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

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

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

What is Interconception Health?

Definition of Terms

• Preconception• Health status and risks before first

pregnancy; health status shortly before any pregnancy

• Interconception• Period between pregnancies

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

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

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

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

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

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

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

Interconception Health Messages and the Postpartum Visit

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

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

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

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

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

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

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

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

http://www.everywomancalifornia.org/postpartumvisit

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

How does domestic violence impact women's perinatal health and their birth outcomes?

Homicide is the second leading cause of injury-related deaths among pregnant women.

(Chang et al, 2005)

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)

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)

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)

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)

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)

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)

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)

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

Domestic violence increases women’s risk for

Unintended Pregnancies

(Sarkar, 2008)

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)

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)

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

Invisible Contraception

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

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

For Additional Information or Questions Contact:

Flojaune Griffin, PhD, MPHPreconception Health Coordinator

Maternal, Child and Adolescent Health DivisionFlojaune.Griffin@cdph.ca.gov

(916) 341-6333

For more information on Preconception Health, please visit: www.everywomancalifornia.org