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Interconception Care

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Title: Interconception Care


1
Interconception Care
  • Presentation to
  • The National Summit on Preconception Care
  • June 21, 2005

Lorraine V. Klerman, Dr.P.H. The Institute for
Child, Youth, and Family Policy The Heller School
for Social Policy and Management, Brandeis
University
2
Interconception Care
  • Interconception care is a subset of preconception
    care
  • If not targeted would include
  • All women with prior pregnancy
  • 4 million births per year, plus stillbirths,
    miscarriages, abortions
  • But still less than all women 15-44
  • If targeted would include
  • Only women at elevated risk
  • This may be within our reach in this decade.

3
Who is at Elevated Risk?
  • Women who experienced
  • Live birth, but preterm, IUGR, congenital
    anomalies
  • Stillbirth, miscarriage, elective abortion
  • Women with chronic disease, regardless of prior
    pregnancy experience
  • Women with history of STDs
  • Women who smoke, drink, use illicit drugs
  • Women with physical, mental, or emotional
    disabilities

4
What Do We Want To Accomplish ThroughInterconcep
tion Care?
5
For all women with prior pregnancy
  • Folic acid fortification
  • Treatment of dental conditions
  • Diagnosis and treatment of infections
  • Adequate immunization status
  • Family planning
  • Help reach familys childbearing objectives
  • Avoid unintended pregnancies
  • Counsel about optimal birth intervals

6
Healthy People 2010 Objective for Interpregnancy
Intervals
  • Reduce the proportion of births occurring within
    24 months of a previous birth
  • 11 of females aged 15 to 44 gave birth within 24
    months of a previous birth in 1995 (NSFG data)
  • Higher rates among African-American, Hispanic,
    and poor women

7
  • In 2002, intervals of lt24 months higher among
    women who were
  • lt18 years of age
  • Formerly married
  • Without high school diploma or GED
  • Poor (living below federal poverty level)
  • Source Chandra A, Martinez GM, Mosher WD, Abma
    JC, Jones J. Fertility, family planning, and
    reproductive health Data from the 2002 NSFG.
    Vital Health Stat 23(25). Forthcoming (2005).

8
For all women with prior pregnancy also want
to achieve
  • Optimal nutritional status
  • Appropriate weight
  • Avoidance of anemia
  • Reduction of stress
  • Avoidance of
  • Smoking
  • Drinking
  • Illicit drugs
  • Identification and avoidance of environmental and
    workplace hazards

9
For women at elevated risk
  • Same as for all women
  • PLUS
  • Clinical evaluation of reasons for less than
    optimum pregnancy outcomes, including genetic
    testing
  • Interventions for treatable risks
  • Physical including chronic illnesses
  • Mental including depression
  • Emotional including domestic violence

10
Interconception Care for women at elevated risk
A first priority?
  • Ultimate Goal
  • Preconception care for all women
  • Intermediate Goal
  • Interconception care for women at elevated risk
  • This strategy may
  • Have largest impact on pregnancy outcomes
  • Be most acceptable to legislators
  • Be able to be implemented using present systems
    of care at least partially

11
Why Interconception Care Should Be Easy
12
  • Almost all the women in need of interconception
    care are already known to the medical care system
  • Over 95 have had some prenatal care
  • Large percentage have been delivered in a
    hospital
  • All live births and still births are identified
    by certificates filed with state
  • Almost all with miscarriages or elective
    abortions were cared for in the medical care
    system
  • Most take infant to pediatric care provider
  • Many seek family planning services

13
Why Interconception Care Is Hard
14
  • Both a supply and a demand problem (1)
  • Clinicians do not routinely provide
    interconception care
  • Often no source of payment
  • Many women whose maternity care was paid for by
    Medicaid lose eligibility 60 days after birth
  • Coverage under private insurance varies
  • No clear billing code for interconception care
  • Many have little interest in interconception care
  • Question effectiveness, cost effectiveness
  • Lack adequate information
  • Information on problems during pregnancy and
    pregnancy outcomes are not available to primary
    care providers
  • Records are often not integrated
  • Absence of follow-up systems

15
  • Consumer demand is low
  • Often women have no source of payment
  • Many women do not have insurance coverage
    public or private between pregnancies
  • Women have little interest in interconception
    care
  • Not aware of value or of availability
  • Unclear about how differs from routine ob/gyn or
    family planning visit
  • Many women do not return for postpartum visits
    the logical place to start interconception care

16
  • How Can We Increase Access to and Use of
    Interconception Care?

17
  • Incorporate into existing systems of care and
    provider networks
  • Reduce financial barriers for providers and for
    women
  • Generate consumer demand
  • Encourage compliance with HEDIS postpartum visit
    measure
  • Increase family planning coverage and services

18
Obstetrical Providers
  • Keep women in care after pregnancy
  • Use follow up/outreach to re-engage women missing
    postpartum visits
  • Make referrals to primary care providers and
    specialty physicians for risk management of
    diabetes, hypertension, and other problems
  • Focus on those at elevated risk

19
Pediatric Providers
  • Use well-child visits to promote healthy
    interconception care practices
  • Encourage pregnancy planning and spacing
  • Offer self-screening tools for mothers
  • Focus on those at elevated risk

20
Internists, Family Practitioners, Nurse
Practitioners, Primary Care Clinics
  • Counsel about pregnancy when caring for women
    with chronic diseases
  • Link to maternity care records to identify risks
    and opportunities for intervention
  • Ask about pregnancy planning and spacing

21
Public Sector Facilities
  • Should develop care protocols for
  • Community/migrant health centers and other FQHCs
  • Maternal and child health programs
  • Federal government should provide funds for
    demonstration programs
  • Already done in Healthy Start
  • Could provide incentives through
  • Title V funding
  • Community health center funding
  • Monitor progress

22
Family Planning Clinics
  • Re-engage women in care after pregnancy
  • For those with prior pregnancies, obtain
    information on pregnancy-related problems and
    outcomes
  • Make referrals to primary care providers and
    specialty physicians for risk management
  • Chronic diseases
  • Substance use/abuse (tobacco, alcohol, drugs)
  • Focus on those at elevated risk
  • Schedule additional visits to monitor
    contraceptive and health status

23
  • Incorporate into existing systems of care and
    provider networks
  • Reduce financial barriers for providers and for
    women
  • Generate consumer demand
  • Encourage compliance with HEDIS postpartum visit
    measure
  • Increase family planning coverage and services

24
  • Pay providers for time spent in interconception
    counseling under public and private insurance
  • Change Medicaid to allow coverage of women for
    five years after birth for all medical needs,
    broadly defined
  • 21 states already have waivers expanding
    eligibility for family planning
  • Increase private insurance coverage
  • In 2004, 99 of managed care plans included an
    annual ob/gyn visit
  • More in HMO plans less in conventional ones

25
  • Incorporate into existing systems of care,
    provider networks
  • Reduce financial barriers for providers and for
    women
  • Generate consumer demand
  • Encourage compliance with current HEDIS
    postpartum visit measure
  • Increase family planning coverage and services

26
  • Educate women to request services
  • Mass media
  • Morning talk shows
  • Womens magazines
  • Oprah Winfry show
  • Billboards targeted at women and men
  • Incorporate into educational programs for
    pregnant and parenting women
  • Home visiting programs
  • Childbirth classes
  • WIC
  • Family planning

27
  • Incorporate into existing systems of care,
    provider networks
  • Reduce financial barriers for providers and for
    women
  • Generate consumer demand
  • Encourage compliance with HEDIS postpartum visit
    measure
  • Increase family planning coverage and services

28
  • HEDIS measure for prenatal and postpartum care
    has two components
  • Percentage of women beginning care in first
    trimester
  • Percentage of women who visited health care
    providers between 21 and 56 days after delivery
    (could be first interconception care visit)
  • Used by Medicaid and private health plans
  • HEDIS important because large proportion of women
    on Medicaid are in managed care plans and many
    are at elevated risk

29
  • Quality improvement efforts generally not focused
    on improving postpartum visit rates, rather on
    prenatal care visits
  • Rate for postpartum check-ups in 2003
  • Commercial plans 80.3 (74.1 in 2000)
  • Medicaid 55.3 (49.8 in 2000)

30
How One IPA Used HEDIS To Improve Postpartum
Check-up Rate (NCQA Quality Profile)
31
  • Baseline performance
  • 63.3 return for check-ups
  • Multi-department task force assembled
  • Barriers identified
  • Physician called out of office
  • visit rescheduled outside time frame (21-56
    days)
  • Women feeling fine do not schedule appointment
  • Physicians offices do not have tracking system
    for check-ups

32
  • As a result of task force report, health plan
    implemented quality improvement effort
  • Importance of postpartum check-up communicated
  • In provider newsletter
  • Consultations with ob/gyn practices
  • Meetings with vendors
  • Incentives to OBs and PCPs for postpartum visits
  • Postpartum check-up measure added as performance
    monitor within global ob/gyn contract
  • Monetary thresholds established for low and high
    performance

33
  • As a result
  • Some practitioners developed office-based
    tracking and reminder systems
  • New mother outreach plan initiated
  • Hospital maternity units gave information to
    women who delivered
  • Some received two postpartum visits
  • Vendors reported differences between those who
    participated in the program and those who did not
    in order to develop next steps to encourage
    compliance

34
RESULTS
35
Expand Use of HEDIS Measures
  • Currently used mainly as measure for OB providers
    in managed care plans
  • Develop similar HEDIS measure for primary care
    providers
  • Should also be used as a benchmark by practices
    outside of managed care plans
  • Perhaps measure of rate of follow-up for women
    at elevated risk
  • Should specify content of postpartum visit and
    other interconception care visits

36
  • Incorporate into existing systems of care,
    provider networks
  • Reduce financial barriers for providers and for
    women
  • Generate consumer demand
  • Encourage compliance with current HEDIS
    postpartum visit measure
  • Increase family planning coverage and services

37
Family Planning Excellent Opportunity for
Interconception Care
  • Need to further increase coverage
  • Private coverage
  • In 2004, 89 of managed care plans provided oral
    contraceptives
  • Coverage greater in HMO plans-less in
    conventional ones
  • All states should require contraceptive coverage
    in private insurance plans
  • Public coverage
  • Through Medicaid family planning waivers
  • Increase in Title X funds

38
  • Need to increase services included in family
    planning
  • Interconception counseling
  • Testing for chronic diseases, with referrals to
    specialists
  • Checking for overt dental disease, with referrals
    to dentists
  • Screening
  • Tobacco, alcohol, illegal drug use/abuse
  • Domestic violence
  • Depression

39
Family Planning Problems
  • Public-supported facilities
  • Limited availability of emergency contraception
  • Insufficient funds to allow distribution of most
    expensive contraceptives at some sites
  • Understaffed for follow-up of missed appointments
  • FDA refusal to allow over-the-counter sale of
    emergency contraception
  • Pharmacists unwillingness to fill contraceptive
    prescriptions

40
(No Transcript)
41
  • The Evidence Base for Interconception Care
  • (weak need as much research in this area as has
    been devoted to prenatal care)

42
Interconception Care Demonstrations
  • Grady Hospital Atlanta
  • Some data on next slide
  • Interconception Health Promotion Initiative
    Denver
  • Final report available on web
  • http//www.coloradotrust.org/repository/publicatio
    ns/pdfs/IHPIFinalReport04.pdf
  • Philadelphia
  • No data yet

43
  • Grady Memorial Hospital (Atlanta) undertook pilot
    study of women who delivered very low birth
    weight infant
  • Subsequent pregnancies within 18 months
  • In historical control group 48.8
  • in intervention group 13.3
  • Want to wait at least 2 years for another
    pregnancy
  • Conditions detected in intervention group
  • Unrecognized or poorly-managed chronic diseases
  • Reproductive tract infections
  • Oral infections and periodontal disease
  • Most preterm deliveries had infectious and/or
    vascular etiology (underlying cause)
  • Source A.W.Brann and A.L.Dunlop

44
Family Planning Waivers
  • Births averted
  • Alabama (2000-2001) 3,612
  • California (1999-2000) 21,335
  • Oregon (2000) 5,414
  • Interpregnancy intervals increased
  • Rhode Island Proportion of women with
    Medicaid-funded deliveries becoming pregnant
    within nine months cut nearly in half (2000)
  • Source Gold,AGI Report on Public Policy, 3/04

45
Programs with Interconception Care Components
  • Nurse Home Visitation
  • Two-year postpartum follow-up
  • Positive impact on pregnancy intervals
  • Early Head Start
  • Postpartum follow-up
  • Positive impact on pregnancy intervals

46
Final Thoughts
  • Strive for preconception care for all women
  • Would benefit mother, child, society
  • While moving toward that goal, work within
    existing systems to provide interconception care
    to all women, especially those at elevated risk
  • Potential for impact on pregnancy outcomes and
    womens heath
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