A Key Strategy to Reduce Infant Mortality

 Preconception care: care a woman gets before she becomes pregnant, prior to conception  Interconception care: care for women who have had a prior adverse pregnancy outcome to address risks

identify and modify biomedical, behavioral, and social risks prevention and management “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, emphasizing those factors which must be acted on before conception or early in pregnancy to have maximal impact.” CDC’s Select Panel on Preconception Care, June 2005

 Many risk factors for infant mortality, preterm birth, and other adverse pregnancy outcomes are related to maternal health.  Experts have identified a wide array of evidence-based interventions that would benefit pregnancy woman and/or infants particularly if provided prior to pregnancy (Jack et al. 2008)

 High quality prenatal care is essential but care during pregnancy cannot : ◦ ameliorate risks associated with women’s health status when not pregnant ◦ Ameliorate risks associated with pregnancies with short interpregnancy interval ◦ Ameliorate risks associated with unintended and unplanned pregnancies

 Reduce unintended pregnancy  Increase appropriate birth spacing  Increase contraception access  Given that half of all pregnancies are unplanned, preconception/interconception care is critical to enhancing the likelihood of a healthy pregnancy outcome  According to the Guttmacher Institute, for every $1 spent on family planning, $3.74 is saved

 Hypertension  Diabetes  STIs and UTI and other infections including bacterial vaginosis  Immunization status  Folic Acid and other micronutrients  Teratogens (e.g., prescription medications, household exposures)  Mental Health

ComponentQualityComponentQualityComponentQuality MultivitaminsIThyroid Disease II-1 Family Planning III Vitamin DIPKU II-1 Weight Status III DiabetesISeizures II-2 Nutrient Intake III TobaccoI-aHypertension II-2 OTC Medication III FolateI-aVitamin A II-2 Underweight III Prior PTB infantI-aCalcium II-2 Eating Disorders III Prior miscarriage1-aPrescription II-2 Immunizations III Chlamydia1-aPrior C-Section II-2 STIs III OverweightI-a/ II a Substance Use II-2/ III Cancer III HIVI-bMMR II-3 Hepatitis B III Dietary Supplements II-c Household Exposure III Rheumatoid Arthritis III Jack, Atrash, et al., 2008

Component of PCC QualityComponent of PCC Quality Alcohol I-a Depression/Anxiety III SyphilisII-1 Schizophrenia III HSV II-1 Bipolar disease III Prior stillbirth II-2 All individuals III Tuberculosis II-2 dTaP III Gonorrhea II-2 Varicella III HPV II-2 Mercury III Lupus II-2 Soil and water hazards III Renal Disease II-2 Workplace exposure III Family historyII-3 Women with disabilities III Ethnicity-based II-3 Males III Asthma II-3CardiovascularIII-3 Uterine anomalies II-3 Jack, Atrash, et al., 2008

 Smoking  Drugs  Alcohol  Nutrition  Exercise  Healthy weight

Percent of Women in Medicaid Percent of All Women Preconception (Pre-pregnancy) Risks and Protective Factors Tobacco use Alcohol use Multi-vitamin use Stress Overweight Obesity Nonuse of Contraceptives Interconception/ Postpartum (PP) Risks and Protective Factors Prior LBW Prior Preterm Use of Contraceptives Tobacco use PP Depression Source: Centers for Disease Control and Prevention. D’Angelo et al. Preconception and Interconception Health Status of Women Who Recently Gave Birth to a Live-Born Infant. MMWR. 2007; Vol. 56 /SS-10.

 Preconception health and well-woman health concepts have been advance but our commitment and investments: ◦ Have not been fully transformed into a national strategy to ensure every woman has a medical / health care home. ◦ Are limited with 4 in 10 low-income women having no health insurance public or private. ◦ Need a commitment to access for women’s clinical and community preventive services as in ACA.

 ACA coverage  ACA preventive benefits, including well- woman visits and preconception care  Family Planning –Title X: vital infrastructure must be supported and expanded even in the face of coverage expansion  Medicaid coverage - women’s postpartum coverage must be extended beyond 60 days  Family Planning – Medicaid Family Planning waivers and State Plan Amendments

 ACA requires all health plans (except those grandfathered and Medicaid) to cover certain preventive services without cost- sharing.  As of Aug. 1, 2012, estimated 47 million insured women enrolling in new health plans or renewing their existing policies will have coverage for preventive health services without cost- sharing: ◦ Well-woman visits (annual preventive visit including preconception care) ◦ Gestational diabetes screening ◦ HPV DNA testing ◦ STI counseling ◦ HIV Screening and counseling ◦ Contraception and contraceptive counseling ◦ Breast-feeding support, supplies, and counseling ◦ Interpersonal and domestic violence screening and counseling  Plus immunizations and other services recommended by the U.S.Task Force on Clinical Preventive Services.

Family planning counseling and use of reproductive life plan  Screen women about intentions to become or not become pregnant and their risk of conceiving.  Encourage use of a reproductive life plan and educate on how it effects contraceptive and medical decisions  Provide information and counseling about all forms of contraception. Physical activity  Assess weight-bearing and cardiovascular exercise and offered recommendations. Nutrition  Calculate BMI calculated at least annually.  When BMI > 26 kg/m g, counsel about risks to their own health, the risks for exceeding the overweight category, and the risks to future pregnancies, including infertility. Offer behavioral strategies and support for enrolling in structured weight loss programs.  When BMI<19.8 kg/m g should be counseled about the short- and long-term risks to their own health and the risks to future pregnancies, including infertility. A ssess for eating disorders and distortions of body image. Nutrient intake  Advise to ingest 0.4 mg of folic acid daily from food and/or supplements and to consume diet of folate-rich food. Immunizations  Assess and update immunization status for tetanus, diphtheria, pertussis; MMR; and varicella.  Assessed for health, lifestyle, and occupational risks for other infections and offered indicated immunizations. Infectious Disease  Assess STI risks, provide counseling and preventive interventions, and provide STI testing and treatment. Parental Exposures  Assess for the use of tobacco, and those who smoke should be counseled, using the 5 As, to limit exposure.  Assess alcohol use patterns and risky drinking behaviors and provided with appropriate counseling.  Advise of risks to the embryo/fetus of alcohol exposure in pregnancy and that no safe level of consumption has been established.

 We need a national campaign to ensure women take advantage of the preventive health visit. ◦ Women need to know about their “right” to preventive health care ◦ Health care providers need training/education in well-woman health care across the life course. ◦ Develop and implement clinical guidelines for well- woman visit ◦ Develop systems of care in which women do not fall through the cracks (e.g., medical care home; link between prenatal, postpartum and well-woman health care) – Key Role for Title V