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Gayla C. Winston, MPH, President & CEO
Stephen L. Everett, MS, Director of Programs
Indiana Family Health Council, Inc.
Indianapolis, Indiana

What is the Indiana Family Health
Council?

When was IFHC founded?

Who can access IFHC services?

Where are the Indiana Family Planning
Resource locations? www.ifhc.org

How can I network with these clinics?

NOTE: The Indiana Data and Statistics are
being compiled and will be added to the
presentation on these slides.
Compiled by: Jacki S. Witt, JD, MSN, WHNP-BC
University 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)
7
Why RLP?
Early Prenatal
Care is Not
Enough
Critical
Periods
of Development
Critical Periods
of Development
Weeks gestation
from LMP
Most susceptible
time for major
malformation
4
5
6
7
8
9
10
11
12
Central
Central Nervous
Nervous System
System
Heart
Heart
Arms
Arms
Eyes
Eyes
Legs
Legs
Teeth
Teeth
Palate
Palate
External
External genitalia
genitalia
Ear
Ear
Missed Period
Mean Entry into Prenatal Care
 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
10
We had used
condoms
except one
time!
It wasn’t my
fertile time
My doctor said I
couldn’t get pregnant
I don’t believe in
doing anything
to stop from
having children
My boyfriend
doesn’t
like using
condoms
I thought if it’s God’s will, I would
get pregnant
I was using
birth control
pills !
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
Vision
Improve health
and pregnancy
outcomes
Goals
Coverage – Risk Reduction
Empowerment – Disparity Reduction
Recommendations
Individual Responsibility - Service Provision
Access – Quality – Information – Quality Assurance
Action Steps
Research – Surveillance – Clinical interventions
Financing – Marketing – Education and training

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.
Singapore
Sweden
Hong Kong
Japan
Finland
Norway
Czech Republic
Portugal
France
Belgium
Greece
Germany
Ireland
Spain
Switzerland
Austria
Denmark
Israel
Italy
Netherlands
England
Australia
New Zealand
Scotland
Canada
Hungary
Cuba
N. Ireland
Poland
United States
Slovakia
IMR: Deaths per 1,000 live births
2.1
2.4
2.4
2.8
3
3.1
3.4
3.5
3.6
3.7
3.8
3.9
4
4.1
4.2
4.2
4.4
4.6
4.7
4.9
5
5
5.1
5.2
5.4
6.2
6.2
6.3
6.4
6.9
7.2
0
United States, Table 1: Health 2008
1
2
3
4
5
6
7
8
All Races………………………………….…….
White ..……………………………………..…..
Black …………………………………………….
Native American ……………………………
Asian …………………………………………….
Hispanic …………………………………………
Mexican …..…………………………………
Puerto Rican …………………………….…
Cuban ………………………………………..
Central and South American ………….
2
National Center for Health Statistics, 2010
1995
2005
7.6
6.3
14.6
9.0
5.3
6.3
6.0
8.9
5.3
5.5
6.9
5.7
13.6
8.1
4.9
5.6
5.5
8.3
4.4
4.7
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  Folic Acid
HIV/AIDS screening
supplements
Management and
 Avoiding
control of:
teratogens:
 Diabetes
 Smoking
 Hypothyroidism
 Alcohol
 PKU
 Oral anticoagulants
 Obesity
 Isotretinoin
Priority # 4:
“Emphasizing the importance of
counseling family planning clients on
establishing a reproductive life plan, and
providing preconception counseling
as a part of family planning services,
as appropriate”

Evidence
Consensus
Guidelines
Best Practice = Reproductive Life Plan for Everyone
Preconception care is not being
consistently delivered today
▪ Most clinicians
don’t provide it
▪ Most insurers
don’t pay for it
▪ Most consumers
don’t ask for it






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

Encourages use of
behavioral change model
for counseling

Reframes conception
Chance  Choice


Challenges us to make
the FP interaction
[more?] patientcentered
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]

Issues
Actions
Focus
• Diabetes
• Folic Acid
• Substance Use
● Obesity
● Testing or immunizations
● STI/HIV
• Client education materials
• Education for staff
● PSA/newsletter/radio
• Analyze other resources (Health Dept, CDC, Title
X, MOD, etc)
• Individual/Couple
● Clinic/Agency
• Community Collaborations ● State
• National

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 seropositivity & 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
 Repro Life Plan
 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


Partners
Practices
 (remember F-I-D-O)
▪
▪
▪
▪



Folic Acid
Immunizations
Drugs
Other
Prevention of STDs
Past History
Pregnancy Plans

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
menses
Family history is significant for adult onset
diabetes (F) and hypertension (F & M)
Does not use illicit drugs or drink alcohol
Has 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
HIV status
Safe conception
Medications
Use of tobacco?
What can you do for her?
Pregnancy prevention
Screening
Pregnancy planning
Substance use
HIV transmission
prevention
Health maintenance/
support
Referrals
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

Initiate the Session

Gather Information

Understand the Client’s Perspective

Provide Structure to the Session

Build a Relationship

Close the Session
Resources for Reproductive Life Planning &
Family Planning

www.ifhc.org

www.cdc.gov

www.mchb.hrsa.gov

www.everywomancalifornia.org

www.ncpublichealth.com
Ad Hoc Committee of PCCHC Select Panel on Reproductive Life Planning, Washington, DC, Nov 23,
2009.
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