Beyond Health Care Reform: The Role of Interconceptional Care in Reinventing Maternal and Child Health

1. Beyond Health Care Reform: The Role of Interconceptional Care in Reinventing Maternal and Child Health BIHCC Collaborative Learning Conference Call The State of Florida Thursday, February 11, 2010 11:00 AM -12:00 PM Presented by Mario Drummonds MS, LCSW, MBA Executive Director, Northern Manhattan Perinatal Partnership, Inc. Linking Women to Health, Power and Love Across the Life Span

2. Lecture Objectives • Discuss the concept of interconceptional care as aftercare. • Describe how interconceptional care improves birth outcomes, particularly in preventing LBW and prematurity. • Explain the rationale for changing the perinatal prevention paradigm to include an emphasis on preconceptional/ interconceptional health and link the rationale to CDC and MCH initiatives. 2

3. International Comparisons of Infant Mortality Rates, 2005 Rank Country Rate 1 Singapore 2.1 2 Hong Kong 2.5 7 Czech Republic 3.4 14 Spain 4.1 25 Canada 5.4 United States, “White” 5.7 26 Cuba 6.2 28 Northern Ireland 6.3 30 United States 6.9 http://www.marchofdimes.com/peristats

4. Terminology • Interconception • From the conception of one pregnancy to the conception of the next pregnancy. • Internatal care • From the birth of one child to the birth of the next child • Interpregnancy Interval • The time between the delivery and conception of two consecutive births. 4

5. Interconceptional Care Interconceptional care is defined as a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management from conception of one pregnancy to the conception of the next pregnancy. 5

7. Select Panel Goals for Improving Preconception Health Goal 1: Improve the knowledge, attitudes and behaviors of men and women related to preconception health Goal 2: Assure that all US women of childbearing age receive preconception care services- screening, health promotion and interventions- that will enable them to enter pregnancy in optimal health 7

8. Select Panel Goals for Improving Preconception Health Goal 3: To reduce risks indicated by a prior adverse pregnancy outcome through interventions in the interconception period Goal 4: Reduce disparities in adverse pregnancy outcomes 8

9. HRSA Position The interconceptional period is a critical time to address both medical and social issues that can increase the risk of infant mortality, and particularly those that contribute to disparities in infant mortality. The National Healthy Start program includes interconceptional care as one of its nine core components in recognition of its important role in eliminating disparities. 9

10. Traditional Perinatal Care Continuum Labor and birth ? Primary care Interconceptionalperiod Preconception period Antepartum Labor and birth Postpartum Well baby care Postpartum visit Prenatal care 10

11. Lifespan Approach Birth Early childhood Pre-teen Teen Young adult Women 35≥ Seniors 11

12. New MCH Life Course Continuum Axis 1

13. MCH Life Course Organization Social Determinants to Health Axis 2

14. A Life Course or Integrative Model Builds on a continuum Emphasis is on health promotion throughout the lifespan (from “womb to tomb”) Emphasis on primary and secondary disease prevention Emphasis on woman, first, rather than her reproductive status 14

15. In obstetrics. . . most of our outcomes or their determinants are already present before we ever meet our patients 15

17. Goals of Interconceptional Care • Increase access to women’s healthcare. • Reduce low birth weight and infant mortality. • Reduce racial-ethnic disparities in mother and infant health outcomes. 17

18. Interconceptional Period • Provides an important opportunity to address risk factors identified in the last pregnancy relative to • Woman’s lifelong health status • Potential impact on future pregnancies Pregnancy is a “stress test” for life 18

19. Pathways to Care 19

20. Pathways Protocol: Entry to Care • New clients receive: • Intake • Screening • Assessment • Existing clients transitioning to interconceptional aftercare receive: • 3rd trimester assessment which is used as a baseline to begin planning continuous interconceptional aftercare (adapted from NC Healthy Start). 20

21. Intake & Screening (new clients) • Initial contact with the prospect that includes gathering demographic information and enough data to determine if they meet program guidelines or would benefit from being referred to alternate resources. • Key points: • Intake tool • Screening tool • Have these tools been evaluated for feasibility or effectiveness? • Sample tool 21

22. Existing Clients • Existing prenatal clients can begin to transition into interconeptional aftercare prior to giving birth. • In addition to the areas identified using the risk assessment what standard interconceptional care interventions can be applied for the following scenarios? • Healthy/Normal Pregnancy • High risk pregnancy with pre-existing or pregnancy related medical conditions 22

23. Healthy/Normal Pregnancy • Basic newborn care • Back-to-sleep/safe sleep • Shaken baby syndrome • Early parenting skills (bathing, handling, bonding, attachment) • Breastfeeding • Preparing for your well baby visit • Preparing for your postpartum visit • Recognizing PMD 23

24. High Risk Pregnancy • Items covered in the healthy/normal pregnancy slide. • Identify referrals for specialist care after birth to assure continuity of care. • Health promotion and education related to high risk condition(s). • Chronic illness • Diabetes (pregestational and gestational) • Overweight/obesity • Prior stillbirth(s), LBW, prematurity, infant mortality 24

25. Core Contents 25

26. Risk Assessment • The interconceptional risk assessment identifies areas where ongoing problems exist, including lack of resources, that need to be addressed in order to improve future birth outcomes. • Key points: • Risk assessment tool • Has this tool been evaluated for feasibility or effectiveness? • Interventions are developed based on the findings from the risk assessment. • Sample tool 26

27. Risk Assessment: FINDS • Family violence • Infections/Immunizations • Nutrition • Depression • Stress Lu, M.

28. Risk Assessment: FINDS • Family violence • Infections/Immunizations • Periodontal • Chlamydia • Other sexually transmitted or urogenital tract infections in selected populations • Nutrition • Depression • Stress Lu, M.

29. Risk Assessment: FINDS • Family violence • Infections/Immunizations • Diptheria-tetanus toxoids booster • Hepatitis B vaccines • Measles and mumps • Rubella • Varicella • Nutrition • Depression • Stress Lu, M.

30. Highlights • F.I.N.D.S. should be used as part of a routine risk assessment after every pregnancy. • For prenatal clients the 3rd trimester is an opportune time to create a baseline using F.I.N.D.S. • Each clinical visit is also a perfect time to conduct F.I.N.D.S.

31. Health Promotion BBEEFF • Breastfeeding • Back-to-sleep • Exercise • Exposures • Household molds and dust mites • Lead • Mercury • Dioxins • Folate • Family planning Lu, M.

32. Health Promotion BBEEFF • Breastfeeding • Back-to-sleep • Exercise • Exposures • Folate • Family planning • Reproductive life plan • Contraceptive use Lu, M.

33. Clinical Interventions • Height and weight measurements • every 3-5 years • Blood pressure • every 2 years • Total skin examination • every 1-3 years • Papanicolau smear and pelvic examination • every 1-3 years • Clinical breast examination • Every 3 year beginning at age 20 • Screening mammography • every 1-2 years beginning at age 40 Lu, M.

34. Psychosocial Interventions • Access to social support services • Public assistance • Childcare • Housing • Literacy programs • Professional clinical support • Mental health services • Services for intimate partner violence • Marital and sexual counseling • Parenting support • Mothers groups • Parenting classes • Fathers groups Lu, M.

35. Socioeconomic Interventions • Access to socioeconomic interventions with multiple levels of impact • Job development • Financial literacy • Investment/savings clubs • Livable wage • Building political power • Transforming race & class

36. Reproductive Life Plan • A written tool created by men and women that outlines their personal goals around having children. It states how to achieve these goals including action steps and interventions. It also addresses those areas that research indicates impact adverse birth outcomes.

37. Potential Benefits of Including Reproductive Life Plan Assessments into Routine Care • Starts a conversation that is patient centered and patient driven • Empowers women (and men, if included in their care) • Reframes pregnancy from chance to choice • Encourages individualized counseling (e.g. contraceptive options, interconceptional lengths, fertility considerations, etc) • May result in higher percentage of pregnancies identified as intended 37

38. Encouraging a Reproductive Life Plan: Example of Questions that could be in RLP • Do you hope to have any (more) children? • How many children do you hope to have? • How long do you plan to wait until you (next) become pregnant? • How much space do you plan to have between your pregnancies? • What do you plan to do until you are ready to become pregnant? • What can I do today to help you achieve your plan? 38

39. Precautions Reproductive life plans are never right or wrong: they are an approach for helping individuals plan, based on their own values and resources, how to achieve a set of personal goals about having children. Reproductive life plans are fluid—they should never be considered set in stone because “life happens”. 39

40. Impacting on the rate of unintendedness is more complex than the content of a single health related encounter Addressing and facilitating intentionaldecision making around if and when to have children is an appropriate health promotion and disease prevention activity that should be built into all clinical and community health encounters Knowing a woman’s intentions can focus much of the rest of the encounter 40

41. Social Service System Physical Environment Health Care System Behaviors & Lifestyle Physical Emotional Economic Environment Healthy Women Social Cognitive Family & Social Support Community & Culture Schools Used with permission of The Nemours Foundation, Division of Health and Prevention Services. Adapted from the 2005 Delaware Children’s Health Chartbook.

42. Achieving Health Equity by: Building a Social Movement, Investing in Ideas, Executing Tasks, Returning Results! 42 Linking Women to Health, Power and Love Across the Life Span

43. For more Information Contact: Mario Drummonds, MS, LCSW, MBA Executive Director/CEO Northern Manhattan Perinatal Partnership 127 W. 127th Street New York, NY 10027 (347) 489-4769 mdrummonds@msn.com