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The Circle of Care for Women

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  1. The Circle of Care for Women Early prenatal care AndMedical homes for non-pregnant women

  2. Acknowledgements • This training was developed by the North Carolina Preconception Health Campaign, a program of the March of Dimes North Carolina Chapter, under a contract and in collaboration with the North Carolina Division of Public Health, Women’s Health Branch. • This material was developed through support provided by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Health, Office of Adolescent Health (grant #SP1AH000004).

  3. Acknowledgements • Many thanks to these agencies and individuals for their generosity in sharing their resources in the area of early prenatal care and medical homes for women: • North Carolina Division of Public Health, Women’s Health Branch • Merry-K Moos, FNP, MPH, FAAN • Alvina Long Valentin, RN, MPH • Sarah Verbiest, DrPH, MSW, MPH • Specific resources used to guide the development of this training: • The National Preconception Curriculum and Resources Guide for Clinicians (Module 1: Preconception Care: What it is and what it isn’t)

  4. Young Moms Connect • Brings together community partners to address challenges faced by pregnant or parenting teens using collaborative, multi-faceted strategies • One component of Young Moms Connect is training for health care providers on six maternal and child health best practices

  5. Maternal & child health best practices • Early entry and effective utilization of prenatal care • Establishment and utilization of a medical home (for non-pregnant women) • Reproductive life planning • Tobacco cessation counseling using the 5 A’s approach • Promotion of healthy weight • Domestic violence prevention

  6. Objectives • Increase awareness about the relationship between preconception health, early prenatal care and a medical home • Increase knowledge about current status of prenatal care among young mothers • Assess local prenatal care services and early entry barriers • Increase awareness about the importance of primary care medical homes for women of reproductive age • Develop strategies to link young women, especially in the postpartum period, to medical homes

  7. What is preconception care? • Identification of modifiable and non-modifiable risk factors for poor health and poor pregnancy outcomes before conception • Timely counseling about risks and strategies to reduce the potential impact of the risks • Risk reduction strategies consistent with best practices CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules

  8. Components of preconception care • Giving protection • (eg.: folic acid, immunizations) • Managing conditions • (eg.: diabetes, maternal PKU, obesity, hypertension, hypothyroidism, STIs, sickle cell) • Avoiding exposures known to be teratogenic • (i.e.: medications, alcohol, tobacco, illicit drugs) CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules

  9. “Opportunistic” care • Preconception care is for every woman of childbearing age every time she is seen • Every woman, every time CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1) http://beforeandbeyond.org/?page=cme-modules

  10. Every woman, every time • Young women who are at risk of pregnancy • Young women who are pregnant • Young mothers who are postpartum • Young mothers who are between pregnancies

  11. From linear care… Moos, MK. Connecting the Dots: Health Status Before Pregnancy and Pregnancy Outcomes. 2011

  12. …to a circle of care

  13. Be healthy before pregnancy • Message for all women of childbearing age: • Remember, being in the best physical, emotional and financial position BEFORE pregnancy is best • Make sure your future pregnancies are planned and intended • Prenatal care should start as early as possible in pregnancy

  14. Early prenatal care • Why is early prenatal care important? • Recommended prenatal care schedule: • Weeks 4-28: 1 visit per month • Weeks 28-36: Visits every 2 weeks • Weeks 36-birth: Weekly visits until delivery

  15. Components of prenatal care • Review of: • Individual medical history • Obstetrical and gynecological history • Family history

  16. Components of prenatal care • Screening, referral and/or treatment for: • Genetic risks • Infectious disease • Chronic disease • Psychosocial issues • Environmental issues • Immunizations • Nutritional concerns

  17. Components of prenatal care • Laboratory studies • Vital signs • Maternal assessment • Fetal assessment • Patient education

  18. Prenatal 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 CDC National Preconception Health Curriculum and Resource Guide for Clinicians, 2008

  19. Importance of prenatal care • Adequate use of prenatal care associated with: • Healthy birth weights • Decreased risk of preterm delivery • Inadequate use of prenatal care associated with increased risk of: • Low birth weight • Preterm delivery • Neonatal mortality • Infant mortality • Maternal mortality Kiely JL, Kogan MD. From data to action: Reproductive health of women (Prenatal Care). Pp. 105-118. 1994

  20. Young mothers are at higher risk • Teens are least likely of all maternal age groups to get early and regular prenatal care1 • Teens are at greater risk than women over age 20 for pregnancy complications such as premature labor, anemia and high blood pressure2 • Teens are more likely than women over age 25 to smoke during pregnancy3 1. National Center for Health Statistics, final natality data, 2007 2. American College of Obstetricians and Gynecologists. Especially for Teens: Having a Baby. Patient Education Pamphlet, August 20073. Centers for Disease Control and Prevention. Preventing Smoking and Exposure to Secondhand Smoke Before, During and After Pregnancy. October 3, 2007

  21. Late entry into prenatal care • Mothers with unintended pregnancies are more likely to enter into prenatal care later in their pregnancies North Carolina State Center for Health Statistics, Risk Factors and Characteristics for 2009 Resident Live Births

  22. Mothers receiving prenatal care in the first trimester2004-2008, live births NC State Center for Health Statistics, 2004-2008. Trends in Key Health Indicators

  23. Mothers not receiving prenatal care in the first trimester in North Carolina, 2008 • 21% of mothers surveyed did NOT access first trimester prenatal care • Rates for not receiving care in the first trimester are highest for: • Young mothers (35% < 20 years, 31% 20-24 yrs) • African-American (34%) and Hispanic mothers (31%) • Unmarried women • Less education • Lower income levels NC State Center for Health Statistics, 2008, Pregnancy Risk Assessment Monitoring System

  24. Access to prenatal care North Carolina mothers who reported they did not receive prenatal care as early as they wanted • 31% of mothers < 20 years of age • 25% of mothers age 20-24 years • Half of all young mothers reported experiencing barriers to prenatal care NC State Center for Health Statistics, 2008, Pregnancy Risk Assessment Monitoring System

  25. Barriers to prenatal care in North Carolina NC State Center for Health Statistics, 2008, Pregnancy Risk Assessment Monitoring System

  26. Prenatal care for African-American mothersin North Carolina • Less likely to start prenatal care in first trimester • 70% of prenatal care is paid by Medicaid • 2/3 enroll in WIC (66%) • 1 in 3 African-American mothers were already enrolled in Medicaid prior to pregnancy (30%) compared to white mothers (9%) NC PRAMS Fact Sheet April 2011. NC African American Maternal Health

  27. Prenatal care for African-American mothersin North Carolina • Significantly more likely to experience at least one prenatal barrier compared to white mothers (48% vs. 37%) • 1 in 5 reported they were not able to get an appointment earlier in pregnancy • 1 in 6 reported having no insurance NC PRAMS Fact Sheet April 2011. NC African-American Maternal Health

  28. Not just early but adequate • Young Moms Connect has two prenatal care goals: • Making sure young women enter prenatal care during the first trimester • Making sure young women continue to follow the recommended prenatal visit schedule • Measures of adequacy of prenatal care • Kotelchuck Index: Looks at month of prenatal care initiation and total number of visits (compares number of expected visits to actual number of visits). Classifies as: inadequate, intermediate, adequate and adequate plus. • Kessner Index: Looks at weeks of gestation and total number of visits. Classifies as: inadequate, intermediate and adequate.

  29. Adequacy of prenatal care, Kessner Index, 2009 NC State Center for Health Statistics, 2009 NC resident births by county and Kessner Index

  30. Location of prenatal care for young women NC State Center for Health Statistics, 2008, Pregnancy Risk Assessment Monitoring System

  31. Preconception health & early prenatal care

  32. Important components of prenatal care and preconception health • Identification & treatment of sexually transmitted infections • Assessment of medication use • Identification of environmental risks (e.g. tobacco use, lead exposure, varicella exposure) • Achieving and/or maintaining healthy weight

  33. Sexually transmitted infections & pregnancy • Chlamydia • Untreated can cause prematurity, pink eye, and breathing problems for the baby • Genital Herpes • 25% of American women are infected (most do not know – asymptomatic); can be transmitted during a vaginal delivery and can cause blindness, brain damage and death of baby • HPV-Genital Warts • Over 6 million new infections/year in United States; can be uncomfortable during pregnancy • Bacterial Vaginosis • May increase a woman's chances of premature rupture of membranes and preterm delivery Cunningham, F.G., et al. Sexually Transmitted Diseases, in Williams Obstetrics, 22nd Edition. New York, McGraw-Hill Medical Publishing Division, 2005, pages 1301-1325 Workowski, K.A., Berman, S.M. Sexually Transmitted Disease Treatment Guidelines, 2006. Morbidity and Mortality Weekly Report, volume 55, RR11, August 4, 2006

  34. Sexually transmitted infections & pregnancy • Gonorrhea • Untreated it can cause blindness, joint infections and life threatening blood infections for the baby • HIV/AIDS • Untreated – higher risk of transmission to the baby • Syphilis • Untreated can cause blindness, brain damage or death for baby in addition to prematurity, stillbirth and congenital malformations • Hepatitis B • Untreated can infect the baby at delivery and can later cause liver disease or liver cancer; Also increases risk for infant to become a Hepatitis B carrier Workowski, K.A., Berman, S.M. Sexually Transmitted Disease Treatment Guidelines, 2006. Morbidity and Mortality Weekly Report, volume 55, RR11, August 4, 2006. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Disease Surveillance 2005 Supplement, Syphilis Surveillance Report. December 2006. 

  35. Gonorrhea and chlamydia in North Carolina • 59% of new gonorrhea cases in 2010 were to women • 80% of new chlamydia cases in 2010 were to women • Both disproportionately affect African-American women • High rates among ages 15-24 year-olds 2010 STD/HIV Surveillance Report. Communicable Disease Branch, N.C. Division of Public Health

  36. HIV in North Carolina • In 2009, 26% of new HIV cases were to women • Rate per 100,000 population • African-American women, 38.7 • White women, 2.7 2009 STD/HIV Surveillance Report. Communicable. Disease Branch, N.C. Division of Public Health

  37. HIV disease cases by county2007-2009 average 2009 HIV/STD Surveillance Report. Table 2. Communicable Disease Branch. NC DHHS

  38. Medication • Because almost half of all pregnancies in North Carolina are unintended, medication use should be monitored carefully during women’s childbearing years

  39. Medications and pregnancy • Medications known to cause serious birth defects if taken during pregnancy: • Isotretinoin • Thalidomide • Medications for the following conditions should be closely monitored for women of childbearing age: • Asthma • Epilepsy • High blood pressure • Depression U.S. Centers for Disease Control and Prevention, retrieved July 2011

  40. Environmental risks • Several environmental risks are associated with increased risk for poor maternal and/or infant outcomes and should be addressed as early as possible during prenatal care and throughout pregnancy • Tobacco use • Alcohol use • Illicit drug use • Exposure to some toxins (e.g. lead exposure) • Experience high levels of stress • Experiencing violence

  41. Maternal smoking during pregnancy • Smoking during pregnancy is the single most modifiable risk factor for poor birth outcomes • Increased risk for mother of: • Ectopic pregnancy • Preterm premature rupture of membranes • Placental complications • Preterm delivery • Spontaneous abortion ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011 Cnattingius S. The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes Nicotine Tob Res, 2004

  42. Maternal smoking during pregnancy • Increased risk for child of: • Low birthweight (causal association – twice as likely in smokers)1 • Sudden infant death syndrome1 • Childhood respiratory illnesses2 • Learning disabilities and conduct disorders1 • If it were possible to eliminate smoking during pregnancy entirely, the infant mortality rate in North Carolina would drop 10-20%.3 1Women and smoking: A report of the Surgeon General. U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, DC, 2001 2Hu FB, et al., Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy, Annals of Allergy, Asthma and Immunology 79(1): 80-84. 1997 3Rosenberg DC, Buescher PA. The Association of Maternal Smoking with Infant Mortality and Low Birth Weight in North Carolina, 1999. SCHS Studies No. 135. Raleigh, NC: North Carolina State Center for Health Statistics; 2002

  43. Smoking during pregnancy • Nationally between 12-20% of all pregnant women report smoking during pregnancy • Current clinical guidelines:“Whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit. Clinicians should offer effective tobacco dependence interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy.” Martin JA et al. Births: Final data for 2002. National vital statistics reports. Vol 52 no 10. National Center for Health Statistics. 2003 Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services. 2008

  44. Smoking during pregnancy, 2005-2009 NC State Center for Health Statistics, NC Residents 2005-2009 # and % of births to mothers that reported smoking prenatally

  45. What providers can do • Move beyond screening and recommendations • Provide brief smoking cessation counseling and use pregnancy-specific self-help materials • Use the 5 A’s regularly with preconception, pregnant and post-partum patients • Connect patients with support such as the NC Quitline Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services. 2008

  46. Women & weight in North Carolina • 58% of women in NC of childbearing age (18-44) are overweight or obese • 43% of young women ages 18-24 are overweight or obese • There is also a racial disparity in weight status for women 18 years and older • 56% of white women are overweight or obese • 73% of African-American women are overweight or obese • 56% of other minorities are overweight or obese NC Behavioral Risk Factor Surveillance System, 2010

  47. Consequences • U.S. society focuses on external consequences of overweight and obesity, i.e. how we look • As health professionals it can be helpful to re-frame discussions toward medical/physical consequences of overweight and obesity • For women of childbearing age the consequences of overweight & obesity span two generations • Risk of consequences increases progressively as BMI increases Kellner, S. Maternal weight: An opportunity to impact infant mortality in North Carolina. 2010

  48. Pregnancy risks • Increased pre-pregnancy BMI is associated with increased risk of: • Preeclampsia • Gestational hypertension • Gestational diabetes • C-section • Induction of labor • Postpartum hemorrhage • Lactation failure Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010

  49. And for the baby….. • Macrosomia • Preterm delivery • Poor APGAR scores • NICU admission • Shoulder dystocia • Late fetal death • NTDs (anencephaly and spina bifida) Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010

  50. The cycle repeats • The likelihood that overweight children will become obese adults is almost 9 times higher than the risk for children who are not overweight • Early prenatal care allows for counseling about appropriate weight gain during pregnancy to slow or stop this cycle Kellner S, Maternal weight: An opportunity to impact infant mortality in North Carolina, 2010