PreConception Counseling into Patient Education Gayla C Winston MPH President amp CEO Stephen L Everett MS Director of Programs Indiana Family Health Council Inc Indianapolis Indiana ID: 460387
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Integrating a Reproductive Life Plan &PreConception Counseling into Patient Education
Gayla C. Winston, MPH, President & CEO
Stephen L. Everett, MS, Director of Programs
Indiana Family Health Council, Inc.
Indianapolis, IndianaSlide2
Indiana Family Health CouncilWhat is the Indiana Family Health Council?
When was
IFHC
founded?Who can access IFHC services?Where are the Indiana Family Planning Resource locations? www.ifhc.orgHow can I network with these clinics?Slide3
Indiana Data and StatisticsNOTE: The Indiana Data and Statistics are being compiled and will be added to the presentation on these slides.Slide4
A Baby? MaybePractical Pointers for Purposeful Planning
Compiled by:
Jacki
S. Witt, JD, MSN, WHNP-BCUniversity of Missouri – Kansas CityProject Director, Title X Clinical Training Center for Family PlanningSlide5
Key QuestionsWhat 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?Slide6
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/couplesSlide7
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)7Slide8
Early Prenatal Care is Not Enough Why RLP
?Slide9
Critical Periods of Development
Critical Periods of Development
4 5 6 7 8 9 10 11 12
Weeks gestation from LMP
Central Nervous System
Central Nervous System
Heart
Heart
Arms
Arms
Eyes
Eyes
Legs
Legs
Teeth
Teeth
Palate
Palate
External genitalia
External genitalia
Ear
Ear
Missed Period
Mean Entry into Prenatal Care
Most susceptible
time for major
malformationSlide10
Early prenatal care is too late to address some birth defectsThe heart begins to beat at 22 days after conceptionThe neural tube closes by 28 days after conception
The palate fuses at 56 days after conception
Critical period of
teratogenesis – Day 17 to Day 5610Slide11
Almost half of pregnancies are unintendedI don’t believe indoing anythingto stop fromhaving children
It wasn’t my
fertile time
My doctor said I couldn’t get pregnantWe had used condoms except one time!I was using birth control pills !My boyfriend doesn’t like using condoms
I thought if it’s God’s will, I would get pregnantSlide12
Unintended Pregnancies in the United StatesApproximately 6.4 million pregnancies per yearSlide13
Purpose of Preconception CareImprove the health of each woman prior to conception by identifying risk factorsProvide education
Stabilize medical condition(s) to optimize maternal and fetal outcomes
The process should be ongoing
“Every woman – every time”Finer,2006Slide14
CDC’s VisionImproving 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).
Slide15
CDC’s VisionAll 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. Slide16
CDC Goals Four Goals:1. Improve the knowledge, attitudes, & behaviors of men & women related to preconception health2. Assure that all women of child-bearing age in the U. S. receive preconception care servicesSlide17
CDC GoalsFour 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 children4. Reduce the disparities in adverse pregnancy outcomesSlide18
CDC’s Reproductive Life PlanFramework
Action Steps
Research
–
Surveillance
–
Clinical interventions
Financing
–
Marketing
–
Education and training
Recommendations
Individual Responsibility - Service Provision
Access – Quality – Information – Quality Assurance
Goals
Coverage – Risk Reduction
Empowerment – Disparity Reduction
Vision
Improve health
and pregnancy
outcomesSlide19
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.Slide20
International Comparisons of IMR, 2005US Ranks 30th
United States, Table 1: Health
2008
IMR: Deaths per 1,000 live birthsSlide21
US IMR by Race 1995 and 2005
2
National Center for Health Statistics, 2010
All Races………………………………….…….White ..……………………………………..…..Black …………………………………………….Native American ……………………………Asian …………………………………………….Hispanic ………………………………………… Mexican …..………………………………… Puerto Rican …………………………….…
Cuban ………………………………………..
Central and South American ………….
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
4.7Slide22
Consequences of Unintended Pregnancy for Women/Families
Delays in initiating prenatal care
Reduced likelihood of breastfeeding
Poor maternal mental healthLower mother-child relationship qualityIncreased risk of physical violence during pregnancySlide23
Life Course Planning (based on the Behavioral-Ecologic Model of Health)Pieces of the puzzle:EducationHealthVocation/career
Relationships/family
Reproductive life plans
Set against backdrop of culture, society, religion, economic statusSlide24
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?Slide25
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, 1980Slide26
Does it Really Matter?Is there scientific data to support it?Slide27
There is evidence that individual components work
Rubella vaccination
HIV/AIDS screening
Management and control of:DiabetesHypothyroidismPKUObesityFolic Acid supplements Avoiding teratogens:Smoking Alcohol Oral anticoagulantsIsotretinoinSlide28Slide29Slide30
US Public Health ServiceSlide31
Title X Program PriorityPriority # 4: “Emphasizing the importance of counseling family planning clients on establishing a reproductive life plan, andproviding preconception counselingas a part of family planning services,
as appropriate”
Slide32
So……..why don’t we do it?
Guidelines
Best Practice = Reproductive Life Plan for EveryoneSlide33
Most clinicians don’t provide itMost insurers don’t pay for itMost consumers don’t ask for it
Preconception care is not being consistently delivered todaySlide34
Barriers to ImplementationFundingStaff buy inPatient buy inTime Competing priorities
Need to know best strategies for your populationSlide35
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 challengesHealth care accessSlide36
Strategies for Successful RLP in your organizationConsider your setting’s characteristics
Who counsels women?
Your best educational methods?
Social and mental health services?Coverage for contraceptives?Slide37
Reproductive Life Planning PearlsRLP is patient-centeredMakes no assumptions (not all want to contracept)
Dynamic: plans & goals can & do change, sometimes from visit to visitSlide38
Reproductive Life Planning PearlsPlans about having children are simple for no one, ambivalence is commonRLPs are NEVER right or wrong*
Reproductive life planning should be offered to everyone, irrespective of assumptions about an individual’s circumstances*Slide39
Benefits of RLP Promotion
Can increase perceived control of [reproductive] future
Reframes conception Chance
ChoiceChallenges us to make the FP interaction [more?] patient-centered Encourages use of behavioral change model for counselingCould decrease unintended pregnancies, short interconceptional periods & poor pregnancy outcomes
Could increase women’s wellness in reproductive years & beyondSlide40
Themes / Areas for ActionSocial 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]Slide41
One Step at a TimeSlide42
S-W-O-T for Successful RLPCurrent RLP services in your setting?RLP tools you need?Most effective ways to train staff?Strategies to maximize implementationSlide43
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) Slide44
Reproductive Plan AssessmentDo 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?Slide45
Reproductive Plan AssessmentPatient-centeredEmpoweringInvites goal setting and action steps
Tested with target population
Short
Culturally-sensitive, respectful toneIf self-administered then appropriate for health and general literacyMakes no assumptionsSlide46
Specific [RLP] InterventionsFolic 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 syndromeHIV/AIDS: timely antiretroviral treatment can be administered, pregnancies can be better plannedHepatitis B: Vaccination is recommended for men & women who are at risk for acquiring hepatitis B virus (HBV) infection. Slide47
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 managementHypothyroidism: Dosage of levothyroxine should be adjusted in early pregnancy to maintain levels needed for fetal neurological development Slide48
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 diseaseSTDs: have been strongly associated with ectopic pregnancy, infertility, & chronic pelvic pain Slide49
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 teratogensIsotretinoin : Use of isotretinoin in pregnancy results in miscarriage & birth defects Oral anticoagulants: Warfarin is a teratogen; medications can be switched before the onset of pregnancySmoking:
Associated adverse outcomes include p
reterm birth, low birth weight.Slide50
Reproductive Life Planning Pearls for Practice: “E.V.E.R.Y. D.A.Y.”Exercise: 30 minutesVitamin: 400 mcg folic acid
E
ducate yourself: medicines/toxins that can cause birth defects
Repro Life PlanYearly Dr’s visits: discuss physical & mental wellnessDiet: vegetables, fruits, & whole grainsAvoid tobacco, drugs, & alcoholYour partner, friends, & family as sources of supportEverywomancalifornia.orgSlide51
Reproductive Life Planning Pearls for Practice: The 5 ‘P’sPartnersPractices(remember F-I-D-O)Folic AcidImmunizationsDrugsOtherPrevention of STDsPast HistoryPregnancy PlansSlide52
Missed Opportunities ?Pregnancy Test ResultsSTD Test ResultsOther?Slide53
Reproductive Plan Assessment: Unintended ConsequencesCould 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 plannedSlide54
Reproductive Life PlanCase StudiesCase 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?Slide55
Sonya’s prior pregnancies included: two miscarriages at 19 weeks, one preterm delivery at 26 weeks and one at 24 weeks, both resulting in early neonatal deaths
She had one pregnancy termination at 9 weeks gestation
Gynecologic history is significant for painful menses
Family history is significant for adult onset diabetes (F) and hypertension (F & M)Does not use illicit drugs or drink alcoholHas a supportive 30 year old male partner who is HIV positive and doing very well Slide56
What other questions do you have for Sonya ?Slide57
Other QuestionsPregnancy intentionContraception
Age
Health status
Maternal outcomeFetal/newborn outcomeSonya and partner’s knowledge of her HIV statusSafe conceptionMedicationsUse of tobacco?Slide58
Sonya’s pregnancy test was negative
What can you do for her?Slide59
RLP [ Review, Listen, Provide ]Pregnancy preventionPregnancy planning
HIV transmission
prevention
Health maintenance/ supportReferrals Screening Substance useFamily history
(including genetic)
Pregnancy history
Folic acidSlide60
Reproductive Life PlanCase StudiesCase Study #2 – Annie is a 20-year old who presents for emergency contraception after ‘the condom broke’ two days ago.What do you want to know about Annie?Slide61
Additional Information about AnnieNever been pregnantNever used prescription birth control methodSexually active X 3 yearsNew boyfriend X 2 months (3rd
partner in lifetime)
BP: 130/88 P: 80 BMI: 35
Significant Family History: Father died age 48 – complications of diabetesSlide62
What other questions do you have for Annie ?Slide63
Other QuestionsPregnancy intentionContraceptionMedications?Use of tobacco?
Illicit drug use?Slide64
Annie says she wants to finish college before having children
What can you do for her?Slide65
RLP [ Review, Listen, Provide ]Pregnancy prevention optionsPregnancy planning
Screening for diabetes
Screening for STDs
Weight loss messageFolic acid Slide66
Basic Counseling SkillsInitiate the SessionGather InformationUnderstand the Client’s Perspective
Provide Structure to the Session
Build a Relationship
Close the Session Slide67
RLP & FP ResourcesResources for Reproductive Life Planning & Family Planningwww.ifhc.org
www.cdc.gov
www.mchb.hrsa.gov
www.everywomancalifornia.orgwww.ncpublichealth.com Slide68
ReferencesAd Hoc Committee of PCCHC Select Panel on Reproductive Life Planning, Washington, DC, Nov 23, 2009.Canady, R.B., Tiedje, L.B. & Lauber, C. (2008). Preconception care and pregnancy planning.
American Maternal Child Nursing Journal
, 13 (2), 90-97.
CDC Vaccine Information Statement (VIS) (Interim) MMR Vaccine (3/13/08) CDC Vaccine Information Statement (VIS) (Interim) d & Tdap Vaccines (11/18/08) Centers for Disease Control and Prevention. 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. Morbidity & Mortality Weekly Report. 2006;55:1-23. Retrieved March 4, 2011 from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htmCheng D, Schwarz E, Douglas E, et al. Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contraception. 2009 Mar;79(3):194-8.
D’Angelo, D, Colley Gilbert B, Rochat R, et al. Differences between mistimed and unwanted pregnancies among women who have live births. Perspect Sex Reprod Health. 2004 Sep–Oct;36(5):192-7.
Ecologic Model of Health. (Adapted from Healthy People 2020).
Hatcher, R. (1980).
Contraceptive Technology Update
. 1(9): 131-132.Slide69
ReferencesHernández Jennings, M. Preconception Health Care: Integrating Reproductive Life Plans into Title X Settings, Colorado Family Planning Initiative Conference, October 23, 2009
Hovell MF, Wahlgren DR, Adams MA. The Logical and Empirical Basis for the Behavioral Ecological Model. In RJ DiClemente, R Crosby, M Kegler, (eds.).
Emerging Theories and Models in Health Promotion Practice and Research (2nd edition)
. San Francisco: Jossey-Bass Publishers; 2009. p. 415-49.Kendall, C. Afable-Munsuz, A. Speizer, I., Avery, A., Schmidt, N., & Santelli, J. (2005). Understanding pregnancy in a population if inner city women in New Orleans-Results of qualitative research. Social Science and Medicine. 60, 297-311.Kost K, Landry D, Darroch J. Predicting maternal behaviors during pregnancy: Does intention status matter? Fam Plann Perspect. 1998 Mar–Apr;30(2):79-88.Logan C, Holcombe E, Manlove J, et al. The consequences of unintended childbearing: A white paper [Internet]. Washington: Child Trends, Inc.; 2007 May [cited 2009 Mar 3]. Available from: http://www.childtrends.org/Files/Child_Trends-2007_05_01_FR_Consequences.pdf
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ReferencesMoos, M-K. Establishing Some Foundations for the RLP Discussion. Presentation at the Office of Population Affair’s Expert Work Group Meeting Implementing Reproductive Life Planning Counseling in Family Planning Clinics. Sep 22-23, 2010.
Moos, MK. (2003). Unintended pregnancies: a call for nursing action.
Maternal Child Nursing
. 28: 25-31.National Campaign to Prevent Teen and Unplanned Pregnancy. Unplanned Pregnancy Rate in the U.S. Retrieved March 31, 2011 from http://www.thenationalcampaign.org/national-data/unplanned-pregnancy-birth-rates.aspxKurtz, Suzanne, Calgary-Cambridge Observation Guide 1, University of Calgary, Alberta, Canada; MaKoul, Gregory Thomas, The SEGUE Framework, Northwestern University Medical School.