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Interconceptional Care and Healthy Start Developed in collaboration between the Florida Department of Health, the March of Dimes, Florida Chapter and the Florida Healthy Start Coalitions What is Interconceptional Care?

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Interconceptional Care and Healthy Start

Developed in collaboration between the Florida Department of Health, the March of Dimes, Florida Chapter and the Florida Healthy Start Coalitions


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What is Interconceptional Care?

Education, counseling and services provided to women between pregnancies that address risk factors for poor infant and maternal outcomes in subsequent pregnancies. In addition, these services also support the woman in maintaining lifelong health for herself and her family.

Note: these services are also relevant to the nulliparous woman of childbearing age (preconceptional care)


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Interconceptional Care and Cultural Competency

  • Counseling, education and services must be provided with consideration to the cultural, language, education/literacy and accessibility needs of the participant. This includes understanding of the:

    • Beliefs, values, traditions and practices of a culture

    • Culturally-defined, health related needs of individuals, families and communities

    • Culturally-based belief systems of the etiology of illness and disease and those related to health and healing

    • Attitudes toward seeking help from the health care providers

      For more information contact the National Center for Cultural Competence at the Georgetown University Center for Child and Human Development at 1-800-788-2066 or htt;://gucdc.georgetown.edu/ncc


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Interconceptional Care and Cultural Competency

  • Examples of varying cultural beliefs or practices among groups:

    • Mexicans – douching a common practice

    • Mormons – procreation as a sacred duty

    • Native Americans – children should be spaced 3 to 4 years apart

    • African Americans – prenatal care may not be readily sought because of negative experiences with healthcare system

    • Cubans – male contraception is not acceptable due to machismo


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Why is Interconceptional Care Important?

  • Approximately 50 percent of all pregnancies among adult women and 95 percent of pregnancies among teens are unplanned

  • Critical periods of development occur often before a woman even realizes she is pregnant


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Critical Periods of Development

Weeks gestation

from LMP

4 5 6 7 8 9 10 11 12

Most susceptible

Central Nervous System

time for major

malformation

Heart

Arms

Eyes

Legs

Teeth

Palate

External genitalia

Ear

Mean Entry into Prenatal Care

Missed Period


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Why is Interconceptional Care Important?

  • Florida’s infant mortality, prematurity and low birth weight rates have risen

  • Recent data from many different sources indicate that an important time to intervene for positive birth outcomes is BEFORE a woman becomes pregnant


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Why is Interconceptional Care Important?

  • The relationship between maternal health and birth outcomes has been established by:

    • Pregnancy Associated Mortality Review (PAMR)

    • Perinatal Periods of Risk (PPOR)

    • Fetal and Infant Mortality Reviews (FIMR)

    • March of Dimes

    • American College of Obstetricians and Gynecologists (ACOG)


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Florida’s Pregnancy Associated Mortality Review (PAMR)

A review of cases where death of a woman has occurred, from any cause, while she is pregnant or within one year of termination of pregnancy, regardless of duration and site of the pregnancy.”

CDC and ACOG definition of maternal mortality


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PAMR1999-2002

  • 67.1% of women with pregnancy related deaths had a history of chronic disease or condition.

  • Many had multiple chronic illnesses.

  • Most common:

    • Obesity 11.8%

    • Hypertension 11.2%


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PAMR1999-2002

Showed higher mortality rates for:

  • Black women,

  • Women >35 years old,

  • Overweight and obese women.

  • Women who are obese have odds of pregnancy related mortality that are

    2 to 5 times higher than the odds for women of normal weight.


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    Florida

    PPOR MAP

    1998-2000 Birth Cohort

    596,585

    Fetal Deaths and

    Live Births

    Maternal Health

    4.1

    Maternal Health

    2460

    Maternal Care

    2.4

    Maternal Care

    1458

    Newborn Care

    1.3

    Newborn Care

    795

    Infant

    Health

    1.7

    = 5734

    Fetal-Infant Deaths

    Infant

    Health

    1021

    = 9.6

    Feto-Infant Death Rate*

    *All Death Rates Per 1,000 Births and Fetal Deaths


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    Maternal Health

    2.4

    Maternal Health

    503

    Maternal Care

    1.7

    Maternal Care

    354

    Newborn Care

    1.0

    Newborn Care

    206

    Infant

    Health

    0.8

    Florida Reference Group

    = 5.8

    Feto-Infant Death Rate*

    Race: White

    Education: 13+

    Age: 20-50

    212,755 Fetal Deaths and Live Births

    = 1229

    Fetal-Infant Deaths

    Infant

    Health

    166

    *All Death Rates Per 1,000 Births and Fetal Deaths


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    Maternal Health

    5.1

    Maternal Health

    1957

    Maternal Care

    2.9

    Maternal Care

    1104

    Newborn Care

    1.5

    Newborn Care

    589

    Infant

    Health

    2.2

    Florida Non-Reference Group

    = 11.7

    Feto-Infant Death Rate*

    Race: Non-White

    OR

    Education: <13

    OR

    Age: <20 or >50

    383,830 Fetal Deaths and Live Births

    = 4505

    Fetal-Infant Deaths

    Infant

    Health

    855

    *All Death Rates Per 1,000 Births and Fetal Deaths


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    Interconceptional Care Topics for Consideration

    • Interconceptional care includes addressing the following topic areas:

      - Access to HealthCare

      - Baby Spacing

      - Nutrition (including folic acid education)

      - Physical Activity

      - Maternal Infections (including periodontal disease)

      - Chronic Health Conditions

      - Substance Abuse

      - Smoking

      - Mental Health

      - Environmental Risk Factors


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    Access to Healthcare

    • Regular health care is critical to the overall health of the woman. Key components of regular care should include:

      • Pap smear

      • Breast exam (with teaching on techniques of self-breast exam)

      • Review of family health history

      • Weight, height, blood pressure

      • Lab testing for diabetes or thyroid conditions if needed

      • Management of chronic health conditions

      • Dental services


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    Baby Spacing

    • Research shows that waiting at least two years between pregnancies is optimal for both the mother and infant’s health.

    • A short pregnancy interval may be associated with:

      • Birth of a small for gestational age infant in a subsequent pregnancy

      • Preterm birth in a subsequent pregnancy

      • Low birth weight

      • Stillbirth

      • Death within the first year of life


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    Baby Spacing

    • Having babies too close together can deplete the mother’s nutrients, energy and finances

    • Family Planning and Primary Care clinics can assist women with their contraceptive needs

    • There is a special Medicaid program for women, 14 – 55 years of age, who lose full Medicaid benefits, including pregnancy related benefits. This program provides coverage for family planning services for up to two years.


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    Nutrition

    • Women’s nutritional status before conception may contribute to positive or negative outcomes during pregnancy and in the infant. For example:

      • Women who are underweight (BMI < 19.8) before pregnancy, have a higher risk of:

        • Low birth weight infant

        • Fetal death

        • Mental retardation in infant


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    Nutrition

    • Women who are overweight (BMI 26.1-29.0) and obese (BMI >29.0) have increased risk of having:

      • Complications during pregnancy and childbirth such as diabetes, hypertension, thromboembolic disease, macrosomia, birth trauma, abnormal labor, cesarean delivery

      • Congenital malformations in infant

      • Maternal mortality

      • A child who will become obese


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    Nutrition

    • Healthy Eating

      • Avoid thinking of foods as “good” or “bad”

      • Avoid skipping meals

      • Focus on eating healthy for life-not “dieting”

      • Eat a variety of foods as represented in the Food Pyramid

      • Pay attention to serving sizes

    • Barriers to Healthy Eating

      • Access to healthy food sources (location, financial)

      • Cultural beliefs


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    Nutrition – Folic Acid

    • Women with low folate status in the periconceptional period are at significantly elevated risk of giving birth to a child with spina bifida or a related neurological defect

    • A baby’s brain and spinal cord begin to grow right at the beginning of pregnancy, before a woman may even suspect she is pregnant


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    Nutrition – Folic Acid

    • Ideal levels of folic acid can prevent:

      • Up to 70 percent of neural tube defects

      • 50 percent of cleft lip and palate defects

      • 40 to 50 percent of congenital heart defects

    • It is also been demonstrated that folic acid may prevent pre-eclampsia and other pregnancy-related complications


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    Nutrition – Folic Acid

    • Hispanic women, particularly those of Mexican origin, appear to have greater risk of neural tube defects

    • Florida Birth defects registry indicates Mexican Hispanic women have a relative risk nine times higher than non-Hispanic women born in the U.S.


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    Nutrition – Folic Acid

    • Folic acid requirements:

      • All woman of childbearing age, regardless of their intentions to become pregnant, should take at least 400 micrograms (0.4 milligrams) of folic acid daily

      • Past history of a baby with a NTD may require a higher, therapeutic dose of folic acid (4.0 milligrams), available through prescription only

      • Folic acid requirement increases during pregnancy


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    Nutrition – Folic Acid

    • Major sources of dietary folate include:

      • Dark green leafy vegetables

      • Citrus fruits and juices

      • Whole grain breads

      • Legumes

      • Liver and other organ meats


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    Nutrition – Folic Acid

    • It is difficult to meet the recommended daily allowance of folic acid through diet alone:

      • 4 cups of orange juice = 400 mcg

      • 20 spears of asparagus = 400 mcg

      • 4 cups of raw spinach = 400 mcg

      • 22 slices of unfortified bread = 400 mcg


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    Florida VitaGrant Project

    • Goal: To provide folic acid and pre/interconceptional health education to underserved women of childbearing age through provision of free multimineral/multivitamin supplements, folic acid awareness materials and pre/interconceptional health materials


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    Florida VitaGrant Project

    • Funded through a $2 million grant awarded to the March of Dimes from the Florida Attorney General’s Office as a result of a settlement with vitamin manufacturers for price fixing

    • Three-year grant


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    Florida VitaGrant Project

    • Distribution of vitamins to occur through a variety of providers, including, but not limited to:

      • Healthy Start

      • WIC

      • Family Planning

      • TOPWA

      • Community Health Centers

      • Through distribution at community events


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    Florida VitaGrant Project

    • Providers to have access to web-based training on interconceptional health, folic acid and the VitaGrant project

    • Any provider serving women of childbearing age is eligible to participate in the project


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    Florida VitaGrant Project

    For more information, or to become a VitaGrant Distribution Provider contact:

    Elizabeth Jensen

    Florida VitaGrant Project Manager

    850-245-4465

    [email protected]


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    Physical Activity

    • Benefits of exercise include:

      • Lower stress, depression and anxiety

      • Feel better about yourself

      • Sleep better

      • Better concentration

      • Decrease your chance of developing a chronic disease

      • Improve your blood pressure and decrease your cholesterol

      • Maintain a healthy weight


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    Maternal Infections

    • Maternal infections have been consistently linked to poor birth outcomes

    • All sexually active women of childbearing age should be counseled on the risks of infection to their own health and their future pregnancies

    • All women should be offered screening, testing and treatment for STD’s including syphilis, gonorrhea, HIV, genital herpes, Chlamydia, and HPV

    • Conditions such as bacterial vaginosis should be screened for and treated if necessary

    • Douching should be discouraged

    • Women should be up to date with immunizations, especially rubella, hepatitis B, and varicella, prior to becoming pregnant

    • Women should receive information on the recognition and risks of untreated urinary tract infections, bacterial vaginosis and sexually transmitted diseases


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    Maternal Infections - Periodontal Disease

    • Periodontal disease -A disease of the gingiva, gums and supporting structures of the teeth.

      • May lead to prematurity and/or low birth weight.

      • Affects between 5-40 percent of women of childbearing age

      • Increase the risk of heart attack and stroke

      • Exacerbate diabetes

      • Contribute to lung disorders such as pneumonia and emphysema


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    Chronic Health Conditions

    • Management of chronic health conditions prior to pregnancy helps reduce risks to mother and baby. These conditions include, but are not limited to:

      • High blood pressure

      • Systemic Lupus Erythematosus (SLE)

      • Kidney disease

      • Diabetes

      • Asthma

      • Endocrine conditions such as thyroid disease

      • Depression


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    Chronic Health Conditions

    • High Blood Pressure - Chronic high blood pressure can increase the risk of pregnancy complications, including placental problems and fetal growth retardation

    • Systemic Lupus Erythematosus (SLE) - can increase the risk of miscarriage or preterm labor. If symptoms have been inactive for at least six months, an affected woman is likely to have a healthy pregnancy. Preconception care helps plan the safest timing of pregnancy


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    Chronic Health Conditions

    • Kidney Disease - Women who have chronic kidney disease should consult their doctors prior to pregnancy to see if pregnancy is safe for them and their baby

    • Diabetes - Women with poorly controlled insulin-dependent diabetes are several times more likely than non-diabetic women to have a baby with serious birth defect. They are also at increased risk of miscarriage and stillbirth


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    Chronic Health Conditions

    • Asthma – Poorly controlled asthma can increase a woman’s likelihood for complications in pregnancy, including compromising the oxygen supply to the developing fetus

    • Endocrine Conditions – Thyroid conditions, if untreated, such as hypothyroidism and hyperthyroidism can affect a women’s fertility, can increase her likelihood for miscarriage and other complications, including mental retardation in the unborn infant


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    Chronic Health Conditions

    • Depression – Women with a history of depression are more likely to experience depression in pregnancy and in the postpartum period. Additionally, women receiving treatment for depression through medication may need consult with their doctor on a medication safe for pregnancy or while breastfeeding


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    Substance Abuse

    • There is no known amount of drugs or alcohol that is safe in pregnancy. Both drugs and alcohol cross the placental barrier to the developing fetus in utero

    • Drugs and alcohol can cause fetal loss, birth defects, fetal alcohol syndrome, low-birth weight and intrauterine growth restriction. Many pregnancies are unplanned

    • Women need support and linkages to substance abuse treatment for their health today and for the health of any children in the future


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    Smoking

    • The causal association between maternal smoking and maternal morbidity, infant mortality and infant morbidity is well established in the epidemiologic literature

    • Smoking remains the single most preventable cause of poor birth outcomes. Smoking is estimated to cause:

      • 20 percent of LBW deliveries

      • 8 percent of preterm births

      • 5 percent of perinatal deaths


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    Smoking – Maternal Harm

    • Causal association:

      • Abruptio placenta

    • Probable causal association:

      • Ectopic pregnancy

      • Premature rupture of membranes (PROM)

    • Possible causal association:

      • Placenta previa

      • Spontaneous abortion


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    Smoking – Infant Harm

    • Causal association:

      • Low birth weight (LBW)

      • Small for gestational age (SGA)

      • Preterm delivery

      • Sudden infant death syndrome (SIDS)

      • Stillbirths


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    Smoking

    • In 2001, the percent of births under 2500 grams (LBW) for mothers who reported smoking on the Florida birth certificate was 11.8 percent

    • Mothers who reported not smoking had a LBW infant rate of 7.8 percent


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    Mental Health

    Stress, anxiety, depression and abuse can have serious effects on a woman’s health and the health of her children


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    Mental Health

    • All women need to be screened for domestic violence and depression

    • 20 percent of women will experience depression at least once during their lifetime

    • One in four women are the victim of abuse

    • About three women die in the US from domestic violence every day


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    Mental Health - Stress

    • Psychosocial stress refers to a psychosocial pressure (cause) that is consciously sensed (distress) and evokes an emotional response

    • There are several components of psychosocial stress:

      • Emotional response to stress (fear, anxiety)

      • Life events (Loss of job, death of friend or family member)

      • Perceptions of stress (appraisal and high stress levels)


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    Mental Health - Stress

    • Studies have proven that high levels of stress can cause:

      • Fatigue

      • Lowered resistance to infectious disease

      • Poor nutrition (no appetite or overeating)

      • Headaches

      • Backaches

      • High blood pressure

      • Heart disease


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    Mental Health - Stress

    • According to PRAMS 2000 data, maternal stress was found to be associated with low birth weight in Florida mothers

    • High psychosocial stress levels are associated with elevated plasma levels of adrenocorticotropin-releasing hormone (ACTH) and corticotrophin-releasing hormone (CRH), estriol and cortisol

    • Data suggests that higher rates of preterm birth are associated with higher maternal serum cortisol levels and corticotrophin releasing hormone (CRH)


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    Mental Health - Stress

    • Studies indicate that chronic psychosocial prenatal maternal stress, as opposed to acute or episodic stress, has a negative impact on pregnancy outcomes and fetal development

    • Both increased anxiety and decreased social support are associated with poorer pregnancy outcomes


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    Mental Health - Stress

    • Dr. Michael Lu proposed the “Weathering Hypothesis”, stating that social inequality may have a negative effect on health outcomes over a lifetime

    • Studies have demonstrated that perception of racism is linked to preterm birth


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    Environmental Risk Factors

    • Women may be exposed to harmful substances at work, at home, or outside, without even knowing it

    • Awareness and education of possible environmental toxins may reduce exposures and possible poor birth outcomes


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    Environmental Risk Factors

    • Lead:

      • Found in paint, dust, soil, pottery, glass, cooking utensils and other places, can damage the brain and nervous system causing behavior, learning, and hearing problems, headaches and delayed growth

      • Some herbal remedies such as Azarcon and Greta may contain high levels of lead

      • Previous maternal exposure to lead can affect the developing fetus


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    Environmental Risk Factors

    • Mercury:

      • A poisonous metal that occurs naturally in the environment. It is released into the air then falls directly into the water. Upon reaching the water it turns into a very toxic form (methyl-mercury).

      • In 2004, the FDA/EPA Consumer Advisory:”What You Need to Know about Mercury in Fish and Shellfish” was released.

      • For more information, call the FDA Food Information Hotline toll-free at 1-888-SAFEFOOD or visit the FDA’s Food Safety Website at www.cfsan.fda.gov/seafodd1.html


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    Environmental Risk Factors

    • Pesticides:

      • Includes bug sprays, fertilizers and wood treatment

      • Migrant farm workers may be more heavily exposed to these toxins


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    Environmental Risk Factors

    • Gases:

      • Carbon Monoxide is given off by cars, gas furnaces, kerosene heaters and cigarette smoke. It can not be seen nor smelled. Side effects of exposure include:

        • Low birth weight

        • Stillbirth

        • Headaches

        • Death


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    Environmental Risk Factors

    • Food-borne risks:

      • Undercooked foods (raw fish, oysters, underheated deli meats)

      • Unpasteurized milk or juice

      • Soft cheeses

      • Some herbal teas

      • Homeopathic remedies

    • Toxoplasmosis:

      • cat litter

      • soil


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    Healthy Start Standards and Guidelines

    Chapter 21 Specifics and Standards


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    Interconceptional Care – Healthy Start Counseling and Education Services

    • Overview

    • Curriculum Topics

    • Components

    • Services

    • Coding


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    Interconceptional Education and Counseling Services Overview Education Services

    • Services are determined based on the coalition service delivery plan and local resources

    • Services are above and beyond health information provided during care coordination.

    • Coalition approved curriculum

    • Services are provided to women determined to be at risk for a poor birth outcome in a subsequent pregnancy

    • May use screening tools to help determine risks


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    Access to care Education Services

    Baby spacing

    Nutrition

    Physical activity

    Maternal infections

    Chronic health problems

    Substance abuse

    Smoking

    Mental health

    Environmental risks

    Interconceptional Education and Counseling Curriculum Topics


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    Interconceptional Education and Counseling Service Components

    • Plan of Care

    • Presentation

    • Demonstration activity

    • Follow-up

    • Feedback

    • Evaluation


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    Interconceptional Education and Counseling Services Components

    • Provided one to one with participant in face to face visit

    • Provided in a support group setting

    • Provided in a classroom setting in a set series of classes


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    Interconceptional Education and Counseling Services Components

    • Trained providers with up to date knowledge of interconceptional health

    • Written follow-up provided to the Healthy Start care coordinator within 30 days

    • Service provider communicates any additional needs identified to the care coordinator


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    Interconceptional Education and Counseling Services Components

    • Documented in the record of the person receiving the service

    • Follow-up on referral documented in participant’s record

    • Consent for release of information between provider and care coordinator

    • Certification of completion provided to care coordinator for participant’s record.

    • Quarterly QA/QI by provider


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    Interconceptional Education and Counseling Services ComponentsCoding

    • Activities that educate and inform the Healthy Start woman about health behaviors that will help to reduce risk and improve subsequent birth outcomes

    • Code is open to program component

      26, 27, 30 and 31


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    Interconceptional Education and Counseling Services ComponentsCoding

    • Who can be provided this Healthy Start service”?

      • any Healthy Start woman determined at risk for a poor outcome of a subsequent pregnancy

      • may be provided prenatally or postnatally

      • may be provided to the Healthy Start participant, or to the mother of a Healthy Start participant on behalf of the participant


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    Interconceptional Education and Counseling Services ComponentsCoding

    • Who can provide and code this Healthy Start service”?

      • Trained and qualified Healthy Start providers

      • May be provided individually, in support groups or formal classes

      • One unit of service =15 minutes


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    Interconceptional Education and Counseling Services ComponentsCoding

    • What is required for the service?

      • Healthy Start coalition approved curriculum with components covering access to health care; baby spacing; nutrition; physical activity; maternal infections; chronic health problems; substance abuse; smoking; mental health; and environmental risk factors

      • Learning objectives for the curriculum


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    Interconceptional Education and Counseling Services ComponentsCoding

    • What if my staff is not trained to provide this special service?

      • Healthy Start care coordinators who do not receive special interconceptional education and counseling training may still provide their participants with the appropriate health education to reduce risks as part of their care coordination activities and code to 3320 or 3321


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    Golden Opportunity Components

    • “We recognize that powerful influences on outcome occur long before pregnancy begins. Pregnancy is shaped by:

      • Social

      • Psychological

      • Behavioral

      • Environmental

      • Biological forces

    • Improving pregnancy outcomes necessitates the linkage of an even broader array of healthcare providers embracing a life course perspective with regard to perinatal health.”

      Dawn Misra, Women’s and Children’s Health Policy Center, Bloomberg School of Public Health, Johns Hopkins University


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    Golden Opportunity Components

    Any health care provider who comes into contact with a woman of reproductive age has the potential to protect the health of that woman and her future offspring


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