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

2. 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

3. 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

4. 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

5. 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 > 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 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.

6. 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 Feb;15(2):
Hussaini KS, Ritenour D, Coonrod DV.
Interpregnancy intervals and the risk for infant mortality: a case control study of Arizona infants Matern Child Health J May;17(4):
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.

7. 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
Innie Chen, MD, MPH1 Gian S. Jhangri,Relationship Between Interpregnancy Interval and Adverse Perinatal and Neonatal Outcomes in Northern Alberta.
J Obstet Gynaecol Can Jul;37(7):
Goldthwaite LM, Duca L Adverse Birth Outcomes in Colorado: Assessing the Impact of a Statewide Initiative to Prevent Unintended Pregnancy. Am J Public Health Sep;105(9).

8. 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 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

9. 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

10. 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

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

12. Site
Dates of WCV
Mom/ Baby Dyads
Total WCV
WCV Mom Present
All ICC
Partial ICC
ICC Screen Rate
Mid-Hudson Family Practice
May Dec 2015
195
287
247
162 81
98.4%
Mountain Area Health Education Center (MAHEC)
Mar Sep 2015
735
1,511
850
615
235
100.0%
UPMC McKeesport
Dec Oct 2015
187
327
298
194 12
69.1%
UPMC Shadyside
Jan Nov 2015
227
445
418
336 11
83.0%
UPMC St. Margaret
Jan 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 (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

13. 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

14. 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

15. 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

16. 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

17. 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%
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

18. 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

19. 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

20. 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

21. 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

22. 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??

23. 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 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??

24. 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    

25. 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

26. 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

27. 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!!!
Project Coordinator: Jessica Brubach

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