# Presentation: 204967

## Women’s Health and Preconceptional Care Between Pregnancies: Development of Internatal Care Programs

**Milton Kotelchuck, PhD, MPH**
**Boston University School of Public Health**
**University of Alaska**
**October 5, 2006**

## 
Ideas and Slides Freely Adapted 
From my Colleagues

Michael Lu
Lorraine Klerman
Kay Johnson

*Ideas and Slides Freely Adapted *
*From my Colleagues*
- Michael Lu
- Lorraine Klerman
- Kay Johnson

## Slide 3

## 
Maternal and Infant
Reproductive Health
Challenges
for the 21st Century

- Maternal and Infant
- Reproductive Health
- Challenges
- for the 21st Century

## Slide 5

## Goals of Talk

- Present the historical context for the current 	reproductive public health initiatives
- Review current preconception and 	interconception health care initiatives
- 3)   Explore the nine MCH / Public Health 	issues that must be addressed to 	implement an internatal care program 	successfully
- 4)  Present a vision for the future

## Historical Context:Limits of Prenatal Care

- Public health community knows how to increase PNC 	utilization
- LBW and prematurity rates are increasing in the US, 	simultaneously with increasing PNC utilization
- Racial and ethnic disparities in birth outcomes are 	increasing, while disparities in PNC are decreasing
- No compelling RCT literature linking comprehensive PNC 	with improved birth outcome
- There have been no recent new significant breakthroughs in 	the content of PNC
- The late 20th Century consensus on comprehensive PNC 	programs as _the_ public health strategy to improve birth 	outcomes and reduce disparities has ended

## Historical Context:  Initial Focus on Preconception Care

- “Can’t cure a lifetime of ills in 9 months of a pregnancy”
- If PNC is not the answer, then address risks prior to or after 	the pregnancy
- Initially, the focus was on the establishment a singular 	preconception visit prior to pregnancy. Cefalo and Moos 	suggested the rationale and clinical risks to be examined
- Preconception care visit programs have not generally 	succeeded (no source of payment, unplanned 	pregnancies, ...)
- Preconception care for women with specific chronic diseases 	has become accepted and is effective (e.g., diabetes)

## Historical Context:  Women’s Health Movement

- Women’s health movement, begun in the 1960’s, 	focused on reproductive control of one’s 	body, the male orientation of medical care, 	and older women’s health issues rather than 	reproductive health
- Women’s health care was seen as a part of a 	broader health and human rights struggle
- Women’s health movement has begun to re-	embrace maternal health

**Notes:**
MK note: Too many

## Historical Context:  Women’s Health Movement

- Historical paradigm: women’s health is viewed as 	important for its impact on birth outcomes 	(women as reproductive vessels)
- Flipped paradigm: pregnancy is viewed as 	important for its impact on women’s health 	(pregnancy as a key health life event)
- Preconception health broadened beyond a PNC 	pregnancy focus to embrace all of women’s 	health
- Women’s health now conceptualized more 	longitudinally and developmentally

**Notes:**
MK note: Too many

## Historical Context:  Growth of Longitudinal Health Models	

- Longitudinal maternal health models introduced to explain racial 	disparities in birth outcomes (e.g. Michael Lu)
- Disparities in birth outcomes seen as less determined by current 	pregnancy experiences than by prior health experiences.
- These models derive from psycho-social stress, racism, 	intergenerational, neighborhood contextual explanations for 	racial disparities
- Models now linked to biological basis: early programming 	(epigenetic coding) and cumulative pathways (weathering)
- Focus newer emphasis on mother’s own pregnancy 	(intergernerational) experiences, girls health,
- MK linkage to women’s lifetime health

## Slide 12

## Slide 13

## Slide 14

## Historical Context: Evolution of the CDC Focus on Women’s Health and Preconception Care

- Psycho-social Pathways to Prevent Premature 	Births among African-American Women
- Safe Motherhood Summit
- National Summit on Preconception Care

## Slide 16

## Slide 17

## Slide 18

## CDC National Summit on Preconception Care Defining Preconception Care

*Preconception care is comprised of interventions that aim to identify and modify biomedical, behavioral, and social risks to a women’s health or pregnancy outcome through prevention and management, emphasizing those factors which must be acted on before conception or early in pregnancy to have maximal impact.  Thus, it is more that a single visit and less than all well-woman care.  It includes care before a first pregnancy or between pregnancies (commonly known as interconception care). *

## CDC National Summit on Preconception Care

***Four Goals***
- Goal 1. To assure that all U.S. women of childbearing age receive preconception care services – screening, health promotion, and interventions – that will enable them to enter pregnancy in optimal health
- Goal 2. To reduce risks indicated by a prior adverse pregnancy outcome through interventions in the interconception (inter-pregnancy) period that can prevent or minimize health problems for a mother and her future children.
- Goal 3. To improve the knowledge, attitudes, and behaviors of men and women related to preconception health
- Goal 4. To reduce the disparities in adverse pregnancies outcomes.

## CDC National Summit on Preconception Care  Risk factors (identified as needing attention during the preconception period)

***- Chronic diseases***
- 	Diabetes; Heart disease; High blood pressure; Thyroid disease; Asthma; Depression (and other mental health disorders); Autoimmune disease; Physical disability, etc.
***-*** ***Infectious diseases***
- 	Vaccine preventable diseases; HIV/AIDS; Sexually transmitted diseases; Peridontal diseases; Toxoplasmosis, etc.
***- Reproductive concerns***
***	***Unplanned pregnancies; Contraception; Infertility; Adverse past pregnancy outcomes, etc.

## Risk factors (continued)

***- Genetic / inherited conditions***
- 	Sickle Cell Anemia; Thalassemia; Tay-Sachs disease;     Fragile X Syndrome; Downs Syndrome; Cystic Fibrosis; Muscular Dystrophy; Hearing & vision loss, etc.
***-*** ***Medication and medical treatment***
- 	Prescription medications contraindicated in pregnant women; Diagnostic radiation exposures, etc.
***- Personal behaviors and exposures***
***	***Smoking; Alcohol consumption; Illicit drug use; Overweight / underweight; Folic acid supplement use; Domestic violence; Eating disorders; Exposure to infections, chemicals and environmental toxins; Consumption of OTC medications; Hyperthermia, etc.

_**CDC National Summit on Preconception Care**_

## CDC National Summit on Preconception Care Recommendations to Improve Preconception Health

***Recommendation 1. Individual responsibility across the life span.***
***	***Encourage each woman and every couple to have a reproductive life plan.
***Recommendation 2. Consumer awareness.***
***	***Increase public awareness of the importance of preconception health behaviors and increase individuals’ use of preconception care services using information and tools appropriate across varying age, literacy, health literacy, and cultural / linguistic contexts.
***Recommendation 3. Preventive Visits***
***	***As a part of primary care visits, provide risk assessment and counseling promotion advice to all women of childbearing age to reduce risks related to the outcome of pregnancy.
***Recommendation 4. Intervention for identified risks.***
- 	Increase the proportion of women who receive interventions as follow up to preconception risk screening, focusing on high priority interventions (i.e., those with high population impact and sufficient evidence of effectiveness).

## Recommendations to Improve Preconception Health (continued)

***Recommendation 5. Interconception care.***
***	***Use the interconception period to provide intensive interventions to women who have had a prior pregnancy ending in adverse outcome (e.g., infant death, low birthweight or preterm birth).
***Recommendation 6.  Pre-pregnancy check ups.***
- 	Offer, as a component of maternity care, one pre-pregnancy visit per pregnancy.
***Recommendation 7. *****Health coverage for low-income women.**
- 	Increase Medicaid coverage among low-income women to improve access to preventative women’s health, preconception, and interconception care.
***Recommendation 8. Public health programs and strategies.***
- 	Infuse and integrate components of preconception health into existing local public health and related programs, including emphasis on those with prior adverse outcomes.
***Recommendation 9.  Research.***
***	***Augment research knowledge related to preconception health.
***Recommendation 10. *****Monitoring improvements.****  **
- 	Maximize public health surveillance and related research mechanisms to monitor preconception health.

## So why focus on Interconception care rather than Preconception care?

- Not easy to create a preconception care program
- Virtually all births and mothers are known and easy to locate
- Interconception care programs are more operationally 	feasible via current public health and clinical care 	programs
- Recognizes profound impact of pregnancy on women’s 	health
- Addresses continuity of risk from one pregnancy to the next
- It is a new, but very under appreciated MCH topic
- Expands on CDC National Summit recommendation #5.

## Interconception Care

- Interconception care is a subset of 	preconception care
- Interconception care addresses the continuity 	of risk from one pregnancy to the next
- Conceptualize the six week post-partum visit 	not as end of the pregnancy, but the 	beginning of a new women’s longitudinal 	health initiative

## Interconception Care 

- Strategy to address women’s health 	(longitudinally and post-delivery)
- Strategy to enhance the health of the parent 	and caregiver
- Strategy to reduce subsequent infant mortality
- Possible strategy to reduce racial disparities 	in birth outcome

## Internatal Care vs. Interconception Care

- Internatal care represents an extention of 	prenatal care
- Avoids the politically charged word “conception”
- The point of entry is the birth of one child
- The end point is the birth (or the conception) of 	next child
- (MK uses it more generally to refer all post 	delivery care)

## Maternal internatal care health concerns

- Maternal smoking relapse
- Maternal mental health and depression
- Diabetes
- Hypertension
- Sexual transmitted diseases
- Obesity and weight control
- Intimate partner violence and injury
- Family planning
- Primary care connectedness
- And many other topics

## Why interconception care should be easier to implement than preconception care?

## 	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

									 L. Klerman, 2005

- 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
- 									 L. Klerman, 2005

## Why interconception care is harder to implement

## Interconception care has both a supply    and a demand problem

## 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 
Evidence-base for interconception care is very weak 

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
								L. Klerman, 2005

- 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
- Evidence-base for interconception care is very weak
- 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
- 								L. Klerman, 2005

- Clinician _supply_ of interconception 	care 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 it differs from routine ob/gyn or family planning 	visits
Many women do not return for postpartum visits – the logical place   	to start interconception care

-  Women shift their concerns to their infant’s health care

Pediatric care could include more family care

								L. Klerman, 2005

- 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 it differs from routine ob/gyn or family planning 	visits
- Many women do not return for postpartum visits – the logical place   	to start interconception care
- -  Women shift their concerns to their infant’s health care
- Pediatric care could include more family care
- 								L. Klerman, 2005

- Consumer _demand_ for interconception 	care is low

## So how do we in the MCH field address these barriers and create an internatal care program? 

## Boston Internatal Care Program (Family Wellness Program)

- Transform the concept of internatal care 	into a specific concrete program
- Create  a new vision of internatal maternal 	care
- Address women’s health in the post-	partum period both for herself and as a 	mother
- Establish continuity of pre- and post-natal 	maternal care

- Milton Kotelchuck, 2004

## Boston Internatal Care Program (Family Wellness Program) 3 Post-partum Visits and A Pill2 week visit2 month visit4 month visitInitial Concept, now under Early Development					Milton Kotelchuck						March of Dimes, June, 2004

## Internatal care: Nine issues      to be addressed

- Eligibility criteria for women
- Content of care
- Timing / frequency of care
- Provider of care
- Payor source
- Motivation to participate
- Community involvement
- Public health policy and infrastructure support
- Research and monitoring databases

## Internatal Care Eligibility Criteria for Women

- Known data
- Poor prior birth outcome is the strongest predictor 	(RR and AR) for a subsequent poor birth outcome
- Approximately a 20-33% chance of sequential poor 	birth outcomes
- Poor birth outcomes are the usual basis for 	enrollment in subsequent community nursing, early 	intervention 	or child development programs
- I believe these facts mislead the preconception care community to focus only on women with a poor prior birth outcome

## Internatal Care Eligibility Criteria for Women

- Focus on all women
- (MK recommendation)
- All women eligible by subgroups
- 		-Healthy pregnancy and healthy birth
- 		-Maternal health problems and healthy birth       	   outcome*
- 		-Maternal health problems and poor birth 		   outcome
- 		-Experience fetal loss*

## Timing and Frequency of Internatal Care Visits 

- Initial proposal for three post-partum visits
-      (In Lu, Kotelchuck, Culhane, Hobel, Klerman and Thorp; MCHJ 2006)
- 2 week visit
- 6 week visit
- 	(Corresponds to current post partum follow up visit)
- 6 month visit
- 12 month / annual visit
- 	(traditionally recommended annual health care visit)
-  Different maternal health concerns arise at different times in post-partum period
-  One six week post-partum visit can’t address all internatal health issues effectively

## Timing and Frequency of Internatal Care Visits

_**Rationale**_
- Don’t change the established 6 week post-partum visit
- Emerging clinical practices (in obstetrics, family practice)
- Consistent with pediatric visit schedule
- European experiences
- Ultimately, timing of visits depends on 	professional consensus

## Different maternal health concerns arise at different times in post-partum period(examples)

- 2 weeks
- 		- Post-partum clinical care
- 		- Breastfeeding initiation
- 		- Smoking resumption
- 6 weeks
- 		- Family planning methods
- 		- GTT diabetes retesting
- 		- Environmental exposures
- 		- SIDS / Back-to-sleep
- 6 month
- 		- Family planning follow-up
- 		- Folate supplementation
- 		- Chronic depression
-    No unique times
- 		- Nutrition
- 		- Stress

## Content of Internatal Care

- Specific content of care proposed:
- In “Preconception care between pregnancies: 	The content of internatal care,” Lu, Kotelchuck, 	Culhane, Hobel, Klerman and Thorp            	(MCH Journal 2006)
- For each visit, and for each of the four groups of 	women, content of care separately articulated
- _Goal of initial proposal:_
- To move from generalities to specific clinical practices
- To start a dialog on the internatal care content
- To link maternal risk status to level of care
- To provide a basis for reimbursement

## Content of Internatal Care(In Lu, Kotelchuck, Culhane Hobel, Klerman and Thorp)

- Risk Assessment
- Health Promotion
- Clinical Interventions
- Psychosocial Interventions
- Service Coordination and Integration
- Follows the content categories used in the U.S. PHS Report: “Caring for Our Future: The Content of Prenatal Care”

## Content of Internatal Care

- Risk Assessment (FINDS)
- 	_F_amily Violence, _I_nfection and Immunization, _N_utrition, _D_epression, _S_tress
- Health Promotion (BBEEFF)
- 	_B_reast Feeding, _B_ack to Sleep, _E_xercise, _E_xposures (Environmental and Toxins), _F_amily Planning, _F_olate Supplementation (Pill)

## Content of Internatal Care

- Clinical Interventions
- 	Minimal, standard for women of childbearing age (height and weight, breast examination, PAP smear).  Additional clinical care for women with specific medical conditions.
- Psychological Interventions
- 	Social services and parenting support (e.g., psychological support with depression, low income family assistance)
- Service Coordination and Integration
- 	Case management, enhanced referral networks, one stop shopping.

## Recommended Content and Schedule of Internatal Care:Core Content of Internatal Care for all Women

| Risk Assessment | Organization | Schedule |
| --- | --- | --- |
| Family Violence | JACHO, AMA | 1, 2, 3 |
| Infections
     Chlamydia
     Periodontal | 
USPSTF, ACPM
ADA | 
2
2 |
| Immunization
    Diptheria-tetanus booster
    Hepatitis B
    Measles and mumps
    Rubella
    Varicella | 
USPTSF, ACPM, HHS
USPTSF, ACPM, HHS
USPTSF, ACPM, HHS, ACIP
USPTSF, ACPM, HHS, ACIP
USPTSF, ACPM, HHS, ACIP | 
2
2
2
2
2 |
| Nutrition | USPSTF | 1, 2, 3 |
| Depression | USPTSF, ACOG | 1, 2, 3 |
| Stress |  | 1, 2, 3 |

- 1= at the 2-week internatal care visit
- 2= at the 6-week internatal care visit
- 3= at the 6-month internatla care visit

## Recommended Content and Schedule of Internatal Care:Core Content of Internatal Care for all Women

| Health Promotion | Organization | Schedule |
| --- | --- | --- |
| Breastfeeding | AAP, HP2010 | 1, 2, 3 |
| Back-to-sleep | AAP, NICHD, HP2010 | 2 |
| Exercise | NHLBI, HHS, HP2010 | 2 |
| Exposures
    Smoking, alcohol, drug use
    Mercury
    Lead
    Dioxins
    Indoor/outdoor pollutants & allergans | 
HHS, ACOG
FDA/EPA
CDC, AAP
IOM
NHLBI | 
1, 2, 3
2, 3
2, 3
2, 3
2, 3 |
| Family Planning | ACOG/AAP | 1, 2, 3 |
| Folate Supplementation | CDC, AAP | 3 |

- 1= at the 2-week internatal care visit
- 2= at the 6-week internatal care visit
- 3= at the 6-month internatla care visit

## Recommended Content and Schedule of Internatal Care:Core Content of Internatal Care for all Women

| Clinical Interventions | Organization | Schedule |
| --- | --- | --- |
| Height and weight measurements | ICSI, ACOG | 1, 2, 3 |
| Blood pressure | ICSI, ACOG | 2 |
| Total skin examination | ACS, ACPM | 2 |
| Clinical breast examination | ACS, ACOG | 3 |
| Papanicolau smear and pelvic examination | ACS, ACOG | 2 |
| Screening mammography | ACS, ACOG | 3 |
| Psychological Interventions |  |  |
| Social services |  | 1, 2, 3 |
| Clinical support |  | 1, 2, 3 |
| Parenting support |  | 1, 2, 3 |

- 1= at the 2-week internatal care visit
- 2= at the 6-week internatal care visit
- 3= at the 6-month internatla care visit

## Recommended Content and Schedule of Internatal Care:Enhanced Content of Internatal Care for all Women

| Risk assessment, health promotion, clinical & Psychological Interventions | Organization |
| --- | --- |
| Chronic hypertension | NHLBI |
| Gestational hypertension | NHLBI, ACOG |
| Pre-gestational diabetes | ADA |
| Gestational diabetes | ADA, ACOG |
| Overweight/Obesity | ACS, ACOG |

## Recommended Content and Schedule of Internatal Care:Enhanced Content of Internatal Care for all Women

| Preterm Birth | Organization |
| --- | --- |
| Risk assessment
    Reproductive history
    Family history
    Medical assessment
    Nutritional assessment
    Social assessment | 
ACOG
ACOG
ACOG
ACOG
ACOG |
| Health Promotion
    Smoking cessation
    Substance abuse treatment
    Optimal pregnancy BMI
    Ensure adequate omega-3 fatty acids intake
    Family planning | 
HHS
ACOG
IOM
ISSFAL, IOM
ACOG/AAP |
| Clinical interventions
    Progesterone use in subsequent pregnancy | 
ACOG |
| Psychological intervention
    Services for children with special health care needs
    Home visitation | 
AAP
AAP |

## Hypertensive disorders before or during 	pregnancy
Pre-gestational or gestational diabetes
Underweight, overweight or obesity
Cigarette smoking or problems with 	alcohol or substance use

- Pre-gestational or gestational diabetes
- Underweight, overweight or obesity
- Cigarette smoking or problems with 	alcohol or substance use

- Content of Internatal CareClinical care specified for the following health problems:

## Content of Internatal Care(ALTERNATIVE MODEL)Philadelphia Collaborative Preterm Prevention Project Jennifer Culhane (P.I.)

- Urogenital Tract Infections
- Peridontal Disease
- Abnormal BMI
- Depression
- Smoking
- Housing Instability / Literacy

- Visits at 1, 6, 12, 18, and 24 months

**Notes:**
MK: Check specifics

## Providers of Internatal Care

- One of the more difficult issues, because of cross-profession 	rivalries, women’s preferences, and different locations 	that the health care system is encountered.
- Internatal care need not be provided only by the prenatal 	care provider.
- _All_ clinical providers should be able to and encouraged to 	provide the basic internatal care. (MK recommendation)
- Internatal care visits would be enhance in clinical settings 	with multiple providers and professions, with electronic 	medical records, and easy referrals to needed 	specialists.

## Providers of Internatal Care

- Changes can be made to establish and enhance 	the proposed Internatal Care program in the 	current professional practices of:
- Obstetricians and Gynecologists
- Pediatricians
- Internists, Primary Care Providers
- Family Practitioners
- Midwives
- Nurses, Nurse Practitioners
- Family Planning Providers

## Sites for Internatal Care

- Home
- Health care sites
- In future via media facilities

## Payor Source for Internatal Care

- This should not be a major barrier to the 	implementation of the proposed Internatal Care 	program
- Internatal Care represents relatively low cost 	primary care for a finite, predictable population
- It is likely to have a positive cost benefit ratio, 	though that is not critical to its implementation
- Once clinical visit periodicity and content is 	established, insurance companies and Medicaid 	will have basis for payments

## Payor Source for Internatal Care

- States have the authority to legislate and regulate programs that have a direct impact on women’s access to care
- Preserving/broadening scope of private 	coverage
- Maintaining/expanding Medicaid
- Extending coverage to uninsured women
- Developing needed infrastructure

## Payor Source for Internatal Care

-  Possible payor sources include:
- 		- Medicaid Family Planning waivers
- 		- Medicaid expansions
- 		- HIFA (Health Insurance Flexibility and    			Accountibality) 1915b waivers
- 		- S-CHIP family coverage
- 		- Title V demonstrations (e.g. Healthy Start)
- 		- Managed care program innovations

## Pay providers for time spent in interconception   	counseling under public and private insurance
Change Medicaid to allow coverage of women for 	up to five years after birth for all medical 	needs, broadly defined
Increase use of Medicaid Family Planning 	waivers
Increase private insurance coverage and 	innovation                   		
                                                                       L. Klerman,2005

- Change Medicaid to allow coverage of women for 	up to five years after birth for all medical 	needs, broadly defined
- Increase use of Medicaid Family Planning 	waivers
- Increase private insurance coverage and 	innovation
-                                                                        L. Klerman,2005

- Financial Reimbursement Recommendations

## State Internatal Care Initiatives

- Illinois – Medicaid / DPH Initiative
- Universal coverage of maternal depression screening

## Motivation to Participate

- 	Why should women go to _three_ post-partum visits when so many do not even go to their one 6 week post-partum visit?

## Motivation to Participate:Generate Consumer Demand

- Self-motivation, like for PNC, is ultimately critical
- We must help women and their communities to 	see the value of post-partum care
- Public health professionals are very experienced 	at developing incentive programs to 	encourage participation
- Motivational programs could include: use of 	mass media; incorporation with childbirth 	education programs; incentive programs; 	enhanced referral programs; centering, etc.

## HEDIS Postpartum Visit Compliance Rates  
in Managed Care Programs

National figures (NCQA, 2003) 
Commercial plans: 80.3%  (74.1% in 2000)
Medicaid              : 55.3%  (49.8 % in 2000)

Boston Medical Center HealthNet Plan
				       : 55.0%  (48.0 % in 2002)

- in Managed Care Programs
- National figures (NCQA, 2003)
- Commercial plans: 80.3%  (74.1% in 2000)
- Medicaid              : 55.3%  (49.8 % in 2000)
- Boston Medical Center HealthNet Plan
- 				       : 55.0%  (48.0 % in 2002)

- Motivation to Participate

## Motivation to Participate

- Who does and does not utilize the
- 6 week post-partum visit?
- Very limited research on this topic
- Demographically higher risk population are less 	likely to attend the 6 week post-partum visit
- Virtually no data exists on usage by women’s 	health risk conditions or prior birth outcome 	experiences

## Community Involvement

- Internatal Care is not simply a clinical intervention
- Communities are critical to motivate and sustain 	women’s efforts to enhance their own health 	and their community’s health
- An internatal care program will require active 	community involvement to be successful
- 		-  A “hundred acts of kindness”
- 		-  Women’s stories in MOD Prematurity 			Campaign

## Public Health Infrastructure                             and Policy Support

- Public health support and encouragement of internatal care is 	critical
- 		- Especially in the early implementation of a new national agenda.
- 		- There is much we can do now!
- 		- Encourage incorporation of internatal care into the existing system 		of health care and provider networks.
- Internatal care protocols should be developed for public sector 	programs
- 		- Community health centers; MCH Title V programs; Indian Health 		Service; WIC
- Federal government should provide funds
- 		- For demonstration and research programs
- 		- Support consensus conferences			                                                                                                                                                                                                                                                                                                                                                                                                                  							L. Klerman, 2005

## More professional training about internatal care (increase 	provider supply)
Payment schedules should be established to reduce the 	financial barriers to internatal care providers and 	women.
Encourage compliance with HEDIS postpartum visit measure
Generate consumer demand
Increase family planning coverage and services
Expand WIC to allow maternal participation (beyond 	breastfeeding mothers) (MK)
								L. Klerman, 2005

- Payment schedules should be established to reduce the 	financial barriers to internatal care providers and 	women.
- Encourage compliance with HEDIS postpartum visit measure
- Generate consumer demand
- Increase family planning coverage and services
- Expand WIC to allow maternal participation (beyond 	breastfeeding mothers) (MK)
- 								L. Klerman, 2005

- Public Health Infrastructure         and Policy Support (con’t)

## Local Internatal Care Initiatives

- Pinellas County, FL. Magnolia Interconceptional 	Education and Counseling Project
- Inter-pregnancy Care Program of Grady Memorial 	Hospital, GA
- Contra Costa County, CA: Post-partum diabetes 	and other medical conditions initiative
- Philadelphia Collaborative Preterm 	Preventative Project
- Various Health Start Post-partum/Chronic 	Maternal Depression Initiatives

## Research and Monitoring Databases

- The evidence base for the effectiveness of interconception care is 	minimal
- 		- We need as much research in this area as has been devoted 			to prenatal care (LK)
- 		- Government support of research is critical
- Monitoring of post-partum visit compliance could be enhanced in 	our national data system
- 		- Expansion of HEDIS measures, future Healthy People objectives
- 		- Better identification of postpartum care in financial data systems
- Establish and utilize more longitudinal data bases that can 	monitor 	maternal health in post-partum period
- Encourage more research on the 6 week post-partum visit.
- 		- Who gets it, who doesn’t, barrier and motivators, etc.

## Research Agenda for Internatal Care (MK)

- Establish the extent and range of maternal morbidity in the 	internatal / post-partum period
- Determine the extent of all forms of health care in the post-	partum period
- Evaluate the utilization of the six week post-partum visit
- Examine the extent of post-partum care by specific 	maternal risk conditions
- Explore barriers and motivators for post-partum care 	(among women, providers, and communities)
- Evaluate internatal care demonstration programs
- Examine effectiveness of specific internatal care 	interventions to improve mother’s health or improve 	subsequent birth outcomes

## CDC National Summit on Preconception Care Action Steps: for Recommendation #5  Interconception Care

- a)  Monitor the percentage of women who complete postpartum visits (e.g., using HEDIS measures for private and Medicaid managed care plans, and Title V State measures) and use these data to identify both communities of women at risk and opportunities to improve provider follow up.
- b)  Develop, evaluate, and replicate intensive interconception care and care coordination models for women at high social and medical risk.
- c)  Enhance the content of postpartum visits to promote interconception health.
- d)  Use existing public health programs serving women in the postpartum period to provide or link to interventions (e.g., family planning, home 	visiting, WIC)
- e)  Encourage more States to develop interconception care projects with funds from the Title V MCH Block Grant, Prevention Block Grant, and similar public health programs.

## Getting the MCH community to embrace and encourage internatal care initiatives

## Programmatic Encouragement for Internatal Care Programs

- Healthy Start Initiative
- 	Broaden development focus: pregnancy through 2 years post-partum for mothers and infants
- Los Angeles Twelve-Point Plan to Reduce Racial Disparities in Birth Outcomes (Dr. Michael Lu, UCLA)
- 	#1 Provide interconception care to women who’ve already had a poor pregnancy outcome
- National Summit on Preconception Care (CDC)
- 	Goal #5: Use the interconception period to provide intensive interventions to women who have had a prior pregnancy ending in adverse outcome (e.g., infant death, low birthweight or preterm birth).
- Early Head Start, Nurse Home Visitation Programs

## The Healthy Start InitiativeExpansion and enhancement of its content and scope

-  Recommendation: “Broaden developmental focus: 	pregnancy through 2 years post-partum for 	mothers and infants”
- [The Healthy Start Initiative: Strategic Assessment and           Policy Options, Kotelchuck & Fine (2000)]

## Los Angeles Twelve-Point Plan
Dr. Michael Lu, UCLA

(In Closing the Black-White gap in birth outcomes: 
A life-course approach”;  Lu, Kotelchuck, Hogan, 
Jones, Jones, and Halfon, Ethnicity and Disease, 2005)

- Dr. Michael Lu, UCLA
- (In Closing the Black-White gap in birth outcomes:
- A life-course approach”;  Lu, Kotelchuck, Hogan,
- Jones, Jones, and Halfon, *Ethnicity and Disease*, 2005)

**Notes:**
So how do we do this? How do we address racial-ethnic disparities in birth outcomes from a life-course perspective? To get us started, let me give you a ten-point plan ...

## LA Twelve-Point PlanBroad Domains

**Improve Women’s Health**
**Improve Family and Community Health**
**Reduce Allostatic Load**

## LA Twelve-Point Plan

**Improve women’s health**
- #1. Provide interconception care to women 	with prior adverse pregnancy outcome.
- #2. Increase access to preconception care.
- #3. Improve the quality of prenatal care.
- #4. Expand health care access over the life 	course.

## LA Twelve-Point Plan

- Provide interconception care to women with prior adverse 	pregnancy outcomes
- Increase access to preconception care for African American 	women
- Improve the quality of prenatal care
- Expand health care access over the life course
- 5.   Strengthen father involvement in African American families
- Enhance service coordination and systems integration
- Create reproductive social capital in After American 	communities
- Invest in Community building and urban renewal
- Close the education gap
- Reduce poverty among black families
- Support working mothers and families
- Undo racism

## Other Programs with Interconception Care Components

- Nurse home visitation programs
- -  Post-partum follow-up
- -  Positive emphasis on family planning, behavioral change, etc.
- Early Head Start
- -  Postpartum follow-up
- WIC
- 	  -  Breastfeeding support

## Healthy People 2010 Objectives in the post-partum period

- (9.2) Reduce the proportion of births occurring within 24 months 	of a previous birth [11%       6%]
- (16-5c) Reduce maternal post-partum complications, including 	post-partum depression [developmental target]
- (16.19 a-c) Increase the proportion of mothers who breastfeed 	their babies [16.19a – in early postpartum period (64%      	75%); 16.19b – at 6 months (29%      50%); and 16.19c – at 	1 year (16%       25%)]
*No other objectives directly target women in post-partum period *

## HEDIS Measurement(Health Plan Employment Data     and Information Set)

- Post-partum care is the proportion of women that had a visit to a health care provider on or between 21 days and 56 days after delivery

## HEDIS Postpartum Check-up Rate Quality Improvement Initiative

- Single site initiative
- Barriers identified (physicians away from office; 	women feel fine; no follow-up system)
- Physician solutions (importance emphasized; 	incentives added; individual practice 	performance measure established)
- Practice innovations (new office-based tracking 	systems established; new mother outreach 	programs established; new reporting 	documents)
- Improved post-partum compliance (63% to 82%)
- 							      L. Klerman, 2005

## Internatal care: Nine issues to be addressed

- Eligibility criteria for women
- Content of care
- Timing/frequency of care
- Provider of care
- Payor source
- Motivation to participate
- Community involvement
- Public health policy and infrastructure support
- Research and monitoring databases

## Slide 87

## United Nations:                                  Convention on the Rights of the Child

- States parties shall pursue full implementation of this right (to enjoy highest attainable standard of health), and in particular, shall take appropriate measures:
**To ensure appropriate prenatal and post-natal care for mothers**
**	****	****	****	****	**									[Article 24 (2)], 1989

## Slide 89

## In the future, maternal internatal care will seem as normal and important as prenatal care is today

- Milton Kotelchuck, 2004