National Association of County and City Health Officials

1. National Association of County and City Health Officials NACCHO Preconception Care Initiative:Support to Rural Local Health Departments

2. Background • Goal: To improve the capacity of rural local health departments to address the preconception health and health care needs of individuals in their community through coordination of existing health department and community services. Project staff developed a request for applications to identify LHD demonstration sites in rural jurisdictions. Applications were judged by MCH/BD Workgroup members. • Selected Demonstration Sites: • Hertford County (NC) Public Health Authority • Okanogan County (WA) Public Health • Uncas (CT) Health District. • Sites Received: • 2 travel stipends to the Second National Summit on Preconception Health and Healthcare • 2 travel stipends to a three-day training on Coalition Building and Group Facilitation Methods • Ongoing Peer to Peer Technical Assistance

3. Focus on Rural LHDs • Vision: The national voice of local public health. • Mission: NACCHO works to support efforts that protect and improve the health of all people and all communities by promoting national policy, developing resources and programs, seeking health equity and supporting effective local public health practice and systems. • Rural LHDs often deliver many components of preconception care. With tight budgets and limited resources, there is a significant need for the coordinated delivery and promotion of preconception health and healthcare. • Rural LHDs must overcome silos, take inventory of existing services, and strategize with community partners to strengthen human and financial resources.

4. March of Dimes Local Schools Physicians Public Health Hospitals Family Planning Tribal Health Organizations Faith-Based Organizations Behavioral Health Social Services Home Visiting Services Community Health Centers Community Partners

5. Hertford County • Located in rural Northeastern North Carolina • Population: 23, 864 • Over 18% below poverty line • 75% of pregnancies are unplanned • 10.5% of babies weigh less than 2500 grams • Infant mortality rate among highest in the state (15.2) • Hertford County Public Health Authority Epidemiology Team has selected preconception health as the new approach to reduce the infant mortality rate. • Strategic priority of the Board of Health

6. Community education being provided through the media and where women gather (churches, nail salons, beauty salons, health fairs, etc) about the importance of preconception health and preconception health care Advocacy for increased public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and pre/interconception care Private primary care providers including intentional reproductive health planning during every encounter with men and women of child bearing age guided by protocols Integrated preconception care services into existing HCPHA services through structured processes Intensive case management of HCPHA clients identified to be at high risk for poor pregnancy outcomes An active Hertford County Infant Mortality Prevention Coalition that will include members from the Preconception Health and Health Care Planning Coalition Hertford County Goals

7. Hertford County Reflections • Success! • Action Plan Developed to Focus on Individual Responsibility Across the Lifespan • Identified and committed individuals will develop an education brochure, in-service education for staff, educate youth through existing organizations, mailing of brochures to clients, educate physicians, series of articles and implement a preconception education component into existing cosmetology class at local community college.

8. Hertford County Reflections • Challenges • “Each meeting brought new faces. We had to repeat and continually educate.” • Strengths • Having LHD as Lead for the Coalition • Representation from State Level- Preconception Health Consultant, March of Dimes Executive Director, and Regional Consultants • Preconception focus in North Carolina

9. Hertford County Reflections • Next Steps • Coalition will continue to meet • HCPHA plans to apply for March of Dimes grant funding to assist with action plan initiatives and hire a Preconception Coordinator

10. Okanogan County • Largest and one of the poorest counties in Washington state • Population: 39,600 • Poverty and low educational attainment are significant health issues • Remote location- access to healthcare and medical homes significant problem • Medicaid births: 71.1%, 5th highest in the state • 30.9% of births were to women with less than a 12 year education. • Birth risk factors significantly exceed most state rates. • Some of the most apparent include: preterm births, cesarean sections, breast cancer screening and breast cancer fatalities.

11. Okanogan County Goals • Okanogan County Preconception Health Coalition Mission: • To use positive messages when educating the community about preconception health issues, provide parents and community adults with information, tools, and strategies to educate children in preconception health, and engage health care providers and educators to implement and support preconception health in Okanogan County.

12. Working with clinics in making sports physicals more comprehensive and valuable for the patient Increasing public awareness of preconception health with free and paid advertising Collaboration with local college in implementing a continuing education class regarding contemporary social issues in Okanogan County Training of stylists as a novel approach to preconception health education and information dissemination Support in the establishment of county school-based clinics Develop data sharing agreements among OCPH and Community Health Centers Okanogan County Activities

13. Okanogan County Reflections • Success! • “We have created a strong partnership with the Colville Confederated Tribes, who gave our coalition $1080 for recording public service announcements to increase awareness of preconception health and health issues in Okanogan County.”

14. Okanogan County Reflections • Challenges • “It may have been beneficial to secure funding for projects prior to establishing a coalition.” • “I am not convinced that this initiative has allowed us to leverage other resources (dollars) at this time.” • Difficult getting providers/physicians to the table • Strengths • Strong partnerships with key agencies and community representatives

15. Okanogan County Reflections • Next Steps • Coalition members continue to meet and believe preconception health is a worthwhile effort • Have contacted March of Dimes for supplemental educational material • Plan to apply for a grant through the Washington Health Foundation

16. Uncas Health District • One of three health departments in New London County, CT • Population: 65,000 • Growing diversity- over 30 languages spoken • Physician shortage and medically underserved area with literally no maternal and child health public health infrastructure • County has highest prevalence of cardiovascular system birth defects in the state. • Rates for central nervous system and chromosomal defects among highest in the state- higher than all urban areas

17. Uncas Health District Goals • Those who provide health care to individuals of reproductive age will include preconception health care as a standard of practice and as one strategy to promote optimum birth outcomes and child well-being.

18. Uncas Health District Reflections • Success! • Community Grant from CT March of Dimes received ($8,000) • “The Health District was extended the opportunity to speak before the statewide advisory committee on maternal and child health. It provided an opportunity for the listeners to learn that the maternal and child health challenges can be the same or similar in the smaller more rural regions of the state compared to those in the urban areas where resources to improve outcomes are concentrated. I am positive that the data on birth defects prevalence in our county caught their attention.”

19. Uncas Health District Reflections • Challenges • Lack of current locally relevant data • Difficult to maintain interest level in the implementation phase • Staying abreast of the current MCH literature • Strengths • Partnership with birthing center- gain access to hospital birth logs • Opportunities to attend the Preconception Summit and facilitation training • Coalition members committed to working together to benefit community- and increasing their own awareness

20. Uncas Health District Reflections • Next Steps • MPH Intern will write guidelines on customs and beliefs surrounding pregnancy, childbirth and infancy of the dominant new cultures. A handbook will be disseminated to local providers. • Continue the coalition through the end of December when the March of Dimes grant commitment expires, and with the intent or reapplying for a March of Dimes grant for sustainability.

21. Lessons Learned • “To initiate a preconception coalition one has to realize that it is a labor intensive activity to assess the community, identify the need, identify potential membership, lead and facilitate the group and the process into a product, strategize for implementation and continuously evaluate along the way.” • “From the beginning, it was important to us to have the coalition members "own" the assessment findings and develop an action plan according to what they chose to be priorities; our role was to provide information and facilitate the process.” • “From a health department perspective, a challenge will be to stay abreast of the literature to identify best practices related to population-based maternal and child health, to have adequate time to provide the consultation and information sharing with the coalition, and generally to provide the continued leadership when there is no compensation to the health department.”