic Status</p><p>IPV Intimate Partner Violence SIDS Sudden Infant Death Syndrome</p><p>IUGR Intrauterine Growth Restriction SRS Social and Rehabilitation Services</p><p>KDHE Kansas Department of Health and Environment SUIDI Sudden Unexplained Infant Death Investigation</p><p>LBW Low Birth Weight WIMR White Infant Mortality Rate</p><p>5 References </p><p>1. Minino AM, Xu JQ, Kochanek KD. Deaths: Preliminary Data for 2008. National vital statistics reports; vol 59 no 2. Hyattsville, MD: National Center for Health Statistics. December 2010. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_02.pdf. Accessed: 18 February 2011.</p><p>2. Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: Final Data for 2007. National vital statistics reports; vol 58 no 19. Hyattsville, MD: National Center for Health Statistics. May 2010. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf. Accessed: 18 February 2011.</p><p>3. Kansas Department of Health and Environment. Annual Report: 2009 Annual Summary of Vital Statistics. Topeka: Division of Health, Bureau of Epidemiology and Public Health Informatics. November 2010. Available from: http://www.kdheks.gov/hci/as/2009/AS_2009.pdf. Accessed: 18 February 2011.</p><p>4. Shore R, Shore B. “KIDS COUNT Indicator Brief: Reducing Infant Mortality.” Annie E. Casey Foundation. July 2009. Available from: http://www.aecf.org/~/media/Pubs/Initiatives/KIDS%20COUNT/K/KIDSCOUNTIndicatorBriefReducingInfantMortalit/ReducingInfantMortality.pdf.</p><p>5. Task Force on Sudden Infant Death Syndrome. American Academy of Pediatrics. “The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk.” PEDIATRICS; vol 116 no 5, pp. 1245- 1255. November 2005. Available from: http://aappolicy.aappublications.org/cgi/reprint/pediatrics;116/5/1245.pdf.</p><p>6. Wise Paul H., “The Anatomy of a Disparity in Infant Mortality.” The Annual Review of Public Health; vol 24, pp. 341-362. May 2003</p><p>7. Office of the Kansas Attorney General. Annual Report: 2010 Annual Report (2008 Data). Topeka: Kansas Child Death Review Board. October 2010. Available from: http://www.ksag.org/files/Final_2010_Annual_Report_with_2008_data.pdf.</p><p>8. Behrman, Richard and Butler, Adriene Stith. “Preterm Birth: Causes, Consequences, and Prevention.” The National Academies Press. 2007</p><p>9. Mandy, George T. “Incidence and Mortality of the Premature Infant.” UpToDate. September 2010. Available from: http://www.uptodate.com/contents/incidence-and-mortality-of-the-premature-infant?source=HISTORY. Accessed: December 2010.</p><p>10. Zacharias, Nikolaos. “Perinatal Mortality.” UpToDate. September 2010. Available from: http://www.uptodate.com/contents/perinatal-mortality? source=search_result&selectedTitle=1~146. Accessed: December 2010.</p><p>11. U.S. Department of Health and Human Services. “Evidence of Trends, Risk Factors, and Intervention Strategies.” Health Resources and Services Administration, Maternal and Child Health Bureau. 2006. Available from: ftp://ftp.hrsa.gov/mchb/OriginalFilesEvidence.pdf .</p><p>12. March of Dimes. “Toward Improving the Outcome of Pregnancy III.” December 2010. Available from: http://www.marchofdimes.com/TIOPIII_FinalManuscript.pdf. 6</p>