Interconception Care Research Articles

Interconception Care Opportunities for Mom and Baby.

Interconception care provides an irreplaceable opportunity to address existing chronic disease and correct maladaptive health behaviors. Utilizing the postpartum visit as an opportunity to improve interconception health and provide education to patients will not only improve the patient's life, but also impact any future offspring. Optimization of interconception health has the potential to improve population wellbeing and reduce the societal burden poor birth outcomes. Evidence-based recommendations are described.

Interpregnancy care

The aim of interconception care is to provide women who have had a prior adverse pregnancy outcome with optimal care in order to reduce risks that may affect the woman׳s health and any future birth she may choose to have. National recommendations call for action, and evidence supports specific clinical interventions. The need for interconception care is documented in national and state survey and surveillance data. Chronic diseases and behavioral risks affect the health of millions of U.S. women of childbearing age. Interconception care demonstration projects have used a “disease management” approach that includes medical care and case management. The increasing use of postpartum visits, as a gateway to interconception interventions, is essential. The Affordable Care Act emphasis on preventive services and expanded health coverage for women offers new opportunities to finance interconception care. Improved and enhanced clinical practices, along with the engagement of women, in interconception care have the potential to improve birth outcomes and reduce disparities.

Intendedness of pregnancy and other predictive factors for symptoms of prenatal depression in a population-based study.

Prenatal depression (PD) as a risk factor for adverse birth outcomes is well documented. Less is known about maternal risks for PD, which could inform preventive strategies for perinatal and interconceptional care. This exploratory study investigates associations between prenatal depression symptoms and unintended and mistimed pregnancies and other maternal risk factors for PD. A subset of birth records from the New York Statewide Perinatal Data System (n = 19,219) was used in this secondary analysis of cross-sectional data. Univariate and multivariate multinomial regression was used to identify factors that are independently associated with four self-reported levels of prenatal depression symptoms. Women with unintended pregnancies were more likely (AOR, 95 % CI) to report severe (3.6, 2.6-5.1) or moderate (2.0, 1.6-2.5) prenatal depression symptoms and less likely to report no symptoms, compared to women with intended pregnancies. Likewise, women with mistimed pregnancies were more likely to report severe (2.7, 2.2-3.5) or moderate (1.7, 1.5-2.1) prenatal depression symptoms than no symptoms, compared to women with intended pregnancies. Low education, drug use, smoking, minority race, being unmarried and having Medicaid insurance were also significant, independent predictors of PD symptoms. Results suggest that routine screening for depression, intendedness of pregnancy and other associated risk factors such as smoking and drug use during prenatal and interconceptional care visits may enable coordinated interventions that can reduce prenatal depression and unintended and mistimed pregnancies and improve pregnancy outcomes.

Preconception Healthcare Delivery at a Population Level: Construction of Public Health Models of Preconception Care

A key challenge of preconception healthcare is identifying how it can best be delivered at a population level. To review current strategies of preconception healthcare, explore methods of preconception healthcare delivery, and develop public health models which reflect different preconception healthcare pathways. Preconception care strategies, programmes and evaluations were identified through a review of Medline and Embase databases. Search terms included: preconception, pre-pregnancy, intervention, primary care, healthcare, model, delivery, program, prevention, trial, effectiveness, congenital disorders OR abnormalities, evaluation, assessment, impact. Inclusion criteria for review articles were: (1) English, (2) human subjects, (3) women of childbearing age, (4) 1980–current data, (5) all countries, (6) both high risk and universal approaches, (7) guidelines or recommendations, (8) opinion articles, (9) experimental studies. Exclusion criteria were: (1) non-human subjects, (2) non-English, (3) outside of the specified timeframe, (4) articles on male healthcare. The results of the literature review were synthesised into public health models of care: (1) primary care; (2) hospital-based and inter-conception care; (3) specific preconception care clinics; and, (4) community outreach. Fifteen evaluations of preconception care were identified. Community programmes demonstrated a significant impact on substance use, folic acid supplementation, diabetes optimization, and hyperphenylalaninemia. An ideal preconception visits entail risk screening, education, and intervention if indicated. Subsequently, four public health models were developed synthesizing preconception care delivery at a population level. Heterogeneity of risk factors, health systems and strategies of care reflect the lack of consensus about the best way to deliver preconception care. The proposed models aim to reflect differing aspects of preconception healthcare delivery.

Likelihood of Emergency Contraception Use Among African-American Women at Risk of Adverse Birth Outcomes

Nearly a half million infants in the United States are born preterm or with low birth weight each year. Providing women who have had a prior adverse birth outcome with access to family planning can help reduce the incidence of subsequent high-risk pregnancies and adverse outcomes. One effective option to prevent unintended pregnancy for women with a prior adverse birth outcome who either do not use contraception consistently or whose contraception fails is emergency contraception (EC). The purpose of our study was to understand willingness to use EC among African-American women who recently had an adverse birth outcome. The Healthy Births Healthy Communities (HBHC) Interconceptional Care Project (ICCP) targeted high-risk African-American women from two low-income Chicago neighborhoods who recently had an adverse birth outcome. The aim of HBHC ICCP was to improve participants' future birth outcomes by providing medical and social services and helping women to clarify their reproductive life goals. Information about participants' pregnancy intentions and willingness to use EC was measured in an interview shortly after enrollment into the study. Over 90% of the 131 women in our study either did not want to become pregnant or did not know if they wanted to become pregnant within the next 2 years. These women had 4.4 times higher odds of reporting willingness to use EC as compared to women who reported a desire to become pregnant within the next 2 years (75.6 vs. 50.0%, respectively; AOR: 4.4; 95% CI 1.1, 17.6). EC is an essential part of the reproductive toolkit for women at high risk of adverse birth outcomes who are not intending pregnancy, along with reproductive life planning and use of effective contraception.

The Implementation of Interconception Care in Two Community Health Settings: Lessons Learned

This study reports on an evaluation of the implementation of a pilot interconceptional care program (ICCP) in Chicago and the experiences of the participants in their first postpartum year. A longitudinal, multi-method approach was used to gather data to measure success in achieving project benchmarks and to gain insights into women's experiences after an adverse pregnancy outcome. The ICCP interventions were provided in two different health care settings. Low-income African-American women with a prior adverse pregnancy outcome were recruited to participate. Data on services delivered are available for 220 women; linked interview data are also available for 99 of these women. The ICCP focused on the integration of social services, family planning, and medical care provided through a team approach. An interview questionnaire asked detailed information about interconceptional health status, attitudes, and behaviors. A services database documented all services delivered to each participant. Key informant interviews were conducted with the ICCP project staff. Simple frequencies were generated. Chi-square and t-tests were used to compare participants and benchmarks at the two different sites. The planned delivery of interventions based on women's unique interconceptional health needs was often replaced by efforts to address women's socioeconomic needs. Although medical care remained important, participants viewed themselves as healthy and did not view medical care as a priority. Women's perceptions of contraceptive effectiveness were not always in sync with clinical knowledge. Interconceptional care is a complex process of matching interventions and services to meet women's unique needs, including their socioeconomic needs.

Preconception Women’s Health and Pediatrics: An Opportunity to Address Infant Mortality and Family Health

THE U.S. INFANT mortality rate remains unacceptably high, with large disparities found by race. Increasingly, research has demonstrated that interventions must go beyond ensuring access to care and prenatal focus to address the preconception health of women. Critical fetal development occurs in the earliest weeks after conception, often before a woman is aware of her pregnancy. The Maternal Child Health Bureau’s life course initiatives and the Centers for Disease Control’s preconception health initiatives are placing infant mortality and child health in a life course context, that is, uniting the reproductive health and pediatric longitudinal perspectives. In the recent report “Clinical Preventive Services forWomen”, the Institute ofMedicine recommended annual well-women visits incorporating preconception care, and Healthy People 2020 includes a section of objectives on preconception health and behaviors. With growing scientific recognition that early antecedents of child and adult health start prenatally and even preconceptionally, women’s health is key. Pediatric clinicians have been leaders in the efforts to reduce infant mortality and in family-centered care, but how can pediatrics further contribute? A golden opportunity exists to serve as preconception care (PCC) clinicians for preconceptional adolescents and interconceptional mothers seen in practice.

Maternal Risk Factors for Peripartum Transfusion

Postpartum hemorrhage remains one of the most significant maternal complications of childbirth in the United States, with peripartum transfusion the most commonly identified morbidity. We completed a retrospective cohort study of women delivering at 20+ weeks at a large regional obstetric hospital between 2000 and 2008. Data were extracted from the institutional data warehouse; women with a potential coagulopathy were excluded. The association of maternal and obstetric factors with odds of transfusion was explored using univariate and multivariable logistic regression. We identified 59,282 deliveries and 614 cases of transfusion, an incidence rate of 10.4/1,000 deliveries. Rates were highest for black (14.1/1,000 deliveries) and lowest for white (8.4/1,000 deliveries) women. Increased odds of perinatal transfusion were seen for women with anemia at entry to labor and delivery (odds ratio [OR] 3.03, 95% confidence interval [CI] 2.43-3.79 for hemoglobin (Hgb) 9.5-10.5 g/dL; OR 12.65, 95% CI 10.35-15.46 for Hgb<9.5 g/dL) and those undergoing a cesarean delivery (OR 4.28, 95% CI 3.62-5.05). The excess risk associated with black race was eliminated after adjusting for anemia and other covariates. A synergistic effect of anemia with delivery method was observed. Anemia was estimated to account for 31.7% of transfusions. Potentially modifiable factors most strongly associated with risk for transfusion were antenatal anemia and cesarean delivery, and their co-occurrence was synergistic. Anemia is an easily identified and treatable risk factor and warrants focus as part of preconception and interconception care in childbearing women.

Barriers to women's participation in inter-conceptional care: a cross-sectional analysis

BackgroundWe describe participation rates in a special interconceptional care program that addressed all commonly known barriers to care, and identify predictors of the observed levels of participation in this preventive care service.MethodsA secondary analysis of data from women in the intervention arm of an interconceptional care clinical trial in Philadelphia (n = 442). Gelberg-Andersen Behavioral Model for Vulnerable Populations to Health Services (herein called Andersen model) was used as a theoretical base. We used a multinomial logit model to analyze the factors influencing women's level of participation in this enhanced interconceptional care program.ResultsAlthough common barriers were addressed, there was variable participation in the interconceptional interventions. The Andersen model did not explain the variation in interconceptional care participation (Wald ch sq = 49, p = 0.45). Enabling factors (p = 0.058), older maternal age (p = 0.03) and smoking (p = < 0.0001) were independently associated with participation.ConclusionsActively removing common barriers to care does not guarantee the long-term and consistent participation of vulnerable women in preventive care. There are unknown factors beyond known barriers that affect participation in interconceptional care. New paradigms are needed to identify the additional factors that serve as barriers to participation in preventive care for vulnerable women.

Barriers to women's participation in inter-conceptional care: a cross-sectional analysis

Barriers to women's participation in inter-conceptional care: a cross-sectional analysis

Infant mortality and subsequent risk of stillbirth: a retrospective cohort study

To examine the association between infant mortality in a first pregnancy and risk for stillbirth in a second pregnancy. Population-based, retrospective cohort study. Maternally linked cohort data files for the state of Missouri. Women who had two singleton pregnancies in Missouri during the period 1989-2005 (n = 320 350). Women whose first pregnancy resulted in infant death were compared with those whose infant from the first pregnancy survived the first year of life. The Kaplan-Meier product limit estimator was employed to compare probabilities for stillbirth in the second pregnancy between both groups of women. Adjusted hazard ratios (AHRs) and 95% confidence intervals (95% CIs) were generated to assess the association between infant mortality in the first pregnancy and stillbirth in the second pregnancy. Exposure was defined as infant mortality in the first pregnancy, and the outcome was defined as stillbirth in the second pregnancy. Women with prior infant deaths were about three times as likely to experience stillbirth in their subsequent pregnancy (AHR 2.91; 95% CI 2.02-4.18). White women with a previous infant death were nearly twice as likely to experience a subsequent stillbirth, compared with white women with a surviving infant (AHR 1.96; 95% CI 1.13-3.39). Black women with a previous infant death were more than four times as likely to experience subsequent stillbirth, compared with black women with a surviving infant (AHR 4.28; 95% CI 2.61-6.99). Previous infant mortality results in an elevated risk for subsequent stillbirth, with the most profound increase observed among black women. Interconception care should consider prior childbearing experiences to avert subsequent fetal loss.

The Impact of Birth Spacing on Subsequent Feto-Infant Outcomes among Community Enrollees of a Federal Healthy Start Project

Numerous studies have shown an association between shorter birth intervals, and several adverse fetal outcomes, including low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA). However, there is little evidence on the effectiveness of interconception care on fetal outcomes associated with sub-optimal interpregnancy interval (IPI). The purpose of this study is to examine the influence of the Federal Healthy Start's interconception care services on IPI and fetal growth outcomes. This is a retrospective cohort study used records from the Central Hillsborough Healthy Start program in Tampa, Florida linked to Florida vital statistics data covering the period 2002-2009. Only first and second pregnancies were considered, and interpregnancy interval (IPI), the exposure of interest, was categorized in months as 0-5, 6-17, 18-23, and ≥24. The following feto-infant morbidities were considered as primary outcomes: LBW, PTB, and SGA. A composite variable coding the presence of any of the aforementioned adverse fetal events was also created. Multivariate logistic regression modeling was applied Overall, mothers with the shortest IPI (0-5 months: AOR = 1.39, 95% CI 1.23-1.56) and longest IPI (≥60 months: AOR = 1.13, 95% CI 1.03-1.23) were at a greater risk for adverse fetal growth outcomes, compared to the referent category (18-23 months). Our findings support the need for inter conception care that addresses IPI and delayed childbearing among women.

Effectiveness of a Federal Healthy Start Program in Reducing Primary and Repeat Teen Pregnancies: Our Experience over the Decade

Study Objective To evaluate the effectiveness of a Federal Healthy Start program in reducing primary and repeat teen pregnancies in a disadvantaged community. Design An ecological study that compares trends in teen pregnancy in the catchment area in which the community-based intervention was administered with two ecologic controls: the county (Hillsborough) and the state (Florida). Setting Our catchment area is East Tampa, a socio-economically disadvantaged community in Hillsborough County, Florida. Participants Preconception care targeted teenagers between the ages of 10 and 19 years. Interconception care involved young mothers under the age of 20 with a previous birth. The population was comprised primarily of African Americans. Intervention Preconception care services for primary teen pregnancy reduction offered sex education, family planning, drug and violence prevention education, and communication and negotiation skills acquisition. Interconception care service offered young women health education through monthly home visitation or monthly peer support group meetings addressing a range of topics using the life course perspective as framework. Main Outcome Measure Reduction in primary teen pregnancy and repeat teen pregnancy among adolescents. Results The decline in primary teen pregnancy in the catchment area was 60% and 80% greater than the reduction experienced at the county level and at the state level respectively over the period of the study. However, efforts to prevent repeat pregnancy were not successful. Conclusion The Federal Healthy Start Preconception Care program, in collaboration with community partners, contributed to the prevention of first-time teen pregnancy in a community faced with significant social and economic challenges.

Interconception Care for Couples After Perinatal Loss

Perinatal loss can be emotionally devastating for couples who experience miscarriage, fetal or neonatal death. Nurses in a variety of settings can assist couples through their grief by providing emotional support, giving information about the grief process, and in planning for a future pregnancy or deciding to forego future childbearing. This article explicates the relationship between grief and perinatal loss and its effects on couples, specifically in the interconception period, when the initial grief and distress have begun to subside. Interconception care focuses on bridging the couple from the end of the postpartum period to the subsequent pregnancy or decision not to conceive again. Nurses assist couples in distinguishing between uncomplicated grief, complicated grief, and depression, and make appropriate referrals. Openness to expressions of grief, helping couples mobilize support, considering readiness for another pregnancy, and directing couples to useful Internet sites are essential nursing interventions.

The Evolving Science of Care in Perinatal Loss

The Evolving Science of Care in Perinatal Loss

581: Interconception care among low-income women in California

581: Interconception care among low-income women in California

Impact of Pre-Conception Health Care: Evaluation of a Social Determinants Focused Intervention

The purpose of this study was to evaluate the outcomes of the social determinants component of a multiple determinants model of pre- and inter-conception care. Health department vital statistics and infectious disease data on birth and factors influencing birth outcomes were analyzed for participants in a program designed to mitigate the effects of social class and stress in contrast to a matched comparison group and other relevant populations. The program showed promising results related to reducing infant mortality and reducing other high-risk factors for poor birth outcomes, including low birth weight and sexually transmitted disease. Social determinant interventions, designed to mitigate the impact of social class and stress, should be considered with efforts to reduce infant mortality, particularly the disparities associated with infant mortality. Additional research should be conducted to refine replicable social determinant focused interventions and confirm and generalize these results.

Characteristics, access, utilization, satisfaction, and outcomes of healthy start participants in eight sites.

To describe the characteristics, access, utilization, satisfaction, and outcomes of Healthy Start participants in eight selected sites, a survey of Healthy Start participants with infants ages 6–12-months-old at time of interview was conducted between October 2006 and January 2007. The response rate was 66% (n = 646), ranging from 37% in one site to >70% in seven sites. Healthy Start participants’ outcomes were compared to two national benchmarks. Healthy Start participants reported that they were satisfied with the program (>90% on five measures). Level of unmet need was 6% or less for most services, except for dental appointments (11%), housing (13%), and child care (11%). Infants had significantly better access to medical care than did their mothers, with higher rates of insurance coverage, medical homes, and checkups, and fewer unmet needs for health care. Healthy Start participants’ rates of ever breastfeeding (72%) and putting infants to sleep on their backs (70%) were at or near the Healthy People 2010 objectives, and considerably higher than rates among low-income mothers in the ECLS. The high rate of health education (>90%) may have contributed to these outcomes. Elimination of smoking among Healthy Start participants (46%) fell short of the Healthy People 2010 objective (99%). The low-birth weight (LBW) rate among Black Healthy Start participants (14%) was three times higher than the rate for Whites and Hispanics (5% each). Overall, the LBW rate in the eight sites (7.5%) was similar to the rate for low-income mothers in the ECLS, but both rates were above the Healthy People 2010 objective (5%). Challenges remain in reducing disparities in maternal and child health outcomes. Further attention to risk factors associated with LBW (especially smoking) may help close the gaps. The life course theory suggests that improved outcomes may require longer-term investments. Healthy Start’s emerging focus on interconception care has the potential to address longer-term needs of participants.

Intermediate Outcomes, Strategies, and Challenges of Eight Healthy Start Projects

Site visits were conducted for the evaluation of the national Healthy Start program to gain an understanding of how projects design and implement five service components (outreach, case management, health education, depression screening and interconceptional care) and four system components (consortium, coordination/collaboration, local health system action plan and sustainability) as well as program staff’s perceptions of these components’ influence on intermediate outcomes. Interviews with project directors, case managers, local evaluators, clinicians, consortium members, outreach/lay workers and other stakeholders were conducted during 3-day in-depth site visits with eight Healthy Start grantees. Grantees reported that both services and systems components were related to self-reported service achievements (e.g. earlier entry into prenatal care) and systems achievements (e.g. consumer involvement). Outreach, case management, and health education were perceived as the service components that contributed most to their achievements while consortia was perceived as the most influential systems component in reaching their goals. Furthermore, cultural competence and community voice were overarching project components that addressed racial/ethnic disparities. Finally, there was great variability across sites regarding the challenges they faced, with poor service availability and limited funding the two most frequently reported. Service provision and systems development are both critical for successful Healthy Start projects to achieve intermediate program outcomes. Unique contextual and community issues influence Healthy Start project design, implementation and reported accomplishments. All eight projects implement the required program components yet outreach, case management, and health education are cited most frequently for contributing to their perceived achievements.

Healthy Start: Lessons Learned on Interconception Care

The Federal Healthy Start program was started in 1991 to address the factors that contribute to the Nation's high infant mortality rate, particularly among populations with disproportionately high rates of adverse perinatal health outcomes. The goals of Healthy Start are to reduce disparities in access to and utilization of health services by using a lifespan approach, improving the local health care system, and increasing consumer and community input into health care decisions. In 2007, Healthy Start served 99 communities in 38 states, the District of Columbia, and Puerto Rico. Most Healthy Start grantees are nonprofit organizations. Since 2005, all 97 Healthy Start grantees (and the 2 additional grantees funded in 2007) have been required to include an interconception care component. Three quarters of grantees enrolled the majority of their interconception clients during the prenatal period. Most grantees used care coordination and case management as the primary approach to improving interconception health care. In 2007, 93 interconception projects reported that 9 out of 10 women had an ongoing source of primary care. Grantees screened to detect health conditions and risks, as well as provided an opportunity to provide vital information to women about their risks for chronic conditions such as obesity, hypertension, and diabetes. The Healthy Start interconception components demonstrate a critical need for and the potential impact of a strong interconception care program for high-risk populations such as women living in poverty, in medically underserved communities, and without health coverage.