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Birth Spacing and Pregnancy Planning/Prevention in Home Visiting Webinar hosted by The National Campaign to Prevent Teen and Unplanned Pregnancy June 17, 2014 3:00PM – 4:30PM (EDT)

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What we will hear

Welcome/Introductions Why the topic of pregnancy spacing and planning is germane to the home visiting community An overview of new OPA/CDC Quality Family Planning Clinical Guidelines, Modern Contraception, Access to Contraception, and Training for Home Visitors A presentation from two home visiting program leaders who are incorporating birth spacing and pregnancy planning/prevention Resources for home visitors and others working in the home visiting sector

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Speakers

David Willis, MD, FAAP – HRSA, HHS Moushumi Beltangady, MSW MPP – HRSA,HHS Sarah Brown, MSPH – The National Campaign to Prevent Teen and Unplanned Pregnancy Susan Moskosky, MS, WHNP-BC, OPA, HHS Shamika Dokes-Brown, Native American Health Center Kristine Campagna, Rhode Island Department of Health Sounivone Phanthavong, Rhode Island Department of Health

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Birth Spacing and Pregnancy Planning/Prevention in Home Visiting

June 17, 2014 David W. Willis, M.D., FAAP Director, Division of Home Visiting and Early Childhood Systems Maternal and Child Health Bureau Health Resources and Services Administration Department of Health and Human Services

5 The Home Visiting Program ● Authorized by Title V of the Social Security Act: Maternal, Infant, and Early Childhood Home Visiting Programs ● $1.5 billion over 5 years  $100M FY2010  $250M FY2011    $350M FY2012 $400M FY2013  $400M FY2014 Sustainable Growth Rate Legislation  $400M FY2015

6 The Home Visiting Program • • • Supports Families • • • Evidence-based parent support services Partnership between parents and home visitors Ongoing visits and dialogue around family needs Voluntary • For families that ask to be empowered with better knowledge, health and parenting Evidence-based • • • Built on four decades of rigorous research and evaluation Includes a rigorous national randomized controlled trial evaluation and local evaluations Now 14 HHS approved home visiting models

The Home Visiting Program • Cost effective • Home Visiting prevents child abuse and neglect, encourages positive parenting and promotes child development and school readiness • • Long term reduction of school dropout rates, teen pregnancy and crime Every $1.00 invested, yields up to $9.50 ROI to society* • Locally designed and run • • • Provides states with maximum flexibility to tailor programs to fit needs of different communities States can choose from 14 evidence-based home visiting models Programs run by local organizations in local communities 7 *Source: Ted R. Miller, “Nurse-Family Partnership Home Visitation: Costs, Outcomes, and Return on Investment,” The Pew Center on the States. (2013).

8 The Home Visiting Program

Home Visiting Benchmarks

1. Maternal and newborn health (8 constructs) 2. Child injuries; child abuse, neglect, or maltreatment; emergency department visits (7) 3. School readiness and achievement (9) 4. Crime (2) or domestic violence (3) 5. Family economic self-sufficiency (3) 6. Coordination/referrals for other community resources (5)

9 Importance of Birth Spacing and Pregnancy Prevention/Planning • Birth spacing, pregnancy planning and preconception health services contribute to improved health outcomes for infants, children, women, and families.

• Interval birth education and preconception health are important components of our home visiting program and key benchmark indicators for measuring our success.

10 Importance of Birth Spacing and Pregnancy Prevention/Planning • Short intervals between pregnancies are associated with increased risk of adverse perinatal outcomes including preterm births and low-birth-weight infants. • Unintended pregnancies can have negative health and economic consequences including delays in seeking prenatal care, reduced likelihood of breastfeeding, maternal depression, lower adult educational attainment and income, and poor mental and physical health during childhood (Sonfield, 2011).

11 The Home Visiting Program

Strategies / Innovations

• • • • • • Ongoing staff training Partnership building with family planning programs Birth spacing curricula and home-based education Referral to preconception health programs and other primary health care providers Workshops, webinars, conferences and printed materials Teen focused education programs

12 The Home Visiting Program

What’s Needed?

• Better integration of home visiting, preconception health and primary health care services • More cross training with and completed referrals to preconception health programs • Continuous monitoring and assessment to improve education and referral services

13 The Home Visiting Program

The opportunity…

... to better integrate home visiting, birth interval education, and preconception health services to improve the life course of the next generation of our nation’s vulnerable children, youth and families.

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Contact Information

David W. Willis, MD, FAAP Director, Division of Home Visiting and Early Childhood Systems Maternal and Child Health Bureau, HRSA 301-443-8590 [email protected]

15 Moushumi Beltangady Senior Policy Advisor for Early Childhood Development Office of the Deputy Assistant Secretary for Early Childhood Development, Administration for Children and Families U.S. Department of Health and Human Services

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Why birth spacing and pregnancy planning matter for home visiting

Sarah Brown, CEO The National Campaign to Prevent Teen and Unplanned Pregnancy

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A bit about The National Campaign

Starting at the beginning

No contraception 18 Gap in contraceptive coverage Cont. Failure Inconsistent Use Pregnancy / Birth Infancy Family and child

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The benefits of pregnancy planning

For example: • Increased opportunities for preconception care • Earlier start in prenatal care • Lowered risk of preterm delivery, low birth weight, fetal growth retardation and infant mortality • Increased opportunity for maternal education • Reduced relationship conflict

The benefits of pregnancy planning extend beyond first births

20 • All the benefits of pregnancy planning noted on previous slide continue to apply with second and higher order births….

• Mainly through preconception care and adequate child spacing which benefit the mother and the child/children already present.

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In the context of home visiting…

• It is logical and amply supported by research to focus some attention on birth spacing -- that is, helping a young mother think about if and when she might want an additional child, and what steps she can take now to ensure a healthy pregnancy and good results – both for herself, her current child and family AND future children. • One major way to help achieve adequate child spacing is through the use of high quality contraception.

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Unintended pregnancy in the populations you may serve

• Among unmarried women in their twenties, 75% of births resulting from unintended pregnancies are to women who have already had at least one pregnancy/birth • 70% of pregnancies to unmarried women in their 20s are unintended • Almost 20% of teen mothers have a second birth before turning 20

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Approaching pregnancy spacing and planning within home visits

• Approach topic in a relaxed, respectful manner • Ask One Key Question: “Would you like to become pregnant in the next year?

• If yes: preconception/prenatal care referrals and links • If no, provide links to family planning care and information

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A note on contraception itself

• Home visitors do not need to be family planning experts; help is available in most communities • Even so, basic knowledge about contraception is important, especially newer low-maintenance methods • Warm concern can make all the difference, along with helping women get the method best for them and avoid gaps in protection

26 Susan Moskosky, MS, WHNP-BC Acting Director, Office of Population Affairs U.S. Department of Health & Human Services [email protected]

What is Title X?

27  Mission: To provide individuals with the information and means to exercise their ability to determine the number & spacing of their children, including providing access to a broad range of acceptable & effective family planning methods and related services  4,200 clinics nationally  State and local health departments, hospitals, university-based clinics, community health centers and free-standing clinics

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Title X Services

         Confidential Voluntary Contraceptive counseling, services & supplies Breast and cervical cancer screening STD screening, counseling and treatment HIV testing, prevention education Pregnancy testing, counseling and referral Other preventive health services Charges based on family income

http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf

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Conceptual Framework

Based on the IOM’s definition of “quality”: Safe Effective Client centered Timely Accessible Efficient Equitable Value Improved quality Improved reproductive health outcomes IOM (2001). Crossing the quality chasm: a new health system for the 21 st century. National Academies of Science, Washington DC.

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Framework for Family Planning, Related and Other Preventive Services

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Contraceptive Services

 Remove medical barriers as a prerequisite to contraceptive provision  Pelvic exams not routinely needed, unless inserting IUD or diaphragm   Cervical cytology Routine HIV screening   Provide in accordance with CDC’s MEC and SPR Offer a full range of FDA-approved methods   Highly effective, reversible contraceptive methods are available and safe for most women and adolescents (LARCs - IUC and Implants) ) Use an evidence-informed counseling process, which includes educating about the most effective contraceptive methods first  Contraceptives are one of the women’s preventive services that must be made available without co-pays or cost sharing under the ACA

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Special Considerations for Adolescents

 Counseling adolescents      Unique needs and characteristics Emphasis on confidentiality Promotion of parent-child communication about sexual health Provide comprehensive information about pregnancy prevention, including contraception and abstinence LARCs are safe and effective for many sexually active adolescents

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Youth Friendly Services

        Accessible Equitable Acceptable Appropriate Appropriate Comprehensive Effective Efficient World Health Organization, 2002

35 Shamika Is a Home Visitor with the Strong Families Tribal Home Visiting Program with the Native American Health Center.

She is a Certified Family Planning Health Worker , Lactation and Childbirth Educator . She has also worked as a Perinatal Health Worker and Birth Doula for over 10 years and strives to ensure that the families who cross her path are informed and empowered to make the right choices for their health and their families. Ultimately, Shamika would like to become a Certified Nurse Midwife and one day open her own Birth and Education center.

Shamika Dokes-Brown [email protected]

510-434-5452

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Birth Spacing, Pregnancy Planning and Prevention in the Home Visiting Setting

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Session Objectives

       Define birth spacing List possible increased risk of closely spaced pregnancies for the mother and baby List benefits of birth spacing Describe work with health care providers and challenges encountered Describe the benefits of having Home Visiting services available Describe how this information is delivered in a Home Visiting setting Explain how the lesson is covered using The Family Spirit curriculum

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Definition

Birth Spacing

The time interval between one child’s birth date until the next child birth date. Studies have proven that at least 16-18 months between deliveries may allow for a healthier outcome for both the mother and infant.

Short birth spacing is used to describe a birth-to pregnancy interval that is less than 2 years.

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Possible increased risks of closely spaced pregnancies

      Pre-term labor Uterine rupture Placenta Previa Third trimester bleeding Low-birth weight Poor marital or family support    Lower folate levels Relationship stress Increased risk for postpartum depression  Depletion of maternal stores of certain nutrients

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Benefits of healthy birth spacing

  Decreased risk of preterm delivery Baby develops well because more bonding time is available  Mom's body has had enough time to restore nutrients and recover before getting pregnant again  Less financial stress

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Strong Families Tribal Home Visiting

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Working with Health care Providers and challenges we have encountered

 NAHC  Behavioral Health, Strong Families Home Visiting (SFHV), Medical, Dental, Traditional Services, @ 3 sites  Challenges  No postpartum appointment after delivery  No return phone calls when clients leave messages  Short appointments  No close follow up or case management for clients who are considered high risk or lost to care

43 The Benefit of Having Home Visiting Services available to work with Health Care providers  Extra support for clients and families considered high risk or lost to care   Decreased no shows for medical appointments Increased breastfeeding because of intergraded services  Decrease in unwanted pregnancies

Delivering this Information in the Home Visiting setting

44  The best time to present contraception information is preconception or during pregnancy  The risk and benefits for each method should be covered following the contraception affectedness chart  As Home Visitors, we are able to elaborate more on the information and assist the client in coming up with a list of questions for her Medical provider if needed  Medical Visits can be short and the pre- education the client receives with the home visitor assists the Medical Provider and also empowers the client because she is made aware of all the contraception methods and is able to select what method that is best for her.

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Family Spirit Curriculum Understanding Reproduction

     Sex after Pregnancy Introduction to Reproductive Anatomy Understanding the Menstrual Cycle How babies are created Activities on both the Male and Female Reproductive Anatomy  After each lesson, a copy of the Reference Manual is given and a copy of the Participant Handout for the client to review and add to their binder

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Contraception Method

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Family Spirit Curriculum

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Updating the contraception sections Family Spirit Curriculum

 A Few errors were found and

Family Spirit

is currently working on updating this information  Used Chastity.com, CDC, ACOG to verify outdated info  Depo-provera (“the Shot”) & Lunelle discussed  Silver nitrate used with infants  Hepatitis B results in Pneumonia

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Lessons learned with Teaching this Curriculum

     Don’t assume that the method the client selected after delivery is still the current method if no PTL was done. Make sure to bring demos of the methods for the accurate size.

Think outside of the box for creative way to explain how the methods work. Take a calendar as a teaching point to keep track of LMP and also Intercourse etc.

Keep an endless amount of condoms on hand.

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Example for the Birth Control Pill

Taking the Birth Control Pill Correctly Not taking the Birth Control Correctly

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References

Basso O, Olsen J, Knudsen LB, Christensen K. "Low birthweight and preterm birth after short interpregnancy intervals," American Journal of Obstetrics and Gynecology 1998; 178(2):259-63.

Measuring Factors Underlying Intendedness of Women’s First and Later Pregnancies, Alan Guttmacher Institute, 2001

3 March of Dimes Foundation. March of Dimes Family Planning: get the facts about pregnancy spacing. Mayo Clinic    

Free Patient Information Printouts

http://www.acphd.org/cpsp-providers.aspx

http://www.everywomancalifornia.org/index.cfm

http://www.cdc.gov/

52 Kristine Campagna Chief:Program Development Perinatal and Early Childhood Sounivone Phanthavong Family Planning Manager Preventative Services and Community Practices

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Home Visiting and Family Planning Building on Collaborations, Integration and Partnership June 17, 2014

Division of Community, Family Health, and Equity

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Who we are, what we do, our core values

• The Division of CFHE ’ s six teams represent priority areas that promote synergy, collaboration, integration and coordination among programs.

• Work to eliminate health disparities by assuring healthy child development, and prevent and control disease and disability.

• Use a life course development approach and address the determinants of health as a framework for health planning.

• Recognize that social, political, and economic policies and conditions determine health outcomes.

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Division of Community, Family Health, and Equity

Who we are, what we do, our core values

• Value the community as a core partner in public health and work to assure the equity in health is a reality.

• Plan, develop, and evaluate programs and systems of care, which are comprehensive, community-based, culturally competent, coordinated, and effective.

Home Visiting and Family Planning

Home Visiting Programs

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First Connections:

• Public Health home visiting program • Referrals – automatically at birth through screening process.

– Community providers – pediatricians, local WIC, etc.

• Short-term referral and response • RN, SW, or CHW visits for prenatal through age three – In 2012, 3,088 children received at least one visit

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Home Visiting Programs

2009-2014 RI implemented new Evidence Based Home Visiting programs through MIECHV • Healthy Families America (HFA) • Nurse-Family Partnership (NFP) • Parents as Teachers (PAT)

Healthy Families America

58 Model – Pregnant women and families with infants up to 12 months – Helps families manage challenges by building on their strengths – Includes home visits by a trained Family Support Worker. Favorable outcomes – Child Health – Child Development and School Readiness – Reductions in Child Maltreatment, – Positive Parenting Practices, – Family Economic Self-Sufficiency, – Linkages and Referrals

Nurse-Family Partnership

59 Model – First-time, low-income mothers and their children.

– It includes one-on-one home visits by a trained public health nurse to participating clients. – Visits a family until a child turns two Favorable outcomes – Health- Maternal & Child – Child Development and School Readiness – Reductions-Child Maltreatment, Juvenile Delinquency Family Violence, and Crime – Improves-Parenting Practices and Family Economic Self Sufficiency

Parents as Teachers

60 Model -Prenatal up to 6 months of age and serves new mothers, and those who already have children -Visits focus on Parent-child interaction, Developmental centered Parenting and Family Well-being - Goal help parents understand their influence on their own child’s development Favorable outcomes – Child Development and School Readiness – Increased Positive Parenting Practices

Integrating Family Planning For Home Visitors

Initial MIECHV Training for all Home Visiting Staff – Family Planning data (e.g. unintended pregnancy rates) – Overview of Title X services & agencies – Framing family planning discussions (e.g. pregnancy intention) Ongoing training and learning opportunities at the model level – Development of Family Planning Talking Points • Recommendations for family planning counseling/education; e.g. tiered approach to contraceptive counseling; e.g. discuss most effective/long-acting reversible contraceptive methods first • Resources 61 Standardized Screening and Ongoing Assessment – Contraceptive method use assessed regularly

Integrating Family Planning – For Families

62 Client-centered counseling with referrals for family planning services • Reproductive life planning (goal setting) • Using birth control kits for examples Development of “Pregnancy Passport” • Outlining goals and next steps • Empowering patients to ask questions

Integrating Home Visiting & Family Planning – With the Community

• Putting “it” in context: Sharing statewide & community level data 63 • Supporting Local Implementation Teams & Community Coalitions – Community driven initiatives • Woonsocket – Conducted baseline survey assessing comfort & knowledge re: sexual health; developed trainings for all local home visiting staff – Opportunity for feedback and ongoing support

Integrating Home Visiting & Family Planning – At Systems Level

Coordinating Bi-directional Referrals Statewide – Home visiting as a resource for Family Planning agencies to refer pregnant/parenting clients Continuous Quality Improvement – Benchmarks: measuring and monitoring interconception, birth spacing, contraceptive use Statewide Strategic Planning – Home Visitor involvement with implementation & development of statewide Preconception Health Strategic Plan – RI Prematurity Task Force 64 Statewide Coordinated Strategic Messaging/Education – Interconception Care – March Of Dimes 39 Weeks Campaign

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For more information

Kristine Campagna 401-222-5949 [email protected]

Sounivone Phanthavong 401-222-5984 [email protected]

Resources for home visitors, and others in the home visiting setting

Sarah Brown (again…) 66 http://thenationalcampaign.org/resource/briefl y-what-home-visitors-can-do

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Reminders

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StayTeen.org

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Games and Quizzes at StayTeen.org

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Thank You!

Please visit us at: TheNationalCampaign.org

StayTeen.org

Bedsider.org

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Q & A