1. 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

2. 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.

3. 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.

4. 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)

5. 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

6. 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

7. 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

9. 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

10. 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

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

12. 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

13. Perceptions of Patient Barriers

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

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

16. Contraception Knowledge

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

18. 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.

19. Questions?