jacki s. witt, jd, msn, whnp-bc university of missouri – kansas city project director, title x...

Jacki S. Witt, JD, MSN, WHNP-BCUniversity of Missouri – Kansas City

Project Director, Title X Clinical Training Center for Family Planning

What is RLP?

Why should we integrate RLP into clinical practice?

How can we make RLP meaningful to individuals and the community?

What barriers do the men & women in our clinic/community face when making RLPs?

Planning for pregnancy – or not

Access to health care services for prevention/health promotion, preconception planning & contraception

Case finding of women with previous adverse pregnancy outcomes to reduce risk for future adverse outcomes

Dialogue between health care staff & women/couples

A set of interventions that aim to identify & modify biomedical, behavioral, & social risks to a woman's health or pregnancy outcome through prevention & management

It is more than a single visit & less than complete well-woman care

It includes care before a first pregnancy or between pregnancies (interconception care)

4

Early Prenatal Care is Not

Enough

Why RLP?

Critical Periods of DevelopmentCritical Periods of Development

4 5 6 7 8 9 10 11 12Weeks gestation from LMP

Central Nervous SystemCentral Nervous System

HeartHeart

ArmsArms

EyesEyes

LegsLegs

TeethTeeth

PalatePalate

External genitaliaExternal genitalia

EarEar

Missed Period Mean Entry into Prenatal Care

Most susceptible time for major malformation

The heart begins to beat at 22 days after conception

The neural tube closes by 28 days after conception

The palate fuses at 56 days after conception Critical period of teratogenesis – Day 17 to

Day 56

7

I don’t believe indoing anythingto stop fromhaving children

It wasn’t my fertile time

My d

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r said

I cou

ldn

’t get p

reg

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t

We

had

use

d

con

do

ms

exce

pt

on

e ti

me!

I was using birth control pills !

My b

oyfrien

d

do

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like usin

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ms

I thought if it’s God’s will, I would get pregnant

Unintended: occur earlier than desired,

29%

Intended, 51%

Unintended: occur after

women have reached their desired family

size,20%

Approximately 6.4 million pregnancies per year

Improve the health of each woman prior to conception by identifying risk factors

Provide education Stabilize medical condition(s) to optimize maternal

and fetal outcomes

The process should be ongoing

“Every woman – every time”

Finer,2006

Improving Preconception Health & Pregnancy Outcomes

All women & men of childbearing age

have high reproductive awareness (i.e., understand risk & protective factors related to childbearing).

All women have a reproductive life plan

(e.g., whether or when they wish to have children, & how they will maintain their reproductive health).

All pregnancies are intended & planned.

All women & men of childbearing

age have health coverage. All women of childbearing age are

screened before pregnancy for risks related to the outcomes of pregnancy.

Four Goals:1. Improve the knowledge, attitudes,

& behaviors of men & women related to preconception health

2. Assure that all women of child-bearing age in the U. S. receive preconception care services

Four Goals (continued):3. Reduce risks indicated by a previous

adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother or her future children

4. Reduce the disparities in adverse pregnancy outcomes

Action StepsResearch – Surveillance – Clinical

interventionsFinancing – Marketing – Education and

training

RecommendationsIndividual Responsibility - Service Provision

Access – Quality – Information – Quality Assurance

GoalsCoverage – Risk Reduction

Empowerment – Disparity Reduction

Vision Improve health and pregnancy

outcomes

U.S. maternal & infant mortality is higher than in many countries

Despite more women receiving early prenatal care rates of preterm birth & low birth weight are increasing in U.S.

United States, Table 1: Health 2008

7.26.9

6.46.3

6.2

5.45.2

5.155

4.94.7

4.64.4

4.24.2

4.14

3.93.8

3.73.6

3.53.4

3.13

2.82.42.4

2.1

6.2

0 1 2 3 4 5 6 7 8

SlovakiaUnited States

PolandN. Ireland

CubaHungaryCanada

ScotlandNew Zealand

AustraliaEngland

NetherlandsItaly

IsraelDenmark

AustriaSwitzerland

SpainIreland

GermanyGreece

BelgiumFrance

PortugalCzech Republic

NorwayFinland

JapanHong Kong

SwedenSingapore IMR: Deaths per 1,000 live

births

2 National Center for Health Statistics, 2010

All Races………………………………….…….White ..……………………………………..…..Black …………………………………………….Native American ……………………………Asian …………………………………………….Hispanic ………………………………………… Mexican …..………………………………… Puerto Rican …………………………….… Cuban ……………………………………….. Central and South American ………….

1995

7.66.3

14.69.05.36.36.08.95.35.5

2005

6.95.713.6

8.14.95.65.58.34.44.7

Delays in initiating prenatal care

Reduced likelihood of breastfeeding

Poor maternal mental health

Lower mother-child relationship quality

Increased risk of physical violence during pregnancy

Pieces of the puzzle: Education Health Vocation/career Relationships/family Reproductive life plans

Set against backdrop of culture, society, religion,

economic status

Encourage young people to develop a “RLP” by asking themselves questions:

Do I want children and if so, how many and when?

How will I feel if I cannot have children?

How will I feel if I have an unwanted pregnancy?

How do I feel about abortion?

What do I most want to accomplish in life?

How much education do I want?

How compatible are my reproductive plans with my religious and moral beliefs?

Hatcher, 1980

Is there scientific data to

support it?

Rubella vaccination HIV/AIDS screening Management and

control of: Diabetes Hypothyroidism PKU Obesity

Folic Acid supplements

Avoiding teratogens: Smoking Alcohol Oral anticoagulants Isotretinoin

Priority # 4: “Emphasizing the importance of 

counseling family planning clients on 

establishing a reproductive life  plan, and

providing preconception counselingas a 

part of family planning services, as appropriate”

Guidelines

Best Practice = Reproductive Life Plan for Everyone

▪ Most clinicians don’t provide it

▪ Most insurers don’t pay for it

▪ Most consumers don’t ask for it

Preconception care is not being consistently delivered today

Funding Staff buy in Patient buy in Time Competing priorities Need to know best strategies for your

population

Consider your population/community

Statistics: unplanned pregnancy rates, infant & maternal morbidity & mortality

Cultural preferences related to health care, pregnancy, social challenges

Health care access

Consider your setting’s characteristics

Who counsels women?

Your best educational methods?

Social and mental health services?

Coverage for contraceptives?

RLP is patient-centered

Makes no assumptions (not all want to contracept)

Dynamic: plans & goals can & do change, sometimes from visit to visit

Plans about having children are simple for no one, ambivalence is common

RLPs are NEVER right or wrong*

Reproductive life planning should be offered to everyone, irrespective of assumptions about an individual’s circumstances*

Can increase perceived control of [reproductive] future

Reframes conception Chance Choice

Challenges us to make the FP interaction [more?] patient-centered

Encourages use of behavioral change model for counseling

Could decrease unintended pregnancies, short interconceptional periods & poor pregnancy outcomes

Could increase women’s wellness in reproductive years & beyond

Social marketing & health promotion for consumers [state and national]

Clinical practice [individuals and couples]

Public health and community [collaborations]

Public policy and finance [state by state]

Data and research [all levels]

Current RLP services in your setting?

RLP tools you need?

Most effective ways to train staff?

Strategies to maximize implementation

Collaboration is essential to provide a comprehensive approach. Examples of organizations:

Other Clinics & Doctor's Offices Faith Based Organizations Community Based Organizations WIC and social services sites Hospital Based Organizations Businesses (nail salons, hair salons, others)

Do you hope to have any (or any more) children?

If no, how will you prevent having more pregnancies?

If yes, how many more children do you want, how would you like to space them, how do you plan to keep from getting pregnant until you are ready for the next child?

How can I help you achieve your plan?

Patient-centered Empowering Invites goal setting and action steps Tested with target population Short Culturally-sensitive, respectful tone If self-administered then appropriate for

health and general literacy Makes no assumptions

Folic Acid Supplements: Reduce the occurrence of neural tube defects by two thirds

Rubella testing &/or immunization: Rubella immunization provides protective sero-positivity & prevents the occurrence of congenital rubella syndrome

HIV/AIDS: timely antiretroviral treatment can be administered, pregnancies can be better planned

Hepatitis B: Vaccination is recommended for men & women who are at risk for acquiring hepatitis B virus (HBV) infection.

Pertussis: very contagious & can cause serious illness―especially in newborns. Teen & adult vaccination is important, especially for families with (or planning) newborns.

Diabetes: 3-fold increase in birth defects among infants of women with type 1 & type 2 diabetes, without management

Hypothyroidism: Dosage of levothyroxine should be adjusted in early pregnancy to maintain levels needed for fetal neurological development

Maternal PKU: Low phenylalanine diet before conception & throughout pregnancy may prevent mental retardation in infants born to mothers with PKU

Obesity: Associated adverse outcomes include neural tube defects, preterm birth, c-section, hypertensive & thromboembolic disease

STDs: have been strongly associated with ectopic pregnancy, infertility, & chronic pelvic pain

Alcohol: Fetal alcohol syndrome (FAS) and other alcohol-related birth defects can be prevented.

Anti-seizure drugs: Some anti-seizure drugs are known teratogens

Isotretinoin : Use of isotretinoin in pregnancy results in miscarriage & birth defects

Oral anticoagulants: Warfarin is a teratogen; medications can be switched before the onset of pregnancy

Smoking: Associated adverse outcomes include preterm birth, low birth weight.

Exercise: 30 minutes Vitamin: 400 mcg folic

acid Educate yourself:

medicines/toxins that can cause birth defects

RLP Yearly Dr’s visits:

discuss physical & mental wellness

Diet: vegetables, fruits, & whole grains

Avoid tobacco, drugs, & alcohol

Your partner, friends, & family as sources of support

Everywomancalifornia.org

Pregnancy Test Results

STD Test Results

Other?

Could be presented in a way that offends women (or men)

Care offered may not be consistent with plan (provider bias)

Could be interpreted as suggesting who should or should not have children

Can be treated by providers as static (“but last time you said you did not want kids”)

Could be seen as ‘blaming’ a woman or man when their RLP is not carried out as planned

Case Study #1 - Sonya is a 32 year old G6 P0330. Her LNMP was 5 weeks ago. She is at the health care center for a pregnancy test.

What do you want to know about Sonya?

Sonya’s prior pregnancies included: two miscarriages at 19 weeks, one preterm delivery at 26 weeks and one at 24 weeks, both resulting in early

neonatal deaths She had one pregnancy termination at 9

weeks gestation Gynecologic history is significant for

painful mensesFamily history is significant for adult onset

diabetes (F) and hypertension (F & M)Does not use illicit drugs or drink alcoholHas a supportive 30 year old male partner

who is HIV positive and doing very well

What other questions do you have for Sonya ?

Pregnancy intention• Contraception• Age• Health status

▪ Maternal outcome▪ Fetal/newborn outcome

Sonya and partner’s knowledge of her Sonya and partner’s knowledge of her HIV statusHIV status

Safe conceptionSafe conception Medications Use of tobacco?

What can you do for her?

Pregnancy prevention

Pregnancy planning

HIV transmission prevention Health

maintenance/ support

Referrals

Screening

Substance use

Family history (including

genetic)

Pregnancy history

Folic acid

Case Study #2 – Annie is a 20-year old who presents for emergency contraception after ‘the condom broke’ two days ago.

What do you want to know about Annie?

Never been pregnant Never used prescription birth control

method Sexually active X 3 years New boyfriend X 2 months (3rd partner

in lifetime) BP: 130/88 P: 80 BMI: 35 Significant Family History: Father died

age 48 – complications of diabetes

What other questions do you have for Annie ?

Pregnancy intention• Contraception

Medications? Use of tobacco? Illicit drug use?

What can you do for her?

Pregnancy prevention options

Pregnancy planning

Screening for diabetes

Screening for STDs

Weight loss message

Folic acid

Ad Hoc Committee of PCCHC Select Panel on Reproductive Life Planning, Washington, DC, Nov 23, 2009.

Canady, R.B., Tiedje, L.B. & Lauber, C. (2008). Preconception care and pregnancy planning. American Maternal Child Nursing Journal, 13 (2), 90-97.

CDC Vaccine Information Statement (VIS) (Interim) MMR Vaccine (3/13/08)

CDC Vaccine Information Statement (VIS) (Interim) d & Tdap Vaccines (11/18/08)

Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care - United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. Morbidity & Mortality Weekly Report. 2006;55:1-23. Retrieved March 4, 2011 from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm

Cheng D, Schwarz E, Douglas E, et al. Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contraception. 2009 Mar;79(3):194-8.

D’Angelo, D, Colley Gilbert B, Rochat R, et al. Differences between mistimed and unwanted pregnancies among women who have live births. Perspect Sex Reprod Health. 2004 Sep–Oct;36(5):192-7.

Ecologic Model of Health. (Adapted from Healthy People 2020).

Hatcher, R. (1980). Contraceptive Technology Update. 1(9): 131-132.

Hernández Jennings, M. Preconception Health Care: Integrating Reproductive Life Plans  into Title X Settings, Colorado Family Planning  Initiative Conference,  October 23, 2009

Hovell MF, Wahlgren DR, Adams MA. The Logical and Empirical Basis for the Behavioral Ecological Model. In RJ DiClemente, R Crosby, M Kegler, (eds.). Emerging Theories and Models in Health Promotion Practice and Research (2nd edition). San Francisco: Jossey-Bass Publishers; 2009. p. 415-49.

Kendall, C. Afable-Munsuz, A. Speizer, I., Avery, A., Schmidt, N., & Santelli, J. (2005). Understanding pregnancy in a population if inner city women in New Orleans-Results of qualitative research. Social Science and Medicine. 60, 297-311.

Kost K, Landry D, Darroch J. Predicting maternal behaviors during pregnancy: Does intention status matter? Fam Plann Perspect. 1998 Mar–Apr;30(2):79-88.

Logan C, Holcombe E, Manlove J, et al. The consequences of unintended childbearing: A white paper [Internet]. Washington: Child Trends, Inc.; 2007 May [cited 2009 Mar 3]. Available from: http://www.childtrends.org/Files/Child_Trends-2007_05_01_FR_Consequences.pdf

Moos, M-K. Establishing Some Foundations for the RLP Discussion. Presentation at the Office of Population Affair’s Expert Work Group Meeting Implementing Reproductive Life Planning Counseling in Family Planning Clinics. Sep 22-23, 2010.

Moos, MK. (2003). Unintended pregnancies: a call for nursing action. Maternal Child Nursing. 28: 25-31.

National Campaign to Prevent Teen and Unplanned Pregnancy. Unplanned Pregnancy Rate in the U.S. Retrieved March 31, 2011 from http://www.thenationalcampaign.org/national-data/unplanned-pregnancy-birth-rates.aspx