Birth Spacing and Pregnancy Planning/Prevention in Home Visiting

1. Birth Spacing and Pregnancy Planning/Prevention in Home Visiting Webinar hosted by The National Campaign to Prevent Teen and Unplanned Pregnancy June 17, 2014 3:00PM – 4:30PM (EDT)

2. What we will hear Welcome/Introductions Why the topic of pregnancy spacing and planning is germane to the home visiting community An overview of new OPA/CDC Quality Family Planning Clinical Guidelines, Modern Contraception, Access to Contraception, and Training for Home Visitors A presentation from two home visiting program leaders who are incorporating birth spacing and pregnancy planning/prevention Resources for home visitors and others working in the home visiting sector 2

3. Speakers David Willis, MD, FAAP – HRSA, HHS Moushumi Beltangady, MSW MPP – HRSA,HHS Sarah Brown, MSPH – The National Campaign to Prevent Teen and Unplanned Pregnancy Susan Moskosky, MS, WHNP-BC, OPA, HHS Shamika Dokes-Brown, Native American Health Center Kristine Campagna, Rhode Island Department of Health Sounivone Phanthavong, Rhode Island Department of Health

4. Birth Spacing and Pregnancy Planning/Prevention in Home VisitingJune 17, 2014 David W. Willis, M.D., FAAP Director, Division of Home Visiting and Early Childhood Systems Maternal and Child Health Bureau Health Resources and Services Administration Department of Health and Human Services 4

5. The Home Visiting Program • Authorized by Title V of the Social Security Act: Maternal, Infant, and Early Childhood Home Visiting Programs • $1.5 billion over 5 years • $100M FY2010 • $250M FY2011 • $350M FY2012 • $400M FY2013 • $400M FY2014 • Sustainable Growth Rate Legislation • $400M FY2015 5

6. The Home Visiting Program • Supports Families • Evidence-based parent support services • Partnership between parents and home visitors • Ongoing visits and dialogue around family needs • Voluntary • For families that ask to be empowered with better knowledge, health and parenting • Evidence-based • Built on four decades of rigorous research and evaluation • Includes a rigorous national randomized controlled trial evaluation and local evaluations • Now 14 HHS approved home visiting models 6

7. The Home Visiting Program • Cost effective • Home Visiting prevents child abuse and neglect, encourages positive parenting and promotes child development and school readiness • Long term reduction of school dropout rates, teen pregnancy and crime • Every $1.00 invested, yields up to $9.50 ROI to society* • Locally designed and run • Provides states with maximum flexibility to tailor programs to fit needs of different communities • States can choose from 14 evidence-based home visiting models • Programs run by local organizations in local communities *Source: Ted R. Miller, “Nurse-Family Partnership Home Visitation: Costs, Outcomes, and Return on Investment,” The Pew Center on the States. (2013). 7

8. The Home Visiting Program Home Visiting Benchmarks • Maternal and newborn health (8 constructs) • Child injuries; child abuse, neglect, or maltreatment; emergency department visits (7) • School readiness and achievement (9) • Crime (2) or domestic violence (3) • Family economic self-sufficiency (3) • Coordination/referrals for other community resources (5) 8

9. Importance of Birth Spacing and Pregnancy Prevention/Planning • Birth spacing, pregnancy planning and preconception health services contribute to improved health outcomes for infants, children, women, and families. • Interval birth education and preconception health are important components of our home visiting program and key benchmark indicators for measuring our success. 9

10. Importance of Birth Spacing and Pregnancy Prevention/Planning • Short intervals between pregnancies are associated with increased risk of adverse perinatal outcomes including preterm births and low-birth-weight infants. • Unintended pregnancies can have negative health and economic consequences including delays in seeking prenatal care, reduced likelihood of breastfeeding, maternal depression, lower adult educational attainment and income, and poor mental and physical health during childhood (Sonfield, 2011). 10

11. The Home Visiting Program Strategies / Innovations • Ongoing staff training • Partnership building with family planning programs • Birth spacing curricula and home-based education • Referral to preconception health programs and other primary health care providers • Workshops, webinars, conferences and printed materials • Teen focused education programs 11

12. The Home Visiting Program What’s Needed? • Better integration of home visiting, preconception health and primary health care services • More cross training with and completed referrals to preconception health programs • Continuous monitoring and assessment to improve education and referral services 12

13. The Home Visiting Program The opportunity… ... to better integrate home visiting, birth interval education, and preconception health services to improve the life course of the next generation of our nation’s vulnerable children, youth and families. 13

14. Contact Information David W. Willis, MD, FAAP Director, Division of Home Visiting and Early Childhood Systems Maternal and Child Health Bureau, HRSA 301-443-8590 dwillis@hrsa.gov 14

15. Senior Policy Advisor for Early Childhood Development Office of the Deputy Assistant Secretary for Early Childhood Development, Administration for Children and Families U.S. Department of Health and Human Services Moushumi Beltangady 15

16. Why birth spacing and pregnancy planning matter for home visiting Sarah Brown, CEO The National Campaign to Prevent Teen and Unplanned Pregnancy

17. A bit about The National Campaign

18. Starting at the beginning No contraception Gap in contraceptive coverage Cont. Failure Inconsistent Use

19. The benefits of pregnancy planning For example: • Increased opportunities for preconception care • Earlier start in prenatal care • Lowered risk of preterm delivery, low birth weight, fetal growth retardation and infant mortality • Increased opportunity for maternal education • Reduced relationship conflict

20. The benefits of pregnancy planning extend beyond first births • All the benefits of pregnancy planning noted on previous slide continue to apply with second and higher order births…. • Mainly through preconception care and adequate child spacing which benefit the mother and the child/children already present.

21. In the context of home visiting… • One major way to help achieve adequate child spacing is through the use of high quality contraception. It is logical and amply supported by research to focus some attention on birth spacing -- that is, helping a young mother think about if and when she might want an additional child, and what steps she can take now to ensure a healthy pregnancy and good results – both for herself, her current child and family AND future children.

22. Unintended pregnancy in the populations you may serve Among unmarried women in their twenties, 75% of births resulting from unintended pregnancies are to women who have already had at least one pregnancy/birth 70% of pregnancies to unmarried women in their 20s are unintended Almost 20% of teen mothers have a second birth before turning 20

23. Approaching pregnancy spacing and planning within home visits Approach topic in a relaxed, respectful manner Ask One Key Question: “Would you like to become pregnant in the next year? If yes: preconception/prenatal care referrals and links If no, provide links to family planning care and information

25. A note on contraception itself Home visitors do not need to be family planning experts; help is available in most communities Even so, basic knowledge about contraception is important, especially newer low-maintenance methods Warm concern can make all the difference, along with helping women get the method best for them and avoid gaps in protection

26. Susan Moskosky, MS, WHNP-BC Acting Director, Office of Population Affairs U.S. Department of Health & Human Services Susan.moskosky@hhs.gov 26

27. What is Title X? • Mission: To provide individuals with the information and means to exercise their ability to determine the number & spacing of their children, including providing access to a broad range of acceptable & effective family planning methods and related services • 4,200 clinics nationally • State and local health departments, hospitals, university-based clinics, community health centers and free-standing clinics 27

28. Title X Services • Confidential • Voluntary • Contraceptive counseling, services & supplies • Breast and cervical cancer screening • STD screening, counseling and treatment • HIV testing, prevention education • Pregnancy testing, counseling and referral • Other preventive health services • Charges based on family income 28

29. http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf 29

30. Conceptual Framework Safe Effective Client centered Timely Accessible Efficient Equitable Value Based on the IOM’s definition of “quality”: Improved quality Improved reproductive health outcomes IOM (2001). Crossing the quality chasm: a new health system for the 21st century. National Academies of Science, Washington DC. 30

31. Framework for Family Planning, Related and Other Preventive Services 31

32. Contraceptive Services • Remove medical barriers as a prerequisite to contraceptive provision • Pelvic exams not routinely needed, unless inserting IUD or diaphragm • Cervical cytology • Routine HIV screening • Provide in accordance with CDC’s MEC and SPR • Offer a full range of FDA-approved methods • Highly effective, reversible contraceptive methods are available and safe for most women and adolescents (LARCs - IUC and Implants) ) • Use an evidence-informed counseling process, which includes educating about the most effective contraceptive methods first • Contraceptives are one of the women’s preventive services that must be made available without co-pays or cost sharing under the ACA 32

33. Special Considerations for Adolescents • Counseling adolescents • Unique needs and characteristics • Emphasis on confidentiality • Promotion of parent-child communication about sexual health • Provide comprehensive information about pregnancy prevention, including contraception and abstinence • LARCs are safe and effective for many sexually active adolescents 33

34. Youth Friendly Services • Accessible • Equitable • Acceptable • Appropriate • Appropriate • Comprehensive • Effective • Efficient World Health Organization, 2002 34

35. Shamika Is a Home Visitor with the Strong Families Tribal Home Visiting Program with the Native American Health Center. She is a Certified Family Planning Health Worker , Lactation and Childbirth Educator . She has also worked as a Perinatal Health Worker and Birth Doula for over 10 years and strives to ensure that the families who cross her path are informed and empowered to make the right choices for their health and their families. Ultimately, Shamika would like to become a Certified Nurse Midwife and one day open her own Birth and Education center. Shamika Dokes-Brown shamikad@nativehealth.org 510-434-5452 35

36. Birth Spacing, Pregnancy Planning and Prevention in the Home Visiting Setting 36

37. Session Objectives Define birth spacing List possible increased risk of closely spaced pregnancies for the mother and baby List benefits of birth spacing Describe work with health care providers and challenges encountered Describe the benefits of having Home Visiting services available Describe how this information is delivered in a Home Visiting setting Explain how the lesson is covered using The Family Spirit curriculum 37

38. Definition Birth Spacing The time interval between one child’s birth date until the next child birth date. Studies have proven that at least 16-18 months between deliveries may allow for a healthier outcome for both the mother and infant. Short birth spacing is used to describe a birth-to-pregnancy interval that is less than 2 years. 38

39. Possible increased risks of closely spaced pregnancies • Pre-term labor • Uterine rupture • Placenta Previa • Third trimester bleeding • Low-birth weight • Poor marital or family support • Lower folate levels • Relationship stress • Increased risk for postpartum depression • Depletion of maternal stores of certain nutrients 39

40. Benefits of healthy birth spacing Decreased risk of preterm delivery Baby develops well because more bonding time is available Mom's body has had enough time to restore nutrients and recover before getting pregnant again Less financial stress 40

41. Strong Families Tribal Home Visiting 41

42. Working with Health care Providers and challenges we have encountered • NAHC • Behavioral Health, Strong Families Home Visiting (SFHV), Medical, Dental, Traditional Services, @ 3 sites • Challenges • No postpartum appointment after delivery • No return phone calls when clients leave messages • Short appointments • No close follow up or case management for clients who are considered high risk or lost to care 42

43. The Benefit of Having Home Visiting Services available to work with Health Care providers Extra support for clients and families considered high risk or lost to care Decreased no shows for medical appointments Increased breastfeeding because of intergraded services Decrease in unwanted pregnancies 43

44. Delivering this Information in the Home Visiting setting The best time to present contraception information is preconception or during pregnancy The risk and benefits for each method should be covered following the contraception affectedness chart As Home Visitors, we are able to elaborate more on the information and assist the client in coming up with a list of questions for her Medical provider if needed Medical Visits can be short and the pre- education the client receives with the home visitor assists the Medical Provider and also empowers the client because she is made aware of all the contraception methods and is able to select what method that is best for her. 44

45. Family Spirit CurriculumUnderstanding Reproduction Sex after Pregnancy Introduction to Reproductive Anatomy Understanding the Menstrual Cycle How babies are created Activities on both the Male and Female Reproductive Anatomy After each lesson, a copy of the Reference Manual is given and a copy of the Participant Handout for the client to review and add to their binder 45

46. Contraception Method 46

47. Family Spirit Curriculum 47

48. Updating the contraception sections Family Spirit Curriculum • A Few errors were found and Family Spirit is currently working on updating this information • Used Chastity.com, CDC, ACOG to verify outdated info • Depo-provera (“the Shot”) & Lunelle discussed • Silver nitrate used with infants • Hepatitis B results in Pneumonia 48

49. Lessons learned with Teaching this Curriculum Don’t assume that the method the client selected after delivery is still the current method if no PTL was done. Make sure to bring demos of the methods for the accurate size. Think outside of the box for creative way to explain how the methods work. Take a calendar as a teaching point to keep track of LMP and also Intercourse etc. Keep an endless amount of condoms on hand. 49

50. Example for the Birth Control Pill Not taking the Birth Control Correctly Taking the Birth Control Pill Correctly 50