Culturally-Sensitive Interconception Care: A Model of Implementation and Selected Project Data May 3rd, 2016 Presenters Scott Hartman, MD University of Rochester Family Medicine Sukanya Srinivasan, MD, MPH University of Pittsburgh Family Medicine

Contributors University of Rochester Family Medicine Ariel Matthews, MPH Matthew Heckman, MD, PhD David Holub, MD Elizabeth Loomis, MD Hayley Martin Holly Russell, MD University of Pittsburgh Family Medicine Residencies Jessica Brubach, MPA Jim Dombroski, MD

What is Interconception Care? An emerging concept for focusing on the health of a woman from the postpartum period up until her subsequent conception. White lettering on a color block is especially effective for catching attention and for retention.

Why Interconception Care? Despite traditional prenatal interventions, low birth weight and prematurity have not decreased Preterm birth (PTB, <37 wks) is the #1 cause of neonatal mortality & morbidity Causes 50% of all pediatric neurodevelopmental problems Low birthweight (LBW, <2500g) is being linked to adult morbidities CAD, DM2, obesity Preconception & interconception health increasingly being linked to preeclampsia, GDM, hemorrhage, and other perinatal complications Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy. The Cochrane Database for Systematic Reviews. Volume (3), 2004. And Downs DS et al. Design of the Central Pennsylvania Women's Health Study (CePAWHS) strong healthy women intervention: improving preconceptional health. 2009 Jan;13(1):18-28. Epub 2008 Feb 13.

Key Components of the ICC Model developed by the IMPLICIT Network Integrate ICC into practices by screening mothers who accompany their children (under 2 years of age) to well child visits Target modifiable risk factors: 1) Smoking 2) Depression 3) Multivitamin with folate supplementation 4) Contraception use to ensure adequate birth spacing Collect and assess data using continuous quality improvement techniques (CQI)

Diverse Settings: University of Rochester Highland Family Medicine (HFM) Family medicine and residency training practice in Western NY State Serve diverse population of varying ethnic & socioeconomic backgrounds Screened 488 unique mothers at 979 WCVs for ICC LANGUAGES SPOKEN: Somali, Spanish, Mandarin, Arabic, Farsi University of Pittsburgh Family Medicine Residencies (UPMC) Three family medicine residency programs at five health centers in south western Pennsylvania (St. Margaret, McKeesport, Shadyside) Serve diverse largely urban underserved population Screened 930 unique mothers at 1,440 WCVs for ICC LANGUAGES SPOKEN: Somali, Vietnamese, Spanish, Japanese

Maternal Demographics The majority of mothers at HFM are White or Caucasian (46%), while the majority of mothers at UPMC are Black or African American (51%)

Maternal Demographics 58% of mothers at HFM are on Medical Assistance, compared to 77% at UPMC

In-Practice Implementation at HFM Collaboration Obtaining on-going approval & involvement from management Recruiting more people in the practice to champion the project as members of an ICC Team or Committee Communication Reinforcement of staff roles and process flow through face to face meetings, office presentations, and emails Correcting misconceptions as they arise Cultural Competency Obtaining information on patient population makeup & using those results to craft screening forms in another language Translating patient education materials into multiple other languages

Example of Patient Education & Translated Materials

In-practice Implementation at UPMC Education Inservice Didactics Incentives Counts for residency scholarly activity/QI Involvement/Engagement Learners need projects Reminders Encouragements/Shout-out’s

Example of Patient Education Materials

Looking at LARC Rates between the two sites Comparing IMPLICIT Interconception Care Data: Contraception Use to ensure adequate birth spacing Looking at LARC Rates between the two sites

Long Acting Reversible Contraception 60.9 million Women aged 15-44 in the U.S. 38.3% not using contraception (Reasons include never sexually active, currently pregnant/seeking pregnancy (5%), infertility, etc. Women who had sex in the past 3 months who were not using birth control are 6.9% of all women 15-44). 7.2% using LARC (6.4% IUD, 0.8% Implant) 20.6% permanent sterilization methods 33.9% all other methods (16% Pill, 9.4% Condoms, 2.8% Depo, 1.6% ring or patch, 4.1% options such as natural family planning, female condom, etc.) LARC Rates by Race/Ethnicity: Used by 8.7% of Hispanic women aged 15-44 7.4% of Non-Hispanic White women 15-44 5% of Non-Hispanic Black women 15-44 5.8% of all other single race or mixed race Preferred method of birth spacing for ICC Source: Daniels K, Daugherty J, Jones J. Current contraceptive status among women aged 15-44: United States, 2011-2013. NCHS data brief, no 173. Hyattsville, MD: National Center for Health Statistics. 2014. National Contraception & LARC Rates Info: The 2011-2013 National Survey of Family Growth Data

Data Summary Overall, women at HFM reported to be on LARC at 201 visits (23%) while women at UPMC report to be on LARC at 179 visits (13%) At HFM, the most common form of LARC at 2 month WCV was Nexplanon (37%), while the most common form of LARC at 12 month WCV was Mirena IUD (44%)

Conclusions ICC can be adaptable to a variety of primary care settings ICC can be delivered in a culturally sensitive manner Screening for modifiable risk factors for preconception health is possibly during WCV’s Educating women about birth spacing at WCVs offers a way to promote LARC usage during the key interconception period Strengths and Limitations: Strengths: 1.) Our individual settings, in that we were able to do this in a large setting with many different clinicians and still got high rates of screening and interventions 2.) We in the network have different types of sites doing different types of materials translations, etc.—we have been able to reach out to other sites for help in process. Limitations: 1.) Regionality—geographic separation means we don’t know what other sites are doing if we don’t ask. 2.) The length of time it takes to fit the project into the schedule & using paper to gather the data (leads to some losses if people toss away, etc.)

Questions? Contact: Ariel Matthews, HFM ICC Coordinator, Ariel_Matthews@URMC.Rochester.edu Jessica Brubach, UPMC ICC Project Coordinator brubachjl2@upmc.edu Scott Hartman, MD, University of Rochester Department of Family Medicine Scott_Hartman@URMC.Rochester.edu White lettering on a color block is especially effective for catching attention and for retention.