First Breath Program 2011 Annual Report. This report was prepared by the Wisconsin Women s Health Foundation

First Breath Program 2011 Annual Report This report was prepared by the Wisconsin Women s Health Foundation

First Breath Annual Report 2011 Executive Summary Overview 2011 was a year of significant growth and transition for First Breath and the Wisconsin Women s Health Foundation. In 2011, First Breath received several grants, pilot tested two new initiatives, and continued to expand its statewide presence. Funding In 2011, First Breath received funding from the State of Wisconsin Tobacco Prevention and Control Program. First Breath also received two grants from the Department of Health and Human Services, Office of Women s Health. Additionally, in partnership with the University of Wisconsin Center for Tobacco Research and Intervention, and the Wisconsin Department of Health Services, First Breath received a grant from the Centers for Medicare and Medicaid Services, through the Medicaid Incentives for the Prevention of Chronic Disease grant program. Program Updates First Breath pilot tested two new initiatives in 2011: a text messaging program, in which participants receive 2-3 encouraging text messages from First Breath staff each week; and, a social networking support group, through which participants can connect with an online community and develop a supportive, encouraging network of fellow First Breath participants. The Wisconsin Women s Health Foundation began to work on two additional First Breath projects: the Wisconsin Women s Quit Project, a two-year project that will support First Breath program development and pilot a peer mentoring initiative; and, the five-year Striving to Quit research project, which builds off the First Breath program and extends services into the postpartum stages. First Breath Sites and First Breath s statewide presence continues to grow, as eight new sites joined First Breath in 2011, and 1,460 women enrolled in First Breath at 87 of the 110 participating sites. First Breath maintained its commitment to providing on-site support and continuing education opportunities for providers, through site visits, the annual statewide meeting, and five regional sharing sessions. First Breath providers also received monthly email newsletters with enrollment updates and educational resources. First Breath Clients The majority of 2011 First Breath enrollees were between the ages of 18 and 34 at the time of enrollment, with an average age of 23. Most were non-hispanic White (68%), had a high school education or lower (74%), were unemployed (56%), and were eligible for Medicaid (78%). Program Results Participants in First Breath showed decreases in smoking during their participation in the program, as evidenced by a significant decrease in self-reported smoking between the and Prenatal Follow-Up visits (p<.05). Women who expressed the strongest desire to quit at enrollment had the most long-term success. In 2011, 37% of women reported staying quit (19%) or quitting (18%) during their participation in First Breath.

First Breath Annual Report Services Provided January 1, 2011 to December 31, 2011 Before the First Breath program I was a smoker for about 5 years. I really wanted to quit for my baby. The First Breath program gave not only me but my fiancé the push to quit smoking, and 3 months into my pregnancy I finally completely quit! Even after I quit First Breath stayed with us and kept helping us. Now my daughter is 2 months old and is very healthy. She was 7 pounds, 10 ounces, and 20 inches long and, again, very healthy. My fiancé and I are both still smoke free, and I could not be happier! -First Breath mom, 2011 Program Description and History First Breath uses a best-practice, counseling-based approach to support pregnant smokers as they attempt to quit smoking. Prenatal care providers receive training in motivational interviewing techniques and delivery of the 5 A s intervention ( Ask, Advise, Assess, Assist, and Arrange ), as well as interactive pregnancy-specific workbooks and materials to use with their clients. First Breath providers see pregnant women where they regularly receive services and provide non-judgmental support and encouragement. First Breath is available to all pregnant women in Wisconsin, regardless of age, income, race/ethnicity, or insurance status. Since First Breath s statewide expansion in 2003, 11,629 women have participated in the program, with an average annual quit rate of 35%. Program Goals The goal of First Breath is to help pregnant women quit smoking or reduce their smoking if they are not yet ready to quit. This program was developed with four objectives: To increase the number of pregnant women who quit smoking To reduce smoking among pregnant women who are not able to quit To improve the health of newborns To decrease the rate of relapse among mothers after they deliver Program and Participation in the program can occur at any time during pregnancy. In addition to women who are actively seeking help to quit smoking, First Breath also encourages women who have recently quit smoking to participate in the program to help prevent relapse. However, women typically enter the

program during their second trimester and stay enrolled until a postpartum visit, which typically occurs close to 60 days postpartum. Thus, First Breath participants spend an average of 6 months in the program. Women who participate in the First Breath program receive: Personal smoking cessation support Intensive smoking cessation counseling Educational and self-help materials Educational materials for their friends and family Participation incentives A gift at delivery Wisconsin Tobacco Quit Line materials, information and access Funding In 2011, First Breath received funding from the State of Wisconsin Tobacco Prevention and Control Program ($300,000). First Breath also received two grants from the Department of Health and Human Services, Office of Women s Health, for a pilot test of a text messaging program and the Wisconsin Women s Quit Project (WWQP). Additionally, in partnership with the University of Wisconsin Center for Tobacco Research and Intervention, and the Wisconsin Department of Health and Human Services, First Breath was awarded a grant from the Centers for Medicare and Medicaid Services to conduct the Striving to Quit (STQ) research study. The WWQP and STQ will be used to support First Breath program expansion and evaluation. Events and Program Updates Statewide Meeting: Each January, First Breath invites program providers and partners to attend the First Breath Statewide Meeting. The Statewide Meeting is an opportunity for providers and partners from throughout the state to come together for a day of shared learning and networking. Experts are invited to present on a variety of topics pertinent to First Breath. The 2011 statewide meeting was held on January 14 in the Wisconsin Dells. Speakers included Scott Caldwell, MA, CSAC, from the Bureau of Prevention Treatment and Recovery, Wisconsin Department of Health Services, who presented a well-received session on Motivational Interviewing. Other session topics included: other tobacco products and electronic cigarettes, and the Pregnancy Risk Assessment Monitoring System (PRAMS). A highlight of the 2011 Statewide Meeting was First Breath mom, Heidi Steller s, lunchtime testimonial. Heidi spoke with courage of her struggle with conceiving and of the support she felt from First Breath in her successful quit. Providers and partners celebrated the tenth anniversary of First Breath and the participation of 10,000 women in the program. The group blew bubbles to represent the 10,000 lives that have been made healthier by the First Breath program. Page 2 of 18

Regional Sharing Sessions: Regional Sharing Sessions (RSS) were held on August 5 (Milwaukee), August 12 (Madison), August 19 (Appleton), August 24 (Eau Claire), and August 25 (Ashland). The RSS agendas are developed with input from First Breath providers. In 2011 RSS topics included: FAQs, Top 10 highlights in tobacco/alcohol research and the Young Mother s Outreach Campaign (a text messaging/social media pilot project). Data Collection First Breath participants complete three surveys during their participation in the program. These surveys include questions about current tobacco use, past tobacco use, and smoking cessation goals. These data are used to evaluate changes in self-reported smoking behavior during the course of participation in First Breath, as well as relationships between demographic variables, cessation goals, and tobacco use. Data are collected from women at three time points: the enrollment visit, which usually takes place during the second trimester; the prenatal follow-up visit, which typically occurs during the third trimester; and the postpartum visit, which on average, takes place within 60 days after delivery. Survey Prenatal Survey Postpartum Survey Client enrolls in First Breath Client attends prenatal followup visits and completes at least one Prenatal Follow-Up survey DELIVERY Final First Breath visit Data analysis for the 2011 annual report includes data collected from all clients who enrolled in 2011, as well as data from all Prenatal Follow-Up and Postpartum forms that were completed in 2011. Therefore, the longitudinal analyses, and some cross-sectional analyses 1, include data from both 2010 and 2011 enrollees. 1 Each set of analyses notes which years of data were included. Page 3 of 18

Program Results In 2011, 1,460 women were enrolled at 87 of the 110 participating sites in 52 of Wisconsin s 72 counties. See Appendix A for 2011 enrollment numbers at each First Breath site and a map of First Breath sites across the state. Demographics Table 1 presents demographic information for the 1,460 women who enrolled in First Breath in 2011. The majority of the 2011 enrollees were between the ages of 18 and 34 at the time of enrollment, with an average age of 23. Most were non-hispanic White (68%), 74% had a high school education or lower, 56% were unemployed, and 78% were eligible for Medicaid. Table 1: First Breath Client Demographics 2010 2011 2010 2011 Age # # % Race # % # % 13-17 112 9 14.9 American Indian or Alaskan Native 70 5 67 5 18-24 752 56 675 46 Asian 5.4 14 1 25-34 445 33 666 46 Black or African American 219 17 303 21 35-44 Unknown 29 0 2 0 102 3 7.1 Hispanic/Latina White Medicaid Eligible # % # % Other 40 3 10 1 Yes 1057 79 1146 78 No 281 21 313 22 Education # # % Employed # % # % Less than high school 11.8 13 1 Yes 559 42 594 41 Some high school 382 29 390 27 No 724 54 818 56 High school or GED 567 42 664 46 Unknown 55 4 48 3 Some college/2-year degree 338 25 341 23 College Post-college education Unknown 22 6 12 2.4.8 32 0 20 2 0 1 34 961 2.6 72 59 988 4 68 Page 4 of 18

Smoking History Table 2 presents information about participants smoking history. Of the 1,460 women who submitted forms in 2011: 62% (n=912) started smoking between the ages of 13 and 17. 36% (n=519) reported smoking 11 to 20 cigarettes per day (there are 20 cigarettes in one pack), three months prior to getting pregnant, and 30% (n=431) reported smoking 6-10 cigarettes per day at that time point 30% (n=439) said that, before they were pregnant, they usually had their first cigarette of the day immediately (within five minutes) after waking up 79% of enrollees had tried to quit smoking previously. Of the 1,153 women with previous quit attempts: o 22% had one previous quit attempt; o 26% had two previous quit attempts; o 14% had three previous quit attempts; and o 16% had four or more previous quit attempts. Table 2: First Breath Clients Smoking History Age started smoking # % Smoking 3 months before pregnancy # % <13 232 16 Not smoking 8.5 13-17 912 62 A few some days, not every day 62 4 18-24 246 17 1-5 cigarettes/day 217 15 25-34 28 2 6-10 cigarettes/day 431 29 35-44 Unknown 0 42 0 3 11-20 cigarettes/day 21-30 cigarettes/day 31-40 cigarettes/day >40 cigarettes/day Unknown Number of years smoked # % Number of quit attempts 2 # % Smoked for 1-5 years 255 17 1 254 22 Smoked for 6-10 years 523 36 2 300 26 Smoked for 11-15 years 362 25 3 161 14 Smoked for 16-20 years 154 11 4 58 5 Smoked more than 20 years Unknown 115 51 8 3 5 >5 Unknown 518 144 44 11 25 23 104 253 35 10 3.5 2 2 9 22 2 1,153 women reported previously trying to quit smoking Page 5 of 18

Smoking Cessation Goals Women were asked what they want to happen with their smoking at each data collection time point. Table 3 presents responses to these questions. 1,460 women completed enrollment forms in 2011, 1,069 women who enrolled in either 2010 or 2011 completed Prenatal Follow-Up forms in 2011, and 799 women who enrolled in 2010 or 2011 completed Postpartum forms in 2011. As shown below, nearly all First Breath moms express a desire to quit smoking and stay quit. Understanding First Breath participants smoking cessation goals helps First Breath adjust program content and suggested quit strategies to fit the needs of individuals with different smoking cessation goals. Table 3: First Breath Clients Smoking Cessation Goals * (n=1460) Prenatal Follow-Up (n=1069) Postpartum (n=799) 84% said they want to quit smoking for good 7% said they don t know what they want 5% said they want to cut down only 4% said they plan on quitting only until their baby is born 35% said they want to remain quit 26% said they want to quit smoking 19% said they want to do better than now (want to quit or smoke less) 4% said they don t know what they want 4% said they want to stay where they re at 1% said they re looking forward to smoking again 34% said they want to remain quit 27% said they want to quit 23% said they want to do better than now (want to quit or smoke less) 10% said they want to stay where they re at 4% said they don t know what they want 1% said they re looking forward to smoking again * The question on the visit survey had different response options than the Prenatal Follow-Up and Postpartum surveys Page 6 of 18

Smoking During Participation in First Breath At each time point women were asked to report how many cigarettes per day they smoked during the past week. Table 4 shows participants responses to this question at each data collection time point during participation in First Breath. Figure 1 presents the self-reported smoking rates for these three time points, as well as three months prior to learning about the pregnancy. As Figure 1 shows, the majority of First Breath participants were heavy smokers prior to pregnancy. Although many women quit smoking or dramatically reduce the amount they smoke when learning of their pregnancy, many women need additional support to stay quit or to quit completely. Table 4: Smoking During First Breath (n=1460) Prenatal Follow-Up (n=1069) Postpartum (n=799) Not smoking 360 (25%) 385 (36%) 264 (33%) Some, but not every day 161 (11%) 139 (13%) 80 (10%) 1-5 cigarettes/day 467 (32%) 310 (29%) 256 (32%) 6-10 cigarettes/day 307 (21%) 150 (14%) 136 (17%) >10 cigarettes/day 161 (11%) 75 (7%) 64 (8%) Figure 1: Smoking During First Breath and 3 Months Prior to Pregnancy 90 80 70 60 50 40 30 Percent not smoking Percent smoking some, not every day Percent smoking 1-5 cigarettes Percent smoking 6+ cigarettes 20 10 0 3 Months Prior to Pregnancy* Prenatal Follow- Up Postpartum *The enrollment survey asks women to retroactively report how much they were smoking 3 months prior to learning they were pregnant Page 7 of 18

Group Differences in Smoking Status at Age Women between 35-44 years of age reported smoking significantly more than women between the ages of 13-17 (p<.01) and 18-24 (p<.01). Race Non-Hispanic White women reported smoking significantly more than African American (p<.01) and Hispanic/Latina (p<.05) women at the enrollment visit. Harm Reduction The ultimate objective of the program is smoking cessation. However, First Breath has adopted a harm reduction perspective and recognizes that smoking reduction and cessation during pregnancy only are beneficial, though not as beneficial as permanent cessation. Harm reduction was analyzed using repeated measures analysis of variance (ANOVA). The results are based on the 622 women for whom we had data at all four time points. There was a dramatic drop in the average self-reported smoking rates between the first time point (3 months prior to pregnancy) and second time point (enrollment in First Breath). Once enrolled in First Breath, there was a significant, though less dramatic, decline in smoking between the average self-reported smoking status at the enrollment and prenatal follow-up visits. There was also a significant difference between average self-reported smoking at enrollment and the postpartum visit. However, there was no significant difference between the prenatal follow-up and the postpartum visit. Thus, the early prenatal stages are an important time for this, and other, prenatal interventions. Figure 2: Harm Reduction 5 4 3 Average self-reported smoking 2 1 3 mo. prior to pregnancy Prenatal Follow- Up Postpartum *Y-axis scale: 1 = not smoking; 2 = smoking a few cigarettes, but not every day; 3= 1-5 cigarettes/day; 4 = 6-10 cigarettes/day; 5 = 11-20 cigarettes/day Page 8 of 18

Harm reduction and age. Because smoking status differed significantly between age groups at several time points, change in smoking status over time for each age group was evaluated. Change in smoking over time by age group is shown in Figure 3. All participants showed decreases in self-reported smoking, though patterns of change differed across groups between several time points. There was no significant difference in smoking between any of the age groups at three months prior to pregnancy, but differences emerged at the enrollment visit and persisted at the prenatal follow-up visit, with older women reporting smoking significantly more than younger women. Age and the number of years spent smoking are highly and significantly correlated (r=.866, p<.01), so the age difference in self-reported smoking may be related to the number of years women in each age group have smoked. Figure 3: Harm Reduction by Age Group 5 4 3 13-17 18-24 25-34 35-44 2 1 3 mo. prior to pregnancy Prenatal Follow-Up Postpartum *Y-axis scale: 1 = not smoking; 2 = smoking a few cigarettes, but not every day; 3= 1-5 cigarettes/day; 4 = 6-10 cigarettes/day; 5 = 11-20 cigarettes/day Page 9 of 18

Harm reduction and race Patterns of change in self-reported smoking across racial-ethnic groups were evaluated due to the group differences in smoking status that emerged at the enrollment visit. Results from a repeated measures ANOVA of smoking status by race are shown in Figure 4. There were no significant differences in patterns of change in self-reported smoking rates, but White women reported smoking more than American Indian and African American women three months prior to pregnancy and more than African American and Hispanic/Latina women at the enrollment visit. Figure 4: Harm Reduction by Race 5 4 3 American Indian or Alaskan Native Asian Black or African American Hispanic/Latina 2 White 1 3 mo. prior to pregnancy Prenatal Follow- Up Postpartum *Y-axis scale: 1 = not smoking; 2 = smoking a few cigarettes, but not every day; 3= 1-5 cigarettes/day; 4 = 6-10 cigarettes/day; 5 = 11-20 cigarettes/day Page 10 of 18

Harm reduction and enrollment visit smoking cessation goals Figure 5 presents the relationship between smoking goals at enrollment and self-reported smoking rates at each time point. Women who said they wanted to quit smoking for good at the enrollment visit smoked significantly less at the postpartum visit than women who, at the enrollment visit, said they wanted to cut down only. In other words, women who expressed the strongest desire to quit at enrollment reported the most long-term success. Figure 5: Harm Reduction by Visit Smoking Cessation Goals 5 4 3 Quit for good Quit until baby is born Cut down Don't know 2 1 3 mo. prior to pregnancy Prenatal Follow-Up Postpartum *Y-axis scale: 1 = not smoking; 2 = smoking a few cigarettes, but not every day; 3 = 1-5 cigarettes/day; 4 = 6-10 cigarettes/day; 5 = 11-20 cigarettes/day Page 11 of 18

Quit Rates Quit rates were calculated for the subsample of 622 women for whom we had data at all four time points (3 months prior to pregnancy, enrollment, prenatal visit, postpartum visit). It should be noted that smoking rates are self-reported and have not been biologically verified. Quit Rates 146 (23%) of the 622 women reported already quitting smoking by the time they enrolled in First Breath 3. Prenatal Quit Rates Of the 146 of women had already quit smoking by the time they enrolled in First Breath, 124 (20%) remained quit at the prenatal follow-up visit. Thus, the prenatal stay quit rate is 20%. Of the 476 women who were still smoking at the enrollment visit, 86 (18%) quit during prenatal enrollment in First Breath. Thus, the prenatal quit rate while enrolled in First Breath is 18%. A total of 211 women (34%) either quit or stayed quit during their prenatal participation in First Breath. Postpartum Quit Rates Of the 124 women who reported quitting smoking by enrollment and remained quit at the prenatal follow-up visit, 97 (16%) were still quit at the postpartum visit. Thus, the postpartum stay quit rate is 16%. Of the 87 women who quit between enrollment in First Breath and the prenatal follow-up visit, 61 (10%) stayed quit after delivery. An additional 72 women (12%) who were smoking at enrollment and had not quit during pregnancy reported quitting by the postpartum visit. Thus, the postpartum quit rate is 22%. A total of 230 women (37%) either quit or stayed quit during their postpartum participation in First Breath. Dose Of the 799 postpartum forms that were completed in 2011, 638 had information about the number of prenatal visits the First Breath provider had with the client. The number of prenatal visits ranged from 1 (n = 68) to more than 10 (n=73), with First Breath providers reporting seeing the client an average of 5 times before delivery. The number of prenatal visits was positively, but only slightly, correlated to self-reported smoking at the prenatal visit (r=.103, p<.05), such that women who attended a greater number of prenatal visits reported smoking slightly more than women who met with a First Breath provider a fewer number of times. However, the number of prenatal visits was not significantly related to any changes in self-reported smoking over time. 3 However, some findings indicate that pregnant women underreport smoking (e.g., Boyd et al., 1996), and that women who report quitting since learning of their pregnancy are more likely to underreport than women who reported quitting before becoming pregnant (Campbell et al., 2001). Page 12 of 18

Relapse Rate Of the 622 women for whom we had complete sets of data (4 data points), 210 women had quit, or stayed quit, by the prenatal follow-up visit. Of these 210 women, 56 (27%) reported smoking at the postpartum visit. Delivery Outcomes There were 793 postpartum forms submitted with delivery outcome information for 2011. Of these 793 women: 94% reported delivering healthy babies 5% reported delivering babies with abnormalities, including premature birth, low birth weight, cardiac anomaly, cystic fibrosis, cleft lip and palate, spina bifida, etc. Birth weights in the First Breath Program ranged from 1418 grams (3 pounds, 2 ounces) to 4876 grams (12 pounds, 10 ounces) and averaged 3164 grams (7 pounds, 15 ounces). Of the 607 women who had birth weight information on their postpartum form, 9% had babies that weighed 2,500 grams or less (2,500 grams is considered low birth weight). Low birth weight babies tend to have impaired immune function and increased risk of disease. They are likely to remain undernourished, with reduced muscle strength, throughout their lives, and to suffer a higher incidence of diabetes and heart disease. Withdrawal from Program Of the 1,460 women who enrolled in First Breath during 2011, 152 withdrew from the program. Of these 152 women: 63% of clients were no longer receiving care at their First Breath site. A client may no longer receive care at a site because they moved from the area or were lost to follow-up. It does not include clients who have delivered their babies or were discharged from care. 28% reported no longer participating in First Breath. Reported reasons that clients choose to no longer participate in First Breath include: not interested any longer, wants to quit on own, doesn t want to change smoking behavior, unable to reach. 9% reported a pregnancy loss/miscarriage. Challenges Staff Turnover at First Breath Sites Staff turnover at First Breath sites continues to be a challenge. First Breath Health Educators address this challenge by following up with sites frequently and by providing training and technical assistance to new staff. Page 13 of 18

Changes to Client Surveys In 2011 First Breath and My Baby & Me surveys were combined in an effort to ease the burden of time for program providers. This was also an opportunity to make changes to existing questions and add additional questions. First Breath program staff encountered some resistance from sites as they introduced the new forms to providers, but most providers reacted positively to the new surveys. The new surveys also created a need for a new database. Program Sustainability at First Breath Sites Sustainability was a challenge in 2011 and will likely continue to be a challenge in the future. Public health has seen a decrease in funding at a state and federal level. Many staff at public health departments have had to cut down their hours or have lost their jobs due to funding. Program Development 2012 promises to be a fruitful year for First Breath, with several large projects set to be completed by January, 2013. These projects include: development of a program manual for First Breath providers; creation of standardized training protocols for new and existing First Breath providers; introduction of a 6-month postpartum follow-up survey; and an expansion of the text messaging program that was piloted in 2011. Program Manual The program manual will include clear guidelines for treatment delivery, detailed outlines of sample First Breath visits, scripts for providers, and tips for successful program implementation. Training Protocol The training protocol will consist of power point presentations, notes, and content guides for different presentation and training contexts (e.g., one presentation for current WIC sites and a different presentation for training of new WIC sites; one presentation for training new providers at private clinics, and a different presentation for follow-up site visits with these clinics). 6-Month Postpartum Follow-Up The 6-month postpartum follow-up survey will be a short survey that consists of several questions about current tobacco use. The survey will be conducted over the phone with a random subsample of First Breath participants, beginning in 2013. Expansion of the Text Messaging Program First Breath pilot tested a text messaging program for young moms in 2011. The results of the pilot suggest that First Breath participants appreciated the extra encouragement and support these texts provided. In 2012, First Breath will invite all participants to join the text messaging program. Participants in the text messaging program will receive two or three text messages per week. Page 14 of 18

Appendix A: 2011 Report 2010 2011 ACCESS COMMUNITY HEALTH CENTERS 6 7 13 ADAMS COUNTY PUBLIC HEALTH 0 0 12 APPLETON CITY HEALTH DEPARTMENT 4 4 56 ASHLAND COUNTY HEALTH & HUMAN SERVICES 2 10 42 ASSOCIATED PHYSICIANS, LLP 0 0 0 BARRON COUNTY DHHS 10 10 94 BAYFIELD COUNTY HEALTH DEPARTMENT 0 3 3 BURNETT COUNTY DHHS 4 2 77 CALUMET COUNTY HEALTH DEPARTMENT 2 3 23 CATHOLIC CHARITIES - GREEN BAY DIOCESE 4 2 9 CENTER FOR QUALITY COMMUNITY LIFE 0 0 0 CHILDREN'S COMMUNITY HEALTH PLAN 5 19 44 CHIPPEWA COUNTY DEPT. OF PUBLIC HEALTH 36 38 309 CLARK COUNTY HEALTH DEPARTMENT 3 4 57 COLUMBIA COUNTY DHHS 23 18 155 COMMUNITY MEMORIAL HOSPITAL 19 3 24 CRAWFORD COUNTY HEALTH DEPARTMENT 4 5 15 DEAN HEALTH PLAN - STRONG BEGINNINGS 1 4 5 DEAN HEALTH SYSTEM 43 60 387 DODGE COUNTY HUMAN SERVICES & HEALTH DEPT. 21 9 151 DOOR COUNTY PUBLIC HEALTH DEPARTMENT 9 15 128 DUNN COUNTY HEALTH DEPARTMENT 4 3 54 EAU CLAIRE CITY CO. HEALTH DEPARTMENT 34 27 150 FAMILY HEALTH/LA CLINICA 6 8 14 FAMILY SERVICES OF NORTHEAST WI 22 7 98 FLORENCE COUNTY HEALTH DEPARTMENT 2 0 23 FOREST COUNTY HEALTH DEPARTMENT 7 5 46 FOREST COUNTY POTAWATOMI HEALTH & WELLNESS 6 4 22 CENTER FRANCISCAN SKEMP - SPARTA 2 0 60 GERALD L. IGNACE INDIAN HEALTH CENTER 0 0 0 GRANT COUNTY HEALTH DEPARTMENT 3 8 61 GREEN COUNTY HEALTH DEPARTMENT 10 16 59 GREEN LAKE COUNTY PUBLIC HEALTH DEPT. 3 10 51 GUNDERSEN LUTHERAN 32 18 248 HEALTH AND NUTRITION SERVICE OF RACINE 231 257 1631 HLS MEDICAL SERVICES 1 1 2 CHAK-HA-CHEE, HO-CHUNK HEALTH 2 0 11 IOWA COUNTY HEALTH DEPARTMENT 8 4 45 Total 2003-2011 Page 15 of 18

2010 2011 ISAAC COGGS HERITIAGE HEALTH CENTER 2 6 8 JEFFERSON COUNTY HEALTH DEPARTMENT 0 0 21 KENOSHA AREA FAMILY AND AGING SERVICES 0 0 44 KENOSHA COMMUNITY HEALTH CENTER 0 0 0 KENOSHA COUNTY DIVISION OF HEALTH 7 21 61 KROHN CLINIC 6 9 130 LA CROSSE COUNTY HEALTH DEPARTMENT 43 31 183 LAC COURTE OREILLES COMMUNITY HEALTH CENTER 7 9 27 LAC DU FLAMBEAU HEALTH & WELLNESS CENTER 0 0 41 LAKEVIEW MEDICAL CENTER 10 10 20 LIFETIME OB/GYN 36 25 61 LINCOLN COUNTY HEALTH DEPARTMENT 4 7 23 LUTHER MIDELFORT NORTHLAND MAYO HEALTH 4 4 24 SYSTEM MANAGED HEALTH SERVICES 24 6 215 MANITOWOC COUNTY HEALTH DEPARTMENT 2 0 50 MARATHON COUNTY HEALTH DEPARTMENT 15 25 244 MARINETTE COUNTY HEALTH & HUMAN SERVICES 8 5 28 MARQUETTE COUNTY HEALTH DEPARTMENT 5 0 32 MARSHFIELD CLINIC OB/GYN 34 30 286 MENOMINEE TRIBAL CLINIC 28 18 127 MERCYCARE HEALTH PLAN 0 5 5 MERITER CENTER FOR PERINATAL CARE 61 48 182 CITY OF MILWAUKEE HEALTH DEPARTMENT 9 5 104 MILWAUKEE HEALTH SERVICES - MLK 6 29 95 MINISTRY MEDICAL GROUP OB/GYN 40 37 514 MOLINA HEALTHCARE 0 9 9 MONROE COUNTY HEALTH DEPARTMENT 17 17 54 MORELAND OB/GYN ASSOCIATES 21 16 213 NEIGHBORHOOD HEALTH PARTNERS 0 8 8 NORTHWEST WISCONSIN COMMUNITY SERVICE 3 9 124 AGENCY ONEIDA COUNTY HEALTH DEPARTMENT 3 5 118 OUTAGAMIE COUNTY HEALTH & HUMAN SERVICES 24 21 195 PEPIN COUNTY HEALTH DEPARTMENT 5 1 52 PIERCE COUNTY HEALTH DEPARTMENT 6 4 95 POLK COUNTY HEALTH DEPARTMENT 53 45 548 PRICE COUNTY HEALTH DEPARTMENT 6 1 56 PROGRESSIVE COMMUNITY HEALTH CENTERS 6 8 19 PUBLIC HEALTH - MADISON & DANE COUNTY 39 38 248 RED CLIFF COMMUNITY HEALTH CENTER 7 7 38 Total 2003-2011 Page 16 of 18

2010 2011 RENEWAL UNLIMTED, INC 0 0 1 ROCK COUNTY HEALTH DEPARTMENT 35 59 232 ROSALIE MANOR 1 0 20 RUSK COUNTY HEALTH & HUMAN SERVICES 7 11 78 SAUK COUNTY HEALTH DEPARTMENT 11 18 89 SCENIC BLUFFS COMMUNITY HEALTH CENTER 0 0 0 SHEBOYGAN COUNTY HEALTH DEPARTMENT 23 18 283 SOKAOGON CHIPPEWA COMMUNITY HEALTH CLINIC 7 6 15 ST. CROIX COUNTY DHHS 18 27 209 ST. JOSEPH WOMEN'S OUTPATIENT CENTER 72 77 191 STOCKBRIDGE-MUNSEE HEALTH & WELLNESS CENTER 9 8 25 UNITY HEALTH INSURANCE 5 4 11 UW HEALTH 20 S. PARK OB/GYN 2 1 5 UW HEALTH EAU CLAIRE FAMILY MEDICINE CLINIC 4 7 29 UW HEALTH EAST CLINIC 5 1 10 UW HEALTH SUN PRAIRIE 4 6 13 UWHP CENTER FOR WOMEN'S HEALTH 4 6 49 VERNON COUNTY HEALTH DEPARTMENT 0 0 0 WALWORTH COUNTY HEALTH DEPARTMENT 6 2 44 WATERTOWN DEPT. OF PUBLIC HEALTH 1 2 34 WAUKESHA COUNTY PUBLIC HEALTH DIVISION 0 0 0 WAUPACA COUNTY HEALTH DEPARTMENT 3 5 36 WAUSHARA COUNTY HEALTH DEPARTMENT 2 3 93 WEE CARE WIC CAPITOL 19 6 48 WEE CARE WIC NORTH 6 8 33 WEE CARE WIC TEUTONIA 5 8 62 WELLNESS CENTER OF DOOR COUNTY 0 4 4 WEST ALLIS HEALTH DEPARTMENT 5 70 116 WHEATON FRANCISCAN HEALTHCARE - ST. FRANCIS 0 0 19 PRENATAL ASSESSMENT WOOD COUNTY HEALTH DEPARTMENT 12 0 150 Total 2003-2011 Page 17 of 18

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For questions regarding the information presented in this report, please contact: Leah Kokinakis, Ph.D. at 608-251-1675 ext.116 or by email at lkokinakis@wwhf.org. For more information about the First Breath Program, please contact: Hillary Whitehorse at 608-251-1675 ext.112 or by email at hwhitehorse@wwhf.org. Wisconsin Women s Health Foundation 2503 Todd Drive Madison, WI 53713 Phone: 800-448-5148 Fax: 608-2514136 Web: www.wwhf.org