Good afternoon everyone, I am so glad you are able to join us this afternoon to talk about the important issue of Preconception Care. I would like to give credit to Albert Einstein College of Medicine CDC MOD For their continued work and efforts on behalf of healthy women everywhere. Preconception services are education, counseling, and services provided to all women before and between pregnancies that address risk factors that address risk factors that could cause poor infant and maternal outcomes in first and subsequent pregnancies. The period between pregnancies includes pregnancies that result in termination, miscarriage, fetal demise, infant death, or live birth. These services ideally occur at every encounter with a woman of childbearing age and includes our encounters with teens. There are many terms you will hear and they are very similar. Preconception talks about the health status and risks before any pregnancy, first or subsequent. Periconception is the period immediately before conception through or-gan-o-genesis And Interconception is the period between pregnancies. In thinking about new approaches for addressing the on-going problem of low birth weight, preterm births, and infant mortality, we have broadened our focus beyond just the prenatal period. We realize that a woman’s birth outcomes are affected by her health before she ever gets pregnant. Given that so many pregnancies are unplanned and that critical development of the fetus occurs before she may realize she is pregnant, we must advocate for good health practices before pregnancy, regardless of her intentions to become pregnant. So—when becoming pregnant, regardless if next year or 5 years from now or even never, the woman will be conscious of and educated on being healthy. As an introduction to ter-at-o-genesis: EMBRYOLOGY Organ formation: The period of time from 17-56 days after conception or 4-10 weeks from the last menstrual period (LMP) is the one where the pregnancy is most susceptible for developing major malformations. (Moore, 1998) The period of time earlier in gestation (before 17 days post-conception) is when exposures to various hazards places pregnancy at risk of spontaneous loss and the period of time after 56 days post-conception is the period where exposures to these hazards may lead to growth disturbances. Since the mean entry into prenatal care is in the 3rd month of pregnancy, issues concerning ter at o genesis need to be addressed prior to the first prenatal visit. When we think of the wonderful health care we have in the United States it does not seem possible that our Infant Mortality is not the lowest in the world, but in fact it is higher than many other countries and although it was declining it has essentially stalled. We have as a nation made prenatal care accessible to most women and yet our preterm birth and low birth weight rates are increasing. Lets look at those statistics. You can see that the rates of some of the other countries who have an infant mortality rate lower than ours-compared to the United States in 2004. The United States is 37th in the list of 206 nations. In 2004, 1 in 8 babies (12.5% of live births) were born preterm in the United States. Preterm birth affected approximately 513,875 infants that year. In 2000, The Healthy People 2010 goal for preterm births was set. The goal is to reduce the rate of preterm births to no more than 7.6% of all live births by 2010. Lets look at the statistics of preterm birth rate, the percentage of babies born at less than 37 completed weeks gestation, now is 12.5 percent and has increased more than 30 percent since 1981, when the government began tracking premature birth. More than 71% of preterm infants were born between 34 and 36 weeks gestation and are considered "late preterm." The National Center of Health Statistics report confirms a March of Dimes finding that those born late preterm are the fastest growing subgroup of premature babies. Many premature babies face risks of lifelong developmental challenges, such as cerebral palsy, mental retardation, chronic lung disease, and vision and hearing loss. The Institute Of Medicine estimates that societal cost of prematurity to be $26 billion. Movement is certainly in the wrong direction!! Low birthweight (LBW) is a major contributor to infant mortality and morbidity, and care of the LBW infant is costly. The NCHS report confirmed an increase in the percent of babies born with low birthweight from 7.9 percent in 2003 to 8.1 percent in 2004. Between 1994 and 2004, the infant mortality rate in the United States declined 15%. http://www.marchofdimes.com/peristats/level1.aspx?reg=99&slev=1&top=6&stop=91&obj=1&lev=1&dv=cg The overall infant mortality rate has declined by 10 percent since 1995, when the rate was 7.57 per 1,000 live births. However, the rate has not declined much since 2000 when it was 6.89. http://www.cdc.gov/nchs/PRESSROOM/07newsreleases/infantmortality.htm But as you can see the rate has become static Florida’s infant mortality has remained essentially the same for the past 10 years and is above the nation. At the same time, Florida’s premature and low birth weight rates have risen. So when you look at the statistics both nationally and for Florida you can see something has to be done. In the 1980’s we worked really hard at making prenatal care accessible to all and then we tried to make sure we had systems in place that address the risks we know make a difference like care coordination, smoking cessation, substance abuse counseling. Thank goodness we have those in place or our numbers would be much worse. But now we have to go the next step…………………. Recent data from many different sources indicate that an important time to intervene for positive birth outcomes is BEFORE a woman becomes pregnant. Lets look at some of the relationships that have been established that completes the picture that maternal health and poor outcomes are correlated. The evidence to support focus on the pre/interconceptional period to affect birth outcomes is well established. We are going to look at Pregnancy Associated Mortality Review and Perinatal Periods of Risk data.. Florida initiated the PAMR process in 1996. Based on the National Fetal Infant Mortality Review (FIMR) model which analyses gaps in maternal health systems and care that may contribute to maternal mortality. Also it Expanded on the Vital Statistics definition of pregnancy-related deaths which included only those that occurred within a 42 day post-pregnancy interval and were assigned a pregnancy-related ICD code. These are women who have been identified most at risk for pregnancy-related death: Age 35 and older (RR=3.65) Black non-Hispanic (RR=3.32) High school education or less (RR=1.72,1.50, respectively) Received no prenatal care (RR=9.95) Cesarean Delivery (RR=5.09) Overweight (OR= 2.13) Obese Categories 1,2,or 3 (OR=3.5, 3.5, 8.0) Our PAMR process also showed that racial disparity was a factor in our maternal population similar to what we find in our FIMR findings. Also: Black non-Hispanic Aged 35 and older High School education or less Received no prenatal care Cesarean Delivery Overweight Obese In 2005, the pregnancy-related mortality rate was 13.3. White: 8.4 Black: 27.1 The disparity is shocking. The second over arching goal of HP 2010 is: to eliminate health disparities among segments of the population, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation. WE still have much work to do. The Perinatal Periods of Risk Approach was developed by Dr. Brian McCarthy from the World Health Organization (WHO), Perinatal Collaborative Center at CDC, and other World Health Organization colleagues. For over a decade, this approach has been used to monitor and investigate feto-infant mortality problems in developing countries and they looked at the United States and then our statisticians looked at Florida. Now lets look at the PPOR (Perinatal Periods of Risk) data for 1998 through 2000 illustrates that of the 5,734 fetal and infant deaths (death up to age one), 2,460 of them were associated with factors relating to the health of the mother. Maternal care, or prenatal care factors, were associated with 1,458 deaths, newborn care (up to 28 days of life) 795 deaths, and infant health (up to age 1) at 1,021 deaths. The relationship between the maternal health and poor birth outcomes persists, even when we adjust for race. This chart represents White mothers only. This chart represents the data for non-White mothers. Again, the largest association with fetal-infant deaths was with the mother’s own health. Centers for Disease Control’s Definition of Preconception Care is is a set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management. It is more than a single visit and less than all well-woman care. Look at the CDC Preconception Care Framework. The very top is the Vision To Improve health and pregnancy outcomes The second tier are the goals: Coverage – Risk Reduction Empowerment – Disparity Reduction The third tier are the Recommendations: Individual Responsibility - Service Provision Access – Quality – Information – Quality Assurance The last tier are the Action Steps: Research – Surveillance – Clinical interventions Financing – Marketing – Education and training What can we do?? Provide: Preconception Screening Education Counseling Services to address the identified risks in screening There are different preconception health screens available. One is available on the March of Dimes (MOD) website. The Department of Health (DOH) and MOD will also be developing one which will be available on a new website that Florida is developing called www.EveryWomanFl.com In considering the health of the mother prior to pregnancy, these are some of the topics of consideration. These areas we know impact her health and her reproductive health. The goal is to assist women to identify and correct or mitigate as many risk factors as possible before they become pregnant. The topics are: Access to health care Nutrition (including folic acid education) Physical activity Maternal infections (including periodontal disease) Chronic health conditions Substance abuse Smoking Mental health Baby spacing Environmental risk factors And any other risks identified on the Preconception Screen We must identify any barriers the woman may have to obtaining health services. Work collaboratively with the participant, clinic staff, and community resources in order to assist the participant with accessing needed health services. Routine health care should include each of these components. Pap smear Breast exam (with teaching on techniques of self-breast exam) Review of family health history Weight, height, blood pressure Lab testing for diabetes or thyroid conditions, if needed Management of chronic health conditions Dental services When we talk to women about eating healthfully, these are discussion areas. We must be sensitive to the fact that some women may have challenges to eating healthfully, not due to lack of information, but due to barriers associated with obtaining healthful sources of food. You need to know in your community what programs are available to assist with obtaining healthy food. Impact of obesity on women’s health can not be overstated they are: Diabetes Hypertension Cardiovascular disease Disabilities The Impact of maternal obesity on reproductive outcomes include: Glucose intolerance of pregnancy Pregnancy-induced hypertension Thrombophlebitis Infertility Neural tube defects (NTD) Prematurity There are also impact of being underweight like Risk of osteoporosis in later life And a Fragile health status The Impact of low pregravid weight on reproductive outcomes are: Infertility Low birth weight Prematurity When we think of Nutritional status we used to think that we could get all we need out of food, however, with food today being processed and processed again not all of us are able to get what we need out of the current food supply. Ask if the woman is taking a multi-vitamin and very importantly ask about Folic Acid/ This is the Impact of inadequate maternal folate levels on reproductive outcomes: Increased incidence of neural tube defects (NTD) Increased incidence of other birth defects Some anemias —mother and infant And the impact of low folate levels and women’s health in general: Increased heart disease and evidence is accumulating about increases in: Colon cancer Breast cancer Some forms of dementia This is a slide of an infant with an open neural tube defect. Neural tube defects generally occur by 26-28 days post-conception. Up to 70% of these defects may be prevented by preconception supplementation with folic acid. (Discussion of doses in nutrition section.) There are also other benefits to taking folic acid, including lowering risk for developing certain types of cancers of the breast, cervix, and colon and lowering risk for developing dementia in the elderly population. It has also provided lower risk for heart disease and stroke. Addditionally: Ideal levels of folic acid can prevent: Up to 70% of neural tube defects Fifty percent of cleft lip and palate defects Forty to fifty percent of congenital heart defects It has also been demonstrated that folic acid may prevent pre-eclampsia and other pregnancy-related complications. Mexican-Hispanic women are at the highest risk of having babies with neural tube defects. The women are less likely to take folic acid or multivitamins when not pregnant due to perceptions that they are only taken in ill-health or in pregnancy and concerns about gaining weight if taking a multivitamin. Florida birth defects registry indicates Mexican-Hispanic women have a relative risk nine times higher than non-Hispanic women born in the U.S. Folic acid requirements: All women of childbearing age, regardless of their intentions to become pregnant, should take at least 400 micrograms (0.4 milligrams) of folic acid daily. Past history of a baby with a NTD may require a higher, therapeutic dose of folic acid (4.0 milligrams), available through prescription only. Folic acid requirement increases during pregnancy. Women who are taking medication for a seizure disorder or who have diabetes may also need to take a higher dose of folic acid. These women are at a higher risk for birth defects. You can see how important Folic Acid is to all of us!! Encourage women to find a physical activity that best suits their needs and abilities. Walking may be the easiest and most economical exercise a woman can do. The benefits are: Benefits of exercise include: Lower stress, depression, and anxiety Feel better about yourself Sleep better Better concentration Decrease your chance of developing a chronic disease Improve your blood pressure and decrease your cholesterol And To Maintain a healthy weight Maternal infections can impact a woman’s birth outcomes, but it can also impact her own health and in some instances, her fertility. Lets look at this list: Maternal infections have been consistently linked to poor birth outcomes. All sexually active women of childbearing age should be counseled on the risks of infection to their own health and their future pregnancies. All women should be offered screening, testing, and treatment for sexually-transmitted diseases (STD’s) including syphilis, gonorrhea, HIV, genital herpes, Chlamydia, and HPV. Conditions such as bacterial vaginosis should be screened for and treated, if necessary. Douching should be discouraged. Women should be up-to-date with immunizations, especially rubella, hepatitis B, and varicella, prior to becoming pregnant. Women should receive information on the recognition and risks of untreated urinary tract infections, bacterial vaginosis, and STD’s. Work with local community resources to assist women in obtaining proper dental health. Provide toothbrushes and dental floss and educate women on the techniques and importance of good oral health. There is work being done that really links Periodontal disease - A disease of the gingiva, gums, and supporting structures of the teeth to prematurity and/or low birth weight. It Affects between 5-40% of women of childbearing age. And Increases the risk of heart attack and stroke. It also, Exacerbates diabetes and Contributes to lung disorders such as pneumonia and emphysema. Management of chronic health conditions prior to pregnancy helps reduce risks to mother and baby. These conditions include, but are not limited to: High blood pressure Systemic Lupus Erythematosus (SLE) Kidney disease Diabetes Asthma Endocrine conditions such as thyroid disease Depression Lets look at these individually High Blood Pressure can increase the risk of pregnancy complications, including placental problems and fetal growth retardation. Systemic Lupus Erythematosus (SLE) can increase the risk of miscarriage or preterm labor. If symptoms have been inactive for at least six months, an affected woman is likely to have a healthy pregnancy. Preconception care helps plan the safest timing of pregnancy Kidney Disease - Women who have chronic kidney disease should consult their doctors prior to pregnancy to see if pregnancy is safe for them and their baby. Diabetes - Women with poorly controlled insulin-dependent diabetes are several times more likely than non-diabetic women to have a baby with a serious birth defect. They are also at increased risk of miscarriage and stillbirth. Asthma – Poorly controlled asthma can increase a woman’s likelihood for complications in pregnancy, including compromising the oxygen supply to the developing fetus. Endocrine conditions are a good example of the importance of maintaining good health, regardless of intentions to become pregnant. If treated and managed appropriately, hyperthyroidism and hypothyroidism will not affect a woman’s pregnancy. Serious complications may result if not treated and managed. Women should be routinely screened for depression throughout their lifespan. Appropriate education, resources, and referrals should be provided to address any depression she may be experiencing. Women who are depressed during pregnancy: Receive less prenatal care. Don’t eat as well and are less likely to take prenatal vitamins. Don’t get enough rest. Are more likely to engage in risky behaviors such as smoking and substance use. And remember: Women with a history of depression are more likely to experience depression in pregnancy and in the postpartum period. Additionally, women receiving treatment for depression through medication may need to consult with their doctor on a medication that is safe for pregnancy or while breastfeeding. There is no known amount of drugs or alcohol that is safe in pregnancy. Both drugs and alcohol cross the placental barrier to the developing fetus in utero. Drugs and alcohol can cause fetal loss, birth defects, fetal alcohol syndrome, low birth weight, and intrauterine growth restriction. Many pregnancies are unplanned and while you are using drugs and alcohol you are affecting your unborn infant. Women need support and linkages to substance abuse treatment for their health today and for the health of any children in the future. We must provide women with ongoing education, with simple messages sent out that teach them the dangers of drugs and alcohol to themselves and to their children. Maintain awareness of the resources in the local community for referring women for counseling and treatment and assist women in receiving the help they need. Use some of the techniques described in Susan Potts’ presentation of Motivational Interviewing to allow these women to talk about these negative health behaviors. The Impact of alcohol use on reproductive outcomes are: Delayed fertility Increased spontaneous abortions (SABs) Fetal alcohol spectrum disorders (full fetal alcohol syndrome can only occur with fetal exposure between days 17-56 of Impact of alcohol use on women’s health are: Risk for motor vehicle and other accidents Risk for unintended pregnancy Risk for addiction Risk for nutritional depletions and inadequacies This is just a partial list of the many negative impacts. Impact of tobacco use on women’s health are: Implicated in most of the leading causes of death for women: Heart disease (#1 cause of death) Stroke (#2) Lung cancer (#3) Lung disease (#4) Impact of tobacco use on reproductive outcomes are: Tobacco is the Leading preventable cause of infant mortality. Preventable cause of low birth weight and prematurity. Associated with placental abnormalities including placenta previa and placenta abruptio. In 2001, the percent of births under 2500 grams, low birth weight (LBW), for mothers who reported smoking on the Florida birth certificate was 13.2%. Mothers who reported not smoking had a LBW infant rate of 8.3% Depression is a risk factor for obesity, substance abuse, tobacco use, poor pregnancy outcome, and has been linked to the development of asthma, heart disease, hypertension, and stroke. Depression can cause serious complications for chronic disease patients and can interfere with their ability to follow treatment recommendations. Depressed mothers are less likely to breastfeed, less likely to follow back to sleep recommendations for their infants, and more likely to have babies with feeding and sleeping difficulties. Infants of depressed mothers exhibit depression-like behavior (i.e. fewer expressions of interest, excessive crying, lower orientation scores, more abnormal reflexes). Source: “Depression During Pregnancy” Bennett, et. al., Clin Drug Invest. Older children of mothers who were depressed during infancy often have poor self-control, aggression, poor peer relationships, and difficulty in school, which increases their chances of grade retention and school dropout. Source: “Improving Maternal and Infant Mental Health: Focus on Maternal Depression,” Ngozi Onunaku, MA, National Center for Infant and Early Childhood Health Policy. All women need to be screened for domestic violence and depression. Twenty percent of women will experience depression at least once during their lifetime. One in four women are the victim of abuse. About three women die in the U.S. from domestic violence every day. As many as 30% of pregnant women experience some degree of depression. For lower-income women, it can be as high as 50%. Studies have proven that high levels of stress can cause: Fatigue Lowered resistance to infectious disease Poor nutrition (no appetite or overeating) Headaches Backaches High blood pressure Heart disease In trying to understand the disparity in health outcomes between African-American women and Caucasian women, research has supported that long-term stress as a result of social inequality and perceptions of racism, may impact the health of the mother and her pregnancies. Dr. Michael Lu proposed the “Weathering Hypothesis,” stating that social inequality may have a negative effect on health outcomes over a lifetime. Studies have demonstrated that perception of racism is linked to preterm birth. Studies indicate that chronic psychosocial, prenatal maternal stress, as opposed to acute or episodic stress, has a negative impact on pregnancy outcomes and fetal development. Both increased anxiety and decreased social support are associated with poorer pregnancy outcomes. As many as 30% of pregnant women experience some degree of depression. For lower-income women, it can be as high as 50% Low pregnancy Body Mass Index (BMI) and low weight gain during pregnancy have been associated with higher symptoms of depression. The altered excretion of hormones as a result of depression has been found to increase the risk of pre-eclampsia. Those with mental disorders were twice as likely to delay getting prenatal care and attended less than 50% of their prenatal visits. Source: “Depression During Pregnancy”, Bennett, et. al., Clin Drug Invest. Women may be exposed to harmful substances at work, at home, or outside, without even knowing it. Awareness and education of possible environmental toxins may reduce exposures and possible poor birth outcomes. Provide education concerning where lead can be found and how to decrease exposure and get tested if she thinks she may have been exposed previously. Lead can be brought into the home on the clothing of persons employed in certain occupations, like radiator repair. Lead: Found in paint, dust, soil, pottery, glass, cooking utensils, and other places, can damage the brain and nervous system causing behavior, learning, hearing problems, headaches, and delayed growth. Some herbal remedies such as Azarcon and Greta may contain high levels of lead. Previous maternal exposure to lead can affect the developing fetus. Women may not realize that certain types of fish should be avoided or only eaten in very small quantities. In general, in trying to remember which fish to eat and which fish not to eat, the larger the fish, the more likely the fish is to have bio-accumulation of harmful substances. Mercury: A poisonous metal that occurs naturally in the environment. It is released into the air then falls directly into the water. Upon reaching the water it turns into a very toxic form (methyl-mercury). In 2004, the Food and Drug Administration (FDA)/Environmental Protection Agency (EPA) Consumer Advisory:”What You Need to Know about Mercury in Fish and Shellfish” was released. For more information, call the FDA Food Information Hotline toll-free at 1-888-SAFEFOOD or visit the FDA’s Food Safety Website at www.cfsan.fda.gov/seafodd1.html. Up until recently, pressure-treated wood was treated with arsenic. Arsenic residue is found on and near pressure-treated wood to include decks, playground equipment, outdoor furniture, and walkways. Pesticides: Includes bug sprays, fertilizers, and wood treatment. Migrant farm workers may be more heavily exposed to these toxins. Gases: Carbon Monoxide is given off by cars, gas furnaces, kerosene heaters and cigarette smoke. It can not be seen nor smelled. Side effects of exposure include: Low birth weight Stillbirth Headaches Death Food-borne risks: Undercooked foods (raw fish, oysters, underheated deli meats) Avoid Sushi when pregnant. Unpasteurized milk or juice Soft cheeses Some herbal teas Homeopathic remedies Toxoplasmosis: cat litter soil Research shows that waiting at least two years between pregnancies is optimal for both the mother and infant’s health. A short pregnancy interval may be associated with: Birth of a small (for gestational age) infant in a subsequent pregnancy. Preterm birth in a subsequent pregnancy. Low birth weight. Stillbirth. Death within the first year of life. Cultural differences may influence a woman’s ideas about optimal spacing between pregnancies but we should still try to provide education on this topic. We need to make sure women are aware of the resources for Family Planning services for up to two years post-pregnancy. Having babies too close together can deplete the mother’s nutrients, energy, and finances. Family Planning and Primary Care clinics can assist women with their contraceptive needs. There is a special Medicaid program for women aged 14–55, who lose full Medicaid benefits, including pregnancy-related benefits. This program provides coverage for family planning services for up to two years. When providing pre/interconceptional education or services, we are more likely to positively affect the behavior of the women if we are aware of and have appreciation for the cultural belief systems of the women. A woman’s experiences and belief systems may affect how she receives and acts upon the information provided so: Counseling, education, and services must be provided with consideration to the cultural, language, education/literacy, and accessibility needs of the participant. This includes understanding of the: Beliefs, values, traditions, and practices of a culture. Culturally-defined, health-related needs of individuals, families, and communities. Culturally-based belief systems of the etiology of illness and disease and those related to health and healing. Attitudes toward seeking help from the health care providers. For more information, contact the National Center for Cultural Competence at the Georgetown University Center for Child and Human Development at 1-800-788-2066 or http://gucdc.georgetown.edu/ncc In considering how we provide information and services to various groups with different cultural norms, we must be aware that each of us has our own sense of “normal” behavior and that these beliefs may affect how we deliver services or information. We need to be mindful of this, particularly at clinic sites. For example, our appointment systems may not be consistent with the norm for some individuals. As we strive for friendly access and strive to have services that families feel welcome in receiving, we must consider our biases and the norms for varying groups. Examples of varying cultural beliefs or practices among groups: Mexicans – douching a common practice. Mormons – procreation as a sacred duty. Native Americans – children should be spaced three to four years apart. African Americans – prenatal care may not be readily sought because of negative experiences with health care system. Cubans – male contraception is not acceptable due to machismo. They came out with 10 recommendations to Improve Preconception Health for us all to follow. Florida is currently working on an initiative called Every Woman Florida This initiative is three fold: A website www.everywomanfl.com Educational materials that will soon be available and will be available on the website A Every Woman Florida Preconception Health Council that will consist on many health care professionals and will assure that every practitioner in Florida is provided education of giving preconception care to every woman every visit.……………………………………….. 1. Each woman, man, and couple should be encouraged to have a reproductive life plan. 2. Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts 3. As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes. 4. Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high priority interventions. 5. Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (e.g. infant death, fetal loss, birth defects, low birth weight, preterm birth, significant maternal morbidity). 6. Offer, as a component of maternity care, one prepregnancy visit for couples and persons planning a pregnancy. 7. Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and interconception care. 8. Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes. 9. Increase the evidence base and promote the use of the evidence to improve preconception health. 10. Maximize public health surveillance and related research mechanisms to monitor preconception health. This chapter was developed through a collaborative effort between the Florida Department of Health and local Healthy Start Coalitions. The standards allow coalitions the flexibility to develop or adapt curriculums to meet their individual needs as long as they include the minimum standards outlined in the chapter. Curriculums and protocols must be approved by the local Healthy Start coalitions before providers begin implementation of the program. We use several tools to identify a client’s individual needs. Women enter Healthy Start voluntarily through Florida’s universal Prenatal and Infant Screening program. It allows providers to identify women and infants at risk for poor birth outcomes and developmental delays. Interconceptional risk factors are identified through further screening of clients who agree to Healthy Start Services. The Women’s Health Questionnaire and the “Tell Us About Yourself” psychosocial questionnaire are two examples of screening tools which assess health behaviors. Emphasis is placed on assuring that education is presented in a culturally- and educationally-competent manner. When possible, education should be presented in the client’s native language or through a qualified interpreter and provided on an education and literacy level appropriate to the client. Fathers, significant others, and family members are encouraged to participate with the participant’s approval. Topics are tailored to the client’s needs and risk factors. Interconceptional Education and Counseling Service Components Plan of Care Presentation Demonstration activity Follow-up Feedback Evaluation We encourage providers to be creative in how they deliver services. Education can be provided on a one-on-one basis, in a support group setting, or in a formal educational group setting, and may be provided through home visiting, or community locations such as clinics, churches, community centers, libraries, or schools. Providers include nurses, social workers, health educators, and trained paraprofessionals who are knowledgeable about community resources, interconceptional topics, and are culturally-competent. Interconceptional Education and Counseling Services Documented in the record of the person receiving the service. Follow-up on referral documented in participant’s record. Consent for release of information between provider and care coordinator. Certification of completion provided to care coordinator for participant’s record. Quarterly Quality Assurance (QA)/Quality Improvement (QI) by provider. Interconceptional Education and Counseling Services Coding Activities that educate and inform the Healthy Start woman about health behaviors that will help to reduce risk and improve subsequent birth outcomes. Code 8013 is open to program components 26, 27, 30, and 31. Services can be provided to a Healthy Start Woman or to the mother on behalf of her Healthy Start Infant. Who can be provided this Healthy Start service?” Any Healthy Start woman determined at risk for a poor outcome of a subsequent pregnancy. May be provided prenatally or postnatally. May be provided to the Healthy Start participant, or to the mother of a Healthy Start participant on behalf of the participant. We have a system of service coding to capture the location of service provision and numbers of services provided, but there is currently no reimbursement for these services. What is required for the service?” Healthy Start coalition-approved curriculum with components covering access to health care; baby spacing; nutrition; physical activity; maternal infections; chronic health problems; substance abuse; smoking; mental health; and environmental risk factors. Learning objectives for the curriculum. What if my staff is not trained to provide this special service?” Healthy Start care coordinators who do not receive special interconceptional education and counseling training may still provide their participants with the appropriate health education to reduce risks as part of their care coordination activities and code to 3320 or 3321. We recognize that powerful influences on outcome occur long before pregnancy begins. Pregnancy is shaped by: Social Psychological Behavioral Environmental Biological forces Improving pregnancy outcomes necessitates the linkage of an even broader array of health care providers embracing a life course perspective with regard to perinatal health.” Dawn Misra, Women’s and Children’s Health Policy Center, Bloomberg School of Public Health, Johns Hopkins University. Any health care provider who comes into contact with a woman of reproductive age has the potential to protect the health of that woman and her future offspring.