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Emerging Issues Preconception Health

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1 Emerging Issues Preconception Health
Comprehensive Perinatal Services Program Statewide Perinatal Services Coordinators Meeting November 3, 2011 Flojaune Griffin, PhD, MPH Preconception Health Coordinator Policy Development Branch Maternal, Child and Adolescent Health Division

2 Acknowledgements Preconception Health at the California Department of Public Health, Maternal, Child and Adolescent Health Division is funded by Title V federal block grant Interconception Care Project of California © 2011 Domestic Violence and Reproductive Coercion

3 Presentation Outline Overview of Interconception Health and its importance Interconception Care Project of California Clinical measures and health behaviors of interest between pregnancies Domestic Violence and Reproductive Coercion By identifying populations in greatest need and targeting programming efforts in preconception and interconception health

4 What is Interconception Health?

5 Definition of Terms Preconception Health status and risks before first pregnancy; health status shortly before any pregnancy Interconception Period between pregnancies

6 Preconception/Interconception Health Conceptual Framework
“Trickle Down” Theory The health status of girls and women prior to pregnancy The health status of pregnant women The initial goal to improve pregnancy outcomes was increasing access to and utilization of PNC; While some service gaps still exist, close to 90% of CA mothers receive PNC in the 1st trimester, yet there are increases in maternal morbidities and mortality and stagnant infant outcomes including birthweight, gestational age, and infant mortality Life course model: Preconception health model focuses on a limited, though broader scope of the life course Understanding of the timeline (health over the lifetime dependent on previous experiences), timing (sensitive periods), environment (physical, social, economic and capacity for change) and equity (health disparities) The health status of newborns and infants

7 Interconception Health
Interconception health refers to a woman's health during the non-pregnant interval between two pregnancies  Goal: promote wellness and prevent or treat conditions and risk behaviors, so that if she becomes pregnant again, her own health and the health of her children will be optimized A holistic approach to women’s health Not limited to health care providers

8 Interconception Health and the Life Course Perspective
Excellent Health Exercise Education Health Care Family Planning Safe Neighborhood Optimal Birth Outcome Healthy Relationships Financial Security Planned Pregnancy Risk Factors Protective Factors Nutrition Healthy Relationships Social Support Disparity at Birth Poor Nutrition Obesity Unsafe Neighborhood Poor Education Lack of Health Care No Family Planning Tobacco/Alcohol Drugs Adverse Childhood Events Exposure to Toxins Poverty No Social Support Mistimed Pregnancy Poor Health Poor Birth Outcome Conception Birth Age 5 Puberty Pregnancy Delivery Pregnancy

9 Early and Adequate Prenatal Care
Early prenatal care is defined as entry during the first trimester (this measure is not the same as that defined by the Kotelchuck index = entry in months 1 and 2); Adequate prenatal care is defined as meeting or exceeding 80% of the expected visits. No evaluation of the content of PNC visits is included in the measure of adequacy. Adequacy is also independent of the adequacy of initiation. Adequacy of prenatal care is defined by the proportion of observed visits to recommended visits, adjusted for data of initiation of PNC or reducing, that number based on the date of PNC initiation. ACOG visit standards are one visit per month through 28 weeks (7 visits), one visit every 2 weeks through 36 weeks (4 visits), and one visit per week thereafter (3 visits). For example, in a 40-week pregnancy ACOG recommends 14 visits; however, if PNC began in month 4 (3 missed visits), then the expected number of visits = 11 (14-3). The proportion of observed visits/expected visits is scaled: Inadequate = 0-49% of expected visits Intermediate = % Adequate = % Adequate plus = 110+% Data Source: California Birth Statistical Master File, 2009. Notes: 1) All values exclude non-California residents; 2) Early PNC is defined as entry during the first trimester and excludes births with unknown PNC initiation; 2) Adequate prenatal care is defined >=80% of recommended visits using the Kotelchuck Index and excludes records with missing PNC data; 3) PI = Pacific Islander; AI/AN = American Indian/Alaska Native. Prepared by the Epidemiology, Assessment and Program Development Branch, MCAH Program

10 Critical Periods of Development
We Currently Intervene Too Late Critical Periods of Development Weeks gestation from LMP Most susceptible Central Nervous System time for major malformation Heart Arms Eyes Legs Teeth The most critical periods of fetal development occur in the first 5-8 weeks following conception Prenatal care typically begins around week 12 – too late to prevent many adverse maternal and infant health outcomes The preconception health status of women of reproductive age is not optimal: Overweight and Obesity Diabetes Smoking and Alcohol Folic Acid Consumption Domestic Violence Mental Health Concerns Rising prevalence of chronic conditions such as obesity and diabetes Overweight/obesity before or during pregnancy has been associated with gestational diabetes, maternal hypertension, increased C-section rates, preterm birth and birth defects The risk of congenital malformations in the general population is 2-3% compared to 3-8% to 6-12% among women with pre-gestational diabetes.* It is estimated that 45% of live births in California each year result from unintended pregnancies Missed opportunity to attain optimal pre-pregnancy health particularly in high-risk populations Risk of early pregnancy exposure to alcohol and teratogenic medications Palate External Genitalia Ear Missed Period Mean Entry into Prenatal Care 10 10

11 The Importance of Timing
Many outcomes or their determinants are present before an obstetrician ever meets a patient Important Examples: Pregnancy Intention Timing of entry into prenatal care Interpregnancy interval Maternal age Spontaneous abortion Abnormal placentation Chronic disease control Congenital anomalies

12 Preconception Health Initiative Goals
To improve the knowledge, attitudes, and behaviors of men and women related to preconception health. To guarantee that all California women of childbearing age receive preconception care services that will allow them to be at their best before pregnancy To reduce risks indicated by a prior adverse pregnancy outcome through interventions in the interconception period Based on the summit presentations and subsequent expert panel deliberations, a refined definition was developed and 10 recommendations were identified. These recommendations were based on four overarching goals that were identified as critical for women reaching optimal health and realizing their reproductive goals. These four broad goals are: Kay Johnson, State Roles in Preconception Health and Health Care, Oct. 2009

13 Interconception Health Messages and the Postpartum Visit

14 Current Landscape Women who have had a poor birth outcome in a prior pregnancy are at increased risk for having another poor birth outcome in a subsequent pregnancy The recurrence risk varies by diagnosis, but is significant: 15 to 30 percent for Preterm Delivery 20 to 60 percent for Pre-Eclampsia 2-12 fold risk for Low Birthweight infants Closely spaced pregnancies (<18 months) are associated with increased Complications Low Birthweight, Small Size for Gestational Age, Preterm Birth; Rapid Repeat Birth (<6 months) Infant Death THE POSTPARTUM VISIT: AN OVERLOOKED OPPORTUNITY FOR PREVENTION Sarah Beth Verbiest, Master of Social Work and Master of Public Health, University of North Carolina

15 Postpartum Visit Opportunity to assess previous pregnancy complications and to formulate a plan to minimize future pregnancy adverse events Part of a holistic approach to ensuring women’s health across the lifespan The post-partum visit is often a missed opportunity to address interconception health Identified Needs: Consensus for Care and Guidelines In patients with gestational diabetes, continuity between antenatal and postpartum care was associated with a two-fold higher rate of appropriate postpartum testing.* One study found that, among participants in Kaiser Permanente’s Early Start prenatal substance abuse program who assessed positive for risk during pregnancy, there was no indication that providers asked about alcohol use in 83 percent of the charts, drug use in 57 percent of the charts, and tobacco use in 26 percent of the charts during the postpartum period.** Identified Needs: Consensus among obstetric providers regarding postpartum care Post-partum Care Guideline for obstetric providers that incorporates risk assessment based on the previous pregnancy and develops recommendations for future care

16 Attendance at Postpartum Visit
Medicaid participation is 59.1% Private Insurance 79.9% Kaiser Permanente participation is 94% The State of Health Care Quality 2007 Kaiser Permanente 2011

17 Maximizing the Post-partum Visit: Interconception Care Project for California
March of Dimes and ACOG District IX Project with Preconception Health Council of California (PHCC) Goal: Produce post-partum care guidelines for obstetric providers that incorporate risk assessment based on the previous pregnancy and develop recommendations for future care Methods: Through a cooperative agreement with March of Dimes, the American Congress of Obstetricians/Gyncologists, District IX (California) formed the Interconception Care Advisory Council (ICAC), a group of experts in their fields of medicine and public health. The group identified the 10 most common pregnancy and delivery complications and risk factors from the California Office of Statewide Health Planning and Development hospital discharge data from 1999 to Over a period of nine months, the 29 ICAC members developed clinical algorithms and patient educational materials for these areas of focus. 17

18 ICPC Guidelines Development Process
Identify an Interconception Care Advisory Council Identify interventions/messages that ALL postpartum women should receive Identify most common diagnoses or identifiable risks for pregnancy complications based on California delivery data Analyze evidence-based recommendations for treatment Develop one-page algorithm for each condition that will assist providers in assessments and referrals Produce web-based guidelines on each high risk diagnosis

19 ACOG Interconception Care
Logic Model Identify an Interconception Care Advisory Council (ICAC), an expansion from the PHCC clinical sub-group (Spring 2009) Identify 10 most common diagnoses for pregnancy complications based on California delivery data (Spring/Summer 2009) Develop sub-groups for each diagnosis to analyze evidence-based recommendations for treatment (Summer 2009) Conduct literature review on diagnoses/conditions; develop recommendations and patient algorithms (Fall 2009) Review findings, reach consensus (in-person meeting: January 30, 2010) Each sub-group to submit final recommendations and algorithm to ICAC (February 2010) Comprehensive literature review on each diagnosis (condition) Selected 4-5 key articles Prepared one-page summary of each article Summaries to be included in final toolkit for providers

20 ICPC Guidelines Content Areas
Alcohol Use Anemia Domestic Violence Gestational Diabetes Gonorrhea and Chlamydia Hepatitis HIV Hypertension Migraine Obesity Postpartum Depression Preeclampsia Preterm Birth Cesarean Section Seizure Substance Abuse Syphilis Thrombocytopenia Thyroid Disorder Tobacco Use Vaccinations ICD-9 Code research conducted to determine 10 most common diagnoses during pregnancy: Recommendations based on previous pregnancy outcome can reduce future adverse outcomes: In patients with gestational diabetes, continuity between antenatal and postpartum care was associated with a two-fold higher rate of appropriate postpartum testing.* Yet the postpartum visit often does not involve this kind of assessment: One study found that, among participants in Kaiser Permanente’s Early Start prenatal substance abuse program who assessed positive for risk during pregnancy, there was no indication that providers asked about alcohol use in 83 percent of the charts, drug use in 57 percent of the charts, and tobacco use in 26 percent of the charts during the postpartum period.** 20

21 ICPC Prevailing Messages
Three standard interconception messages that ALL women should receive at the post-partum visit Messages printed on Patient Algorithms and Provider Handouts Three to five standard interconception messages that ALL women should receive at the post-partum visit (to be determined). For example:

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25 Emerging Issues in Preconception Health: Reproductive Coercion and Birth Control Sabotage

26 How does domestic violence impact women's perinatal health and their birth outcomes?
Estimated Activity Time: 15 minutes Notes to Trainer: For this activity, you will need a flipchart and markers. Ask participants to call out responses to the question “How does domestic violence impact women’s perinatal health and their birth outcomes?” Repeat participants’ responses, clarify as needed and give hints about what is missing. For example, if depression has not been mentioned the facilitator could ask , “So let’s talk about how this might impact moms’ feelings or emotional health…” If you are working with another trainer, one of you should be the note-taker. The note-taker records what the participants call out onto the flipchart and then tapes sheets when they are full around the room so the responses can be seen by the audience. When the trainer feels that some of the key effects have been identified, move forward through the next slides in this module to review and highlight examples that were given, as well as anything that was missing.

27 Homicide is the second leading cause of injury-related deaths among pregnant women.
Notes to Trainer: Inform participants that a majority of female homicides are women who were murdered by a current or former intimate partner. Pregnancy-associated homicides were analyzed with a national dataset ( ) from the Pregnancy Mortality Surveillance System at the Centers for Disease Control and Prevention for this study. Pregnancy-associated injury deaths and homicides were defined as women who died during or within one year of pregnancy. Of all pregnancy-associated injury deaths, motor vehicle accidents was the leading cause (44.1%) and homicide was the second leading cause (31.0%). The rest of the pregnancy-associated injury deaths were attributed to unintentional injuries (12.7%), suicides (10.3%), and other (2.0%). Chang J, Berg CJ, Saltzman LE, Herndon J. Homicide: A Leading Cause of Injury Deaths Among Pregnancy and Postpartum Women in the United States, American Journal of Public Health. 2005;95(3): (Chang et al, 2005)

28 Smoke tobacco Drink during pregnancy Use drugs Experience depression, higher stress, and lower self-esteem Attempt suicide Receive less emotional support from partners Women Who Experience Abuse Around the Time of Pregnancy Are More Likely to: (Amaro, 1990; Bailey & Daugherty, 2007; Berenson et al, 1994; Campbell et al, 1992; Curry, 1998; Martin et al, 2006; Martin et al, 2003; Martin et al, 1998; McFarlane et al, 1996; Perham-Hester & Gessner, 1997) Experiencing domestic violence around the time of pregnancy has been shown to be associated with substance abuse, mental health problems, and other risk behaviors that are associated with poor pregnancy outcomes. Amaro H, Fried LE, Cabral H. Zuckerman B. Violence During Pregnancy and Substance Use. American Journal of Public Health. 1990;80(5): Bailey BA, Daugherty RA. Intimate Partner Violence During Pregnancy: Incidence and Associated Health Problems in a Rural Population. Maternal and Child Health Journal. 2007;11(5): Berenson AB, Wiemann CM, Wilkinson GS, Jones WA, Anderson GD. Perinatal Morbidity Associated with Violence Experienced by Pregnant Women. American Journal of Obstetrics and Gynecology. 1994;170: Campbell JC, Poland ML, Waller JB, Ager J. Correlates of Battering During Pregnancy. Research in Nursing and Health. 1992;15: Curry MA. The Interrelationships Between Abuse, Substance Use, and Psychosocial Stress During Pregnancy. JOGNN. 1998;27(6): Martin SL, Beaumont JL, Kupper LL. Substance Use Before and During Pregnancy: Links to Intimate Partner Violence. American Journal of Drug and Alcohol Abuse. 2003;29: Martin SL, Kilgallen B, Dee DL, Dawson S, Campbell JC. Women in Prenatal Care/Substance Abuse Treatment Programme: Links between Domestic Violence and Mental Health. Journal of Maternal and Child Health. 1998;2:85-94. McFarlane J, Parker B. Soeken K. Physical Abuse, Smoking and Substance Abuse During Pregnancy: Prevalence, Interrelationships and Effects on Birth Weight. Journal of Obstetrics, Gynecology and Neonatal Nursing. 1996;25: Perham-Hester KA, Gessner BD. Correlates of Drinking During the Third Trimester of Pregnancy in Alaska. Maternal and Child Health Journal. 1997;1(3):

29 Tobacco Cessation and DV
42% of women experiencing some form of DV could not stop smoking during pregnancy compared to 15% of nonabused women. In this retrospective study by Bullock et al. (2001), rural postpartum women (n=293) were interviewed during their hospital stay about their tobacco use and experiences with DV. DV was measured with the Abuse Assessment Screen which includes questions on physical, sexual, and emotional abuse within the past year and since pregnancy. The rate of smoking among abused women during pregnancy is in agreement with other prospective studies that found between 44% and 60% of abused women continue to smoke during pregnancy. Bullock LFC, Mears JLC, Woodcock C, Record R. Retrospective Study of the Association of Stress and Smoking During Pregnancy in Rural Women. Addictive Behaviors. 2001;26: (Bullock et al, 2001)

30 Impact of Psychological Abuse
Psychological abuse by an intimate partner was a stronger predictor than physical abuse for the following health outcomes for female and male victims: Depressive symptoms Substance use Developing a chronic mental illness In this study: Women were significantly more likely than men to experience physical or sexual abuse and abuse of power and control by an intimate partner compared to men. Both physical and psychological abuse by an intimate partner were associated with significant physical and mental health problems for male and female victims. Coker AL, Smith PH, Thompson MP, McKeown RE, Bethea L, Davis KE. Social Support Protects Against the Negative Effects of Partner Violence on Mental Health. Journal of Women’s Health & Gender-Based Medicine. 2002;11(5): (Coker et al, 2002)

31 Domestic Violence During Pregnancy is Associated With
Lower gestational weight gain during pregnancy (Moraes et al, 2006) Low and very low birth weight (Lipsky et al, 2003) Pre-term births (Silverman et al, 2006) Numerous studies have documented the impact of domestic violence on pregnancy. An overview of the effects of domestic violence on women’s reproductive health and pregnancy can be found in a review study by Sarkar (2008). Lipsky S, Holt VL, Esterling TR, Critchlow C. Police-Reported Intimate Partner Violence During Pregnancy and Risk of Antenatal Hospitalization. Maternal and Child Health Journal. 2009;8(2):55-63. Moraes CL, Amorim AR, Reichenheim ME. Gestational Weight Gain Differentials in the Presence of Intimate Partner Violence. International Journal of Gynaecology and Obstetrics. 2006;95: Silverman JG, Decker MR, Reed E, Raj A. Intimate Partner Violence Victimization Prior to and During Pregnancy Among Women Residing in 26 U.S. States: Associations with Maternal and Neonatal Health. American Journal of Obstetrics and Gynecology. 2006;195: Sarkar NN. The Impact of Intimate Partner Violence on Women’s Reproductive Health and Pregnancy Outcome. Journal of Obstetrics and Gynaecology. 2008;28(3):

32 Domestic Violence and Breastfeeding
Women experiencing physical abuse around the time of pregnancy are: 35%-52% less likely to breastfeed their infants 41%-71% more likely to cease breastfeeding by 4 weeks postpartum This study analyzed data from 26 U.S. states that participated in the Pregnancy Risk Assessment Monitoring System (PRAMS). Domestic violence (DV) was measured by two questions as follows: “During the 12 months before you got pregnant, did your husband or partner push, hit, slap, kick, choke or physically hurt you in any other way?” “During your most recent pregnancy, did your husband or partner push, hit, slap, kick, choke, or physically hurt you in any other way?” Women who reported DV in the year prior to pregnancy but not during pregnancy, women who reported DV during pregnancy but not in the year prior to pregnancy, and women who reported DV during the year prior to pregnancy and during pregnancy were significantly less likely to breastfeed their infants. Silverman JG, Decker MR, Reed E, Raj A. Intimate Partner Violence Victimization Prior to and During Pregnancy Among Women Residing in 26 U.S. States: Associations with Maternal and Neonatal Health. American Journal of Obstetrics and Gynecology. 2006;195: (Silverman et al, 2006)

33 Postpartum Maternal Depression
Women with a controlling or threatening partner are X more likely to experience persistent symptoms of postpartum maternal depression This data is from the Alaska Pregnancy Risk Assessment Monitoring System (PRAMS). Women completed a survey within a few months after delivery and were then contacted again approximately two years later. Blabey MH, Locke ER, Goldsmith YW, Perham-Hester KA. Experience of a Controlling or Threatening Partner Among Mothers with Persistent Symptoms of Depression American Journal of Obstetrics & Gynecology. 2009;201:173.e1-9. (Blabey et al, 2009)

34 Women Who Talked to Their Health Care Provider About the Abuse Were
4 times more likely to use an intervention 2.6 times more likely to exit the abusive relationship Notes to Trainers: This section closes with a review of the research that has shown that just having the opportunity to talk to a health care provider about domestic violence can increase access to domestic violence services. Examples are also provided for home visitation programs that have had significant impact on domestic violence. In this study by McCloskey et al. (2006), 132 women outpatients who disclosed domestic violence in the preceding year were recruited from multiple hospital departments and community agencies. Abused women who talked with their health care providers about the abuse were more likely to use an intervention and exit the abusive relationship. Women who were no longer with their abuser reported better physical health than women who stayed. McCloskey LA, Lichter E, Williams C, Gerber M, Wittenberg E, Ganz M. Assessing Intimate Partner Violence in Health Care Settings Leads to Women’s Receipt of Interventions and Improved Health. Public Health Reporter. 2006;121(4): (McClosky et al. 2006)

35 Definition: Reproductive Coercion
involves behaviors that a partner uses to maintain power and control in a relationship that are related to reproductive health: Explicit attempts to impregnate a partner against her wishes Controlling outcomes of a pregnancy Coercing a partner to have unprotected sex Interfering with birth control methods

36 Domestic violence increases women’s risk for
Unintended Pregnancies Sarkar conducted a literature review of publications from 2002 through 2008 on the impact of domestic violence on women’s reproductive health and pregnancy outcomes. In a study by Goodwin et al (2000), women who had unintended pregnancies were 2.5 times more likely to experience physical abuse compared to women whose pregnancies were intended. Goodwin MM, Gazmararian JA, Johnson CH, et al. Pregnancy Intendedness and physical abuse around the time of pregnancy: Findings form the pregnancy risk assessment monitoring system, PRAMS Working Group. Pregnancy Risk Assessment Monitoring System. Maternal and Child Health Journal. 2000;4(2):85-92. Sarkar NN. The Impact of Intimate Partner Violence on Women’s Reproductive Health and Pregnancy Outcome. Journal of Obstetrics and Gynaecology. 2008;28(3): (Sarkar, 2008)

37 Adolescent mothers who experienced physical abuse within three months after delivery were nearly twice as likely to have a repeat pregnancy within 24 months Why is Reproductive Coercion Important? Rapid Repeat Pregnancy In this study with teenage mothers (ages 12-18) who were recruited from a labor and delivery unit at a university hospital, physical abuse by an intimate partner was defined as being hit, slapped, kicked, or physically hurt enough to cause bleeding or having been hit during an argument or while her partner was drunk or high. The odds of repeat pregnancy was 1.9 times higher among teen mothers who were physically abused by their partner within three months of delivery compared to non-abused teen mothers. Raneri LG, Wiemann CM. Social Ecological Predictors of Repeat Adolescent Pregnancy. Perspectives on Sexual and Reproductive Health. 2007;39(1):39-47. (Raneri & Wiemann, 2007)

38 Teen Birth Control Sabotage
Among teen mothers on public assistance who experienced recent domestic violence: 66% experienced birth control sabotage by a dating partner 34% reported work or school- related sabotage by a dating partner In this study by Raphael (2005), 474 teen girls on Temporary Assistance to Needy Families completed written surveys. The teens were recruited from two state-funded Teen Parent Services sites and two community-based health clinics. Seventy percent were between the ages of 15 and 17 at the time of the birth of their first infant (mean =18 years) and 95% of the girls were African Americans. Almost half (43%) of the girls were involved with males who were older by 4 or more years. Fifty-five percent disclosed domestic violence in the past 12 months. Findings included: Two-thirds (66%) of teen dating violence victims experienced birth control sabotage compared to 34% of non-abused teens 34% of teen dating violence victims reported work or school related sabotage compared to 7% of teens who did not experience dating violence but were sabotaged in relation to work or school. Raphael J. Teens Having Babies: The Unexplored Role of Domestic Violence. The Prevention Researcher. 2005;12(1):15-17. (Raphael, 2005)

39 Birth Control Sabotage
Tactics include: Destroying or disposing contraceptives Impeding condom use (threatening to leave her, poking holes in condoms) Not allowing her to obtain or preventing her from using birth control Threatening physical harm if she uses contraceptives Qualitative and quantitative research have shown an association between birth control sabotage and domestic violence. Fanslow et al. (2008) conducted interviews with a random sample of 2,790 women who had ever had sexual intercourse. Women who had ever experienced domestic violence were more likely to have had partners who refused to use condoms or prevented women from using contraception compared to women who had not experienced domestic violence (5.4% vs. 1.3%). Miller et al (2007) conducted interviews with 53 sexually active adolescent females. One-quarter (26%) of participants reported that their abusive male partners were actively trying to get them pregnant. Common tactics used by abusive male partners included: Manipulating condom use Sabotaging birth control use Making explicit statements about wanting her to become pregnant Campbell J, Pugh LD, Campbell D, Visscher M. The Influence of Abuse on Pregnancy Intention. Women’s Health Issues. 1995;5: Coggins M, Bullock LF. The Wavering Line in the Sand: the Effects of Domestic Violence and Sexual Coercion. Issues in Mental Health Nursing. 2003:24(6-7): Fanslow J, Whitehead A, Silva M, Robinson E. Contraceptive Use and Associations with Intimate Partner Among a Population-based Sample of New Zealand Women. Australian & New Zealand Journal of Obstetrics & Gynaecology. 2008;48(1):83-89. Lang DL, Salazar LF, Wingood GM, DiClemente RJ, Mikhail I. Associations Between Recent Gender-based Violence and Pregnancy, Sexually Transmitted Infections, Condom Use Practices, and Negotiation of Sexual Practices Among HIV-Positive Women. Journal of Acquired Immune Deficiency Syndromes. 2007;46(2): Miller E, Decker MR, Reed E, Raj A, Hathaway JE, Silverman JG. Male Partner Pregnancy-Promoting Behaviors and Adolescent Partner Violence: Findings From a Qualitative Study with Adolescent Females. Ambulatory Pediatrics. 2007;7(5): Wingood GM, DiClemente R. The effects of an Abusive Primary Partner on the Condom Use and Sexual Negotiation Practices of African-American Women. Journal of Public Health. 1997;87:

40 Invisible Contraception
Birth Control Methods That Are Less Likely to be Detected by a Sexual Partner

41 A Vision for Improving Preconception Health and Pregnancy Outcomes
All women and men have high reproductive knowledge All women have a reproductive life plan All pregnancies are intended All women of childbearing age have health coverage All women of childbearing age are screened prior to pregnancy for risks related to outcomes Women with a prior pregnancy loss have access to interconception care aimed at reducing their risks

42 For Additional Information or Questions Contact:
Flojaune Griffin, PhD, MPH Preconception Health Coordinator Maternal, Child and Adolescent Health Division (916) For more information on Preconception Health, please visit:


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