Introduction 1 2 3 4 before between 5 Given the diversity of women of reproductive age, the numerous health and psychosocial issues that impact reproductive health outcomes and the varied settings for delivery of health care, a single ‘best’ model of preconception care for all women is unlikely. Rather, tailoring the delivery of preconception care interventions to women with specific circumstances and in specific care settings will be necessary. This paper describes two programs for delivering preconception care for women at-risk for poor health and pregnancy outcomes. One targets women whose risk status is defined by African-American ethnicity and delivery of a very low birth weight (VLBW; <1500 g) infant and, thus, specifically involves the provision of an interconception intervention. The other program targets women whose risk status is defined by African-American ethnicity and residence in Jacksonville-Duvall County, Florida, and involves the delivery of an intervention with preconception and interconception components. The grady memorial hospital Interpregnancy Care (IPC) program Background 6 7 17 18 19 In 1998 the Georgia Task Force on Perinatal Care was convened to make recommendations for reducing Georgia's overall feto-infant mortality rate and racial disparities in feto-infant mortality. From its findings as outlined above, the Task Force specifically recommended that interpregnancy care be initiated and evaluated for women at risk for having recurrence of VLBW delivery. The Grady Memorial Hospital Interpregnancy Care (IPC) Program was initiated in response to the recommendation of the Task Force. Target population African-American women residing in Fulton or DeKalb counties, Georgia who qualify for county-supported indigent care services and who deliver liveborn or stillborn VLBW infants at Grady Memorial Hospital in Atlanta are considered eligible for the IPC program. Program description The Grady Memorial Hospital IPC program provides 24 months of integrated primary health care and dental services through enhanced nurse case management and community outreach via a Resource Mother. The Resource Mother is a layperson who is trained by the Fulton County Health Department using a specific set of objectives to facilitate life skills and health education acquisition to support high-risk women. The nurse case manager offers all women who deliver a VLBW (stillborn or liveborn) infant at Grady Memorial Hospital enrollment in the program during or soon after their delivery admission. Women who choose to enroll in the IPC program have their initial home visit with the Resource Mother within 1–2 weeks of discharge from the delivery admission; they are scheduled for their initial IPC clinical evaluation at a clinic within Grady Memorial Hospital at 4–6 weeks postpartum. At the initial IPC clinical evaluation, the IPC program's family physician or nurse- midwife performs a comprehensive survey of medical, obstetrical, nutritional, psychological, and social issues (using standardized assessment tools); a thorough physical examination including pelvic exam; and laboratory evaluations to screen for anemia, nutritional deficiencies, sexually transmitted diseases (STDs) and reproductive tract infections. Standard postpartum care issues are addressed in the initial IPC clinical evaluation, thus eliminating a separate postpartum appointment. As part of the evaluation, the participant and provider explicitly discuss a care plan for the 24-month period of the program. For each woman, the care plan addresses the following seven areas epidemiologically linked to LBW delivery: 1) Pregnancy intendedness and child-spacing through the provision of health education concerning the importance of achieving at least a 9-month (and preferably an 18-month) interpregnancy interval, assisting the woman to articulate her own reproductive plan and select a corresponding contraceptive method; 2) Management of chronic disease (if present) through the promotion of self-care and adherence to scheduled appointments in Grady Health System that are facilitated by nurse case management; 3) Screening and treatment for nutritional deficiencies; 4) Prevention, screening, and treatment for STDs and reproductive tract infections; 5) Treatment and referral for substance abuse (if present) including linkage with rehabilitation programs for illicit substance abuse, and support in and linkage with existing programs for tobacco and alcohol abuse; 6) Screening and treatment or support for depression, psychosocial stressors, and domestic violence; 7) Prevention, screening and treatment for periodontal disease. 20 Resource Mother support services are focused on identification and management of psychosocial stressors, and life skills enhancement, including parenthood preparedness, safe housing, skills training, employment acquisition, and relationship issues. Resource Mother support is offered at least twice monthly in the form of home visits and telephone contact. Participants are able to contact the Resource Mother via her cell phone to request support, if needed. Providers Primary care and outreach services are delivered by a multidisciplinary team comprised of a family physician, an advanced practice nurse trained as both a nurse midwife and a family nurse practitioner, a periodontist, a nurse case manager, and a Resource Mother. Social workers affiliated with Grady Health System also support the IPC program and interface with the IPC team. Outcome objectives The purpose of the Grady Memorial Hospital IPC program is to investigate whether interpregnancy care can improve the health status, pregnancy planning and child spacing of women at risk of recurrent VLBW delivery. Findings will contribute to the field of primary health care of reproductive age women in several important ways: (a) the content of a successful IPC package for improving the health of high-risk women will be explored; (b) the concept of IPC will be tested as a means of improving attainment of desirable interpregnancy intervals and decreasing the occurrence of subsequent adverse pregnancy outcomes for high-risk women; (c) the cost of providing IPC to high-risk women will be studied. Funding The health care services rendered to IPC participants were provided through the services of the Grady Health System. Funding for the research and evaluation components of the IPC Program, including Vasser-Wooley Foundation, Healthcare Georgia Foundation, Centers for Disease Control and Prevention (CDC), Rockdale Foundation, and March of Dimes. Results from the first year of the IPC program Enrollment During November 2003 through March 2004, the feasibility phase of the IPC program was initiated by enrolling the first sequential 29 eligible women who gave their informed consent for participation. During the enrollment period, a total of 47 women delivered VLBW infants at Grady Memorial Hospital. Of these 47 women, nine were not African-American or did not reside in Fulton or DeKalb counties, four declined enrollment, three who wished to be contacted afterdischarge from the hospital were unable to be contacted, and two were discharged from the hospital within 24 h and before being offered enrollment. Participation Twenty-one of 29 enrolled women (72.4%) successfully completed the initial 12 months of the planned 24 months of follow-up. During the first 12 months, eight women became disenrolled from the program two moved out of state (and informed us of their move), three electively disenrolled (two before prior to the initial home visit and the initial IPC clinical evaluation; one after a single IPC clinic visit), and three became lost to follow-up (two before the initial IPC clinical evaluation; one after a single IPC clinic visit and four home visits) all of whom who had noted problems with cocaine abuse in their medical records during their pregnancy. Outcomes Chronic diseases that were previously unrecognized or poorly managed were identified for 7/21 participants, and include valvular heart disease (1/21), sickle cell anemia (1/21), hypertension (2/21), diabetes (1/21), asthma (1/21), systemic lupus erythematosus (1/21), prolactinoma (1/21), panic attacks (1/21), and generalized anxiety disorder (1/21); Reproductive tract infections were diagnosed and treated for 15/21 participants; Iron-deficiency anemia was diagnosed and treated for 5/21 participants; Concerns about finances, employment, and needs of the child are almost universal stressors; Average annual outpatient charges per participant for IPC are $1,801 (average 4.6 visits, $389 per visit). With extensive case management and patient education, 21/21 women who had at least two visits during their first 12 months of IPC, stated a reproductive plan for themselves and initiated a contraceptive plan in accordance with their stated reproductive plan. Despite a stated desire to either avoid or delay a pregnancy (21/21 women), a significant number of barriers to effective contraception existed and were dealt with, including misinformation about contraceptive methods and reproduction, concerns about side effects of contraceptive methods, and perceptions of partners’ desires regarding child bearing and contraception. All of the women who had at least two visits during their first 12 months of IPC (21/21) achieved at least a nine-month interpregnancy interval (i.e., none have become pregnancy within nine months of the index VLBW delivery). For the 21 actively participating women, pregnancy ascertainment involved ongoing contact with the women and reviewing the Grady Healthy System medical record system for any evidence of health care visits or laboratory tests in which a pregnancy was diagnosed, incidentally noted, or treated. No pregnancies are known to have occurred within nine months of the index VLBW delivery for the eight women who became disenrolled, for which pregnancy ascertainment involved telephone follow-up, where possible (two women), and review of the Grady Health System medical record system. It is possible that those women with whom contact was lost have had a pregnancy for which no care was sought or care was sought outside of Grady Health System. Barriers In the United States, a major barrier to studying the impact of interpregnancy care on the health status and reproductive outcomes of high-risk women has been the lack of financial coverage for the health care component of the IPC intervention. For the IPC program in Atlanta, the Grady Health System has provided the two years of primary health care and treatment of all identified diseases for all enrollees. Specific barriers exist for retaining participation in the IPC program. Women with substance abuse problems who do not enroll in formal substance abuse treatment programs are difficult to maintain in the IPC program. These women seem to have poor insight into the effects that substance abuse has on their repeated poor pregnancy outcomes. For some enrolled women, receiving health care services is less of a priority than securing employment, which negatively influences their health care seeking behaviors. Next steps Upon conclusion of the planned 24 months of follow-up, the final results for all evaluated outcome objectives from the feasibility phase will be reported. The IPC program is currently seeking grant support to conduct a randomized clinical trial to test the hypothesis of whether IPC can decrease the occurrence of subsequent adverse pregnancy outcomes for pregnancies conceived within 18 months of a VLBW delivery at Grady Memorial Hospital. The project plans to enhance participant retention by offering more opportunities for life skills enhancement, job training, and delivery of health care services via the community-based Grady Neighborhood Health Centers. The magnolia project Background In 1998, infant mortality rates in Jacksonville-Duval County, Florida were increasing while statewide rates were declining. The Northeast Florida Healthy Start Coalition, Duval County Health Department and other community partners undertook a community assessment and identified racial disparities as a major factor contributing to the city's high infant mortality. The Coalition utilized the Perinatal Periods of Risk (PPOR) and findings from its Fetal & Infant Mortality Review (FIMR) project to analyze linked birth and death data. The results of this analysis indicated the need for interventions that focused on the health of women, particularly African-American women, before conception. The Coalition used this information to apply for federal Healthy Start funding under a 1999 initiative to address racial disparities in birth outcomes. This funding was used to establish The Magnolia Project, which adapts selected Healthy Start program models to at-risk African-American women of childbearing age who are not pregnant, but sexually active and likely to become pregnant. The project is implemented in a five-zipcode area of Jacksonville-Duval County that accounts for over half of all African-American infant mortality and about 30% of African-American births. Target population The Magnolia Project targets African-American women ages 15–44 living in a socioeconomic high-risk area of Jacksonville-Duval County. The project focuses on women of childbearing age who are likely to become pregnant and have some identified risk factor associated with poor birth outcomes. The project also maintains a small caseload of pregnant women (<10% of patients). Program description The Magnolia Project provides outreach, case management, risk reduction, support, well-woman prenatal care, health education, and community development. The project engages high-risk women through an empowerment model that promotes improved wellness and health, rather than future childbearing. Clinical services and health education are available to all eligible women in the target area. The project offers intensive case management to a subset of women who have specific risk factors identified through FIMR, including previous fetal or infant death or delivery of a LBW infant; repeated STDs; lack of family planning; substance abuse; first pregnancy before age 15; and lack of access to health care. A comprehensive assessment of each participant's abilities and needs at program entry Participant care and goal plan Ongoing monitoring and service coordination Anticipatory guidance, health education and advocacy Providers The clinical component of the program is staffed by a nurse-midwife and related nursing, lab and support staff. The program has a full-time health educator who provides a brief counseling intervention on key issues (e.g., use of multivitamins, nutrition, douching, and safe sex) to every woman who comes into the clinic. The clinic serves approximately 800 women annually. A team that includes a nurse, a social worker and two specially trained paraprofessionals provides intensive case management to about 75 women a year. Community development and outreach staff, as well as members of the Magnolia Project Community Council, who are indigenous neighborhood leaders, conduct outreach and community awareness activities. The project uses a collaborative, multi-agency staffing model. The Northeast Florida Healthy Start Coalition is the grantee and project administrator. Subcontractors include the Duval County Health Department (clinical care and case management) and Shands Jacksonville, a tertiary care and teaching hospital (case management and outreach). Staff is co-located at a storefront community site within walking distance of six public housing complexes. The University of North Florida Center for Community Initiatives serves as project evaluator. Outcome objectives The project addresses all the outcome objectives required by the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA) regarding birth outcomes (LBW, VLBW, infant mortality, adequacy of prenatal care, etc.). However, because the project primarily focuses on women who are not pregnant, it has developed specific outcome objectives that examine its success in reducing key risks associated with poor outcomes through its case management activities. These include lack of family planning and STDs. Specific outcome objectives have been developed to measure the program's success in addressing participant risks identified at program entry and closure. Funding The Magnolia Project is primarily funded through a grant from the federal Healthy Start program ($925,000). Additional funding is provided through Medicaid and other third- party reimbursement for prenatal, family planning and STD services; state categorical funding through the health department (about $250,000 a year); and smaller community grants for special projects. Total 2004–2005 budget was just over $1 million. Results to date 1 Table 1 Frequency of risks/problems, case management participants, The Magnolia Project, July 2001–May 2005  Risk factor/problem n n Social problems  Family planning issues 26 43.5  Job placement 8.2 33.0  Education/training 11.3 27.3  Stress 8.7 21.7  Housing 4.1 15.7  Domestic violence 7.2 11.3  Depression 8.2 11.1  No source of care 6.7 8.7  Lack of exercise 7.0 8.7  Injury prevention/safety 2.8 8.0  Drug abuse 10.0 6.7  Transportation 4.4 5.9  Sexual abuse 7.0 4.4  Alcohol abuse 6.4 4.1 Medical problems  Bacterial vaginosis 12.9 30.2  Poor nutrition 17.8 19.3  Repeated STDs 12.4 16.5  Tobacco use 13.2 15.5  Breast health 3.9 11.3  Douching 8.5 10.8  Abnormal pap 9.5 9.5  Overweight 11.6 9.5 Source: Magnolia Project database; compiled by UNF Center for Community Initiatives, August 2005. Two-hundred-forty-seven participants received at least three months of case management and were closed to care because they completed their care plans, voluntarily withdrew or were lost to service. For key risk factors, case management participants were most successful in resolving or managing issues related to domestic violence (68%) and poor nutrition (63%). The project was least successful in addressing substance abuse by participants (31%). In October 2004, the HRSA Office of Performance Review conducted a site visit and assessment of Magnolia Project outcomes and activities. Its report noted that participants receiving case management services from 2001 to 2003 successfully addressed two priority risks: 86% of participants with family planning issues were consistently using a method at closure; 74% of participants with repeated STDs had no recurrent STDs at closure. Barriers Insufficient funding has limited expansion of the Magnolia Project. Existing funding streams focus primarily on pregnancy, not women's health. The Magnolia Project has successfully cobbled together categorical funding and Medicaid reimbursement for most clinical services, however, in Duval county, the delivery of most categorically funded services remains siloed (e.g., STDs, primary care, prenatal care). Additionally, case management/risk assessment is not universally accepted or valued in the medical model of health care, even though many of the risk factors associated with poor outcomes are social, rather than medical, in nature. More longitudinal evaluations are needed to determine the impact of preconception intervention on pregnancy outcomes. Longitudinal evaluations are not easily incorporated into service delivery projects that rely on short-term outcomes for continued funding. Finally, although outcomes have improved in the target area since the implementation of the Magnolia Project, infant mortality rates in the overall community remain high. The project is unlikely to affect these rates because of its comparatively small reach. Next steps The Magnolia Project is aggressively seeking funding for a longitudinal evaluation. Current program evaluation is limited to an assessment of how well the project is achieving short-term objectives and objectives set by the funding agency (primarily focusing on birth outcomes for the small number of pregnant women served by the project). The CDC recently provided support to the Duval County Health Department for the initial design and piloting of tools for a longitudinal assessment of case management participants served by the project. Additionally, the project is working to interest local providers in replicating the intervention in other at-risk areas in Jacksonville-Duval County. Funding for replication is a significant challenge. Discussion The Grady IPC program and the Magnolia project use a classic public health model of care. They identify women at known risk for an adverse outcome and attempt to alter the woman's risk status to improve outcomes. These programs deliver aspects of preconception care to women at risk for poor health and pregnancy outcomes. The programs do, however, target different categories of high-risk African-American women and utilize different sites for contacting and interfacing with them. The IPC program identified women at risk based on race/ethnicity, qualification for charity care (based on financial status and geographic residence in two counties of metropolitan Atlanta) through Grady Memorial Hospital, and a prior poor birth outcome (VLBW delivery). The IPC program enrolled women soon after their VLBW delivery and provided interconception care in the clinical setting of the hospital (with community outreach). The Magnolia project serves women at risk based on race/ethnicity and residence in Jacksonville-Duval County, Florida. It provides preconception care in a community-based storefront setting with enhanced interconception care for women with a previous LBW delivery or a previous fetal or infant death. Access to the Magnolia project is enhanced by offering evening clinics and walk-in Wednesdays. Both programs deliver services via a multidisciplinary team approach, though there are differences in the exact composition of the team. Inherent in the team approach of each program is attention to participants’ physical and psychological health and social well-being. The programs emphasize several comparable intervention strategies, including community outreach via lay persons; psychosocial support; group education and health promotion modeled on the Centering Pregnancy philosophy of care; and provision of health services. Both programs also emphasize the provision of family planning services for helping women achieve intendedness of any subsequently conceived pregnancy. Each program offers unique strategies as part of the interconception intervention. Because of the link between periodontal disease and preterm delivery (almost all VLBW deliveries are preterm), the IPC program incorporates the services of a periodontist to screen and treat women. To specifically enhance particpants’ life skills, the IPC program utilizes a layperson as a Resource Mother who has undergone a tailored training program through the local department of health. A unique feature of the Magnolia Project's approach is its reliance on indigenous neighborhood leaders (e.g., Magnolia Project Community Council) and community-based organizations to provide outreach, community awareness, and education. The Magnolia Project also has established a partnership with the Ryan White III program for STD/HIV/AIDS screening and treatment. Both programs have had success in accessing and providing services to the specific target group of women. Women who choose not to avail themselves of the services seem to have greater socioeconomic issues, such as substance abuse and lack of housing, jobs, and childcare. Due to the magnitude of some of the problems, maintaining contact is challenging and care often is not continuous. 21 22 23 24 Both programs demonstrate several components essential to any successful preconception care program: identification of risk factors amenable to change by the target population; tailored interventions for the target population; integration of preconception care into existing services; incorporation of family planning counseling and clinical services, health education, and community outreach. Preconception care aims to promote the health of women of reproductive age before conception and thereby improve pregnancy-related outcomes. Both the IPC program and the Magnolia Project show promise in achieving this goal for their target audiences.