Reproductive Life Planning: Concepts and Applications

1. Reproductive Life Planning:Concepts and Applications Polly Hill O’Keefe, LCSW Consultant, Family Planning Council February 24, 2011

2. Goals of Today’s Training • Introduce/review CDC recommendations for Preconception Care • Discuss the components of a RLP • Identify appropriate settings/times to discuss RLP with clients and the counseling skills with which to do so effectively • Explore strategies for integrating RLP into Family Planning in a holistic, on-going manner

3. Isn’t Prenatal Care Enough?

4. NO!!! • Early prenatal care is too late to address some birth defects: • The heart begins to beat at 22 days after conception • The neural tube closes by 28 days after conception • The palate fuses at 56 days after conception • Critical period of teratogenesis – Day 17 to Day 56

5. Teens • Of all maternal age groups, teens are least likely to get early and regular prenatal care • 2000 - 2002: average 7.1 percent of mothers <20 received late or no prenatal care, compared to 3.7 percent for all ages (5). • Teen birth rates in the U. S. rose in 2007 for the second year in a row. These increases follow a continuous decline between 1991 and 2005. • Teen mothers are more likely to give birth prematurely (before 37 completed weeks of pregnancy). Premature babies face an increased risk of newborn health problems, long-term disabilities and even death. March of Dimes website. (5) National Center for Health Statistics, final natality data. Hamilton, B.E., et al. Births: Preliminary Data for 2007. National Vital Statistics Report, volume 57, number 12, March 18, 2009.; Martin, J.A., et al. Births: Final Data for 2006. National Vital Statistics Reports, volume 57, number 7, January 7, 2009; National Campaign to Prevent Teen Pregnancy. Why It Matters. Accessed 1/12/09;

6. Preterm Babies • In 2004, 1 in 8 infants born in the United States were born preterm, compared with 1 in 18 in Ireland and Finland • Preterm infants have much higher rates of death or disability than infants born at 37 weeks of gestation or more. The United States’ higher percentage of preterm births has a large effect on infant mortality rates • The percentage of preterm births in the United States has risen 36% since 1984 MacDorman MF, Mathews TJ. Behind international rankings of infant mortality: How the United States , compares with Europe. NCHS data brief, no 23. , Hyattsville, MD: National Center for Health Statistics. 2009.

7. Barriers to the use of prenatal care: Sociodemographic • Poverty • Inner-city or rural residence • Minority status • Age of <18 years • High parity • Non-English speaking • Unmarried • Less than high school education Institute of Medicine. Prenatal care: reaching mothers, reaching infants. Washington, DC: National Academy Press, 1988. Brown SS. Drawing women into prenatal care. FamPlannPerspect 1989;21:73–80.

8. Barriers to the use of prenatal care: Attitudinal • Pregnancy unplanned, viewed negatively, or both • Ambivalence • Signs of pregnancy not known or recognized • Prenatal care not valued or understood • Fear of doctors, hospitals, procedures • Fear of parental discovery • Fear of deportation or problems with the Immigration and Naturalization Service • Fear that certain health habits will be discovered and criticized (smoking, eating disorders, drug or alcohol abuse) • Attitudes related to selected lifestyles (drug abuse, homelessness) • Attitudes related to inadequate social supports and personal resources • Excessive stress • Denial or apathy • Concealment Institute of Medicine. Prenatal care: reaching mothers, reaching infants. Washington, DC: National Academy Press, 1988. Brown SS. Drawing women into prenatal care. FamPlannPerspect 1989;21:73–80.

9. Nearly half of pregnancies in the United States are unintended Approximately 6.4 million pregnancies per year

10. International Comparisons of IMR, 2005US Ranks 30th IMR: Deaths per 1,000 live births United States, Table 1: Health 2008

11. US IMR by Race1995 and 2005 1995 7.6 6.3 14.6 9.0 5.3 6.3 6.0 8.9 5.3 5.5 2005 6.9 5.7 13.6 8.1 4.9 5.6 5.5 8.3 4.4 4.7 All Races………………………………….……. White ..……………………………………..….. Black ……………………………………………. Native American …………………………… Asian ……………………………………………. Hispanic ………………………………………… Mexican …..………………………………… Puerto Rican …………………………….… Cuban ……………………………………….. Central and South American …………. 2 National Center for Health Statistics, 2010

13. CDC 2006 Recommendations on Preconception • In April, 2006 the CDC and the Select Panel released Recommendations to Improve Preconception Health and Health Care—United States The recommendations were based on: • Review of published research • CDC/ASTDR Work group representing 22 CDC programs • Presentations at the National Summit on Preconception Care, 2005 • Proceedings of the Select Panel on Preconception Care, 2005

14. Summary of CDC/Select Panel’s Ten Recommendations to Improve Preconception Health and Health Care Consumer • Individual responsibility across the lifespan • Consumer awareness Clinical • Preventive visits • Interventions for identified risks • Interconception care • Prepregnancy checkup Financing • Health insurance coverage for women with low incomes Public health Programs and Strategies Research • Surveillance of impact • Increase evidence base

15. Preconception Care • Most preconceptional health promotion is appropriate to all women, irrespective of pregnancy plans • Preconception must be integrated with other services as: • some women will not make an appointment for preconception care only • many, if not most, insurance plans don’t cover

16. Every Women – Every Time • Takes advantage of all health care encounters to stress prevention opportunities throughout the lifespan • Recognizes that in almost all cases preconceptional wellness results in good health for women, irrespective of pregnancy intentions (see module 1) • Addresses conception and contraception choices at every encounter • Involves all medical specialties—not only those directly involved in reproductive health

17. Preconception Care • Preconception care offers health services that allow women to maintain optimal health for themselves, to choose the number and spacing of their pregnancies and, when desired, to prepare for a healthy baby. . . Atrash, et al. Where is the “W”oman in MCH? AJOG.

18. Thus, preconception care is not something new that is being added to the already overburdened healthcare provider, but it is a part of routine primary care for women of reproductive age. . . Atrash, et al. Where is the “W”oman in MCH? AJOG.

19. “. . .the provision of smoking cessation services is preconception care; choosing a medication for a patient with hypertension is preconception care. .. Atrash, et al. Where is the “W”oman in MCH? AJOG.

20. Much of preconception care merely involves the provider reframing his or her thinking, counseling and decision-making. . .”to accommodate the possibility of a pregnancy before the next clinical encounter. Atrash, et al. Where is the “W”oman in MCH? AJOG.

21. Determinants of Health Adapted from McGinnis et al., Health Affairs 2002

22. Identify modifiable and nonmodifiable risk factors for her own health status and the health of any pregnancies and offspring • Provide timely counseling about risks and strategies to reduce the potential impact of the risks on her and on any future pregnancies • Provide risk reduction strategies consistent with best practices.

23. Smoking • Teens - more likely than women over age 25 to smoke during pregnancy • Babies of women who smoke during pregnancy are at increased risk for premature birth, low birthweight and sudden infant death syndrome (SIDS) (6). Women who smoke during pregnancy also have an increased risk for pregnancy complications, including placental problems (6). (6)Centers for Disease Control and Prevention (CDC). Preventing Smoking and Exposure to Secondhand Smoke Before, During and After Pregnancy. October 3, 2007.

24. STD’s • Of 19 million new cases of sexually transmitted infections (STIs) reported each year, more than 9 million affect young people ages 15 to 24 (8). These STIs include: • Chlamydia, which can cause sterility in the affected individual and eye infections and pneumonia in the newborn. • Syphilis, which can cause blindness, maternal death and infant death. • HIV, the virus that causes AIDS. Treatment during pregnancy greatly reduces the risk of an infected mother passing HIV to her baby. March of Dimes Website

25. Family Planning and Reproductive Life • Routine health promotion activities for all women of reproductive age should begin with screening women for their intentions to become or not become pregnant in the short and long term and their risk of conceiving (whether intended or not). Providers should encourage patients (women, men and couples) to consider a reproductive life plan and educate patients about how their plan impacts contraceptive and medical decision making. Every woman of reproductive age should receive information and counseling about all forms of contraception and the use of emergency contraception that is consistent with their reproductive life plan and risk of pregnancy.

26. CDC Recommendations • Improving preconception health can result in improved reproductive health outcomes, with potential for reducing societal costs as well • The recommendations are designed to promote optimal health throughout the lifespan for women, children, and families

27. Definition of Preconception Care CDC, MMWR 2006;55(No. RR-6): 1-23 Preconception care is comprised 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 It is more than a single visit and less than all well-woman care. It includes care before a first pregnancy or between pregnancies (interconception care)

28. CDC: Goals and Recommendations regarding Preconception • Four Goals: • To improved the knowledge, attitudes, and behaviors of men and women related to preconception health 2. To assure that all women of child-bearing age in the U. S. receive pre-conception care services

29. CDC Recommendations • Four Goals: 3. To reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a Mother or her future children 4. To reduce the disparities in adverse pregnancy outcomes

30. CDC Recommendations Recommendation 1: • Individual Responsibility across the lifetime • Each woman, man, and couple should be encouraged to have a reproductive life plan • Considerations: must recognize and respect variations in age, literacy (including health literacy), and cultural/linguistic contexts

31. CDC Recommendations Recommendation 2: • Consumer Awareness: • Increase public awareness of the importance of preconception health behaviors and preconception health services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts. • Integrate reproductive health messages into existing health promotions (smoking cessation, weight control)

32. E.V.E.R.Y. D.A.Y. • Exercise: 30 minutes • Vitamin: 400 mg folic acid • Educate yourself: medicines/toxins that can cause birth defects • RLP • Yearly Dr’s visits: discuss physical and mental wellness • Diet: vegetables, fruits, and whole grains • Avoid tobacco, drugs, and alcohol • Your partner, friends, and family as sources of support Everywomancalifornia.org

33. CDC Recommendations Recommendation 3: • Prevention Visits • Integrate with primary care visits • Provide risk assessment, educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes

34. CDC Recommendations Recommendation 4: • Interventions for Identified Risks • Separating childbearing from the management of chronic health problems and infectious diseases places women, their future pregnancies, and their future children at unnecessary risk • Iotretinoins, alcohol misuse, anti-epileptic drugs, diabetes (preconceptual), folic acid deficiency, Hep B, HIV/AIDS, hypothyroidism, maternal phenyketonurea (PKU), obesity, smoking, STD’s

35. CDC Recommendations Recommendation 5: • Interconception Care • Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (e.g., infant death, fetal loss, birth defects, low birthweight or preterm birth).

36. CDC Recommendations Recommendation 6: • Prepregnancy checkup • Include: preconception care content, risk assessment, health promotion, specific interventions related to circumstances when couples are trying to conceive • Challenge: this may not be reimbursable

37. CDC Recommendations Recommendation 7: • Health insurance coverage for women with low incomes • Approximately 17 million women do not have health insurance (2006) • 2010 National Report Card: 23.4% of women ages 18-44 are uninsured in the U.S. • These women are more likely to postpone or forgo care

38. CDC Recommendations Recommendation 8 • Public Health Programs and Strategies • Title X family planning programs provide approximately 4.6 million women with family planning education, contraceptives, and pregnancy tests, yet only a limited number offer more comprehensive risk screening, reproductive health promotions, and RLP • Above info from 2006 – Still true?

39. CDC Recommendations Recommendation 9 • Research • Increase the evidence base and promote the use of evidence to improve preconception health Recommendation 10 • Monitor Improvements • Maximize public health surveillance and related research mechanisms to monitor preconception health

40. What is 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. • It is more than a single visit and less than all well-woman care. It includes care before a first pregnancy or between pregnancies (interconception care) Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care.Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep. 2006 Apr 21;55(RR-6):1-23.

41. Preconception Interventions: Give protection • Folic Acid Supplements:Reduce the occurrence of neural tube defects by two thirds • Rubella Sero-negativity:Rubella immunization provides protective sero-positivity and prevents the occurrence of congenital rubella syndrome • HIV/AIDS: timely antiretroviral treatment can be administered, pregnancies can be better planned • Hepatitis B:Vaccination is recommended for men and women who are at risk for acquiring hepatitis B virus (HBV) infection.

42. Preconception Interventions: Manage conditions • Diabetes:3-fold increase in birth defects among infants of women with type 1 and type 2 diabetes, without management • Hypothyroidism:Dosage of Levothyroxine should be adjusted in early pregnancy to maintain levels needed for neurological development • Maternal PKU:Low phenylalanine diet before conception and throughout pregnancy prevents mental retardation in infants born to mothers with PKU • Obesity:Associated adverse outcomes include neural tube defects, preterm birth, c-section, hypertensive and thromboembolic disease. • STDs:have been strongly associated with ectopic pregnancy, infertility, and chronic pelvic pain.

43. Preconception Interventions: Avoid Teratogens • Alcohol use:Fetal alcohol syndrome (FAS) and other alcohol-related birth defects can be prevented. • Anti-epileptic drugs:Some anti-epileptic drugs are known teratogens • Accutane use:Use of Accutane in pregnancy results in miscarriage and birth defects • Oral anticoagulants:Warfarin is a teratogen; medications can be switched before the onset of pregnancy • Smoking:Associated adverse outcomes include preterm birth, low birth weight.

44. Summary • PCC is not just for the benefit of babies, but equally for the benefit of women; e.g., stop smoking • Reduce prematurity and asthma in baby • Reduce her risk of lung cancer and heart disease • Many women make healthier decisions during pregnancy for the sake of their baby’s health…they can make changes prior to becoming pregnant and live longer and healthier themselves • For preconception care to be successful there must be a shift from delivering procedure-based, acute care to counseling-based, preventive care

45. What is a Reproductive Life Plan? • A RLP is a set of goals that you make about having or not having children • Planning helps you think about how you want to live your life and reach your goals • It will also help you to be healthy and ready if you choose to become pregnant www.everywomancalifornia.org

46. Reproductive Life Plan • If you want children, a RLP helps you think about: • When you want to become pregnant • How many children you want to have • How many years apart you want your children to be born • If you don’t want to become pregnant, or don’t want to become pregnant now, a RLP will help you consider what to do/use to prevent pregnancy

47. Reproductive Life Plan • If you don’t want to have children, or if you are not ready to become pregnant now, a RLP helps you to create a realistic plan based on abstinence or a form of birth control that works for you • A RLP includes goals to improve your own health, because one of the best things you can do to have a healthy baby is to live a healthy lifestyle before becoming pregnant

48. An Effective RLP is Comprehensive • Personal habits • Health problems • Reproductive tracking • Vaccines/immunizations • Medications • Family history • Personal safety • Personal development (future goals) • Emotional health • Insurance/financial security

49. Considers • Cultural diversity • Religious beliefs • Literacy • Language • Support systems • What choice(s) does the consumer have regarding childbearing • Does religion play a role in preg prev decisions • Can the consumer read and comprehend english • is the consumer health literate

50. Opportunities for Preconception Care What opportunities for introducing PCC or RLP can you identify?