The future of preconception care

A Quality Improvement Innovation for Reproductive Health Planning in the Time of COVID

OBJECTIVES

To see if an outreach approach with telehealth is feasible and acceptable to patients to talk about their reproductive health; and as a secondary outcome, capture data on time spent on the visit and what kind of information was discussed.

METHODS

A registry was created from three family physicians' panels of all adult patients with anticipated ability to become pregnant ages 18-45 who had not had a documented reproductive health discussion in the previous 6 months. Using that registry, outreach was performed to schedule a telehealth visit to discuss their reproductive health with their primary care provider. The visit was standardized using the One Key Question approach. For patients who agreed to participate in the research, the patient completed a survey about their experience. The provider also completed a survey on the time spent and the issues addressed.

RESULTS

Two hundred and six patients were called. Ninety patients (44%) could not be reached. Of the remaining patients, 34 scheduled either a telehealth or in-person visit and 7 also agreed to participate in the survey. New information was uncovered in the visit in 86% of participants. The most common need uncovered during the visit was unrelated medical needs (71%), followed by preconception health education/advice (43%) and contraception needs/counseling (29%). Most participants found the telehealth visit valuable.

CONCLUSIONS

An outreach methodology can uncover unmet health needs, both reproductive and otherwise. We found that people who had the visit often needed something, but a majority of patients declined the visit saying that they did not think they needed it. It is possible that patients are not aware of the value of reproductive health discussions, and therefore clinicians need to take every opportunity to have these discussions whenever possible, whether through outreach or inreach (during already scheduled visits).

Obstetric medical care in the United States of America

The current models of obstetric medical care utilized in the United States, how those models fit in with the overall care system, and ways to increase the role of obstetric internists will be reviewed.

Facilitators and Barriers for Successful Implementation of Interconception Care in Preventive Child Health Care Services in the Netherlands

Objectives Successful implementation of preconception and interconception care contributes to optimizing pregnancy outcomes. While interconception care to new mothers could potentially be provided by Preventive Child Health Care services, this care is currently not routinely available in the Netherlands. The purpose of this study was to identify facilitators and barriers for implementation of interconception care in Preventive Child Health Care services. Methods We organized four focus groups in which Preventive Child Health Care physicians and nurses, related health care professionals and policymakers participated. A semi-structured interview approach was used to guide the discussion. The transcribed discussions were analyzed. Results All four groups agreed that several facilitators are present, such as the unique position to reach women and the expertise in preventive health care. Identified barriers include unfamiliarity with interconception care among patients and health care providers, as well as lack of consensus about the concept of interconception care and how it should be organized. A broad educational campaign, local adaptation, and general agreement or a guideline for standard procedures were recognized as important for future implementation. Conclusions for practice This study identifies potentially important facilitators and barriers for the implementation of interconception care in Preventive Child Health Care services or comparable pediatric settings. These factors should be considered and strategies developed to achieve successful implementation of interconception care.

Reducing Preconception Risks Among African American Women with Conversational Agent Technology

BACKGROUND

Systems and tools are needed to identify and mitigate preconception health (PCH) risks, particularly for African American (AA) women, given persistent health disparities. We developed and tested "Gabby," an online preconception conversational agent system.

METHODS

One hundred nongravid AA women 18-34 years of age were screened for over 100 PCH risks and randomized to the Gabby or control group. The Gabby group interacted with the system for up to six months; the control group received a letter indicating their health risks with a recommendation to talk with their clinician. The numbers, proportions, and types of risks were compared between groups.

RESULTS

There were 23.7 (SD 5.9) risks identified per participant. Eighty-five percent (77 of 91) provided 6 month follow up data. The Gabby group had greater reductions in the number (8.3 vs. 5.5 risks, P < .05) and the proportion (27.8% vs 20.5%, P < 0.01) of risks compared to controls. The Gabby group averaged 63.7 minutes of interaction time. Seventy-eight percent reported that it "was easy to talk to Gabby" and 64% used information from Gabby to improve their health.

CONCLUSION

Gabby was significantly associated with preconception risk reduction. More research is needed to determine if Gabby can benefit higher risk populations and if risk reduction is clinically significant.

Interpregnancy care

The aim of interconception care is to provide women who have had a prior adverse pregnancy outcome with optimal care in order to reduce risks that may affect the woman׳s health and any future birth she may choose to have. National recommendations call for action, and evidence supports specific clinical interventions. The need for interconception care is documented in national and state survey and surveillance data. Chronic diseases and behavioral risks affect the health of millions of U.S. women of childbearing age. Interconception care demonstration projects have used a "disease management" approach that includes medical care and case management. The increasing use of postpartum visits, as a gateway to interconception interventions, is essential. The Affordable Care Act emphasis on preventive services and expanded health coverage for women offers new opportunities to finance interconception care. Improved and enhanced clinical practices, along with the engagement of women, in interconception care have the potential to improve birth outcomes and reduce disparities.

Preterm birth in the United States: the impact of stressful life events prior to conception and maternal age

OBJECTIVES

We determined whether and to what extent a woman's exposure to stressful life events prior to conception (PSLEs) was associated with preterm birth and whether maternal age modified this relationship.

METHODS

We examined 9350 mothers and infants participating in the first wave of the Early Childhood Longitudinal Study, Birth Cohort, a nationally representative sample of US women and children born in 2001, to investigate the impact of PSLEs on preterm birth in the United States. We estimated the effect of exposure on preterm birth with weighted logistic regression, adjusting for maternal sociodemographic and health factors and stress during pregnancy.

RESULTS

Of the women examined, 10.9% had a preterm birth. In adjusted analyses, women aged 15 to 19 years who experienced any PSLE had over a 4-fold increased risk for having a preterm birth. This association differed on the basis of the timing of the PSLE.

CONCLUSIONS

Findings suggest that adolescence may be a sensitive period for the risk of preterm birth among adolescents exposed to PSLEs. Clinical, programmatic, and policy interventions should address upstream PSLEs, especially for adolescents, to reduce the prevalence of preterm birth and improve maternal and child health.

Surveillance of preconception health indicators in behavioral risk factor surveillance system: emerging trends in the 21st century

OBJECTIVES

This article assesses emerging trends in the 21st century, if any, in preconception health indicators among women of reproductive age.

METHODS

This is a secondary analysis of cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS), 2003-2010. Subjects were a sample of noninstitutionalized, 18-44-year-old, nonpregnant, women in the United States (n=547,177) grouped into two categories, 2003-2006 (n=275,630) and 2007-2010 (n=271,547). Overall crude and adjusted prevalence odds ratios were calculated for preconception indicators before 2006 and after 2006.

RESULTS

Significant improvements were found for any and heavy alcohol use, smoking, social and emotional support, moderate/vigorous physical activity, and having had an influenza shot in the last year. In contrast, binge drinking, having a medical condition (i.e., diabetes, high blood pressure, asthma, or obesity), and self-reported health significantly worsened. No change was found for mental distress, HIV testing, and having a routine checkup.

CONCLUSIONS

As the 21st century unfolds, emerging trends suggest that we need to focus on educating women, providers, and public health advocates about improved health before pregnancy, especially for women with chronic conditions and those who binge drink alcohol.

Reaching women through health information technology: the Gabby preconception care system

PURPOSE

The Centers for Disease Control and Prevention have endorsed the concept of preconception care (PCC). New tools must be developed to promote PCC.

DESIGN

Development and testing of a health information technology system to provide PCC.

SETTING

An urban safety net hospital and an urban university.

SUBJECTS

Community recruitment of 31 women in focus groups and 15 women participating in observed usability testing; 9 students recruited from the Office of Minority Health Preconception Peer Educators program participated in pilot testing for 2 months.

INTERVENTION

Online interactive animated character ("Gabby") designed to identify and modify preconception risks.

MEASURES

Qualitative transcripts, preconception risk assessment, server data for system usage, self-administered satisfaction surveys, and follow-up phone calls.

ANALYSIS

Descriptive statistics of subjects' demographics, satisfaction, PCC risks, and system usage. Transcripts coded using NVIVO.

RESULTS

Subjects (n = 24) reported an average of 23 preconception risks; in the pilot, 83% of risks added to the "My Health To-Do List" were addressed by the subject. Seventy-three percent of risks identified as contemplative progressed to action or maintenance. Differences were noted in effectiveness of the system based on initial stage of change for each risk.

CONCLUSION

Results suggest that the PCC system could be effective in influencing positive behavior change. Adding stage of change-focused functionality might have added benefits. This system has great potential to assist in the delivery of PCC.

Integrating preconceptional care into an IVF programme

AIM

  This paper is a report of a mixed method study of the outcomes of integrating preconceptional care into an in-vitro fertilization programme on nurses' and patients' attitudes and patients' weight and smoking behaviour.

BACKGROUND

  Increasing evidence points to the significant effect of lifestyle factors on in-vitro fertilization outcomes. Optimizing the health of couples before they commence in-vitro fertilization may improve the chance of achieving success.

METHOD

  In 2007, 130 couples attending a university hospital in-vitro fertilization unit and seven nurses were invited to participate in the study. Questionnaires were developed to assess the attitudes of both patients and nurses. Furthermore, the impact of interventions on body mass index and smoking patterns were evaluated.

RESULTS

  All nurses (n = 7) and 101 patients (77·7%) returned completed questionnaires. Analysis revealed a considerable degree of scepticism among the nurses at the outset as to the value of the programme and their ability to perform their new role effectively. Patients valued positively the increased attention to adjusting lifestyle factors with the goal to improve fertility outcomes. Of those participants who smoked or had a body mass index >30, 30% (n = 7/23) of the patients quit smoking and 50% lost weight (n = 15/30), mean loss: 6·1 kg.

CONCLUSION

  Fertility nurses can play a key role in the provision of preconceptional care. Patients with a fertility problem can be motivated to address lifestyle issues before embarking on in-vitro fertilization treatment. The integration of preconceptional care and lifestyle interventions was shown to be feasible in our clinical setting.

The reproductive life plan as a strategy to decrease poor birth outcomes

The purpose of this article is to discuss the importance of implementing a life course perspective model that includes a reproductive life plan to improve health outcomes, especially in populations at risk for adverse outcomes. A reproductive life plan is a comprehensive strategy that can be incorporated into nursing practice at all levels to improve birth outcomes. Health care providers, especially nurses, should incorporate reproductive life planning into their daily encounters with patients.

2020 vision for a high-quality, high-value maternity care system

A concrete and useful way to create an action plan for improving the quality of maternity care in the United States is to start with a view of the desired result, a common definition and a shared vision for a high-quality, high-value maternity care system. In this paper, we present a long-term vision for the future of maternity care in the United States. We present overarching values and principles and specific attributes of a high-performing maternity care system. We put forth the "2020 Vision for a High-Quality, High-Value Maternity Care System" to serve as a positive starting place for a fruitful collaborative process to develop specific action steps for broad-based maternity care system improvement.

Reproductive life plans: initiating the dialogue with women

This article examines the concept of the reproductive life plan and provides information about translating this important idea into practice. The idea of the reproductive life plan was introduced in a report from the , but has thus far received little attention in the nursing literature. Reproductive life plans are important for women and their partners during their childbearing years, for they facilitate discussion about childbearing intentions and choices. Additionally, a dialogue about reproductive life planning may help nurses open a gateway to the utilization of preconception care as an intervention to improve maternal fetal outcomes. Nurses are ideally prepared and situated to assist women and their partners in learning about and developing reproductive life plans.

Preconception care: practice and policy implications for nurses

Statistical reports describe a troubling portrait of infant mortality in the United States today. This rate, an indicator of the health of a nation, has not declined in the past 5 years and is marked by enormous disparities among racial and ethnic groups. Although the overall infant mortality rate in the United States is 6.86 per 1,000 live births, the rate for non-Hispanic Black infants is 13.63 deaths per 1,000 live births. Among developed nations, the United States now ranks 29th in infant mortality. It is believed that lack of preconception care and late entry into prenatal care are contributing factors to infant mortality. Preconception care, although not a new concept, has not been universally adopted into the health care setting. This article examines the potential barriers to developing and using preconception care and policy implications related to nursing practice.

Policy and finance for preconception care opportunities for today and the future

This special supplement of Women's Health Issues offers 2 types of articles related to the policy and finance context for improving preconception health and health care. These articles discuss the impact of finance and policy on preconception health and health care, as well as the strategies that are being used to overcome the challenge of implementing preconception care with limited resources and inadequate health coverage for women. Invited papers from authors with expertise in health policy and finance issues describe how women's health and preconception care fit into the larger debates on health reform and how the paradigm for women's health must change. Other invited papers discuss opportunities and challenges for using programs such as Medicaid, Title X Family Planning, Title V Maternal and Child Health Services Block Grant, Healthy Start, and Community Health Centers in improving preconception health and health care. Contributed articles on health services research in this supplement characterize the types of change occurring across the country. This paper also presents a framework for understanding the role of policy and finance in the larger Centers for Disease Control and Prevention Preconception Health and Health Care Initiative.