Kay Johnson

The clinical content of preconception care: an overview and preparation of this supplement

In June 2005, the Select Panel on Preconception Care established implementation workgroups in 5 areas (clinical, public health, consumer, policy and finance, and research and surveillance) to develop strategies for the implementation of the Centers for Disease Control and Prevention recommendations on preconception health and healthcare. In June 2006, members of the clinical workgroup asked the following questions: what are the clinical components of preconception care? What is the evidence for inclusion of each component in clinical activities? What health promotion package should be delivered as part of preconception care? Over the next 2 years, the 29 members of the clinical workgroup and > 30 expert consultants reviewed in depth > 80 topics that make up the content of the articles that are contained in this supplement. Topics were selected on the basis of the effect of preconception care on the health of the mother and/or infant, prevalence, and detectability. For each topic, the workgroup assigned a score for the strength of the evidence that supported its inclusion in preconception care and assigned a strength of the recommendation. This article summarizes the methods that were used to select and review each topic and provides a summary table of the recommendations.

The National Summit on Preconception Care: A Summary of Concepts and Recommendations

The Centers for Disease Control and Prevention (CDC) and 35 partner organizations have engaged in developing an agenda for Preconception Health. A summit was held in June 2005 to discuss the current state of knowledge regarding preconception care and convene a select panel to develop recommendations and action steps for improving the health of women, children, and families through advances in clinical care, public health, and community action. A Select Panel on Preconception Care, convened by CDC, deliberated critical related issues and created refined definition of preconception care. The panel also developed a strategic plan with goals, recommendations, and action steps for improving preconception health. The recommendations and action steps are specific to the implementation of health behavior, access, consumer demand, research, and surveillance activities for monitoring and improving the health of women, children and families. The outcome of the deliberations is the CDC publication of detailed recommendations and action steps in the Morbidity and Mortality Weekly Report series, Recommendations and Reports.

Preconception care: a 2008 update.

Purpose of review This study reviews what we know about preconception care, its definition, goals, and content; the science behind the recommended interventions; opportunities for implementing preconception care; and the challenges facing its implementation. Recent findings There is solid scientific evidence that many interventions will improve pregnancy outcomes if delivered before pregnancy or early in pregnancy. Experts continue to explore the most effective means for implementing preconception care, taking into consideration issues related to policy, finance, public health practice, research/surveillance, and consumer and provider education. Summary Over the past 4 years, there has been renewed interest and a great emphasis on preconception health and healthcare as alternative and additional approaches to counter the persistent increasing incidence in adverse pregnancy outcomes in the United States. Following the publication of the ‘Recommendations to Improve Preconception Health and Healthcare’ in 2006, many state and local health departments initiated programs to implement the recommendations. Several countries such as Canada, Belgium, and the Netherlands have also started to implement preconception care programs. There are many opportunities for promoting preconception health and providing preconception care; however, making preconception care a standard practice continues to face many barriers.

Innovative Strategies to Reduce Disparities in the Quality of Prenatal Care in Underresourced Settings

This study examined what innovative strategies, including the use of health information technology (health IT), have been or can be used to reduce disparities in prenatal care quality in underresourced settings. Based on literature review and key informant interviews, the authors identified 17 strategies that have been or can be used to (a) increase access to timely prenatal care, (b) improve the content of prenatal care, and (c) enhance the organization and delivery of prenatal care. Health IT can be used to (a) increase consumer awareness about the importance of preconception and early prenatal care, facilitate spatial mapping of access gaps, and improve continuity of patient records; (b) support collaborative quality improvement, facilitate performance measurement, enhance health promotion, assist with care coordination, reduce clinical errors, improve delivery of preventive health services, provide decision support, and encourage completeness of documentation; and (c) support data integration and engineer collaborative innovation.

Maternal and child health services for medically indigent children and pregnant women.

Millions of low-income children and women of childbearing age are completely uninsured. Medicaid, the nations largest public health financing program for the poor, is an inadequate resource for uninsured families with children. By 1984, the program served only 46% of the poor and near-poor, down from 65% in 1976. To assess the availability of maternity and pediatric services for low income uninsured women and children, a survey of 51 Title V Maternal and Child Health agency officials was conducted in 1986. While nearly all states (48) offer some prenatal care programs for indigent women, restrictive eligibility requirements and limited distribution meant that these programs reached only a small proportion of those in need. Only one state, Massachusetts, offered a truly statewide program to all uninsured pregnant women with incomes under 185% of the poverty level. Twenty-three states reported the existence of inpatient maternity programs for indigent women. Yet these, too, were extremely limited. Sixteen programs restricted funds either to women who participated in certain designated maternity programs or else only to those who were identified as high risk prior to the labo and delivery period. Fifteen state agencies reported that hospitals were denying admission to women about to deliver. Another 13 reported that hospitals were denying admission to women not yet in “active‘’ labor. Six additional states were aware of patient dumping but did not identify the specific populations that were affected. Forty-six states reported the existence of pediatric outpatient programs. However, the majority (30) offered only “well-child‘’ care. Seven states maintained pediatric programs limited to only certain ages of children; three of these imposed an age requirement as low as 2 years or younger. Only two states reported the availability of any pediatric inpatient programs financed or administered by Title V agencies other than those for children with special health care needs.

A National Action Plan for Promoting Preconception Health and Health Care in the United States (2012–2014)

Preconception health and health care (PCHHC) has gained increasing popularity as a key prevention strategy for improving outcomes for women and infants, both domestically and internationally. The Action Plan for the National Initiative on Preconception Health and Health Care: A Report of the PCHHC Steering Committee (2012-2014) provides a model that states, communities, public, and private organizations can use to help guide strategic planning for promoting preconception care projects. Since 2005, a national public-private PCHHC initiative has worked to create and implement recommendations on this topic. Leadership and funding from the Centers for Disease Control and Prevention combined with the commitment of maternal and child health leaders across the country brought together key partners from the public and private sector to provide expertise and technical assistance to develop an updated national action plan for the PCHHC Initiative. Key activities for this process included the identification of goals, objectives, strategies, actions, and anticipated timelines for the five workgroups that were established as part of the original PCHHC Initiative. These are further described in the action plan. To assist other groups doing similar work, this article discusses the approach members of the PCHHC Initiative took to convene local, state, and national leaders to enhance the implementation of preconception care nationally through accomplishments, lessons learned, and projections for future directions.

Healthy Start : Lessons Learned on Interconception Care

The Federal Healthy Start program was started in 1991 to address the factors that contribute to the Nations high infant mortality rate, particularly among populations with disproportionately high rates of adverse perinatal health outcomes. The goals of Healthy Start are to reduce disparities in access to and utilization of health services by using a lifespan approach, improving the local health care system, and increasing consumer and community input into health care decisions. In 2007, Healthy Start served 99 communities in 38 states, the District of Columbia, and Puerto Rico. Most Healthy Start grantees are nonprofit organizations. Since 2005, all 97 Healthy Start grantees (and the 2 additional grantees funded in 2007) have been required to include an interconception care component. Three quarters of grantees enrolled the majority of their interconception clients during the prenatal period. Most grantees used care coordination and case management as the primary approach to improving interconception health care. In 2007, 93 interconception projects reported that 9 out of 10 women had an ongoing source of primary care. Grantees screened to detect health conditions and risks, as well as provided an opportunity to provide vital information to women about their risks for chronic conditions such as obesity, hypertension, and diabetes. The Healthy Start interconception components demonstrate a critical need for and the potential impact of a strong interconception care program for high-risk populations such as women living in poverty, in medically underserved communities, and without health coverage.

The future of preconception care: a clinical perspective.

The concepts of preconception care (PCC) have been discussed for over 20 years and the standards for PCC have been recently promulgated by the clinical committee of the Centers for Disease Control and Preventions Select Panel of Preconception Care. For PCC to be fully realized, however, changes must be made in clinical practice, public health supports, and health coverage. This article discusses 1) the clinical content and delivery of PCC, 2) barriers to why this care does not fit easily into the current clinical paradigm for providing medical care, and 3) how new information technologies within the concept of the medical home might be a promising new way to assist in the diffusion of these concepts.

Financing state newborn screening programs: sources and uses of funds.

BACKGROUND. Financing for newborn screening is different from virtually all other public health programs. All except 5 screening programs collect fees as the primary source of program funding. A fee-based approach to financing newborn screening has been adopted by most states, to ensure consistent funding for this critical public health activity. METHODS. Two types of data are reported here, ie, primary data from a survey of 37 state public health agencies and findings from exploratory case studies from 7 states. RESULTS. Most of the programs that participated in this survey (73%) reported that their newborn screening funding increased between 2002 and 2005, typically through increased fees and to a lesser extent through Medicaid, Title V Maternal and Child Health Services Block Grant, and state general revenue funding. All of the responding states that collect fees (n = 31) use such funds to support laboratory expenses, and most (70%) finance short-term follow-up services and program management. Nearly one half (47%) finance longer-term follow-up services, case management, or family support beyond diagnosis. Other states (43%) finance genetic or nutritional counseling and formula foods or treatment. CONCLUSIONS. Regardless of the source of funds, the available evidence indicates that states are committed to maintaining their programs and securing the necessary financing for the initial screening through diagnosis. Use of federal funding is currently limited; however, pressure to provide dedicated federal funding would likely increase if national recommendations for a uniform newborn screening panel were issued.

Women's health and health reform: implications of the Patient Protection and Affordable Care Act.

Purpose of review An overview of provisions in the 2010 health reform legislation with implications for womens health and obstetrician-gynecologists. Recent findings Between now and 2014, provisions of the Patient Protection and Affordable Care Act (ACA) will expand access to health coverage, primary care, and preventive services. Other provisions relate to federal abortion funding, medical liability, and disparities. Summary From a life-course perspective, ACA makes it feasible to link preconception, prenatal, family planning, and other care in a seamless continuum for women of childbearing age. Now is the time to implement a comprehensive well woman standard of care.