Interconception Care

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Interconception Care

• Presentation to
• The National Summit on Preconception Care
• June 21, 2005

Lorraine V. Klerman, Dr.P.H. The Institute for
Child, Youth, and Family Policy The Heller School
for Social Policy and Management, Brandeis
University
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Interconception Care

• Interconception care is a subset of preconception
  care
• If not targeted would include
• All women with prior pregnancy
• 4 million births per year, plus stillbirths,
  miscarriages, abortions
• But still less than all women 15-44
• If targeted would include
• Only women at elevated risk
• This may be within our reach in this decade.

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Who is at Elevated Risk?

• Women who experienced
• Live birth, but preterm, IUGR, congenital
  anomalies
• Stillbirth, miscarriage, elective abortion
• Women with chronic disease, regardless of prior
  pregnancy experience
• Women with history of STDs
• Women who smoke, drink, use illicit drugs
• Women with physical, mental, or emotional
  disabilities

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What Do We Want To Accomplish ThroughInterconcep
tion Care?
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For all women with prior pregnancy

• Folic acid fortification
• Treatment of dental conditions
• Diagnosis and treatment of infections
• Adequate immunization status
• Family planning
• Help reach familys childbearing objectives
• Avoid unintended pregnancies
• Counsel about optimal birth intervals

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Healthy People 2010 Objective for Interpregnancy
Intervals

• Reduce the proportion of births occurring within
  24 months of a previous birth
• 11 of females aged 15 to 44 gave birth within 24
  months of a previous birth in 1995 (NSFG data)
• Higher rates among African-American, Hispanic,
  and poor women

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• In 2002, intervals of lt24 months higher among
  women who were
• lt18 years of age
• Formerly married
• Without high school diploma or GED
• Poor (living below federal poverty level)
• Source Chandra A, Martinez GM, Mosher WD, Abma
  JC, Jones J. Fertility, family planning, and
  reproductive health Data from the 2002 NSFG.
  Vital Health Stat 23(25). Forthcoming (2005).

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For all women with prior pregnancy also want
to achieve

• Optimal nutritional status
• Appropriate weight
• Avoidance of anemia
• Reduction of stress
• Avoidance of
• Smoking
• Drinking
• Illicit drugs
• Identification and avoidance of environmental and
  workplace hazards

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For women at elevated risk

• Same as for all women
• PLUS
• Clinical evaluation of reasons for less than
  optimum pregnancy outcomes, including genetic
  testing
• Interventions for treatable risks
• Physical including chronic illnesses
• Mental including depression
• Emotional including domestic violence

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Interconception Care for women at elevated risk
A first priority?

• Ultimate Goal
• Preconception care for all women
• Intermediate Goal
• Interconception care for women at elevated risk
• This strategy may
• Have largest impact on pregnancy outcomes
• Be most acceptable to legislators
• Be able to be implemented using present systems
  of care at least partially

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Why Interconception Care Should Be Easy
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• Almost all the women in need of interconception
  care are already known to the medical care system
• Over 95 have had some prenatal care
• Large percentage have been delivered in a
  hospital
• All live births and still births are identified
  by certificates filed with state
• Almost all with miscarriages or elective
  abortions were cared for in the medical care
  system
• Most take infant to pediatric care provider
• Many seek family planning services

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Why Interconception Care Is Hard
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• Both a supply and a demand problem (1)
• Clinicians do not routinely provide
  interconception care
• Often no source of payment
• Many women whose maternity care was paid for by
  Medicaid lose eligibility 60 days after birth
• Coverage under private insurance varies
• No clear billing code for interconception care
• Many have little interest in interconception care
  
• Question effectiveness, cost effectiveness
• Lack adequate information
• Information on problems during pregnancy and
  pregnancy outcomes are not available to primary
  care providers
• Records are often not integrated
• Absence of follow-up systems

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• Consumer demand is low
• Often women have no source of payment
• Many women do not have insurance coverage
  public or private between pregnancies
• Women have little interest in interconception
  care
• Not aware of value or of availability
• Unclear about how differs from routine ob/gyn or
  family planning visit
• Many women do not return for postpartum visits
  the logical place to start interconception care

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• How Can We Increase Access to and Use of
  Interconception Care?

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• Incorporate into existing systems of care and
  provider networks
• Reduce financial barriers for providers and for
  women
• Generate consumer demand
• Encourage compliance with HEDIS postpartum visit
  measure
• Increase family planning coverage and services

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Obstetrical Providers

• Keep women in care after pregnancy
• Use follow up/outreach to re-engage women missing
  postpartum visits
• Make referrals to primary care providers and
  specialty physicians for risk management of
  diabetes, hypertension, and other problems
• Focus on those at elevated risk

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Pediatric Providers

• Use well-child visits to promote healthy
  interconception care practices
• Encourage pregnancy planning and spacing
• Offer self-screening tools for mothers
• Focus on those at elevated risk

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Internists, Family Practitioners, Nurse
Practitioners, Primary Care Clinics

• Counsel about pregnancy when caring for women
  with chronic diseases
• Link to maternity care records to identify risks
  and opportunities for intervention
• Ask about pregnancy planning and spacing

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Public Sector Facilities

• Should develop care protocols for
• Community/migrant health centers and other FQHCs
• Maternal and child health programs
• Federal government should provide funds for
  demonstration programs
• Already done in Healthy Start
• Could provide incentives through
• Title V funding
• Community health center funding
• Monitor progress

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Family Planning Clinics

• Re-engage women in care after pregnancy
• For those with prior pregnancies, obtain
  information on pregnancy-related problems and
  outcomes
• Make referrals to primary care providers and
  specialty physicians for risk management
• Chronic diseases
• Substance use/abuse (tobacco, alcohol, drugs)
• Focus on those at elevated risk
• Schedule additional visits to monitor
  contraceptive and health status

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• Incorporate into existing systems of care and
  provider networks
• Reduce financial barriers for providers and for
  women
• Generate consumer demand
• Encourage compliance with HEDIS postpartum visit
  measure
• Increase family planning coverage and services

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• Pay providers for time spent in interconception
  counseling under public and private insurance
• Change Medicaid to allow coverage of women for
  five years after birth for all medical needs,
  broadly defined
• 21 states already have waivers expanding
  eligibility for family planning
• Increase private insurance coverage
• In 2004, 99 of managed care plans included an
  annual ob/gyn visit
• More in HMO plans less in conventional ones

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• Incorporate into existing systems of care,
  provider networks
• Reduce financial barriers for providers and for
  women
• Generate consumer demand
• Encourage compliance with current HEDIS
  postpartum visit measure
• Increase family planning coverage and services

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• Educate women to request services
• Mass media
• Morning talk shows
• Womens magazines
• Oprah Winfry show
• Billboards targeted at women and men
• Incorporate into educational programs for
  pregnant and parenting women
• Home visiting programs
• Childbirth classes
• WIC
• Family planning

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• Incorporate into existing systems of care,
  provider networks
• Reduce financial barriers for providers and for
  women
• Generate consumer demand
• Encourage compliance with HEDIS postpartum visit
  measure
• Increase family planning coverage and services

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• HEDIS measure for prenatal and postpartum care
  has two components
• Percentage of women beginning care in first
  trimester
• Percentage of women who visited health care
  providers between 21 and 56 days after delivery
  (could be first interconception care visit)
• Used by Medicaid and private health plans
• HEDIS important because large proportion of women
  on Medicaid are in managed care plans and many
  are at elevated risk

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• Quality improvement efforts generally not focused
  on improving postpartum visit rates, rather on
  prenatal care visits
• Rate for postpartum check-ups in 2003
• Commercial plans 80.3 (74.1 in 2000)
• Medicaid 55.3 (49.8 in 2000)

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How One IPA Used HEDIS To Improve Postpartum
Check-up Rate (NCQA Quality Profile)
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• Baseline performance
• 63.3 return for check-ups
• Multi-department task force assembled
• Barriers identified
• Physician called out of office
• visit rescheduled outside time frame (21-56
  days)
• Women feeling fine do not schedule appointment
• Physicians offices do not have tracking system
  for check-ups

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• As a result of task force report, health plan
  implemented quality improvement effort
• Importance of postpartum check-up communicated
• In provider newsletter
• Consultations with ob/gyn practices
• Meetings with vendors
• Incentives to OBs and PCPs for postpartum visits
• Postpartum check-up measure added as performance
  monitor within global ob/gyn contract
• Monetary thresholds established for low and high
  performance

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• As a result
• Some practitioners developed office-based
  tracking and reminder systems
• New mother outreach plan initiated
• Hospital maternity units gave information to
  women who delivered
• Some received two postpartum visits
• Vendors reported differences between those who
  participated in the program and those who did not
  in order to develop next steps to encourage
  compliance

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RESULTS
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Expand Use of HEDIS Measures

• Currently used mainly as measure for OB providers
  in managed care plans
• Develop similar HEDIS measure for primary care
  providers
• Should also be used as a benchmark by practices
  outside of managed care plans
• Perhaps measure of rate of follow-up for women
  at elevated risk
• Should specify content of postpartum visit and
  other interconception care visits

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• Incorporate into existing systems of care,
  provider networks
• Reduce financial barriers for providers and for
  women
• Generate consumer demand
• Encourage compliance with current HEDIS
  postpartum visit measure
• Increase family planning coverage and services

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Family Planning Excellent Opportunity for
Interconception Care

• Need to further increase coverage
• Private coverage
• In 2004, 89 of managed care plans provided oral
  contraceptives
• Coverage greater in HMO plans-less in
  conventional ones
• All states should require contraceptive coverage
  in private insurance plans
• Public coverage
• Through Medicaid family planning waivers
• Increase in Title X funds

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• Need to increase services included in family
  planning
• Interconception counseling
• Testing for chronic diseases, with referrals to
  specialists
• Checking for overt dental disease, with referrals
  to dentists
• Screening
• Tobacco, alcohol, illegal drug use/abuse
• Domestic violence
• Depression

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Family Planning Problems

• Public-supported facilities
• Limited availability of emergency contraception
• Insufficient funds to allow distribution of most
  expensive contraceptives at some sites
• Understaffed for follow-up of missed appointments
• FDA refusal to allow over-the-counter sale of
  emergency contraception
• Pharmacists unwillingness to fill contraceptive
  prescriptions

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(No Transcript)
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• The Evidence Base for Interconception Care
• (weak need as much research in this area as has
  been devoted to prenatal care)

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Interconception Care Demonstrations

• Grady Hospital Atlanta
• Some data on next slide
• Interconception Health Promotion Initiative
  Denver
• Final report available on web
• http//www.coloradotrust.org/repository/publicatio
  ns/pdfs/IHPIFinalReport04.pdf
• Philadelphia
• No data yet

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• Grady Memorial Hospital (Atlanta) undertook pilot
  study of women who delivered very low birth
  weight infant
• Subsequent pregnancies within 18 months
• In historical control group 48.8
• in intervention group 13.3
• Want to wait at least 2 years for another
  pregnancy
• Conditions detected in intervention group
• Unrecognized or poorly-managed chronic diseases
• Reproductive tract infections
• Oral infections and periodontal disease
• Most preterm deliveries had infectious and/or
  vascular etiology (underlying cause)
• Source A.W.Brann and A.L.Dunlop

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Family Planning Waivers

• Births averted
• Alabama (2000-2001) 3,612
• California (1999-2000) 21,335
• Oregon (2000) 5,414
• Interpregnancy intervals increased
• Rhode Island Proportion of women with
  Medicaid-funded deliveries becoming pregnant
  within nine months cut nearly in half (2000)
• Source Gold,AGI Report on Public Policy, 3/04

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Programs with Interconception Care Components

• Nurse Home Visitation
• Two-year postpartum follow-up
• Positive impact on pregnancy intervals
• Early Head Start
• Postpartum follow-up
• Positive impact on pregnancy intervals

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Final Thoughts

• Strive for preconception care for all women
• Would benefit mother, child, society
• While moving toward that goal, work within
  existing systems to provide interconception care
  to all women, especially those at elevated risk
• Potential for impact on pregnancy outcomes and
  womens heath