Guidance for commissioners of perinatal mental health services
Emerging Issues Preconception Health Comprehensive Perinatal Services Program Statewide Perinatal...
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Emerging Issues Preconception Health
Comprehensive Perinatal Services Program Statewide Perinatal Services Coordinators Meeting
November 3, 2011
Flojaune Griffin, PhD, MPHPreconception Health Coordinator
Policy Development BranchMaternal, Child and Adolescent Health Division
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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
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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
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What is Interconception Health?
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Definition of Terms
• Preconception• Health status and risks before first
pregnancy; health status shortly before any pregnancy
• Interconception• Period between pregnancies
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Preconception/Interconception Health Conceptual Framework
The health status of girls and women prior to pregnancy
The health status of pregnant women
The health status of newborns and infants
“Trickle Down” Theory
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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
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Conception Birth Pregnancy DeliveryAge 5 Puberty
Poor Birth Outcome
OptimalBirth Outcome
PovertyNo Social Support
Mistimed Pregnancy
Adverse Childhood Events
Exposure to Toxins
Poor NutritionObesity
Unsafe NeighborhoodPoor Education
Lack of Health CareNo Family Planning
Tobacco/AlcoholDrugs
NutritionHealthy Relationships
Social Support
ExerciseEducation
Health CareFamily Planning
Safe Neighborhood
Healthy Relationships
Financial SecurityPlanned Pregnancy
Interconception Health and the Life Course Perspective
Pregnancy
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Early and Adequate Prenatal Care
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
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We Currently Intervene Too Late
Critical Periods of Development
4 5 6 7 8 9 10 11 12Weeks gestation
from LMP
Central Nervous System
Heart
Arms
Eyes
Legs
Teeth
Palate
Ear
Missed Period Mean Entry into Prenatal Care
Most susceptible time for major malformation
External Genitalia
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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
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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
Kay Johnson, State Roles in Preconception Health and Health Care, Oct. 2009
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Interconception Health Messages and the Postpartum Visit
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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. 2008. Sarah Beth Verbiest, Master of Social Work and Master of Public Health, University of North Carolina
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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
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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
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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
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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
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ACOG Interconception CareLogic Model
Interconception care Advisory
Council (ICAC) and
Project Intern
ACTIVITIES
Monthly Review of Data
(Conference Calls)
DELIVERABLES
Production of ICAC Guidelines
(Web-based and CD)
HEALTH OUTCOMES
Improve the Health of Women
INPUTS
Project Coordinator and
Executive Director
Two Consensus-Building Meetings
Consensus-Building Statement
Improve Prenatal and Postpartum Care and Reduce Birth Defects
Evidence-Based Summary
Develop Guidelines
Patient Care pamphlet/web-based handout (diagnosis
specific)
Reduce Morbidity and Mortality
Increased Satisfaction in Delivery of Care
Continuing Medical Education on ACOG
Website
Increase satisfaction with care received during post-
partum visits
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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
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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
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http://www.everywomancalifornia.org/postpartumvisit
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Emerging Issues in Preconception Health:Reproductive Coercion and Birth Control Sabotage
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How does domestic violence impact women's perinatal health and their birth outcomes?
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Homicide is the second leading cause of injury-related deaths among pregnant women.
(Chang et al, 2005)
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Women Who Experience Abuse Around the Time of Pregnancy Are More Likely to:
• Smoke tobacco
• Drink during pregnancy
• Use drugs
• Experience depression, higher stress, and lower self-esteem
• Attempt suicide
• Receive less emotional support from partners
(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)
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Tobacco Cessation and DV
42% of women experiencing some form of DV could not stop smoking during pregnancy compared to 15% of nonabused women.
(Bullock et al, 2001)
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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
(Coker et al, 2002)
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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)
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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
(Silverman et al, 2006)
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Postpartum Maternal Depression Women with a controlling or
threatening partner are 5X more likely to experience persistent symptoms of postpartum maternal depression
(Blabey et al, 2009)
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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
(McClosky et al. 2006)
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Definition: Reproductive Coercion
Reproductive Coercioninvolves behaviors that a partner usesto maintain power and control in arelationship 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
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Domestic violence increases women’s risk for
Unintended Pregnancies
(Sarkar, 2008)
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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
(Raneri & Wiemann, 2007)
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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
Teen Birth Control Sabotage
(Raphael, 2005)
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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
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Invisible Contraception
Birth Control Methods That Are Less Likely to be Detected by a Sexual Partner
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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
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For Additional Information or Questions Contact:
Flojaune Griffin, PhD, MPHPreconception Health Coordinator
Maternal, Child and Adolescent Health [email protected]
(916) 341-6333
For more information on Preconception Health, please visit: www.everywomancalifornia.org