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A Baby? Maybe [ Practical Pointers for Purposeful Planning ]

Jacki S. Witt, JD, MSN, WHNP-BC University of Missouri – Kansas City Project Director, Title X Clinical Training Center for Family Planning. A Baby? Maybe [ Practical Pointers for Purposeful Planning ]. Key Questions. What is RLP ? Why should we integrate RLP into clinical practice?

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A Baby? Maybe [ Practical Pointers for Purposeful Planning ]

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  1. Jacki S. Witt, JD, MSN, WHNP-BC University of Missouri – Kansas City Project Director, Title X Clinical Training Center for Family Planning A Baby? Maybe[Practical Pointers for Purposeful Planning]

  2. Key Questions • What is RLP? • Why should we integrate RLP into clinical practice? • How can we make RLP meaningful to individuals and the community? • What barriers do the men & women in our clinic/community face when making RLPs?

  3. What is RLP? • Planning for pregnancy – or not • Access to health care services for prevention/health promotion, preconception planning & contraception • Case finding of women with previous adverse pregnancy outcomes to reduce risk for future adverse outcomes • Dialogue between health care staff & women/couples

  4. What is RLP? • A set of interventions that aim to identify & modify biomedical, behavioral, & social risks to a woman's health or pregnancy outcome through prevention & management • It is more than a single visit & less than complete well-woman care • It includes care before a first pregnancy or between pregnancies (interconception care)

  5. Why RLP? Early Prenatal Care is Not Enough

  6. Critical Periods of Development Critical Periods of Development Weeks gestation from LMP 4 5 6 7 8 9 10 11 12 Most susceptible Central Nervous System Central Nervous System time for major malformation Heart Heart Arms Arms Eyes Eyes Legs Legs Teeth Teeth Palate Palate External genitalia External genitalia Ear Ear Mean Entry into Prenatal Care Missed Period

  7. 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

  8. Almost half of pregnancies are unintended I don’t believe in doing anything to stop from having children It wasn’t my fertile time We had used condoms except one time! My doctor said I couldn’t get pregnant I thought if it’s God’s will, I would get pregnant My boyfriend doesn’t like using condoms I was using birth control pills !

  9. Unintended Pregnancies in the United States Approximately 6.4 million pregnancies per year

  10. Purpose of Preconception Care • Improve the health of each woman prior to conception by identifying risk factors • Provide education • Stabilize medical condition(s) to optimize maternal and fetal outcomes • The process should be ongoing “Every woman – every time” Finer,2006

  11. CDC’s Vision • Improving Preconception Health & Pregnancy Outcomes • All women & men of childbearing age have high reproductive awareness (i.e., understand risk & protective factors related to childbearing). • All women have a reproductive life plan (e.g., whether or when they wish to have children, & how they will maintain their reproductive health).

  12. CDC’s Vision • All pregnancies are intended & planned. • All women & men of childbearing age have health coverage. • All women of childbearing age are screened before pregnancy for risks related to the outcomes of pregnancy.

  13. CDC Goals Four Goals: 1.Improve the knowledge, attitudes, & behaviors of men & women related to preconception health 2. Assure that all women of child-bearing age in the U. S. receive preconception care services

  14. CDC Goals Four Goals (continued): 3. 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. Reduce the disparities in adverse pregnancy outcomes

  15. CDC’s Reproductive Life PlanFramework Vision Improve health and pregnancy outcomes Goals Coverage – Risk Reduction Empowerment – Disparity Reduction Recommendations Individual Responsibility - Service Provision Access – Quality – Information – Quality Assurance Action Steps Research –Surveillance –Clinical interventions Financing – Marketing –Education and training

  16. Why should we integrate RLP into our clinical practice? • U.S. maternal & infant mortality is higher than in many countries • Despite more women receiving early prenatal care rates of preterm birth & low birth weight are increasing in U.S.

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

  18. US IMR by Race 1995 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

  19. Consequences of Unintended Pregnancy for Women/Families Delays in initiating prenatal care Reduced likelihood of breastfeeding Poor maternal mental health Lower mother-child relationship quality Increased risk of physical violence during pregnancy

  20. Life Course Planning (based on the Behavioral-Ecologic Model of Health) • Pieces of the puzzle: • Education • Health • Vocation/career • Relationships/family • Reproductive life plans • Set against backdrop of culture, society, religion, economic status

  21. Reproductive Life Planning is Not New • Encourage young people to develop a “RLP” by asking themselves questions: • Do I want children and if so, how many and when? • How will I feel if I cannot have children?

  22. Reproductive Life Planning isNot New • How will I feel if I have an unwanted pregnancy? • How do I feel about abortion? • What do I most want to accomplish in life? • How much education do I want? • How compatible are my reproductive plans with my religious and moral beliefs? Hatcher, 1980

  23. Is there scientific data to support it? Does it Really Matter?

  24. There is evidence that individual components work • Rubella vaccination • HIV/AIDS screening • Management and control of: • Diabetes • Hypothyroidism • PKU • Obesity • Folic Acid supplements • Avoiding teratogens: • Smoking • Alcohol • Oral anticoagulants • Isotretinoin

  25. US Public Health Service

  26. Title X Program Priority • Priority # 4:“Emphasizing the importance of  counseling family planning clients on  establishing a reproductive life plan, and providing preconception counseling as a part of family planning services,  as appropriate”

  27. So……..why don’t we do it? Guidelines Best Practice = Reproductive Life Plan for Everyone

  28. Preconception care is not being consistently delivered today • Most clinicians don’t provide it • Most insurers don’t pay for it • Most consumers don’t ask for it

  29. Barriers to Implementation • Funding • Staff buy in • Patient buy in • Time • Competing priorities • Need to know best strategies for your population

  30. Strategies for making RLP meaningful to individuals & the community • Consider your population/community • Statistics: unplanned pregnancy rates, infant & maternal morbidity & mortality • Cultural preferences related to health care, pregnancy, social challenges • Health care access

  31. Strategies for Successful RLP in your organization • Consider your setting’s characteristics • Who counsels women? • Your best educational methods? • Social and mental health services? • Coverage for contraceptives?

  32. Reproductive Life Planning Pearls • RLP is patient-centered • Makes no assumptions (not all want to contracept) • Dynamic: plans & goals can & do change, sometimes from visit to visit

  33. Reproductive Life Planning Pearls • Plans about having children are simple for no one, ambivalence is common • RLPs are NEVER right or wrong* • Reproductive life planning should be offered to everyone, irrespective of assumptions about an individual’s circumstances*

  34. Benefits of RLP Promotion Encourages use of behavioral change model for counseling Could decrease unintended pregnancies, short interconceptional periods & poor pregnancy outcomes Could increase women’s wellness in reproductive years & beyond • Can increase perceived control of [reproductive] future • Reframes conception Chance  Choice • Challenges us to make the FP interaction [more?] patient-centered

  35. Themes / Areas for Action • Social marketing & health promotion for consumers [state and national] • Clinical practice [individuals and couples] • Public health and community [collaborations] • Public policy and finance [state by state] • Data and research [all levels]

  36. One Step at a Time

  37. S-W-O-T for Successful RLP • Current RLP services in your setting? • RLP tools you need? • Most effective ways to train staff? • Strategies to maximize implementation

  38. Opportunities for Collaboration Collaboration is essential to provide a comprehensive approach. Examples of organizations: • Other Clinics & Doctor's Offices • Faith Based Organizations • Community Based Organizations • WIC and social services sites • Hospital Based Organizations • Businesses (nail salons, hair salons, others)

  39. Reproductive Plan Assessment • Do you hope to have any (or any more) children? • If no, how will you prevent having more pregnancies? • If yes, how many more children do you want, how would you like to space them, how do you plan to keep from getting pregnant until you are ready for the next child? • How can I help you achieve your plan?

  40. Reproductive Plan Assessment • Patient-centered • Empowering • Invites goal setting and action steps • Tested with target population • Short • Culturally-sensitive, respectful tone • If self-administered then appropriate for health and general literacy • Makes no assumptions

  41. Specific [RLP] Interventions • Folic Acid Supplements:Reduce the occurrence of neural tube defects by two thirds • Rubella testing &/or immunization:Rubella immunization provides protective sero-positivity & 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 & women who are at risk for acquiring hepatitis B virus (HBV) infection.

  42. Specific [RLP] Interventions (cont) • Pertussis:very contagious & can cause serious illness―especially in newborns. Teen & adult vaccination is important, especially for families with (or planning) newborns. • Diabetes:3-fold increase in birth defects among infants of women with type 1 & type 2 diabetes, without management • Hypothyroidism:Dosage of levothyroxine should be adjusted in early pregnancy to maintain levels needed for fetal neurological development

  43. Specific [RLP] Interventions (cont) • Maternal PKU: Low phenylalanine diet before conception & throughout pregnancy may prevent mental retardation in infants born to mothers with PKU • Obesity:Associated adverse outcomes include neural tube defects, preterm birth, c-section, hypertensive & thromboembolic disease • STDs:have been strongly associated with ectopic pregnancy, infertility, & chronic pelvic pain

  44. Specific [RLP] Interventions (cont) • Alcohol:Fetal alcohol syndrome (FAS) and other alcohol-related birth defects can be prevented. • Anti-seizure drugs:Some anti-seizure drugs are known teratogens • Isotretinoin :Use of isotretinoin in pregnancy results in miscarriage & 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.

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

  46. Missed Opportunities ? • Pregnancy Test Results • STD Test Results • Other?

  47. Reproductive Plan Assessment: Unintended Consequences • Could be presented in a way that offends women (or men) • Care offered may not be consistent with plan (provider bias) • Could be interpreted as suggesting who should or should not have children • Can be treated by providers as static (“but last time you said you did not want kids”) • Could be seen as ‘blaming’ a woman or man when their RLP is not carried out as planned

  48. Reproductive Life PlanCase Studies Case Study #1 - Sonya is a 32 year old G6 P0330. Her LNMP was 5 weeks ago. She is at the health care center for a pregnancy test. What do you want to know about Sonya?

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