Interconceptional Care and the Florida VitaGrant Project

1. Interconceptional Care and the Florida VitaGrant Project Developed in collaboration between the Florida Department of Health and the March of Dimes, Florida Chapter

2. 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

3. 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

4. Florida VitaGrant Project Distribution of vitamins to occur through a variety of providers, including, but not limited to: Healthy Start Healthy Families Florida WIC Family Planning TOPWA Community Health Centers Through distribution at community events

5. 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

6. Florida VitaGrant Project Project includes small evaluation component - Distribution sites without follow-up - Distribution sites with follow-up

7. Florida VitaGrant Project - Sites without Follow-up Collect general demographic information about women receiving vitamins

8. Florida VitaGrant Project - Sites with Follow-up Three or more pilot sites to be selected Collect information at initial contact, first point of follow-up and second point of follow-up Supplement history Birth defects history Knowledge of folic acid (pre and post) Supplement experience following education and provision of multivitamins

9. Florida VitaGrant Project Five Outreach Worker Staff, employed through the March of Dimes, will assist in: Tracking distribution of vitamins Participating in local community events Providing technical assistance to providers for VitaGrant project Maintaining collected data

10. Florida VitaGrant Project Outreach staff located throughout state Tampa Ft. Lauderdale Miami Gainesville Jacksonville

11. 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. The period between pregnancies includes pregnancies that result in miscarriage, fetal demise, infant death or live birth.The period between pregnancies includes pregnancies that result in miscarriage, fetal demise, infant death or live birth.

12. Interconceptional Care and Cultural Competancy 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

13. Interconceptional Care and Cultural Competancy 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

14. 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

15. As an introduction to teratogenesis: EMBRYOLOGY Organ formation: The period of time from 17-56 days after conception or 4-10 weeks from the last menstrual period (LMP) is the one where the pregnancy is most susceptible for developing major malformations. (Moore, 1998) The period of time earlier in gestation (before 17 days post-conception) is when exposures to various hazards places pregnancy at risk of spontaneous loss and the period of time after 56 days post-conception is the period where exposures to these hazards may lead to growth disturbances. Since the mean entry into prenatal care is in the 3rd month of pregnancy, issues concerning teratogenesis need to be addressed prior to the first prenatal visit.As an introduction to teratogenesis: EMBRYOLOGY Organ formation: The period of time from 17-56 days after conception or 4-10 weeks from the last menstrual period (LMP) is the one where the pregnancy is most susceptible for developing major malformations. (Moore, 1998) The period of time earlier in gestation (before 17 days post-conception) is when exposures to various hazards places pregnancy at risk of spontaneous loss and the period of time after 56 days post-conception is the period where exposures to these hazards may lead to growth disturbances. Since the mean entry into prenatal care is in the 3rd month of pregnancy, issues concerning teratogenesis need to be addressed prior to the first prenatal visit.

16. 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

17. 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)

18. The Florida Department of Health analyzed PPOR data to try and better understand fatal and infant mortality. They looked at several factors that could contribute to infant mortality, including maternal care or prenatal care, newborn care, infant health and maternal health. Through their analysis, they found that maternal health had the highest association with fetal and infant death rates. DOH also looked at whether this relationship persisted across different educational, racial and age groups. They found that the relationship between maternal health and fetal and infant mortality persisted across groups. In other words, regardless of race, age or educational status, the largest predictor of fetal and infant health was the mother’s health. This analysis fueled the need to look at proving interconceptional or preconceptional education and services to women.The Florida Department of Health analyzed PPOR data to try and better understand fatal and infant mortality. They looked at several factors that could contribute to infant mortality, including maternal care or prenatal care, newborn care, infant health and maternal health. Through their analysis, they found that maternal health had the highest association with fetal and infant death rates. DOH also looked at whether this relationship persisted across different educational, racial and age groups. They found that the relationship between maternal health and fetal and infant mortality persisted across groups. In other words, regardless of race, age or educational status, the largest predictor of fetal and infant health was the mother’s health. This analysis fueled the need to look at proving interconceptional or preconceptional education and services to women.

19. 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

20. 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 Identify any barriers the woman may have to obtaining health services Work collaboratively with the participant, clinic staff and community resources in order to assist the participant with accessing needed health services Identify any barriers the woman may have to obtaining health services Work collaboratively with the participant, clinic staff and community resources in order to assist the participant with accessing needed health services

21. 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

22. 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. This program provides coverage for family planning services for up to two years.

23. 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

24. 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

25. 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

26. 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

27. This is a slide of an infant with an open neural tube defect. Neural tube defects generally occur by 26-28 days post-conception. Up to 70% of these defects may be prevented by preconception supplementation with folic acid. (Discussion of doses in nutrition section.) This is a slide of an infant with an open neural tube defect. Neural tube defects generally occur by 26-28 days post-conception. Up to 70% of these defects may be prevented by preconception supplementation with folic acid. (Discussion of doses in nutrition section.)

28. Nutrition – Folic Acid Ideal levels of folic acid may help 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

29. 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.

30. Nutrition – Folic Acid Low folic acid level is also associated with: Cancer of the cervix, breast and colon Elevated homocysteine levels that are associated with arteriosclerosis, coronary heart disease and stroke

31. 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 dose of folic acid (4.0 milligrams) Folic acid requirement increases during pregnancy

32. Public Health Recommendations/Policies All women capable of becoming pregnant 400 ?g folic acid/day Vitamins and/or fortified foods Healthy foods rich in folate The overwhelming scientific evidence prompted public health recommendations as early as 1992, and as recent as 1998 when the Institute of Medicine, National Academy of Sciences issued a recommendation that (READ SLIDE).The overwhelming scientific evidence prompted public health recommendations as early as 1992, and as recent as 1998 when the Institute of Medicine, National Academy of Sciences issued a recommendation that (READ SLIDE).

33. 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

34. 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

35. Nutrition - Folic Acid 2004 March of Dimes Survey of women of childbearing age indicated need for greater awareness of folic acid: 12 percent of women knew that folic acid should be consumed prior to conception 24 percent knew that folic acid could prevent birth defects 37 percent of non-pregnant women report taking a vitamin with folic acid each day

36. 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 Encourage women to find a physical activity that best suits their needs and abilities Walking may be the easiest and most economical exercise a woman can do Encourage women to find a physical activity that best suits their needs and abilities Walking may be the easiest and most economical exercise a woman can do

37. 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 risks of urinary tract infections, bacterial vaginosis and sexually transmitted diseases

38. 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 Work with local community resources to assist women in obtaining proper dental health Provide toothbrushes and dental floss and educate women on the techniques and importance of good oral health Work with local community resources to assist women in obtaining proper dental health Provide toothbrushes and dental floss and educate women on the techniques and importance of good oral health

39. 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

40. 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

41. 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

42. 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

43. 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 depressions through medication may need consult with their doctor on a medication safe for pregnancy or while breastfeeding

44. 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 inutero 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 Provide women with ongoing education with simple messages sent out that teach them the dangers of drugs and alcohol to themselves and to their children Maintain awareness of the resources in the local community for referring women for counseling and treatment and assist women in receiving the help they need Provide women with ongoing education with simple messages sent out that teach them the dangers of drugs and alcohol to themselves and to their children Maintain awareness of the resources in the local community for referring women for counseling and treatment and assist women in receiving the help they need

45. 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

46. Smoking – Maternal Harm Causal association: Abruptio placenta Probable causal association: Ectopic pregnancy Premature rupture of membranes (PROM) Possible causal association: Placenta previa Spontaneous abortion

47. Smoking – Infant Harm Causal association: Low birth weight (LBW) Small for gestational age (SGA) Preterm delivery Sudden infant death syndrome (SIDS) Stillbirths

48. 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

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

50. 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

51. 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)

52. 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

53. 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)

54. 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

55. 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

56. 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

57. 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 Provide education concerning where lead can be found and how to decrease exposure Provide education concerning where lead can be found and how to decrease exposure

58. 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).

59. Environmental Risk Factors Pesticides: Includes bug sprays, fertilizers and wood treatment Migrant farm workers may be more heavily exposed to these toxins

60. 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

61. 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

62. Golden Opportunity “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