Preconception and Interconception Health: What to Plan When You re not Expecting

Transcription

1 Preconception and Interconception Health: What to Plan When You re not Expecting John McHugh, MD Assistant Professor of Obstetrics and Gynecology, VCF The University of California at Irvine

2 Disclosure Some Data Courtesy of the Preconception Health Council of California a non-profit collaborative funded by the State of California

3 Learning Objectives O Eight Key Areas of Preconception Risk Screening O Opportunities to Address Preconception Health O Evidence for the benefit of Preconception and Interconception Care O The Importance of the Postpartum Visit O Resources for California Caregivers

4 If you take care of women of reproductive age, it s not a question of whether you provide preconception care, rather it s a question of what kind of preconception care you are providing. O Joseph Stanford and Debra Hobbins

5 Preconception Care, Sparta 500BC...ordered the maidens to exercise themselves with wrestling, running, throwing the quoit and casting the dart, to the end that the fruit they conceived might, in strong and healthy bodies, take firmer root and find better growth

6 USA 2013 Preconception care consists of identifying those conditions that could affect a future pregnancy, and that may be amenable to intervention. American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care

7 Eight areas of risk screening 1) reproductive awareness 2) environmental toxins and teratogens 3) nutrition and folic acid 4) Genetics 5) substance use 6) medical conditions and medications 7) infectious diseases and vaccination 8) psychosocial concerns

8 In obstetrics... most of our outcomes or their determinants are already present before we ever meet our patients

9 Current Practices 9

10 Are We Making Time for Preconception Care? >1 in 6 OB/GYNs had provided preconception care to the majority of women for whom they provided prenatal care

11 Missed Opportunities Abound women average 3.8 health care encounters/yr With providers over 3 years O Only 50% talked about diet, exercise or nutrition O calcium intake (43%) O smoking (33%) O alcohol (20%) O 31% of had talked about their sexual history

12 Discussion of more specific topics was even more rare: O STDs (28%) O HIV/AIDS (31%) O Emergency contraception (14%) O Domestic and dating violence (12%)

13 Attendance at Postpartum Visit O Medicaid participation is 59.1% O Private Insurance 79.9% O Kaiser Permanente 94% O The State of Health Care Quality 2007

14 Increasing Rates of: -Obesity -Maternal Age At Delivery -Multiple Pregnancies Place Greater Strain on: -Lower Back -Pelvic Girdle -Pelvic Floor Postpartum Visit is optimal time to assess and refer: -Breastfeeding helps with weight loss and subsequent decreased strain on supporting structures (back, hips, pelvic floor) -Physical Therapy -Assess Bladder Function -Assess Wound Healing

15 Optimizing Postpartum Follow Up O O O O O O Schedule postpartum visits 4-5 weeks (not 6 weeks) after delivery. O if appt missed, time to reschedule before 8 weeks. Schedule prior to delivery, within 4 weeks of the EDC Piggyback w/ infant appointments if both are patients at your site. During the prenatal period, make sure patients know they will need a postpartum check up, and make sure they know who they should see for this. Use updated, compliant HEDIS codes tor postpartum visits. wound checks <21 days are not considered PPVs for QARR, so make sure the patient understands the importance of returning prior to 8 weeks for a complete PPV.

16 The Postpartum Follow Up Initiative Hawaii Med J 2011 Mar 70 (3): 56-9 O Two main interventions. O 1: providing women with the time and date of their first postpartum appointment while the patient was still in the hospital. A picture was taken of the patient and her baby. O 2: The picture was presented to the patient in a photo album with the hospital s logo when she returned for her second postpartum visit O Results: O Significant Increase In Postpartum Visits O Significant Increase in Breastfeeding O Significant Increase in Contraception Use

17 Integrate Preconception Care O Premarital examination and testing O Contraception counseling O Evaluation for sexually transmitted disease or vaginal infection O After a negative pregnancy test O Anytime a woman of childbearing age presents for a periodic health examination

18 1. A Negative Pregnancy Test 2. Emergency Contraception 3. I have a New Partner and I want every STD test

19 Barriers O Reimbursement O Screening Tests only covered in pregnancy. O low income women may have: O multiple risk factors for adverse outcomes O less information about pregnancy and health. O reluctant to seek care w/o health insurance O Difficulties with child care and transportation

20 How to Do it Right O 8 Areas of Risk Screening O Proposal to Reinvest in Preconception Care O Hold Payors and Providers Accountable to Provide Public Health

21 Risk Screening #1 Reproductive Awareness O Fertility O Infertility O Family Planning O A Reproductive Life Plan

22 How Fertile am I? Estimates of human fertility and pregnancy loss. Zinaman MJ, Clegg ED, Brown CC, O'Connor J, Selevan SG Fertil Steril. 1996;65(3):503.

23 Percent (%) California Unintended Pregnancies Almost half of live births in California result from unintended pregnancies Black Hispanic White Asian/Pacific Islander Percent of mothers in California with a recent live birth by race/ethnicity, 2007 Data Source: Maternal and Infant Health Assessment Survey State Total

24 The economic costs of unintended pregnancies O cost-benefit analysis of California s F-PACT O each pregnancy averted saved the public sector O $6,557 from conception to age 2 O $14,111 from conception to age 5 O a return on investment of $9.25 for every dollar spent (Biggs MA, Foster DG, Hulett D, and Brindis C., 2010).

25 What happens when we don t address BCM postpartum? O 31% who desired did not receive PPTL O Within 1 year of delivery, 46.7% of women who did not receive the requested PPTL became pregnant. One-Year Follow-up of Women With Unfulfilled Postpartum Sterilization Requests Thurman, Andrea Ries MD; Janecek, Torri DO Obstetrics & Gynecology 116:5 pp1071-7

26 Reproductive Awareness Is Not Only About Pregnancy Prevention

27 Practical Tips: Establish a Reproductive Plan Establish Access to Fertility and Contraception Resources for all patients Introduce Preconception Care at other visits Emergency Contraception Negative Pregnancy Tests STD Screens Annual Exams

28 Risk Factor #2: Environmental toxins and teratogens

29 Environmental Toxins The production of industrial chemicals continues to rise ACOG DISTRICT IX CLINICIAN S GUIDE AN ENVIRONMENTAL TOXIN AND REPRODUCTIVE HEALTH INFORMATION BRIEF

30 Common Questions. O Can I dye my hair? O I work in a Nail salon. O Can I go to a tanning parlor? O Can I drink out of plastic bottles? O Is eating fish a problem?

31 Free Resource to Patients and Providers

32 Risk Factor #3 Nutrition and folic acid

33 Percent (95% CI) Folic Acid Consumption Daily folic acid use during the month before pregnancy, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 32.9% 20.3% 22.6% 29.8% 39.5% 44.4% 27.1% 25.7% 40.8% 43.2% 0% CA Black HispanicAsian/PI White Source: California Department of Public Health, Maternal, Child and Adolescent Health Program, Maternal and Infant Health Assessment Data are weighted to reflect the population of women delivering a live birth in the survey year.

34 1996 FDA ordered the addition of folic acid to all enriched cereal grain products 23% decrease in the prevalence of NTD-affected pregnancies

35 Percent (95% CI) 100% 90% 80% Healthy Weight Women with a healthy weight just before pregnancy (BMI kg/m 2 ), % 60% 50% 40% 30% 20% 52.6% 59.7% 52.3% 50.3% 52.9% 52.2% 43.2% 46.2% 65.6% 58.5% 10% 0% CA Black Hispanic Asian/PI White Source: California Department of Public Health, Maternal, Child and Adolescent Health Program, Maternal and Infant Health Assessment Data are weighted to reflect the population of women delivering a live birth in the survey year.

36 Practical Resources: Weight and Folic Acid Understand the Recommendations for Folic Acid for all groups: Average Risk Diabetics Anti-Epilieptics Prior NTD Encourage a Balanced Diet for All with Natural Sources of Folate Chart BMI and Address Make use of the Routine Visits: Pregnancy Tests, Annual s and EC

37 Preconception Risk Factor #4 Genetics

38 Look back at the revolution in IT, and realize that genetics is changing 5x faster Imagine the resources available for preconception care in 30 years

39 Genetic Technology is becoming cheaper faster than IT

40 The cost of preconception genetics is putting universal preconception genetic screening in the hands of consumers but do we have the knowledge to help them?

41 Practical Reccomendations O Be aware of ACOG guidelines (limited) O Be aware that your patients are exposed to MANY more options

42 non prescription substance use (legal and illegal) O Tobacco O Alcohol O Street Drugs O Vitamins and Supplements

43 Percent (95% CI) 100% 90% 80% 70% 60% 50% Alcohol Abstinence Data Did not drink alcohol during the three months before pregnancy, % 30% 55.6% 74.1% 57.0% 53.3% 52.5% 52.6% 54.9% 67.1% 64.4% 20% 32.4% 10% 0% CA Black Hispanic Asian/PI White Source: California Department of Public Health, Maternal, Child and Adolescent Health Program, Maternal and Infant Health Assessment Data are weighted to reflect the population of women delivering a live birth in the survey year.

44 Percent (95% CI) Tobacco Abstinence Data Women who did not smoke during the three months before pregnancy, % 90% 80% 70% 60% 50% 40% 88.0% 88.0% 83.9% 85.2% 90.4% 93.0% 81.6% 91.8% 91.4% 81.9% 30% 20% 10% 0% CA Black HispanicAsian/PI White Source: California Department of Public Health, Maternal, Child and Adolescent Health Program, Maternal and Infant Health Assessment Data are weighted to reflect the population of women delivering a live birth in the survey year.

45 Early Start Program Could Save US 2 Billion/yr Early intervention mitigates risk of substance abuse among pregnant women O integrates obstetric care with substance-abuse treatment O all women are screened by questionnaire for drug, cigarette and alcohol use, and by urine toxicology testing O a substance-abuse expert sees the patients at their prenatal visit O all providers and patients are educated about the effects of drug, alcohol and cigarette use during pregnancy.

46 Risk Factor #6 Maternal Medical Conditions and Medications

47 Maternal Morbidities Increasing Trends in Maternal Morbidity and Disparities California, Adjusted Trends in Maternal Morbidities in All Hospital Deliveries in California in 1999, 2002 and March Prepared under contract with the University of California, Los Angeles by the Maternal Quality Indicators Project. SOURCE: Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data N=1,551,017 NOTES: ICD-9 Diagnosis 401, 402, 403, 404, 405, 642 (hypertension), 648.0, 648.8, 250 (diabetes), 493 (asthma) PI = Pacific Islander; AI/AN = American Indian/Alaska Native. For all percent change estimates P<0.001; exception asthma among AI/AN p=0.06

48 Postpartum Screening for DM O Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every 3 years. (B) O Less than one half (45%) of women with GDM underwent postpartum glucose testing (At an academic medical center)

49 Practical Reccomendations O Use the Postpartum Visit to Address Ongoing Medical Issues: O GDM O HTN O Fertility O Etc O Interconception Protocols at

50 Risk Factor #7 infectious diseases and vaccination O Two Resources: O Excellent Review: O The clinical content of preconception care: immunizations as part of preconception care AJOG 2008 S290-5 O California Specific Resources: O

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52 Reccomendations: O Review immunization status for all patients. O Vaccinate pregnant and postpartum women for influenza O Vaccinate for pertussis (with Tdap) O Vaccinate for rubella (with MMR vaccine) and varicella. O Follow CDC STI Screening Guidelines for all women at all visits

53 Risk Factor #8 psychosocial concerns (e.g., depression or violence)

54 Women Who Experience Abuse Around the Time of Pregnancy Are More Likely to: too: O O O O O O Smoke tobacco Drink during pregnancy Use drugs Experience depression, higher stress, and lower self-esteem Attempt suicide Receive less emotional support from partners (Amaro, 1990; Bailey & Daugherty, 2007; Berenson et al, 1994; Campbell et al, 1992; Curry, 1998; Martin et al, 2006; Martin et al, 2003; Martin et al, 1998; McFarlane et al, 1996; Perham-Hester & Gessner, 1997)

55 Tobacco Cessation and DV 42% of women experiencing some form of DV could not stop smoking during pregnancy compared to 15% of nonabused women. (Bullock et al, 2001)

56 Impact of Psychological Abuse Psychological abuse by an intimate partner was a stronger predictor than physical abuse for the following health outcomes for female and male victims: Depressive symptoms Substance use Developing a chronic mental illness (Coker et al, 2002)

57 Domestic Violence During Pregnancy is Associated With O Lower gestational weight gain during pregnancy (Moraes et al, 2006) O Low and very low birth weight (Lipsky et al, 2003) O Pre-term births (Silverman et al, 2006)

58 Women Who Talked to Their Health Care Provider About the Abuse Were 4 times more likely to use an intervention 2.6 times more likely to exit the abusive relationship McCloskey LA, Lichter E, Williams C, Gerber M, Wittenberg E, Ganz M. Assessing Intimate Partner Violence in Health Care Settings Leads to Women s Receipt of Interventions and Improved Health. Public Health Reporter. 2006;121(4):

59 Practical Tips O Screen for Intimate Partner Violence O Recognize and Refer O ACOG Committee Opinion Number 518, February 2012 Intimate Partner Violence O

60 What Can We do? 1. Be Informed 2. Create Accountability 1. Develop and implement indicator quality improvement measures for preconception care. -For example, use HEDIS measures to monitor the percentage of women who complete preconception care and postpartum visits

61 O Health Effectiveness Data and Information Set O What practice administrators track.. O Changing reimbursement and HEDIS altered the stage of breast cancer diagnosis O Approximately 50% of women in the group with improved coverage were diagnosed at an earlier stage

62 Is there Hope? The ACA O Covers O At least one well-woman preventive visit, including preconception care, annually for adult women to obtain recommended preventive services, allowing for additional visits, depending on the women's health status, needs, and other risk factors;

63 Imagine O using HEDIS to track public health. O % of Women fully vaccinated at preconception visits O % of ECP visits offered LARC O % of women screened for IPV O % of eligible patients offered genetic counseling

64 If you take care of women of reproductive age, it s not a question of whether you provide preconception care, rather it s a question of what kind of preconception care you are providing. O Joseph Stanford and Debra Hobbins