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Interconception Care Program Recruitment Strategies
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Acknowledgements
 March of Dimes
 Lori Reeves for TA with today’s webinar.
 The W.K. Kellogg Foundation
 Every Woman Southeast Volunteers
 Our Speakers
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Kentucky, Louisiana, Mississippi, North Carolina, South
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women and infants in the Southeast.
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Today’s Webinar
Interconception Care Program
Recruitment and Retention
Strategies
October 24, 2012
Why This Topic?
 Reducing risks indicated by a previous adverse
pregnancy outcome is a top goal of the National
Preconception Health and Health Care Initiative
 In the SE – 3 states have demonstration projects to
provide interconception care to high risk women
 Limited information about best practices in serving
this population
Objectives
 Describe current efforts to promote interconception
health care for high risk women
 Describe how to overcome at least one challenge to
recruitment
 Describe at least two strategies that improved
recruitment and retention
 Discuss ways that interested groups can continue to
connect on this issue.
Speakers
 Sarah Verbiest, DrPH, MSW, MPH
 Dean Coonrod, MD, MPH
 Jennifer Culhane, PhD, MPH
 Anne Dunlop, MD, MPH
 Betsy Bledsoe-Mansori, PhD, Mphil, MSW
 Carol Brady, MPH
The Postpartum Plus
Prevention Program in NC
S a r a h Ve r b i e s t , D r P H , M S W, M P H
Executive Director
UNC Center for Maternal and Infant Health
Director
Every Woman Southeast Coalition
The Postpartum Plus Prevention Program (P4)
 Designed to increase knowledge about how to
provide health and wellness services to mothers of
medically fragile infants.
 Services: postpartum visit, a wellness kit at 3
months, and contact with a nurse midwife at 3, 6, 9,
12 and 18 months postpartum.
 P4 also provided onsite medical care to any woman
in the NICU who requested help.
Enrollment
 Women were approached for enrollment by a nurse
midwife while their infant was in the NICU. We
didn’t have anyone decline participation.
 A convenience sample of 44 mothers was recruited
from the Newborn Intensive Care Unit at UNC.
 Nearly all (87%) of the women had received a
medical service from the nurse midwife prior to
being recruited into the study.
What We Found
 Almost every mother (97%) returned to UNC post-
discharge for infant follow-up.
 Initial expectations were that mothers would only be
reachable by phone but the majority of mothers also
received in-person support.
 Mothers were open to talking with the nurse midwife
during pediatric visits for their infant.
Contacts
 We anticipated about 220 total contacts with the women
in the study. We had 645 contacts!
 The nurse midwife had an average of 15 contacts with
each mother. The number of contacts per woman ranged
from 6 to 42 – the lowest number was still above our
expectation.
 One third of the women went through a period of time
where they had weekly contact with the nurse midwife –
usually due to a crisis in their baby’s health.
Content
 Almost all contacts began with a mother-led
conversation about the infant’s health.
 The nurse midwife introduced wellness messages in
the context of the impact of the mother’s health on
the well-being of her infant.
 Mothers needed support for nonmedical issues such
as relationship with the infant’s father, poverty,
employment, and loss/grieving.
Conclusions
 Mothers of medically fragile infants are receptive to
tailored wellness messages when provided along with
clinical care for themselves and their baby.
 The NICU provides a key opportunity for initial
outreach to high-risk mothers.
 Telephonic support is a good option for providing
services and support, especially when paired with inperson contact through pediatric services to the
infant.
Conclusions
 Mothers’ capacity to attend to their own health and
wellness needs is linked to the immediate health
status of their infant.
 Easy access to health care services from a
professional they trusted was very important.
 Innovative partnerships between OB/GYN and NICU
follow-up clinics should be considered to best serve
both high-risk mothers and infants.
ARIZONA’S INTERNATAL CLINIC
Dean V Coonrod, MD-MPH
Chair, Department of Ob/Gyn
Maricopa Integrated Health System / District
Medical Group
University of Arizona College of Medicine Phoenix
Context
Preconception vs Interconception vs
Internatal Care
*
= preconception care
*
* = interconception
= pregnancy
= no more kids!
= internatal care
Program Eligibility

Index pregnancy
 Preterm
birth 35 weeks or less
 Early pregnancy loss 15 weeks and more
 Stillbirth
 Low birthweight
 Prolonged NICU stay
 Initially

3 days now 5 days
Not permanently sterilized
Schedule of Visits

2 weeks


6 weeks





Breastfeeding, review family planning
Standard postpartum visit
6 months
12 months
Yearly thereafter
Preconception visit
Our Visits

Seen by care coordinator
Introduce program
 Edinburg Postpartum Depression scale
 “6-week” intake form
 Go over education & goals for nutrition, exercise, dental
care, folate
 Psychosocial support, stress management

Our Visits

Seen by physician
Reason for visit
 Index pregnancy reviewed
 Neonatal status
 Breast feeding / back to sleep

 Prior
ob history
 Reproductive life plan, contraception
 Gyn, STI history / screening
 PMH / PSH / Dental care
Underlined = Done
at all visits
Our Visits

Infection / immunization


TB, Rubella, Tdap (pertusis), varicela, influenza
Nutrition / exercise

Anemia, food security, BMI, folate, exercise (type / amount)

Meds / allergies

Habits / Social / Exposures


Behavioral health


Tobacco, alcohol, drugs, DV, work, environmental exposures
EPDS, other mental health, eating disorders
Physical exam

Weight (BMI), BP etc

Problem focused exam
Our Project Patients: End of 2010


696 approached
142 had a visit
 90%
Latina
71 seen for clinical services in the last 6 months and are
considered active

71 have relocated or have been lost to follow up
Final Results (n=102 women)










In program for 12 to 18 months
Of those pregnant at least 12 month interval
Of those pregnant with first trimester care
Of those pregnant, tob, ETOH, drug free
Using contraception (if indicated)
On folate
Regular exercise (30 min 5 days a week)
Normal BMI
Those with oral health needs who have treatment
Those with mental health needs who have treatment
64%
40%
87%
100%
88%
61%
23%
26%
20%
100%
Follow Up Data
Baseline
6-month
12-month
Health is Excellent
46%
55%
70%
Regular Exercise
23%
76%
70%
Very Interested in
Getting
Preconception
Information
53%
76%
69%
Alcohol Can Effect
Fetus
73%
83%
94%
Watchful About
Eating Fish
48%
77%
88%
Lessons Learned





Care coordination key
Mothers / families after a pregnancy ending in stillbirth very
interested
Patients with preterm birth have varying levels of interest
No show rate a significant problem
Interval of visits often dictated by family planning or other
issues / mental health


Usually more frequent than the idealized one
TLC is always provided and likely of benefit
Thanks to our partners and funders:



March of Dimes
Maricopa Dept of Public
Health
ADHS









BHS
Mercy Care Plan
University Health Plan
Az Public Health
Association
Mayo Clinic Family
Medicine
Maricopa Integrated
Health System





Ob/Gyn
MFM
Family Medicine
Ambulatory
Social Work
Southwest Human
Development
St Luke’s Health Initiatives
AHCCCS
Questions?
Dean_Coonrod@DMGAZ.org
The Philadelphia Collaborative
Preterm Prevention Project
Jennifer F. Culhane MPH, PhD
The Study

Before discharge from the post partum hospital
stay
– Consent including access to medical records
– Conduct survey
– Randomization
– Smoking intervention begins
– Schedule 1st postpartum visit (1 month)
Postpartum Study Visits


When: 1, 6, 12, 18, and 24 months
postpartum
Or, at 20 weeks gestation of the
subsequent pregnancy
Postpartum Study Visits








Survey
Periodontal exam (1, 12 and 24
months only)
Vaginal fluid (self collection)
Blood
Urine
Anthropometric measurements
Blood pressure
Transportation, flexible hours,
childcare, barriers eliminated
Intervention Arm

Evaluated and offered treatment for:
–
–
–
–
–
–
–
Depression
Periodontal disease
Urogenital tract infections
Abnormal BMI
Housing instability/inadequacy
Smoking
Literacy
Recruitment Rate
77.7%
Figure 2.
Webb, et al. BMC Medical Research Methodology, 2010, 10:88
Retention/Data Capture Rates for Study Population
Randomization
Intervention
Group
Control
Total
First Post Partum
Assessment
83.5%
76.0%
80.0%
Second Post Partum
Assessment
67.6
57.5
64.6
Third Post Partum
Assessment
60.0
48.9
54.4
Fourth Post Partum
Assessment
54.2
46.3
50.3
Fifth Post Partum
Assessment
47.3
40.8
43.6
Strategies to Improve
Retentions
• Two full-time staff dedicated to cohort
maintenance
• Provided transportation - either tokens or cab
pick up
• Evening and weekend hours
• Child care and food provided
• If required visit conducted at participant's
home
• Clinic had washing machines and dryers
• Staff required to be courteous and totally
participant -focused
Risk Factor Prevalence, Acceptance Rates and
Rates of Minimal Participation
in PCPP Intervention Arms
Prevalence/
Eligible (a)
N (%)
Acceptance
Rate (b)
N (%)
Particpation
Rate 2
N (%)
268 (57.1)
240 (87.9)
228 (85.1)
Periodontal
265 (59.4)
233 (87.9)
136 (58.3)
Smoking
185 (38.9)
99 (53.8)
53 (28.6)
Depression 1
290 (61.1)
223 (76.9)
140 (48.3)
Literacy
105 (22.1)
79 (75.2)
62 (59.0)
Housing
389 (81.9)
356 (91.5)
319 (83.3)
Intervention/
Treatment
Infection
1
2
Depressive Symptomatology (CESD > 16)
Percentages are based on the number of women eligible in column 1
Strategies to Improve
Participation in Interventions
Phone medicine for depression care available
• Staff accompany participants to dentist
• Provide valium for dental visits
• Smoking intervention conducted in
particpant’s home
• Medicines delivered to particpant’s home
• Food and caloric supplements delivered to
participant's home
•
Selected Findings
Exposures associated with adverse
outcomes are moderately prevalent and cooccur.

There is a wide range of participation
across interventions- even with every
traditional barrier to care addressed.

Volunteering
for treatment is MUCH
different than random assignment to
treatment- people who really need the
Important Research Questions
Why
don’t some women avail
themselves of care?
 Not just traditional barriers to care
 Complex decision making that may seem
irrational to providers but may make perfect
sense in certain contexts- what are those
contexts?
Important Research Questions
RHIME factors (Racism, Housing challenges,
Insufficient resources, Multiple burdens
and Emergencies) play a role in women’s
everyday lives and influence care participation
We need to become aware of, document and
address the ways various institutional
structures, rules
and ways of doing business
create additional
burdens for already
stressed women
Summary
Truly ‘at risk’ women may not participate
Even if an intervention “works” it may not be
successfully implemented- what do we
mean by works?
More research needed to understand
complex barriers to participation
The Interpregnancy Care Program
Overview of Engagement Strategy
For Women Who Recently Delivered
A Very-Low-Birthweight Infant
Anne L. Dunlop, MD, MPH
October 24, 2012
IPC Participants

Eligibility: African-American women who qualified for
indigent care and delivered a VLBW infant at Grady
Memorial Hospital (GMH) during the feasibility phase
(11/2003 through 3/2004).

Recruitment/Enrollment:

29 women enrolled (of 38 eligible);

24-months of follow-up complete 3/2006.
IPC Intervention Package

Definition of an individualized IPC plan to address 7 areas
epidemiologically linked to low birth weight/preterm delivery:

Reproductive planning (assistance in achieving intendedness and spacing)

Prevention, screening and treatment for sexually-transmitted infections

Micronutrient supplementation & screening/treatment for nutritional deficiencies

Prevention, screening and treatment for periodontal disease

Management of chronic disease

Treatment and referral for substance abuse

Screening and treatment for depression, psychosocial stressors, & domestic violence

Provision of health and dental services in accordance with the IPC plan
for 24 months;

Community outreach via a trained Resource Mother.
Provision of IPC

Contact with a multidisciplinary team:




Family nurse practitioner, family physician, periodontist,
nurse case manager, social worker, and Resource Mother;
Initial contact with nurse case manager followed by Resource
Mother during the delivery hospitalization.
Primary care visits occurred every 1 -3 months (dependent
upon extent of health problems) in a group setting with
integration of group educational experiences according to
the Centering Pregnancy Model of prenatal care;
Home visits and telephone contact by the Resource Mother
monthly to address psychosocial issues.
Participation in IPC

21/29 (72%) actively participated;

8/29 (28%) not actively participated:



2 moved out of state;
3 electively disenrolled (2 prior to 1st IPC visit; 1 after single
visit);
3 become lost to follow-up (2 prior to 1st IPC visit; 1 after single
visit).
Impact of IPC:
Social Outcomes (Education)
Educational Attainment:


18/21 (85.7%) active participants without h.s diploma
or GED at study entry;
Of those 18 without diploma or GED, 13/18 (72.2%)
were assisted in earning diploma or GED during the
study:


8/18 earned h.s. diploma or GED;
5/18 enrolled in G.E.D. training program,
but did not complete the program.
Impact of IPC:
Social Outcomes (Training)
Other Training:



In addition to GED, 4 participants completed technical
training (2 computer literacy, 2 medical assistance);
In addition to h.s. diploma, 1 participant completed
Upward Bounds (college preparatory program);
A participant with a h.s. diploma completed technical
training (administrative assistance).
Impact of IPC:
Social Outcomes (Housing)
Housing Acquisition:


14/21 active participants with inadequate (crowded, dirty,
unsafe) housing or homeless at study entry;
Of those 14 who were homeless or with inadequate
housing, 11/14 assisted in finding adequate housing.
Cost of IPC per Participant:
Full 24 months

Health care:


Mean charges = $ 2,397 (median = $2,104)

Mean visits = 7 (median = 6)

Mean cost per visit = $342 (median = $350)
Resource mother outreach:

Estimated $1,800
Total Program Cost per Participant per 24-Months: $4,197
Cost Analysis

The 29 enrolled women received 24-months of IPC at $4,197 each,
and delivered 1 LBW infant (initial hospitalization $55,576)
conceived within 18-months of the index VLBW:

Cost of program: 29 x $4,197 = $ 121,713

Cost of LBW infant:
$ 55,576
$ 177,289

Based on the historical control cohort, we expected 5 LBW infants
to be conceived within 18-months of the index VLBW:

Cost of LBW infants: 5 x $55,576 = $277,880
Net savings: $100,591
Translation of IPC:

“Planning for Healthy Babies” Georgia Medicaid Waiver, beginning
January 2011, will expand Medicaid coverage for specific
reproductive health services to Georgia women ≤ 200% FPL:



‘Interconception primary care, case management, and resource mother
support’ for all women who deliver a VLBW infant after Jan 1, 2011.
Services to be delivered through the Georgia Medicaid CMO’s:


Family planning services (broadly) for all women of reproductive age;
Amerigroup, Peach State, WellCare
Small trial of NICU-based engagement in 3 metro area NICUs
Engaging and Retaining Difficult to Reach Mothers
in Treatment Services: Overview of a Brief
Intervention.
Betsy (Sarah E.) Bledsoe-Mansori, PhD, MPhil, MSW
Assistant Professor – School of Social Work
University of North Carolina at Chapel Hill
October 24, 2012
Acknowledgements

Pregnant women and adolescents from Pittsburgh, PA;
Seattle and King County, WA; and Alamance and Wake
Counties, NC who participated in the research studies
supporting this work.

Funding sources -- National Institute of Mental Health,
National Institutes of Health, Horizons Foundation,
Seattle, WA, Jane H. Pfouts Research Grant, ArmfieldReeves Innovation Fund, University of North Carolina
Program on Ethnicity Culture and Health Outcomes,
University of North Carolina

Co-investigator s and collaborators: Nancy Grote, PhD;
Holly Swartz, MD; Allan Zuckoff, PhD; Ellen Frank, PhD;
Katherine Wisner, MD; Wayne Katon, MD; Carol Anderson,
PhD; Sharon Geibel, MSW
An Ecological Model of Barriers to
Treatment Engagement and Retention
Distal Influences ----> Proximal Influences
Outcomes
Community Barriers
---->
Rx Adherence ----> Rx
Helping System Barriers
violence, safety concerns
lack of support services
unemployment; poverty
lack of access to M.H. services
bias or cultural insensitivity in
environment, procedures, providers
lack of evidence-based treatments
lack of diversity in clients & staff
provider overload and burn-out
Social Network Barriers
Client Barriers
negative attitudes toward RX
practical- time, financial, transportation, childcare
social network strain
psychological - stigma, low energy,
negative RX experiences; previous or current
trauma
cultural – women’s view of depression; multiple
stressors
Barriers to Care

Practical – Do I have time? Can I get
there? Can I afford it?

Psychological – Can I trust my therapist?
Can she/he really understand me and help
me?

Cultural – Will treatment be relevant to
my needs, goals, values, preferences and
practices?
Practical Barriers to Care



Costs
◦ 40% African Americans and 52% Hispanics lack health
insurance in the US (US Census Bureau, 2003)
Access
• Inconvenient or inaccessible clinic locations
• Limited clinic hours
• Transportation problems
Competing Obligations
• Child care and social network
• Loss of pay for missing work
• Time in dealing with chronic stressors
Psychological Barriers to Care:
STIGMA:
 “I don’t want to be that person to get the medication and be
called “DEPRESSED”; my sister had to live with that label –
and everyone avoided her and treated her like it was her
fault.”
NEGATIVE EXPERIENCES WITH SERVICE
PROVIDERS:
 “I didn’t want the therapist to report my depression to child
protective services because they might take my baby away. I
felt betrayed.”
CHILDHOOD TRAUMA AND LACK OF TRUST
 Greater risk of insecure attachment and lack of trusting
others
(Mickelson et al., 1997)
 Implications for seeking treatment: go-it-alone attitude; poor
Cultural Barriers to Care:
CULTURE OF POVERTY
 “My therapist seemed overwhelmed by all my practical
problems, so how could she help me?”
CULTURE OF RACE/ETHNICITY/NATIONALITY
 No – it doesn’t matter…
 “Sitting in front of a white therapist isn’t necessarily like
she thinks she is better than me, BUT there are some
white people who think they can look down on you and
show favoritism to people of their nature and culture and
treat you any kind of way.”
Development of an Engagement Strategy
Before Treatment Begins

To deal with practical, psychological, and cultural barriers to
care and ambivalence about going for depression treatment

Integration of two theoretical approaches:
◦ Ethnographic interviewing
◦ Motivational interviewing
Ethnographic Interviewing (EI)

A method of eliciting information designed to
help the interviewer understand the ideas,
values, and patterns of behavior of members
of another culture without bias (Schensul, Schensul,
& LeCompte, 1999)
◦ Anthropological Uses
 Foreign cultures
 Sub-cultures
-
Motivational Interviewing (MI)

Client-centered, goal-oriented method for
enhancing a person’s own motivation to change by
working with and resolving ambivalence (Miller &
Rollnick, 2002)
Principles of Engagement
(Grote, Zuckoff, Swartz, Bledsoe, & Geibel, 2007)
1) Work to understand the perspectives and values
of the woman without bias or agenda
2) Adopt a one-down position as learner
3) Help the woman to feel safe to tell her story
(what’s bothering her) without fear of judgment
4) Find out how the depression or stress is
interfering with what is important to her – this
primary motivator for change!
Principles of Engagement
5) Affirm the woman’s strengths and coping capacities
(e.g., resilience, knowledge, spirituality, family)
6) Obtain permission before giving information or
advice
7) Provide psychoeducation about the problem and
effective treatments and elicit the woman’s
reaction
8) Identify pros and cons about getting treatment
(ambivalence); pull for the negatives
9) Express empathy, especially for the reasons against
seeking treatment (as well as reasons for seeking
treatment)
Principles of Engagement
10) Foster personal choice and control ( “It’s up to
you!”)
11) Problem-solve all the barriers with the woman
12) If the woman commits, collaborate with him or
her to make the connection with mental health
services
13) Offer hope, acceptance of ambivalence, affirmation
14) Leave the door open, if she does not commit
Engagement Session: 5 components
(Unpublished manual, Zuckoff, Swartz, Grote, Bledsoe & Speilvogle)

Total time: 50-60 minutes -- These components can be used
separately if time is limited or repeated as needed.
1) Getting the story
2) Past efforts at coping and attitudes toward
treatment
3) Feedback and psychoeducation
4) Addressing barriers to care
5) Eliciting commitment and planning for treatment
engagement
Engagement Component 1: The Story

Introduce session
◦ “During this time I would like to get to know you better – how you
see what’s bothering you, whether you want help, and if so, what you
would want out of treatment services.”

◦ “How have you been feeling lately and how is this interfering with
what’s important to you?”
Explore the Story
A. Problem: understanding of the woman’s view of her
depression/stress & how it is interfering with client’s life
B. Context: social context of the problem: acute stressors (stressful
life events; pregnancy) and chronic stressors (like poverty)
C. Summary: empathically summarize client’s story; highlight concerns
and wishes; identify and affirm strengths
Engagement Component 2:
Treatment History & Hopes for Treatment

History of the problem: ask about past or current efforts to cope with
the problem (e.g. spiritual beliefs, family, inspirational people); identify and
affirm strengths – empathically summarize

Treatment history: ask about client’s or family members’ experiences with
or ideas about treatment; get both positive and negative; ask about
experiences with social agencies/health care providers

Treatment hopes/expectations:
◦ “What would you like to be doing if treatment worked?”
◦ “What do you want/not want in treatment or in a therapist?”
Does race/ethnicity matter?
◦ Empathically summarize hopes and fears for treatment, capturing the
woman’s ambivalence while highlighting hope
Engagement Session Component 3:
Feedback and Psychoeducation

Feedback
A. Elicit: “Would it be OK if I shared some of the results from the
questionnaire you filled out?” or “my ideas about what you’re struggling
with?”
B. Provide: symptom severity, consequences of depression/stress
C. Elicit: “What do you make of this?” “How does this sound?”

Psychoeducation
A. Elicit: “What is your view of depression?” “Would it be OK if I gave
you some information about it and treatment options?”
B. Provide: information about depression and treatment
C. Elicit: “How does this sound to you?” “Does this make sense?”
Engagement Session Component 4:
Problem-solving the Barriers to Care

Practical – “What might make it hard to come even if you wanted to?”

Psychological – “Beyond these practical concerns, what else might keep
you from coming?” Keep asking, “What else”?
Transportation? Childcare? Scheduling? Finances?
Negative attitudes about treatment? The burden of dealing with the
symptoms of the problem? Guilt about taking time for self? Concerns that CPS
might become involved? Doubts about whether treatment will help? Perceived
stigma from family and friends?

Cultural – “How is treatment viewed in your family or community?”
1) How can treatment help me with getting a job, house, food, etc.?
2) Preferred community approaches for treatment (e.g., church)?
3) Therapist differences in race, class, gender, age, nationality?
◦ therapist would judge, not understand, act disrespectful, not care
◦ therapist does not know how to cope with client’s problems – no
experience
Engagement Session Component 5:
Elicit Commitment

Grand Summary: summarize woman’s story, ambivalence, barriers and
solutions; highlight her change talk – “I can’t take this anymore.”

Change Plan: outline next steps, e.g., scheduling an appointment, number
of treatment sessions

Elicit Commitment:“What would you like to do?” “Does this sound right
for you?

Leave Door Open:“It’s fine if you want to think about it, you can give me
a call.”

Instill Hope:Affirm woman’s participation in the session and the
strengths client brings to treatment; express optimism about treatment
Randomized Study of Pregnant, Depressed Women:
Rx Engagement and Retention (Grote, Zuckoff, et al., 2007)
p<.001
p<.001
p<.001
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
No Engagement
Engagement
1st
session
4 plus
7 to 8
Less than 1/3 of phone intakes attend 1 Rx session in community mental
settings
Typical number of Rx sessions attended in community mental health = 1
% with Major Depression Diagnoses
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
92%
79%
42%
30%
5%
Pre-Rx
Pre – Post-Rx: p<.05
Post-Rx
0%
Follow Up
Pre – F/U: p<.05
Brief IPT
Usual Care
Feasibility Study of Depressed
Pregnant Adolescents (Bledsoe,Wike, Olarte, et al,
2010)
88% of eligible adolescents entered and 93%
completed.
More Research on Engagement Session

“PREMIUM” (Program for Effective Mental Health
Interventions in Under-resourced Health Systems) in
Goa, India funded by the Wellcome Trust, UK (Vikram
Patel, PI)

“Patient Navigation for Depressed Mothers in Head
Start in Boston, MA- An Engagement Strategy funded by
NIMH (Michael Silverstein, PI)
Questions & Answers
F a c i l i t a te d b y :
Amy Mullenix
Every Woman Southeast co-chair
Please submit your questions via chat. Feel
free to contact speakers after the webinar with
a n y a d d i t i o na l q u e s t i o n s .
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Harriet Beecher Stowe