Welcome

1. Welcome Interconception Care Program Recruitment Strategies

2. Housekeeping There are over 100 registered participants for this call. Phones will be muted during the webinar. If you have a question, please post it via the chat function. Questions will be taken from chat. Submit questions as soon as they come to mind – we’ll keep track of them. Slides, speaker bios and speaker contact info are available at www.everywomansoutheast.org.

3. Acknowledgements • March of Dimes • Lori Reeves for TA with today’s webinar. • The W.K. Kellogg Foundation • Every Woman Southeast Volunteers • Our Speakers

4. What is Every Woman Southeast? • A coalition of leaders in Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina and Tennessee to working together to build multi-state, multi-layered partnerships to improve the health of women and infants in the Southeast.

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8. Join Your State Team • We have 9 state teams – one for each state. • Find your team lead by clicking on your state webpage on our website. • Contact the lead and connect. This is a great way to link up with the latest resources and opportunities on preconception health.

9. Today’s Webinar Interconception Care Program Recruitment and Retention Strategies October 24, 2012

10. Why This Topic? • Reducing risks indicated by a previous adverse pregnancy outcome is a top goal of the National Preconception Health and Health Care Initiative • In the SE – 3 states have demonstration projects to provide interconception care to high risk women • Limited information about best practices in serving this population

11. Objectives • Describe current efforts to promote interconception health care for high risk women • Describe how to overcome at least one challenge to recruitment • Describe at least two strategies that improved recruitment and retention • Discuss ways that interested groups can continue to connect on this issue.

12. Speakers • Sarah Verbiest, DrPH, MSW, MPH • Dean Coonrod, MD, MPH • Jennifer Culhane, PhD, MPH • Anne Dunlop, MD, MPH • Betsy Bledsoe-Mansori, PhD, Mphil, MSW • Carol Brady, MPH

13. The Postpartum Plus Prevention Program in NC Sarah Verbiest, DrPH, MSW, MPH Executive Director UNC Center for Maternal and Infant Health Director Every Woman Southeast Coalition

14. The Postpartum Plus Prevention Program (P4) • Designed to increase knowledge about how to provide health and wellness services to mothers of medically fragile infants. • Services: postpartum visit, a wellness kit at 3 months, and contact with a nurse midwife at 3, 6, 9, 12 and 18 months postpartum. • P4 also provided onsite medical care to any woman in the NICU who requested help.

15. Enrollment • Women were approached for enrollment by a nurse midwife while their infant was in the NICU. We didn’t have anyone decline participation. • A convenience sample of 44 mothers was recruited from the Newborn Intensive Care Unit at UNC. • Nearly all (87%) of the women had received a medical service from the nurse midwife prior to being recruited into the study.

16. What We Found • Almost every mother (97%) returned to UNC post-discharge for infant follow-up. • Initial expectations were that mothers would only be reachable by phone but the majority of mothers also received in-person support. • Mothers were open to talking with the nurse midwife during pediatric visits for their infant.

17. Contacts • We anticipated about 220 total contacts with the women in the study. We had 645 contacts! • The nurse midwife had an average of 15 contacts with each mother. The number of contacts per woman ranged from 6 to 42 – the lowest number was still above our expectation. • One third of the women went through a period of time where they had weekly contact with the nurse midwife – usually due to a crisis in their baby’s health.

18. Content • Almost all contacts began with a mother-led conversation about the infant’s health. • The nurse midwife introduced wellness messages in the context of the impact of the mother’s health on the well-being of her infant. • Mothers needed support for nonmedical issues such as relationship with the infant’s father, poverty, employment, and loss/grieving.

19. Conclusions • Mothers of medically fragile infants are receptive to tailored wellness messages when provided along with clinical care for themselves and their baby. • The NICU provides a key opportunity for initial outreach to high-risk mothers. • Telephonic support is a good option for providing services and support, especially when paired with in-person contact through pediatric services to the infant.

20. Conclusions • Mothers’ capacity to attend to their own health and wellness needs is linked to the immediate health status of their infant. • Easy access to health care services from a professional they trusted was very important. • Innovative partnerships between OB/GYN and NICU follow-up clinics should be considered to best serve both high-risk mothers and infants.

21. Arizona’s Internatal Clinic Dean V Coonrod, MD-MPH Chair, Department of Ob/Gyn Maricopa Integrated Health System / District Medical Group University of Arizona College of Medicine - Phoenix

22. Context

23. Preconception vs Interconception vs Internatal Care * * *= interconception = preconception care = pregnancy = no more kids! = internatal care

24. Program Eligibility • Index pregnancy • Preterm birth 35 weeks or less • Early pregnancy loss 15 weeks and more • Stillbirth • Low birthweight • Prolonged NICU stay • Initially 3 days now 5 days • Not permanently sterilized

25. Schedule of Visits • 2 weeks • Breastfeeding, review family planning • 6 weeks • Standard postpartum visit • 6 months • 12 months • Yearly thereafter • Preconception visit

26. Our Visits • Seen by care coordinator • Introduce program • Edinburg Postpartum Depression scale • “6-week” intake form • Go over education & goals for nutrition, exercise, dental care, folate • Psychosocial support, stress management

27. Our Visits • Seen by physician • Reason for visit • Index pregnancy reviewed • Neonatal status • Breast feeding / back to sleep • Prior ob history • Reproductive life plan, contraception • Gyn, STI history / screening • PMH / PSH / Dental care Underlined = Done at all visits

28. Our Visits • Infection / immunization • TB, Rubella, Tdap (pertusis), varicela, influenza • Nutrition / exercise • Anemia, food security, BMI, folate, exercise (type / amount) • Meds / allergies • Habits / Social / Exposures • Tobacco, alcohol, drugs, DV, work, environmental exposures • Behavioral health • EPDS, other mental health, eating disorders • Physical exam • Weight (BMI), BP etc • Problem focused exam

29. Our Project Patients: End of 2010 • 696 approached • 142 had a visit • 90% Latina 71 seen for clinical services in the last 6 months and are considered active • 71 have relocated or have been lost to follow up

30. Final Results (n=102 women) In program for 12 to 18 months Of those pregnant at least 12 month interval Of those pregnant with first trimester care Of those pregnant, tob, ETOH, drug free Using contraception (if indicated) On folate Regular exercise (30 min 5 days a week) Normal BMI Those with oral health needs who have treatment Those with mental health needs who have treatment 64% 40% 87% 100% 88% 61% 23% 26% 20% 100%

31. Follow Up Data

32. Lessons Learned • Care coordination key • Mothers / families after a pregnancy ending in stillbirth very interested • Patients with preterm birth have varying levels of interest • No show rate a significant problem • Interval of visits often dictated by family planning or other issues / mental health • Usually more frequent than the idealized one • TLC is always provided and likely of benefit

34. March of Dimes Maricopa Dept of Public Health ADHS BHS Mercy Care Plan University Health Plan Az Public Health Association Mayo Clinic Family Medicine Maricopa Integrated Health System Ob/Gyn MFM Family Medicine Ambulatory Social Work Southwest Human Development St Luke’s Health Initiatives AHCCCS Thanks to our partners and funders:

35. Questions? Dean_Coonrod@DMGAZ.org

36. The Philadelphia Collaborative Preterm Prevention Project Jennifer F. Culhane MPH, PhD

37. The Study • Before discharge from the post partum hospital stay • Consent including access to medical records • Conduct survey • Randomization • Smoking intervention begins • Schedule 1st postpartum visit (1 month)

38. Postpartum Study Visits • When: 1, 6, 12, 18, and 24 months postpartum • Or, at 20 weeks gestation of the subsequent pregnancy

39. Postpartum Study Visits • Survey • Periodontal exam (1, 12 and 24 months only) • Vaginal fluid (self collection) • Blood • Urine • Anthropometric measurements • Blood pressure • Transportation, flexible hours, childcare, barriers eliminated

40. Intervention Arm • Evaluated and offered treatment for: • Depression • Periodontal disease • Urogenital tract infections • Abnormal BMI • Housing instability/inadequacy • Smoking • Literacy

41. Recruitment Rate 77.7% Figure 2. Webb, et al. BMC Medical Research Methodology, 2010, 10:88

42. Retention/Data Capture Rates for Study Population

43. Strategies to Improve Retentions Two full-time staff dedicated to cohort maintenance Provided transportation - either tokens or cab pick up Evening and weekend hours Child care and food provided If required visit conducted at participant's home Clinic had washing machines and dryers Staff required to be courteous and totally participant -focused Compensation for time

44. Risk Factor Prevalence, Acceptance Rates and Rates of Minimal Participation in PCPP Intervention Arms

45. Strategies to Improve Participation in Interventions Phone medicine for depression care available Staff accompany participants to dentist Provide valium for dental visits Smoking intervention conducted in particpant’s home Medicines delivered to particpant’s home Food and caloric supplements delivered to participant's home

46. Selected Findings Exposures associated with adverse outcomes are moderately prevalent and co-occur. There is a wide range of participation across interventions- even with every traditional barrier to care addressed. Volunteering for treatment is MUCH different than random assignment to treatment- people who really need the intervention may not seek care

47. Important Research Questions Why don’t some women avail themselves of care? Not just traditional barriers to care Complex decision making that may seem irrational to providers but may make perfect sense in certain contexts- what are those contexts?

48. Important Research Questions RHIME factors (Racism, Housing challenges, Insufficient resources, Multiple burdens and Emergencies) play a role in women’s everyday lives and influence care participation We need to become aware of, document and addressthe ways various institutional structures, rules and ways of doing business create additional burdens for already stressed women

49. Summary Truly ‘at risk’ women may not participate Even if an intervention “works” it may not be successfully implemented- what do we mean by works? More research needed to understand complex barriers to participation

50. The Interpregnancy Care Program Overview of Engagement Strategy For Women Who Recently Delivered A Very-Low-BirthweightInfant Anne L. Dunlop, MD, MPH October 24, 2012