AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
ANNETTE PHELPS: By way of introduction, I am Annette Phelps. I am Division Director for Family Health Services in Florida in the Department of Health. In that capacity I have a variety of programs and have worked with MCH for a long time.
I see lots of familiar faces that I’ve know through AMCHP for a long time and it’s really good to see everyone again.
I will go ahead and introduce the other speakers and then we will just proceed through our presentations. Arlene Cullum has a Masters in Public Health and she’s the Director of Women’s and Children’s Services, Regional Programs and at the Sutter Medical Center in Sacramento, California. She administers 14 maternal and child health regional programs, which are prevention or early intervention, focused and is responsible for all maternal neonatal, pediatric and tertiary care contracting for the Regional Center for data management programs. The regional programs included regional lactation programs and a retail store, high risk infant follow up, home visiting programs for women with HIV and pregnant and parenting teens, regional perinatal programs for 25 counties and newborn hearing coordination center.
Miss Cullum has served on the CDC select panel for preconception care to help develop recommendations for the nation and she has many years of experience in administration, program planning, health education, development in community clinics, health departments, and hospital settings. And she’s held leadership positions in public policy for maternal and child health through work with the March of Dimes, the California Children’s Lobby and Sutter Health. She received her MPH from the University of California in Los Angeles in 1981 and her BS in Human Development from the University of California Davis in 1979. She lives in Sacramento with her husband and has two sons 18 and 21.
Next to Arlene is Betsy Wood. Betsy is the Executive Community Health Nursing Director in the Florida Department of Health responsible for infant maternal and reproductive health. She is a nurse from FSU and she has a Masters in Public Health from University of South Florida. She has many accomplishments including a stellar career serving families of Children with Special Healthcare Needs, HIV aids, testing, treatment, and screening. She developed and implemented several tele health programs to increase access to healthcare and assessment for children receiving services through the child protection teams.
And we also have with us Bill Hollingshead who is a Pediatrician. He says he wants to retail peds before becoming more involved in Public Health. And he is a longtime member of AMCHP, currently serves as the secretary. He has spent many years working to link data and information electronically and has a wonderful system in Rhode Island where he is the Medical Director of the Division of Family Health. And I also know that he has a grandchild that he’s very, very fond of and plans to go visit in, of course, France after this meeting. So thank you to our presenters.
And we’ll go ahead and try to set the stage a little bit for what we’re doing. Why perception care? And the presentation that I have is actually from Hani Atrash from CDC. I’ve adapted it by taking out a bunch of the slides, so that we can fit it into the amount of time here. There’s lots and lots of information that CDC’s been putting together on this.
In September of 2005 ACOG put out an opinion regarding preconception care saying that optimizing a women’s health before and between pregnancies is an ongoing process that requires full participation of all segments of the healthcare system. And then the select panel, also, has developed a definition for what they were going to be working with and that began in June of 2005 saying that it is a set of interventions that aim to identify, modify, behavioral, social respecters in a women’s health or pregnancy through prevention and management emphasizing those factors which must be acted on before conception or orally in pregnancy to have a maximum impact.
So again, the question was why would we do preconception care? Well, we have a lot of outcomes to look at. In looking at the data we see that maternal mortality had a great big decrease between 1960 and 1980, but since that time there’s not been much progress. And we also have a great disparity between races.
Low birth weight actually has been increasing a little bit over time. And preterm deliveries, as we know, continue to be one of our big areas of concern. Infant mortality rates, we’ve made a great bit of progress in declines in those rates but we still have great disparities in our outcomes and the rates are still not acceptable. Adverse outcomes of pregnancy especially the fact that we have about 50 percent of our pregnancies being unintended continues to be a major issue in this country.
Risk factors among women getting pregnant or at risk of pregnancy are also continuing to be very significant as you can see from this slide. And we know that the period of time earlier in gestation, before 17 days post conception is when exposure to various hazards places pregnancy at the greatest risk of spontaneous loss and the period of time after 56 days post conception is the period where exposures to hazards may lead to other growth disturbances. So early prenatal care is not enough and in many cases it’s just too late.
So what are the components or preconception care? First of all screening for the risk, providing health education, and delivering effective interventions. These are some of the components related to screening for the maternal assessment component that we need to be paying more attention to and assuring that all of our providers and people who interact with women at risk of becoming pregnant are paying attention to.
The science says that there are some things in these individual components of preconception care that work. We know that rubella vaccination, HIV aids screening, management of and control of chronic diseases makes a difference. We’ve learned lots about folic acid lately and also avoiding certain kinds of things that we know make a difference in the outcome of pregnancy like smoking and alcohol, Accutane, oral anticoagulants and some others.
Over the years we’ve developed several kinds of guidelines that are out there for clinical practice and guidelines. And this is just a listing of some of those. Another example is that in 2002 the American College of OBGYN recommended that all health encounters during a women’s reproductive years particularly those that are a part of the preconception care should include counseling or appropriate medical care and behavior to optimize pregnancy outcomes. Even in the Healthy people 2000 objectives for the nation, we had measures. And the U.S. Public Health Service has recommended back in 1989 that women and partners have preconception visits as a part of their primary care. But it’s just not being delivered today despite all of these. We know that most providers don’t provide it. Most insurers don’t pay for it and most consumers don’t even know that they should ask for it.
According to CDC the percent seen for preconception care by type of providers remains low as you can see from this particular slide, the highest being just over 25 percent. We have a lot of challenges in implement preconception care. There is no real national policy despite all of those different recommendations that I showed you. We don’t necessarily have all of the clinical tools that we need to have and we haven’t necessarily demonstrated through evidence base that there are proven delivery models or programs that are going to work for all women in all kinds of settings. We also have had inadequate education of providers and consumers in this area.
So what has CDC done? They’ve been convening a group studying and reporting and we’ll talk a little bit about that. It was a broad group that they convened as a select panel on preconception care. Over 35 organizations came together to collaborate on this select panel. And this is just a representation of some of those folks who were there. The purposes were several. Develop the national recommendations to improve preconception care. Improve provider knowledge, attitudes, and behaviors. Identify opportunities to integrate preconception care programs and policies and to federal, state, and local programs. Develop tools and promote guidelines for practice. Evaluate existing programs for feasibility and demonstrated effectiveness. And what have they done? They’ve established an internal working group and some other external working groups and that began in 2004. They convened a meeting of the work groups in November of 2004 and held a national summit on preconception care in June of 2004.
A select panel was also convened at that June meeting in 2004 and there has been development of some recommendations to improve preconception care. Those are expected to be published now in May I’m hearing, and also that there will be a special MCH Journal that is also due out in May.
The next steps that are planned are to begin to publish and disseminate these recommendations. That’s a part of why we are having this session here and there are sessions that are being held across the country in various settings. We need to increase awareness among the public and private providers, identify opportunities where we can integrate preconception programs and policies into state, local, and community health. And also then, develop the tools and guidelines for practice that we all need to be able to implement this. Just having the recommendations won’t work. And then we also need to be doing more in terms of evaluation of existing programs and finding out whether or not it’s feasible and demonstratable that we have evidence to assure that these kinds of recommendations are implemented.
Through this collaboration and consensus building, what we’ve done so far and as I said, Arlene and I have been members of this panel and CDC has been leading the effort assessing the current scientific knowledge. Identifying the best and the promising practices that are out there, looking at the issues that need further attention and preparing to give that attention, redefining the definition that I gave you earlier and developing that vision and goals that we need to have to keep us on track. Also, the recommendations have been developed and the action steps. And I did put a draft copy on the back table. That’s not the official copy. It could be a little different with some tweaking of words and that sort of thing. But that is the draft of what the committee put together. And also producing documents that can be shared across professional fields is going to be very important.
This framework, a familiar figure to the MCH folks, but this is the framework for the work that CDC has been doing, building, planning the vision, the goals, the recommendations and then the very broad action steps.
There were five things that came out of all of this work with CDC and those are that we need to do better with social marketing and health promotion for consumers. Clinical practice needs to be enhanced. Public Health and communities need to be involved and paying attention and helping to assure that these practices are implemented. We need to look at public policy and financing strategies because that’s going to be very important in whether or not things actually get done. And then, of course, as I had mentioned, we need to have the data and research to support what we’re doing. There were four goals that were established in this area.
To improve the knowledge, attitudes, behaviors of men and women related to preconception health and that was one of the things that we all talked about very strongly is that we need to be sure that it’s not just women that we’re talking about in this process. Men need to be involved as well. Goal two, to assure, that all US women of childbearing age, receive preconception care services, screening, health promotion and interventions that will enable them to enter pregnancy in optimum health. Goal three, to reduce the risk indicated by a prior adverse pregnancy outcome through interventions in the inner conception or inner pregnancy period that can be prevented or minimized for the mother and her future children and goal four, to reduce the disparities in adverse pregnancy outcomes.
Some of the recommendations that are summarized from the handout that I gave you; individual responsibility across the lifespan was one of the first recommendations that we made. We need to encourage that people have reproductive life plans.
Secondly, we recommended that there be more consumer awareness, increasing the public knowledge and awareness of the importance of the preconception period, related health behaviors and how individuals use preconception care services was also included in that.
Recommendation three was to prevent, to be sure that we have preventative visits as a part of the primary care visits. This risk assessment and counseling could be provided and we thought that that’s something that could be very doable.
Recommendation four was for interventions for identified risk. And again, this is something that, we have lots of tools to screen and there are interventions that can be provided that are substantiated by the evidence that we can make a difference.
Recommendation five was interconception care using that period to be sure that we have intensive interventions for women that we know have had prior pregnancy problems or other risks that we know we could intervene with.
Recommendation six, pre pregnancy checkups, offering that again as a component of maternity care, one pre pregnancy visit for couples who are planning a pregnancy.
Recommendation seven, health coverage for low-income women, increasing Medicaid coverage among low-income women to improve access to preventive women’s healthcare preconception and interconception care. And we were thinking in line with assuring that like we have the Medicaid family planning waivers that are insuring that women who have had a Medicaid sponsored pregnancy care service be able to continue with their Medicaid coverage for up to two years after they’ve lost their coverage.
Recommendation eight, Public Health programs and strategies, being sure to infuse and integrate the components of preconception care into what we do at the local level and in related programs, emphasizing again those women who have had a prior adverse outcome.
Recommendation nine, research, we need to augment that research base that we have related to preconception health. And ten, we need to be monitoring the improvement, maximizing our Public Health surveillance and research related mechanisms so that we are really paying attention to preconception health in that way.
Finally, there are some quick things that we felt like that we could do and some states have already been moving forward with partnerships. March of Dimes is a strong partner in many areas and I know that in Florida we are moving forward with a preconception health related to our reduction in preterm delivery. And we’ll hear again from some other states today, with the kinds of things that they are doing to go ahead and move into action as we implement some of the other recommendations.
So with that Arlene Cullum is going to come and talk about the kinds of things that are going on in California.