TM 1 "The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry" Hani K. Atrash, MD, MPH Associate Director for Program Development National Center on Birth Defects and Developmental Disabilities And, The CDC Select Panel on Preconception Care The CDC/ATSDR Workgroup on Preconception Care, and CDC’s Preconception Health and Health Care Initiative: History and An Update 2007 CityMatCH Urban MCH Leadership Conference August , 2007, Denver, Colorado

TM 2 The Preconception Care Team Steering Committee: CDC, HRSA/MCHB, ACOG, MOD, AMCHP, CityMatCH, Consultants Select Panel: Representatives of partner organizations, subject matter experts CDC/ATSDR Workgroup: Representatives of 22 programs (80+ members) Workgroups (Clinical, Public Health, Consumer, Policy and Finance): Practitioners, members of select panel, members of CDC/ATSDR workgroup Pilot Urban Practice Collaborative

TM 3 Why Preconception Care 1.Poor Pregnancy Outcomes Continue To Be At Un- acceptable Levels 2.Women Enter Pregnancy “At Risk” For Adverse Outcomes 3.There Is Consensus That We Must Act Before Pregnancy 4.Intervening Before Pregnancy Will Help Improve Outcomes 5.We currently intervene too late

TM 4 If you continue to do what you always did, You will continue to get What You always got Anonymous

TM 5 From Anticipation and Management to Health Promotion and Prevention From Healthy Mothers Healthy Babies to Healthy Women Healthy Mothers Healthy Babies Paradigm Shift

TM 6 Not a New Concept Aristotle, Problemata, BCE: Foolish, drunken, or harebrain women most often bring forth children like unto themselves William Potts Dewees, first American textbook on Pediatrics 1825: “The physical treatment of children should begin as far as may be practicable, with the earliest formation of the embryo; it will, therefore, necessarily involve the conduct of the mother, even before her marriage, as well as during her pregnancy.” Domestically, starting in 1979: Reference in government and professional reports Internationally MCH and women’s health meeting reports starting in the 1960s

TM 7 Opportunities are missed New strategies are needed Facilitate collaboration Develop recommendations Identify and address obstacles and opportunities: »Clinical, Public health, Consumer, Policy & Finance, Research Why a CDC Preconception Health and Health Care Initiative?

TM 8 Challenges to Implementation (2004) Absence of a national policy that supports implementation Lack of National/State/Local Model programs Lack of tools and practical guidelines for practice (Who does it, who gets it, how much, what is it, why do it, how to do it, where to do it, when to do it, etc?) Inadequate education of providers and consumers Lack of demonstrated practicality, feasiblity and effectiveness of preconception “programs”

TM 9 The CDC PCC Initiative Initial Plan Make the scientific case; Solidify the scientific evidence Make the business case Develop consensus within and outside CDC Develop recommendations and national policy Develop guidelines and tools for implementation Develop marketing strategies: Implement recommendations Enhance knowledge and skills of providers Educate consumers

TM 10 The CDC PCC Initiative: Timeline 6/04 CDC Workgroup 11/04 Meeting with Partners 4/06 Recommendations 6/05 Select Panel Meeting 6/05 1 st Summit 5/06 Clinical, PH, Consumer Workgroup Meetings 3/07 Policy & Finance Workgroup Meetings 5/07 2 nd Select Panel Meeting 10/07 2 nd Summit 9/06 Supplement 1/06 Steering Committee Meeting

TM 11

TM 12 Partners With CDC’s Environmental Health, Birth Defects and Developmental Disabilities, Chronic Disease, Infectious Diseases, National Immunization Program, Health Marketing, Health Statistics, HIV, STD, and TB Prevention, Women’s Health, Genomics and Public Health

TM 13 Recommendations 1-5 Recommendation 1. Individual responsibility across the life span Recommendation 2. Consumer awareness Recommendation 3. Preventive visits Recommendation 4. Interventions for identified risks Recommendation 5. Interconception care

TM 14 Recommendations 6-10 Recommendation 6. Pre-pregnancy check ups Recommendation 7. Health coverage for low-income women Recommendation 8. Public health programs and strategies Recommendation 9. Research Recommendation 10. Monitoring improvements

TM 15 1.Define contents 2.Integrate existing guidelines 3.Disseminate information 4.Demonstrate effectiveness 5.Explore means for financing 6.Monitor practice 7.Study association between women’s health and pregnancy outcomes 7.Conduct a cost study Steering Committee Meeting The Road Ahead

TM 16 Implementation: The Goals consumer Changing consumer knowledge, attitudes, and practices clinical providers’ Changing clinical providers’ knowledge, attitudes, and practices public health Change public health professionals’ knowledge, attitudes, and practices

TM 17 Strategies to Implement The Recommendations Workgroup Meetings: June 27/ : oClinical oPublic Health oConsumer March 2007: oPolicy and Finance

TM 18 1.Clinical guidelines and tools 2.Consumer information 3.Public health programs and strategies 4.Monitoring and surveillance 5.Research agenda 6.Public policy and finance 7.Professional education/training 8. Best practices 9.Demonstration projects 10.State and local initiatives Strategies for Implementation

TM CLINICAL GUIDELINES & TOOLS Develop guidelines; Assess screening tools; Disseminate products; Redesign postpartum visit; Implement demonstration / quality improvement / research projects Strategies for Implementation 2. CONSUMER INFORMATION Develop consumer messages; Conduct community participatory action research; Compile consumer self-assessment tools; Study effectiveness of bundled messages

TM PUBLIC HEALTH PROGRAMS AND STRATEGIES Encourage integration of PC practices; Develop, evaluate, and disseminate integrated approaches; Analyze and evaluate Healthy Start PCC activities; Encourage action at the community; Support a Preconception Health Practice Collaborative Strategies for Implementation 4. MONITORING & SURVEILLANCE Improve surveillance and monitoring; Conduct needs / gaps assessment; Link to laboratory leadership; Link to prevention of birth defects

TM RESEARCH AGENDA Develop a list of priority research projects; Generate research project proposals Strategies for Implementation 6. PUBLIC POLICY AND FINANCE Develop a menu of public policy options; Develop Medicaid demonstration; Develop a private health plan finance pilot / demonstration project 7. PROFESSIONAL EDUCATION AND TRAINING Promote education and training for public health and clinical care professionals; Review and disseminate existing and new training modules

TM BEST PRACTICES Develop a catalogue of promising practices; Share promising practices; Maintain Internet web portals; Convene a national meeting in 2007 Strategies for Implementation 9. DEMONSTRATION PROJECTS Evaluate current projects; Initiate new projects; Identify opportunities in public health settings 10. STATE & LOCAL INITIATIVES Support state and local initiatives

TM 23 Clinical Workgroup Developing a Curriculum for training clinical care providers Developing a uniform set of guidelines Developing a standard assessment tool Delivering lectures at various meetings and conferences Developing a clinical demonstration project and other research projects

TM 24 Public Health Workgroup Assessing existing screening tools Promoting education for public health students and workers Modifying existing surveys to include questions on preconception health and health care Evaluating preconception/interconception care activities under Healthy Start Implementing Public Health Practice Collaboratives in Los Angeles, Nashville and Hartford

TM 25 Consumer Workgroup/Other Consumer Workgroup: Developing consumer messages with market research Conducting participatory action research with women at risk Other: Speakers’ Bureau with over 30 volunteers available to speak about preconception care CDC and March of Dimes updated their websites to include more information about preconception care Members of the steering committee are supporting several states who started working on preconception care

TM 26 The CityMatCH Pilot Urban Practice Collaborative Acts on CDC Recommendation 8: “Integrate components of preconception health into existing local public health and related programs, including emphasis on interconnection interventions for women with previous adverse outcomes”  Uses a “practice collaborative” model to promote adoption and integration of Preconception health recommendations among peers  Encourages more integrated preconception health practices and policies in public health programs in urban settings

TM 27 Led by the urban public health program (CityMatCH member is the health department) 5-person teams with expertise in: community assessment/engagement prevention programming clinical practice policy development and systems integration of reproductive/women’s health Each team has representatives from local March of Dimes, State MCH Director, & local community organizations Each team will select a project to address preconception health in their community CityMatCH Pilot Urban Practice Collaborative: Team Composition

TM 28 Team Hartford Smaller racial/ethnically diverse urban area in the Northeast Large Latina population Project Focus: Integration of preconception health into existing MCH programs

TM 29 Team Los Angeles Large urban center with 1 of 4 US births occurring in the county Tremendous potential impact on maternal and infant health outcomes Project Focus: Improve data and surveillance preconception health issues

TM 30 Team Nashville Mid-size, traditional Southern urban area with large Black population Project Focus: Target special populations to address preconception health concerns of childbearing age women including young women with sickle cell disease & trait

TM 31 Thank You! Questions???