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

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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
• 1100 AM -1200 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
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Lecture Objectives

1. Discuss the concept of interconceptional care as
   aftercare.
2. Describe how interconceptional care improves
   birth outcomes, particularly in preventing LBW
   and prematurity.
3. 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.

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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
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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.

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Interconceptional Care

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

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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

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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

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HRSA Position

1. 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.
2. The National Healthy Start program includes
   interconceptional care as one of its nine core
   components in recognition of its important role
   in eliminating disparities.

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Traditional Perinatal Care Continuum
Labor and birth
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Primary care
Interconceptional period
Preconception period
Antepartum Labor and birth Postpartum
Well baby care
Postpartum visit
Prenatal care
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Lifespan Approach
Birth Early childhood Pre-teen Teen
Young adult Women 35 Seniors
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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 Womens Health Protocol Depression Group Work Womens Health Protocol
Perinatal Care UPK Beacon School College Prep Perinatal Care 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 Chronic Disease
Birth Early Child-hood Pre-Teen Teen Young Adult Womengt35 Senior Citizens
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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 Mamas Club Consumer Involvement Organization
Individual Impact OB/GYN Medical Homes Case Management Depression Screening Treatment
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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

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

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(No Transcript)
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Goals of Interconceptional Care

1. Increase access to womens healthcare.
2. Reduce low birth weight and infant mortality.
3. Reduce racial-ethnic disparities in mother and
   infant health outcomes.

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Interconceptional Period

• Provides an important opportunity to address
  risk factors identified in the last pregnancy
  relative to
• Womans lifelong health status
• Potential impact on future pregnancies
• Pregnancy is a stress test for life

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Pathways to Care
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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).

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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

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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

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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

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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

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Core Contents
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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

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Risk Assessment FINDS

• Family violence
• Infections/Immunizations
• Nutrition
• Depression
• Stress

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Risk Assessment FINDS

• Family violence
• Infections/Immunizations
• Periodontal
• Chlamydia
• Other sexually transmitted or urogenital tract
  infections in selected populations
• Nutrition
• Depression
• Stress

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Risk Assessment FINDS

• Family violence
• Infections/Immunizations
• Diptheria-tetanus toxoids booster
• Hepatitis B vaccines
• Measles and mumps
• Rubella
• Varicella
• Nutrition
• Depression
• Stress

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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.

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Health Promotion BBEEFF

• Breastfeeding
• Back-to-sleep
• Exercise
• Exposures
• Household molds and dust mites
• Lead
• Mercury
• Dioxins
• Folate
• Family planning

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Health Promotion BBEEFF

• Breastfeeding
• Back-to-sleep
• Exercise
• Exposures
• Folate
• Family planning
• Reproductive life plan
• Contraceptive use

Lu, M.
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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.
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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.
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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

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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.

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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

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Encouraging a Reproductive Life Plan Example of
Questions that could be in RLP

1. Do you hope to have any (more) children?
2. How many children do you hope to have?
3. How long do you plan to wait until you (next)
   become pregnant?
4. How much space do you plan to have between your
   pregnancies?
5. What do you plan to do until you are ready to
   become pregnant?
6. What can I do today to help you achieve your plan?

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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 fluidthey should
  never be considered set in stone because life
  happens.

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• 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 womans intentions can focus much of
  the rest of the encounter

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Used with permission of The Nemours Foundation,
Division of Health and Prevention Services.
Adapted from the 2005 Delaware Childrens Health
Chartbook.
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Linking Women to Health, Power and Love Across
the Life Span
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For more Information Contact

• Mario Drummonds, MS, LCSW, MBA
• Executive Director/CEO
• Northern Manhattan Perinatal Partnership
• 127 W. 127th Street
• New York, NY 10027
• [phone]
• mdrummonds_at_msn.com