Improving the Health of Women Before Pregnancy

1. Improving the Health of Women Before Pregnancy A Key Strategy to Reduce Infant Mortality

2. Care Prior to Pregnancy= Well Woman’s Health Care • Preconception care: care a woman gets before she becomes pregnant, prior to conception • Interconception care: care for women who have had a prior adverse pregnancy outcome to address risks

3. Consensus Definition of Preconception Care “A set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’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.” CDC’s Select Panel on Preconception Care, June2005

4. Why focus on woman’s health before pregnancy to prevent infant mortality? • Many risk factors for infant mortality, preterm birth, and other adverse pregnancy outcomes are related to maternal health. • Experts have identified a wide array of evidence-based interventions that would benefit pregnancy woman and/or infants particularly if provided prior to pregnancy (Jack et al. 2008)

5. Why focus on women’s health before pregnancy? • High quality prenatal care is essential but care during pregnancy cannot : • ameliorate risks associated with women’s health status when not pregnant • Ameliorate risks associated with pregnancies with short interpregnancy interval • Ameliorate risks associated with unintended and unplanned pregnancies

6. A focus on women’s health = Opportunity to plan pregnancies • Reduce unintended pregnancy • Increase appropriate birth spacing • Increase contraception access • Given that half of all pregnancies are unplanned, preconception/interconception care is critical to enhancing the likelihood of a healthy pregnancy outcome • According to the Guttmacher Institute, for every $1 spent on family planning, $3.74 is saved

7. A focus on women’s health = Opportunity to Reduce Risks • Hypertension • Diabetes • STIs and UTI and other infections including bacterial vaginosis • Immunization status • Folic Acid and other micronutrients • Teratogens (e.g., prescription medications, household exposures) • Mental Health

8. Strength of Recommendations and Quality of Evidence for Preconception Clinical Interventions – A’s (Best Evidence,35) Jack, Atrash, et al., 2008

9. Strength of Recommendations and Quality of Evidence Preconception Clinical Interventions – B’s (Fair evidence, 25) Jack, Atrash, et al., 2008

10. A focus on women’s health = Opportunity to Change Behavior • Smoking • Drugs • Alcohol • Nutrition • Exercise • Healthy weight

11. Prevalence of Risk, Medicaid and Total, PRAMS, 26 Reporting Areas, 2004 Source: Centers for Disease Control and Prevention. D’Angelo et al. Preconception and Interconception Health Status of Women Who Recently Gave Birth to a Live-Born Infant . MMWR. 2007; Vol. 56 /SS-10.

12. It is Time for a Reinvestment in Women’s Health when Not Pregnant • Preconception health and well-woman health concepts have been advance but our commitment and investments: • Have not been fully transformed into a national strategy to ensure every woman has a medical / health care home. • Are limited with 4 in 10 low-income women having no health insurance public or private. • Need a commitment to access for women’s clinical and community preventive services as in ACA.

13. We Can and Should Build on Prior Investments • ACA coverage • ACA preventive benefits, including well-woman visits and preconception care • Family Planning –Title X: vital infrastructure must be supported and expanded even in the face of coverage expansion • Medicaid coverage - women’s postpartum coverage must be extended beyond 60 days • Family Planning – Medicaid Family Planning waivers and State Plan Amendments

14. ACA Women’s Clinical Preventive Services Coverage • ACA requires all health plans (except those grandfathered and Medicaid) to cover certain preventive services without cost-sharing. • As of Aug. 1, 2012, estimated 47 million insured women enrolling in new health plans or renewing their existing policies will have coverage for preventive health services without cost-sharing: • Well-woman visits (annual preventive visit including preconception care) • Gestational diabetes screening • HPV DNA testing • STI counseling • HIV Screening and counseling • Contraception and contraceptive counseling • Breast-feeding support, supplies, and counseling • Interpersonal and domestic violence screening and counseling • Plus immunizations and other services recommended by the U.S.Task Force on Clinical Preventive Services.

15. Recommendations for Risk Assessment and Health Promotion In Preconception Care (Adapted from Moos et al, 2008)

16. We need to take the next step… • We need a national campaign to ensure women take advantage of the preventive health visit. • Women need to know about their “right” to preventive health care • Health care providers need training/education in well-woman health care across the life course. • Develop and implement clinical guidelines for well-woman visit • Develop systems of care in which women do not fall through the cracks (e.g., medical care home; link between prenatal, postpartum and well-woman health care) – Key Role for Title V