the circle of care for women

EARLY PRENATAL CAREAND

MEDICAL HOMES FOR NON-PREGNANT WOMEN

The Circle of Care for Women

Acknowledgements

This training was developed by the North Carolina Preconception Health Campaign, a program of the March of Dimes North Carolina Chapter, under a contract and in collaboration with the North Carolina Division of Public Health, Women’s Health Branch.

This material was developed through support provided by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Health, Office of Adolescent Health (grant #SP1AH000004).

Acknowledgements

Many thanks to these agencies and individuals for their generosity in sharing their resources in the area of early prenatal care and medical homes for women: North Carolina Division of Public Health, Women’s Health

Branch Merry-K Moos, FNP, MPH, FAAN Alvina Long Valentin, RN, MPH Sarah Verbiest, DrPH, MSW, MPH

Specific resources used to guide the development of this training: The National Preconception Curriculum and Resources Guide

for Clinicians (Module 1: Preconception Care: What it is and what it isn’t)

Young Moms Connect

Brings together community partners to address challenges faced by pregnant or parenting teens using collaborative, multi-faceted strategies

One component of Young Moms Connect is training for health care providers on six maternal and child health best practices

Maternal & child health best practices

Early entry and effective utilization of prenatal care

Establishment and utilization of a medical home (for non-pregnant women)

Reproductive life planningTobacco cessation counseling using the 5 A’s

approachPromotion of healthy weightDomestic violence prevention

Objectives

Increase awareness about the relationship between preconception health, early prenatal care and a medical home

Increase knowledge about current status of prenatal care among young mothers

Assess local prenatal care services and early entry barriers

Increase awareness about the importance of primary care medical homes for women of reproductive age

Develop strategies to link young women, especially in the postpartum period, to medical homes

What is preconception care?

Identification of modifiable and non-modifiable risk factors for poor health and poor pregnancy outcomes before conception

Timely counseling about risks and strategies to reduce the potential impact of the risks

Risk reduction strategies consistent with best practices

CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules

Components of preconception care

Giving protection (eg.: folic acid,

immunizations)

Managing conditions (eg.: diabetes, maternal

PKU, obesity, hypertension, hypothyroidism, STIs, sickle cell)

Avoiding exposures known to be teratogenic (i.e.: medications, alcohol,

tobacco, illicit drugs)


“Opportunistic” care

Preconception care is for every woman of childbearing age every time she is seen

Every woman, every time


Every woman, every time

Young women who are at risk of pregnancy

Young women who are pregnant

Young mothers who are postpartum

Young mothers who are between pregnancies

From linear care…

Moos, MK. Connecting the Dots: Health Status Before Pregnancy and Pregnancy Outcomes. 2011

…to a circle of care

Be healthy before pregnancy

Message for all women of childbearing age: Remember, being in the

best physical, emotional and financial position BEFORE pregnancy is best

Make sure your future pregnancies are planned and intended

Prenatal care should start as early as possible in pregnancy

Early prenatal care

Why is early prenatal care important?

Recommended prenatal care schedule: Weeks 4-28: 1 visit per

month Weeks 28-36: Visits

every 2 weeks Weeks 36-birth: Weekly

visits until delivery

Components of prenatal care

Review of: Individual medical history Obstetrical and gynecological history Family history


Screening, referral and/or treatment for: Genetic risks Infectious disease Chronic disease Psychosocial issues Environmental issues Immunizations Nutritional concerns


Laboratory studiesVital signsMaternal assessmentFetal assessmentPatient education

Prenatal development

CDC National Preconception Health Curriculum and Resource Guide for Clinicians, 2008

4 5 6 7 8 9 1011 12

Weeks gestation from LMP

Central Nervous System

Heart

Arms

Eyes

Legs

Teeth

Palate

External genitalia

Ear

Missed Period Mean Entry into Prenatal Care

Most susceptible time for major malformation

Importance of prenatal care

Adequate use of prenatal care associated with: Healthy birth weights Decreased risk of preterm delivery

Inadequate use of prenatal care associated with increased risk of: Low birth weight Preterm delivery Neonatal mortality Infant mortality Maternal mortality

Kiely JL, Kogan MD. From data to action: Reproductive health of women (Prenatal Care). Pp. 105-118. 1994

Young mothers are at higher risk

Teens are least likely of all maternal age groups to get early and regular prenatal care1

Teens are at greater risk than women over age 20 for pregnancy complications such as premature labor, anemia and high blood pressure2

Teens are more likely than women over age 25 to smoke during pregnancy3

1. National Center for Health Statistics, final natality data, 20072. American College of Obstetricians and Gynecologists. Especially for Teens: Having a Baby. Patient Education Pamphlet, August 2007

3. Centers for Disease Control and Prevention. Preventing Smoking and Exposure to Secondhand Smoke Before, During and After Pregnancy. October 3, 2007

Late entry into prenatal care

0%

5%

10%

15%

20%

25%

30%

Unintended pregnancy

Intended pregnancy

NC Women Entering Prenatal Care in the Third Trimester or not at all Mothers with

unintended pregnancies are more likely to enter into prenatal care later in their pregnancies

North Carolina State Center for Health Statistics, Risk Factors and Characteristics for 2009 Resident Live Births

Mothers receiving prenatal care in the first trimester

2004-2008, live births

North Carolina 82%

Bladen 72%

Nash 76%

Onslow 90%

Rockingham 85%

Wayne 71%

NC State Center for Health Statistics, 2004-2008. Trends in Key Health Indicators

Mothers not receiving prenatal care in the first trimester in North Carolina,

2008

21% of mothers surveyed did NOT access first trimester prenatal care

Rates for not receiving care in the first trimester are highest for: Young mothers (35% < 20 years, 31% 20-24 yrs) African-American (34%) and Hispanic mothers (31%) Unmarried women Less education Lower income levels

NC State Center for Health Statistics, 2008, Pregnancy Risk Assessment Monitoring System

Access to prenatal care

North Carolina mothers who reported they did not receive prenatal care as early as they wanted31% of mothers < 20 years of age25% of mothers age 20-24 years

Half of all young mothers reported experiencing barriers to prenatal care


Barriers to prenatal care in North Carolina

Barrier Teens Ages 20-24

Did not want the pregnancy known 16% 16%

Couldn’t get an appointment earlier 15% 21%

Didn’t have my Medicaid card 15% 16%

Transportation 13% 9%

No money or insurance 12% 22%


Less likely to start prenatal care in first trimester70% of prenatal care is paid by Medicaid2/3 enroll in WIC (66%)1 in 3 African-American mothers were already

enrolled in Medicaid prior to pregnancy (30%) compared to white mothers (9%)

NC PRAMS Fact Sheet April 2011. NC African American Maternal Health

Prenatal care for African-American mothers

in North Carolina

Significantly more likely to experience at least one prenatal barrier compared to white mothers (48% vs. 37%) 1 in 5 reported they were

not able to get an appointment earlier in pregnancy

1 in 6 reported having no insurance

NC PRAMS Fact Sheet April 2011. NC African-American Maternal Health

Prenatal care for African-American mothers

in North Carolina

Not just early but adequate

Young Moms Connect has two prenatal care goals: Making sure young women enter prenatal care during the

first trimester Making sure young women continue to follow the

recommended prenatal visit schedule

Measures of adequacy of prenatal care Kotelchuck Index: Looks at month of prenatal care

initiation and total number of visits (compares number of expected visits to actual number of visits). Classifies as: inadequate, intermediate, adequate and adequate plus.

Kessner Index: Looks at weeks of gestation and total number of visits. Classifies as: inadequate, intermediate and adequate.

Adequacy of prenatal care, Kessner Index, 2009

Number of Births

AdequateIntermediat

eInadequate

North Carolina

126,785 78% 16% 5%

Bladen 378 74% 18% 7%

Nash 1,269 68% 23% 8%

Onslow 4,058 86% 11% 3%

Rockingham

1,048 87% 10% 3%

Wayne 1,661 63% 29% 8%

NC State Center for Health Statistics, 2009 NC resident births by county and Kessner Index

Location of prenatal care for young women

Care provider Teens Ages 20-24

Private practice/HMO 39% 47%

Health department 28% 29%

Hospital clinic 15% 16%

Other 18% 8%


Preconception health & early prenatal care

Important components of prenatal care and preconception health

Identification & treatment of sexually transmitted infections

Assessment of medication use

Identification of environmental risks (e.g. tobacco use, lead exposure, varicella exposure)

Achieving and/or maintaining healthy weight

Sexually transmitted infections & pregnancy

Chlamydia Untreated can cause prematurity, pink eye, and breathing

problems for the baby

Genital Herpes 25% of American women are infected (most do not know –

asymptomatic); can be transmitted during a vaginal delivery and can cause blindness, brain damage and death of baby

HPV-Genital Warts Over 6 million new infections/year in United States; can be

uncomfortable during pregnancy

Bacterial Vaginosis May increase a woman's chances of premature rupture of

membranes and preterm delivery

Cunningham, F.G., et al. Sexually Transmitted Diseases, in Williams Obstetrics, 22nd Edition. New York, McGraw-Hill Medical Publishing Division, 2005, pages 1301-1325Workowski, K.A., Berman, S.M. Sexually Transmitted Disease Treatment Guidelines, 2006. Morbidity and Mortality Weekly Report, volume 55, RR11, August 4, 2006

Sexually transmitted infections & pregnancy

Gonorrhea Untreated it can cause blindness, joint infections and life

threatening blood infections for the baby

HIV/AIDS Untreated – higher risk of transmission to the baby

Syphilis Untreated can cause blindness, brain damage or death for

baby in addition to prematurity, stillbirth and congenital malformations

Hepatitis B Untreated can infect the baby at delivery and can later cause

liver disease or liver cancer; Also increases risk for infant to become a Hepatitis B carrier

Workowski, K.A., Berman, S.M. Sexually Transmitted Disease Treatment Guidelines, 2006. Morbidity and Mortality Weekly Report, volume 55, RR11, August 4, 2006. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Disease Surveillance 2005 Supplement, Syphilis Surveillance Report. December 2006.

Gonorrhea and chlamydia in North Carolina

59% of new gonorrhea cases in 2010 were to women

80% of new chlamydia cases in 2010 were to women

Both disproportionately affect African-American women

High rates among ages 15-24 year-olds

2010 STD/HIV Surveillance Report. Communicable Disease Branch, N.C. Division of Public Health

HIV in North Carolina

In 2009, 26% of new HIV cases were to women

Rate per 100,000 population African-American women, 38.7 White women, 2.7

2009 STD/HIV Surveillance Report. Communicable. Disease Branch, N.C. Division of Public Health

CountyRank among 100 NC counties

Cases per 100,000 residents

Bladen 10 26

Nash 26 18

Wayne 35 14

Rockingham 61 9

Onslow 69 7

HIV disease cases by county2007-2009 average

2009 HIV/STD Surveillance Report. Table 2. Communicable Disease Branch. NC DHHS

Medication

Because almost half of all pregnancies in North Carolina are unintended, medication use should be monitored carefully during women’s childbearing years

Medications and pregnancy

Medications known to cause serious birth defects if taken during pregnancy: Isotretinoin Thalidomide

Medications for the following conditions should be closely monitored for women of childbearing age: Asthma Epilepsy High blood pressure Depression

U.S. Centers for Disease Control and Prevention, retrieved July 2011

Environmental risks

Several environmental risks are associated with increased risk for poor maternal and/or infant outcomes and should be addressed as early as possible during prenatal care and throughout pregnancy Tobacco use Alcohol use Illicit drug use Exposure to some toxins (e.g. lead exposure) Experience high levels of stress Experiencing violence

Maternal smoking during pregnancy

Smoking during pregnancy is the single most modifiable risk factor for poor birth outcomes

Increased risk for mother of: Ectopic pregnancy Preterm premature

rupture of membranes Placental complications Preterm delivery Spontaneous abortion

Cnattingius S. The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes Nicotine Tob Res, 2004ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011

Maternal smoking during pregnancy

Increased risk for child of: Low birthweight (causal association – twice as likely in

smokers)1

Sudden infant death syndrome1

Childhood respiratory illnesses2

Learning disabilities and conduct disorders1

If it were possible to eliminate smoking during pregnancy entirely, the infant mortality rate in North Carolina would drop 10-20%.3

1Women and smoking: A report of the Surgeon General. U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, DC, 2001

2Hu FB, et al., Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy, Annals of Allergy, Asthma and Immunology 79(1): 80-84. 1997

3Rosenberg DC, Buescher PA. The Association of Maternal Smoking with Infant Mortality and Low Birth Weight in North Carolina, 1999. SCHS Studies No. 135. Raleigh, NC: North Carolina State Center for Health Statistics; 2002

Smoking during pregnancy

Nationally between 12-20% of all pregnant women report smoking during pregnancy

Current clinical guidelines:“Whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit. Clinicians should offer effective tobacco dependence interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy.”

Martin JA et al. Births: Final data for 2002. National vital statistics reports. Vol 52 no 10. National Center for Health Statistics. 2003Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services. 2008

Smoking during pregnancy, 2005-2009

Number of women

Percent

North Carolina 70, 529 12

Bladen County 341 16

Nash County 759 12

Onslow County 1,821 11

Rockingham County

1,109 21

Wayne County 1,097 12

NC State Center for Health Statistics, NC Residents 2005-2009 # and % of births to mothers that reported smoking prenatally

What providers can do

Move beyond screening and recommendations

Provide brief smoking cessation counseling and use pregnancy-specific self-help materials

Use the 5 A’s regularly with preconception, pregnant and post-partum patients

Connect patients with support such as the NC Quitline

Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services. 2008

Women & weight in North Carolina

58% of women in NC of childbearing age (18-44) are overweight or obese

43% of young women ages 18-24 are overweight or obese

There is also a racial disparity in weight status for women 18 years and older 56% of white women are overweight or obese 73% of African-American women are overweight or obese 56% of other minorities are overweight or obese

NC Behavioral Risk Factor Surveillance System, 2010

Consequences

U.S. society focuses on external consequences of overweight and obesity, i.e. how we look

As health professionals it can be helpful to re-frame discussions toward medical/physical consequences of overweight and obesity

For women of childbearing age the consequences of overweight & obesity span two generations

Risk of consequences increases progressively as BMI increases

Kellner, S. Maternal weight: An opportunity to impact infant mortality in North Carolina. 2010

Pregnancy risks

Increased pre-pregnancy BMI is associated with increased risk of: Preeclampsia Gestational hypertension Gestational diabetes C-section Induction of labor Postpartum hemorrhage Lactation failure

Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010

And for the baby…..

MacrosomiaPreterm deliveryPoor APGAR scoresNICU admissionShoulder dystociaLate fetal deathNTDs (anencephaly and spina bifida)


The cycle repeats

The likelihood that overweight children will become obese adults is almost 9 times higher than the risk for children who are not overweight

Early prenatal care allows for counseling about appropriate weight gain during pregnancy to slow or stop this cycle


Recommended pregnancy weight guidelines

Weight gain during pregnancy: Reexamining the Guidelines. Institute of Medicine, 2009

Gestational weight gain counseling should be tailored to the woman’s pre-pregnancy BMI

Women who gain within guidelines consistently have better birth outcomes than those who gain more or less than the Institute of Medicine guidelines

Medicaid covers medical nutrition therapy (nutritional counseling provided by a registered dietician) for pregnant women who are overweight, obese or underweight

Recommended pregnancy weight guidelines

Weight gain during pregnancy: Reexamining the Guidelines. Institute of Medicine, 2009

Early prenatal care counseling

When does your practice give patients information about risk behaviors (alcohol, smoking, cat litter, etc.), medication use, healthy weight and preventive measures to ensure a healthy pregnancy and birth outcome?

Do all women receive this information in a way that can be tracked?

Who provides this information?What method of information sharing is used?Who in the community does a good job of getting

this information to women in effective ways?

Case study

Maya is a 17-year-old young woman who found out she was pregnant after missing two periods. She was very confused about what she should do and kept living her life as normally as possible. She visited the health department at around 20 weeks to see if she could find out if the baby was a girl or a boy.

Case study

Sarah is a 15 year old young woman who kept her pregnancy hidden for the first trimester. Her parents took her to their private practice physician after they discovered her pregnancy at around 22 weeks.

Prenatal care & transition to medical home

Maternal & child health best practices

Early entry and effective utilization of prenatal careEstablishment and utilization of a medical

home (for non-pregnant women)Reproductive life planningTobacco cessation counseling using the 5 A’s

approachPromotion of healthy weightDomestic violence prevention

Principles of a medical home

Personal physician: Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care

Physician directed medical practice: The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients

Whole person orientation: The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals

Joint principles of the patient-centered medical home. 2007. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association

Principles, cont.

Care is coordinated and/or integrated across specialists, hospitals, home health agencies, etc.

Quality and safety are assured by a care planning process, evidence-based medicine, clinical decision-support tools, performance measurement, active participation of patients in decision-making, and other factors.

Enhanced access to care is available (e.g., via "open scheduling, expanded hours and new options for communication").

Payment must appropriately recognize the added value provided to patients who have a patient-centered medical home

Joint principles of the patient-centered medical home. 2007. American Academy of Family Physicians,American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association

What can medical homes provide for healthy, non-pregnant women?

A place for regular check-upsA place women can call if they’re not feeling well to

help them decide if they need: a clinic appointment, an emergency department visit, a referral to a specialist, or no visit at all

A place that coordinates referrals for women; helps assess if further treatment or testing is needed

A place that can provide preconception or interconception health counseling about relevant topics: healthy weight, substance use, tobacco use, screenings for mental health issues, sexually transmitted infections, etc.

What can medical homes provide for non-pregnant women with chronic

conditions?

All the services on the previous slide, plus:A place for regularly scheduled check-ups, lab work,

prescriptions and sometimes medications/suppliesA place to receive specialized counseling related to

their condition (such as nutrition counseling for diabetes)

A place that coordinates referrals for services such as annual eye exams (for women with diabetes)

A place with a provider who can receive and read referral results and makes a plan of care based on those results

Transition from pregnancy to primary care provider/medical home

The postpartum visit is an important opportunity to establish a medical home for young women and provide preconception guidance for future pregnancies

Considered the “gateway to well-woman care”Opportunity to revisit health concerns that came up

in prenatal visits and throughout the pregnancyMay be the only clinical visit for a woman between

pregnanciesSometimes a lost opportunity

Nationally, only 59% of Medicaid patients and 80% of privately insured patients receive a postpartum visit

The State of Health Quality, National Committee for Quality Assurance, 2007The Postpartum visit: An overlooked opportunity for prevention, Verbiest, SB, 2009

Barriers to postpartum visit compliance

A survey of local public health nurses in North Carolina showed several barriers to access of postpartum care in local health departments: Lack of transportation, lack of childcare, children not being

welcome at the postpartum appointment, women not realizing the importance of this visit

Financial issues such as an outstanding prenatal care bill or the loss of Medicaid coverage

Inconvenient hours and poor customer service (long waits during appointments and difficulty getting through on the phone to schedule appointment)

Long Valentin, A. "Postpartum Visit Utilization Assessment: North Carolina Local Public Health Departments," North Carolina Division of Public Health, Women's Health Branch, 2008

Postpartum visit components

Basic physical exam including pelvic exam and incision exam (if applicable)

Glucose testing for women who had gestational diabetes

Postpartum depression & domestic violence screenings

Breastfeeding support Reproductive life planning

counseling, focus on pregnancy spacing

Contraception if desired Active assistance in helping

patient transition to a “medical home”

Immunizations like varicella and MMR

Smoking cessation counseling, as up to 70% of women who quit during pregnancy start smoking again within a year after delivery

Birth spacing recommendations

Recommended birth spacing in the U.S. is at least 18 months between prior delivery and next conception (and no more than five years)

42% of North Carolina women had less than an 18 month interval in 2008 Under age 20, 73% Age 20-24, 54%

Zhu BP. Effect of interpregnancy interval on birth outcomes: findings from three recent US studies. International Journal of Gynecology and Obstetrics (2005) 89, S25—S33

North Carolina State Center for Health Statistics, 2008.

Transition to a medical home

In addition to the postpartum visit, discuss medical home at: Prenatal visits during the last month of pregnancy Hospital discharge Home visits Newborn pediatric visits WIC appointments

The Postpartum visit: An overlooked opportunity for prevention, Verbiest, SB, 2009

Transition to medical home

Do women who have recently (or maybe not so recently) had a baby consider their OB/GYN or midwife their primary health care provider?

Is this an ideal arrangement?If not, how would you suggest starting a

conversation with a young mother about where her new medical home could be?

Are pediatricians involved in recommending medical homes? Could they be?

Points of entry into medical homes/primary care providers

What are the medical homes for non-pregnant young women in this community?

How and when do young women access these medical homes?

What are the entry points by which they may reach these medical homes? Postpartum visits Pregnancy planning visits Annual exams Sick care Referral from health department family planning clinics Referral from negative pregnancy tests Other?

Medical homes in this community

Who are safety net providers that serve as medical homes?

Is there a referral network in place throughout the community to make sure all women who want a medical home can access one?

Resources (Also found in Section 3 of the Circle of Care for Women Training Materials & Toolkit binder):Nchealthcarehelp.orgNccarelink.govNcfreeclinics.org

Step by step to a medical home

1. Remind patients that medical homes help them stay healthy and prevent emergency room visits

2. Provide specific local medical home options, reminding young patients that the best medical home for their needs may change over time

3. Write out the steps of how to connect with a medical home

4. Be specific: practice names, phone numbers and guidance about when to call the medical home

5. Some practices follow up by phone as part of routine postpartum care, ensuring the patient has connected with the medical home

Case study

Kristina had a baby boy 6 weeks ago. She is 18 years old and her Medicaid benefits are about to expire. She had genital herpes and was treated during the pregnancy. She also has a history of depression and asthma. She asks for some extra depression and asthma medications at her postpartum visit.

Case study

You see a 19 year old mother at a (pediatric) baby well check and she asks you about prescribing her the patch as she wants to stop smoking for the baby. After some basic questions you learn that she no longer has any health insurance and lists her OB/GYN at the local community health center as her primary physician.

The circle of care for women

the circle of care for women

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