Birth Spacing and Pregnancy
Planning/Prevention in Home
Visiting
Webinar hosted by The National
Campaign to Prevent Teen and
Unplanned Pregnancy
June 17, 2014
3:00PM – 4:30PM (EDT)
1
What we will hear
Welcome/Introductions
Why the topic of pregnancy spacing and planning is germane
to the home visiting community
An overview of new OPA/CDC Quality Family Planning
Clinical Guidelines, Modern Contraception, Access to
Contraception, and Training for Home Visitors
A presentation from two home visiting program leaders who
are incorporating birth spacing and pregnancy
planning/prevention
Resources for home visitors and others working in the home
visiting sector
2
Speakers
David Willis, MD, FAAP – HRSA, HHS
Moushumi Beltangady, MSW MPP – HRSA,HHS
Sarah Brown, MSPH – The National Campaign to Prevent
Teen and Unplanned Pregnancy
Susan Moskosky, MS, WHNP-BC, OPA, HHS
Shamika Dokes-Brown, Native American Health Center
Kristine Campagna, Rhode Island Department of Health
Sounivone Phanthavong, Rhode Island Department of Health
3
Birth Spacing and Pregnancy
Planning/Prevention in Home Visiting
June 17, 2014
David W. Willis, M.D., FAAP
Director, Division of Home Visiting and Early
Childhood Systems
Maternal and Child Health Bureau
Health Resources and Services
Administration
Department of Health and Human Services
4
The Home Visiting Program
● Authorized by Title V of the Social Security Act:
Maternal, Infant, and Early Childhood Home
Visiting Programs
● $1.5 billion over 5 years
 $100M FY2010
 $250M FY2011
 $350M FY2012
 $400M FY2013
 $400M FY2014
 Sustainable Growth Rate Legislation
 $400M FY2015
5
The Home Visiting Program
• Supports Families
• Evidence-based parent support services
• Partnership between parents and home visitors
• Ongoing visits and dialogue around family needs
• Voluntary
• For families that ask to be empowered with better
knowledge, health and parenting
• Evidence-based
• Built on four decades of rigorous research and evaluation
• Includes a rigorous national randomized controlled trial
evaluation and local evaluations
• Now 14 HHS approved home visiting models
6
The Home Visiting Program
• Cost effective
• Home Visiting prevents child abuse and neglect,
encourages positive parenting and promotes child
development and school readiness
• Long term reduction of school dropout rates, teen
pregnancy and crime
• Every $1.00 invested, yields up to $9.50 ROI to society*
• Locally designed and run
• Provides states with maximum flexibility to tailor programs to
fit needs of different communities
• States can choose from 14 evidence-based home visiting
models
• Programs run by local organizations in local communities
7
*Source: Ted R. Miller, “Nurse-Family Partnership Home Visitation: Costs,
Outcomes, and Return on Investment,” The Pew Center on the States. (2013).
The Home Visiting Program
Home Visiting Benchmarks
1. Maternal and newborn health (8 constructs)
2. Child injuries; child abuse, neglect, or
maltreatment; emergency department visits
(7)
3. School readiness and achievement (9)
4. Crime (2) or domestic violence (3)
5. Family economic self-sufficiency (3)
6. Coordination/referrals for other community
resources (5)
8
Importance of Birth Spacing and
Pregnancy Prevention/Planning
• Birth spacing, pregnancy planning and
preconception health services contribute to
improved health outcomes for infants,
children, women, and families.
• Interval birth education and preconception
health are important components of our
home visiting program and key benchmark
indicators for measuring our success.
9
Importance of Birth Spacing and
Pregnancy Prevention/Planning
• Short intervals between pregnancies are
associated with increased risk of adverse
perinatal outcomes including preterm births and
low-birth-weight infants.
• Unintended pregnancies can have negative
health and economic consequences including
delays in seeking prenatal care, reduced
likelihood of breastfeeding, maternal depression,
lower adult educational attainment and income,
and poor mental and physical health during
childhood (Sonfield, 2011).
10
The Home Visiting Program
Strategies / Innovations
Ongoing staff training
Partnership building with family planning programs
Birth spacing curricula and home-based education
Referral to preconception health programs and other
primary health care providers
• Workshops, webinars, conferences and printed
materials
• Teen focused education programs
•
•
•
•
11
The Home Visiting Program
What’s Needed?
• Better integration of home visiting, preconception
health and primary health care services
• More cross training with and completed referrals
to preconception health programs
• Continuous monitoring and assessment to
improve education and referral services
12
The Home Visiting Program
The opportunity…
... to better integrate home visiting, birth
interval education, and preconception
health services to improve the life course of
the next generation of our nation’s
vulnerable children, youth and families.
13
Contact Information
David W. Willis, MD, FAAP
Director, Division of Home Visiting
and Early Childhood Systems
Maternal and Child Health Bureau, HRSA
301-443-8590
dwillis@hrsa.gov
14
Moushumi
Beltangady
Senior Policy Advisor for
Early Childhood Development
Office of the Deputy Assistant Secretary for Early
Childhood Development, Administration for
Children and Families
U.S. Department of Health and Human Services
15
Why birth spacing and pregnancy
planning matter for home visiting
Sarah Brown, CEO
The National Campaign to
Prevent Teen and
Unplanned Pregnancy
16
A bit about
The National Campaign
17
Starting at the beginning
No
contraception
Pregnancy /
Gap in
contraceptive
coverage
Cont. Failure
Inconsistent
Use
18
Birth
Infancy
Family and
child
The benefits of pregnancy planning
For example:
• Increased opportunities for preconception care
• Earlier start in prenatal care
• Lowered risk of preterm delivery, low birth weight, fetal
growth retardation and infant mortality
• Increased opportunity for maternal education
• Reduced relationship conflict
19
The benefits of pregnancy planning
extend beyond first births
• All the benefits of pregnancy planning noted
on previous slide continue to apply with
second and higher order births….
• Mainly through preconception care and
adequate child spacing which benefit the
mother and the child/children already
present.
20
In the context of home visiting…
• It is logical and amply supported by
research to focus some attention on
birth spacing -- that is, helping a
young mother think about if and
when she might want an additional
child, and what steps she can take now
to ensure a healthy pregnancy and
good results – both for herself, her
current child and family AND future
children.
• One major way to help achieve adequate child spacing is through
the use of high quality contraception.
21
Unintended pregnancy in the
populations you may serve
• Among unmarried women in their twenties, 75%
of births resulting from unintended pregnancies are
to women who have already had at least one
pregnancy/birth
• 70% of pregnancies to unmarried women in their
20s are unintended
• Almost 20% of teen mothers have a second birth
before turning 20
22
Approaching pregnancy spacing and
planning within home visits
• Approach topic in a relaxed, respectful
manner
• Ask One Key Question: “Would you like to
become pregnant in the next year?
• If yes: preconception/prenatal care referrals
and links
• If no, provide links to family planning care
and information
23
24
A note on contraception itself
• Home visitors do not need to be family
planning experts; help is available in most
communities
• Even so, basic knowledge about
contraception is important, especially newer
low-maintenance methods
• Warm concern can make all the difference,
along with helping women get the method
best for them and avoid gaps in protection
25
Susan Moskosky, MS, WHNP-BC
Acting Director, Office of Population Affairs
U.S. Department of Health & Human Services
Susan.moskosky@hhs.gov
26
What is Title X?
 Mission: To provide individuals with the information and means to
exercise their ability to determine the number & spacing of their
children, including providing access to a broad range of acceptable &
effective family planning methods and related services
 4,200 clinics nationally
 State and local health departments,
hospitals, university-based clinics,
community health centers and
free-standing clinics
27
Title X Services
 Confidential
 Voluntary
 Contraceptive counseling, services & supplies
 Breast and cervical cancer screening
 STD screening, counseling and treatment
 HIV testing, prevention education
 Pregnancy testing, counseling and referral
 Other preventive health services
 Charges based on family income
28
http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
29
29
Conceptual Framework
Based on the IOM’s definition of “quality”:
Safe
Effective
Client centered
Timely
Improved
quality
Accessible
Efficient
Equitable
Value
Improved
reproductive
health outcomes
IOM (2001). Crossing the quality chasm: a new health system for
the 21st century. National Academies of Science, Washington DC.
30
Framework for Family Planning,
Related and Other Preventive Services
31
Contraceptive Services

Remove medical barriers as a prerequisite to contraceptive provision
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32
Pelvic exams not routinely needed, unless inserting IUD or diaphragm
Cervical cytology
Routine HIV screening

Provide in accordance with CDC’s MEC and SPR

Offer a full range of FDA-approved methods

Highly effective, reversible contraceptive methods are available and safe for most women
and adolescents (LARCs - IUC and Implants) )

Use an evidence-informed counseling process, which includes educating about the most
effective contraceptive methods first

Contraceptives are one of the women’s preventive services that must be made available
without co-pays or cost sharing under the ACA
Special Considerations for Adolescents
 Counseling adolescents
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33
Unique needs and characteristics
Emphasis on confidentiality
Promotion of parent-child communication about sexual health
Provide comprehensive information about pregnancy
prevention, including contraception and abstinence
LARCs are safe and effective for many sexually active
adolescents
Youth Friendly Services








Accessible
Equitable
Acceptable
Appropriate
Appropriate
Comprehensive
Effective
Efficient
World Health Organization, 2002
34
Shamika Is a Home Visitor with the Strong
Families Tribal Home Visiting Program
with the Native American Health Center.
She is a Certified Family Planning Health
Worker , Lactation and Childbirth
Educator . She has also worked as a
Perinatal Health Worker and Birth Doula
for over 10 years and strives to ensure
that the families who cross her path are
informed and empowered to make the
right choices for their health and their
families.
Ultimately, Shamika would like to become
a Certified Nurse Midwife and one day
open her own Birth and Education center.
Shamika Dokes-Brown
shamikad@nativehealth.org
510-434-5452
35
Birth Spacing, Pregnancy
Planning and Prevention in the
Home Visiting Setting
36
Session Objectives
 Define birth spacing
 List possible increased risk of closely spaced pregnancies for the
mother and baby
 List benefits of birth spacing
 Describe work with health care providers and challenges
encountered
 Describe the benefits of having Home Visiting services available
 Describe how this information is delivered in a Home Visiting
setting
 Explain how the lesson is covered using The Family Spirit
curriculum
37
Definition
Birth Spacing The time interval between one child’s
birth date until the next child birth date.
Studies have proven that at least 16-18 months between
deliveries may allow for a healthier outcome for both
the mother and infant.
Short birth spacing is used to describe a birth-topregnancy interval that is less than 2 years.
38
Possible increased risks of closely
spaced pregnancies


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39
Pre-term labor
Uterine rupture
Placenta Previa
Third trimester bleeding
Low-birth weight
Poor marital or family
support
 Lower folate levels
 Relationship stress
 Increased risk for
postpartum depression
 Depletion of maternal
stores of certain nutrients
Benefits of healthy birth spacing
 Decreased risk of preterm delivery
 Baby develops well because more bonding time is
available
 Mom's body has had enough time to restore nutrients
and recover before getting pregnant again
 Less financial stress
40
Strong Families Tribal Home
Visiting
41
Working with Health care Providers
and challenges we have encountered
 NAHC
 Behavioral Health, Strong Families Home Visiting (SFHV),
Medical, Dental, Traditional Services, @ 3 sites
 Challenges

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42
No postpartum appointment after delivery
No return phone calls when clients leave messages
Short appointments
No close follow up or case management for clients who are
considered high risk or lost to care
The Benefit of Having Home Visiting Services
available to work with Health Care providers
 Extra support for clients and families considered high
risk or lost to care
 Decreased no shows for medical appointments
 Increased breastfeeding because of intergraded
services
 Decrease in unwanted pregnancies
43
Delivering this Information in the
Home Visiting setting
 The best time to present contraception information is preconception
or during pregnancy
 The risk and benefits for each method should be covered following
the contraception affectedness chart
 As Home Visitors, we are able to elaborate more on the information
and assist the client in coming up with a list of questions for her
Medical provider if needed
44
 Medical Visits can be short and the pre- education the client receives
with the home visitor assists the Medical Provider and also empowers
the client because she is made aware of all the contraception
methods and is able to select what method that is best for her.
Family Spirit Curriculum
Understanding Reproduction

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
Sex after Pregnancy
Introduction to Reproductive Anatomy
Understanding the Menstrual Cycle
How babies are created
Activities on both the Male and Female
Reproductive Anatomy
 After each lesson, a copy of the Reference
Manual is given and a copy of the Participant
Handout for the client to review and add to their
binder
45
Contraception Method
46
Family Spirit Curriculum
47
Updating the contraception sections
Family Spirit Curriculum
 A Few errors were found and Family Spirit is currently
working on updating this information
 Used Chastity.com, CDC, ACOG to verify outdated info
 Depo-provera (“the Shot”) & Lunelle discussed
 Silver nitrate used with infants
 Hepatitis B results in Pneumonia
48
Lessons learned with Teaching this
Curriculum
 Don’t assume that the method the client selected
after delivery is still the current method if no PTL was
done.
 Make sure to bring demos of the methods for the
accurate size.
 Think outside of the box for creative way to explain
how the methods work.
 Take a calendar as a teaching point to keep track of
LMP and also Intercourse etc.
 Keep an endless amount of condoms on hand.
49
Example for the Birth Control Pill
Taking the Birth Control Pill
Correctly
50
Not taking the Birth Control
Correctly
References
Basso O, Olsen J, Knudsen LB, Christensen K. "Low birthweight and preterm birth after short
interpregnancy intervals," American Journal of Obstetrics and Gynecology 1998; 178(2):259-63.
Measuring Factors Underlying Intendedness of Women’s First and Later Pregnancies, Alan
Guttmacher Institute, 2001 3
March of Dimes Foundation. March of Dimes
Family Planning: get the facts about pregnancy spacing. Mayo Clinic
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51
Free Patient Information Printouts
http://www.acphd.org/cpsp-providers.aspx
http://www.everywomancalifornia.org/index.cfm
http://www.cdc.gov/
Kristine Campagna
Chief:Program Development
Perinatal and Early Childhood
Sounivone Phanthavong
Family Planning Manager
Preventative Services and
Community Practices
52
Home Visiting and Family Planning
Building on Collaborations, Integration and
Partnership
June 17, 2014
53
Division of Community, Family
Health, and Equity
Who we are, what we do, our core values
• The Division of CFHE’s six teams represent priority
areas that promote synergy, collaboration, integration
and coordination among programs.
• Work to eliminate health disparities by assuring
healthy child development, and prevent and control
disease and disability.
• Use a life course development approach and address
the determinants of health as a framework for health
planning.
• Recognize that social, political, and economic policies
and conditions determine health outcomes.
54
Division of Community, Family
Health, and Equity
Who we are, what we do, our core values
• Value the community as a core partner in public health
and work to assure the equity in health is a reality.
• Plan, develop, and evaluate programs and systems of
care, which are comprehensive, community-based,
culturally competent, coordinated, and effective.
Home Visiting and Family Planning
55
Home Visiting Programs
First Connections:
• Public Health home visiting program
• Referrals
– automatically at birth through screening process.
– Community providers – pediatricians, local WIC,
etc.
• Short-term referral and response
• RN, SW, or CHW visits for prenatal through
age three
– In 2012, 3,088 children received at least one visit
56
Home Visiting Programs
2009-2014 RI implemented new EvidenceBased Home Visiting programs through
MIECHV
• Healthy Families America (HFA)
• Nurse-Family Partnership (NFP)
• Parents as Teachers (PAT)
57
Healthy Families America
Model
– Pregnant women and families with infants up to 12
months
– Helps families manage challenges by building on their
strengths
– Includes home visits by a trained Family Support
Worker.
Favorable outcomes
–
–
–
–
–
–
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Child Health
Child Development and School Readiness
Reductions in Child Maltreatment,
Positive Parenting Practices,
Family Economic Self-Sufficiency,
Linkages and Referrals
Nurse-Family Partnership
Model
– First-time, low-income mothers and their children.
– It includes one-on-one home visits by a trained public
health nurse to participating clients.
– Visits a family until a child turns two
Favorable outcomes
59
– Health- Maternal & Child
– Child Development and School Readiness
– Reductions-Child Maltreatment, Juvenile Delinquency
Family Violence, and Crime
– Improves-Parenting Practices and Family Economic SelfSufficiency
Parents as Teachers
Model
-Prenatal up to 6 months of age and serves new mothers,
and those who already have children
-Visits focus on Parent-child interaction, Developmental
centered Parenting and Family Well-being
- Goal help parents understand their influence on their own
child’s development
Favorable outcomes
– Child Development and School Readiness
– Increased Positive Parenting Practices
60
Integrating Family Planning For Home Visitors
Initial MIECHV Training for all Home Visiting Staff
– Family Planning data (e.g. unintended pregnancy rates)
– Overview of Title X services & agencies
– Framing family planning discussions (e.g. pregnancy intention)
Ongoing training and learning opportunities at the model level
– Development of Family Planning Talking Points
• Recommendations for family planning counseling/education; e.g.
tiered approach to contraceptive counseling; e.g. discuss most
effective/long-acting reversible contraceptive methods first
• Resources
Standardized Screening and Ongoing Assessment
– Contraceptive method use assessed regularly
61
Integrating Family Planning –
For Families
Client-centered counseling with referrals
for family planning services
• Reproductive life planning (goal setting)
• Using birth control kits for examples
Development of “Pregnancy Passport”
• Outlining goals and next steps
• Empowering patients to ask questions
62
Integrating Home Visiting & Family
Planning – With the Community
• Putting “it” in context: Sharing statewide &
community level data
• Supporting Local Implementation Teams &
Community Coalitions
– Community driven initiatives
• Woonsocket – Conducted baseline survey
assessing comfort & knowledge re: sexual health;
developed trainings for all local home visiting staff
– Opportunity for feedback and ongoing support
63
Integrating Home Visiting & Family
Planning – At Systems Level
Coordinating Bi-directional Referrals Statewide
– Home visiting as a resource for Family Planning agencies to refer
pregnant/parenting clients
Continuous Quality Improvement
– Benchmarks: measuring and monitoring interconception, birth spacing,
contraceptive use
Statewide Strategic Planning
– Home Visitor involvement with implementation & development of statewide
Preconception Health Strategic Plan
– RI Prematurity Task Force
Statewide Coordinated Strategic Messaging/Education
64
– Interconception Care
– March Of Dimes 39 Weeks Campaign
For more information
Kristine Campagna 401-222-5949
kristine.campagna@health.ri.gov
Sounivone Phanthavong 401-222-5984
sounivone.phanthavong@health.ri.gov
65
Resources for home visitors, and
others in the home visiting setting
Sarah Brown (again…)
http://thenationalcampaign.org/resource/briefl
y-what-home-visitors-can-do
66
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Reminders
70
StayTeen.org
71
Games and Quizzes at
StayTeen.org
72
Thank You!
Please visit us at:
TheNationalCampaign.org
StayTeen.org
Bedsider.org
73
Q&A
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