AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
ARLENE CULLUM: Thank you Annette. Good morning. I’m thrilled to be here today and wanted to thank Justine Desmarais for inviting me to speak to you about preconception care in California.
First of I’d just like to acknowledge Shabbir Ahmad who is also from California whose with our State Department of Health Services, a partner with us, Shabbir, please. And I’m going to be referencing a couple of handouts. You should have a white envelope that has this packet in it, and so, if you could kind of pull that out. And then I have a jog in article two.
In California we have over 500,000 births. That’s more than some small countries. It’s huge. And to impact change in California is quite difficult. So what I would like to talk to you today are about three different efforts where we’re just at the infancy stages of starting to look at preconception care and how we might impact it in California.
The first one is the California preconception care initiative, which is a provider awareness project that we spearheaded with the March of Dimes. The second is the healthy births initiative and I’m speaking on behalf of Dr. Carolina Reyes who is the executive director of this project and it’s a LA county-based intervention project. And then lastly I’d like to give you kind of a sneak preview of our planning efforts in California for a state preconception care committee.
We’ve also already heard from Annette on why preconception-care and how a healthy pregnancy is very much influenced by a woman’s health status, her health behaviors and history actually prior to conception.
In California, which is greater than the national average, more than 60 percent of pregnancies are unintended, so most women are not planning their pregnancy. That’s the bad news. The good news is in California we do have a window of opportunity. More than half of the women, 70 percent of them, actually obtain a routine physical exam each year. So there is a mechanism to intervene with women.
First, talking about the preconception care initiative, you know, we were finding a number of years ago that providers were not providing preconception care and I don’t think, I still don’t think they are in California. But in 1997 we convened a Regional Perinatal Quality Improvement Committee. And we were looking at topics with improvement potential, you know, ones that could be cost effective that linked to, you know, objectives for the nation, ones that there was evidence in the literature that showed that we could really make a difference. And at that time preconception care was brought to the surface for this committee and they said, “You know what? We think it’s a good idea, Arlene, but there’s no consensus on what the package of services should be. It’s kind of scattered throughout the literature and it really hasn’t really come to a head yet.” So we decided, okay. We’re going to push the issue here. So we went after national March of Dimes Mission Investment Opportunities Program funding and some state March of Dimes funding and started the initiative between ’98 and 2003.
The institution that I work for Sutter Medical Center Sacramento was, you know, was the lead agency for this project. And we brought together partners, the American College of Obstetricians and Gynecologists, the California Academy of Family Physicians, UCSF Center for Health Policy Studies and the UCLA Center for Human Nutrition.
This was a project that involved getting the input from a lot of players. We had a steering committee. We had a medical advisory committee that was composed of representative providers from around the state who actually, blessed what we do and approved what the package of services ended up being and we had a technical advisory committee that really worked on the nuts and bolts of the language that we did in our handouts.
Mary Kay Moose, who many of you probably know, is a foremost consultant in preconception care especially for the March of Dimes and she was a consultant to our project.
So this was the process that we used. We first contract with Dr. Carol Korenbrot who is a researcher at UCSF Center for Health Policies Studies and asked her to really do the background report, which I’ll be talking about in a minute. Then we got approval for the package of services that were cost effective based on the work of Dr. Korenbrot and then developed key messages and patient education materials through the technical advisory committee.
A private marketing firm in San Francisco was used to actually put together this package that we’ll be going through in just a minute. And then we did distributions through mailings and professional organization meetings and then, of course, the project was evaluated.
Dr. Korenbrot helped us look at, what is really, what exists in terms of a quantitative effectiveness and cost effectiveness of preconception care. And this is the primary question, which is really important to ask. Does preconception care lead to earlier onset of prenatal care, lower risks of poor outcomes at onset of prenatal care or better maternal and neonatal outcomes than prenatal care alone? And the conclusions that she came up with was that yes, every routine healthcare exam for women of reproductive age should include the following components: Counseling about folic acid, education about risks for diabetes, education to increase women’s awareness, the importance of healthy lifestyle, diet, weight, fitness, identification of and help for victims of DV, screening prevention and treatment of infectious diseases, and finally interconception care provides an additional opportunity to reinforce healthy behaviors and improve outcomes.
So the reason why we developed this packet in front of you was to increase the awareness of the importance or preconception care among medical providers in California and also to improve access to preconception care services for women of reproductive age. And so I’d like to invite you to open up your packet for just a minute and I’m going to go through some of the components for you. And for those of you who might have, there are a couple at the, in the front and there’s some extras in the box on the table back there.
So on the left hand side, on your left hand side of the packet, there is a cover letter. And this is a cover letter that really describes why providers should be interested in preconception care. We thought it would be most helpful that they would be most interested in listening to their professional colleagues and so it is signed, as you note, by the Region Nine Chair of ACOG and the Chair of the California Academy of Family Physicians and the national president of the March of Dimes, Jennifer Howse. Then behind this piece is an executive summary, which outlines the findings from Carol Korenbrot’s cochran analysis that she did.
And below that, perhaps most importantly for the providers is how they can bill for preconception care because they’re going to say well, why should we do this is we’re not going to get any money for it, really, that’s what they want to know. And so what we did was we gave them some ideas of how they can, what actual codes they could use in our state funded family packed program and how they might begin to implement this. Then on the right hand side this was an evaluation form that was used to independently evaluate the project and determine the usefulness of the packet. And then below that are patient education handouts. And so anyway, I just wanted to familiarize you with this packet. The handouts are also available on the March of Dimes website, the Sutter Health website and the ACOG website and those websites are listed in the packet. One thing you’ll notice if you pull out one of the patient education handouts, you’ll see that all of the patient education handouts have this little, have this little sidebar. It says healthy woman, healthy baby. And the reason for that is, of course, prevention in nature. Whether it may be a visit where you’re just wanting to talk about folic acid but that woman of childbearing age also needs to know that she needs to take a multivitamin, that she needs to stop smoking, all the different healthy behaviors that she has a possibility to change before she would possibly get pregnant. And that’s why we have that same little sidebar on each of the patient education handouts. And so the patient education topics, as you see in the packet include folic acid, importance or glycemic control, infections and immunizations, medical conditions and genetic counseling, smoking, domestic violence, and healthy lifestyle choices.
Dr. Korenbrot did an evaluation of the preconception care initiative and we were very happy to see that 75 percent indicated the material in the packet would actually change practice, would change advice in the practice setting somewhat or very much. The majority of people said they would distribute the packet and would also use the billing codes.
Now I’m going to switch gears a minute and talk about the work of Dr. Carolina Reyes in LA County with the Healthy Births Initiative. LA Count, in LA County 50 percent of the births are Medical. Two out of five women live below 200 percent poverty level and one out of 15 is born low birth weight. And the issue that this initiative really addresses is women with prior adverse birth outcomes are at increased risk for another subsequent pregnancy. Fifteen to 30 percent for a preterm delivery, 20 percent for a repeat teen pregnancy, and two to 12 fold for low birth weight infant. The goal of the initiative is to optimize health and well being for each mother and child in LA County. And the program elements are really wide spread. I thought I would just focus today on the case management program and social support.
The healthy births initiative by First Five LA through tobacco taxes and also the Colorado trust. And they’re really looking at really targeting the interconception population at high risk. So prior, early preterm or very low birth weight birth, fetal or infant death, pregnancy affected by preventable congenital anomalies, adolescent pregnancy, diabetes or other chronic health problems associated with adverse pregnancy outcomes.
The case management program was, or continues to be a psychosocial assessment program for resources and social stressors and clients are assisted in self efficacy and health behaviors and they’re assisted to identify personal and community resources. The five-year demonstration outcomes include a 41 percent increase in completion of post partum and family planning visits, increased pregnancy spacing.
Women who’ve been in the program over six months, 34 percent had fewer subsequent low birth weight infants and fewer in ICU admits. And women followed for two years, 20 percent had repeat low birth weight infant compared to 57 percent or women followed but who declined to participate in the case management program.
And now I’d like to talk about the last component that I’m going to speak with you today about, which is our California State Preconception Care Committee. Knowing that the recommendations for the nation are going to be released, we thought, actually it was supposed to be January and then it was March and now it’s May. This is, our committee’s going to be a little bit premature because we’re going actually be meeting before the recommendations are released now, but that’s okay. We knew that those recommendations were going to be coming down and so we wanted to start planning in California for how we could best meet those recommendations. And so this committee that we’re putting together will be an advisory capacity to the State Department of Health Services Maternal Child Health Branch and also the California state March of Dimes. We’re going to be bringing together about 25 to 30 members that represent professional organizations. We have, you know, ACOG. We have the California Academy of Family Physicians, the Nurse Midwives Association, the Diabetes Association, Dietetics Association, internists; a number of professional organizations are going to be represented. Also providers, elected officials, we’re going to bring in funders and evaluators at a later date but they’re going to also be involved. The Department of Health Services and, of course, the March of Dimes. And we’re hoping to convene quarterly meetings and this will be hosted with funding from the March of Dimes, but it’ll be jointly hosted by the Department of Health Services and the March of Dimes.
The functions of the state committee will include the following. We’ll be reviewing the CDC recommendations and we’re really thrilled because I did have confirmation Hani Atrash that I think he and both Kay Johnson are going to be coming out for our first meeting, which is going to be in May. We’ll be assessing readiness for implementation and political will, which is a huge hurdle, a huge hurdle in California as I imagine it is in other states as well. We have anything that is earmarked with general fund money is of concern in California because there is, you know, is no general fund money left. And even though we had increase in, you know, property taxes this year, it’s a horrid fight down at the legislature for anything that adds additional services. So that political will thing is going to be an interesting one. We’re then going to develop a plan for preconception care and oversee the implementation of that.
So what might the first steps be? Well, we would like to learn from our sister states that, and there are many of them that have already developed self administered risk assessment surveys, which could be administered in multiple locations. We’re hoping that that self-administered survey that we develop in California will be low Ed level. It will have to be developed in multiple languages, probably at least five to seven languages to make it even work in California with accompanying education curriculum. And then we also hope that we can somehow incorporate preconception care counseling into many of our existing state and federally funded programs serving women of childbearing age.
So as we look ahead to the future what do we hope in California? Well, we hope that all pregnancies are planned, all risks are identified, that there’s a comprehensive plan available to assist women in making healthy lifestyle choices to promote a healthy pregnancy, that there’s a multi disciplinary team approach to care all along the continuum for women of childbearing ages, and that women continually receive preconception care, every woman, every time.
I’d like to thank my colleagues from the March of Dimes, Leslie Kowalewski and Kiko Malin, and also Dr. Carolina Reyes from Health Births Initiative. Thank you so much.