EXCERPTS OF STATE INITIATIVES IN PRECONCEPTION HEALTH
CALIFORNIA
Every Woman Every Time Project
This project was created in 1989 through a partnership between Sutter Medical Center in
Sacramento and the March of Dimes. It conducted a metanalysis of the preconception care
literature and used this information in a consensus development process to produce a marketing
packet for providers. Key components of the packet included the rationale for providing
preconception care, a description of the essential elements of care, patient education materials
and information on billing methods. More than 9,000 packets were distributed statewide. An
evaluation found that among 187 providers responding, 75% indicated the information was very
useful, 80% said they would distribute materials to patients, and 72% said they would use the
billing codes provided. (Cullum AS, unpublished data, 2005.)1
COLORADO
Interconception Health Promotion Initiative
This initiative was a demonstration project, funded by the Colorado Trust, which was developed
at Denver Health from 1995 to 2001. Denver Health is a vertically integrated safety net health
care system, including a public hospital and a network of 13 affiliated community health centers
which provide prenatal care to the majority of Denver’s low income pregnant women. The
object of the initiative was to develop a home-based case management program for women who
had delivered a low birth weight baby, had a fetal demise or a baby with congenital anomalies,
and who planned on having more children, with the goal of improving outcomes of future
pregnancies. Patients were recruited at the time of delivery of a qualifying infant and received a
comprehensive evaluation, and then intensive, relationship-based home visitation services by a
social worker or nurse. These home visitation services focused on various domains, including
maternal role, medical and reproductive health issues, contraception and life course. The women
were followed for up to three years or through a subsequent pregnancy. The program evaluation
suggest that women who participate in a comprehensive home visitation and case management
program after a poor outcome birth have higher rates of compliance with post-partum care and
family planning. They have longer interconception intervals and better outcomes as measured by
NICU admission and cumulative low birth weight rates.2
DELAWARE
Christiana Care Health System, Wilmington
The Adventures of Folic Acid Man/Woman program is designed for elementary and middle
school children. The 30 minute program includes class discussion of health lifestyles and the
importance of folic acid. The class then presents a short play about folic acid. Each student
receives a folic acid activity book and folic acid drink cup and is asked to share the message with
family and friends. The second piece of this program is a Folic Acid Woman patch developed
with the Chesapeake Bay Girl Scout Council, involving the scouts in various activities to learn
about folic acid. The school program is facilitated by a nurse educator or registered dietician.
The scout program is facilitated by troop leaders.3
1
Delaware State Plan
In May 2005 the state of Delaware’s Infant Mortality Task Force’s final report outlined a 3 year
plan with 20 recommendations to reduce the high infant mortality rate in Delaware. These
recommendations outline strategies to improve access to perinatal care among minority
populations. They called for the creation of the Delaware Healthy Mother and Infant
Consortium (DHMIC), which would provide guidance to maternal and infant health systems that
impact birth outcomes. The anticipated results of the interventions, include an increase in the
number of high-risk women and infants with health insurance, expanded access to prenatal care
through target outreach and interventions and enhanced data collection and surveillance around
maternal and infant health. They also call for improved prevention and management of chronic
diseases among pregnant women, improved prevention and early detection of birth defects and
genetic disorders, expanded access to comprehensive reproductive health and family planning
services for the uninsured and underinsured. Lastly the results included implementation of a
statewide educational campaign and cultural competence curriculum for providers.4
In 2006 the Division of Public Health, (DPH) selected two contractors, Delmarva Rural
Ministries, Inc., and Westside Health, Inc. to expand wraparound services in preconception,
prenatal, and postnatal care to targeted populations in Delaware. Targeted populations were
defined as women residing in specific zip codes where the number of infant deaths was high
compared with other regions, and women who had a history of poor birth outcomes. These
services supplemented those currently provided by Medicaid and other insurers such as
psychosocial screening and support, and additional nutrition monitoring. The Fetal Infant
Mortality Rate (FIMR) committee established three full-time staff positions to implement the
program. The PRAMS project completed a pilot study, applied and was awarded federal funding
to begin annual data collection January 1, 2007. The Delaware Healthy Mother and Infant
Consortium (DHMIC) was established and convened four times. DHMIC appointed five critical
area committees to monitor implementation of the Infant Mortality Task Force recommendations
including systems of care, standards of care, health disparities, health education and prevention,
and data and science. The Center for Excellence in Maternal and Child Health and Epidemiology
contracted with the CDC to employ the State Maternal and Child Health (MCH) Epidemiologist,
and established three full time positions to provide scientific expertise in study design, program
evaluation, and data analyses to all maternal and child health programs at DPH.5
Partnership with DPH, Planned Parenthood and Christiana Health System
The Delaware Division of Public Health has recently signed nearly $1.5 million in contracts with
Christiana Care Health System and Planned Parenthood of Delaware to provide education,
nutrition and community services for women at high risk of having unplanned pregnancies and
poor outcomes. Christiana Care’s program will offer clinical health services to at-risk women
who visit the Wilmington Hospital Health Center and the Women’s Health Office at Christiana
Hospital. They will provide these women with access to health educators, nutrition services and
other programs that can help them improve their health. Christiana is also partnering with
Children and Families First to provide three additional resource mothers who will focus on
preconception issues. Resource mothers work with pregnant women considered at high risk to
help them with transportation to doctor’s appointments and assist them with housing and social
services. Christiana Care will also partner with the Delaware Chapter of the March of Dimes to
provide patient and physician education.6
2
Planned Parenthood of Delaware plans to use the $228,000 grant from the state to further educate
women about the importance of eating well and getting help for chronic health problems like
obesity and hypertension that may affect future pregnancies. They recently hired a community
services director to work with higher-risk patients by helping them get the resources they need to
improve their health.7
FLORIDA
The Magnolia Project
The Magnolia Project in Jacksonville is a Healthy Start program in which a comprehensive array
of services was offered in an effort to improve birth outcomes. Services included case
management, education and risk reduction, and well-woman care. The target population was
high-risk African-American women aged 15-44 years who lived in five zip codes areas of
Jacksonville. The project operates as a collaborative between the Northeast Florida Healthy Start
Coalition, the Duval County Health Department and local community-based organizations. As
reported a 2004 assessment of project services conducted by HRSA Office of Performance
Review found high rates of success (>70%) in the resolution of key risks among the project
participants (Brady, CM, unpublished data, 2005.)8
Save Our Babies, Orange County, FL
The primary target population of this project was African American women who live in Orange
County with zip codes with the poorest birth outcomes. Information was disseminated to the
community - hosting training workshops and informational sessions in non-traditional
environments such as beauty salons and churches, and engaging the community for action. The
2004 Annual Report and Evaluation indicated an increased awareness of racial disparities in
birth outcomes in the community, increased awareness of maternal child health issues,
willingness of citizens and businesses to form an advisory committee for the program in order to
take ownership of the problem and increased understanding of how to access the current
healthcare.9
Florida’s Healthy Start Program
In the fall of 2004, Healthy Start initiated a campaign to address infant mortality and improve
pregnancy outcomes through education and counseling aimed at improving a women’s health
status before she becomes pregnant. Florida’s Healthy Start Interconceptional Care and
Counseling component was initiated through collaboration with Healthy Start Coalitions and
Healthy Start providers, and subsequently integrated into existing Healthy Start programs
without additional funding. Providers, including nurses, social workers, health educators, and
paraprofessionals in Healthy Start programs throughout the state were being trained to provide
interconceptional education in a culturally sensitive manner that was applicable to the participant
and their assessed risk factors. Technical assistance guidelines were also developed for use in
Florida’s county health departments as a guide for programs like Family Planning and prenatal
care clinics to provide pre/interconceptional care to women of child bearing age. Educational
components of both these initiatives included access to health care; management of maternal
infections and chronic health conditions; weight, physical activity and nutritional counseling;
appropriate baby spacing; substance abuse and smoking; mental health issues; and environmental
risk factors.10
3
GEORGIA
Grady Memorial Hospital, Atlanta
Interpregnancy Care (IPC) program at Grady Memorial Hospital in Atlanta provided primary
health care and dental services, enhanced case management and other outreach services to
African-American women who delivered a very low birth weigh infant at the hospital and who
qualified for indigent or charity care. The IPC program provided 24 months of primary health
care and dental services, enhanced nurse case management, and outreach in the community
setting via a Resource Mother. Health care visits were offered every 1 -3 months and address 7
key areas linked to LBW delivery: (1) poorly –controlled chronic diseases; (2) short
interpregnancy intervals; (3) reproductive tract infections, including bacterial vaginosis; (4)
periodontal disease; (5) nutritional disorders; (6) substance abuse; and (7) psychosocial stressors,
including depression and domestic violence. Group educational experiences are integrated into
IPC health care visits. Home visits and telephone contact by the Resource Mother are offered
twice monthly. Primary care and outreach services are delivered by a team comprised of a
family physician, nurse midwife/family nurse practitioner, periordontist, nurse case manager, and
Resource Mother. Preliminary evaluation of the 22 women retained in the pilot program
indicated that approximately one-quarter of them were affected by unrecognized or poorly
managed chronic health problems and none of the participants wanted to become pregnant
during the next 2 years. 11
ILLINOIS
Title X Family Planning Program
The Illinois Department of Human Services’ Office of Family Health (OFH) integrates
preconception care into several programs. The Family Planning program, financed primarily
through federal Title X Family Planning funds, provides counseling and education on pregnancy
avoidance and timing and delivers clinical health services such as pap smears, sexually
transmitted infections (STI) screenings, and physical exams to low-income women. The OFH
has also worked in partnership with the Illinois Chapter of March of Dimes on a statewide
campaign to raise awareness about the importance of consuming folic acid before and during
pregnancy. Prenatal vitamins were distributed through WIC and some Title X agencies, and
postpartum women were screened in WIC on folic acid intake and counsel and the WIC Food
Package provided folic acid.12
Illinois Healthy Women
In April 2004, Illinois began a 5 year Medicaid Waiver for Family Planning for women 19 – 44
years of age who were no longer eligible for medical assistance. The waiver provided limited
coverage for family planning and related reproductive health, sexually transmitted infection
testing and treatment, mammograms and folic acid.13
Illinois – Family Care
This program offers comprehensive health care coverage to parents or relatives living with their
children 18 years or younger with income up to 185% of poverty. Beneficiaries must be US
citizens or meet immigration requirements. The program requires very modest co-pays, but no
co-pays for family planning.14
4
MARYLAND
WELL Project
The Women Enjoying Life Longer (WELL) project was initiated by Maryland DHMH
following a community needs assessment. Comprehensive preventive women’s health services
were added to three Title X family planning clinics in Baltimore County, using Title X and
Maternal and Child Health funding. Augmented services included nutrition and physical activity
counseling, adult immunizations, smoking cessation interventions and preconception counseling,
as well as referrals for problems such as substance abuse, depression, domestic violence, and
chronic disease. Early evaluation data indicated that patients and staff have responded positively
to new services, patient knowledge of women’s health has improved, and patient volume has
increased 37% (CHENG, D, unpublished data, 2005.) 15
MISSOURI
Bootheel Healthy Start Project,
Missouri Bootheel Health Start project, a provider of referral and education services in a five
county area of southeast Missouri, uses community-based education and interventions to
improve adverse perinatal outcomes. The project has been one of few in the area that has
promoted a family-focused approach to health education through the inclusion of various
services directed at men. The curriculum for fathers has addressed a variety of issues, such as
communication with the mother, addressing stress in the relationship, and the impact of nutrition
on birth outcomes (Dean CG, Campbell T, Frazier V, Washington J, unpublished data 2005.) 16
NEBRASKA
The Douglas Preconception Plan
The DOUGLAS Preconception Program provides education for women of child bearing years on
diet, omitting drugs, alcohol and smoking, underlying health conditions, gynecological visits
annually, lactation for a lifetime of good health, birth control, screening and immunizations.
Public health nurses partnered with multiple resources, which lead to the development of an
educational program, including a pamphlet and power point presentation which have been
utilized though out the community. A “Pre and Post Pregnancy I.Q. Tool” from March of Dimes
has recently been added to our presentations as an evaluation tool.
The pilot project was called Madres Saludables, a Spanish speaking women’s group, focused on
preconception health in Lincoln, Nebraska. Regular group meetings were held three times per
month at convenient public locations and discussions at these sessions covered the various topics
of the DOUGLAS Plan. Health screenings were offered twice per year and referrals are made to
primary care physicians, dentists and other resources.
Plans are currently underway to duplicate this program for women who speak Arabic and could
be adapted for presentations to any group of women between the ages of 14 and 45. Partnerships
are being formed with other health departments to share preconception health resources and
ideas on how to expand opportunities to reach all women in their child bearing years. Funding
for the Madres Saludables program has been obtained from a “Building Strong Families Grant”.
This grant has also facilitated a monthly calender and newsletter, which allows for greater
dissemination of the DOUGLAS Plan and community resources.17
5
NEW YORK
Albert Einstein College of Medicine/Montefiore Medical Center
A research project conducted at a New York inner-city hospital served by Albert Einstein
College of Medicine/Montefiore Medical Center sought to evaluate the knowledge and
awareness of providers regarding preconception care. A pre-intervention chart review and a
provider survey were conducted to evaluate delivery of preconception care. The two part
intervention included a lecture for all providers and a standardized preconception care form
inserted into all charts. A post-intervention chart review of convenience sample and repeated
provider survey were then conducted. The result was a significant improvement in
documentation of the delivery of preconception care; however provider knowledge and attitudes
measured by the survey did not change significantly (Bernstein P, unpublished data, 2005.) 18
Montefiore Medical Center
The Comprehensive Family Care Center at Montefiore Medical Center implemented the group
model of prenatal care developed by the Centering Pregnancy and Parenting Association.
Traditional prenatal visits were replaced with group appointments lasting approximately 2 hours
and attended by 10 to 12 women. Typical clinical care services were provided during the visits
and were supplemented with group discussions on pregnancy-related topics. Issues related to
preconception health were covered during many of the meetings and included nutrition,
substance abuse, contraception, and family planning. Since its inception, the group care model
has been employed for 14 patient groups with high levels of patient and provider satisfaction
reported, particularly related to enhanced opportunities for patient education (Bernstein P, Rising
SS, Dolan S, Pardanani S, Merkatz IR, unpublished data 2005.) 19
OKLAHOMA
Women’s Health Appraisal
Oklahoma Birth Defects Registry developed, implemented and evaluated a preconception
“Women’s Health Appraisal” project. The intervention was comprised of a 3-page health
appraisal for women, with follow-up risk counseling, in selected family planning clinics. It
involved using a preconception care education booklet. Pre-evaluation results indicated that
84% of nurses found the questionnaire helpful in assessing risk factors, 90% of nurses found it
helpful as a guide to counseling and referrals, and 86% of patients increased their understanding
of risk factors. Post-evaluation results found that 62% of patients modified one to three risk
factors in a three –month period (Feuer VR, Pearson K, unpublished data, 2005.)20
WISCONSIN
Wisconsin Perinatal Associations’ “Becoming a Parent”
The “Becoming a Parent” toolkit provides materials for both consumers and providers, including
any primary care provider, specialist and community health provider who see women of
childbearing age. It includes a preconception checklist and a health care provider’s reference
(accompanies checklist and provides instructions for use, information, references and resources
for the providers.) It also providers a detailed booklet called “Information to Consider if You’re
Thinking of Becoming Pregnant” for women and families to use to think about the implication
of a pregnancy and family. There is a “Becoming a Parent” video – 20 minute video of
testimonials that encourages people of childbearing age to think about two things, the decision to
become a parent and healthy lifestyle.21
6
Sheree L. Boulet, Kay Johnson, Christopher Parker, Samuel F. Posner and Hani Atrash, “A Perspective of
Preconception Health Activities in the United States,” Maternal and Child Health Journal 2006, 10 (5): 13-20.
2
The Research and Evaluation Group, Department of Family Medicine, University of Colorado and the
Interconception Health Promotion Initiative, Interconception Health Promotion Initiative, Final Report, 9 June
2003.
3
Sue Samuels, “The Adventures of Folic Acid Woman [Abstract],” CDC National Summit on
Preconception Care, June 2005.
4
Delaware Infant Mortality Task Force, Reducing Infant Mortality in Delaware, The Task Force Report,
May 2005.
5
Ibid.
6
Kelly Bothum, “Getting Women to Focus on Themselves.” The News Journal, Wilimington, DE, March
2007, 6.
7
Ibid.
8
Boulet, S. et al., 2006. Janis Biermann, Anne Lang Dunlop, Carol Brady, Cynthia Dubin, and Alfred
Brann, “Promising Practices in Preconception Care of Women at Risk for Poor Health and Pregnancy Outcomes,”
Maternal and Child Health Journal 2006, 10(5), 21-28.
9
Lesli Ahonkhai, “Save Our Babies – Orange County, FL [Abstract],” CDC National Summit on
Preconception Care, June 2005.
10
Laura Levine, “Interconceptional Education and Counseling of the Healthy Start High Risk Woman
[Abstract],” CDC National Summit on Preconception Care, June 2005.
11
Biermann, J. et al., 2006.
12
NACCHO, Issue Brief: Preconception Care, May 2006.
13
Anne Marie Murphy and Stephen Saunders, “Implementing Preconceptual Care: A State Example,
[PowerPoint Presentation],” CDC National Summit on Preconception Care, June 2005.
14
Ibid.
15
Boulet, S. et al., 2006.
16
Ibid.
17
Patty Baker, “The Douglas Preconception Plan [Abstract],” CDC National Summit on Preconception
Care, June 2005.
18
Boulet, S. et al., 2006.
19
Ibid.
20
Ibid.
21
Ann Conway and Jennifer Wilen, “A Preconception Toolkit- Making It Easy for Providers to Educate
Women and Families [Abstract],” CDC National Summit on Preconception Care, June 2005.
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