IMPLICIT Focus on Family Planning and Interpregnancy Interval Lisa Schlar, MD UPMC Shadyside Family Medicine Residency December 2015

Objectives Review evidence on birth spacing and family planning Present IMPLICIT ICC Phase 2 birth spacing and family planning data Share best practice strategies from Shadyside Family Health Center

IMPLICIT ICC PROGRAMS Active ICC/Entering Data: Lancaster General Mid-Hudson Family Practice Mountain Area Health Education Center (MAHEC) University of Pennsylvania UPMC McKeesport UPMC Shadyside UPMC St. Margaret Active ICC/Not Sharing Data: Lawrence U Mass Middlesex University of Rochester White lettering on a color block is especially effective for catching attention and for retention. With support from

Family planning & birth spacing Multivitamin with folic acid use 4 behavioral risks affecting future birth outcomes Smoking Depression Family planning & birth spacing Multivitamin with folic acid use Built on evidence regarding smoking and depression to also contraception and MVI (1) grade a evidence for future birth outcomes, (2) screening and intervention can be brief and done in the context of a WCV IMPLICIT ICC Model

Evidence Summary Significant association between short interpregnancy interval and spontaneous early preterm delivery – multiple studies Short IPI and PTB in Adolescents Linear Relationship (shorter interval assoc with higher rate of PTB, LBW and SGA > 36-60 mo assoc with SGA, LBW ) Shorter IPI associated with neonatal mortality Unintended, unwanted, and mistimed pregnancies associated with a significantly increased risk of LBW and PTB Optimal IPI 18-59 months LARC use significantly decreased PTB -Short IPI and assoc with early PTB - <34 weeks ---adjusted for maternal age, school education, previous birth outcomes, antenatal care, smoking habits, body mass index and gestational weight gain) -Short Interpregnancy Interval Associated with Preterm Birth in US Adolescents April 2015, 85,077 singleton live births to women aged <20 who had one previous live birth, 69 % of which followed IPIs ≤18 months. Compared with IPIs 18–23 months, short IPIs were associated with moderately preterm birth for IPIs <3 months (aOR 1.89, 95 % CI 1.70–2.10), 3–5 months (aOR 1.33, 95 % CI 1.22–1.47), and 6–12 months (aOR 1.11, 95 % CI 1.02–1.21). IPIs <3 and <6 months were also associated with very preterm birth, with aORs of 2.52 (95 % CI 1.98–3.22) and 1.68 (95 % CI 1.35–2.10) respectively. Many adolescent mothers with repeat births have short IPIs, and shorter IPIs are associated with preterm birth in a dose-dependent fashion. Increasing adolescent mothers’ use of effective contraception postpartum can address both unintended adolescent births and preterm birth. LARC use significantly decreased PTB CO Study 2015 For women living in counties with Title X clinics, the odds of PTB were significantly lower in 2012 compared with 2008 (odds ratio = 0.85; 95% confidence interval = 0.81, 0.89; interaction P = .02). For women living in Title X clinic counties in 2012, a higher proportion of LARC use (> 12.4%) was significantly associated with decreased risk of PTB (P = .02) compared with a low proportion of LARC use (≤ 4.96%). There were significantly increased odds of LBW among unintended pregnancies [odds ratio (OR) 1.36, 95% confidence interval (CI) 1.25, 1.48] ending in a live birth. Within the unintended category, mistimed (OR 1.31, 95% CI 1.13, 1.52) and unwanted (OR 1.51, 95% CI 1.29, 1.78) pregnancies were associated with LBW. There were statistically significantly increased odds of PTB among unintended (OR 1.31, 95% CI 1.09, 1.58), and unwanted (OR 1.50, 95% CI 1.41, 1.61) but not for mistimed (OR 1.36, 95% CI 0.96, 1.93) pregnancies. Unintended, unwanted, and mistimed pregnancies ending in a live birth are associated with a significantly increased risk of LBW and PTB.

Evidence Summary Rodrigues T, Barros H, Short interpregnancy interval and risk of spontaneous preterm delivery, Eur. J. Obstet. Gynecol (2007). Conde-Agudelo, A. Birth Spacing and Risk of Adverse Perinatal Outcomes: A Meta-analysis in JAMA, April 2006. Shah PS, Balkhair T Intention to become pregnant and low birth weight and preterm birth: a systematic review. Matern Child Health J. 2011 Feb;15(2):205-16. Hussaini KS, Ritenour D, Coonrod DV. Interpregnancy intervals and the risk for infant mortality: a case control study of Arizona infants 2003-2007. Matern Child Health J. 2013 May;17(4):646-53. Kozuki N, Lee AC, Silveira MF, The associations of birth intervals with small- for-gestational-age, preterm, and neonatal and infant mortality: a meta- analysis. BMC Public Health. 2013;13 Suppl 3:S3.

Evidence Summary Maureen K. Baldwin , M.D., M.P.H The Effect of Long-Acting Reversible Contraception on Rapid Repeat Pregnancy in Adolescents: A Review Journal of Adolescent Medicine April 2013Volume 52, Issue 4, Supplement, Pages S47– S53. Lina M. Nerlander .Short Interpregnancy Interval Associated with Preterm Birth in US Adolescents Maternal and Child Health Journal. April 2015, Volume 19, Issue 4, pp 850-858. Innie Chen, MD, MPH1 Gian S. Jhangri,Relationship Between Interpregnancy Interval and Adverse Perinatal and Neonatal Outcomes in Northern Alberta. J Obstet Gynaecol Can. 2015 Jul;37(7):598-605. Goldthwaite LM, Duca L Adverse Birth Outcomes in Colorado: Assessing the Impact of a Statewide Initiative to Prevent Unintended Pregnancy. Am J Public Health. 2015 Sep;105(9).

IMPLICIT ICC Model: Family Planning Assess women for contraception use Educate about benefits of longer IPI Offer contraception or arrange appointment/referral (encourage LARC) White lettering on a color block is especially effective for catching attention and for retention. Best outcome interval is 18-59 months, worst is <6 months Standard antenatal counseling alone does not improve postpartum contraceptive use PP visit rates vary by population, highest risk women are often least least likely to return

Family Planning - Phase 1 Built on evidence regarding smoking and depression to also contraception and MVI (1) grade a evidence for future birth outcomes, (2) screening and intervention can be brief and done in the context of a WCV Family Planning - Phase 1

Family Planning – Phase 2 Built on evidence regarding smoking and depression to also contraception and MVI (1) grade a evidence for future birth outcomes, (2) screening and intervention can be brief and done in the context of a WCV Family Planning – Phase 2

IMPLICIT Interconception Care Data White lettering on a color block is especially effective for catching attention and for retention. IMPLICIT Interconception Care Data

Site Dates of WCV Mom/ Baby Dyads Total WCV WCV Mom Present All ICC Partial ICC ICC Screen Rate Mid-Hudson Family Practice May 2015- Dec 2015 195 287 247 162 81 98.4% Mountain Area Health Education Center (MAHEC) Mar 2015- Sep 2015 735 1,511 850 615 235 100.0% UPMC McKeesport Dec 2014- Oct 2015 187 327 298 194 12 69.1% UPMC Shadyside Jan 2015- Nov 2015 227 445 418 336 11 83.0% UPMC St. Margaret Jan 2015- Sep 2015 306 552 519 299 22 61.8% All Sites Total 1,650 3,122 2,332 1,606 361 84.3% White lettering on a color block is especially effective for catching attention and for retention. Began Phase 2 data collection in January 2015 (or when sites went live with standardized screening questions) 3,122 WCVs from 1,650 different babies across 5 Network sites Mothers accompanied their babies to 2,332 WCVs (74.7%) Women were screened for ICC at 1,967 WCVs (84.3%) 1,606 ALL ICC (69%) and Partial ICC (15%) MAHEC 62% and Partial 28% **Data not entered in REDCap for LGH and U Penn for Phase 2 ICC Phase 2 Data January 2015-December 2015

Maternal Demographics (N=525) *Completed 31.8% of Maternal Demographics Demographics Percent Medical Assistance 74.9% African American 34.5% Hispanic 21.8% Maternal Education Less than High school degree or equivalent 22.2% High school grad/equivalent 37.5% Maternal Age <19 years old 3.5% White lettering on a color block is especially effective for catching attention and for retention. 31.8% complete LAME! May be more since have to pull from babies in Phase 1 ICC Phase 2 Data January 2015-December 2015

Is mother using contraception? (N=1,791) *Assessed contraception at 91.1% of visits with complete or partial ICC Response Frequency (visits) Percent Yes, IUD or Implant - Long Acting Reversible Contraception (LARC) 383 21.4% Yes, Permanent sterilization methods (tubal, vasectomy, hysterectomy) 132 7.4% Yes, Other 690 38.5% No, Mother is currently pregnant 48 2.7% No, Trying to conceive 29 1.6% No 509 28.4% Should be 1967 =N if all screened ICC Phase 2 Data January 2015-December 2015

Is mother using contraception? (N=1,791) White lettering on a color block is especially effective for catching attention and for retention. Another way to look at same data! Newborns not on contraception Compared to National Average More LARC ICC Phase 2 Data January 2015-December 2015

Is mother using contraception? (N=1,791) White lettering on a color block is especially effective for catching attention and for retention. All the yeses by program Very interesting no BCM at Newborn for most except SHY Major Site variation Immediate PP LARC would greatly improve this! ICC Phase 2 Data January 2015-December 2015

If not using contraception, was an intervention done? (N=439) *Assessed contraception intervention at 81.6% of eligible visits- 99 missing data points Response Frequency (visits) Percent Yes 372 84.7% No 67 15.3% 509+29 which is all No’s = 538 Didn’t complete! Need to analze all the blanks… Should we treat the missing data points as NO???? How should we report the data ICC Phase 2 Data January 2015-December 2015

If not using contraception, was an intervention done? (N=439) White lettering on a color block is especially effective for catching attention and for retention. ICC Phase 2 Data January 2015-December 2015

Has mother been pregnant since last visit? (N=1,803) *Assessed pregnancy status at 91.6% of visits with complete or partial ICC Visit Frequency Yes (visits) Percent (Yes) N Newborn (0-1 months) 4 1.20% 339 2M (2-3 months) 8 2.7% 291 4M (4-5 months) 2 1.0% 210 6M (6-8 months) 6 222 9M (9-11 months) 2.4% 170 12M (12-14 months) 14 7.6% 184 15M (15-17 months) 6.9% 116 18M (18-23 months) 27 15.3% 177 24M (24+ months) 8.5% 94 Total 81 4.50% 1,803 White lettering on a color block is especially effective for catching attention and for retention. 91.6 of ICC times it was initiated VISITS 4.5% ICC Phase 2 Data January 2015-December 2015

Cumulative percentage of moms pregnant by age of child at visits (N=1,803) White lettering on a color block is especially effective for catching attention and for retention. 18 unique women less than 6 months Jessica looked Kaplan Myer Curve ICC Phase 2 Data January 2015-December 2015

Cumulative percentage of moms pregnant by age of child at visits (N=1,803) White lettering on a color block is especially effective for catching attention and for retention. 4.5% MaHEAC no +pregnancies ICC Phase 2 Data January 2015-December 2015

Spotlight on UPMC Shadyside Screened 83% (347) of mothers for ICC Screened mothers at 339 visits for contraception (97.8%) At visits 16.8% of mothers were not using any (57) At 91.2% (52 ) visits mothers received an intervention At 18% (61) visits mothers were using LARC Screened mothers at 343 visits for pregnancy status (98.8%) At 25 visits mothers report being pregnant (7.3%) Phase 2- February 2015 Attempted to do Chart Review Look at WCC and the ICC times/answers Open Moms chart and look at her HX and BCM and Birth outcomes and spacing Why did these moms get pregnant Did they get ICC before they got pregnant Do we not screen for ICC at a visit so missed an opportunity What was outcome of births??

Spotlight on UPMC Shadyside Why Successful?? Part of Routine Built in EMR- EPIC Well Child SmartSet Part of pre-office Huddle Faculty education/buy-in Quarterly Email Report Cards Faculty Champion accessible Phase 2- February 2015 Attempted to do Chart Review Look at WCC and the ICC times/answers Open Moms chart and look at her HX and BCM and Birth outcomes and spacing Why did these moms get pregnant Did they get ICC before they got pregnant Do we not screen for ICC at a visit so missed an opportunity What was outcome of births??

Family Planning Interventions AmeriCorps Member – Direct Service Depo reminder calls for all women EMR search, Dr. request for refills, scheduling mom nurse visit Talking to ICC women who have screened “yes, other” or “no”  for contraception at past WCV to discuss contraceptive plan and offer education At WCV, meet mom discuss plan, request Rx from Dr. or schedule f/u visit   Suggesting Nexplanon to Depo Users Contraception health fair with on-site referrals      

Data Summary Screening at 84% of Visits Largely Minority-Low Income Women Cumulatively women are using LARC at 21.4% of visits National LARC Rates are 7.2% High Intervention Rates Impressive Volume! 2000 Screens in <1 year Minority low income women most to gain from proper birth spacing

Data Summary Women receive a partial screen at 18% of visits Missing maternal demographics – 68% No BCM at NB Visit for most 30% of Women on No Contraception 18 women with Short IPI (<6months) Minority low income women most to gain from proper birth spacing

Project Coordinator: Jessica Brubach (Brubachjl2@upmc.edu) Discussion Comments/Suggestions Why so many partials? Create Data Review Team To find issues need to review Data frequently Quarterly as a network?? Monthly as a program?? Why is N changing with each question???? For MAEHEC too many partials~! Need to decide on what data we want and build it!!! http://www.fmec.net/implicitnetwork.htm Project Coordinator: Jessica Brubach (Brubachjl2@upmc.edu)

A SPECIAL THANK YOU TO MIKE HORST FOR DATA CRUNCH ALSO THANK YOU TO JESSICA BRUBACH! CONGRATULATIONS on MPA TODAY!