Interconception Care Research Articles

Women and Health Insurance: Implications for Financing Preconception Health

This article examines health insurance coverage among women of reproductive age and considers how national health insurance reform may affect access to high-quality, timely, and affordable preconception and interconception care. A focus on preconception and interconception care increasingly is understood as essential, not only to the health of women, but to that of infants as well, and thus, as a key part of a comprehensive infant health strategy. After a brief overview that examines the relationship between preconception and interconception health care and health insurance reform, the article examines the current state of health insurance coverage among women of childbearing age and the underlying causes of uninsurance and underinsurance in this population group. The article then sets forth a proposed health insurance reform taxonomy in the context of health and health care generally, and preconception and interconception health care in particular. It is the underlying assumption of this article that preconception and interconception care can serve as bellwethers of the extent to which health reform achieves preventive results. Such results include coverage reforms that not only put acute treatments within financial reach, but that also help finance interventions that can help to achieve population-wide preventive results, in this case, long-term improvement in the health of both women and children.

Welfare Reform and Insurance Coverage During the Pregnancy Period: Implications for Preconception and Interconception Care

Welfare reform has had far-reaching consequences for unmarried women and their children, including effects on their health insurance status. Those who would be receiving cash assistance absent welfare reform may have lower rates of health insurance if they failed to enroll separately for Medicaid (whose rules did not tighten over this time period), or if the new employment they entered did not provide health insurance. Administrative difficulties involved in accessing Medicaid separately from cash welfare may also have been a factor in the short run. Our research uses data from a large and nationally representative household survey that tracks the same individuals over time, the Survey of Income and Program Participation, to examine the effect of welfare reform (AFDC waivers and TANF implementation) on the health insurance status of unmarried mothers with High School completion or less (the population whose health insurance we expect would be affected by the welfare reform, or the "treatment group") in the time period surrounding a particularly important life event, pregnancy. We look at the effects of these policies over the time period 1990-1999, as well as over the time period 1990-2003, to explore the short run vs. long run impact. Our "control group", those who should not be affected by welfare reform itself but are expected to be affected by other national or state events that are happening contemporaneously, consists of married mothers with High School completion or less; the insurance experience of these women is used to control for the other forces that might otherwise lead us to attribute too little or too large an effect to welfare reform. Given the importance of access to health care at all points in the period surrounding and during pregnancy, we look at how welfare reform has affected insurance status before conception, during pregnancy, and after the birth of the child. We find that the Aid to Families with Dependent Children (AFDC) waivers of the 1990s as well as Temporary Assistance for Needy Families implementation have decreased access to Medicaid health insurance, increased access to employer health insurance, and led to a decrease in overall insurance, depending on the point in pregnancy considered and the time period of the study, with the largest effects found in coverage after the birth of a child. These findings have particular implications for the increasing emphasis on preconception and interconception care as a strategy to improve women's and infant's health.

Transforming Preconceptional, Prenatal, and Interconceptional Care Into A Comprehensive Commitment To Women's Health

Preconception and interconception care respond to the growing body of evidence that many of the most important determinants of birth outcomes may exist before pregnancy occurs. In this sense, the strategy of extending prenatal care into the preconception and interconception periods marks a useful step in reforming the public health approach to improving birth outcomes. However, although helpful in underscoring the continuity of risk that can ultimately find expression in adverse birth outcomes, the concern is that without greater critical attention these relatively new care constructs have the potential to undermine rather than strengthen a comprehensive system of women's health care.

Prevalence of Chronic Illness in Pregnancy, Access to Care, and Health Care Costs: Implications for Interconception Care

Access to health care after pregnancy is especially important for pregnant women with chronic illness. The purpose of our study was to describe the prevalence of chronic illness in pregnant women and factors affecting the receipt of ongoing care. We conducted a cross-sectional analysis of 6,294 women between 19 and 45 years of age from the Medical Expenditure Panel Survey (MEPS). Chronic illness was defined using aggregate clinical classification codes in the MEPS. Women were divided into 4 groups: pregnant and currently not pregnant, with and without chronic illness. We analyzed group differences in demographic variables, socioeconomic status, and access to health care. We also estimated inpatient, outpatient, emergency room, and pharmacy expenditures for the 4 study groups. All analyses accounted for the complex survey design of MEPS. Overall, 27% of pregnant women and 39% of nonpregnant women reported a chronic illness. There were no differences in race/ethnicity, poverty, or health insurance status between pregnant women with and without chronic illness. Women with chronic illness were more likely to have a usual source of care. Among pregnant women, the presence of a chronic condition did increase out-of-pocket expenditures, but did not increase total average health care expenditures, even after adjusting for other characteristics. Pregnant women with chronic illness were similar to pregnant women without chronic illness in terms of access to care and total health care costs. Further research is needed to determine whether these similarities persist after delivery, given the relatively high prevalence of women with chronic illness who are of childbearing age.

Fetal death repetition: The event memory hypothesis

Fetal death recurrence is an important problem in reproductive health that is poorly understood. Based on preliminary epidemiologic evidence, we propose an "event memory" hypothesis which posits that when fetal death occurs the event is retained (memorized) as a program that is replayed in future pregnancies. We describe a pathway through which excessive programmed death (apoptosis) that mediates fetal demise in an initial pregnancy gets stored as an apoptotic cascade program that is replayed in a subsequent pregnancy regardless of the cause of the initial pregnancy loss. We propose an innovative method by which this hypothesis could be tested. If proven, the hypothesis will potentially represent a shift in paradigm in the field of epidemiology by introducing a new dimension (memory recall) to the cause--effect inference model; it will create a new intervention concept in prevention science, and will positively influence inter-conceptional care for mothers with a previous fetal death.

Comparison of Guidelines Available in the United States for Diagnosis and Management of Diabetes before, during, and after Pregnancy

Women with preexisting diabetes are at increased risk of adverse pregnancy outcomes and birth defects. Women with gestational diabetes are at increased risk for adverse outcomes, including neonatal hypoglycemia, hyperbilirubinemia, macrosomia, increased risk of obesity and diabetes in the offspring later in life, and increased risk for other maternal comorbidities. Studies have shown that tight glycemic control before and during pregnancy can decrease the risk for adverse outcomes, congenital malformations, and maternal complications resulting from maternal preexisting diabetes. It is important to identify women with gestational diabetes and provide interconception care to minimize the risk of a future pregnancy complicated by type 2 diabetes. To reduce the risk of adverse consequences for both the woman and her baby, it is important to effectively manage diabetes before, during, and after pregnancy. Several professional organizations have developed guidelines in an effort to establish some consistency in the diagnosis and treatment of diabetes and to decrease the risk of adverse outcomes. The objectives of this paper are to (1) compare the guidelines for women with preexisting (types 1 and 2) and gestational diabetes available to healthcare providers in the United States, highlighting the similarities and differences among them, and (2) discuss how differences among the guidelines might affect efforts to address the challenges of controlling and preventing diabetes and resulting complications during pregnancy.

Promising Practices in Preconception Care for Women at Risk for Poor Health and Pregnancy Outcomes

Objectives: Two programs targeting urban African-American women are presented as promising models for preconception care, which includes interconception care. Methods: The Grady Memorial Hospital Interpregnancy Care (IPC) Program in Atlanta, Georgia, and the Magnolia Project in Jacksonville, Florida, are described. The IPC program aims to investigate whether IPC can improve the health status, pregnancy planning and child spacing of women at risk of recurrent very low birthweight (VLBW). The Magnolia Project aims to reduce key risks in women of childbearing age, such as lack of family planning and repeat sexually transmitted diseases (STDs), through its case management activities. Results: Seven out of 21 women in the IPC were identified as having a previously unrecognized or poorly managed chronic disease. 21/21 women developed a reproductive plan for themselves, and none of the 21 women became pregnant within nine months following the birth of their VLBW baby. The Magnolia Project had a success rate of greater than 70% in resolving the key risks (lack of family planning, repeat STDs) among case management participants. The black to white infant mortality (IM) ratio was better for the babies born to women managed in the Magnolia Project compared to the same ration for the United States. Conclusions: Preconception care targeted to African-American women at risk for poor birth outcomes appears to be effective when specific risk factors are identified and interventions are appropriate. Outreach to women at risk and case management can be effective in optimizing the woman's health and subsequent reproductive health outcomes.

Predictors of Compliance with the Postpartum Visit among Women Living in Healthy Start Project Areas

Few studies have examined factors associated with compliance with a postpartum visit (PPV). The identification of such factors is of particular importance in populations with high rates of unintended pregnancies and medical complications of pregnancy. This study seeks to determine factors associated with compliance with a PPV among low-income women in the population served by fourteen Healthy Start sites. Data from the Healthy Start Survey of Postpartum Women were reviewed to identify variables associated with compliance with a PPV at or beyond 6 weeks. Multiple logistic regression models were created, based on a sociobehavioral model of health services use, to examine which types of factors (demographic, social, enabling or need) are most strongly associated with the use of a PPV. The study population consisted of survey respondents interviewed six weeks or more following delivery. Eighty-five percent of respondents had had a PPV at time of interview. In a multiple regression analysis, enabling factors such as multiple moves (OR (95% CI)=0.34 (0.18, 0.67)), trouble understanding the provider (OR (95% CI)=0.65 (0.43, 0.99)) and appointment reminders (OR (95% CI)=2.37 (1.40, 4.02)) were most strongly associated with a PPV. This work finds that women with unstable housing, transportation barriers, and difficulties communicating with providers are at risk for not receiving a PPV. This suggests that access to postpartum health services in the Healthy Start communities studied may not be entirely equitable. Policies aimed at improving interconception care will need to address these barriers to accessing health services.

A Framework for the Development of MaternalQuality of Care Indicators

In collaboration with the California Department of Health Maternal and Child Health Branch, the authors formed a Working Group to identify potential clinical indicators that could be used to inform decision making regarding maternal health care quality. To develop potential indicators for the assessment of maternal health care quality. A Working Group was convened to review information from the published literature and expert opinion. Selection of potential indicators was guided by the following goals: 1) To identify key areas for routine aggregate monitoring; 2) To include perspectives of relevant stakeholders in maternal health care services; 3) To include measures that are comprehensive and reflect a balance between maternal and fetal interests; and 4) To develop measures that would be valid, generalizable, mutable, and feasible. Ninety potential indicators were identified. Each underwent a thorough review based on: its definition, objective, and validity; its contribution to innovation; the cost and timeliness of implementation; its feasibility, acceptability, and potential effectiveness; and its compatibility with ethics, values, and social policy. This process yielded 24 final indicators from the following categories: Health Status and Access (e.g., availability of 24 h inpatient anesthesia); Preconception and Interconception Care (e.g., Pap smear use); Antenatal Care (e.g., hospitalization for uncontrolled diabetes or pyelonephritis); Labor and Delivery Care (e.g., chorioamnionitis or obstetrical hemorrhage), and Postpartum Care (e.g., rate of postpartum visits). These potential indicators, representative of the women's health continuum, can serve as a foundation to structure the development of consensus and methods for maternal health care quality assessment.

Interconception Care: A New Role for the Pediatrician

The infant mortality rate continues to be higher in this country than in many other industrialized nations.1 Federal, state, and local governments have responded by spending large amounts of money on attempts to reduce the infant mortality rate, and expert groups, task forces, and commissions have issued reports on the subject.2-4 Until recently, however, there seemed little that the primary care pediatrician—as distinct from the neonatologist—could do about this problem, because approximately two thirds of infant deaths occur in the neonatal period (before the 28th day of life and often before the neonate leaves the hospital). But this situation should change as attention is increasingly shifted from what can be done after the baby is born to what can be done before the baby is conceived.

Early teenage pregnancy, contraception, and repeat pregnancy

A total of 1,824 births to patients aged 16 and under during 1971 and 1972 were examined. Premature birth, and fetal, neonatal, and perinatal death were more common in this young age group. Contraceptive acceptance was high at postpartum visit. Approximately half of the patients registered for continuing interconceptional care. The population is described and contraceptive acceptance, contraceptive continuation, and repeat pregnancy are recorded.