Interconceptional Care and Healthy Start

1. Interconceptional Care and Healthy Start Developed in collaboration between the Florida Department of Health, the March of Dimes, Florida Chapter and the Florida Healthy Start Coalitions

2. What is Interconceptional Care? Education, counseling and services provided to women between pregnancies that address risk factors for poor infant and maternal outcomes in subsequent pregnancies. In addition, these services also support the woman in maintaining lifelong health for herself and her family. Note: these services are also relevant to the nulliparous woman of childbearing age (preconceptional care) The period between pregnancies includes pregnancies that result in termination, miscarriage, fetal demise, infant death or live birth.The period between pregnancies includes pregnancies that result in termination, miscarriage, fetal demise, infant death or live birth.

3. Interconceptional Care and Cultural Competency Counseling, education and services must be provided with consideration to the cultural, language, education/literacy and accessibility needs of the participant. This includes understanding of the: Beliefs, values, traditions and practices of a culture Culturally-defined, health related needs of individuals, families and communities Culturally-based belief systems of the etiology of illness and disease and those related to health and healing Attitudes toward seeking help from the health care providers For more information contact the National Center for Cultural Competence at the Georgetown University Center for Child and Human Development at 1-800-788-2066 or htt;://gucdc.georgetown.edu/ncc When providing pre/interconceptional education or services, we are more likely to positively affect the behavior of the women if we are aware of and have appreciation for the cultural belief systems of the woman. A woman’s experiences and belief systems may affect how she receives and acts upon the information provided. When providing pre/interconceptional education or services, we are more likely to positively affect the behavior of the women if we are aware of and have appreciation for the cultural belief systems of the woman. A woman’s experiences and belief systems may affect how she receives and acts upon the information provided.

4. Interconceptional Care and Cultural Competency Examples of varying cultural beliefs or practices among groups: Mexicans – douching a common practice Mormons – procreation as a sacred duty Native Americans – children should be spaced 3 to 4 years apart African Americans – prenatal care may not be readily sought because of negative experiences with healthcare system Cubans – male contraception is not acceptable due to machismo In considering how we provide information and services to various groups with different cultural norms, we must be aware that each of us has our own sense of “normal” behavior and that these beliefs may affect how we deliver services or information. We need to be mindful of this, particularly at clinic sites. For example, our appointment systems may not be consistent with the norm for some individuals. As we strive for friendly access and strive to have services that families feel welcome in receiving, we must consider our biases and the norms for varying groups. In considering how we provide information and services to various groups with different cultural norms, we must be aware that each of us has our own sense of “normal” behavior and that these beliefs may affect how we deliver services or information. We need to be mindful of this, particularly at clinic sites. For example, our appointment systems may not be consistent with the norm for some individuals. As we strive for friendly access and strive to have services that families feel welcome in receiving, we must consider our biases and the norms for varying groups.

5. Why is Interconceptional Care Important? Approximately 50 percent of all pregnancies among adult women and 95 percent of pregnancies among teens are unplanned Critical periods of development occur often before a woman even realizes she is pregnant In thinking about new approaches for addressing the on-going problem of low-birth-weight, preterm births and infant mortality, we have broadened our focus beyond just the prenatal period. We realize that a woman’s birth outcomes are affected by her health before she ever gets pregnant. Given that many pregnancies are unplanned and that critical development of the fetus occurs before she may realize she is pregnant, we must advocate for good health practices before pregnancy, regardless of her intentions to become pregnant. In thinking about new approaches for addressing the on-going problem of low-birth-weight, preterm births and infant mortality, we have broadened our focus beyond just the prenatal period. We realize that a woman’s birth outcomes are affected by her health before she ever gets pregnant. Given that many pregnancies are unplanned and that critical development of the fetus occurs before she may realize she is pregnant, we must advocate for good health practices before pregnancy, regardless of her intentions to become pregnant.

6. As an introduction to teratogenesis: EMBRYOLOGY Organ formation: The period of time from 17-56 days after conception or 4-10 weeks from the last menstrual period (LMP) is the one where the pregnancy is most susceptible for developing major malformations. (Moore, 1998) The period of time earlier in gestation (before 17 days post-conception) is when exposures to various hazards places pregnancy at risk of spontaneous loss and the period of time after 56 days post-conception is the period where exposures to these hazards may lead to growth disturbances. Since the mean entry into prenatal care is in the 3rd month of pregnancy, issues concerning teratogenesis need to be addressed prior to the first prenatal visit.As an introduction to teratogenesis: EMBRYOLOGY Organ formation: The period of time from 17-56 days after conception or 4-10 weeks from the last menstrual period (LMP) is the one where the pregnancy is most susceptible for developing major malformations. (Moore, 1998) The period of time earlier in gestation (before 17 days post-conception) is when exposures to various hazards places pregnancy at risk of spontaneous loss and the period of time after 56 days post-conception is the period where exposures to these hazards may lead to growth disturbances. Since the mean entry into prenatal care is in the 3rd month of pregnancy, issues concerning teratogenesis need to be addressed prior to the first prenatal visit.

7. Why is Interconceptional Care Important? Florida’s infant mortality, prematurity and low birth weight rates have risen Recent data from many different sources indicate that an important time to intervene for positive birth outcomes is BEFORE a woman becomes pregnant

8. Why is Interconceptional Care Important? The relationship between maternal health and birth outcomes has been established by: Pregnancy Associated Mortality Review (PAMR) Perinatal Periods of Risk (PPOR) Fetal and Infant Mortality Reviews (FIMR) March of Dimes American College of Obstetricians and Gynecologists (ACOG) The evidence to support focus on the pre/interconceptional period to affect birth outcomes is well established. The evidence to support focus on the pre/interconceptional period to affect birth outcomes is well established.

9. Florida’s Pregnancy Associated Mortality Review (PAMR) A review of cases where death of a woman has occurred, from any cause, while she is pregnant or within one year of termination of pregnancy, regardless of duration and site of the pregnancy.” CDC and ACOG definition of maternal mortality Florida initiated the PAMR process in 1996. Based on the National Fetal Infant Mortality review model which analyses gaps in maternal health systems and care that may contribute to maternal mortality. Expanded on the Vital Statistics definition of pregnancy related deaths which included only those that occurred within a 42 day post-pregnancy interval and were assigned a pregnancy related ICD code.Florida initiated the PAMR process in 1996. Based on the National Fetal Infant Mortality review model which analyses gaps in maternal health systems and care that may contribute to maternal mortality. Expanded on the Vital Statistics definition of pregnancy related deaths which included only those that occurred within a 42 day post-pregnancy interval and were assigned a pregnancy related ICD code.

10. PAMR 1999-2002 67.1% of women with pregnancy related deaths had a history of chronic disease or condition. Many had multiple chronic illnesses. Most common: Obesity 11.8% Hypertension 11.2% What we found was that 2/3 of our women had a history of chronic disease or condition. Many had more than one including asthma, diabetes, epilepsy, with obesity and hypertension being the most prevalent. What we found was that 2/3 of our women had a history of chronic disease or condition. Many had more than one including asthma, diabetes, epilepsy, with obesity and hypertension being the most prevalent.

11. PAMR 1999-2002 Showed higher mortality rates for: Black women, Women >35 years old, Overweight and obese women. Women who are obese have odds of pregnancy related mortality that are 2 to 5 times higher than the odds for women of normal weight. Our PAMR process also showed that racial disparity was a factor in our maternal population similar to what we find in our FIMR findings. Women >35 years of age are at 3.3 times greater risk of maternal death than those who were age 19. And overweight and obese women carry a risk 2-5 times greater than women of normal weight. Our PAMR process also showed that racial disparity was a factor in our maternal population similar to what we find in our FIMR findings. Women >35 years of age are at 3.3 times greater risk of maternal death than those who were age 19. And overweight and obese women carry a risk 2-5 times greater than women of normal weight.

12. Risk of Pregnancy Related Death associated with obesity correlates with a women’s Body Mass Index or BMI. Women in the Obese 3 category with the highest BMI >40 carried over 5 times the risk of normal weight women. But I would also like to point out the risk of being underweight. Those women with a BMI of <18.4 were 2.5 times more likely to die than women of normal weight. BMI Categories Under Wt. <18.4 Norm 18.5-24.5 Over Wt 25-29.9 Obese 1 30-34.9 Obese 2 35-39.9 Obese 3 > 40 Risk of Pregnancy Related Death associated with obesity correlates with a women’s Body Mass Index or BMI. Women in the Obese 3 category with the highest BMI >40 carried over 5 times the risk of normal weight women. But I would also like to point out the risk of being underweight. Those women with a BMI of <18.4 were 2.5 times more likely to die than women of normal weight. BMI Categories Under Wt. <18.4 Norm 18.5-24.5 Over Wt 25-29.9 Obese 1 30-34.9 Obese 2 35-39.9 Obese 3 > 40

13. PPOR (Perinatal Periods of Risk) data for 1998 through 2000 illustrates that of the 5734 fetal and infant deaths (death up to age one), 2,460 of them were associated with factors relating to the health of the mother. maternal care, or prenatal care factors were associated with 1,458 deaths, newborn care (up to 28 days of life) 795 deaths and infant health (up to age 1) at 1,021 deaths. PPOR (Perinatal Periods of Risk) data for 1998 through 2000 illustrates that of the 5734 fetal and infant deaths (death up to age one), 2,460 of them were associated with factors relating to the health of the mother. maternal care, or prenatal care factors were associated with 1,458 deaths, newborn care (up to 28 days of life) 795 deaths and infant health (up to age 1) at 1,021 deaths.

14. The relationship between the maternal health and poor birth outcomes persists, even when we adjust for race. This chart represents White mothers only.The relationship between the maternal health and poor birth outcomes persists, even when we adjust for race. This chart represents White mothers only.

15. This chart represents the data for non-white mothers. Again, the largest association with fetal-infant deaths was with the mother’s own health. This chart represents the data for non-white mothers. Again, the largest association with fetal-infant deaths was with the mother’s own health.

16. Interconceptional Care Topics for Consideration Interconceptional care includes addressing the following topic areas: - Access to HealthCare - Baby Spacing - Nutrition (including folic acid education) - Physical Activity - Maternal Infections (including periodontal disease) - Chronic Health Conditions - Substance Abuse - Smoking - Mental Health - Environmental Risk Factors In considering the health of the mother prior to pregnancy, these are the topics of consideration. These areas impact her health and her reproductive health. The goal is to assist women to identify and correct or mitigate as many risk factors as possible before they become pregnant.In considering the health of the mother prior to pregnancy, these are the topics of consideration. These areas impact her health and her reproductive health. The goal is to assist women to identify and correct or mitigate as many risk factors as possible before they become pregnant.

17. Access to Healthcare Regular health care is critical to the overall health of the woman. Key components of regular care should include: Pap smear Breast exam (with teaching on techniques of self-breast exam) Review of family health history Weight, height, blood pressure Lab testing for diabetes or thyroid conditions if needed Management of chronic health conditions Dental services We must identify any barriers the woman may have to obtaining health services Work collaboratively with the participant, clinic staff and community resources in order to assist the participant with accessing needed health services Routine healthcare should include each of these components We must identify any barriers the woman may have to obtaining health services Work collaboratively with the participant, clinic staff and community resources in order to assist the participant with accessing needed health services Routine healthcare should include each of these components

18. Baby Spacing Research shows that waiting at least two years between pregnancies is optimal for both the mother and infant’s health. A short pregnancy interval may be associated with: Birth of a small for gestational age infant in a subsequent pregnancy Preterm birth in a subsequent pregnancy Low birth weight Stillbirth Death within the first year of life Cultural differences may influence a woman’s ideas about optimal spacing between pregnancies. Cultural differences may influence a woman’s ideas about optimal spacing between pregnancies.

19. Baby Spacing Having babies too close together can deplete the mother’s nutrients, energy and finances Family Planning and Primary Care clinics can assist women with their contraceptive needs There is a special Medicaid program for women, 14 – 55 years of age, who lose full Medicaid benefits, including pregnancy related benefits. This program provides coverage for family planning services for up to two years. We need to make sure women are aware of the resources for family planning services for up to two years post-pregnancy. Enrollment in the Extended Family Planning Waiver for women who had pregnancy related Medicaid or SOBRA are automatically enrolled for the first year. She must recertify after the first year to extend coverage through the second year.We need to make sure women are aware of the resources for family planning services for up to two years post-pregnancy. Enrollment in the Extended Family Planning Waiver for women who had pregnancy related Medicaid or SOBRA are automatically enrolled for the first year. She must recertify after the first year to extend coverage through the second year.

20. Nutrition Women’s nutritional status before conception may contribute to positive or negative outcomes during pregnancy and in the infant. For example: Women who are underweight (BMI < 19.8) before pregnancy, have a higher risk of: Low birth weight infant Fetal death Mental retardation in infant Both woman who are underweight and overweight are at a heightened risk for poor birth outcomes. Both woman who are underweight and overweight are at a heightened risk for poor birth outcomes.

21. Nutrition Women who are overweight (BMI 26.1-29.0) and obese (BMI >29.0) have increased risk of having: Complications during pregnancy and childbirth such as diabetes, hypertension, thromboembolic disease, macrosomia, birth trauma, abnormal labor, cesarean delivery Congenital malformations in infant Maternal mortality A child who will become obese Healthy nutritional habits and maintaining a healthy weight is important throughout the life span and should be included in all routine health care encounters. Healthy nutritional habits and maintaining a healthy weight is important throughout the life span and should be included in all routine health care encounters.

22. Nutrition Healthy Eating Avoid thinking of foods as “good” or “bad” Avoid skipping meals Focus on eating healthy for life-not “dieting” Eat a variety of foods as represented in the Food Pyramid Pay attention to serving sizes Barriers to Healthy Eating Access to healthy food sources (location, financial) Cultural beliefs When we talk to women about eating healthfully, these are discussion areas. We must be sensitive to the fact that some women may have challenges to eating healthfully, not due to lack of information, but due to barriers associated with obtaining healthful sources of food. When we talk to women about eating healthfully, these are discussion areas. We must be sensitive to the fact that some women may have challenges to eating healthfully, not due to lack of information, but due to barriers associated with obtaining healthful sources of food.

23. Nutrition – Folic Acid Women with low folate status in the periconceptional period are at significantly elevated risk of giving birth to a child with spina bifida or a related neurological defect A baby’s brain and spinal cord begin to grow right at the beginning of pregnancy, before a woman may even suspect she is pregnant Taking folic acid, by itself or as part of a multivitamin formulation, is one of the easiest things a woman can do to prevent serious birth defects in her unborn child. To be effective in lowering the risk for neural tube defects, it needs to be taken prior to and during the first few weeks of pregnancy. Taking folic acid, by itself or as part of a multivitamin formulation, is one of the easiest things a woman can do to prevent serious birth defects in her unborn child. To be effective in lowering the risk for neural tube defects, it needs to be taken prior to and during the first few weeks of pregnancy.

24. This is a slide of an infant with an open neural tube defect. Neural tube defects generally occur by 26-28 days post-conception. Up to 70% of these defects may be prevented by preconception supplementation with folic acid. (Discussion of doses in nutrition section.) This is a slide of an infant with an open neural tube defect. Neural tube defects generally occur by 26-28 days post-conception. Up to 70% of these defects may be prevented by preconception supplementation with folic acid. (Discussion of doses in nutrition section.)

25. Nutrition – Folic Acid Ideal levels of folic acid can prevent: Up to 70 percent of neural tube defects 50 percent of cleft lip and palate defects 40 to 50 percent of congenital heart defects It is also been demonstrated that folic acid may prevent pre-eclampsia and other pregnancy-related complications There are also other benefits to taking folic acid, including lowering risk for developing certain types of cancers of the breast cervix and colon and lowering risk for developing dementia in the elderly population. It has also provided to lower risk for heart disease and stroke. There are also other benefits to taking folic acid, including lowering risk for developing certain types of cancers of the breast cervix and colon and lowering risk for developing dementia in the elderly population. It has also provided to lower risk for heart disease and stroke.

26. Nutrition – Folic Acid Hispanic women, particularly those of Mexican origin, appear to have greater risk of neural tube defects Florida Birth defects registry indicates Mexican Hispanic women have a relative risk nine times higher than non-Hispanic women born in the U.S. Mexican Hispanic women are at the highest risk. The women are less likely to take folic acid or multivitamins when not pregnant due to perceptions that they are only taken in ill-health or in pregnancy and concerns about gaining weight if taking a multivitamin. Mexican Hispanic women are at the highest risk. The women are less likely to take folic acid or multivitamins when not pregnant due to perceptions that they are only taken in ill-health or in pregnancy and concerns about gaining weight if taking a multivitamin.

27. Nutrition – Folic Acid Folic acid requirements: All woman of childbearing age, regardless of their intentions to become pregnant, should take at least 400 micrograms (0.4 milligrams) of folic acid daily Past history of a baby with a NTD may require a higher, therapeutic dose of folic acid (4.0 milligrams), available through prescription only Folic acid requirement increases during pregnancy Women who are taking medication for a seizure disorder or who have diabetes may also need to take a higher dose of folic acid. These women are at a higher risk for birth defects. Women who are taking medication for a seizure disorder or who have diabetes may also need to take a higher dose of folic acid. These women are at a higher risk for birth defects.

28. Nutrition – Folic Acid Major sources of dietary folate include: Dark green leafy vegetables Citrus fruits and juices Whole grain breads Legumes Liver and other organ meats

29. Nutrition – Folic Acid It is difficult to meet the recommended daily allowance of folic acid through diet alone: 4 cups of orange juice = 400 mcg 20 spears of asparagus = 400 mcg 4 cups of raw spinach = 400 mcg 22 slices of unfortified bread = 400 mcg In addition to eating a varied diet rich in folate, we encourage all women take a multivitamin everyday. In addition to eating a varied diet rich in folate, we encourage all women take a multivitamin everyday.

30. Florida VitaGrant Project Goal: To provide folic acid and pre/interconceptional health education to underserved women of childbearing age through provision of free multimineral/multivitamin supplements, folic acid awareness materials and pre/interconceptional health materials The Florida VitaGrant project provides free multivitamins and educational materials to non-pregnant women of childbearing age. The grant is a partnership between the March of Dimes, Florida Chapter and the Department of Health. The Florida VitaGrant project provides free multivitamins and educational materials to non-pregnant women of childbearing age. The grant is a partnership between the March of Dimes, Florida Chapter and the Department of Health.

31. Florida VitaGrant Project Funded through a $2 million grant awarded to the March of Dimes from the Florida Attorney General’s Office as a result of a settlement with vitamin manufacturers for price fixing Three-year grant The grant will continue through 2007. The grant will continue through 2007.

32. Florida VitaGrant Project Distribution of vitamins to occur through a variety of providers, including, but not limited to: Healthy Start WIC Family Planning TOPWA Community Health Centers Through distribution at community events Vitamins and related materials are available through a variety of different providers and settings. Women interested in receiving a bottle of the multivitamins can call the family health line (1-800-451-2229) to get the contact number for the VitaGrant Regional Outreach Coordinator to find out where in their community they can obtain the vitamins. Most health departments are participating in the distribution. Vitamins and related materials are available through a variety of different providers and settings. Women interested in receiving a bottle of the multivitamins can call the family health line (1-800-451-2229) to get the contact number for the VitaGrant Regional Outreach Coordinator to find out where in their community they can obtain the vitamins. Most health departments are participating in the distribution.

33. Florida VitaGrant Project Providers to have access to web-based training on interconceptional health, folic acid and the VitaGrant project Any provider serving women of childbearing age is eligible to participate in the project Providers who are interested in serving as a site for the distribution can receive training, materials and vitamins for the duration of the grant. Providers who are interested in serving as a site for the distribution can receive training, materials and vitamins for the duration of the grant.

34. Florida VitaGrant Project For more information, or to become a VitaGrant Distribution Provider contact: Elizabeth Jensen Florida VitaGrant Project Manager 850-245-4465 Ejensen@marchofdimes.com

35. Physical Activity Benefits of exercise include: Lower stress, depression and anxiety Feel better about yourself Sleep better Better concentration Decrease your chance of developing a chronic disease Improve your blood pressure and decrease your cholesterol Maintain a healthy weight Encourage women to find a physical activity that best suits their needs and abilities Walking may be the easiest and most economical exercise a woman can do Encourage women to find a physical activity that best suits their needs and abilities Walking may be the easiest and most economical exercise a woman can do

36. Maternal Infections Maternal infections have been consistently linked to poor birth outcomes All sexually active women of childbearing age should be counseled on the risks of infection to their own health and their future pregnancies All women should be offered screening, testing and treatment for STD’s including syphilis, gonorrhea, HIV, genital herpes, Chlamydia, and HPV Conditions such as bacterial vaginosis should be screened for and treated if necessary Douching should be discouraged Women should be up to date with immunizations, especially rubella, hepatitis B, and varicella, prior to becoming pregnant Women should receive information on the recognition and risks of untreated urinary tract infections, bacterial vaginosis and sexually transmitted diseases Maternal infections can impact a woman’s birth outcomes, but it can also impact her own health and in some instances, her fertility. Maternal infections can impact a woman’s birth outcomes, but it can also impact her own health and in some instances, her fertility.

37. Maternal Infections - Periodontal Disease Periodontal disease -A disease of the gingiva, gums and supporting structures of the teeth. May lead to prematurity and/or low birth weight. Affects between 5-40 percent of women of childbearing age Increase the risk of heart attack and stroke Exacerbate diabetes Contribute to lung disorders such as pneumonia and emphysema Work with local community resources to assist women in obtaining proper dental health Provide toothbrushes and dental floss and educate women on the techniques and importance of good oral health Work with local community resources to assist women in obtaining proper dental health Provide toothbrushes and dental floss and educate women on the techniques and importance of good oral health

38. Chronic Health Conditions Management of chronic health conditions prior to pregnancy helps reduce risks to mother and baby. These conditions include, but are not limited to: High blood pressure Systemic Lupus Erythematosus (SLE) Kidney disease Diabetes Asthma Endocrine conditions such as thyroid disease Depression

39. Chronic Health Conditions High Blood Pressure - Chronic high blood pressure can increase the risk of pregnancy complications, including placental problems and fetal growth retardation Systemic Lupus Erythematosus (SLE) - can increase the risk of miscarriage or preterm labor. If symptoms have been inactive for at least six months, an affected woman is likely to have a healthy pregnancy. Preconception care helps plan the safest timing of pregnancy

40. Chronic Health Conditions Kidney Disease - Women who have chronic kidney disease should consult their doctors prior to pregnancy to see if pregnancy is safe for them and their baby Diabetes - Women with poorly controlled insulin-dependent diabetes are several times more likely than non-diabetic women to have a baby with serious birth defect. They are also at increased risk of miscarriage and stillbirth

41. Chronic Health Conditions Asthma – Poorly controlled asthma can increase a woman’s likelihood for complications in pregnancy, including compromising the oxygen supply to the developing fetus Endocrine Conditions – Thyroid conditions, if untreated, such as hypothyroidism and hyperthyroidism can affect a women’s fertility, can increase her likelihood for miscarriage and other complications, including mental retardation in the unborn infant Endocrine conditions are a good example of the important of maintaining good health, regardless of intentions to become pregnant. If treated and managed appropriately, hyperthyroidism and hypothyroidism will not affect her pregnancy. If not treated and managed, serious complications can result. Endocrine conditions are a good example of the important of maintaining good health, regardless of intentions to become pregnant. If treated and managed appropriately, hyperthyroidism and hypothyroidism will not affect her pregnancy. If not treated and managed, serious complications can result.

42. Chronic Health Conditions Depression – Women with a history of depression are more likely to experience depression in pregnancy and in the postpartum period. Additionally, women receiving treatment for depression through medication may need consult with their doctor on a medication safe for pregnancy or while breastfeeding Women should be routinely screened for depression throughout their lifespan. Appropriated education, resources, and referrals should be provided to address any depression she may be experiencing. Women who are depressed during pregnancy: Receive less prenatal care Don’t eat as well and are less likely to take prenatal vitamins Don’t get enough rest Are more likely to engage in risky behaviors such as smoking and substance use.Women should be routinely screened for depression throughout their lifespan. Appropriated education, resources, and referrals should be provided to address any depression she may be experiencing. Women who are depressed during pregnancy: Receive less prenatal care Don’t eat as well and are less likely to take prenatal vitamins Don’t get enough rest Are more likely to engage in risky behaviors such as smoking and substance use.

43. Substance Abuse There is no known amount of drugs or alcohol that is safe in pregnancy. Both drugs and alcohol cross the placental barrier to the developing fetus in utero Drugs and alcohol can cause fetal loss, birth defects, fetal alcohol syndrome, low-birth weight and intrauterine growth restriction. Many pregnancies are unplanned Women need support and linkages to substance abuse treatment for their health today and for the health of any children in the future We must provide women with ongoing education with simple messages sent out that teach them the dangers of drugs and alcohol to themselves and to their children Maintain awareness of the resources in the local community for referring women for counseling and treatment and assist women in receiving the help they need We must provide women with ongoing education with simple messages sent out that teach them the dangers of drugs and alcohol to themselves and to their children Maintain awareness of the resources in the local community for referring women for counseling and treatment and assist women in receiving the help they need

44. Smoking The causal association between maternal smoking and maternal morbidity, infant mortality and infant morbidity is well established in the epidemiologic literature Smoking remains the single most preventable cause of poor birth outcomes. Smoking is estimated to cause: 20 percent of LBW deliveries 8 percent of preterm births 5 percent of perinatal deaths Women who report smoking during pregnancy has risen in Florida from 9.01% in 2004 to 9.53% during the first quarter of 2005. This is up from the lowest point of 8.05% in 2003.Women who report smoking during pregnancy has risen in Florida from 9.01% in 2004 to 9.53% during the first quarter of 2005. This is up from the lowest point of 8.05% in 2003.

45. Smoking – Maternal Harm Causal association: Abruptio placenta Probable causal association: Ectopic pregnancy Premature rupture of membranes (PROM) Possible causal association: Placenta previa Spontaneous abortion

46. Smoking – Infant Harm Causal association: Low birth weight (LBW) Small for gestational age (SGA) Preterm delivery Sudden infant death syndrome (SIDS) Stillbirths

47. Smoking In 2001, the percent of births under 2500 grams (LBW) for mothers who reported smoking on the Florida birth certificate was 11.8 percent Mothers who reported not smoking had a LBW infant rate of 7.8 percent

48. Mental Health Stress, anxiety, depression and abuse can have serious effects on a woman’s health and the health of her children Depression is a risk factor for obesity, substance abuse, tobacco use, poor pregnancy outcome and has been linked to the development of asthma, heart disease, hypertension and stroke. Depression can cause serious complications for chronic disease patients and can interfere with their ability to follow treatment recommendations. Depressed mothers are less likely to breastfeed, less likely to follow back to sleep recommendations for their infants, more likely to have babies with feeding and sleeping difficulties. Infants of depressed mothers exhibit depression-like behavior (i.e. fewer expressions of interest, excessive crying, lower orientation scores, more abnormal reflexes). Source: “Depression During Pregnancy” Bennett, et. al., Clin Drug Invest Older children of mothers who were depressed during infancy often have poor self control, aggression, poor peer relationships and difficulty in school, which increases their chances of grade retention and school dropout. Source: “Improving Maternal and Infant Mental Health: Focus on Maternal Depression,” Ngozi Onunaku, MA, National Center for Infant and Early Childhood Health PolicyDepression is a risk factor for obesity, substance abuse, tobacco use, poor pregnancy outcome and has been linked to the development of asthma, heart disease, hypertension and stroke. Depression can cause serious complications for chronic disease patients and can interfere with their ability to follow treatment recommendations. Depressed mothers are less likely to breastfeed, less likely to follow back to sleep recommendations for their infants, more likely to have babies with feeding and sleeping difficulties. Infants of depressed mothers exhibit depression-like behavior (i.e. fewer expressions of interest, excessive crying, lower orientation scores, more abnormal reflexes). Source: “Depression During Pregnancy” Bennett, et. al., Clin Drug Invest Older children of mothers who were depressed during infancy often have poor self control, aggression, poor peer relationships and difficulty in school, which increases their chances of grade retention and school dropout. Source: “Improving Maternal and Infant Mental Health: Focus on Maternal Depression,” Ngozi Onunaku, MA, National Center for Infant and Early Childhood Health Policy

49. Mental Health All women need to be screened for domestic violence and depression 20 percent of women will experience depression at least once during their lifetime One in four women are the victim of abuse About three women die in the US from domestic violence every day As many as 30% of pregnant women experience some degree of depression. For lower income women, it can be as high as 50%. As many as 30% of pregnant women experience some degree of depression. For lower income women, it can be as high as 50%.

50. Mental Health - Stress Psychosocial stress refers to a psychosocial pressure (cause) that is consciously sensed (distress) and evokes an emotional response There are several components of psychosocial stress: Emotional response to stress (fear, anxiety) Life events (Loss of job, death of friend or family member) Perceptions of stress (appraisal and high stress levels)

51. Mental Health - Stress Studies have proven that high levels of stress can cause: Fatigue Lowered resistance to infectious disease Poor nutrition (no appetite or overeating) Headaches Backaches High blood pressure Heart disease

52. Mental Health - Stress According to PRAMS 2000 data, maternal stress was found to be associated with low birth weight in Florida mothers High psychosocial stress levels are associated with elevated plasma levels of adrenocorticotropin-releasing hormone (ACTH) and corticotrophin-releasing hormone (CRH), estriol and cortisol Data suggests that higher rates of preterm birth are associated with higher maternal serum cortisol levels and corticotrophin releasing hormone (CRH) A population-based cohort analysis of 521,490 live births in 1995 found a significantly higher risk of LBW, VLBW and preterm infants for women who had a psychiatric diagnosis.A population-based cohort analysis of 521,490 live births in 1995 found a significantly higher risk of LBW, VLBW and preterm infants for women who had a psychiatric diagnosis.

53. Mental Health - Stress Studies indicate that chronic psychosocial prenatal maternal stress, as opposed to acute or episodic stress, has a negative impact on pregnancy outcomes and fetal development Both increased anxiety and decreased social support are associated with poorer pregnancy outcomes As many as 30% of pregnant women experience some degree of depression. For lower income women, it can be as high as 50% Low pregnancy BMI and low weight gain during pregnancy have been associated with higher symptoms of depression, The altered excretion of hormones as a result of depression has been found to increase the risk of pre-eclampsia. Those with mental disorders were twice as likely to delay getting prenatal care and attended less than 50% of their prenatal visits. Source: “Depression During Pregnancy”, Bennett, et. al., Clin Drug InvestAs many as 30% of pregnant women experience some degree of depression. For lower income women, it can be as high as 50% Low pregnancy BMI and low weight gain during pregnancy have been associated with higher symptoms of depression, The altered excretion of hormones as a result of depression has been found to increase the risk of pre-eclampsia. Those with mental disorders were twice as likely to delay getting prenatal care and attended less than 50% of their prenatal visits. Source: “Depression During Pregnancy”, Bennett, et. al., Clin Drug Invest

54. Mental Health - Stress Dr. Michael Lu proposed the “Weathering Hypothesis”, stating that social inequality may have a negative effect on health outcomes over a lifetime Studies have demonstrated that perception of racism is linked to preterm birth In trying to understand the disparity in health outcomes between African American women and Caucasian women, research has supported that long-term stress as a result of social inequality and perceptions of racism, may impact the health of the mother and her pregnancies. In trying to understand the disparity in health outcomes between African American women and Caucasian women, research has supported that long-term stress as a result of social inequality and perceptions of racism, may impact the health of the mother and her pregnancies.

55. Environmental Risk Factors Women may be exposed to harmful substances at work, at home, or outside, without even knowing it Awareness and education of possible environmental toxins may reduce exposures and possible poor birth outcomes

56. Environmental Risk Factors Lead: Found in paint, dust, soil, pottery, glass, cooking utensils and other places, can damage the brain and nervous system causing behavior, learning, and hearing problems, headaches and delayed growth Some herbal remedies such as Azarcon and Greta may contain high levels of lead Previous maternal exposure to lead can affect the developing fetus Provide education concerning where lead can be found and how to decrease exposure and how to get tested if she thinks she may have been exposed previously. Lead can be brought into the home on the clothing of persons employed in certain occupations like radiator repair. Provide education concerning where lead can be found and how to decrease exposure and how to get tested if she thinks she may have been exposed previously. Lead can be brought into the home on the clothing of persons employed in certain occupations like radiator repair.

57. Environmental Risk Factors Mercury: A poisonous metal that occurs naturally in the environment. It is released into the air then falls directly into the water. Upon reaching the water it turns into a very toxic form (methyl-mercury). In 2004, the FDA/EPA Consumer Advisory:”What You Need to Know about Mercury in Fish and Shellfish” was released. For more information, call the FDA Food Information Hotline toll-free at 1-888-SAFEFOOD or visit the FDA’s Food Safety Website at www.cfsan.fda.gov/seafodd1.html Women may not realize that certain types of fish should be avoided or only eaten in very small quantities. In general, in trying to remember which fish to eat and which fish not to eat, the larger the fish the more likely the fish is to have bio-accumulation of harmful substances. Women may not realize that certain types of fish should be avoided or only eaten in very small quantities. In general, in trying to remember which fish to eat and which fish not to eat, the larger the fish the more likely the fish is to have bio-accumulation of harmful substances.

58. Environmental Risk Factors Pesticides: Includes bug sprays, fertilizers and wood treatment Migrant farm workers may be more heavily exposed to these toxins Up until recently, pressure treated wood was treated with arsenic. Arsenic residue is found on and near pressure treated wood to include decks, playground equipment, outdoor furniture and walkways. Up until recently, pressure treated wood was treated with arsenic. Arsenic residue is found on and near pressure treated wood to include decks, playground equipment, outdoor furniture and walkways.

59. Environmental Risk Factors Gases: Carbon Monoxide is given off by cars, gas furnaces, kerosene heaters and cigarette smoke. It can not be seen nor smelled. Side effects of exposure include: Low birth weight Stillbirth Headaches Death

60. Environmental Risk Factors Food-borne risks: Undercooked foods (raw fish, oysters, underheated deli meats) Unpasteurized milk or juice Soft cheeses Some herbal teas Homeopathic remedies Toxoplasmosis: cat litter soil Avoid Sushi when pregnant.Avoid Sushi when pregnant.

61. Healthy Start Standards and Guidelines Chapter 21 Specifics and Standards This chapter was developed through a collaborative effort between the Florida Department of Health and local Healthy Start Coalitions. This chapter was developed through a collaborative effort between the Florida Department of Health and local Healthy Start Coalitions.

62. Interconceptional Care – Healthy Start Counseling and Education Services Overview Curriculum Topics Components Services Coding The chapter outlines the minimum educational content, provider qualifications, documentation, and coding required to provide Interconceptional Care and Counseling to our Healthy Start clients. The chapter outlines the minimum educational content, provider qualifications, documentation, and coding required to provide Interconceptional Care and Counseling to our Healthy Start clients.

63. Interconceptional Education and Counseling Services Overview Services are determined based on the coalition service delivery plan and local resources Services are above and beyond health information provided during care coordination. Coalition approved curriculum Services are provided to women determined to be at risk for a poor birth outcome in a subsequent pregnancy May use screening tools to help determine risks Currently there is no additional reimbursement for providing Interconceptional services. Local Healthy Start Coalitions must provide these services using other community resources or The standards allow coalitions the flexibility to develop or adapt curriculums to meet their individual needs as long as they include the minimum standards outlined in the chapter. Curriculums and protocols must be approved by the local Healthy Start Coalitions before providers begin implementation of the program. We use several tools to identify a clients individual needs. Women enter Healthy Start voluntarily through Florida’s universal Prenatal and Infant Screening program allows providers to identify women and infants at risk for poor birth outcomes and developmental delays. Interconceptional Risk factors are identified through further screening of clients who agree to Healthy Start Services. The Women’s Health Questionnaire and the “Tell Us About Yourself” psychosocial questionnaire are two examples of screening tools which assess health behaviors. Currently there is no additional reimbursement for providing Interconceptional services. Local Healthy Start Coalitions must provide these services using other community resources or The standards allow coalitions the flexibility to develop or adapt curriculums to meet their individual needs as long as they include the minimum standards outlined in the chapter. Curriculums and protocols must be approved by the local Healthy Start Coalitions before providers begin implementation of the program. We use several tools to identify a clients individual needs. Women enter Healthy Start voluntarily through Florida’s universal Prenatal and Infant Screening program allows providers to identify women and infants at risk for poor birth outcomes and developmental delays. Interconceptional Risk factors are identified through further screening of clients who agree to Healthy Start Services. The Women’s Health Questionnaire and the “Tell Us About Yourself” psychosocial questionnaire are two examples of screening tools which assess health behaviors.

64. Interconceptional Education and Counseling Curriculum Topics Access to care Baby spacing Nutrition Physical activity Maternal infections Chronic health problems Substance abuse Smoking Mental health Environmental risks Emphasis is placed on assuring that education is presented in a culturally and educationally competent manner. When possible education should be presented in the clients native language or through a qualified interpreter and provided on an education and literacy level appropriate to the client. Fathers, significant others, and family members are encouraged to participate with the participant’s approval. Topics are tailored to the clients needs and risk factors. Emphasis is placed on assuring that education is presented in a culturally and educationally competent manner. When possible education should be presented in the clients native language or through a qualified interpreter and provided on an education and literacy level appropriate to the client. Fathers, significant others, and family members are encouraged to participate with the participant’s approval. Topics are tailored to the clients needs and risk factors.

65. Interconceptional Education and Counseling Service Components Plan of Care Presentation Demonstration activity Follow-up Feedback Evaluation

66. Interconceptional Education and Counseling Services Provided one to one with participant in face to face visit Provided in a support group setting Provided in a classroom setting in a set series of classes We encourage providers to be creative in how they deliver services. Education can be provided on a one-to-one, in a support group setting, or in a formal educational group setting, and may be provided through home visiting, or community locations such as clinics, churches, community centers, libraries, or schools. We encourage providers to be creative in how they deliver services. Education can be provided on a one-to-one, in a support group setting, or in a formal educational group setting, and may be provided through home visiting, or community locations such as clinics, churches, community centers, libraries, or schools.

67. Interconceptional Education and Counseling Services Trained providers with up to date knowledge of interconceptional health Written follow-up provided to the Healthy Start care coordinator within 30 days Service provider communicates any additional needs identified to the care coordinator Providers include nurses, social workers, health educators, and trained paraprofessionals who are knowledgeable about community resources, interconceptional topics, and are culturally competent. Providers include nurses, social workers, health educators, and trained paraprofessionals who are knowledgeable about community resources, interconceptional topics, and are culturally competent.

68. Interconceptional Education and Counseling Services Documented in the record of the person receiving the service Follow-up on referral documented in participant’s record Consent for release of information between provider and care coordinator Certification of completion provided to care coordinator for participant’s record. Quarterly QA/QI by provider

69. Interconceptional Education and Counseling Services Coding Activities that educate and inform the Healthy Start woman about health behaviors that will help to reduce risk and improve subsequent birth outcomes Code is open to program component 26, 27, 30 and 31

70. Interconceptional Education and Counseling Services Coding  Who can be provided this Healthy Start service”? any Healthy Start woman determined at risk for a poor outcome of a subsequent pregnancy may be provided prenatally or postnatally may be provided to the Healthy Start participant, or to the mother of a Healthy Start participant on behalf of the participant Services can be provided to a Healthy Start Woman or to the mother on behalf of her Healthy Start Infant. Services can be provided to a Healthy Start Woman or to the mother on behalf of her Healthy Start Infant.

71. Interconceptional Education and Counseling Services Coding Who can provide and code this Healthy Start service”? Trained and qualified Healthy Start providers May be provided individually, in support groups or formal classes One unit of service =15 minutes We have a system of service coding to capture the location of service provision and numbers of services provided, but there is currently no reimbursement for these services. We have a system of service coding to capture the location of service provision and numbers of services provided, but there is currently no reimbursement for these services.

72. Interconceptional Education and Counseling Services Coding  What is required for the service? Healthy Start coalition approved curriculum with components covering access to health care; baby spacing; nutrition; physical activity; maternal infections; chronic health problems; substance abuse; smoking; mental health; and environmental risk factors Learning objectives for the curriculum

73. Interconceptional Education and Counseling Services Coding What if my staff is not trained to provide this special service? Healthy Start care coordinators who do not receive special interconceptional education and counseling training may still provide their participants with the appropriate health education to reduce risks as part of their care coordination activities and code to 3320 or 3321

74. Golden Opportunity “We recognize that powerful influences on outcome occur long before pregnancy begins. Pregnancy is shaped by: Social Psychological Behavioral Environmental Biological forces Improving pregnancy outcomes necessitates the linkage of an even broader array of healthcare providers embracing a life course perspective with regard to perinatal health.” Dawn Misra, Women’s and Children’s Health Policy Center, Bloomberg School of Public Health, Johns Hopkins University

75. Golden Opportunity Any health care provider who comes into contact with a woman of reproductive age has the potential to protect the health of that woman and her future offspring