Sukanya Srinivasan, MD, MPH University of Rochester Family Medicine Understanding the Challenges in Providing Contraceptive Care in Residency Family Health Centers November 9, 2018 Presenters Scott Hartman, MD Elizabeth Loomis, MD Lauren Cowen University of Rochester Family Medicine Sukanya Srinivasan, MD, MPH University of Pittsburgh Family Medicine Contributor Jocelyn Young, MD University of Rochester Family Medicine Christina Gasbarro, MD University of Pittsburgh Family Medicine

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)

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 Presented at STFM Conference May 3, 2016 by Scott Hartman MD and Sukanya Srinivasan MD, MPH

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

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 1312 unique mothers at 2638 WCVs for ICC LANGUAGES SPOKEN: Somali, Spanish, Mandarin, Arabic, Farsi University of Pittsburgh Family Medicine Residencies (UPMC St M) Three health centers in south western Pennsylvania Serve diverse largely urban underserved population Screened 849 unique mothers at 3,108 WCVs for ICC LANGUAGES SPOKEN: Somali, Vietnamese, Spanish, Japanese

Implementation of Evidence-Based Interconception Care Program: Barriers to contraceptive care access Looking at staff and clinician perceptions of challenges to providing contraceptive care between the two sites FMEC Conference November 9, 2018

Patient Visit Desiree is a 22-year-old mother of two children – Maya (18 mo) and Shane (4 mo). She is here for Shane’s 4-month WCC. Smoking – current smoker (1/2 ppd x 5 years) Depression – negative PHQ2 Family Planning – feels overwhelmed at home and does not desire to have another child in the next few years Multivitamin – does not take a multivitamin but has leftover prenatal vitamins at home

Discussion What barriers to providing contraception care have you identified? Can you think of ways to manage these barriers at your health center?

Participant Demographics Staff Providers 76 participants 95 participants 93% female 56% female 67% white, 19% black, 4% Latino, 82% white, 13% Asian, 3% mixed or other, 1% black, 1% Latino 7% mixed or other, 3% Asian HFM HFM St. Margaret St. Margaret

Perceptions of Patient Barriers

Staff Identified Barriers Average Ranking Score Potential Staff Barrier to Providing Contraception Care Highland Family Medicine St. Margaret

Provider Identified Barriers Average Ranking Score Potential Provider Barrier to Providing Contraception Care Highland Family Medicine St. Margaret

Contraception Knowledge

Future Directions Disseminate study findings Scheduling Education Presented results to HFM’s ICC Committee (January 12 2018) Poster presentation at 2018 STFM Conference (May 6 2018) Scheduling Development of tracking system to follow-up on patients requesting LARC at St. Margaret Education Contraception didactic activity for staff at HFM (May 10 2018) Focus Group HFM 3rd year resident focus group surrounding reliable availability of LARC devices (April 6 2018) Quality Improvement projects To be determined

Conclusions Clinician-identified barriers: appointment timing. Clinician perception of patient barriers: side effects and patient lack of awareness or misconceptions regarding contraception. Staff-identified barriers: scheduling and finance. Staff perception of patient barriers: St. Margaret (side effects and patient lack of awareness or misconceptions regarding contraception). HFM (transportation, though rated many other factors). There is a significant gap in staff knowledge about IUD contraception.

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