BIHCC Collaborative Learning Conference Call 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

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

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

Terminology Interconception Internatal care Interpregnancy Interval 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

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

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

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

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. Grantees were less likely to offer services that addressed medical risk factors, including hypertension follow-up (74 percent), diabetes follow-up (73 percent), and obesity reduction (71 percent). When these services were offered, grantees reported they were typically received by fewer than half of all interconceptional clients. 9 9

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

Lifespan Approach Birth Early childhood Pre-teen Teen Young adult Women 35≥ Seniors Diminished role and impact of prenatal care. Maternal health prior to pregnancy is key. Explores and learns from history of poor birth outcomes It will take more than one generation to equalize birth disparities 11

New MCH Life Course Continuum Axis 1 Centering Pregnancy Child Abuse Prevention Latch-Key Program Managing Relationships Health Policy Activities Reproductive Social Capital Internatal Care School Readiness Fitness & Health Activities Pregnancy Prevention Women’s Health Protocol Depression Group Work Perinatal Care UPK Beacon School College Prep Reproductive Life Planning Specialty Care Harlem Birthing Center Early Head Start/ Head Start Health/ Life Stories Telling Preconception Inter- conceptional Care Chronic Disease Chronic Disease Management Birth Early Child-hood Pre-Teen Teen Young Adult Women>35 Senior Citizens

MCH Life Course Organization Social Determinants to Health Axis 2 Public Policy Initiatives Economic Empowerment Zone Supermarket Zone Expansion Policy NYC Affordable Housing Policy Community Environmental Impact St. Nick Tenant Organizing Food & Fitness Coalition Affording Housing Organizing Organizational Impact Healthy Start Consortium Diabetes Prevention Coalition Harlem Works Job Readiness Group/ Interpersonal Impact Centering Pregnancy Baby Mama’s Club Consumer Involvement Organization Individual Impact OB/GYN Medical Homes Case Management Depression Screening & Treatment

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

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

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

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

Pathways to Care 19 screening Intake & Assessment Pregnant Prenatal case management Interconceptional case management Not Pregnant 19

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

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

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

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

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

Core Contents 25 Risk Assessment Reproductive Life Plan Health Promotion Clinical Interventions Psychological Interventions Socioeconomic Interventions Male Involvement Reassessment at 90 days Update Reproductive Life Plan (as needed) 25

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

Risk Assessment: FINDS Family violence Infections/Immunizations Nutrition Depression Stress Go back to the training from the LCC in August and revisit the tools that are being used to capture this data. Lu, M.

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

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

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.

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

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

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 Clinical breast examination Every 3 year beginning at age 20 Screening mammography every 1-2 years beginning at age 40 Lu, M.

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.

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

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.

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

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

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

Impacting on the rate of unintendedness is more complex than the content of a single health related encounter Addressing and facilitating intentional decision 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

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

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

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 43 43