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

HealthHealthBIHCC Collaborative Learning

Conference CallThe State of Florida

Thursday, February 11, 201011:00 AM -12:00 PM

Presented byMario Drummonds MS, LCSW, MBAExecutive Director, Northern Manhattan Perinatal Partnership, Inc.

Linking Women to Health, Power and Love Across the Life Span

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Lecture ObjectivesLecture Objectives1. 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 International Comparisons of Infantof Infant Mortality Rates, 2005 Mortality Rates, 2005Rank 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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TerminologyTerminologyInterconception

◦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 CareInterconceptional CareInterconceptional 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.

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Select Panel Goals for Select Panel Goals for Improving Preconception Improving Preconception HealthHealthGoal 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 Select Panel Goals for Improving Preconception Improving Preconception HealthHealth

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 PositionHRSA 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 Traditional Perinatal Care ContinuumContinuum

Preconception period

Antepartum Labor and birth Postpartum

Primary care

Labor and birth

Well baby care

Interconceptional period

Postpartu

m visit

Prenatal care

?

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Lifespan ApproachLifespan 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

Women’s Health Protocol

Depression Group Work

Women’s 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

BirthBirth Early Early Child-Child-hoodhood

Pre-Pre-TeenTeen

TeenTeen YounYoung g

AdultAdult

WomenWomen>35>35

Senior Senior CitizenCitizen

ss

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MCH Life Course Organization Social Determinants to Health Axis 2 Public Policy Public Policy InitiativesInitiatives

Economic Empowerment Zone

Supermarket Zone Expansion Policy

NYC Affordable Housing Policy

Community Community Environmental Environmental ImpactImpact

St. Nick Tenant Organizing

Food & Fitness Coalition

Affording Housing Organizing

Organizational Organizational ImpactImpact

Healthy Start Consortium

Diabetes Prevention Coalition

Harlem Works Job Readiness

Group/Group/Interpersonal Interpersonal ImpactImpact

Centering Pregnancy

Baby Mama’s Club Consumer Involvement Organization

Individual ImpactIndividual Impact OB/GYN Medical Homes

Case Management Depression Screening & Treatment

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A Life Course or Integrative A Life Course or Integrative ModelModelBuilds on a continuumEmphasis 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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Goals of Interconceptional Goals of Interconceptional CareCare1. Increase access to women’s

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 PeriodInterconceptional 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

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Pathways to CarePathways to Care

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Pathways Protocol: Entry to Pathways Protocol: Entry to CareCare

1. New clients receive:◦Intake◦Screening◦Assessment

2. 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 Intake & Screening (new clients)(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 ClientsExisting ClientsExisting 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 Healthy/Normal PregnancyPregnancy

Basic newborn care◦Back-to-sleep/safe sleep◦Shaken baby syndrome◦Early parenting skills (bathing,

handling, bonding, attachment)BreastfeedingPreparing for your well baby visitPreparing for your postpartum visitRecognizing PMD

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High Risk PregnancyHigh Risk PregnancyItems 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 ContentsCore Contents

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Risk AssessmentRisk AssessmentThe 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: FINDSRisk Assessment: FINDSFamily violenceInfections/ImmunizationsNutritionDepression Stress

Lu, M.

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Risk Assessment: FINDSRisk Assessment: FINDSFamily violenceInfections/Immunizations

Periodontal Chlamydia Other sexually transmitted or urogenital tract

infections in selected populations

NutritionDepression Stress

Lu, M.

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Risk Assessment: FINDSRisk Assessment: FINDSFamily violenceInfections/Immunizations

Diptheria-tetanus toxoids booster Hepatitis B vaccines Measles and mumps Rubella Varicella

NutritionDepression Stress

Lu, M.

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HighlightsHighlightsF.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 BBEEFFHealth Promotion BBEEFFBreastfeedingBack-to-sleepExerciseExposures

◦ Household molds and dust mites◦ Lead◦ Mercury◦ Dioxins

FolateFamily planning

Lu, M.

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Health Promotion BBEEFFHealth Promotion BBEEFFBreastfeedingBack-to-sleepExerciseExposuresFolateFamily planning

◦Reproductive life plan◦Contraceptive use

Lu, M.

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Clinical InterventionsClinical 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 InterventionsPsychosocial 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 Socioeconomic InterventionsInterventionsAccess 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 PlanReproductive Life PlanA 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 Potential Benefits of Including Reproductive Life Including Reproductive Life Plan Assessments into Plan Assessments into Routine CareRoutine 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 Encouraging a Reproductive Life Plan: Example of Questions Life Plan: Example of Questions that could be in RLPthat could be in RLP1. 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?38

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PrecautionsPrecautionsReproductive 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”.

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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 woman’s intentions can focus much of the rest of the encounter

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Healthy Women

Phys

ical

Soci

al

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.

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Achieving Health Equity by: Building a Social Movement, Achieving Health Equity by: Building a Social Movement, Investing in Ideas, Executing Tasks, Returning Results!Investing in Ideas, Executing Tasks, Returning Results!

Linking Women to Health, Power and Love Across the Life SpanLinking Women to Health, Power and Love Across the Life Span

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For more Information Contact:

Mario Drummonds, MS, LCSW, MBAExecutive Director/CEO

Northern Manhattan Perinatal Partnership

127 W. 127th Street

New York, NY 10027

(347) 489-4769

mdrummonds@msn.com