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Gayla C. Winston, MPH, President & CEO Stephen L. Everett, MS, Director of Programs Indiana Family Health Council, Inc. Indianapolis, Indiana. Integrating a Reproductive Life Plan & PreConception Counseling into Patient Education. Indiana Family Health Council.

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integrating a reproductive life plan preconception counseling into patient education

Gayla C. Winston, MPH, President & CEO

Stephen L. Everett, MS, Director of Programs

Indiana Family Health Council, Inc.

Indianapolis, Indiana

Integrating a Reproductive Life Plan &PreConception Counseling into Patient Education

indiana family health council
Indiana Family Health Council
  • What is the Indiana Family Health Council?
  • When was IFHC founded?
  • Who can access IFHC services?
  • Where are the Indiana Family Planning Resource locations?
  • How can I network with these clinics?
indiana data and statistics
Indiana Data and Statistics
  • NOTE: The Indiana Data and Statistics are being compiled and will be added to the presentation on these slides.
a baby maybe practical pointers for purposeful planning

Compiled by: Jacki S. Witt, JD, MSN, WHNP-BC

University of Missouri – Kansas City

Project Director, Title X Clinical Training Center for Family Planning

A Baby? MaybePractical Pointers for Purposeful Planning

key questions
Key Questions
  • 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?
what is rlp
What is RLP?
  • 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
what is rlp1
What is RLP?
  • 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)

Why RLP?

Early Prenatal Care is Not Enough


Critical Periods of Development

Critical Periods of Development

Weeks gestation

from LMP

4 5 6 7 8 9 10 11 12

Most susceptible

Central Nervous System

Central Nervous System

time for major














External genitalia

External genitalia



Mean Entry into Prenatal Care

Missed Period

early prenatal care is too late to address some birth defects
Early prenatal care is too late to address some birth defects
  • 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
almost half of pregnancies are unintended
Almost half of pregnancies are unintended

I don’t believe in

doing anything

to stop from

having children

It wasn’t my

fertile time

We had used condoms except one time!

My doctor said I

couldn’t get pregnant

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

My boyfriend doesn’t

like using condoms

I was using birth control pills !

unintended pregnancies in the united states
Unintended Pregnancies in the United States

Approximately 6.4 million pregnancies per year

purpose of preconception care
Purpose of Preconception Care
  • 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”


cdc s vision
CDC’s Vision
  • 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).
cdc s vision1
CDC’s Vision
  • 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.
cdc goals
CDC Goals

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

cdc goals1
CDC Goals

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

cdc s reproductive life plan framework
CDC’s Reproductive Life PlanFramework


Improve health

and pregnancy



Coverage – Risk Reduction

Empowerment – Disparity Reduction


Individual Responsibility - Service Provision

Access – Quality – Information – Quality Assurance

Action Steps

Research –Surveillance –Clinical interventions

Financing – Marketing –Education and training

why should we integrate rlp into our clinical practice
Why should we integrate RLP into our clinical practice?
  • 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.
international comparisons of imr 2005 us ranks 30 th
International Comparisons of IMR, 2005US Ranks 30th

IMR: Deaths per 1,000 live births

United States, Table 1: Health 2008

us imr by race 1995 and 2005
US IMR by Race 1995 and 2005























All Races………………………………….…….

White ..……………………………………..…..

Black …………………………………………….

Native American ……………………………

Asian …………………………………………….

Hispanic …………………………………………

Mexican …..…………………………………

Puerto Rican …………………………….…

Cuban ………………………………………..

Central and South American ………….

2 National Center for Health Statistics, 2010

consequences of unintended pregnancy for women families
Consequences of Unintended Pregnancy for Women/Families

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

life course planning based on the behavioral ecologic model of health
Life Course Planning (based on the Behavioral-Ecologic Model of Health)
  • Pieces of the puzzle:
    • Education
    • Health
    • Vocation/career
    • Relationships/family
    • Reproductive life plans
  • Set against backdrop of

culture, society, religion, economic status

reproductive life planning is not new
Reproductive Life Planning is Not New
  • 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?
reproductive life planning is not new1
Reproductive Life Planning isNot New
  • 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

there is evidence that individual components work
There is evidence that individual components work
  • Rubella vaccination
  • HIV/AIDS screening
  • Management and control of:
    • Diabetes
    • Hypothyroidism
    • PKU
    • Obesity
  • Folic Acid supplements
  • Avoiding teratogens:
    • Smoking
    • Alcohol
    • Oral anticoagulants
    • Isotretinoin
title x program priority
Title X Program Priority
  • 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”

so why don t we do it
So……..why don’t we do it?


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
barriers to implementation
Barriers to Implementation
  • Funding
  • Staff buy in
  • Patient buy in
  • Time
  • Competing priorities
  • Need to know best strategies for your population
strategies for making rlp meaningful to individuals the community
Strategies for making RLP meaningful to individuals & the community
  • Consider your population/community
  • Statistics: unplanned pregnancy rates, infant & maternal morbidity & mortality
  • Cultural preferences related to health care, pregnancy, social challenges
  • Health care access
strategies for successful rlp in your organization
Strategies for Successful RLP in your organization
  • Consider your setting’s characteristics
  • Who counsels women?
  • Your best educational methods?
  • Social and mental health services?
  • Coverage for contraceptives?
reproductive life planning pearls
Reproductive Life Planning Pearls
  • RLP is patient-centered
  • Makes no assumptions (not all want to contracept)
  • Dynamic: plans & goals can & do change, sometimes from visit to visit
reproductive life planning pearls1
Reproductive Life Planning Pearls
  • 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*
benefits of rlp promotion
Benefits of RLP Promotion

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

  • Can increase perceived control of [reproductive] future
  • Reframes conception Chance  Choice
  • Challenges us to make the FP interaction [more?] patient-centered
themes areas for action
Themes / Areas for Action
  • 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]
s w o t for successful rlp
S-W-O-T for Successful RLP
  • Current RLP services in your setting?
  • RLP tools you need?
  • Most effective ways to train staff?
  • Strategies to maximize implementation
opportunities for collaboration
Opportunities for Collaboration

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)
reproductive plan assessment
Reproductive Plan Assessment
  • 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?
reproductive plan assessment1
Reproductive Plan Assessment
  • 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
specific rlp interventions
Specific [RLP] Interventions
  • 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.
specific rlp interventions cont
Specific [RLP] Interventions (cont)
  • 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
specific rlp interventions cont1
Specific [RLP] Interventions (cont)
  • 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
specific rlp interventions cont2
Specific [RLP] Interventions (cont)
  • 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.
reproductive life planning pearls for practice e v e r y d a y
Reproductive Life Planning Pearls for Practice: “E.V.E.R.Y. D.A.Y.”
  • 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

reproductive life planning pearls for practice the 5 p s
Reproductive Life Planning Pearls for Practice: The 5 ‘P’s
  • Partners
  • Practices
    • (remember F-I-D-O)
      • Folic Acid
      • Immunizations
      • Drugs
      • Other
  • Prevention of STDs
  • Past History
  • Pregnancy Plans
missed opportunities
Missed Opportunities ?
  • Pregnancy Test Results
  • STD Test Results
  • Other?
reproductive plan assessment unintended consequences
Reproductive Plan Assessment: Unintended Consequences
  • 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
reproductive life plan case studies
Reproductive Life PlanCase Studies

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 ?

other questions
Other Questions
  • 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?
rlp review listen provide
RLP [ Review, Listen, Provide ]

Pregnancy prevention

Pregnancy planning

HIV transmission


Health maintenance/




Substance use

Family history

(including genetic)

Pregnancy history

Folic acid

reproductive life plan case studies1
Reproductive Life PlanCase Studies

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?

additional information about annie
Additional Information 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 ?

other questions1
Other Questions
  • Pregnancy intention
    • Contraception
  • Medications?
  • Use of tobacco?
  • Illicit drug use?
rlp review listen provide1
RLP [ Review, Listen, Provide ]

Pregnancy prevention options

Pregnancy planning

Screening for diabetes

Screening for STDs

Weight loss message

Folic acid

basic counseling skills
Basic Counseling Skills
  • Initiate the Session
  • Gather Information
  • Understand the Client’s Perspective
  • Provide Structure to the Session
  • Build a Relationship
  • Close the Session
rlp fp resources
RLP & FP Resources

Resources for Reproductive Life Planning & Family Planning


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

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:


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

Kurtz, Suzanne, Calgary-Cambridge Observation Guide 1, University of Calgary, Alberta, Canada; MaKoul, Gregory Thomas, The SEGUE Framework, Northwestern University Medical School.