1. 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

2. 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

3. 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.

4. 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 Jan;13(1): Epub 2008 Feb 13.

5. 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)

6. 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

7. 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%)

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

9. 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 s
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

10. Example of Patient Education & Translated Materials

11. 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

12. Example of Patient Education Materials

13. 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

14. Long Acting Reversible Contraception
60.9 million Women aged 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, NCHS data brief, no 173. Hyattsville, MD: National Center for Health Statistics
National Contraception & LARC Rates Info: The National Survey of Family Growth Data

17. 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%)

18. 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.)

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