Tool for Preconception and Interconception Care: REPRODUCTIVE LIFE PLANNING An ongoing quality improvement project by the Louisville Metro Public Health and Wellness Department Louisville, Kentucky 2014
Who are we and what do we do? A Synopsis 2013-14 Louisville Metro Healthy Start Funding for Healthy Start is provided by project H49MC07306 from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Bureau (Title V, Social Security Act) and by a grant from the Norton Healthcare James R. Petersdorf Fund.
Metro Louisville Healthy Start is a parenting education and support program for families, with a goal of increasing care for at-risk families during pregnancy and into the first two years of the child s development
Direct outreach and client recruitment Health education Case management Depression screening and referral Interconceptional care services
Healthy Start is improving health outcomes for babies in West Louisville by reducing rates of infant mortality, low birth weight deliveries, and prematurity among births to program participants
Louisville Metro Healthy Start lowers the rate of infant mortality among program participants
The rate of very low birth weight deliveries continued to decline in the past 6 years of Louisville Metro Healthy Start. Among Healthy Start participants, the rate of births under 1500 grams dropped 41% between 2006 and 2012.
Among Healthy Start participants, the rate of prematurity has dropped 26%, from 183 per 1000 births in 2006 to 136 per 1000 births in 2012. While the decreasing rate of prematurity for Healthy Start participants is promising, considerable disparity remains, in that the prematurity rate for Louisville minus the program area was below 100 premature births per 1000 (2012).
Births with adequate prenatal care (percent) The percentage of program participants receiving adequate prenatal care has remained in the low to high 50% range since 2006. In 2012 Healthy Start participants received adequate prenatal care at a rate of 5 percentage points higher than non-participants in the area (53% vs. 48%), but 18 percentage points lower than Louisville minus the program area (71%).
The percentage of program participants receiving prenatal care in the first trimester increased seven (7) percentage points between 2006 and 2012; from 63% in 2006 to 70% in 2012. Since 2009 the Healthy Start program has maintained a slightly higher rate of participants receiving prenatal care in the first trimester than non-participants in the program area.
Participants with a Reproductive Life Plan (percent) In 2010, Louisville Metro Healthy Start developed a tool and protocol for family and career planning. The Healthy Start nurses take the lead in working with families in completing the RLP, and the Healthy Start resource workers play a critical role in removing barriers and encouraging HS participants to adhere to their plans.
Participants with an Edinburgh Scale rating (percent) Louisville Metro Healthy Start attends to the mental health needs of participants through screening and referral for assessment and treatment. Women are assessed for their risk of depression by the Healthy Start nurse, during the initial prenatal assessment home visit and again during the initial postpartum home(s) visit.
The Healthy Start Interconception Care Learning Communities (ICC LC) is a partnership that equally includes: 1. All Healthy Start grantees, as well as consumers and providers from Health Start Communities 2. An Expert Work Group of 18 leaders in women s health, primary care, public health, quality improvement, and Healthy Start 3. The Maternal and Child Health Bureau, Health Resources and Services Administration (MCHB- HRSA); and 4. Project team from Abt Associates, Inc. and Johnson Group Consulting, Inc.
The Louisville Healthy Start Staffs were fortunate to be original members of the Healthy Start ICC-LC. As a result, Louisville s Healthy Start staffs have developed expertise in implementing evidence-based interconception care practices that have included maternal depression and reproductive life planning.
What is Reproductive Life Planning? Simply put by the Centers for Disease Control (CDC), the reproductive life plan (RLP) is a set of personal goals about having (or not having) children. Despite its simplicity, this statement raises many questions. When should a person start a RLP? What personal values and resources need to be considered in formulating one s RLP? What skills are needed for a person to negotiate an RLP with his or her reproductive partner? What are the best sources of accurate information for developing an RLP? The RLP is a simply a starting point, and we have learned that when discussing an RLP with a program participant, issues such as health literacy are critical; social and cultural dimensions are involved, as well as implications for health policy.
Planning for pregnancy and spacing children, managing health conditions that impact pregnancy outcomes, addressing environmental risk factors, and promoting healthy behaviors that improve pregnancy outcomes will lead to: Less unintended pregnancies Less preterm births Lower risk for low birth weight infants Decreased rates of birth defects Improved health status for women Decreased health disparities
A sub-group of Louisville s ICC-LC team met and through a rigorous research process identified six nationally recognized reproductive life planning tools that had been successfully used in other states evidence-based programming.
The quality improvement change projects initiated through the ICC LC included healthy weight, family planning, case management, screening assessment, maternal depression, and primary care linkages. The Metro Louisville Healthy Start Program elected maternal depression in the first cycle and reproductive life planning in cycle II and III as its change projects.
The Metro Louisville Healthy Start Program, Cycle II Interconception Care Committee Subgroup: Family Planning and Reproductive Life Plan Development Members; Latacha Stallard, RN, BSN; Patricia P. Brodie RN, MSN Tenoeda Shavers, Community Health Services Assistant; Cece Briggs, Administrative Assistant
Tasks of the Subgroup: 1. Literature review of reproductive life planning. 2. Review of reproductive life plan formats that had been implemented, reviewed and are evidencebased. 3. Adaptation of formats for the identified needs of Metro Louisville Healthy Start program participants. 4. Development of protocols for the use of the adapted reproductive life plan format.
Over 50 relevant articles were examined and a selected bibliography of 12 sources were utilized. Generally, throughout the literature, a reproductive life plan (RLP) is defined as a plan that incorporates a person s intentions about the number and timing of pregnancies and is based on the person s personal values and life goals. RLP s were viewed as an interconception care tool and strategy to support the reduction of poor birth outcomes.
Preconception care was defined by the Centers for Disease Control in 2006 as a series 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. The CDC encourages the inclusion of men in preconception planning(2006). Recommendation 1, titled To Improve Preconception Health and Health Care, states that all women, men, and couples should have a reproductive life plan.
Interconception care is a subset of preconception care, defined as care and counseling between pregnancies building on important information learned from the previous pregnancy.
Attempts to implement reproductive life planning have not been successful for most women, especially minority women and men. Some of the most important contributions to implementing a reproductive life plan include: Education of health care providers (nurses, doctors, social workers, etc.) use of a life course perspective. Health literacy understand information provided and using it to do something different. Daily encounters teaching-learning moments at diverse contacts. It s a conversation and talk is cheap!
1. PC² You Decide. Association of Reproductive Health Professionals 2. GHI HMO Reproductive Life Plan 3. You re a Busy Teenager, Utah Department of Health 4. Voices of Appalachia Healthy Start, Whitley County, Kentucky 5. Are you Ready? Sex and Your Future, DHHS, Div of Public Health, Women s Branch, N.C. 6. Are You Ready? Is Parenting in Your Future: Arizona Dept. of Health (Adapted from N.C. and the Florida Dept. of Health s Healthy Start Program)
Common elements and substantive content were identified in the six plans: Family planning goals Educational goals Goals to deal with challenges and barriers: emotional and physical health, substance use and abuse, financial issues, lack of support system, family/partner violence. A decision was made by the subgroup to combine the brevity of the Voices of Appalachia format and the visual and language elements of the NC and AZ formats. Copies of the final document are available as a handout.
PDSA Model PLAN DO STUDY ACT
Keys to success: Building rapport + motivational counseling + goal setting = progress towards behavior change
CONCLUSION 1. The rate of Louisville Healthy Start participants with a RLP increased from 23% in 2010 to 84% in 2013. 2. Program participants are able to see more clearly the link between having children and what is required to support their children and themselves in the short and longer term. 3. The RLP anchors the HS staff approach to case management by referral and places the mother and her partner in the drivers seat of life planning.